Can ‘Title X’ Improve Women and Young People’s Reproductive Health?

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A Critical Analysis of Whether Health Policies, such as, Title X Can Improve Women and Young People’s Reproductive Health

Sexuality is a controversial issue within the United States (U.S.). In particular, young people and women face barriers in asserting their bodily and sexual autonomy. In 1970, Title X of the Public Health Act was created to ensure that all individuals have their right to access reproductive healthcare fulfilled (Vamos, Dayley, Perin, Mahan, & Buhl, 2012). Title X supports the funds and the infrastructures of family planning clinics across the U.S. which are used to provide confidential services, such as contraception, non-directive counseling for abortion, and services for young people (Dailard, 2001). Title X has faced political attacks from powerful religious organizations and conservative Republicans due to the cultural anxiety surrounding premarital sex and women’s sexuality. These attacks have reduced Title X’s funding and constrained its ability to improve reproductive health (Dailard, 2001). However, Title X continues to be implemented due to the advocacy on behalf of women’s rights groups and the medical community as access to contraception is conceptualized as a right and a medical need.

Religious organizations like the Christian Coalition have consistently aimed to reduce Title X’s effectiveness (Kohn, 1995). These political attacks occur because religious groups frame Title X as immoral on the grounds that it would encourage young people to become sexually active (Dailard, 2001). To achieve their goal, religious organizations pressure politicians to define ‘medical care’ in a manner which excludes contraception during the policy’s categorization process (Rasmussen, 2011). The political power of these religious groups to do so stems from their use of ‘voter cards’ which are information pamphlets created to inform religious voters on the voting behaviour of Congress members (Braml, 2011). This has a significant influence on a politician’s decision to support/oppose Title X due to the potential of being politically attacked during campaigns/elections by religious groups (Braml, 2011). Interestingly, liberals like Ross (1996) also oppose Title X on the basis that it allows young people to access to contraception without parental knowledge. Ross (1996) states that parents must be notified when their children access contraception because young people are ‘immature’ and require social control. I argue that considering young people as too immature to have sex is a contemporary social construction which is also informed by religious ideology as, historically, a young person’s sexuality was normalized until the average marrying age began to increase (Jimenez, 2012). After this period, the majority of the academic literature began to heavily focus on the negative consequences of young people’s sexuality which has since been used to fuel the debate against Title X (Jimenez, 2012). It can be seen that cultural anxiety surrounding premarital sex constrains Title X’s ability to effectively improve young people’s reproductive health.

Title X has repeatedly been attacked by conservative Republican politicians who argue that access to contraception will, in particular, encourage young unmarried women to be ‘promiscuous’ (Ehrlich, 2013). They frame young sexually active women as entities with lessened value as they transgress the social construction of an ‘ideal’ young unmarried woman as pure, modest, and sexually passive (Odem, 1995; Mann, 2010). In contrast, the impact of increased access to contraception on a young unmarried man’s sexual activity attracts less attention as male sexuality is viewed as normal and natural (Pillard, 2006). I argue that these social constructions which are used to both empower a man’s sexuality and suppress a woman’s indicates that Title X faces a larger societal barrier, that is, patriarchy. In a patriarchal system, Title X is controversial because it would allow a young woman to gain power over her own body and be able to independently assert her sexual autonomy which has consistently been regulated by powerful male dominated political/religious institutions like the government and the church (McCann, 1999 & Richards, 2013). For example, the Comstock Act was used to criminalize ‘obscene’ literature and acts (Swisher, Miller & Shapo, 2012). However, due to its vagueness, the government used their legal power to criminalize women who used or distributed information about birth control until the 1960s. This occurred as a result of the fear that a young woman’s sexuality would escape male control (Swisher et al., 2012). Essentially, this demonstrates that the war on birth control and Title X is based on the cultural ideology that men have the right to control and regulate women’s bodies.

The growth of women’s rights groups has facilitated Title X’s ability to improve access to reproductive healthcare and outcomes (Di Mauro, & Joffe; 2007). Through a feminist lens, women’s sexuality is constructed as natural and of equal importance in comparison to men’s sexuality (Goggin, 1993). As a result, feminists frame Title X in a positive manner since it would provide women with an equal right to assert her sexual and bodily autonomy (Goggin, 1993). These women’s rights groups were able to lobby for birth control policies through public protests, for example, by picketing the White House for a year, through public campaigns funded by wealthy women, and blogging (Kramarae & Spender, 2004; Baker, 2012). Here, it can be seen that feminism’s power to create change mainly lies in the solidarity amongst women. However, Margaret Sanger (feminist and founder of Planned Parenthood) stated that contraception should be provided to poor non­white women as their high fertility are ‘threats’ to upper class society (Hall, 2011). Using this negative social construction can alienate poor and non­white women and, in turn, weaken the power of women’s rights movement (Zinn, Hondagneu­ Sotelo, & Messner, 2001). This weakened solidarity can constrain Title X’s ability to improve reproductive health when considering the power of opposing groups like the Christian Coalition and conservative Republican politicians, as well as, the lack of female representation at the governmental level.

Title X’s ability to continue improving women and young people’s reproductive health has been facilitated by the medical community. Medical practitioners became involved in birth control when the rates of sexually transmitted diseases began to increase and when Margaret Salinger sought an alliance with physicians to give birth control politics scientific legitimacy (Steel, 2014). Through a medical lens, accessibility to contraception is now able to be framed as a ‘health need’ that must be met by the government during the political categorization process of birth control policies (Rasmussen, 2011). Also, the medical community’s ability to influence policy due to their prestige and economic power to fund political action committees can help keep birth control policies like Title X as a political priority (Milstead, 2004). However, the medical community’s participation has also led to negative consequences, for example, the increased medicalization of women’s bodies. Medical practitioners were able to gain this power by labelling pregnancy as a pathological condition, increasing their knowledge of pregnancy via medical technologies, and by employing a medical setting that enabled practitioners to control women’s bodies (Krajnc & Prosen, 2013). Medicalization is evident within the Title X policy as a woman can access abortion related referrals only on medical grounds (Bloche, 1992). This shifts the power to regulate a woman’s body from the woman to the medical practitioners, does not provide a woman with the same reproductive rights as men, and contradicts the women’s rights based framework that Title X was founded on. This demonstrates that while the medical community has increased Title X’s ability to improve reproductive health outcomes, it also continues to suppress women’s bodily autonomy through medicalization. Hence, this supports assertions that medicalization which reflects patriarchy constrains policy.

The ability of Title X to improve reproductive health outcomes is dependent on context. In terms of sexuality, there has been a fluctuation in progressive and regressive moments throughout history (Di Mauro & Joffe, 2007). These fluctuations are related to power as when Nixon (a liberal Democrat) was the president there was a ‘sexual revolution’ and Title X was implemented, whereas when Reagan and Bush (both of whom are conservative Republicans) were in power, Title X funds were significantly reduced with Reagan also aiming to abolish Title X (Di Mauro & Joffe, 2007;Dailard, 2001). The effectiveness of Title X may also differ due to the local environment’s politics and values. For example, Kansas (a state with strong conservative values) spends the least amount of Title X funds on contraception per women and recently rejected a $6000 Title X grant on the basis that intrauterine devices were ‘murder’ tools (Shally­Jensen, 2015; Sonfield & Gold, 2005; Dreweke, 2014). Whereas California (a state with moderate to liberal views on young people’s sexuality) spends the greatest amount of Title X funds on contraception per women (Constantine, Jerman & Huang, 2007; Sonfield & Gold, 2005). It can be seen that Title X’s effectiveness depends largely on the values of the presidents and the local social environment. Hence, policy is only ever the outcome of negotiation and when a group in that negotiation is minoritized (i.e. has less power) the negotiation is unbalanced and policy is limited by dominant biases.

Reproductive health care policies like Title X are controversial. Their ability to be effective has been constrained by opposition from powerful religion organizations, conservative republicans, and even liberals. This political position stems from the cultural ideology that pre­marital sex is immoral, young people are too ‘immature’ to be sexuality active and require parental control, and the patriarchal notion that men have the right control a woman’s sexuality and body. Despite the controversy, Title X still continues to facilitate women and young people’s access to reproductive health services. The facilitators of Title X have been women’s rights groups who argue that women deserve the right to access these services and the powerful medical community who frame contraception as a health need. This demonstrates that health policy is a complex issue characterized by opposing/supporting groups who have different values and ideologies, and that essentially the power of these groups is an important determinant of health policy’s success. It is important to note that it is too simplistic to state that health policies will always produce positive, negative, or no impact. A policy’s success is largely dependent on the national and local context, for example, the values of the current president and the local social environment. However, to increase the likelihood of success for policies like Title X, the inclusion of poor and non­white women’s voices, young people’s opinions, and a reduction in the medicalization of women’s bodies is essential. Positive change is possible.


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Written by: Nidha Khan
Written at: University of Auckland
Written for: Tara Coleman
Date written: 08/2015

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