The Issue with LARCs for Black Women

Remember that time in 2016 right after the election when women across the country panicked and rushed to get intrauterine devices (IUDs) and birth control implants? Yeah, us too! It was such an unnerving time. We were all bracing for the potential long-term changes that a new presidency might bring. After the election, Google trends showed a surge  in searches for “IUD” “birth control” and “Planned Parenthood”. There was a growing concern for whether the incoming administration and Congress would make birth control inaccessible by repealing the Affordable Care Act provision that required health insurance plans to cover birth control, and that they’d roll back reproductive rights more broadly. 

As Black sexual wellness educators, we were conflicted. What we didn’t see emerge from the shadows of this national conversation was the reality that for many women, there is a long and disturbing history of reproductive injustice and obstetric violence that makes accessing birth control especially challenging and complicated. Although the conversation about reproductive freedom always focuses on women being denied birth control, Black and other women of color have also been coerced or forced into birth control they didn’t want — and LARCs are central to that rarely discussed story. 

What is a LARC, you might be asking? LARC is the acronym for long-acting reversible contraceptives, birth control methods that once inserted, work for extended periods of time and are highly effective in preventing pregnancy. In the United States, there are two types of LARCs: IUDs and implants. Combining LARCs with a barrier method like an internal condom or external condom is the best way to protect yourself against an unintended pregnancy and sexually transmitted infection. Though LARCs are not currently the leading birth control choice among women, the use of IUDs in particular has been on the rise in recent years because of the method’s popular “set it and forget it” functionality and high effectiveness at preventing pregnancy.  While these benefits are great, some folks will still not choose LARCs for many reasons, and for women of color, a history of coercive LARC use and sterilization may be a reason. 

Although there’s way more to say on this topic, here is a quick primer on how the state has attempted to control and regulate the bodies of women of color, low-income women, immigrant women, women receiving public assistance and women with disabilities for over one hundred years. 

Reproductive Freedom Denied (a Brief History)

From the turn of the early 20th century, states began passing sterilization laws specifically targeting minoritized and marginalized communities. This was also supported by the U.S. Supreme Court in the infamous Buck vs Bell decision which legalized involuntary sterilization for people with disabilities (it has yet to be overturned). Also during this era, sterilization for women of color had become commonplace. By 1965, one-third of all Puerto Rican women of child-bearing age had been sterilized, many without their knowledge or consent. This devastating mass sterilization became commonly known as “La operacion”. The reproductive violence didn’t stop at forced sterilization — it continued on with coercive contraception practices. 

Beginning in the 1980s the promotion of contraceptives like the implant Norplant became “front-line weapons” in the war against the poor and folks of color. It was marketed as a cure for all the fictitious “welfare queens” Ronald Reagan created to bolster his political campaign for presidency in the 1980s, and gave way to the mid-1990s welfare reform and devastating family caps, laws that limit or deny financial assistance to low-income women who have more than a certain number of children. Norplant was popularized in the media with The Philadelphia Inquirer asking in 1990, “Poverty and Norplant—Can Contraception Reduce the Underclass?” and a Washington Post article reporting on a radio talk show host who proposed requiring all young girls reaching puberty to use Norplant. In almost no time, states began introducing legislation that would give women receiving public assistance “bonuses” if they used LARCs like Norplant. And while none of this legislation was ever passed, it is noteworthy that in the mid 1990s, 85 percent of all Norplant implants were government-funded, from community-based clinics to school nurse programs. Though this may sound like a win, it is not the win we would ask for. The government would pay for insertion, but many states declined to pay for removal in an attempt to coerce women into keeping Norplant in for the full five years. These “insertion-only” services left low-income people, particularly people of color and teenagers, stuck with devices in their bodies even when they no longer wanted them. It gets worse… Norplant was also used in criminal legal cases where some women convicted of drug abuse or child abuse were asked to choose between having Norplant implanted or going to jail. 

But It’s Not Just History

It would be great if this misogyny, classism, racism and ableism in reproductive healthcare was just a bad chapter in the history books, but that would be too good to be true. Contraceptive coercion and sterilization abuse is still happening today. As recent as 2010, doctors in the California prison system were caught illegally coercing incarcerated women into sterilization. Just two years ago, Tennessee lawmakers were moved to pass an anti-coercion bill after a judge in White County was found to be offering reduced jail sentences to folks who chose to have a LARC device inserted. Today, we still see subtle discriminatory biases when it comes to funding the removal of LARC devices in some state Medicaid programs if the recipient wants to get pregnant. In recent years, trusted medical bodies like The American College of Obstetricians and Gynecologists (ACOG) have released numerous opinions on supporting the use of LARCs like IUDs in a wide range of women, but haven’t always considered the troubling history we just shared. As late as 2007, ACOG released comments that suggested that LARCs “should be considered as first-line choices” for teenagers at risk for unintended pregnancy, which bears a striking resemblance to previous coercive campaigns. It’s important to understand and acknowledge the coercive history of LARC use in order to rectify and not repeat the problems of the past.

Where Do We Go From Here?

We believe that people should be able to choose whatever birth control method that works best for them, including LARCs. The promotion of LARC use today must take this history and reality into account in order to move forward, prioritizing patients’ reproductive autonomy. Knowing all that you know now, it’s important to be fully informed about different birth control options so that you can make a decision in alignment with your unique history, preferences and priorities. Making an informed decision means that you are aware of the risks, costs, harms and benefits of all options while considering your unique needs. 

You can start by making a list of your preferences and concerns when it comes to choosing a birth control method.

Consider whether you prefer the following:

• a method that will almost never fail (think effectiveness)  
• a method that can be started or discontinued as you choose, without the assistance of a healthcare provider (think do-it-yourself) 
• a method that aligns with your future family planning goals (think timing) 
• a method with minimal personal involvement (think set it-and-forget it) 

Now consider whether (or how much) you are concerned about the following:  

• the detectability of the method by a partner/parent
• the effect of a method on your menstrual cycle
• the cost and health insurance barriers related to a birth control method
• the side effects of birth control as it relates to your health

*Feel free to add to this list of preferences and concerns. 

Prepare your questions and have a collaborative conversation with your healthcare provider

It’s important to approach medical providers with a clear agenda and expectations so that your provider can meet your specific needs. Before your next interaction with your healthcare provider, jot down the things you want to talk about. Even if you feel rushed, be sure you get all your questions answered before making a choice about what contraceptive you feel is right for you. 

Whatever your needs are, it’s important to find a healthcare provider who prioritizes helping you  choose a birth control method that works best for you. LARCs are widely recommended in the medical community as a first-line contraceptive thanks to effectiveness and forgettable appeal, but that may not be what’s most important to you in your birth control. Your choice of birth control is connected to your entire life and future decisions so you should be in partnership with a healthcare provider who prioritizes  your unique needs. 

LASTLY, remember, YOU and only YOU get to make decisions about your body. 

About the Authors

Kimberly Huggins, LSW, MPH, MEd, and Brittany Brathwaite, MSW, MPH, are the Co-Founders and Co-CEOs of Kimbritive, a New York-based company focused on creating real, empowering conversations and sexual wellness workshops for Black women and girls.  Kimberly is a licensed social worker and human sexuality educator who is passionate about reproductive health and the emotional wellbeing for people living with HIV and stigmatized health conditions. Brittany is a reproductive justice activist, youth worker and community accountable scholar with a deep commitment to supporting the leadership, organizing, and healing of girls of color.