The Case of Dr Carlos Morín, Barcelona, Spain – “Hasta el final”

23/06/2016 § Leave a comment

The history of the persecution of Dr Carlos Morín, former director of the Ginemedex clinic in Barcelona, Spain, the staff of his clinic and the thousands of women who had abortions there began in Britain in 2004 and reached its climax, at least for the moment, on 17 June 2016, in the Regional Court of Barcelona, where during a re-trial ordered by the Supreme Court, three years after he and all his staff had been acquitted of all charges against them, Dr Morín was found guilty of having carried out 11 illegal abortions and a psychiatrist from the clinic, Dr Pascual Javier Ramón, was found guilty of signing the forms authorising the abortions.

What happened in between is the stuff of nightmares. The case was dragged through the justice system and the media for more than ten years by anti-abortion groups, who succeeded in having all Dr Morín’s clinics closed six years before he was even tried in court, and everyone who had been working in the clinics and the patients were investigated. Not only Dr Morín and his wife, who worked with him, but also many members of their staff were finally put on trial in 2012. In the interim, he was unable to practise his profession as a doctor and suffered from both public condemnation and bankruptcy, due to huge legal costs throughout the whole process.

The story began in Britain on 10 October 2004, when the Sunday Telegraph ran a story, based on “undercover” work[1] by a woman journalist pretending to be pregnant, that women beyond the legal time limit for abortion in England and Wales were being helped by the British Pregnancy Advisory Service (Bpas) to obtain abortions in Dr Morín’s clinic in Spain. Following an investigation by the Chief Medical Officer for the Department of Health, Bpas were criticised for the way the undercover call was handled, but were exonerated of any wrongdoing.

Moreover, according to the Chief Medical Officer’s report, the Barcelona newspaper La Vanguardia reported on 14 October 2004 that the Health Department of Catalunya had come to the conclusion that the Barcelona clinic “attends patients in a correct and legal manner”. The Catalunyan Department added that they had carried out an inspection which confirmed that the clinic concerned had provided services within the terms defined by the regulatory and legal system.

The British Chief Medical Officer’s report also stated: “My investigation has shown that it can be difficult for women to access late abortion services.” (Chief Medical Officer report, 2005)

Thus, no wrongdoing was found in either Britain or Spain. The situation did not end there, however. It was advanced further following an undercover visit to the Ginemedex clinic by a Danish public television crew, which was aired on TV in 2006 in Denmark, France and the Netherlands. That led to an investigation of a clinic in the Netherlands who, like Bpas, sometimes referred women with late second trimester abortions (25-28 weeks) and rarely a third trimester abortion who were beyond the legal time limit in their countries to the Ginemedex clinic. The ultra-religious group E-Cristians used the Danish TV show to call for an investigation of whether the Ginemedex clinic was doing abortions outside the law.

Under the law in Spain until 2010, abortion was legal up to 12 weeks if the pregnancy resulted from rape, up to 22 weeks in cases of severe fetal anomaly, and with no time limit if it was necessary to avoid a grave danger to the life  or the physical or mental health of the pregnant woman. Throughout this period, the Ginemedex clinic followed the guidelines for assessing the women who came to them in line with legal protocols. The woman was seen by a psychiatrist who also authorised that the abortion was legal and on that basis, the staff carried out the abortions.

According to Anne-Marie Rey, an abortion rights activist in Switzerland since 1971, who has closely followed the case from the beginning:

“Up to 2007, the Ginemedex clinic was a last resort for women who sought an abortion in advanced stages of pregnancy. Women were sent to Barcelona from many countries, when it was not possible to help them at home. Personally I gave his address to several women from Switzerland and they were always treated with respect and empathy. Yes, Dr Morín did interpret the Spanish abortion law liberally. But, in fact, he only applied the World Health Organization definition of “health” as “a state of complete physical, mental and social well-being”. And he applied this interpretation also in the case of desperate women who needed an abortion late in pregnancy, after 24 weeks gestation.”

As has been shown all over Europe, women requesting an abortion after 24 weeks of pregnancy are rare. In Britain, for example, in 2002, of the 175,932 abortions that took place, only 117 were after 24 weeks of pregnancy, that is, 0.06% of the total. (Chief Medical Officer report, 2005) This number and proportion are not unusual. The Chief Medical Officer’s report stated that in 2003, of all the patients seen within the 26 abortion clinics in Catalunya, only 812 patients were foreign (of whom only 14 were from the UK). 98.9% of the abortions on foreigners were at less than 22 weeks of pregnancy. In 3 cases it was in the 24th week and in 5 cases in the 26th week. (Chief Medical Officer’s report, 2005)

What came next, according to an article by the anti-abortion group Religion en Libertad, with information they say came from E-Cristians, would not have taken place without; 1) foreign media involvement, 2) follow-up by anti-abortion groups who kept written records and spent money, 3) the written testimony of a woman who attended the Ginemedex clinic, who was given protected witness status, and 4) a judge and prosecutor who decided to pursue the case “hasta el final” (up to the very end).

In 2007, as part of what became a long investigation, Dr Morín was charged with carrying out “illegal abortions”. He was jailed for two months until a judge ruled that he could be released pending trial, his four Ginemedex clinics were closed, and the clinics’ records, including the personal records of several thousand women, were confiscated for examination. The investigation, including interviews with all the staff and many patients, took six years. In September 2012, the case opened in the Audiencia de Barcelona, a regional court.

Between 2007 and 2012, when the case was finally heard, many other clinics in Spain were also affected. According to one report,[2] there were increased political inspections and administrative and judicial harassment for all abortion clinics and the women patients they cared for, and there was more radical anti-choice activity. Complaints were laid against other abortion providers in registered clinics. One clinic especially suffered “virulent persecution by both anti-abortion groups and by the government itself” for a time, until the situation was clarified.

Some 115 charges of illegal abortion were laid against 12 people, including Dr Morín, his wife (who helped to run his clinics), the psychiatrist Dr Pascual Javier Ramón, and 9 other physicians and nurses. There were hundreds of statements submitted by the prosecution and thousands of pages of judicial and police reports.

According to Religion en Libertad, up to 2012 when the case came to court, E-Cristians had spent 55,000 Euros, including for “extra-judicial actions” and the involvement of lawyers who “knew the terrain” and another 39,000 Euros for other costs (Defiende usted la vida? 2012) [3]

The case concluded with a verdict on 31 January 2013. The verdict was the acquittal of every person charged and on every charge, as reported in El País on 1 February 2013. The court accepted that the abortions were performed “with the consent and at the express request of pregnant women” despite some administrative irregularities. However, both the Prosecutor in the case and the anti-abortion groups who had accused Dr Morín and his staff (E-Cristians, Spanish Alternative, Thomas More Foundation and the College of Physicians of Barcelona) did not accept the verdict and appealed to the Supreme Court. Nine months later, the Supreme Court criticised the Regional Court’s judgement and ordered a re-trial in the Regional Court with different judges. They gave two reasons: first, they argued that the Danish television programme should have been taken in evidence, which the Regional Court had decided against doing. Second, they said that because Dr Morín exercised his right not to testify, the judges did not allow the prosecutor to read out the questions they had prepared to ask him. The Supreme Court thought, however, that these had to be made public and answered, in order to determine, as claimed by the Prosecutor, whether there were contradictions between the pre-trial and the trial evidence.

In March 2015, Dr Morín appealed to the European Court of Human Rights in Strasbourg. Within less than two months, the Court replied that they would not consider the case because the request did not comply with the requisites of admissibility of articles 34 and 35 of the Convention. (CEDH-Lesp11.00R, MMI/MCM/agz, Demanda No.13465/15, letter dated 30 April 2015) The presumption is that he had not exhausted his right of appeal to the very top of the Spanish court system.

The re-trial took place in the Regional Court of Barcelona in January-February 2016. This time, both Dr Morín and Dr Ramón were found guilty and sentenced – not to 390 years or 278 years in prison as the Prosecutor had asked for originally, but to 18 months in prison – and not for over 100 illegal abortions but for 11 illegal abortions. All the other defendants in the case were again acquitted. One could be forgiven for asking whether this new judgement was in fact safe, let alone just.

The final irony, however, is that according to El País of 17 June 2016, the sentence is not firm and can actually be appealed, once again, to the Supreme Court. [4] Thus, it would appear that in Spain, if ultra-religious, anti-abortion NGOs, who have no legal standing, don’t like the verdict of a court of law, the defendants can be tried again in the same court on the same charges by different judges, with different verdicts and opinions on what constitutes evidence, for as long as it pleases the courts to take, and the European Court of Human Rights is prevented by its own rules from considering whether the human rights of the defendants have been and continue to be violated.

A note of thanks to Carlos Morín – I join with Anne-Marie Rey who said on 20 June upon hearing of the verdict: “This latest sentence is a scandal. Thank you, Dr Morín, and all your staff, for all you did for those women! And for your standing up for the right of women to decide for themselves in difficult life situations. I do hope some help is still possible for Dr Morín in return.”

Acknowledgement Thanks to Anne-Marie Rey for providing a wide range of documentation about this history over several years and for her help in preparing this article. Any errors are the author’s alone.

References

An Investigation into the British Pregnancy Advisory Service (BPAS) Response to Requests for Late Abortions. A report by the Chief Medical Officer. Department of Health, September 2005.

Defiende usted la vida? El caso Morín ouede cambiar la historia del abortion…pero requiere dinero. http://www.religionenlibertad.com/articulo_imprimir.asp?idarticulo=22994. 5 June 2012.

Condenado por abortos ilegales un médico absuelto hace tres años, El País, 17 June 2016.

Visit the website of the International Campaign for Women’s Right to Safe Abortion, where this article was first published on 22 June, for the Annex that lists the 34 articles from El País covering this history from 2006 to 2016. The titles and first lines are in Spanish, translated by me, with the help of SDL Free Translation, into English. The articles are in Spanish.

Footnotes

[1] Some might call it attempted entrapment.

[2] Anonymous, personal communication, October 2011.

[3] This is a direct translation from the Spanish.

[4] “La sentencia tampoco es firme y puede ser recurrida, de nuevo, ante el Tribunal Supremo.”

Prof Homa Hoodfar imprisoned in Iran: call for her release (Note: Homa was finally released)

16/06/2016 § Leave a comment

Homa Hoodfar, a respected Canadian-Iranian professor of anthropology of the Middle East in Canada, has been arrested in Tehran, Iran, and is being held in Evin prison without access to her lawyer, family members or to needed medical care.

Full information about her and the campaign in support of her release can be found at: www.homahoodfar.org.

If you are an academic or an author, please consider signing the petition by academics and authors from around the world who are calling for her unconditional release. The petition can be found at: http://www.homahoodfar.org/#!academic-petition/ler5z

The petition, which has already been signed by more than 3,500 academics and authors so far, reports this about her:

“In early March just before her scheduled departure from Iran, the Counter Intelligence Unit of the Iranian Revolutionary Guard raided Prof. Hoodfar’s residence, and confiscated her personal computer, phone, and passports. After summoning her for several long interrogations, just before the Iranian New Year they released her on bail but denied her the right to leave the country. Since then, Prof. Hoodfar has been subject to more than ten grueling interrogations without the presence of a lawyer. Her academic research seems to have been interpreted as a threat to national security on the basis of her comparative research on women’s status, law, development, and the family in different Muslim contexts. After she was called for yet another interrogation on Monday, June 6th, she was incarcerated at the notorious Evin prison in Tehran.

“Prof. Homa Hoodfar had travelled to Iran in February 2016 to visit family as well as to access the archives of the Iranian parliamentary library for an historical book project. Her detention by the Iranian Revolutionary Guard is a clear violation of her right to academic freedom, a right that is also recognized by the Islamic Republic of Iran. For the past three months, the Counter Intelligence Unit of the Iranian Revolutionary Guard has repeatedly sought to build a case against her, with no evidence presented thus far. The authorities have not specified the charges against Prof. Hoodfar. Throughout this entire ordeal Prof. Hoodfar’s health has drastically deteriorated, as she has been increasingly suffering from blackouts. Prof. Hoodfar suffers from a neurological condition (myasthenia gravis-MG) that requires specialized medical care and she suffered a minor stroke last year. Since her detention at Evin prison, where she is currently being held, she has been denied access to medical care and to her medications.

“In addition to her long tenure as Professor of Anthropology at Concordia University since 1991, Prof. Homa Hoodfar is also a member of numerous professional international academic associations. She has published extensively on diverse topics including poverty, development, women’s labour force and political participation, family law, and refugees in many different countries in the Middle East, Canada, and South Asia. She is known for highlighting Muslim women’s ability to realize their rights within an Islamic framework, and for her critique of essentialising Western stereotypes about veiling. It is not clear what charges the Counter Intelligence Unit of the Iranian Revolutionary Guard might bring against her. Any accusations against Prof. Hoodfar are undoubtedly based on a fundamental misinterpretation of the nature of her ethnographic research which has never been a threat to the Iranian regime. Instead, her arrest points to a renewed campaign to target and intimidate other scholars writing about Iran.”

The website suggests a wide range of actions you might take. Many thanks for any support you can give.

 

Interview for Amnesty, 22 August 2015

04/06/2016 § Leave a comment

The following are my answers (with some additions) to questions in an interview with Saphia Crowther of Amnesty International via email, for publication by them last year:

  1.   What drives you to campaign for sexual and reproductive rights? Was there one person, incident or news story that inspired you to become an activist?

I became active in my mid-20s in the second half of the 1970s in the UK National Abortion Campaign because I had an unintended pregnancy from a relationship with someone who did not want to know, and I decided, after a long month of thinking what to do, to have an abortion. This was not long after the 1967 Abortion Act had been passed, and my GP was quite scathing about it and said she was only referring me because I wasn’t married. The ob-gyn who did the abortion came round the room and told each of us he was just going to “pop an IUD in” when he’d finished, and I had to fight not to have that. Luckily the nurse who found me sobbing when I woke up (a common side effect of anaesthesia combined with misery) patted me on the arm and told me that it was my life and I had done what I thought best, and not to feel bad about it. That experience made me an abortion rights advocate for the rest of my life.

  1.    Tell us why access to safe abortion is important. How do restrictions on safe abortion in countries like El Salvador and Ireland impact on women’s equality?

Access to safe abortion is necessary for women because they have sexual relationships with men. While the sex is hopefully wanted, pregnancy as a consequence of it may or may not be either intended, or when it happens, wanted. Moreover, sex is far too often not wanted, particularly among young women, and the data on the extent of sexual abuse of girls is shockingly high. Wanted or unwanted, however, having sex is not a good reason or qualification for having a baby and being a parent. The advent of contraception and safe abortion has allowed us to separate sex from pregnancy, and to choose to have a child(ren) at the point when we definitely want them and are best able to raise them. It has been shown that unwanted children have a more difficult time in life in many ways. It has also been shown that having children by choice is the best way to have children. This is not to say that an unintended pregnancy cannot become a wanted one, it can and sometimes does. Moreover, an initially wanted pregnancy may later become unwanted ‒ due to a serious changed life circumstance, such as illness or divorce, or the baby may be found to have a serious anomaly that the woman/couple feel they cannot cope with.

  1.     How are the situations in Ireland and El Salvador similar? And how do they differ?

They are similar in that in both countries all or almost all abortions are illegal. They are different in that women in Ireland can seek a safe abortion in Britain or another EU country nearby, while in El Salvador, there is nowhere close by to travel to. Hence, in El Salvador there are many unsafe abortions among poor women as they cannot afford to pay for a safe illegal abortion. Furthermore, in El Salvador when women present at a hospital with complications from an unsafe abortion, or even from a miscarriage or stillbirth, they are at risk of being arrested, put on trial for either illegal abortion or homicide, and sent to prison, often for many years. For several years now, there has been an internationally supported campaign to free 17 of those women (Las 17), which Amnesty has been centrally involved in supporting. In fact, we know of women in at least 26 countries who are in prison for having had an abortion.

  1.      You founded the journal Reproductive Health Matters in 1992 to put women’s voices and experiences at the centre of research into sexual and reproductive health. Two decades on, are women still marginalized in discussions and decisions about their reproductive health?

Yes, and particularly in regard to their right to a safe abortion on request.

  1.      Public pressure is crucial to getting legal restrictions on abortion overturned. How have public perceptions of abortion changed in recent decades, and how can people put pressure on those in power?

Across the world the great majority of people support access to safe abortion on at least some grounds, certainly when there is a risk to the woman’s life or health, if the pregnancy resulted from rape or sexual abuse, and in cases of serious fetal anomaly. The numbers who support access to safe abortion at a girl/woman’s request are also very high (with a rising trend) in countries where safe abortion is available, and the numbers are growing in countries that have not yet changed their laws, most of which are leftovers from colonial times. An increasingly vicious anti-abortion movement is trying to turn the clock back everywhere. This is because they believe women should be enslaved by their own fertility and denied autonomy over their own lives, not because they are interested in there being billions more babies in the world. The anti-abortion movement ignores and does nothing for living children in need. People can put pressure on those in power by taking a public stance as part of a movement, through their trades unions, NGOs they work for, and as part of human rights, family planning, maternal health, sexual and reproductive health and rights movements. Or as individuals by writing to their member of parliament and expressing opposition to any attempt to restrict or criminalise abortion.

  1.      What’s been your greatest challenge as an activist? And your greatest success?

Challenge: Finding ways to overcome the differences in views and reach consensus on how to act and what to support among those who are part of the “movement” I am part of, and how to get governmental and inter-governmental support for putting a stop to the violent behaviour and expose the lies of the anti-abortion movement. Success: Publishing a large body of peer-reviewed work and first-class political thinking on the issue of abortion (as well as many other aspects of sexual and reproductive health) through Reproductive Health Matters up to 2015 and being able to promote and share that knowledge as an activist for the right to safe abortion.

  1.      Finally, women’s empowerment and education are vital to upholding their sexual and reproductive rights. Does men’s education also have a role in promoting women’s equality?

Men have 50% of the responsibility for causing unintended pregnancies in wanted sex, and 100% of the responsibility when they force sex on a girl or woman. This is as true among those who sit at the top of governments as among those who use the priesthood to sexually abuse children as among those at every level of the social ladder. There is therefore an ethical imperative on men and boys not to force sex on anyone, to protect themselves as well as their partners against unintended pregnancy, and to support women’s right to safe abortion upon request. This should be a central part of sex and relationships education.

IN MEMORIAM Rosa Tunberg

29/05/2016 § Leave a comment

300

It is with great sadness that I wish to inform everyone who knew her that Rosa Tunberg, who worked for Reproductive Health Matters from  October 1999 to August 2007, died from cancer on 10 January 2015 in California.

Rosa was born on 5 February 1939, in Santiago, Chile, the middle of three sisters. Her father died when she was young. When she was 18, she left Chile with her mother and younger sister to move to Los Angeles CA in the USA. Her older sister stayed in Chile. Rosa studied comparative literature at UCLA and worked at Twentieth Century Fox, where she met Karl Tunberg, a Hollywood screenwriter, whom she married in 1968. She also became a stepmother to her husband’s two children, Terence and Thomas Tunberg. While raising her own two children (Carlos and Victoria) she earned her Montessori Primary Diploma in 1976 and began teaching. In 1978, the family moved to England. Rosa worked at Richmond College outside London for some years. She was widowed in 1992.

In around 1999, Peter Hall, who had been a scientist at the World Health Organization in Geneva, retired, moved to London and started an NGO called the Reproductive Health Alliance Europe. He opened an office for RHAE next door to Reproductive Health Matters in Kentish Town and advertised for a part-time secretary/administrator to manage the office. Peter showed me her CV and before he was even able to interview her, I jumped in and asked if I might interview her as well. Rosa agreed and was duly hired by us both immediately afterwards. Rosa was a bright, cheerful, highly skilled and exceedingly warm-hearted person with a sharp and thoughtful mind. She was able to do everything you might ask for and then some. She helped to promote and publicise the journal, and increase the readership, and worked closely with Paula Hajnal-Konyi, finance manager, and with me. She always had a twinkle in her eye and at the right moments, a witty retort on her lips. She worked unstintingly, expected a lot from others and gave a lot in return.

In 2007, she decided to retire, and she and Carlos moved back to Los Angeles to join Victoria, who had returned to the USA in 2004. Rosa remained active and inquisitive about everything and reconnected with old friends in Los Angeles. The three of them travelled when they could – to Hawaii, Italy, Northern California, Florida. Rosa fought the cancer for three years, and died peacefully and quietly. She remained strong, never showing suffering.

by Victoria Tunberg, her daughter, and Marge Berer

“Just because abortion is easy doesn’t mean it’s right” : do you agree?

26/03/2016 § Leave a comment

During a day of excellent presentations on the question of “How can a state control swallowing?” on medical abortion and the law, organised by Prof Sally Sheldon of Kent University Law School, an unexpected question was asked from the floor, during the session I chaired: “Just because it [abortion] is easy doesn’t mean it’s right: do you agree?”

The questioner did not at that stage state his views but the question sounded, even on the surface, anti-abortion. I decided to respond myself. Of course not, I said. But no matter what aspect of reproductive health we look at, tradition as developed by the law and the medical profession has been to make things as difficult for women as possible. When doing surgical abortions, pain relief is often not offered at all, or too little is offered or too late. When pain relief during labour and delivery was finally developed in the 20th century, many were against it because the Old Testament talks about Eve being punished for her sin by having to suffer pain during labour and delivery. And although contemporary abortion methods, both manual vacuum aspiration and medical abortion, are extremely easy to provide, are very safe, take very little time and are very low tech, they are fenced in with a huge range of barriers and regulations. Gynaecologists in many countries still insist on using D&C, which takes much more time and skills, requires general anaesthetic and an overnight stay in hospital, as well as carrying a higher risk of complications. The fact that WHO has not recommended using D&C for something like two decades makes no difference. In short, things are often made as difficult for women as possible when it comes to pregnancy, and especially when it comes to abortion.

This is the same kind of myth as the one which says: if you make abortion easily available, everyone will want to have one. Thus confusing abortion with ice cream or sweets.

What I should have said, in order to keep the exchange as succinct as possible, was: “It doesn’t make it wrong either…”.

In fact, it’s wonderful for women that abortion has become so easy. Now all we need to do is liberate it from those who will use any means they can find ‒ out-of-date laws, punitive morality, clinically unjustified regulations, and even bald-faced lies ‒ to keep it difficult.

 

Opposing the criminalisation of self-use of abortion pills

14/03/2016 § Leave a comment

More officials in European governments seem to have discovered that women are buying MA pills over the internet and are having abortions outside their health systems. The immediate response to this is that these abortions are or should be “illegal”; indeed, they are illegal under the law in Ireland, the UK and Italy, if not also elsewhere. Two women were charged last year in Northern Ireland and are awaiting trial, three women are in prison in England (two for self-use of MA pills for very late abortions, one for selling them). Italy has just increased the fine for these abortions from €51 to €5,000-10,000. In Ireland the punishment is up to 14 years in prison. Women in the US have also faced criminal charges for this, and a case was heard in Australia as well, though in that instance the couple involved were let off.

Is the abortion rights movement ready for this new form of criminalisation of abortion to spread? I don’t think so, and I think we need to be talking about it quite urgently, especially in Europe.

A recent Guardian article about the extent of conscientious objection to abortion in Italy(http://www.theguardian.com/world/2016/mar/11/italian-gynaecologists-refuse-abortions-miscarriages), misses the point that for more than 90% of abortions, i.e. those in the first trimester, and indeed uncomplicated abortions up to 18-20 weeks, women don’t need a gynaecologist. Care from a trained nurse or midwife or other mid-level provider, with home use in the first trimester and in a day clinic in the second trimester are fine for uncomplicated abortions; WHO recommendations support this. It is primarily women with fetal anomalies and other later and complicated cases who need hospital-based abortion services under a gynaecologist, as these are understood today, and while it is crucial to provide and protect these services, they are not the model for all abortions.

Based on the evidence, we can push this a step further and say that for most women, abortion “services” should be offered mainly by pharmacies, and for the rest the health professionals who become abortion “providers” and the education and training they receive needs to change a lot. Pro-choice gynaecologists should be among those to take the lead in arguing this as they have the standing to be listened to.

We need to start arguing that medical abortion pills are safe enough that they should be as readily available for early abortions as emergency contraception is for the morning after. And we need to be informing women of this because most women probably don’t know it. Not the way we know it.

Do we even have a consensus on these points among ourselves? I’m not sure. But what I hope we all do agree on is that criminalising the self-use of MA pills is happening and must be opposed, and I believe urgently.

Most of the mainstream media articles on women self-inducing abortions quote one official or other that the pills are dangerous if used without the supervision of a health professional. The article about Italy is an example. There is a lot of evidence to the contrary that needs to be shared as widely as possible.

Quinacrine: the non-surgical sterilisation method that refuses to die

16/01/2016 § Leave a comment

A response to all the articles on so-called “permanent contraception” in Contraception 2015;92(2):89-176)

It is with a deep sigh, after more than 10 years, that I sit down to respond to your articles on “permanent contraception”, particularly the one by Jack Lippes pushing quinacrine sterilisation, that dead letter, to the fore once again, in your August journal issue (Contraception 2015;92(2):89-176).

Dr Lippes whitewashes the history of why quinacrine was rejected as a female sterilisation method,[1] rejected not only because of concerns about its carcinogenic potential but for many other reasons as well. Dr Jaime Zipper from Chile, who invented the method, would never be allowed today to get away with the “research” he carried out on women with quinacrine for tubal sterilisation in the absence of any pre-testing of the drug for safety, dosage or efficiacy ‒ before it was ever injected into a single woman. Women were treated like guinea pigs in his and other “research”, and no proper long-term work on safety or optimal dosage was ever completed. Not was the method in fact ever properly approved or registered in any country. There were only a handful of countries where quinacrine sterilisation was ever used, and even in those cases, it was always individual doctors who used it, while others carried suitcases full of quinacrine pellets across borders to share with them, e.g. in a remote rural area of India.

The early high failure rates Dr Lippes reports of 9-12% were indicative of the absence of proper research, since they should have led to a rejection of the method early on. The far lower failure rates shown in the studies in his Table 1 were all from very small studies except for one; most had too short follow-up periods and the findings were never confirmed in larger randomised, controlled studies. The very large study by Dr Do Trong Hieu of Viet Nam, published in the Lancet, in which over 30,000 women were subjected to the procedure, led to the closure of the programme in Viet Nam following a critical analysis of its findings. I was personally involved in creating an outcry about it at that time. (I will return to this below.)

The dismissal by Dr Lippes of the data on cancer risk arising from inflammation in rats, and indeed his whole article, is an example of how the proponents of quinacrine did then and continue to minimise the negative evidence and exaggerate the positive evidence to claim the method is safe.

Dr Lippes’s review of the literature ignores several articles I published in the early days of Reproductive Health Matters (RHM) and one in the BMJ almost ten years later. In 1993 in RHM, Amy Pollack and Charles Carignan[2] examined the same evidence examined in Contraception by Lippes. They noted, for example, that in the Viet Nam paper, 20,000 of the 31,000 women in the total study sample were excluded from follow-up for pregnancy rates, and the finding in one province of 91 pregnancies out of 937 women was also excluded. A year after their article was published, concern was expressed by Ralph Heywood, consultant toxicologist to WHO in 1994,[3] that more research needed to be done to exclude toxicological effects related to mutagenicity, teratology and persistence of the compound in tissues. He recommended that toxicological testing of quinacrine in animals should be done prior to any further clinical trials or any other provision of the method to women.3 Dr Lisa Rarick, the then Medical Officer at USFDA, also raised concerns, given the uncertain failure rate, that a quinacrine failure might increase the risk of ectopic pregnancy.3 Yet despite this published concern, a number of individual doctors continued to promote and perform quinacrine sterilisations ‒ e.g. in rural India and Pakistan. I asked what should be done when consensus views are ignored or rejected by individual providers. The question still holds. A year later, and following a further statement on toxicity and quinacrine by Ralph Heywood,[4] quinacrine sterilisations were still being done in Chile too, led by Dr Jaime Zipper, but challenged by the Foro Abierto de Salud y Derechos Reproductivos (Open Forum for Reproductive Health and Rights).[5] It was this and other feminist activism that led to the decision by WHO not to recommend quinacrine sterilisation of women to be continued, until far more rigorous examination of safety and efficacy was carried out.

But the problem of promotion of untested methods remains with us. In 2004, the BMJ published an article about a “clinical trial” in India evaluating the antibiotic erythromycin as a female sterilisation method,[6] following the ban by India on the use of quinacrine for that use, due to safety and efficacy doubts. Quinacrine’s dwindling supporters were looking for an alternative. They tried erythromycin tablets, which were placed in the upper part of the uterine cavity in 790 women “volunteers”. The failure rate was unacceptably high at 28–35% after 12 months. This “trial” was criticised as illegal and unethical, and highlighted the ease with which unethical clinical trials could still be conducted in India on vulnerable populations by errant doctors.

The FHI360 article was a real eye-opener for me, as it seems they were responsible for the erythromicin study in India, which I do not recall. It is not surprising, however, as FHI was a driving force in this whole history. The history revealed in this article is indicative of the determination not to let this idea go, and even to bring unnamed advocates on board to try and legitimise what could not be justified.[7]

Turning to the other articles on the subject of non-surgical sterilisation in your August edition, I was interested to see how the article by Elizabeth K Harrington et al[8] quietly denigrated the whole idea of surgical sterilisation because it is surgical, in that it requires training and a decent service delivery setting. Is training and a decent service delivery setting still not a reasonable expectation for women in the global South? She is right, not everyone prefers a surgical method. Yet she admits that surgical female sterilisation has not only been shown to be very safe but is also the most widely used fertility control method globally.

Interestingly, none of these articles takes up the alternative of vasectomy ‒ an unfinished job if ever there was one ‒ let alone the idea of a permanent non-surgical male method. Odd that no one has tried inserting quinacrine in men’s nether parts, or is it? The biases may not seem obvious in the absence of a thorough review of the issues, but bias there is indeed among the cluster of authors who populate this whole journal edition.

The comparison I felt was most relevant and most missing in these papers, however, was that between surgical vs. medical abortion, the only existing surgical and non-surgical methods of fertility control. Both these abortion methods are easy to provide in the first trimester of pregnancy, and both have been shown by WHO to be safe for mid-level providers to offer at primary care level, with simple training.[9] Both have advantages as well as disadvantages, but the real value is that women have a choice between them.

My generation put the notion of “choice” in fertility control on the global map and showed that the more and varied methods there were to choose from, the more people were likely to find at least one method that was acceptable and met their needs. Your authors in this edition have quite a different perspective. They want something that will end fertility, and the less likely it is to “fail” or “fail to be used” the better. From this position, Elizabeth Harrington et al3 and Jeffrey Jensen[10] seem to assume that a long-acting method of contraception is always preferable to the others. This has not been shown, nor is it likely to be true ‒ if one asks a large enough number of women and their partners, and especially young people. And in spite of the still rising numbers of people with HIV and other sexually transmitted infections, the importance of condoms seems to have passed these authors by altogether. In fact, both qualitative studies by Elizabeth Harrington et al3,[11] find the demand for safety to be uppermost as a value among study participants. Moreover the preference expressed for a non-surgical sterilisation method is hypothetical and with caveats ‒ and not based on the experience of surgical sterilisation or an actual non-surgical method.

I would also question these authors’ preference for the term “permanent contraception” rather than “sterilisation” and “vasectomy”. Both these surgical methods can be reversed, and although Jeffrey Jensen likes to think women’s fertility intentions fall rigidly into only three categories, there are quite a few people who have opted for sterilisation or vasectomy who have later changed their minds, and for whom reversal methods were consequently developed. To use the term “permanent” belies that availability, and might even put people off. It would certainly mislead them into thinking there is no going back. Perhaps that is what the supporters of quinacrine sterilisation are aiming for. They seem not to have considered that the lack of potential for reversal with quinacrine might greatly decrease its appeal, even among those for whom “something non-surgical” may be preferable. Of course, no one has attempted to reverse a quinacrine sterilisation. Once the fallopian tissue is thus scarred, it is presumably very permanent indeed.

Lastly, I must say that for a journal that publishes first class research on abortion, I was very disappointed to see you allowing remarks about the need for abortion as a sign of failure ‒ whether of contraceptive methods themselves or of the women who choose them. Can we not finally acknowledge contraception as a fallible form of prevention and abortion as a solution when prevention fails? The belief that contraception which never fails is possible is, in my view, a chimera. Moreover, if women were given proper information and unrestricted access to safe abortion methods, most abortions would take place well before 8 weeks LMP, and even (with medical abortion) as early as 35 days of pregnancy (Beverly Winikoff, personal communication, July 2015). Let’s try developing new non-surgical post-fertilisation methods of birth control, for example.[12]

However, whether or not one thinks a non-surgical method of sterilisation would be preferable to a surgical method, quinacrine is not the answer. Let’s re-bury it and keep it buried.

References

[1] Lippes J. Quinacrine sterilization (QS): time for reconsideration. Contraception 2015;92(2):91-95. http://www.sciencedirect.com/science/article/pii/S0010782415002322.

[2] Pollack AE, Carignan C. The use of quinacrine pellets for non-surgical female sterilisation. Reproductive Health Matters 1993;1(2):119-22. http://www.rhm-elsevier.com/article/0968-8080(93)90018-O/pdf

[3] Berer M. The quinacrine controversy one year on. Reproductive Health Matters 1994;2(4):99-106. http://www.rhm-elsevier.com/article/0968-8080(94)90016-7/pdf.

[4] Berer M. The quinacrine controversy continues. Reproductive Health Matters 1995;3(6):142-44. http://www.rhm-elsevier.com/article/0968-8080(95)90169-8/pdf.

[5] Shallat L. Business as usual for quinacrine sterilisation in Chile. Reproductive Health Matters 1995;3(6):144-46. http://www.rhm-elsevier.com/article/0968-8080(95)90170-1/pdf.

[6] Mudur G. Use of antibiotic in contraceptive trial sparks controversy. BMJ 2004;328(7433):188.

Summarised in: Law and Policy Round Up. Reproductive Health Matters 2004;12(24):2111. http://www.rhm-elsevier.com/article/S0968-8080(04)24153-2/pdf.

[7] Katz KR, Nanda K. A nonsurgical permanent contraception stakeholder advisory committee: FHI 360’s experience. Contraception 2015;92(2):139-42. http://www.sciencedirect.com/science/article/pii/S0010782415000384.

[8] Harrington EK et al. Conceptualizing risk and effectiveness: a qualitative study of women’s and providers’ perceptions of nonsurgical female permanent contraception. Contraception 2015;92(2):128-34. http://www.sciencedirect.com/science/article/pii/S0010782415000955.

[9] Health worker roles in providing safe abortion care and post-abortion contraception. Geneva: WHO Department of Reproductive Health and Research; July 2015. http://www.who.int/reproductivehealth/topics/unsafe_abortion/abortion-task-shifting/en/.

[10] Jensen JT. Nonsurgical permanent contraception for women: let’s complete the job. Contraception 2015;92(2):89-90. http://www.sciencedirect.com/science/article/pii/S0010782415002486.

[11] Harrington EK et al. Interest in nonsurgical female permanent contraception among men in Portland, Oregon and eastern Maharashtra, India. Contraception 2015;92(2):135-38. http://www.sciencedirect.com/science/article/pii/S0010782415001006.

[12] Berer M. Compelling arguments for developing new post-fertilisation methods of birth control. Berer Blog. 11 July 2015. https://bererblog.wordpress.com/2015/07/11/compelling-arguments-for-developing-new-post-fertilisation-methods-of-birth-control/.