Wisconsin’s Strange History of State-Sponsored Sterilization

“It would be a rare phenomenon if the progeny of two mentally deficient parents were not likewise deficient. Yet in every state there are hundreds such in the pauper class free to bear children of whom a large percentage are certain to have criminal tendencies, murderous proclivities or vicious social traits. The public expense and private property loss they cause is beyond computation, and their presence at large is a menace that grows with the spreading branches of their family tree. What’s to be done?  ‘Well’, says Mr. John Average Public, ‘Why not try a safe and sane compulsory human sterilization law conservatively administered as in Wisconsin?’”

Frank C. Richmond, State Director of Psychiatric Field Services, 1934

The Law

People tend to be shocked when I tell them that the last state-sponsored sterilization in Wisconsin took place in 1963. It gives one a lot of cognitive dissonance imaging that some surgeon could have performed a coerced salpingectomy one afternoon and then popped over to the cinema to watch The Birds.  But so it was, and the law that permitted such operations actually stayed on the books until 1978. Although estimating the exact number has proven difficult, between 1,500 and 2,000 people were sterilized by the state under the Wisconsin Sterilization Act.

The passage of the act in 1913 was a victory long in the making for proponents of the practice of eugenics.  Wisconsin prided itself on using science to guide state policy, and eugenics was endorsed as science by representatives from the University and beyond. Writing a half-century later, Rudolph J. Vecoli documented in fascinating detail how “the congruity between  the eugenic doctrines and  certain aspects of the Progressive mentality,” including the Wisconsin Idea of connecting university and government, folded neatly into the creation of a law to restrict the freedom of its citizens to reproduce. Nonetheless in the early years of the 20th Century sterilization remained controversial and politically risky.  A law preventing the unfit from marrying had been passed in 1907, but it was unpopular and fated to be overturned in the courts the following year.  In the intervening years, two bills that would have codified state-sponsored sterilization had been defeated in the legislature. The 1913 bill succeeded in part because it was promoted as a conservative approach that would not take the extreme measures that had been seen in other states (then as now, a lot could be achieved in Wisconsin politics with by rallying around shared distaste for Illinois).

EugenicsPoster1926

Education poster from 1926 (source)

Wisconsin was the eleventh state to legalize compulsory sterilization, but it was not the last.  Thirty-two states passed sterilization laws in the 20th century, and five more generated a historical record of involuntary sterilizations without the blessing of the legislature. Wisconsin is an instructive case precisely because it kept the scope of its sterilizations narrow.  While other states defined the unfit broadly or loosely, and some used sterilization as a punishment for criminals and sex offenders (in Oregon men could be castrated for having sex with other men), Wisconsin separated the concept of sterilization from punishment.  The law outlined only three conditions that justified it: epilepsy, insanity, and “mental deficiency.”

Wisconsin’s law represents one of the least extreme cases of government regulation of fertility, and as such it is among the most instructive. In his book Breeding Contempt: The History of Coerced Sterilization in the United States, Mark Largent notes that in historical debates surrounding sterilization, “Even the most aggressive opponents of coerced sterilization often set aside some particularly problematic group for the procedures,” and the same might be said to be true today. People with cognitive disabilities are often made to occupy that role of the particularly problematic group for whom an exception might be made to the concepts of autonomy and the right to reproduce, opening a back door to legitimization of coerced sterilization.  Of the three medical conditions made explicit in the law, mental deficiency provided the rationale for surgery in the overwhelming majority of cases, perhaps because it was the most acceptable.  As it was put by one prominent supporter of the law, University of Wisconsin professor of sociology E.A. Ross, “The wedge should have a very thin end indeed. Sterilization should at first be applied only to extreme cases…As the public become accustomed to it, and it is seen to be salutary and humane, it will be possible gradually to extend its scope until it fills its legitimate sphere of application.” Continue reading

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What I Learned on my OB/GYN Rotation

OB/GYN happened a few months back, but I haven’t blogged about it yet. Area medical student discovers blogging difficult to schedule during third year. Story on page 12. Ahem. Anyway, here are some more lessons learned:
saying-vaginas-could-save-your-life

  1. The human body is freakin’ amazing, and female bodies are amazing in specific ways. I mean, the human ovary, man. This is an organ that ruptures and heals itself once a month for like thirty years. The first time I saw an ovarian cyst removed, I was confused about why we were closing up when the de-cysted ovary still looked like a frittata, but the attending told me, “In a month or two it will have completely remodeled and repaired itself, like you never know we were here.” That’s pretty wild.
  2. I am not a future surgeon. Yeah I could have told you that before, but I am so strongly interested in reproductive health (this is the one rotation during which I actually looked forward to studying for the stupid SHELF exam) that part of me thought maybe, just maybe. I liked my residents, I loved the patient population, I was interested in the diseases, but I just don’t love the OR. I really like to talk to my patients, which is less fulfilling when they’re unconscious. And I can’t get used to the practice of avoiding contamination by resting my hands on an anesthetized patient as though they were a table.
  3. Here is a list of surgery-adjacent activities that are acutely physically painful: Standing for hours, sitting for hours, holding retractors in the same position for hours, keeping ones hands sterile for hours by folding them over ones thorax as though preparing to break into a chorus of How do you Solve a Problem Like Maria?, being the first person awake in your whole neighborhood (mediated by emotional pain). Have I mentioned I’m about to start my surgery rotation?Miranda
  4. Ovarian cancer really sucks. I’ve made a pest of my self on every rotation since OB/GYN trying to get my superiors to test for ovarian cancer in patients who are in the hospital for, say, psychiatric disorders. As you probably know, the biggest challenge is getting a diagnosis early, because the symptoms are not very specific and are often ignored. If you haven’t yet, tell your gal pals, your girlfriends, your wives, your sisters, and your moms over 40(ish), not to ignore digestive, urinary, or abdominal symptoms. Meanwhile I’ll try to work on their doctors (not the OB/GYNs, though, they’re on it).
  5. Spanish skills are in short supply around here (see the photo below, taken in the surgeon’s lounge, of the cup of soup that had been reserved for a chief resident). Because of cost, interpreters were sometimes only requested on the L&D floor when there were at least three Spanish-speaking patients. The thought of going through labor surrounded by people who can’t understand you gives me chills. As far as my education went, having enough Spanish to hang got me a lot of opportunities to work with patients. But I also found out the hard way while rounding on a patient the morning after her c-section that I didn’t know how to say “pass gas”–I racked my brains unsuccessfully for a Spanish translation of “fart,” and finally wound up acting it out. I figure there’s about a 30% chance the patient in question just wanted to see what I would do. IMG_0421
  6. Among OB/GYNs, gender was a weaker predictor of awesomeness than I expected. The only clinician I observed exhibiting true indifference to patients’ comfort was female. There were certainly some male OB/GYNs who truly believed themselves to be the victims of discrimination, and that was, ahem, frustrating. As one of my female colleagues put it–and in order to honor her original wording while preserving this blog’s PG rating I will be making use of the French word for seal–“Oh, they’re at a disadvantage in one field? Boo Phoque3-ing hoo.”  On the other hand, one of my awesomest male colleagues really clicked with this rotation, and I’m psyched about it, because of things like this: When one of the attendings found out he was considering OB, she encouraged him to talk to some of the male doctors about their experience. “Why would I need to do that?” he answered. “I already talked to the female doctors.” Basically a doctor with humility trumps a doctor whose genitals and/or gender identity matches your own.

Six Times Psychiatry was Accurately Represented in TV or Film

This post was brought to you by my psych rotation. I won’t be telling you anything, really, about my experiences on the psych unit, because these are some of the most vulnerable patients in all of medicine and it doesn’t feel appropriate. Media representations of psychiatry, on the other hand, I will talk about all day. It’s been on my mind ever since the morning I got to sit in on some ECT sessions. ECT, if you’re not familiar, is Electroconvulsive Therapy, colloquially called shock treatments, and if you are familiar it’s probably because you’ve had some. Otherwise chances are you’ve been exposed to some wildly inaccurate conceptions of this medical procedure.

I haven’t experienced ECT as a patient, and wouldn’t presume to speak for those who have. As a rule, however, modern ECT is not represented in media from the patient’s perspective, and for good reason: that would be hard to film, and boring, because patients go through this procedure under anesthesia. In fact it’s kind of boring to watch IRL, in the best possible sense. ECT is performed with the patient 1) asleep and 2) medically prevented from having muscle spasms associated with some types of naturally occurring seizure. The patient points their foot, and makes a face (caused by involuntary muscle contractions, not pain, see above asleepness), and that’s the whole show. Well I guess the machine also makes an inoffensive beep to make sure everyone knows the shock is being administered. But there’s just…not much to see. Do these important details come through in the way ECT is represented in, say, Homeland?

HomelandECT

Haha, not likely! No, Homeland wants you to know that mental health treatment not only ruins careers, it looks and sounds like a living nightmare. At least that’s how it seems by the end of Season 1; I stopped watching after that because of this scene. Also because of the more than slightly exploitative approach to its protagonist (as this blogger put it, “It says a lot that for the most part the obsequious wannabe terrorist was a more sympathetic character than the mentally ill woman he was conning”), because of its casual islamophobia, and because it is a major pet peeve of mine when supposedly hardened, CIA-employed characters say nonsarcastic lines like, “My god. You’re in love with him!”

Look ECT isn’t magic, though TBH it can feel that way when a really sick patient who isn’t responding to medications or therapies starts to get better after having this treatment. This isn’t going to be a summary of the evidence base surrounding its use, though please feel free to post one on your own blog. I raise this issue because I think it typifies the representations of psychiatry and mental health care in popular culture. In contrast to the way medical doctor characters are so often written as relatable heroes (Grey’s Anatomy, E.R.), or at worst as lovable scamps even when their behavior is sociopathic (Scrubs, House), our baseline cultural understanding of psychiatry is pretty different. I object to the double standard. There are deep historical reasons for the mistrust between the public and psychiatrists, but yo, there are deep historical reasons to distrust anyone remotely connected to medicine (paging Dr. J. Marion Sims). I don’t believe the double standard is fair or accurate. The stigma attached to mental illness is bad enough–do we have to stigmatize the treatment of those illnesses too?

And so, by way of counteracting the trope of the sadistic power-mad and also just vanilla-mad shrink, I have assembled a collection of representations that I believe give a more realistic picture of psychiatrists. They’re not hero-healers, they’re just folks, and sometimes they help their patients live with incurable and potentially life-ruining diseases. This is list is by no means comprehensive–hello, I’m in medical school, I don’t have time to watch good TV, much less shows I hate like The Sopranos–but let me know if you’d like to do an updated content analysis some day. Here is a link to an out-of-date scholarly analysis if that’s your bag.

Below the jump the entire post is spoilers. Continue reading

What I Learned on my Radiology Rotation

1. Radiologists are, on average, pretty chill, happy people. They also, on average, swear a lot, which relaxes me and frees up the 25% of my mental effort that usually goes toward not dropping F-bombs, for learning.

2. Most kinds of images are not taken by radiologists themselves, they’re done by radiology technicians. I already knew that, but I’d never thought about it before. An experienced and knowledgeable tech makes all the difference in the world. Incidentally it takes them a buttload of time to train, and they’re highly specialized to the kind of images they take. Most of the techs I asked said that good communication with the doctors was everything. Also they would like the doctors to appreciate that some pictures are just really hard to take, and that they are doing their best.

3. Imaging is a consultation, not an order. The x-ray doesn’t spit out an answer; what you get is another doctor’s assessment of the patient’s condition.

4. Therefore, radiologists really, really, really, really, really, want clinicians to provide a clinical history when they order imaging. What they are looking for and how they interpret what they find are both influenced by the patient’s story. You know, like, everything else in medicine. And no, they can’t look it up in the patient’s chart. Another med student on this rotation with me ran the numbers and figured out that if the radiologists at UW took two minutes for each patient to look into their charts, it would add 7 hours to their day.

5. MRA can stand for Magnetic Resonance Angiography. I now plan to imagine the uglier corners of the internet as arteries.

MRA-Kidneys

6. The experience that trained me the best for reading images is taking Art Humanities in college. In case you were looking for another reason why premeds should get a liberal arts education.

7. ALARA, as you may know, stands for As Low as Reasonably Achievable, and it is the principle that guides exposure to radiation from medical imaging (and other things). I checked, and the number of US babies named Alara is on the rise. How many of their parents are radiologists, and how many are teenagers that are into Magic the Gathering? We’ll never know.

AlaraBabies

What I Learned on my Primary Care Rotation

The astute readers among you will have noticed a little change to the header of this blog a few months back. As many of you know I indeed recently finished my PhD, and have returned to medical school, where I have been thrown in with a group of people, some of them 10 years my junior, who have not taken a five-year hiatus from their clinical studies. This afternoon I finished my first of the third-year rotations, the clinical courses in which we are sent out to clinics and hospitals around the state to learn from practicing doctors and try not to get in anyone’s way. I was lucky to be assigned to begin with primary care. Lucky because it is a broad overview which I sorely needed, and lucky because it’s the part of med school I had been waiting for, ever since I started back when Bush II was in office. I got to split my time this summer between a rural family practice clinic, a pediatric clinic here in Madison, and a super-cool nonprofit, and frankly, I loved the whole thing. I started my third year wanting to go into primary care, and nothing that has happened in the past eight weeks has changed my mind. In fact I have quaffed deeply of the primary care kool-aid.

Now, mind you, none of this means I expect a good grade in the course. My performance on my first practical exam of the year can’t really be summarized by one gif alone, but perhaps in combination you’ll get some of the feel of it:

6-Dancing-on-Breads

Titanic

PoopingHippo

Whereas the national board exam was more like:

classic_game_over_screen_by_el_tortuga-d5eeh9l

But in the clinic I was really content. I’m not saying I put my best foot forward with every patient or enjoyed every interaction, cause it’s med school and not The Nexus. Like any other time of my life, the rotation had its highs–like watching a patient and their parent go from “I don’t want to see a med student” to “thank you, that was really helpful.” And it had its lows, like when the earpiece of my stethoscope caught on the hem of my skirt and I accidentally flashed my (male) preceptor–a situation mitigated only by my loyalty to the world’s comfiest and most conservative undies, albeit in flamingo pink.

What I am saying is that I feel more strongly than ever that this is the work I want to do. And I’ve been lucky enough to spend the summer learning from people I really respect, who seem to think I could be good at it some day. I’ve learned a lot in a short time.

So here, in summary, is a list (not exhaustive, thank you very much) of lessons I have learned, and in many cases re-learned, this summer. Some I learned right away, and some I had to mess up repeatedly. Some I didn’t really put together until the rotation was over, and my poor beleaguered preceptors were probably thinking, “How is she not getting this yet?”  Anyway…

  • At this point in my career, my job is to learn how to form an assessment. Even though I’ll pretty much always be wrong.
  • A lot of the job is communication. As much as certain representatives of the medical school have treated my humanities background as an unfortunate handicap, it’s what’s taught me to listen analytically, write, teach, and make an argument. Which is kind of what I do all day now.
  • Before you talk to the patient about anything else, establish the identities of the people they brought with them.
  • My teenage hijinks, though bad decisions at the time, are coming in handy in peds clinic. Apparently, as med students go, I’m hard to shock.
  • I really suck, however, at using tongue depressors. I’ve seen so few oropharynxes that for or all I know 50% of children are born without them.
  • I like working with seniors. The demographic with which I have had the best luck establishing rapport is women over fifty, especially if they are “non-compliant,” and/or believe they are psychic.
  • It is possible for a moth to get stuck inside a human ear canal.
  • Rural medicine is for badasses.
  • With respect to rural populations, my cultural competence has a long way to go. I literally do not understand one sentence on this magazine cover.OutdoorLife
  • It’s on me to recognize the limits of my Spanish. I’m most likely to get in trouble when I’m feeling awkward about making someone repeat themselves.
  • That being said, a lot of patients are pretty stoked to find someone who speaks Spanish at all.
  • People who see the world very differently can be very much in sync when it comes to what they value in medicine
  • A lot of medical students are really excellent people. I have always held my colleagues to a pretty high standard, and sometimes my disappointments have dominated my feelings to the point where I almost forgot just how many fantastic people I had the privilege of knowing in med school. I’ve now met about 20 members of my new class, and I’ve liked all of them. When was the last time you met 20 people in a row in any context and liked them all? I’ve met young people with a lot of wisdom, men who care about women, people who respect their patients not because of some higher calling but just because they basically like people. They’re going to be great doctors.
  • Some doctors are really excellent people, too. My colleagues and myself are in danger of having the compassion ground out of us by a tough and often irrational medical education system, before we ever get out and to practice independently. But I’m beginning to believe most of us will be ok.

Wisconsin’s Abortion Ban is a Bad Idea–No Matter How you Feel about Abortion

We need to talk about the abortion ban that is well on its way to becoming Wisconsin law. People who believe abortion is never justified need to talk about it. People who believe abortion is morally neutral need to talk about it. Most people’s take on abortion is more complex than either of the above, and they most of all need to talk about it. The ethics of abortion are hard, and I respect that different people will give these issues years of careful thought and still come to different conclusions. If we all endorse the adage that good ethics begin with good facts, then we have enough consensus to start a conversation, so let’s begin. If you disagree, then this is probably not the post (or the blog) for you. Perhaps you would like to pass the time instead by reading this heartbreaking classic by the great American poet Lucille Clifton. Clifton knew better than anyone that it would be easier not to talk about abortion. But that’s not good enough. So this is what I have to say.

There is no evidence that banning abortion late in pregnancy leads to fewer abortions. Other states have tried it, and there is no evidence that it worked. For one thing, very few such abortions are performed–as you probably know, they are only about one percent of all abortions in the U.S. As you also probably know, these are mostly abortions performed in response to a medical diagnosis, maternal, fetal, or both. One doctor has publicly speculated that the ban may lead to more abortions as families may not have time to wait to get all the information, and may wind up ending a pregnancy that could have led to a live birth.

These are the stories no one wants to think about. It’s easier to pretend that if you want a baby, and you take the greatest possible care trying to bring your baby into the world, if you believe in the sanctity of life, and try to be a good person and a good mother, that you and your baby will thrive. We could all pretend that no pregnant woman is diagnosed with cancer, that all fetuses develop kidneys and brains, that live-born children with Trisomy 18 don’t suffer in the 48 hours during which 95% of them will die. We could also pretend that these things only happen to people who did something wrong, or who are in some way different from us. Compassion is much harder. What if a few moments’ witness to the pain of a family having to lose the baby they wanted is just too much, and it breaks us?

Some of the figures involved in Wisconsin politics right now are claiming that pregnancy never kills. It’s an easy enough lie to tell, because these scenarios are rare. Most people don’t know anyone who had to end a pregnancy to save their own life, so it’s easy for them to dismiss such stories as abstractions. Not, however, for doctors. Doctors meet the people who are living this nightmare. They have to deliver the news no one ever wants to hear. That’s one of the reasons so many doctors oppose this kind of legislation. It’s one of the reasons why the Wisconsin Medical Society and the American College of Obstetricians and Gynecologists, neither of them known for their fringe political stances, have opposed this bill in Wisconsin. As of this writing the proposed law still contains an exception for cases when carrying a pregnancy to term would kill someone–at least I think it does. The language is pretty vague, and I’m no lawyer.

But the truth is, this is all beside the point. You may think parents should not have the right to make these decisions for any reason, but we can agree to disagree. Likewise you may feel persuaded by the argument that any amount of uncertainty over whether later abortions cause fetal pain means those abortions should not happen, even if the weight of the evidence is against it. That is also beside the point. It’s all beside the point as far as this law goes, because abortion bans don’t work.

What is the purpose of this bill? It pretty clearly won’t end abortions, late or otherwise. Wisconsin women will have to obtain them in other states. To quote this econometrics paper, “The demand for abortion is quite inelastic.” That could never be more true than in the case of late abortions. It should not surprise anyone that the consequences of having to travel for an abortion can be devastating for families living in poverty. As was the case before Roe and now, restrictions on abortion do not apply equally. Money could always get you an abortion, probably even a safe one.

The real purpose of this bill is probably to provoke a ruling in the U.S. Supreme Court. Then the conversation about abortion will change. Most of that conversation will surround the ethics of abortion. And it will be a waste of time. Not because the ethics aren’t important–they are–but because they are moot. Making abortion illegal doesn’t make abortion go away. These attempts tend to backfire. Looking at aggregate data, countries in which abortion is illegal actually have more abortions. The demand for abortion is inelastic. Abortion need not even be illegal to prove that point. Even within my time in medical school, a doctor here in Madison told me about a patient who was flown in from a rural area after she nearly died attempting to give herself an abortion with a knitting needle.

I still believe that it is possible to achieve consensus on abortion in the U.S. No one actually has to change their mind or compromise any ethics in order to achieve this consensus; all we need to do is embrace the practice of evidence-based policy. Cause the evidence suggests making abortion a crime is not going to reduce abortions.  Are you bothered by how many abortions are performed in the U.S. right now? Guess what, me too. Let’s get cracking on preventing unwanted pregnancies. Are you bothered by the idea that someone might feel like they couldn’t continue a wanted pregnancy because of a diagnosis of Down Syndrome? Guess what, me too. How about we get some legislation going that supports families of children with special needs, and makes the deck a tiny fraction less stacked against people living with cognitive disabilities. I would so much rather be working on either of those issues, wouldn’t you?

And let’s not do a few other things. Let’s not make women choose between watching their child suffer and going to prison. Let’s not force women to risk their lives by continuing a pregnancy because they could not prove there was a zero percent chance of survival without an abortion. Let’s not create an underground economy for abortions because they are no longer performed legally by doctors.

On this blog I usually try to make my points with a dose of humor, but I can’t on this one. The truth is I’m profoundly depressed about the state of politics in Wisconsin, and the general unwillingness of the politicians who control all three branches of government right now to use evidence. I’m not utterly clueless. I have a pretty shrewd idea of what’s going to happen with this law. I sure hope it doesn’t lead to more abortions. But it probably will.