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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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

Let’s Talk About Intentional Weight Loss and Evidence-Based Medicine

You are a doctor. You are trying to get through a busy clinic day when there is a knock at your office door. It is a pharmaceutical rep. Before you can say anything, he lets himself in, saying, “I’ll only take up a minute of your time, but I just have to tell you about this exciting new weight loss drug. It’s 95% effective at treating obesity in adults.” Sounds good right? Oo, he’s giving away a free pocket knife with the drug’s logo on it. Maybe you do have a minute to spare. You know you have some questions about the study that got this new drug approved.

Pixton_Comic_Pharmaceutical_Rep_Visit_by_Epiphenomena
You start by asking how much weight the study participants lost on average. Turns out it’s about 10% of their body weight in the first year. So women weighing 250 pounds at the start of the study weighed, on average, 225 pounds after a year.

Well ok, so it’s not a cure for obesity, but it still sounds useful. Everyone’s always telling you how small weight loss can have a dramatic effect on health. And besides if you took the drug for five years you could lose 50% of your body weight, right?

Well…the rep tugs at his collar…not exactly. By the end of the second year, people in the study had started to regain the weight. At the end of the study subjects taking the drug weighed, on average, about six pounds less than the control group. In fact, by the end of year five, less than half the subjects had sustained their modest weight loss. Somewhere between 20-80% of subjects (depending on who you counted and how long they stayed in the study) had gained even more weight than they lost.

Ouch. So in the long run this drug could actually hurt more people than it helps? That can’t be right, can it? Still, that’s still a lot of people who are able to sustain weight loss in the long term. Given the terrible consequences of obesity, maybe a small chance at weight loss is worth the risk. Well, actually, now that you think of it, what are the other risks? That is, what are the side effects?

The rep clears his throat and begins to mumble a list. Depression, worsened self-esteem, difficulty concentrating, constant hunger, obsession with food, increased risk of eating disorders. Also bone loss.

But the side effects were rare, right? Was the drug well tolerated? The rep scratches the back of his neck. Actually not so rare. Actually about half of people assigned to take the drug dropped out of the study and no one’s sure what happened to them.

Whoa. That doesn’t sound harmless at all. Still, if it’s a choice between depression and obesity, you know most of your patients will choose depression. So which of your patients might be good candidates for this new drug?  It’s a new treatment, so maybe all of your patients should try it, just in case it works.

But then the rep starts shuffling his feet. He mutters something and you realize that this supposedly new drug is just a reformulation of a drug that has been around for a long, long time. In fact, it’s been around so long that people accept it as dogma that it works, despite its lack of evidence base. It’s extremely popular. In fact, now that you think about it, you don’t have very many obese patients who haven’t tried this drug in one form or another, on and off for most of their lives. Does it really makes sense to make them try the same drug that has failed them so many times?

But you’re not ready to give up yet. What about the control group in this drug study? What about the poor souls who did not even get to try the drug, who were just abandoned to their disease? I mean, whatever the drug’s effects, it can’t be worse than just continuing to live with obesity, can it?

The rep is ready for this. There was a control group in this trial, he is excited to tell you. He is excited, because it turns out the numerous prior studies of this drug rarely have a well-chosen control group, they just compare different formulations of the same drug if they even have a comparison group. But this control group was given no weight loss intervention at all! Instead of being encouraged to lose weight, they were just counseled on their “health” (the rep uses air quotes for this word, as though people like that could even have health). They were given mental health interventions, including learning how to read their body’s cues for hunger and satiety, and support for body image issues. They were encouraged and supported in physical activity, and taught to find ways to move their body that felt good and were sustainable. The rep is giggling now.

So it sounds like the control group must have gained a lot more weight? He stops giggling. Actually no. And how did the two groups compare in terms of other metabolic outcomes like blood pressure and cholesterol? The control group did better. And mental health outcomes? The control group did way better (though the rep whispers But who cares, it’s not like mental health is really health.) And did half of this group drop out too? No, they mostly stayed.

You politely escort the pharmaceutical rep out, thanking him for the pocket knife and accepting his card. He has given you a lot to think about.

Will you recommend the new drug? To anyone? Only to the few people that have never tried it before? How many times should you require your patients to try and fail with this drug before you recommend they stop?

Well friends, by now you see where I’m going with this: the drug in this story is not really a drug invented by some sleazy big pharma boogeyman. It is every weight loss intervention there is. It is Weight Watchers, Jenny Craig, Nutrisystem, the Atkins Diet, the Paleo Diet, the Blood Type Diet, the French Woman’s Diet, the Aerobic Housecleaning Lifestyle, the Grapefruit Diet, the Sugar-Free Diet, the Ice Cream Diet, a sensible low fat diet, and MyPyramid. It is Orlistat (slower regain but more fecal incontinence) and all the other weight loss drugs. It is gastric bypass surgery and lap bands (those probably produce slower regain, but no one really knows because the quality of the evidence is so poor, though it clearly involves greater risk of being hospitalized for things that happen when someone surgically remodels your stomach). The diets, the pills, the surgeries, they all work the same–for the vast majority there will be temporary weight loss followed by weight regain, often at serious cost to mental and physical health.

Please remember this when some recommendation comes out suggesting “treat the weight first” and that all other health problems will have to take a back seat. Remember this when academics are slap-fighting about whether BMI is linked to mortality. None of it actually matters at all to the patients you have today, because existing weight loss interventions don’t work. Even with outcomes for which weight loss could be beneficial, the benefit will be temporary if and when the weight comes back. Quickly or slowly it will come back for all but a very few. The best most people can expect for their pain and suffering is to be about five to ten pounds lighter, and those are the minority for whom the treatment succeeds. It doesn’t matter how big a problem you think obesity is, and it doesn’t matter whether or not you’re right about it, because we do not have any tool that will make obesity go away.

Like the villain in this story, there are a lot of people and a lot of companies who make money off of the promise of weight loss. It’s a great business model; the more the intervention fails, the more money people pour into it. These people and companies have a vested interest in perpetuating the lie that anyone can and should become thin. But medicine doesn’t have to be a part of it.


To any reader who would like an overview of these issues in scientific language rather than in the form of a short story, I highly recommend this review article by Linda Bacon.

Update 1/24/2015: It’s been great to see how much interest this post has generated, and I hope that it will start a lot of productive conversations. Hello and welcome to everyone that’s new here. Out of more than 1,000 visitors that have stopped by in the past 24 hours, only one person has felt the need to leave hostile comments, which I have since deleted. However in the interest of keeping the dialogue constructive I don’t think I can continue to leave comments unmoderated, and since I can’t commit to moderating them in a timely manner I have disabled comments. Thank you to everyone who is contributing to a civil discourse around these complex issues.

Bedbugs: An Especially Disgusting Epidemic, and How to Avoid Catching them at a Hotel

Did you know that the CDC does not consider bedbugs to be a public health threat? Well I’m going to call shenanigans on that one. Bedbugs are parasites, and any parasite that causes this much physical and psychological discomfort to this many people is a public health threat to me. Now is probably the time to issue a Grossness Alert. If you’d prefer not to contemplate insects that live and poop in your bed, emerging at night to suck your blood, this is not the post for you. Perhaps you’d like to pass the time by watching a Tim Minchin video instead. The rest of you, please read on. Continue reading