If we don't stay in the discussion on population and climate change and insist on family planning and reproductive health programs that respect individual rights, what solutions might emerge from people who are unaware about what can happen when population policies and programs are driven purely by demographic targets?
Discussions of global climate
change and environmental degradation are putting "population" back
in the spotlight. Population stabilization has been noted by respected
climate researchers, such as Brian O’Neill and PAI’s Leiwen Jiang, as a potential strategy in the race to keep
carbon in check (although more research is needed to determine how much
it might contribute). Clearly, consumption and emissions in the West
are the major contributors to global warming, but how important is population
to climate change in the short and long term? Does it make any difference
to the atmosphere if the world’s population is six, nine or 12 billion
Work by Brian, Leiwen and other
colleagues shows that the relationship between population and climate
change is complex and that age structure, household composition and
urbanization are important demographic factors, in addition to population
size. Within this complexity, members of our field (broadly defined
as those working on family planning, reproductive health and sexual
and reproductive health and rights) are discussing the pros and cons
of engaging in the discussion on population and climate change.
In her work on developing a
justice framework for addressing population and environment issues,
Laurie Mazur, who is currently editing a book titled Population, Justice
and the Environmental Challenge, has noted that some colleagues,
"even those concerned about the carrying capacity of the planet –
want to silence the talk about population and the environment, for fear
of what it might unleash." She called the space between the
reproductive health and rights and environmental movements "something
of a demilitarized zone."
Some argue that linking population
with climate change should not include discussion of family planning
as part of the solution, for fear of reversing gains made at the 1994 International Conference
on Population and Development in Cairo
towards programming based on a rights framework rather than on a demographic
rationale. This group worries about tendencies towards coercion in setting population targets. In an online discussion of population and climate change conducted by
the webBulletin of the
Atomic Scientists, Betsy Hartmann, director
of Hampshire College’s Population and Development Program, argued that "when population control is the objective,
the quality of [family planning] service suffers and coercive methods
often override freedom of choice." But Suzanne Petroni, Program Officer
at the Summit Foundation, who also cautions about making the population-climate
change connection, notes that "we
must engage the discussion, if only to prevent a return to the days of
coerced sterilizations, forced abortions and two-child per family mandates."
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And others say
that acknowledging the link between population and climate, and the
role family planning can play, won’t automatically lead to coercive policies.
In the Atomic Scientists discussion, John
Guillebaud, emeritus professor at University College, London, and Martin
Desvaux, trustee of the Optimum Population Trust in Britain, wrote that
this argument "perpetuates some infamous myths about people
who have a qualitative concern about human population… [including]
that being concerned about population leads intrinsically to coercion."
This latter group argues that
voluntary family planning is critical to meeting the needs of millions
of women (PDF) who express the desire to space or
limit pregnancy and yet are not using contraception. Meeting this need
for contraception at the individual level, by providing universal access
to family planning and reproductive health (a goal set in Cairo), will
ultimately have a positive effect on population stabilization. Fred
Meyerson, assistant professor at the University of Rhode Island, in
the same online discussion, emphatically states that "stopping emissions
growth and climate change will be unattainable without universal
effective [family planning] programs and population stabilization…" but adds that "There is agreement..about
the need to provide FP/RH…and related education to everyone on
the planet in a non-coercive way."
As someone who has been involved
in population, family planning, reproductive health and sexual reproductive
health and rights work for over two decades, I am in the "let’s
talk about it" camp. We are the ones who know the history of
our field and understand that Cairo reaffirmed the need for voluntary,
rights-based sexual and reproductive health services, including, but
not limited to, family planning.
the ultimate goal is the improvement of the quality of life of present
and future generations, the objective is to facilitate the demographic
transition as soon as possible in countries where there is an imbalance
between demographic rates and social, economic and environmental goals,
while respecting human rights." (Emphasis mine.)
This is language that nearly
180 countries signed on to in Cairo in 1994.
If we don’t stay in the discussion
on population and climate change and insist on family planning and reproductive
health programs that respect individual rights, what solutions might
emerge from people who are unaware about what can happen when population
policies and programs are driven purely by demographic targets?
In a time of great strife, in which those who seek to divide us have a very large platform, I remember that these things are all true:
You can oppose an illegitimate or unnecessary war, and still individually and collectively honor and love the troops that serve.
You can honor and love the troops that serve, but protest the ways in which war is waged and abhor the behavior of individual soldiers who abuse human rights and dehumanize the civilians in a population. You can honor and love and support the troops that serve but still work to change the systems, and hold politicians and individuals responsible for crimes they perpetrate.
You can honor and love any and all public servants—as I do deeply—but still abhor systemic problems in civil services that lead to racist behaviors and outcomes (or those based on class, immigrant status, gender, ability, or any other basis for discrimination).
You can honor, love, and respectpolice, but abhor the militarization of our police forces; racial and ethnic profiling; abuses of fines, fees, and arrests that both target and most adversely affect the poorest individuals; and the growing dependency of the budgets for police forces based on fines drawn from those who can least afford it. You can honor, love, and respect the police, but still understand why there is a great level of distrust of policing in some communities. You can honor, love, and respect the police, but still recognize real abuses of power by individuals or groups among them, and seek to hold those responsible accountable for their actions.
You can honor and love police for putting their lives on the line for public safety, but recognize the very deeply legitimate concerns of movements—like Black Lives Matter, immigrants’ rights groups, women’s rights groups, LGBTQ rights groups, and others for whom policing often is not about public safety, but is itself a source of fear—because law enforcement is and has been too often used against these groups in ways that are disrespectful, demeaning, and sometimes deadly.
You can honor, respect, and love the police, but support the work of Black Lives Matter, immigrants’ rights groups, women’s rights groups, and LGBTQ rights groups, and defend them against blame for the behavior of someone acting in their name who is not actually acting in their name at all.
You can honor and respect the work of prosecutors, judges, and other law enforcement officials, but recognize when the systems in which they are working are not working for the people or to promote justice, or when individuals within those systems operate more on bias than on integrity.
You can protest and advocate for change in any and all of these systems without dishonoring the individuals within them. Indeed, by protesting and seeking to make them better, you make the world better for those within and outside of law enforcement and, hopefully, promote a more universal justice.
You can and we all must honor and treasure the freedoms of speech and of assembly, and abhor violence, while also recognizing that sometimes it is perpetrated by people, like veterans, whose own needs for health care, love, and honor have not been met by the country that sent them to war, or by people who feel so alienated that they—wrongly but nonetheless—resort to violence.
You can be confused by or even irritated by something you don’t understand, but it is on you, not others, to try to understand it. As Proverbs 4:7 says, “The beginning of wisdom is this: Get wisdom. Though it cost all you have, get understanding.” Read, discuss, challenge yourself. Try to open yourself up to what may seem like radical ideas. Make yourself vulnerable to learning. If you don’t understand the movement for Black lives, women’s rights, LGBTQ rights, immigrant rights, then listen to the very people fighting for their rights in order to better understand them. You may have started from a very different place than they do; you may stand in a very different place today. The issues may seem alien at first. But just because you don’t have cancer does not mean cancer does not exist. Try hard to understand why there is distance, what you don’t understand, and what you can—what we all must—do to narrow that distance in understanding each other.
We can love, honor, and respect each other and still recognize and raise awareness of our collective weaknesses. Indeed, that is the essence of progress and of democracy. Don’t fight it. Try to help it along.
People are human and therefore flawed. The systems we create also are therefore often flawed. We need mutual love and respect, along with vigorous debate and sometimes protest, to right the wrongs that are the inevitable result of our flawed selves and our flawed systems.
Love, honor, respect, and accountability: We need them all. Accountability, along with freedom, is the essence of a functioning democracy and part of the struggle for justice. The right to speak, the right to protest, the right to agitate for changes in systems that are flawed because we are all flawed in some way. The right to make things better.
Speaking up, speaking out, changing systems… This is not disrespect or lack of love and support. It is the essence of the struggle for the rights of all people. It is democracy. Some will tell you that in speaking out you are being disrespectful, but the opposite is true. You are respecting the many who have fought and given their lives—and who continue to be placed in harm’s way—on behalf of all of us so that we may all exercise our basic freedoms.
Let’s embrace the struggle. We can love, honor, respect police and other public servants, politicians, soldiers, and ourselves, and still work to hold them and ourselves accountable. These things are all true. I can hold these true simultaneously.
Can we all hold these things true simultaneously? I hope so, because I fear our failure to do so will only result in more violence and hatred.
Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”
Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”
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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.
All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.
Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”
For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.
“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”
“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”
Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.
Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.
“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”
Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”
The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.
In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.
Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.
“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”
Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.
LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
“Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”
In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.
“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”
Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.
“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.
While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.
“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”
The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.
Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.
Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.
“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”
Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.
“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”