24 October 2010

Project Prevention: Beams and Motes

We now have such a crisis…that we ought to give active consideration to paying female drug users to take long-term contraception.”

Ah-ha! You think – another diatribe against Project Prevention.

Sections of the drugs support and treatment community have been up in arms as Barbara Harris came to the UK and used her model of cash incentives to promote long-term contraception and sterilisation for drug users.

Nowhere was this state of high dudgeon more apparent than on the pages of the Wired In community where diatribe after diatribe has appeared. Which is ironic as the quote at the top of this article is not from Project Prevention but from the UK’s own Professor Neil McKeganey in an article from the BBC  in 2004. And Professor McKeganey is also one of the Advisory Board of Wired In.
Despite the Professor’s apparent support for at least some of the measures promoted by Project Prevention, he doesn’t seem keen to step in to the current fray and defend the idea of incentivised long term contraception to Wired In members or the wider public. Conversely, despite McKeganey’s stated views on the subject, Wired In don’t seem to have any problem with him being on their Advisory Board.

There are of course significant differences between the views espoused by McKeganey and Project Prevention. McKeganey drew the line at long term contraception while Harris goes further and promotes these measures and sterilisation. And to my knowledge McKeganey only promoted measures for women, not for men.

Of course he is not the only person to make such proposals in recent times: a Greenock MSP made suggested adding oral contraceptives to methadone .

The approach and measures suggested by Barbara Harris are odious and the promotion and incentivisation of non-reversible or permanent sterilisation, to a client group ill-equipped to make such a fundamental decision, is ethically and morally repugnant. It is right that her appearance in the UK has attracted such a wide range of condemnation.

But mere condemnation of Project Prevention is not, in itself, an adequate response. We need to look at some of the failings of interventions in the UK which have created fertile ground for the sterilisation policies of Project Prevention. The wider social picture is one where drugs users are demonised and denigrated in the media. Judgemental and stigmatising language is routinely used and the type of language and attitude which is now unacceptable when discussing mental health, ethnicity or sexuality is commonplace when considering drug use.

This stigmatisation helps foster a climate where measures that would be unacceptable if
  promoted for any other social group become more acceptable when applied to drug users.

The wider social context is important, but beyond this, the issue of contraception and family planning for drug users in chaos is something that does warrant proper and detailed discussion. It is a serious and sensitive subject, and one of the tragedies of the Project Prevention backlash is that it will be harder to have this discussion now without people resorting to end-arguments like “Hitler” and “Eugenics.”

It is also a subject that has been considered before, most sensibly in the 2003 ACMD report
Hidden Harm, which advocated:

Contraceptive services should be provided through specialist drug agencies including methadone clinics and needle exchanges. Preferably these should be linked to specialist family planning services able to advise on and administer long-acting injectable contraceptives, contraceptive coils and implants.”

This is an eminently sensible proposal – and one that most right-thinking people would have little problem with. A “belts and braces” approach – temporary barrier contraception (i.e. condoms) to address the risk of STDs combined with effective long acting contraception seems like a balanced approach provided that it is undertaken with the patient’s informed consent and there is sufficient consideration for follow up and referral and support in to drug treatment.

But we haven’t really done this properly. Too much contraception is delivered in a half-hearted way – a couple of condoms given out with a bag of needles, the basket of condoms in the reception of a drugs project – rather than a proper assessment and contraception care plan.

If this were done, and were done properly then the number of unplanned and unwanted pregnancies amongst drug users in chaos could be addressed. And by doing so we can demonstrate there is no place for the bribed sterilisation of Project Prevention. Just as badly delivered needle exchange or badly executed drugs education helps create a climate which embraces “just say no” or “abstinence” models so a failure to adequately address family planning with drug users creates a climate which is ready for Project Prevention.

So instead of just sending off angry letters about how wrong Project Prevention is (and it is very wrong) it is equally important that the field engages with a sensible discussion about how to ensure that the contraception – effective and reversible – is made accessible to drug users, especially those in chaos.


Michaela Jones said...

Hi there,

Michaela Jones from Wired In here.

I feel the need to point out a couple of things just for the record. Call me picky - lots of people do!

Professor McKeganey is indeed on the Advisory Board of Wired In which is there to input on the development of Wired In as an organisation.

The Wired In community (which I know is known as Wired In which I admit can be confusing) is just that - a community. And this community reflects the views, ideas and thoughts of its members - not of the Advisory Board.

KFx said...

Thank you for the clarification. Having said that, Professor McKeganey is also a member of the Community. I remain curious as to whether the Professor is prepared to defend his position on incentives for long term contraception. Or, conversely, whether the Wired In community feel his views square with their own and the intolerable aspect of Project Prevention is less the cash incentives to adopt long-term contraception and more the issue of sterilisation.
Please don't get me wrong - I am making no attempt to defend Project Prevention's stance on sterilisation - which I think is morally, legally and ethically indefensible. What do you think of Professor McKeganey's stance?

Anonymous said...

As a needle exchange worker I'd be quite reluctant to even go as far as your suggestions in this piece.

Whilst i am perfectly happy, and support, giving out condoms and sign posting to sexual health (and therefore family planning) clinics, i would feel like i was making a judgment on the clients ability to parent by actively suggesting long term contraception without the client initiating this conversation.

Whilst i agree that some family planning information could be built into assessments, I don't see how you could word it in any way other than suggesting you think that their drug use inherently makes them a bad parent at that time.

As drugs organisations, I feel we need to be aware of the boundaries of our service which i understand is in conflict with your ACMD qoute.

I feel however that encouraging women to access needle exchange and further drug services can be problematic.
To build in judgement around their abilities as a parent could add to stigmatism and stereotypes at the one place they are treated without judgment. This is turn could lead to some women not continuing to access our services.
For clients who all ready have children, bringing up the idea of long term contraception could imply we have active concerns about their current children and might phone social services.

Obviously these would be extreme reactions, but I would imagine realistic ones.

I understand and can empathise with peoples wishes for children not to grow up in what can be chaotic environments, am not advocating for children to be allowed to remain in dangerous situations and also understand (and agree with) the focus of adult services being slanted towards protecting children, sometimes at the cost of the adults long term engagement.

Discussions about long term contraception should be client led however, probably developed over time in 1:1's. It could even be that 'half hearted' attempts at giving out condoms could be the thing that starts that thought process.

Extreme organisations such as Project Prevention love taking extreme examples and portraying them as normality. I feel your article sort of supports some of the beliefs that drug users are inevitably bad parents. As drug service workers we deal with a very small percentage of a large drug using population in the UK and, imo, harmful parents make up a small percentage of this client group.

There are many many awful parents in the UK, the vast majority of them non drug users. It frustrates me that over simplified reporting means that we tend to pick one easy line and run with it, instead of acknowledging that these issues are complex - your article at least goes towards opening that debate out further.

Anonymous said...

To follow on from my earlier post...

I slso get the impression your article suggests that McKeganey is a voice of reason within the drugs work field? And occupys the middle ground between 'drugs worker diatribe' against PP and the extreme views of PP?

If i'm right in my assumptions about the tone of your article, then I'd like to draw your attention to the BBC article you linked to:

"Professor McKeganey also suggested that drug addicts who were already parents could be given a year to kick the habit or face the prospect of having their children put up for adoption."

I've only been a drugs worker for a few years, but have never worked with anyone with views any where near this extreme and would find it hard to believe that they are giving a non judgemental and fair service to any client who has, or is planning to have, children.

I would hope that most Harm Reduction minded drugs workers would completely disagree with this view...and should take any other comments made by him on this subject with this in mind.

Its yet another example of generalising complex arguements and putting our clients down.

KFx said...

Thank you for both your posts, which raise interesting points, although as you would expect I don't agree with them all...

"I also get the impression your article suggests that McKeganey is a voice of reason within the drugs work field?"

Absolutely not - what I wanted to do was highlight the massive outpouring against "Project Prevention" on (for example) Wired In, but the strange silence when it came to Prof McKeganey's views.

As you would expect I did read the whole article on the BBC to which I linked but as the comments on adoption were not verbatim quotes I decided not to use them - I didnt want to risk a misquote. But I agree with you - these views are ones that few drugs workers would feel common cause. Which makes me question why a person holding and stating such views is given credibility by being invited to support organisations such as Wired In, or page space in DDN.

On a different note and in terms of your wider points about stigma, is your problem with longer acting contraception per se, or with how it is introduced, discussed and managed. I think it can be done sensitively, and can be done without stigmatising - dependent on the skills of the worker and the environment in which the discussion takes place. But I don't agree that "Discussions about long term contraception should be client led..." I think the onus is also on workers to bring things to the table again in a sensitive way.

By analogy, if you were working with an injector, would you raise the subject of Hep B vaccination or would you wait for them to raise it. They are already using needle exchange and condoms so have reduced their risks. They've never asked about vaccination. I'd raise the subject and discuss it. Proactively.

Again thanks for your comments. Can I encourage you to post by a real name, not "anonymous."

ed holder said...

My problem is definitly not with long term contraception or the giving of options to people.

I would disagree with your analogy though.

Contracting a blood borne virus is an inherent risk in being an injecting drug user, and one of the main drivers behind a needle exchange to minimise this. Not having a discussion with clients about these risks would mean you're not doing your job properly.

Certainly, if i was speaking to someone i knew sex worked i would probably be interested in their views on long term contraception, but only as becoming pregnant is a risk in their daily life.

I do agree with your point about workers also having a responsibilty to bring difficult subjects to the table, which i know seems to contradict what i've all ready said, but i think we have this responsibility only within the boundaries of our services remit. Otherwise aren't we giving permission for workers to bring their own moral views into the workplace?

Then we start getting into the realms of Kathy Gyngell where "Evidence is over-rated, experience and reason underrated" and we all take a big step backwards.