Q&A: ‘Fighter for the underserved’ sees shifts in family planning access over 60 years

The recent U.S. Supreme Court ruling overturning federal protection for abortion access is just one of several pivotal legal moves affecting access to contraception and infertility care and the right to privacy underpinning this access.

Gary L. Gross, MD, has been a proponent of access to family planning resources for 60 years. In the early 1970s, he worked with members of the Family Planning Consortium of the Commonwealth of Massachusetts to design a model for access to family planning using newly designated federal support for contraception known as Title X. The plan granted funds to Action for Boston Community Development (ABCD), a nongovernmental organization “that was deeply involved in all the aspects of reproductive justice, not just discussing family planning, but making family planning truly safe for families,” Gross told Healio.

Gross served as the medical director of ABCD Family Planning Services from 1981 until his retirement on March 31. ABCD recently awarded Gross its Lifetime Health Access Champion Award in recognition of his dedication.

“We can’t thank Dr. Gross enough for his tireless and outstanding work over the past 40 years to ensure that people in need throughout Boston area low-income communities receive access to the highest quality health services available, making a difference in reducing health care disparities in disadvantaged neighborhoods,” Sharon Scott-Chandler, president and CEO of ABCD, said in a press release. “He is a fighter for the underserved, a hero for the rights of women and families. He played a significant role in bringing Title X family planning services to Massachusetts, he unfailingly advocated for family planning at the state level and he provided consistent and effective leadership to the program.”

Healio spoke with Gross to learn more about the impact he has had on family planning and what obstacles to access still remain today.

Healio: What sparked your interest in working to provide access to family planning services?

Gross: My medical school years were spent at Yale between 1961 and 1965. Then, later on, I was a resident in OB/GYN at Yale during 1966 to 1970. One of my mentors in medical school was C. Lee Buxton, MD, who was the chairman of the department of OB/GYN at Yale. He was the plaintiff U.S. Supreme Court during the 1960s for Poe v. Ullman and Griswold v. Connecticut.

[Buxton] had been an OB/GYN professor at Columbia who could prescribe contraception to his patients in New York. Yet, when he accepted a position as chairman of the OB/GYN department at Yale, he discovered that he could not prescribe contraception to patients in Connecticut. Connecticut had a Comstock law that had been placed on the books by P.T. Barnum in the 1870s that made it a felony for people to either buy, sell, borrow or loan any form of contraception. Uniquely, it also made it a felony to use any form of contraception. That law also stated that any physician who advised people about using contraception or prescribed it was equally guilty of a felony as an accessory.

Because of that, no public clinic in Connecticut — that is, no clinic affiliated with a medical school, nor any clinic affiliated with Planned Parenthood — could prescribe contraception. Private physicians sometimes did, but they did not do it in writing. They called pharmacies to tell them they had prescribed a diaphragm, but they did not write out a prescription. Patients who wanted to purchase any form of contraception in Connecticut would be referred by Planned Parenthood to a clinic in Port Chester, New York, just across the state border to obtain contraceptive devices there.

During the summer of 1964, I was writing my medical school thesis at Yale in the OB department in a little office in the department of OB/GYN. Late in the afternoon or early evening, as Dr. Buxton was leaving his office in the department, he would stop by my little office and talk with me about the need to go home and see my wife and child, and about his role in the contraceptive cases. As a young married medical student in New Haven, where you could not even purchase condoms unless you knew the pharmacist, I had personal experience with how difficult it was to have access to contraception. And so, he imprinted upon me the real importance of making family planning available.

Healio: What has changed in family planning services since you began?

Gross: In the 1970s, it was a new idea that we could provide no-cost access or a sliding scale cost access to contraceptive care to people in underprivileged communities. Middle class individuals could have access to contraception from their private physicians, but it was new that university hospitals, medical school clinics and neighborhood health centers could provide contraceptive care.

In the beginning, we were somewhat hidebound in the more traditional format of patients coming in for an initial visit, undergoing a consultation and a physical examination and laboratory testing, then having to come back for second and third visits before they were actually prescribed a contraceptive method after their physical exam and laboratory evaluation had been completed. In the 50 years since that has transpired, we have moved to simple quick-start contraception, where as soon as individuals present themselves, they are able to gain access to standard birth control pills, patches or rings or have access to long-acting forms of contraception, like implants and IUDs, rather than making multiple visits. Of course, particularly for people in underprivileged communities who have to give up work, have to arrange transportation or have to arrange childcare in order to come to clinics, having one visit that [addresses] all issues provides much greater access to contraception than there used to be.

The other thing, of course, that has happened is we have gone from services that were limited to providing condoms or birth control pills to the provision of long-acting contraceptives, such as contraceptive implants and intrauterine devices that provide long-term effective care. We have seen the medical profession being so enamored with long-acting contraception that the goal seemed to be to prescribe that to everyone before recognizing that it was better to be allowing a lot more patient input in terms of decisions about what method of contraception they choose.

Obamacare has provided insurance coverage for contraception, coverage that did not always exist in the past. The absence of such coverage made some methods out of reach. A lot of things have become much more accessible than they were in the 1970s when I first became the medical director for the family planning programs in Boston.

Healio: What was the social/political environment when you began your work?

Gross: Access to family planning or even family planning information existed only for middle class individuals, and the idea that family planning was not just about contraception, it was also talking about how to deal with infertility, was new in the 1970s. People commonly did not discuss infertility; it was a very private issue. Nowadays, it is an issue that people share all the time on Facebook.

In 1978, I created the first federally funded program in the context of a family planning clinic for providing infertility consultation and treatment in a publicly funded family planning clinic as part of ABCD’s program, and at the same time, I had the wonderful opportunity to take a very small local organization called RESOLVE and enable it to become a national organization that provided consultation and information for couples facing infertility, information that could not be obtained elsewhere in the era before the internet.

Then, of course, the internet made information about infertility and contraception much more readily available. Establishing the right to privacy, the right to choose a means of controlling when and how one will become pregnant has been so important and has done so much.

As I said to Catherine Roraback [who represented Estelle Griswold and C. Lee Buxton in Griswold v. Connecticut] in the year before her death: What had been done with Griswold v. Connecticut made our modern world possible. When I was a college undergraduate or a medical student, women were expected to be nurses, teachers and mothers, and really nothing more. Yet in the 60 years that has transpired since that time, women now have become welcome in all fields of endeavor in America. We now have more women governors, we have more women legislators, both locally and in Congress. We have more women lawyers; we have more women physicians.

When I was a medical student at Yale, there were only five female medical students a medical school class of ‘75, because that is what the admissions office said reflected the applicant pool. Nowadays, more than half of the class in medical school is made up of women, whether you are talking about Yale or Harvard or any medical school here in the United States.

Life has changed so drastically in terms of opportunities for women, and that has led to a greater liberation for men as well. I can never state it quite as well as U.S. Supreme Court Justice William J. Brennan Jr. did, but in the Supreme Court cases that involved contraception in Massachusetts, Brennan made some statement to the effect that it was a cruel and unusual punishment for fornication to either bear or beget a child.

But access to contraceptive care has given all of us so much better control over our futures. The availability of contraception, the right to privacy and the right to decide when, where and how one will bear a child is a major factor in the modern world and in the opportunities for both women and men.

The way we live today is so vastly different from the experience of the 1950s and 1960s when women's roles were so drastically limited. An example of that is what happened to the small college in Virginia called Sweet Briar College, which my wife attended. The board of trustees and the chairman of the board decided about a decade ago that there was no longer a role for a small women’s college because it did not prepare women for roles in the world, and they voted to close down the college. Yet the graduates of that college, who were by that time judges, legislators, lawyers, physicians and CEOs, banded together, sued and won in the Virginia court the right to dismiss that board of trustees and the chairman of the board and to re-open the school. In 60 days, they raised the funds to reopen that college and keep it going nowadays. Those women would have had none of that opportunity to do that 60 years ago when my wife attended college.

Life has changed very drastically as a result of the availability of contraception and reproductive choice and justice.

Healio: What is the proudest moment of your career in family planning?

Gross: Because I had known Lee Buxton, because I was the longtime director of one of the major family planning programs here in the country — the one that ABCD supervised — and probably also in part because of a tangential relationship to Kathy Douglas Stone, the widow of U.S. Supreme Court Justice William O. Douglas who wrote the Supreme Court opinion in Griswold v. Connecticut, I became the medical person most familiar with the legal history leading up to Griswold v. Connecticut. So, I had the honor of being asked to speak at a celebration of the 40th anniversary of the Griswold v. Connecticut decision in Massachusetts and then to go down to Washington for the 40th anniversary celebration.

I met Catherine Roraback, who was truly one of the most remarkable people. She was the first woman to graduate from Yale Law School, she was the first woman to be president of the ACLU, she is the person who wrote the briefs for the Griswold v. Connecticut case as it proceeded through the Connecticut courts, the briefs that were the basis for the brief that was presented in the Supreme Court in the fall of 1964 by Yale law professors. To have the honor of escorting her about all of those 40th anniversary events in Washington was certainly a very proud moment for me.

Also, getting the [Lifetime Health Access Champion] award. To be recognized for all of the years of effort that I put into ABCD and to making their family planning program unique — unique in the number of services provided; unique in its introduction of fertility counseling and early treatment as an integral part of family planning; unique in its recognition of the role of men in family planning; and unique in the constant attendance to the fact that there are those people who seek family planning who do not want to use medical methods, who want to use natural methods and being sure that those methods were always available alongside medical methods.

Healio: What challenges still face access to family planning services?

Gross: One of the aspects of family planning at ABCD has been to provide adolescent care. Adolescents who become sexually active need to know about safe sex, about preventing pregnancy and about preventing sexually transmissible diseases. Providing access and privacy to them has always been an integral issue at ABCD and remains an integral issue nowadays.

In the past, it was somewhat easier to shield that privacy than in the present with the relative availability of electronic records to the parents of adolescents, parents to whom adolescents have not always confided. While it is essential to instruct adolescents that it is important to involve a responsible adult in their family or some responsible adult in many of their major life decisions — certainly about becoming sexually active and using contraception — it is still important for those adolescents who cannot share that information with parents for one reason or another that they have privacy and confidentiality. So, it is an important issue to be able to shield adolescent confidentiality.

It is an important issue to extend outreach so that people that are from underprivileged communities and who often do not necessarily seek medical care will know that it is available at no or low cost to them, so that they can take advantage of it. After all, the way that most families enter into the health care system is when women seek contraceptive advice or come in for prenatal care.

When women come in for care, they then bring their children if they have children and ultimately, they have the opportunity to involve their male partners. That is usually the point of entry into the health care system — women who are seeking advice about reproductive care. It is important that we extend outreach to make them aware, no matter where they stand in the community, about the availability of care. It is a problem that oftentimes, the most publicly acknowledged provider of contraceptive care is Planned Parenthood, a wonderful organization that has certainly over 100 years spearheaded the movement for making a reproductive justice available. Nonetheless, not only are they known as the largest provider of reproductive care, they are also known to the public and to legislators as one of the largest providers of abortion services. In the current climate, the two are often conflated, but abortion services are just a portion of reproductive care. But it's often conflated, both in the media and by certain organizations as being contiguous. Because abortion rights have become endangered, the right to privacy and the right to contraceptive care is also somewhat endangered in this current political environment.

Healio: How does the recent Dobbs decision impact family planning?

Gross: On the one hand, it has removed the overarching protection of Roe v. Wade and the Casey decisions and turns it back to the state legislatures. The state legislatures often still have on the books laws passed between 1870 and 1965 that limit the right to abortion. The right to abortion has certainly become an issue in terms of politics, and in many states, it has been vitiated. Will there be a threat to the right to access to contraception? That is now a question.

Healio: What should be the focus in future work to address obstacles to family planning services?

Gross: Again, it should be made clear it is important to retain the right to bodily autonomy for individuals and that the individual and their physicians or health care providers be able to make decisions about whether or not to continue a pregnancy. But it is far more important to make available contraception to prevent even the very question of how to deal with an unplanned pregnancy coming up. It is truly important that one separate to a certain extent those two issues to be sure that the right to contraception remain secure.

Healio: Is there anything else you would like to add?

Gross: I am old enough to have lived through the world as it existed before 1965, when women and men did not have control over when and how they would procreate, and to have lived for decades in an era where such control was truly available.

It is a little bit frightening to see the fact that it is now somewhat in question compared to how things existed just a year or so ago, when one took it for granted that individuals would have total control over their own decisions about whether or not to become pregnant or to continue with a pregnancy. It is important that we engage in an effort to make sure that we continue to have that freedom to decide about our reproductive futures.

People should plan to have their families at a time that works best for them. People should not have a child when they are not ready to do so. What is far more destructive than not having control over when and how one will procreate is when an unplanned pregnancy results in the birth of a child that is not wanted. That is difficult for the child, it is difficult for the mother, it is difficult for the father. It is not just difficult, it colors all of their life experiences. It has been such a privilege to live in a world from 1965 until just last year when none of that was in question, and it is a little frightening to see that it is in question nowadays.

Also, what is frightening is that so many people who grew up after 1973 when the Roe v. Wade decision became recognized law had taken for granted that all through their lives, the choice [to use all family planning services] was completely available. It still may be available in Massachusetts where I lived for 45 years, it is still available in California where I live now, but it sure is not available in places like Ohio or Texas or in the Deep South.

References:

• ACLU Connecticut. Catherine G. Roraback dies at 87. www.acluct.org/en/press-releases/catherine-roraback-dies. Published Oct. 21, 2007. Accessed Nov. 30, 2022.
• Action for Boston Community Development. ABCD Honors Dr. Gary Gross, with “Lifetime Health Access Champion” Award at November 18 Community Heroes Celebration. Published Nov. 8, 2022. Accessed Nov. 30, 2022.