AdvancedHistoryCapstoneJournal 2025-2026
ByMadelineMacallister
HEALTHINSURANCE BYPAYCHECK: THEJOBTRAPTHATBUILTUNEQUALACCESSINAMERICA
ByKymanniIsaiahBabb
IntheUnitedStates,healthcarehasneverbeenaguaranteedpublicsystemforeveryone. Instead,accesstocarehasoftendependedonwhethersomeonehasinsuranceandcanobtainit throughstableemployment.Potentialaccesscamefromdecadesofchoicesaboutwhoshould controlmedicine,howsomeone'smedicalcostsshouldbepaid,andhowmuchpowerthefederal governmentshouldhaveinhealthcare.Thosechoiceshelpedexpandcoverageforsome Americans,buttheyalsomadeiteasiertobuildunequalaccessintothesystem.Inthispaper, “unequalaccess”meansthatinsuranceandmedicalcaredependedonjobstability,jobtype,and italsodependedonwhetherhospitalsandmedicalinstitutionswouldprovideequaltreatmentin thefirstplace.Sincejobopportunitieswerenotequalacrossclass,race,andoccupation,a systemtiedtoemploymentexpandedcoverageforsomepeoplewhileleavingotherswithfewer options.
Oneofthemainshiftsinthemedicalscenehappenedbetweenthe1930sandthepostwar decades.Beforethat,therewasnonationalinsurancesystem,andmostpeoplestilldealtwith medicalbillsindividually,whichmadeaccesstocareheavilydependentonincomeandstability. ThentheGreatDepressioncreatedpressurefornewwaystopayforcare,especiallyashospitals neededasteadyincomeandfamiliescouldnotaffordtherisingcosts.DuringWorldWarII,the countryshiftedagain,andwartimelaborandinflationpoliciespushedbenefitsintothe workplace.Overtime,thegrowthofthelabormovementandthetaxcodehelped employer-sponsoredcoverageexpandevenfaster,whichiswhyjob-linkedinsurancebecamethe
normratherthanauniversalprogram.1 Thatshiftmatteredbecauseitsetupthesameproblemthe reformersweretryingtosolve:medicalcostswererising,buttheabilitytopayforthecostswas uneven,whichmadeaccessdependonstabilityratherthanactualneed.
Asmedicalcarehasbecomemoreexpensive,familieshavenotdealtwiththosecosts evenly.Somepeoplecouldhandleanunexpectedbill,butmanycouldnot,whichmadeithard forfamiliestoplanyeartoyear.In Medical Care for the American People,theU.S.Department ofHealth,Education,andWelfarecommitteeexplainsthatmedicalcostswereunequally distributedacrosshouseholdsandthatlower-incomefamiliesoftenpaidtoolittletoreceive adequatemedicalcare.Becauseofthis,thecommitteesupportedpayingforcarethrougha broadersystem,suchascommunity-basedgrouppayments,andtheyalsodiscussedtaxationasa waytospreadcostsacrossalargerpopulationtomakecaremoreaffordableandpredictable. 2 By theendoftheGreatDepression,thispatternwasclear:whenmedicalcostswereunpredictable anddependedonwhatadoctorcharged,familieswithfinancialstabilityhadgreateraccessto care,whileothersdelayedorwentwithoutcare.
DuringtheGreatDepression,hospitalswerehithardbecausefewerpatientscouldpay, receiptsdropped,andcharitycareincreased,promptinghospitalstoseekmorestablewaystoget paidthroughearlyhospitalserviceplans.3 Onemajorchangeinthe1930swasthegrowthof privateprepaymentplansconnectedtohospitals,includingearlyBlueCross-styleplans.Louis Reeddescribeshowcitiescreatedhospitalserviceplansthatofferedgrouphospitalizationtothe public.HeexplainsthatinJuly1933,voluntaryhospitalsinSt.Paul,Minnesota,offeredgroup hospitalizationandhelpedcreatetheBlueCrosssymbol.Healsodescribessimilarlocalplansin
1 MichaelA Morrissey,“HistoryofHealthInsuranceintheUnitedStates,”in Health Insurance,2nded (Chicago:HealthAdministrationPress,2013),1
2 CommitteeontheCostofMedicalCare, Medical Care for the American People: The Final Report of the Committee on the Cost of Medical Care (Chicago:UniversityofChicagoPress,1932),120–21,149–50
3 Morrissey,“HistoryofHealthInsurance,”6
placeslikeNewJersey,Durham,andNewOrleansintheearly1930s.4 Theseplansshowthat privatesystemswerealreadyfillinggapsthatnationalpolicycouldhavefilled,andtheywere doingsothroughvoluntaryprogramsbuiltaroundhospitalsandlocalorganizations.
Eventhoughtheseearlyplansexplainwhatwashappeningontheground,historianshelp explainwhytheUnitedStatesmovedtowardprivate,job-linkedcoverageinsteadofbuildinga universalpublicsystem.TwokeyworksthatshapethisexplanationarePaulStarr’s The Social Transformation of American Medicine andJenniferKlein’s For All These Rights.PaulStarr arguesthatthestructureofAmericanhealthcarewasshapedasmuchbypowerasbymedical progress.Inhisview,doctorsbuiltstrongprofessionalauthorityintheearlytwentiethcenturyby controllingtraining,licensing,andtheorganizationofmedicalpractice.5 Oncephysicianshad thatauthority,itbecamepowerbecauseitwasbuiltintoinstitutionsandcouldshapewhatkinds ofreformswereevenconsideredacceptable.6 Starrarguesthatmedicalauthoritydidnotstay cultural;itbecamecontroloverorganizationsandgovernmentpolicy,whichmadeiteasierfor physicianstoresistreformsthatwouldexpandstateinvolvementinmedicine.Heexplainsthat doctorstriedtokeepthegovernmentfromcompetingwithprivatepractice,confiningpublic medicalservicestothepoor,andpreventingcrucialhealthinsurance.7
JenniferKleinaddsanotherkeypiecebyshowinghowsocialbenefitsintheUnited Statesoftenexpandedthroughemploymentratherthanthroughuniversalgovernmentprograms. In For All These Rights,Kleinexplainshowlabor,employers,andgovernmentpolicyshapeda systeminwhichbenefitslikehealthcoveragearetiedtowork,helpingsomeworkersgain securitybutleavingoutpeoplewithoutstableorgoodjobs.Sheshowsthatthiswasnotjusta
4 LouisS Reed, Blue Cross and Medical Service Plans (Washington,DC:FederalSecurityAgency,US PublicHealthService,October1947),10–12.
5 PaulStarr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (NewYork:BasicBooks,1982),19-20.
6 Starr, The Social Transformation of American Medicine, 9
7 Starr, The Social Transformation of American Medicine, 28
randomoutcome;itwasapoliticalandeconomicchoicethatbecamenormalbecauseitwas easiertoexpandbenefitsthroughworkplacesthanthroughasinglenationalprogram.Herpoint isthattheworkplaceroutewaseasierbecauseitletbenefitsgrowthroughprivatedecisionsand bargaining,notthroughonebigfederalchoicethatwouldhaveneededhugepoliticalagreement. Employersandinsurancecompaniescouldkeepmorecontrolifbenefitsstayedtiedtojobs,and thegovernmentcouldsupportthatsystemwithoutfullytakingresponsibilityforhealthcareasa universalright.Soinsteadofbuildingonepublicsystemthatincludedeveryone,theU.S. normalizedasystemwheresecuritydependedonemployment,whichmadeinequalityeasierto buildinfromthestart.8 LargentandReynoldsarguethatunequalaccesswasreinforcedinside medicalinstitutions,notjustthroughinsurance. EmilyLargentexplainsthathospitalsegregation shapedwhocouldbeadmitted,wherepatientswereplaced,andwhetherBlackdoctorscould gainprivileges,meaningaccesscouldbeblockedevenwhensomeonehadcoverage.9 Reynolds thenshowshowfederalenforcementthroughTitleVIandMedicarebecameoneoftheonly wayshospitalswereforcedtochange.10
Risingmedicalcostsintheearly1930screateddemandforreform,andprivateplans expandedashospitalsandcommunitieslookedforstablewaystopayforcare.11 By1933,Blue Cross-stylehospitalplanswerealreadyformingindifferentcitiesthroughvoluntaryhospital serviceprograms.12 DuringWorldWarII,wagecontrolsbeginningin1942andlaborshortages pushedemployerstoofferbenefits,andemployer-sponsoredhealthinsurancegrewquicklyinthe
8 JenniferKlein, For All These Rights: Business, Labor, and the Shaping of America’s Public-Private Welfare State (Princeton,NJ:PrincetonUniversityPress,2003),2–4.
9 EmilyA Largent,“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation,” Public Health Reports 133,no.6(2018):716,accessedMarch4,2026, https://pmcncbinlmnihgov/articles/PMC6225869/pdf/101177 0033354918795891pdf
10 P PrestonReynolds,“TheFederalGovernment’sUseofTitleVIandMedicaretoRaciallyIntegrate HospitalsintheUnitedStates,1963through1967,” American Journal of Public Health 87,no 11(1997): 1850,1853-54,1856,accessedMarch4,2026,https://ajphaphapublicationsorg/doi/epdf/102105/AJPH87111850
11 Morrissey,“HistoryofHealthInsurance,”6.
12 Reed, Blue Cross and Medical Service Plans,10–12
1940s.13 Afterthewar,thetaxexclusionwasreinforcedandclarifiedin1954withtheInternal RevenueCode,whichhelpedlockjob-basedinsuranceintotheworkplace.14 Overtime,those privatesystemsbecametiedtoemployment,socoverageexpandedfastestforpeopleinstable, benefit-payingjobs.Federalpolicyencouragedthatroute,andorganizedmedicinehelpedblock nationalhealthinsurance,sotheUnitedStatesbuiltjob-basedcoverageinsteadofauniversal publicprogram.Thesechoicescreatedasystemthatexpandedcoveragethroughemployment, whilestillleavingunequalaccessinplacethroughworkandmedicalinstitutions.
ThispaperfirstexplainshowWorldWarIIwagecontrolsandlatertaxpolicypushed healthinsuranceintotheworkplace,makingemployercoveragetheeasiestwaytoexpand insurance.Next,itshowswhynationalhealthinsurancekeptfailingpolitically,includinghow groupsliketheAMAused“freedom”and“socializedmedicine”messagingtoblockstronger federalprograms.Finally,itshowsthatunequalaccesswasreinforcednotonlythroughthelabor forcebutalsothroughmedicalinstitutions,includingsegregatedhospitalsandunequaltreatment thatlimitedcareevenforinsuredpatients.
WorldWarIIwagecontrolspushedemployerstocompetebyofferingbenefits,sohealth insurancespreadthroughworkplacesratherthanthroughgovernmentprograms.In1942,the federalgovernmenttriedtocontrolinflationwithwageandpricerestrictions,butthewar economyalsocreatedlaborshortagesandintensecompetitionforworkers.Sinceemployers couldnotalwaysraisewagestoattractandretainemployees,theNationalWarLaborBoard
13 KarlRhodes,“FromLoopholetoMandate,” Econ Focus (FederalReserveBankofRichmond),First Quarter2014,31,accessedMarch4,2026, https://wwwrichmondfedorg/-/media/RichmondFedOrg/publications/research/econ focus/2014/q1/pdf/economic h istorypdf
14 UnitedStates, Internal Revenue Code of 1954,Pub.L.83–591,68AStat.3(1954),sec.106,32,accessed March4,2026,https://wwwgovinfogov/content/pkg/STATUTE-68/pdf/STATUTE-68A-Pg1pdf
allowedtheexpansionoffringebenefits,includingemployer-sponsoredhealthinsurance,which grewintheworkplaceduringthe1940sratherthanbecomingauniversalpublicprogram.15
Whenwageswerelimited,employersstillneededawaytoattractandkeepworkers, especiallyinlabormarkets.Thatmadefringebenefitsfeelliketheloopholethatwasallowed, andithelpedsetthedirectiontowardjob-basedinsurance.Onereasonfringebenefitsmattered duringthisperiodisthattheycouldbeseenaslessinflationarythanrisingcashwages.Inthe BureauofLaborStatisticsoverview,Schumannexplainsthatfringebenefitsweretreatedas noninflationarybecausetheywerenotpaidincash,sothelimitwasnotbroken.Schumannalso notesthatinthelate1940s,thesebenefitsbecamemorecommonthroughnegotiationsover workers'contracts.Theideaoffringebenefitsspreadbecauseunionsandemployersstarted treatingthemaspartofcompensation.16
Atthesametime,wage-controlpolicywasnotjusthappeninginthebackground.It shapedwhatwascountedaswagesinthefirstplace.InHelms’spaper,hediscusseswartime wageandsalaryregulationsthattreatedinsuranceandpensionbenefitsdifferentlyfromsalary, essentiallysayingthatifabenefitwasconsideredreasonable,itwasnotcountedunder wage-controlrules.Thatshowshowbenefitscouldgrowevenwhendirectwageincreaseswere capped,whichmadetheemployer-basedroutemoreattractivethanpushingforanational programinthemiddleofawar.17 Employersbenefitedbecausethisallowedthemtocompetefor workerswithoutraisingwagesandtoshapewhogotcoverage.Workersinstrongindustriesand unionsgainedaccessfirst,whilepeopleoutsidestable,benefit-payingjobshadfeweroptions.
15 Rhodes,“FromLoopholetoMandate,”31
16 RichardSchumann,“CompensationfromWorldWarIIthroughtheGreatSociety,” Compensation and Working Conditions (Fall2001):1–2,accessedMarch4,2026, https://wwwblsgov/opub/mlr/cwc/compensation-from-world-war-ii-through-the-great-societypdf
17 RobertB Helms,“TaxPolicyandtheHistoryoftheHealthInsuranceIndustry”(Washington,DC: AmericanEnterpriseInstitute,2008),7,accessedMarch4,2026, https://wwwaeiorg/wp-content/uploads/2011/10/healthconference-helmspdf
Youcanalsoseetheshifttowardjob-basedcoverageinthegrowthofBlueCross-style hospitalplansduringandrightafterthewar.Reedexplainsthatsince1943,employer participationinservicebenefitsgrewrapidly,andbyearly1947,thesebenefitswerecommonin unions,withemployerspayingallhealthcarecosts.Reedalsonotesthatthesebenefitswereoften usedasleverageinunionbargaining,showinghowlabor-marketpowershapedwhoreceived coveragefirst18
Thisisalsowhereraceandclassshowupinrealways,notjustasabstractideas.Since benefitsspreadfastestthroughstableindustrialanddefenseworkwherebargainingpower existed,accessdependedonwhetherpeoplecouldgetintothosejobsinthefirstplace.ButBlack workersindefenseindustriesstillfaceddiscriminationandunequaltreatment,evenafter ExecutiveOrder8802formallybanneddiscriminationindefenseemployment,meaningthewar economydidnotcreateequalaccesstothebestjobsandopportunities.19 Atthesametime,the wareconomydidcreaterealgainsforsomeBlackworkers,especiallyBlackwomen.Baileyand Collinsshowthatinthe1940s,Blackwomen’saveragerealweeklywagesnearlydoubled,and thewagegapbetweenBlackandwhitewomennarrowedbyabout15percentagepoints.20 Thatis arealbenefitofwartimelabordemand.ButBaileyandCollinsalsoshowthatthesegainsstill happenedinsideanunequallabormarket,whereBlackwomenwereheavilyconcentratedin serviceworkandpatternsoflabormarketdiscriminationthatlastedbeyondjustthebetter conditionsofWorldWarII.21 Soevenasjob-basedcoverageexpanded,itexpandedunevenly,
18 Reed, Blue Cross and Medical Service Plans,64–65
19 FrankMcGriggs,“StrengtheningAmericaatHome:BlackWorkersinWWII,” U S Department of Labor Blog,February23,2024,accessedMarch4,2026, https://blogdolgov/2024/02/23/strengthening-america-at-home-black-workers-in-wwii
20 Bailey,MarthaJ,andWilliamJ Collins,“TheWageGainsofAfrican-AmericanWomeninthe1940s,” NBERWorkingPaperNo 10621(June2004),1,accessedApril8,2026 https://www.nber.org/system/files/working papers/w10621/revisions/w10621.rev0.pdf
21 BaileyandCollins,“TheWageGainsofBlackWomeninthe1940s,”3-4
becauseaccessstilldependedonwhocouldreachthemoststablejobswherebenefitswere negotiated.
Atthispoint,theissueisnotjustthatemployersstartedofferinginsurance.Itiswartime laborpolicy,andlaborshortagesmadetheworkplacetheeasiestplaceforhealthcoverageto grow,eventhoughworkitselfwasnotdistributedequallyacrossraceandclass.Thatiswhat makesthismomentmorecomplicatedthanjust“coverageexpanded.”Thesystemdidexpand, butitexpandedthroughbargainingpowerandjobstabilityratherthanthroughauniversalright tocare.Wartimepolicypracticallysolvedtheproblemofaccessforsomeworkerswhilealso makinginequalitypartofthestructure,becausethejobsthatopenedthedoortoinsurancewere notequallyavailabletoeveryone.Thatselectiveexpansionmatteredlaterbecauseonce insurancewasalreadygrowingthroughemployment,itbecameeasierforpolicymakersto supporttheemployerroutethantoreplaceitwithamoredifficultpublicsystem.Afterthewar, taxpolicydidnotcreatethatpathfromnothing.Itreinforcedapatternthatwartimelabor conditionshadalreadyhelpednormalize.
Thatwartimeshiftdidnotstaytemporary.AfterWorldWarIIended,employer-based insurancecontinuedtogrowbecausefederaltaxpolicymadeitthebestdealforbothemployers andmanyworkers,comparedtosimplyraisingwages.Morrisseyexplainsthatthefederaltax codewasoriginallysilentonwhetheremployer-sponsoredhealthinsurancewastaxableincome, butin1943,theIRSruledthatemployer-providedhealthinsurancebenefitswerenotsubjectto federalincometaxation.Healsoexplainsthatcontradictoryandinconsistentrulingspersisted throughthe1940sandearly1950s,promptingCongresstostepin.In1954,Congresspassed legislationthatexemptedemployer-sponsoredhealthinsurancefromfederalincometaxation,
whichmadetheemployerroutemorepermanentandhardertoreplacewithauniversal program.22
YoucanseethislawintheInternalRevenueCodeitself.Inthe1954code,Section106 statesthat“grossincomedoesnotincludecontributionsbytheemployertoaccidentorhealth plans”foremployees.23 Thisshowsthatemployer-paidhealthinsurancebecomesabenefitfor workers,astheydonotpayincometaxonit,unlikewages.Oncethatbecomesthenorm, employershaveabuilt-inincentivetooffermoreinsurancebenefitsratherthanraisewages,and workershaveanincentivetoacceptthem,astheybenefitthemandtheirfamilies.
Helmshelpsexplainhowthispolicyaffectsrealpeopleandwhyitconnectsdirectlyto classinequality Heexplainsthatthetaxexclusionworkslikeagovernment-fundeddiscount, andthehigheraperson’smarginaltaxrate,whichishowmuchyourlastdollaristaxed; distinguishingyourbracketofwealth,thebiggerthediscountbecomes.Becauseofthat,an employeewouldratherspendadditionaldollarsonhealthinsurancethanraisetheirwage,since wagesaretaxedandhealthbenefitsarenot.24 Helmsthentalksabouthowthisfunctioncreatesa largerevenuelossandthatitdistributestaxreductionsregressively,meaningthebenefitis focusedtowardhigherearnerswhogetmorevaluefromataxbreakthantheirwagesbeing raised,provingtheinequalityinthissystem.25 Soeventhoughemployerinsuranceexpands coverage,thetaxsystemmakesitexpandinawaythatrewardspeoplewithhigherincomesand morestablejobscomparedtoself-employedartists,entrepreneurs,andpeopleinsmallfirms.
Thisalsoconnectsbacktorace,asaccesstostable,higher-payingjobswasunequal.If employmentopportunitiesareunequal,thenasystemthattiesinsurancetoemploymentwill
22 Morrissey,“HistoryofHealthInsurance,”11–12
23 UnitedStates, Internal Revenue Code of 1954,Pub L 83–591,68AStat 3(1954),sec 106,32
24 Helms,“TaxPolicyandtheHistoryoftheHealthInsuranceIndustry,”18.
25 Helms,“TaxPolicyandtheHistoryoftheHealthInsuranceIndustry,”18
distributecoverageandtaxadvantagesunevenlyaswell.Section106oftheInternalRevenue
Codedidnotrewardpeoplesimplybecausetheyneededcare.Itrewardedemployer contributionstoemployeehealthplans,whichmeantthestrongesttaxadvantageswenttopeople alreadyinsideastableemploymentscenario.Atthesametime,Helmsshowsthatthevalueof thattaxbreakrosewithincome,sothepolicydidnotjustexpandemployerinsurance.It expandeditinawaythatgavethebiggestfinancialadvantagetoworkerswithstrongerwages, stablejobs,andemployersabletoprovidecoverageinthefirstplace.Thatiswhythepostwar taxexclusionhelpedlockinasystemthatgavethebiggestbenefitstothegroupsmostlikelyto holdstablejobs,whichonlywidenedthegapsthatalreadyexisted.
AfterWorldWarII,nationalhealthinsurancemovedfrombeingabroadreformideato beingadirectfederalproposal.InNovember1945,PresidentHarryS.Trumanformallysent Congressa‘SpecialMessage’recommendinganationalhealthprogram,whichmadehealthcare reformanexplicitnationalpolicyquestionratherthanjustanidea.Heframesitasaproblem affectingeverydaypeople,notjusthospitalsordoctors.Hepointstoservicemedicalexamsand arguesthatthecountryhadaserioushealthproblemthatwaslimitingworkingcapacityand shorteninglives.Healsosaysaccesstomodernmedicalcarewasunequal,andthatlowand moderate-incomefamilies,ruralcommunities,andBlackAmericansdidnotreceivethesame qualityoramountofcare.Truman’spointisthathealthsecurityshouldapplyregardlessof residence,station,orrace,andthatpeopleshouldnotfaceeconomicdisasterjustbecausethey getsick.26 ThismatteredbecauseTrumanwasturningunequalaccesstocareintoafederal politicalissue,notjustaprivatemedicalprogram.
26 HarryS Truman,“SpecialMessagetotheCongressRecommendingaComprehensiveHealthProgram,” November19,1945,HarryS TrumanLibrary&Museum,accessedMarch4,2026, https://www.trumanlibrary.gov/library/public-papers/192/special-message-congress-recommending-comprehensivehealth-program
27
Truman’splanwasalsodesignedtoremovethemainbarrierhekeepscomingbackto: cost.Hearguesthatpeopledelaycallingadoctorbecausetheyfeartheexpense,andthatpaying forcareonanindividualbasisatthetimetheyneeditisthereasonpeopledonotgetthecare theyneed.Hissolutionisbasicallyarequiredprepaymentthroughanationalpoolbuiltonthe existingsocialinsurancesystem.Heemphasizesthatthegoalistospreadrisksothatsickness costsarenotborneonlybythosewhogetsick.Healsoanticipatesapoliticalattackandsays directlythatrequiredprepaymentisnot“socializedmedicine,”becausepatientswouldstill choosetheirowndoctorsandhospitals,anddoctorswouldnotbecomegovernmentemployees.
Evenwiththatframing,theproposalranstraightintopowerfulresistanceandthepolitics ofthemoment.Morrisseyexplainsthat,asWorldWarIIwascomingtoanend,Trumanbegan workingonanationalhealthinsuranceplanthatwouldcoverallAmericansandbefinanced througha4percentpayrolltaxonthefirst$3,600ofwagesandsalaries.Morrisseyalsoexplains thatTrumanargueditwasnotsocializedmedicineforthesamereasontheAMAemphasized. ButthatdidnotweakenoppositiontoTruman’sidea.Physicianoppositionremainedstrong becauseTruman’splandidnotjustproposemorecoverage.Italsothreatenedtheprivate structureofAmericanmedicinebyincreasingfederalresponsibilityforhealthcare.Insteadof supportinganationalsystem,theAMAandtheAmericanHospitalAssociationdefended hospitalindependenceandprofessionalcontrol,whichhelpedkeephealthcaretiedtoprivate institutionsratherthanturningitintoabroaderpublicguarantee.28
PoliticsinCongressalsomadethetimingharder.AlsanandNeberaiexplainthat Truman’s1945addresswasamajormomentfornationalhealthinsurance,butsoonafter, RepublicansgainedcontrolofCongressinthe1946midtermelections,makingitmuchless
27 Truman,“SpecialMessagetotheCongressRecommendingaComprehensiveHealthProgram.”
28 Morrissey,“HistoryofHealthInsurance,”15
likelythatTrumancouldpasssweepinglegislation.Theyalsostatethatafter1945,theAMA HouseofDelegatespushedstateandlocalmedicalsocietiestodeveloptheirownprivateplansas promptlyaspossible,whichshowsorganizedmedicinewasactivelybuildingacaseagainstthe ideaofanationalsystem.29 Thiscanbeseenasaturningpoint;Trumanlaysoutanational argumentforhealthsecurityanddirectlyconnectsittoinequalitybyincome,geography,and race.Butbythispoint,organizedmedicinehadboththemotiveandpowertofightnational insurance,andthepostwarpoliticalenvironmentmadeiteasiertostallfederalchangethanto buildit.Thenationalplandidnotjustfailquietly.Itwasattackedinawaythatturnedthedebate intoafightover“freedom,”“governmentcontrol,”and“socializedmedicine,”drivenbypostwar fears.
Thatoppositiondidnotstaypassive.Truman’sproposalfornationalhealthinsurance facedastrategiccampaignthatshiftedthedebate,sothepubliccametofearnationalhealth insuranceratherthanseeitasaformofprotection.Insteadoffocusingonunequalaccess, medicalcosts,orthepeopleTrumanarguedwerebeingleftbehind,thedebatebecameabout freedom,governmentcontrol,andwhatwasconsideredAmerican.
AlsanandNeberaiexplainthatafterTruman’s1945proposal,theAMAtreatednational healthinsuranceasamajorthreatandfinancedanationalcampaigntodefeatit.Theydescribed howthecampaignwasrunbyWhitakerandBaxter,anearlypoliticalpublicrelationsfirm,and thatithadtwomajorcomponents:physicianoutreachandmasscommunications.30 The campaignwasnotjustlobbyinginWashington.Itwasdesignedtoshapepublicopinionsothat membersofCongresswouldfeelpressuretorejectnationalhealthinsurance.
29 MarcellaAlsanandYousraNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance? TheRoleoftheAmericanMedicalAssociation,”EconomicGrowthCenterDiscussionPaperno 1127(NewHaven, CT:YaleUniversity,November2024),7,accessedMarch4,2026, https://egc.yale.edu/sites/default/files/2024-11/ama main.pdf.
30 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”7
Thefirstpartofthecampaignfocusedonphysiciansasmessengers.AlsanandNeberai explainthatdoctorsweresentpamphletsandencouragedtowarnpatientsaboutsocialized medicineandtopromoteprivatehealthcareplans.31 Theyalsoexplainthatphysicianswould pushtheirorganizationstopassrulingsopposingnationalhealthinsuranceandsendthemto electedofficials.32 Thismatteredbecauseitmadeoppositionlookcommunity-basedratherthan ascomingfromanationalorganizationprotectingitsownpower.Italsomadethemessagefeel personalbecauseitcamethroughtrustedlocaldoctors.
Thesecondpartofthecampaignreliedonmassadvertising,especiallyinnewspapers. AlsanandNeberaidescribehowthecampaignframednationalhealthinsuranceasun-American andassociateditwithsocializedmedicine,whileframingprivateinsuranceasconnectedto freedomandtheAmericanway 33 Thecampaignalsousedwordsthatdescribednationalhealth insuranceasiftheproposalwasforcedgovernmentcontrolratherthanfinancialprotection.By repeatingthatframing,thecampaignturnednationalhealthinsuranceintosomethingpeople fearedratherthandemanded.
AlsanandNeberaialsoshowthatthecampaignhadrealeffectsbeyondrhetoric.They findthathigherexposuretotheAMAcampaignexplainspartoftheincreaseinprivatehealth insuranceenrollmentandasimilardeclineinpublicsupportfornationalhealthinsurance becomingalaw.34 Theyalsofindevidencethatthecampaigninfluencedpoliticalspeech, includingRepublicanrhetoricinCongressthatmirroredthecampaign'sframing.35 Thisshows thecampaigndidnotjustreacttopublicopinion.Ithelpedcreateit.
31 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”7–8
32 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”8–9
33 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”9
34 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”3.
35 AlsanandNeberai,“WhyDoesn’ttheUnitedStatesHaveNationalHealthInsurance?,”3
Thisstrategydidnotendinthe1940s.OperationCoffeecupshowshowtheAMA continuedfightinggovernmentexpansioninhealthcare,especiallyMedicare,becauseitsaw publicinsuranceasasteptowards“socializedmedicine”andgreaterfederalcontroloverdoctors andhospitals.In1961,theAMAfundedOperationCoffeecup,whichusedarecordedspeechby RonaldReaganwarningaboutthedangersofsocializedmedicine.Therecordwasdistributed throughtheAMA'sphysicians'wives,whowereinstructedtoinvitefriendsover,playthe recording,andhelporganizewritingletterstoCongresssoitwouldlooknatural.36 Thecampaignmaterialseventoldsupportersto“putonthecoffeepot,”inviteanaudience,and getletterswrittenwhilewewereinthehouse.37
OperationCoffeecupalsoshowshowColdWarfearstrengthenedthesocializedmedicine frame.St.OngeexplainsthatMedicarewasframedasthefirststeptowardalossoffreedom,a fearstemmingfromtheColdWar.38 Whetherornotthoseclaimswereaccurate,thecampaign waseffectivebecauseitshiftedtheargumentawayfromaccessandaffordabilitytoward ideologyandfear.Thatkindofmessagingmadeiteasiertostallnationalhealthcareandprotect privateinsuranceastheAmericanpathway.39
BythetimetheAMA’smessagespreadthroughdoctors’offices,newspapers,andeven livingrooms,nationalhealthinsurancewasnolongerbeingjudgedonwhetheritsounded American.Thatshiftmatteredbecauseitmadeiteasierforpoliticianstoavoiduniversal coveragewithoutappearingtovoteagainsthealth.Instead,thecountrykeptexpandingthe acceptableoption:privateinsurancetiedtowork.Butthatsolutiononlyworkedforpeoplewho
36 JeffreySt Onge,“OperationCoffeecup:RonaldReagan,RuggedIndividualism,andtheDebateover ‘SocializedMedicine’,” Rhetoric & Public Affairs 20,no 2(2017):228–29,accessedMarch4,2026, https://wwwacademiaedu/34720137/OPERATION COFFEECUP
37 St Onge,“OperationCoffeecup,”231
38 St.Onge,“OperationCoffeecup,”228.
39 St Onge,“OperationCoffeecup,”224–25
hadaccesstothekindsofjobsthatofferedbenefitsinthefirstplace.Thatiswhereunequal accessstopsbeingjustanoutcomeandbecomesthestructureofthesystem.
Insurancebeingtiedtojobsdidnotjustcreateanewwaytogetcoverage.Itcreateda systeminwhichaccessdependedonjobqualityandjobstability,notjustonwhethersomeone neededmedicalcare.Thatmattersbecausejobswerenotequalacrossincome,race,and occupation,sotheworkplaceroutecouldexpandcoveragewhilestillleavingmajorgaps.
Youcanseethisdirectlyinhowemployment-basedcoverageworkedfordifferenttypes ofworkers.FieldandShapiro’sreportshowsthatin1990,full-timeworkershadmuchhigher directemployercoveragethanpart-timeworkers.Forpeopleworkingpart-timeforafullyear, only22percentreporteddirectemployment-basedcoverage.Incomparison,full-yearworkers overallgotmuchhigheremployment-basedcoverage,andformanypeople,itcamedirectly throughtheiremployerratherthanapublicprogram.40 Thesystemdoesnotjustcoverworkers.It coversworkerswhosejobsarestableenoughandstructuredinawaythatprovidesbenefits.
Thisbecomesevenclearerwhenyoufactorinincome.Thesamereportexplainsthatlack ofemployment-basedcoverageiscommonforlow-wageworkers.Amongfull-time,full-year wageandsalaryworkerswithlowincomesin1990,onlyone-thirdhaddirectemployment-based coverage,comparedwithworkerswithhigherincomes.41 Thatdifferencemattersbecauseit showswhyunequalaccessisnotjustanaccident.Ifemployerinsuranceisthemainwayto coverage,thenpeoplewithlowerincomesarealreadystartingatadisadvantage.Theyaremore likelytobeworking,butstillnothavethekindofjobthatactuallyincludesbenefits.Thisgap
40 MarilynJ FieldandHaroldT Shapiro,eds, Employment and Health Benefits: A Connection at Risk (Washington,DC:NationalAcademyPress,1993),90–91,accessedMarch4,2026, https://www.ncbi.nlm.nih.gov/books/NBK235989/.
41 FieldandShapiro, Employment and Health Benefits,92
didnotappearrandomly.Itgrewbecausepolicyandlabornegotiationsmadeemployerbenefits themainpathtocoverageinthefirstplace.
Thisgapalsomakessensewhenyoulookathowthesystemwasbuilt.AsIshowed earlier,wartimelaborpolicyandlatertaxpolicyencouragedemployerstousehealthbenefitsas compensation.FieldandShapiro’sreportexplainsthatWarLaborBoarddecisionsallowed employercontributionstobenefitsduringwagecontrolsandthatbytheendofthewar,coverage hadtripled.Italsoexplainsthatby1954,federalpolicyclarifiedthatemployercontributions wereexcludedfromemployees’taxableincome,andemployerhealthspendingrose.42 Thepointhereisthatwhenbenefitsbecomeanormalpartofcompensation,peopleoutsidethe stablebenefitarebeingstructurallyleftout.
Thisiswhereraceandoccupationcomeintoplay,becausethejobsthatwereexcludedor unstablewerenotrandomlydistributed.DeWittexplainsthattheSocialSecurityActof1935 limitedcoveragetoworkersincommerceandindustry,meaningtheprogramappliedtoonly abouthalfofthejobsintheeconomy.Thoseleftoutwereusuallyfarmworkersanddomestic workers.43 DeWittalsoexplainswhyscholarsfocusonthisActwhentalkingaboutrace,because alargenumberofAfricanAmericanswereworkinginagriculturalanddomesticlaboratthe time.44 EventhoughDeWittarguestheexclusionwasnotcreatedonlyoutofracialmotives,the impactstillmatters.Inotherwords,theissuewasnotthatAfricanAmericanswereuniversally shutoutofsocialprotection.Itwasthestructureofprotectionthatfavoredtheworkersmost likelytobecoveredinthejobsthatleftmanyBlackworkersconcentratedinthejobsoutsidethat protection.
42 FieldandShapiro, Employment and Health Benefits,69–70
43 LarryDeWitt,“TheDecisiontoExcludeAgriculturalandDomesticWorkersfromthe1935Social SecurityAct,” Social Security Bulletin 70,no 4(2010):49,accessedMarch4,2026, https://www.ssa.gov/policy/docs/ssb/v70n4/v70n4p49.html.
44 DeWitt,“DecisiontoExcludeAgriculturalandDomesticWorkers,”49
Healsoexpressesthattheexclusiondebatewasconnectedtolaborcontrol,especiallyin theSouth.Southernpoliticianswantedtodriveawedgeforfederalinterferencewiththe “[African-American]question,”sotheycouldnotchallengehowtheSouthcontrolledBlack labor ThisalsomadeSouthernemployersworriedthatfederalbenefitsmightdiscourageBlack workersfromtakinglow-payingjobsinfields,factories,andkitchens.45 Thismattersbecauseit isdirectevidencethataccesstosocialprotectionswasshapedbywhoemployerswantedtokeep inlow-wagework.Whenbenefitsaretiedtoemployment,andsomegroupsaresteeredinto low-payingjobcategories,thesystemdoesnotjustreflectinequality;ithelpsmaintainit.Thisis notjustaone-timedetailaboutSocialSecurity;itrevealsthebroaderpatternofhowtheU.S. decidedwhichworkerscountedas“worthprotecting”andwhichcouldbeleftoutsidethe system.
Kleinhelpsexplainwhyjob-basedbenefitscreatedinsidersandoutsidersinsteadofa universalbase.SocialSecuritywasnothealthinsurance,butitrevealsthesamepolicylogicthat latershapedemployer-basedhealthcoverage.Associalprotectionexpandedinthe1930s,itwas builtaroundcertainkindsofjobsandleftoutmajorcategoriesofworkers.46 Thatmattershere becauseoncebenefitsareorganizedaroundemploymentcategories,healthcarecangrowalong thesameunequallines.IntheSouth,AfricanAmericanswereheavilyrepresentedintermsof domesticwork,whichmadeitharderforthemtogainsteadyemploymentbenefitsthatwere becomingahugethinginotherindustries.47 Thisshowsunequalaccesswasnotonlyaboutwho workedhardorwhodeservedcoverage.Itwasaboutwhichjobscountedasstableand protectable,andwhichjobsweretreatedasoutsidethesystem:targetingthosewhoworkedthose jobsinmind.
45 DeWitt,“DecisiontoExcludeAgriculturalandDomesticWorkers,”50
46 Klein, For All These Rights,104.
47 Klein, For All These Rights,106
Thesameproblemsrecurwithjob-basedhealthinsurance.Wheninsuranceistiedto employment,whogetscoveragedependsonwhetheryouareinajobthatoffersit,whichoften meansstable,higher-wageemployment.Peopleinlow-wagejobs,domesticwork,oragricultural workwhoweremostlikelytobeofanotherraceweremuchlesslikelytobecoveredthrough benefits,andthesystemgavethemfewerreliablepathstogainhealthinsurance.Theresultis thatemployer-basedinsurancecanappeartoexpandaccess,butitdoessomosteffectivelyfor peoplewhoalreadyhadaccesstothebestjobs,whichwerenotequallyavailableacrossraceand occupation.
Evenafteryoucrossthefirstbarrierofaccessbygettinginsurancethroughajob,that stilldoesnotmeanyoucanactuallygetequalcare.Insuranceisonlyonegate.Thenextgateis thehospitalsystemitself,meaningwhathospitalsexistnearyou,whothosehospitalsserve,and whathappenswhenyouwalkinthedoor.IntheUnitedStates,hospitalsandmedicalinstitutions werenotbuiltasneutralspaces.Theywereshapedbysegregationandunequalinvestment, whichmeantaccesscoulddependonrace,evenwhensomeonecouldpayorhadcoverage.That iswhyunequalaccessisnotjustaresultofpeoplehavingdifferentjobs.Itisalsotheresultof institutionsdeliveringcareunevenly Inotherwords,job-basedinsurancemightgetsomeone closertocare,butitdidnotremovetheinstitutionalbarriersthatdecidedwhoactuallyreceived treatment.
EvenwhenBlackpatientshadmoneyorcoverage,hospitalswerestillcontrolledby systemsthatexcludedBlackdoctorsandrestrictedBlackpatients.EmilyLargentexplainsthat, aslateasthemid-1960s,opensegregationinfectedthehealthcaresystemandwaslegally allowedinmanyplaces.SheusesaquotefromtheNationalMedicalAssociation’spresident
statingthatBlackdoctorsweredeniedhospitalstaffmembershipandBlackpatientswere discriminatedagainstbothinadmissionandplacementinsidethehospital.48
Thatisexactlyhowthepeopleincontrolkeptpower,bylimitingBlackdoctorsand patients.Theywereabletoshapethesystemaroundwhotheythoughtdeservedfullaccessand whocouldperformthecare.Thisiswhyunequalaccessisnotfixedjustbyhavinginsurance.If thehospitalsdeliveringcarestilltreatedsomepeopleasbelongingandothersasnot,then insurancedidnottranslateintoequaltreatment.
TheHill-BurtonAct,passedbyCongressin1946,illustratesthisevenbetter,asitshows thatthefederalgovernmenthelpedexpandthehospitalsystemwhilestillallowingsegregation. LargentexplainsthatHill-Burtonwasamassivefederalhospitalconstructionprogramandthat, tohelpprovidecareintheSouth,itwouldprovidecare.ItfollowedtheSouth’sJimCrowLaws' separatebutequalmottothatalloweddiscriminationiftherewerefacilitiesoflikequalityforthe groups.
49 Shealsosaysthisisnotablebecauseitwastheonlydirectandclearseparate-but-equal actinthetwentiethcentury,showingfederallegislationusedfederalfundstosupportracial exclusion.
50 Unequalaccesswasnotonlytolerated.Itwasbuiltintotheexpansionofthehealth structureusingfederalmoney Soevenasthehospitalsystemgrew,itdidnotgrowevenlyor fairlyforAfricanAmericans.Thismeantthatbeginningin1946,thefederalgovernmentwas helpingexpandthehospitalsystemwithoutrequiringequalaccessacrossrace.
ReynoldsexpandsonLargent’spoint,goingdeeperintohowthesefundswereusedand thepracticalimplicationstheycaused.Sheexplainsthattheseparate-but-equalimplementation, whichwasso-called“non-discriminatory,”stillroutinelydeniedAfricanAmericansaccessas patientsandasmembersofthemedicalstaff.Shealsostatesthatthefederalfundsledtomore
48 Largent,“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation,”716.
49 Largent,“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation,”716
50 Largent,“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation,”716
inequality,asmoreoftenthannot,theywereusedtobuildandexpandservicesforwhite AmericanscomparedtoBlackAmericans.51 Thismattersbecauseitprovesthesystemwas unequalevenatthepointofphysicalaccess.
Evenifyoucouldpay,thehospitalyoucouldreach,enter,andbetreatedatwasshaped bysegregationandbywhereresourceswereinvested.Thatmattersbecauseaccessisnotonly abouthavingmoneyorinsurance,butalsoaboutwhetherthesystemactuallyprovidesareal placetoreceivecare.Iffederalmoneyhelpedexpandhospitalsthatservedwhitecommunities first,thenthesystemwasbuildingthataccessunevenlyonpurpose,notbyaccident.Inthat situation,aBlackfamilycouldhavecoverageandstillfacebarrierswithworsefacilities,fewer beds,andjuststraight-updenial.Thiswasbecausethehospitalnetworkwasnotdesignedto benefitthem.Thisiswhyunequalaccessisnotjustapersonalproblem.Itisasystemicproblem inwhichresourcesdeterminewhogetsfullcareandwhogetspushedtotheside.AndtheUnited StatesCommissiononCivilRights'TitleVIActreportprovesthiswasnotjustanormalpattern; itwasapracticehospitalsopenlyengagedinevenwhiletakingfederalmoney.Itshowswhat segregationactuallylookedlikeinsidehospitals,evenaftercompliancewithbeingequalbut separatewassupposedtohappen.
Bythemid-1960s,evenafterTitleVIhadbeenpassed,theUnitedStatesCommissionon CivilRights’reportafteroneyeargavesomeofthestrongestproofofwhatsegregationstill lookedlikeinsidehospitals.Thereportdiscusseshowhospitalssignedagreementstoreceive Hill-Burtonfundswhilemaintainingsegregationandensuringequalaccess.Itdescribesa hospitaladministratorsayinga[African-American]andawhitepatientprobablyneverwouldbe
51 Reynolds,“TheFederalGovernment’sUseofTitleVIandMedicare,”1851
assignedtothesameprivateroom,evenwhilethehospitalwasexpandingwithfederalfunds.52
Thereportalsodescribeshospitalsthatgotridof“[African-American]Wings”butcontinued racialroomassignmentsthroughoutthefacility,includingadministratorsstatingtheywouldnot desegregateroomsunlessforced.53 Unequalaccesswasnotonlyaboutwhetheryouhadthe incomeorpolicy.Itwasaboutwhetherhospitalswouldtreatyoulikeafullpatientwithaccessto care.
TheCommissionreportevenexplainswhysegregationcouldreduceaccessconcretely.It notesthatwhenBlackpatientswereonseparatefloorsorbuildingsandthoseareasfilledup, Blackpatientscouldbeforcedintohallsordeniedadmissionevenwhenbedswereemptyinthe whitesection.54 Segregationworkedlikeabarriertocare,notjustasocialrule.Ifbedswere availablebutBlackpatientscouldnotusethem,thenaccesswasbeingrationedbasedonrace.It meantBlackpatientscouldbedelayed,placedinworseconditions,orturnedawayduringthe exactmomentswhenhospitaltreatmentmatteredmost.Inthatsituation,havinginsuranceor beingabletopaydidnotguaranteethecare,becausetheinstitutionstillhadthepowertodecide whocountedasafullpatient.Thisiswhyunequalaccesstohospitalswasdangerous.Because thesebarrierswerebuiltintohowhospitalsoperated,changeonlyhappenedwhenfederalpolicy attachedrealconsequencestodiscrimination.
Thesepracticesdidmorethanseparatepatientsinsidehospitals.Theyshowedthateven wheninstitutionsacceptedpublicfundsandclaimedtobecomplyingwiththelaw,Black patientsandBlackdoctorscouldstillbepushedtothemarginsofcare.Bythemid-1960s, AfricanAmericanshadlittlereasontotrusthospitalpromisesofequalcare.Opensegregation
52 UnitedStatesCommissiononCivilRights, Title VI… One Year After: A Survey of Desegregation of Health and Welfare Services in the South (Washington,DC:US GovernmentPrintingOffice,1966),22,accessed March4,2026,https://www2.law.umaryland.edu/marshall/usccr/documents/cr12h34.pdf.
53 UnitedStatesCommissiononCivilRights, Title VI One Year After,12
54 UnitedStatesCommissiononCivilRights, Title VI One Year After,12
stillshapedadmission,placement,andtreatment,andBlackdoctorswerestillbeingdeniedfull participationinsidehospitals.55 Theproblemwasnotjustthatdiscriminationhadexistedinthe past.Itwasthatmanyhospitalswerestilltakingfederalmoneywhilecontinuingsegregated practices,whichmadeofficialpromisesoffairnesshardtobelieve.56 ThatiswhyTitleVIand Medicarematteredsomuch.Theydidnotjustannounceequalityintheory.Theyattachedreal financialconsequencestodiscriminationandforcedhospitalstochange.57
By1964and1965,federalpolicyhadfinallymovedintoanewphase.TitleVIofthe CivilRightsActof1964banneddiscriminationinfederallyassistedprograms,andMedicare, passedin1965,gavethefederalgovernmentapowerfulwaytoenforcecompliancewhen hospitalswantedfederalreimbursement.58 TitleVIandMedicarematteredbecausehospitalsdid notdesegregatesimplybecausepublicopinionhadchanged.Theydesegregatedwhenfunding wastiedtoanagreement.Reynoldsexplainsthatthisactenforceditsrulesbywithholdingfunds. Theideawastomakecompliancemorebeneficialthanresistance.Theentireemployer-based systemalsoworksthroughincentivesandpower.Hospitalsbehaveddifferentlywhenthe financialstructurechanged.ShealsofocusesonMedicare’sstrongimpact.Sheexplainsthat Medicareisoftenviewedasaprogramtopayforelderlycare,butitalsoledtothedismantling ofsegregationinthemedicalscenebyJuly1,1966.59 Institutionalinequalitywasnotminoror accidental.Itwasstrongenoughthatittookfederalforcesattachedtomajorfundingtocreate realaccesstocare.Ifunequalaccesswereonlyaboutindividualprejudice,itwouldnothave requiredthislevelofstructuralchange.
55 Largent,“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation,”716.
56 UnitedStatesCommissiononCivilRights, Title VI One Year After,5,7–8,12
57 Reynolds,“TheFederalGovernment’sUseofTitleVIandMedicare,”1853-54,1856.
58 Reynolds,“TheFederalGovernment’sUseofTitleVIandMedicare,”1850–51,1853-1854,1856
59 Reynolds,“TheFederalGovernment’sUseofTitleVIandMedicare,”1856
HospitalsegregationdidnotonlyaffectwhereBlackpatientswereplacedoncethey enteredcare.Itwasalsoconnectedtowhohadauthorityinsidemedicine,becauseunequal medicaleducationandhospitalprivilegeshelpedkeepthosesameinstitutionsunderwhite control.Onereasonhospitalswereunequalisthatthemedicalsystemwasunequalbefore patientsevenreachedthehospital.TheFlexnerReport’schapteron The Medical Education of the Negro, writtenin1910,showsthatthetrainingandprogressofBlackphysiciansweretreated aslimitedandcontrolled.AbrahamFlexnerarguesthatthemedicalcareofthe [African-American]shouldnotbelefttoBlackphysiciansandthatthepracticeoftheBlack doctorwouldbelimitedbyhisrace.60 HeframesBlackhealthassomethingthatthreatenswhite health,callingBlackpeopleapotentialsourceofinfectiontowardstheirhealth.Hestatesthat medicaleducationforBlackdoctorsisonlypartlynecessaryforself-protectionagainstthem.61 Thesystemdidnotbuildequalmedicalcapacityinthefirstplace.Ifmedicaleducationandthe professionalsystemofitwereshapedbyracistidealsaboutwhodoctorsshouldserveandwhy theyshouldexist,thentheinstitutionsthemselveswerebuiltonthatsystem,whichwasnever designedtoprovideequalaccess.
Flexneralsomakesitclearthatthecountrywasnotinterestedinsupportingmultiple strongBlackmedicalschools.Hearguesthatthevalueofthe[African-American]medical schoolsislow,andhavingmanyschoolsisworthless;it'sbettertohavegood [African-American]schools.62 Hethencontinuesaboutthesevenmedicalschoolsfor African-Americans,hestatesfiveareineffectiveandshouldnotsurvive,whileonlyHowardand
60 AbrahamFlexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching,BulletinNumberFour(NewYork:CarnegieFoundationforthe AdvancementofTeaching,1910),180,accessedMarch4,2026, https://ia803109 us archive org/32/items/carnegieflexnerreport/Carnegie Flexner Report pdf
61 Flexner, Medical Education in the United States and Canada,180
62 Flexner, Medical Education in the United States and Canada,180
Meharryareworthsponsoring,withresources.63 EventhoughFlexnerpresentsthisasefficiency, itstillsupportsmyargumentthatmedicalinstitutionswerebeingshapedwithunequalcapacity andunequalopportunity Thisdidnotmattermorethanhospitalsegregationitself,whichdirectly limitedcareforBlackpatients.Butitdidreinforcethatunequalsystembyrestrictinghowmany Blackdoctorscouldbetrained,wheretheycouldpractice,andhowmuchauthoritytheycould holdinsidehospitals.
Thisbecomesanotherbarriertoequalmedicalcarebecausebeingleftoutofthemedical professionallowedthegroupsalreadyinpowertomaintaincontroloverhowhealthcarewas organizedandwhoreceivedtreatment.IfBlackdoctorsarelimitedintrainingopportunitiesand pushedoutofhospitalstaffroles,thenBlackcommunitieshavelessaccesstodoctorswhocan advocatefortheminsideinstitutions.Atthesametime,themedicalprofessionandhospital leadershipremaindominatedbythesamegroupsthatshapedthesystemthroughprivatecontrol, makingiteasiertoprotectemployer-basedinsuranceandprivatemedicinefrommajorreform.
Theemployer-basedsystemwasnotjustbuiltthroughpolicy;itwasalsoprotectedthroughthe institutionsthatprovidedcareanddecidedwhohadauthorityinmedicineandwhodidnot.
Evenmoreimportantly,hospitalsdidnotoperatelikeneutralpublicspaceswhere insuranceautomaticallyequalscare.Theywereinstitutionsthatcoulddecidewhowasadmitted, wherepatientswereplaced,andwhatleveloftreatmenttheyreceived,andfordecades,those decisionswereshapedbyrace.Thisshowsthatunequalaccesswasbuiltinatmultiplelevels.
Job-basedinsurancealreadymadecoverageunevenbecausestable,benefit-payingworkwasnot equallyavailableacrossraceandclass.Butevenwhensomeonedidhaveinsurance,thenext barrierwaswhetherthehospitalsystemwouldactuallygivethemequalcare.Ifacommunity’s hospitalwasunderfunded,segregated,orcontrolledbyleadershipthatexcludedBlackdoctorsor
patients,theninsurancedidnotguaranteetreatment.Thatchanceattreatmentdependedon whethertheinstitutionwouldallowit.
Thisalsohelpsexplainwhyemployer-basedinsurancestayedinplaceforsolong.If nationalhealthinsuranceisblockedpoliticallyandinsuranceistiedtowork,thenthesystem keepsexpandingalongapaththatbenefitssomegroupsmorethanothers.Peoplecouldgain coverageandstillbetreatedlikesecond-classpatientsoncetheyenteredsegregatedorunequal institutions.Thatiswhyunequalaccessbecameingrainedinthesystem.Employmentshaped whocouldgetinsurance,andmedicalinstitutionsshapedwhetherthatinsurancecouldbeturned intorealcare.WhenTitleVIandMedicarefinallyforcedhospitalstochangebyattaching federalfundingtocompliance,itexposedwhohadpowerinsidethesystem.Thisfitsthelarger understandingofthispaper:policychoicesandprivateinstitutionsbuiltastructureinwhich unequaljobsandunequalhospitalsworkedtogethertokeephealthcareunequal.
Overall,theUnitedStatesdidnotendupwithemployer-basedhealthinsurancebecauseit wasthemostequitableorauniversalsolution.Itbecamethemainpathtocoveragebecauseitfit thepoliticalandeconomicpowerstructurethatdevelopedintheearlytwentiethcentury.Bythe 1930s,risingmedicalcostswerecreatingpressureforchange,andthecountrywasalready debatinghowpeopleweresupposedtopayforcarewhenexpenseswerepracticallyrandom.At thesametime,privatehospitalserviceplanslikeBlueCrossinhospitalswereexpandingthrough voluntaryandlocalmodels,whichmeantprivatesolutionswerealreadybecomingnormalized.
OnceWorldWarIIwagecontrolspushedbenefitsintotheworkplace,healthinsurancespread throughemploymentinsteadofbecomingafederalbenefit.Afterthewar,taxpolicy strengthenedthisgrowingmodelandhelpedlockitin.
Thissystemalsostayedinplacebecausenationalhealthinsurancefailedpolitically.
Truman’sproposalmadeanargumentthatbeinghealthyshouldnotdependonincomeorrace, andhetriedtoframeitasfinancialprotectionratherthangovernmentcontrol.Butorganized resistancereframedtheunderstandingintoafightoverfreedom,socializedmedicine,and governmentcontrol.Thismatteredbecauseitpushedthecountryawayfromuniversalcoverage andmadeemployerinsuranceacceptable.Expandingprivateinsurancethroughworkwaseasier thanpassinganationalprogram,evenifitleftmanypeopleoutofhealthsecurity.
Comingalltogetheristhatunequalaccesswasnotjustanoutcomethatappearedlater.It camedirectlyfromthestructurethattheUnitedStatesbuilt.Wheninsuranceistiedto employment,accessdependsonjobstabilityandjobtype,andthoseopportunitieswerenever givenequallyacrossrace,class,andoccupation.Thesystemwasbuiltaroundbenefit-paying jobs,whichcouldexpandcoverageforpeopleinstablecompanieswhilestillleavingpeoplein low-wageandagriculturalworkwithfeweroptionsintermsofhealthcare.Thesystemrewarded stabilityandbargainingpowerratherthanactualmedicalneed.
Evenso,insurancedidnotguaranteeequalcareoncesomeonereachedthehospital. Hospitalsandmedicalinstitutionswereshapedbysegregation,unequalfunding,andexclusion, whichmeantaccesscouldstilldependonraceevenwhenapatientwascapableofpaying.
Federalpolicyexpandedhospitalswhilestillallowingseparatebutequalsystems.Thechange onlyhappenedthroughfederalpressureonhospitalstocomply.Thisshowstheinequalityon multiplelevelsofthissystem.Thefirstbarrierwascoveragethroughwork,thenwhether institutionsdeliveringcarewouldactuallyprovide.
Fromthe1930stothe1960s,theUnitedStatesbuiltahealthcaresystemthatdependedon privateinsuranceandemploymentratherthanauniversalhealthcarestructure.Thatmodel
expandedaccessformanyAmericans,butitalsocreatedgapsbecauseofjobopportunitiesand medicalinstitutionsnotbeingequal.ThisiswhytheUnitedStatescouldincreasecoveragein jobsandstillmaintainunequalaccesstohealthcare.
Acknowledgement
IfirstwanttothankGodforguidingmeandhelpingmegetthroughthispaper.Ialsowantto thankMrs.Mustoforherfeedbackonmystructure,claims,arguments,andwriting.Her commentshelpedmefocusonimprovingmyargumentinsteadofjustrepeatingevidence.Iam alsogratefultomyclassmateswhoreadpartsofmydraftsandpointedoutwheremyideas neededtobeclearerormoredeveloped.Iknowthistopicisbiggerthanonepaper.Myfocusis onhowemployer-basedinsuranceandmedicalinstitutionsshapedunequalaccess,especially throughrace,occupation,andsegregation,butIcouldnotincludeeveryperspectivefully.In particular,women’sexperiencesandtheroleofgenderdeservemoreattentionthanIwasableto givehere.Anymistakesormissingpiecesaremyown.Thisismyhonestwork.Thankyou.
Bibliography
Alsan,Marcella,andYousraNeberai.“WhyDoesn'tTheUnitedStatesHaveNationalHealth Insurance?TheRoleoftheAmericanMedicalAssociation.” Economic Growth Center Discussion Paper No. 1127.NewHaven,CT:YaleUniversity,November2024.Accessed March4,2026.https://egc.yale.edu/sites/default/files/2024-11/ama_main.pdf
Bailey,MarthaJ.,andWilliamJ.Collins.“TheWageGainsofAfrican-AmericanWomeninthe 1940s.”NBERWorkingPaperno.10621,June2004.AccessedApril8,2026. https://www.nber.org/system/files/working_papers/w10621/revisions/w10621.rev0.pdf
CommitteeontheCostofMedicalCare. Medical Care for the American People: The Final Report of the Committee on the Cost of Medical Care. Chicago:UniversityofChicago Press,1932.AccessedMarch4,2026. https://babel.hathitrust.org/cgi/pt?id=osu.32435010615904&seq=10
DeWitt,Larry.“TheDecisiontoExcludeAgriculturalandDomesticWorkersfromthe1935 SocialSecurityAct.” Social Security Bulletin 70,no.4(2010):49–68.AccessedMarch4, 2026.https://www.ssa.gov/policy/docs/ssb/v70n4/v70n4p49.html
Field,MarilynJ.,andHaroldT Shapiro,eds. Employment and Health Benefits: A Connection at Risk. Washington,DC:NationalAcademyPress,1993.AccessedMarch4,2026. https://www.ncbi.nlm.nih.gov/books/NBK235989/.
Flexner,Abraham. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. BulletinNumberFour.New York:CarnegieFoundationfortheAdvancementofTeaching,1910.AccessedMarch4, 2026.
https://ia803109.us.archive.org/32/items/carnegieflexnerreport/Carnegie_Flexner_Report. pdf
Helms,RobertB.“TaxPolicyandtheHistoryoftheHealthInsuranceIndustry.”Washington, DC: AmericanEnterpriseInstitute,2008.AccessedMarch4,2026. https://www.aei.org/wp-content/uploads/2011/10/healthconference-helms.pdf
Klein,Jennifer. For All These Rights: Business, Labor, and the Shaping of America’s Public-Private Welfare State. Princeton,NJ:PrincetonUniversityPress,2003.
Largent,EmilyA.“PublicHealth,Racism,andtheLastingImpactofHospitalSegregation.” Public Health Reports 133,no.6(2018):715–720.AccessedFebruary10,2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC6225869/pdf/10.1177_0033354918795891.pdf
McGriggs,Frank.“StrengtheningAmericaatHome:BlackWorkersinWWII.” U.S. Department of Labor Blog,February23,2024.AccessedMarch4,2026. https://blog.dol.gov/2024/02/23/strengthening-america-at-home-black-workers-in-wwii
Morrissey,MichaelA.“HistoryofHealthInsuranceintheUnitedStates.”In Health Insurance. 2nded.,1-25.Chicago:HealthAdministrationPress,2013.AccessedMarch4,2026. https://account.ache.org/iweb/upload/Morrissey2253_Chapter_1-3b5f4e08.pdf
Reed,LouisS. Blue Cross and Medical Service Plans. Washington,DC:FederalSecurity Agency,U.S.PublicHealthService,October1947.AccessedMarch4,2026. https://babel.hathitrust.org/cgi/pt?id=rul.39030039857869&seq=1
Reynolds,P.Preston.“TheFederalGovernment’sUseofTitleVIandMedicaretoRacially IntegrateHospitalsintheUnitedStates,1963through1967.” American Journal of Public Health 87,no.11(November1997):1850–1858.AccessedMarch4,2026. https://ajph.aphapublications.org/doi/epdf/10.2105/AJPH.87.11.1850
Rhodes,Karl.“FromLoopholetoMandate.” Econ Focus (FederalReserveBankofRichmond), FirstQuarter2014,31–34.AccessedMarch4,2026.
https://www.richmondfed.org/-/media/RichmondFedOrg/publications/research/econ_focu s/2014/q1/pdf/economic_history.pdf
Schumann,Richard.“CompensationfromWorldWarIIthroughtheGreatSociety.” Compensation and Working Conditions (Fall2001).AccessedMarch4,2026. https://www.bls.gov/opub/mlr/cwc/compensation-from-world-war-ii-through-the-great-so Ciety.pdf
St.Onge,Jeffrey.“OperationCoffeecup:RonaldReagan,RuggedIndividualism,andthedebate over‘SocializedMedicine’.” Rhetoric & Public Affairs 20, no.2(2017):223-251. AccessedMarch4,2026.
https://www.academia.edu/34720137/OPERATION_COFFEECUP
Starr,Paul.TheSocialTransformationofAmericanMedicine:TheRiseofaSovereign ProfessionandtheMakingofaVastIndustry NewYork:BasicBooks,1982.
Truman,HarryS.“SpecialMessagetotheCongressRecommendingaComprehensiveHealth Program.” Public Papers of the Presidents. November19,1945.HarryS.Truman Library&Museum.AccessedMarch4,2026.
https://www.trumanlibrary.gov/library/public-papers/192/special-message-congress-reco mmending-comprehensive-health-program.
UnitedStatesCommissiononCivilRights. Title VI… One Year After: A Survey of Desegregation of Health and Welfare Services in the South. Washington,DC:U.S.GovernmentPrinting Office,1966.AccessedMarch4,2026.
https://www2.law.umaryland.edu/marshall/usccr/documents/cr12h34.pdf.
UnitedStates. Internal Revenue Code of 1954 PublicLaw83-591.UnitedStatesStatutesat Large68A(1954):3.AccessedMarch4,2026.
https://www.govinfo.gov/content/pkg/STATUTE-68/pdf/STATUTE-68A-Pg1.pdf
INSIDETHEMURDEROUSMIND:THEPSYCHOLOGICALANDINVESTIGATIVE EVOLUTIONOFSERIALKILLERS
ByMadelineBriggsMacallister
Serial killers are statistically rare, yet their impact on developments in law enforcement and the criminal justice system is abnormally large. Databases show the United States has the most serial killers known to date. They have existed across centuries, some have been arrested, died, are currently in prison, or were never caught. With an approximate three thousand six hundred thirteen killers known as of 2020, the United States has the most known serial killers compared to other countries.64 While this number may seem high, many of these cases went years without being connected, and these crimes were not viewed as patterns. Early investigations treated serial murder as isolated incidents. With the limited research, communication, and lacking technology, patterns could not be identified, and crimes went undetected or unsolved for many years. During the 1960s to 1970s, a huge number of serial killersemerged.Itisunclearastowhythisincreasewassosignificant,butmanytheoriesinclude the reason being the development of the term serial killer and the early stagesofidentifyingthe patterns they have. The increase, however, sparked the need to understand these killers on a deeper level with further psychologicalresearchandattemptstodevelopconceptsthatwouldaid incatchingaserialkiller.
RobertResslerfirstusedthetermserialkillerinthe1960s.ResslerwasanFBIagentwho identified serial killers by their habitual routine. Ressler describes aserialkillerasapersonwho has killed three or more people, taking place in differentlocations,withsomeamountofa“cool
64 TaylorStacy,“SerialKillerStatistics,” Putting Methods to the Madness (blog),UniversityofMichigan, March4,2023,https://sites.lsa.umich.edu/qmss/2023/03/04/serial-killer-statistics/.
down” period between murders.65 A serial killer is a unique kind of person identified by their highly educated and meticulous actions. Besides the number of victims and the specific timing, serial killers are identified uniquely by the repetitive and habitual patterns they must follow while they commit their crimes. Mass and spree killers are driven byemotionalreactions,while serial killers are methodical with crimes thatextendoveralongerperiodoftime.Thecrimesare planned out and contain aconsistentpattern.Theyhaveaspecifichabitcalledasignature,which is a huge factor that makes serial killers so unique. These “signatures” also are what link these crimes together, making it clear to law enforcement that it is the same killer. John Douglas was an FBI agent who introduced the term “signature.66 Most law enforcement, media, and psychiatrists agree that this habit exists in serial killers' cases. Not only does the signature link the victims to one killer, but it also contributestotheinvestigationbyallowinglawenforcement to see the main habits of the killer. These compulsions are what show the state of psychopathy that most of these killers exhibit. Their actions are often fueled by some sort of sexual fantasy, and they gain some sort of sexual release from theircrimes.Oncelawenforcementgainedsome understanding of these compulsions, they were able to identify patterns and, when looking at specific crimes, determine what they were and whether they could connect them. These agents make it extremely clear that while these patterns can directly point the investigation in the correct direction and identify the suspect, they must also be interpreted carefully, and other factorshavetobeconsideredtoensurethecorrectsuspectisidentified.
Julius Ludwig August Koch was a psychologist who coined the term psychopath.Koch was a German psychiatrist from 1841 to 1908. His research was heavily focused on personality
65 HaroldSchechter, The Serial Killer Files: The Who, What, Where, How, and Why of the World’s Most Terrifying Murderers (NewYork:BallantineBooks,2003)
66 RobertK Ressler,AnnW Burgess,andJohnE Douglas, Crime Classification Manual: A Standard System for Investigating and Classifying Violent Crimes (Washington,DC:US DepartmentofJustice,Federal BureauofInvestigation,1992),https://www.ojp.gov/pdffiles1/Digitization/134597NCJRS.pdf.
disorders, which set up research on serial killers and their psychological uniqueness.67 A psychopath is not capable of experiencing many, if not all, of the emotions. Their only senseof feelings is a desire for control, and they need their recurring behavior 68 Traits common with obsessive compulsive disorder, also known as OCD, are seen in the offenders; however, OCD does not make youmorelikelytobecomeaserialoffender.69 OCDcanactuallymakepeoplefeel like they need to commit heinous crimes, yet most people who experience this actively work to get help and dismiss these thoughts. Serial killers may display symptoms and signs of OCD; however, itisnotthedrivingpsychologicalfactorthatcausesthemtokill.70 Theresearchintothe psychology of serial killers is helpful to understand their common motivators and traits that cause them to have similar habits. It is important to note that not all psychopaths are serial killers, and not all serial killers are psychopaths; however, in almost every case, they display these traits. Although there are some unique cases where serial killers arenotpsychopaths,they still display the common traits, and the research is helpful in relation to all serial cases. A majority of serial killers have common traits; however, in most cases, they have to have experienced some sort of trauma to unlock the compulsive acts of killing. These traits are commonly associated with psychopathy The social settings andcertainlivedexperienceshavea large role in how serial killers emerge.71 In addition, it is crucial to understand that not every
67 PhilippGutmann,“JuliusLudwigAugustKoch(1841–1908):Psychiatrist,Philosopher,andChristian,” Würzburger medizinische geschichtliche Mitteilungen 25(2006):215–30, https://pubmedncbinlmnihgov/17333864/
68 Schechter, The Serial Killer Files: The Who, What, Where, How, and Why of the World’s Most Terrifying Murderers
69 PsychCentral “OCDandCrime”June7,2016 https://psychcentral.com/blog/ocd-reflections/2016/06/ocd-and-crime#1.
70 “OCDandCrime”
71 Schechter, The Serial Killer Files: The Who, What, Where, How, and Why of the World’s Most Terrifying Murderers
psychopath will commit serial murder.72 Despite this, law enforcement must not solely rely on these facts, and psychology can not completely explain a serial killer's actions. There is always going to be a factor of unpredictability; if law enforcement relies on the expectations of what could happen, they could be led astray and set back their investigation. The use of psychology helps identify patterns and gain insight into potential habits, reactions, or actions of the serial killer. However, relying only on this research is not the whole picture. Psychology is a helpful thing to understand the basic information about the traits of aserialkiller,butitisnotasingular answertounderstandingwhy,how,andwhowillbecomeaserialkiller.
Modern advancements in technology, science, and media have significantly altered the way society and law enforcement look at and understand serial killers. In the grand scheme of things, they are better known than theywereinthe1970sandearlier,especiallyduetoincreased media coverage. Media coverage and law enforcement advances influence society to know of more serial killers, yet studies show the actual number of serial killers is at an all-time low.73 Serial killers can be dated back to the 1800s, with some notable cases such as Jack the Ripper, Dr. Thomas Neill Cream, H. H. Holmes, and more.74 There have always been known cases; however, there werefewer,andoftentimesthekillerswerenotcaughtoridentified.Thesecrimes show patterns over time and similarities between killers, which help identify the uniqueness.
Advancements in the technology thatlawenforcementuseshelpmaketheseconnections.Before the 1960s,serialkillerswerelargelyunknowntothegeneralpublic,asmediacoverageofviolent crimes was limited, localized, and slower to be spread nationally. The mainstream methods for
72 HoganAssessments,“ThePersonalityofSerialKillers,” Hogan Assessments Blog,October11,2022, https://www.hoganassessments.com/blog/personality-serial-killers/
73 NortheasternUniversity “WhyAreThereFewerSerialKillersToday?”April26,2023 https://newsnortheasternedu/2023/04/26/serial-killer-decline/
74 HeatherThomas,“EarlyAmericanSerialKillers,” Headlines & Heroes: Newspapers, Comics & More Fine Print (LibraryofCongress,October22,2019), https://blogslocgov/headlinesandheroes/2019/10/early-american-serial-killers/
news included local newspapers and theradio.TherewassomeexistenceofTV;however,itwas not as mainstream or common a source of information. As television, radio, and newspapers expanded the media exposure of violent crime, the public reacted with a response of fear and fascination.75 Specifically, television brought crime reports to a national audience. This immediately created a reaction simplybecausethenumberofpeoplewhoknewaboutthecrimes increased significantly.76 Radio shows and programs discussed serial killers and cases, which increased awareness as well as exposure to this kind of violence. Magazines such as True Detective and Crime Digest, and news coverage that aired about the Boston Stranger (1962-1964) wereearlyexposuresthatgainednationalattention.Thisincreasingmediaattention, combined with early investigative techniques, laid the foundationfortheFBIandotheragencies tobeginprofilingserialkillersaswellasdevelopingandadvancinginvestigativetechniques.
The rise of serial killer awareness prompted law enforcement to develop systematic approaches toidentifypatterns,whichledtotheFBIcreatingtheBehavioralScienceUnit,where they introduced and used profiling techniques as well as advanced technology and techniques. DNA testing, cameras, recordingdevices,andothertechnologyareextremelyhelpfulnotonlyto link crimes together but to catch killers. Following the increase of known serial killings in the 1960s, the necessityforrecognizingthepatternsinthesecrimesbecameextremelyimportant. In addition, behavioral profiling and understanding patterns can even aid law enforcement in predicting crimes and identifying suspects. It is clear that with advanced techniques and technology, serial killers are more likely to be caught, and following their arrest, the mediawill
75 PeterVronsky, Serial Killers: The Method and Madness of Monsters (NewYork:BerkleyBooks,2004)
76 ScottBonn, Why We Love Serial Killers: The Curious Appeal of the World’s Most Savage Murderers (Naperville,IL:Sourcebooks,2014)
blow up the case, and they will be known on a national or potentially a global level due to the significantincreaseinmediauseandcoverage.
Research on serial killers can be doneinmanydifferentfields.Criminology,psychology, and studying the media can give insights into the behavior and understanding of serial killers. Criminology research focuses on how to define a serial killer and how their patterns can be identified. Scholars such as Steven A. Egger focused on the challenges for police and law enforcement in his recent study from 2002, Serial Murder: An Elusive Phenomenon. He argued that recognizing that murder victims are connected to one single killer is extremely difficult, especially when they are spread out by time and location. Egger discussed the idea of “linkage blindness,” which is when law enforcement does not seetheconnectionbetweencrimes. 77 Ona similar note, in 1988, Jack Levin and James Alan Fox explained how serial murder is different from mass or spree killings in their study, Mass Murder: America’s Growing Threat.Theypoint out the time frame difference, where serial killers commit their crimes over a longer period of time and have specific repeating patterns.78 The specific work done by Jack Levin and James Alan Fox exemplifies that modern society has become increasingly more threatened by killers duetothespotlighttheyhave.Thesescholarsstudiedtoprovethattheconceptofaserialkilleris not just the number of victims but rather how the killer engages with the victim and how law enforcementidentifiesthecrimes.
77 Egger,StevenA "AWorkingDefinitionofSerialMurderandtheReductionofLinkageBlindness" Journal of Police Science and Administration 12,no 3(September1984):348–357 https://wwwojpgov/pdffiles1/Digitization/103445NCJRSpdf
78 Fox,JamesAlan,andJackLevin “MultipleHomicide:PatternsofSerialandMassMurder” Crime and Justice 23(1998):407–55.http://www.jstor.org/stable/1147545.
The study, Sexual Homicide: Patterns and Motives, isalsoanincrediblesourcebyRobert Ressler, Ann Burgess, and John Douglas, which was written in 1988.79 This FBI study outlines the definitions, habits, patterns, and behaviors of serial killers. From a law enforcement perspective, it is crucial to understand their background when identifying and capturing serial killers. The study was conducted in the 1970s to 1980s by the Behavioral Science Unit. It provides detailed definitions that distinguish serial killers and identify the differences that separate them from other forms of homicide. Terms such as signatures and sexual homicide are frequently used to emphasize the patterns in these crimes.80 Gathering a background of the mental state of a serial killer can help understand the motives and behavior. Studies by Julius Lidwig August Koch, Hervey Cleckley, and Robert Hare provide helpful background and foundations on the psychological factors of serial murder They suggest that common traits shared among serial killers are the desire for control, emotional distance, or repetitive compulsion. Koch describes personality disorders and explains the antisocial traits that many serial killers have with his study Die psychopathischen Minderwertigkeiten (Psychopathic Inferiority) from 1891.81 HerveyCleckleywrote The Mask of Sanity in1941,whichdefinesthese traits further, such as their lack of empathy, manipulative charm, and toxic behavior 82 Robert Hare completed his study, Without Conscience: The Disturbing World of the Psychopaths Among Us, which introduces the “checklist” that confirms the traits a serial killer has.83 These
79 RobertK Ressler,AnnW Burgess,andJohnE Douglas, Sexual Homicide: Patterns and Motives (Lexington,MA:LexingtonBooks,1988)
80 Ressler,Burgess,Douglas, Sexual Homicide: Patterns and Motives
81 JuliusLudwigAugustKoch, Die psychopathischen Minderwertigkeiten (FreiburgimBreisgau:H Loehle,1891).
82 HerveyCleckley, The Mask of Sanity: An Attempt to Clarify Some Issues About the So Called Psychopathic Personality (St Louis:C V Mosby,1941),accessedMarch31,2026, https://gwernnet/doc/psychology/personality/psychopathy/1941 cleckley maskofsanitypdf
83 RobertD.Hare, Without Conscience: The Disturbing World of the Psychopaths Among Us (NewYork: GuilfordPress,1993)
psychological explanations can help identify serial killers and help law enforcement recognize patterns. The researchers and psychologists also note that it is important not to rely solely on psychology The focus on this research and how it influenced criminal justice after the 1970s is becausetheuseofthestudiesbecameincreasinglynecessary,andchangesbegantohappen.
Even though research exists in many different fields, such as psychology and law enforcement, there are not a lot of studies thatexplainhowtheyallengagetogether.Psychology isviewedasresearchonmentalhealth,andlookingatlawenforcementisviewedasthefactsand proof. In addition, psychology was not needed for investigations that did not have patterns or repeating offenders; the psychology aspect only came into play when it was needed to understand the crimes and predict what could happen. Many people do not connect the two; however, they coexist when the investigation pertains to serial killers. Rather than focusing on one field, examining the relationships between them and how they influence each other is beneficial to the research. It is important to continue studying these topics in correlation to understand how serial killers in the United States haveimpactedpsychology,investigations,law enforcement, andthecriminaljusticesystem.Asserialkillersbecamemorewidelyrecognizedin the United States during the 1960s to 1970s due to media coverage and increasing use of technology, many advancements were made. Existing limitations in policing exposed the need for new approaches and tools, whichledtothedevelopmentofbehaviorprofiling,psychological research and analysis, and new forensic technology. These developments reshaped modern law enforcement and the criminal justice system, which influenced courtroom procedures, legal standards,andcriminaljusticepoliciesintheUnitedStates.
This paper will trace the relationships between psychological law enforcement advancements and changes in the criminal justice system in response to serial killers in the
United States since the 1960s. It begins with a historical contextexplainingtheearlylimitations of law enforcement during the 1960sandearlier.Thiswillexplaintheframeworkstounderstand how this shaped early investigations of serial killings and set up the understanding of how the developments started. It then goes into detail about how psychologicalresearchandanalysisare conducted. This will provide a clear understanding of the analysis, traits, background, and motivation behind serial killers. From there, I will explore how law enforcement created the development of specializedunits,suchasbehavioralprofilingunits,theimprovementofforensic techniques, and communication with the public. This section will also include details of interviews with serial killers and different tools and termsusedbylawenforcement.Next,Iwill explain the specific forensic and technological advancements. This will include details about programs, lab testing, and databases. Finally, the paper identifies the greater outcome of these developments, such as cold casesbeingsolved,killersbeingcaught,andlastly,theimpactonthe justicesystem.
Section1
Before the 1960s, law enforcement hadmanylimits,andtheextremelylocalizedsystems made it very difficult to catch and identify serial killers. Jurisdictionsexistedspecificallywithin cities and counties, and policing was confined within them. Each police departmenthaditsown way of recording information and keeping track of records, which was often not shared. They also conducted their own investigations, andtheknowledgeofthecasewouldremainwithinjust one jurisdiction. Due to the lack of sharing information or joint investigations, crimes were viewed as isolated incidents, and patterns were not detected. The systemic limitations allowed for serial killers to exist and kill for an extended period of time. In some cases, it would take months, years, or even decades to be caught, and in some cases, they were never identified.84
84 Egger"AWorkingDefinitionofSerialMurderandtheReductionofLinkageBlindness"
Their crimes had patterns to be connected; however, law enforcement departments lacked the systems and strategies to be able to identify them. This was considered the idea of linkage blindness. Professor Steven A. Egger, who taught criminal justice at the University of Illinois, defined linkage blindness. He coined the term and argued that when law enforcement could not see outside of their jurisdiction, crimes could not be connected as a result.85 Computer systems and databases marked the biggest change for this issue by creating systems and techniques to connectcrimes.
An example of these limitations can be seen when looking at the case of H. H. Holmes. Holmes was one of the first documented serial killers in the United States and operated in Chicago during the 1890s. During this time frame, Chicago was expanding due to the 1893 World’s Fair, which made it easy for missing individuals to go undetected. The population was growing rapidly due to temporary residents looking for opportunities. Holmes used this rapid expansion in the population to his advantage.Manyofhisvictims,specificallyyoungwomenhe had romantic interest in, were from other places anddisappearedindifferentways;thesefactors made it nearly impossible to connect them all to one killer.86 The women he murdered had no local ties and were visiting Chicago in search of jobs and better opportunities. Their disappearances were less likely to be noticed or investigated because there was low pressureon law enforcement. Holmes’s ability to remain undetected was not due to his specific level of caution but to the flaws in American policing. Holmes was only identified as the killer after being arrested for insurancefraud,andinvestigatorsbeganuncoveringhiscrimes.87 Newspapers
85 Egger "AWorkingDefinitionofSerialMurderandtheReductionofLinkageBlindness"
86 BiographycomEditors “HH Holmes’Victims:WhoWereThey?” Biography com https://wwwbiographycom/crime/hh-holmes-victims
87 JerrodBrown,EricHickey,andBlakeHarris,“H H Holmes:America’sFirstSerialKiller,” Forensic Scholars Today (ConcordiaUniversity,St.Paul),accessedMarch31,2026, https://digitalcommonscspedu/cgi/viewcontentcgi?article=1007&context=forensic scholars today
reported on his case, and Holmes gave a detailed confession. A newspaper article from 1896 described Holmes as a “multimurderer,” and it reflects on the shocking nature of his crimes. Authorities of the time could not understand theextentofhisactionsandhowhiscrimesexisted for so long.88 The victims who were from different states were not reported missing on a large enough scale to be tracked and connected to Holmes. Holmes’s most well-known victims were the family, and specifically the daughters of his well-respected business partner. He has other suspected victims, but the most well-known ones were of an upper-class white family, and they were well respected; they gained attention when they went missing. Comparatively, his other suspected victims were random young women, traveling alone, looking for opportunities. The lack of communication and information being shared between the authorities prevented them fromidentifyingpatterns.
In addition, forensic science was essentially nonexistent at the time during the investigation of Holmes. Without these tools, there were no reliable methods for connecting evidence from crime scenes. Ultimately, it took Holmes being arrested in Massachusetts for a separate crime of committing fraud to be investigated further and charged with all of the murders.89 The concept of “linkage blindness” was developed by criminologists to describe the specific inability of law enforcement to connect crimes, which was evident in Holmes’s case. Before the1960s,thisconceptwasseenfrequentlyduetothelackofdatabases,consistentrecord keeping and updating, and overall communication methods.Mostcrimesthatexistedinmultiple jurisdictions could not be compared, and police departments relied on handwritten reports and
88 The Journal,April11,1896,LibraryofCongress, https://tilelocgov/storage-services/service/sgp/sgpbatches/batch dlc forsyth ver01/data/sn84031792/print2430/189 6041101/0185pdf
89 Brown,Hickey,Harris,“H H Holmes:America’sFirstSerialKiller,” Forensic Scholars Today
memory. Even when some cases had noticeable similarities and patterns, there was no guaranteedwaytoidentifythem.
These limitations demonstrate how law enforcement systems were not capable or advanced enough to respond to early serial killers. Between a lack of communicationoutsideof jurisdictions and forensic tools andevidencenotbeingdevelopedenoughtouse,anenvironment for serial killers to go long periods of timewithoutbeingcaughtexistedfordecades.Casessuch as H. H. Holmesrevealedthattheissuesdidnotsolelyliewiththecriminalbutalsothesystemic struggles and capabilities. Law enforcement was unsure of how many crimes he hadcommitted and took a long time to apprehend him. By the time he was hanged, his victim count and understanding of his crimes were not fully understood. Newspaper articles from the time of his death and crimes do not make it clear exactly what happened, and law enforcement was unsure how to handle the case, as it was one of the first known serial killing cases.90 Murders were treated as isolated incidents, and without the ability to connectthem,lawenforcementcouldnot develop effective investigative tools and strategies. Holmes was one of the early cases that highlighted the need for further advances in criminal psychology, forensic science, andpolicing systems.
Section2
Serial killers brought up unique challenges for law enforcement because their actions were not understood, and there was not enough information about them. Mass and spree killers were able to be investigated using traditional investigative methods, and law enforcement had more of an understanding of these crimes and criminals. Serial killers committed crimes over a longer period of time and had very specific behavioral patterns. In the 1960s and 1970s, law
90 SanFranciscoCall,“HolmestheCastleSwindler,”May8,1896 LibraryofCongress, https://www.loc.gov/resource/sn85066387/1896-05-08/ed-1/?sp=1.
enforcement began to see a growing need to understand and investigate serial murder because cases were coming to light, and many crimes were being left unconnected. To gain an understanding, psychological research became a central focus for law officials and authorities because an understanding of psychology exposed that many serial killers share common traits and patterns, and understanding them would help connect crimes and apprehend suspects. Psychologists and law enforcement agents such as Robert Ressler, Ann Burgess, and John Douglas did intensive research on serial murderers and established that these repeat offenders demonstrate consistent behavioral traits and motivations.91 Gaining an understanding of these traits and habits allowed for the crimes to be analyzed for patterns and toestablishiftherewere any connections. Douglas and Ressler were partnersworkingfortheFBI,withthegrowingneed for investigative strategies of serial offenders, they investigated 36 serial killers. With the information and research they had, they worked to create a database that would be beneficialto connecting patterns of crimes to each other. This system was called the Violent Criminal Apprehension Program, also known as ViCAP.92 This era of psychological research directly changed how criminals were investigated, how psychology was analyzed, and how psychology became a tool to identify patterns and predict the behavior of serial killers. The developmentof behavioral profiling was created using this research with the help of improved technology and databases.
One of the most significant developments in understanding the behavior of serial killers was the conclusion that they shared psychological traits and behaviors. Robert Hare was a psychologist who identified a lot of the main commonalities between serial killers.
91 Ressler,Burgess,andDouglas, Crime Classification Manual: A Standard System for Investigating and Classifying Violent Crimes
92 “TheHistoryandPurposeBehindCriminalProfiling,” Criminal Justice Programs,accessedMarch31, 2026,https://www.criminaljusticeprograms.com/articles/the-history-of-criminal-profiling/
Characteristics such as a lack of empathy, impulsivity, inability to feel emotions, superficial charm, and manipulativeness are indicators of psychopathy. 93 Although Hare did not inventthe term psychopath, he did significant research on what it meanstobeapsychopathandconnected serial killers to his findings. As a personality disorder, the traits psychopaths share are out of their control. Along the lines of Hare’s research, Hervey Cleckley described serial killers as individuals who were able to act and present as normal while their morals and emotions were lacking compared to a normal person. These traits, however, allowed for serial killers to blend into society, and investigative strategies for traditional crimes made it extremely difficult to understand and identify them.94 Ted Bundy is a prime example of a serial killer who was described as charming, charismatic, and intelligent. He was able to use this to his benefit by gaining the trust of his victims. Bundy was described as being able to functionandflourishasa normal person; this included being successful in his career and having a thriving social life. 95 Identifying these traits emphasizedthatserialkillersdidnotalwaysappearinherentlydangerous, and the need for psychological profiling would benefitlawenforcement.Investigatorswereable tomovebeyondsurface-levelevidenceandanalyzetheoffenders'behaviormoresystematically.
Another major areaofresearchspecifictothepsychologyofserialkillerswasfocusedon the origins of their behavior A long-lasting debate questions whether their behavior is the outcome of nurture or nature. Starting in the early 1800s, research begantoprovethattraitsand aspects of a person are established when they are born. This argument shifted to include psychological studies of how environments can impact traits and personalities as well. By the
93 Hare,“Psychopathy,Crime,andCriminalBehavior,”in Criminological Theory: The Encyclopedia of Crime and Justice
94 Cleckley, The Mask of Sanity: An Attempt to Clarify Some Issues About the So Called Psychopathic Personality
95 DouglasB SamuelandThomasA Widiger,“DescribingTedBundy’sPersonalityandWorkingTowards DSM V,” Independent Practitioner 27,no.1(2007):20–22,accessedMarch31,2026, http://sampplpsychpurdueedu/ dbsamuel/Samuel%20&%20Widiger%20(2007)%20DIV42pdf
late 1900s, the focus of these studies was combined to focus on serial killers specifically.Some researchers believe that biological factors and genetic predispositions contribute to the development ofviolentbehavior Ontheotherhand,environmentalfactorsalsoplayasignificant role in shaping their behavior Many serial killers experience and are exposed to childhood trauma, abuse, or neglect, and these factors influence their psychologicaldevelopment.Edmund Kemper, for example, was known to have a bad relationship with his mother and experienced a lot of abuse and neglect growing up. In his later interviews, he claims his violence and actions are connected to his childhood experiences.96 Serial killers' traits and psychopathy rely on both predisposed genetic factors, but also their environment and influences play a large role in their traits. This connection gives law enforcement the ability to create offender profiles and identify similarities in criminal backgrounds. In addition to identifying their traits and backgrounds, researchers also focus on the motivations behind serial murder. Ressler, Burgess, and Douglas determined that many serial killerscommitcrimesbecauseoftheirdesireforpower,control,and fantasies. These motivations develop over the course of their crimes, which is why they often commit crimes over a long period of time and repeat patterns.97 In some of the interviews conducted by the FBI, Edmund Kemper described his motivations for his actions to be the compulsive urge and need for control, and essentially seeking revenge for his mother's behavior.98 Additionally, habits such as the killer's signature added to their fantasy and became something they had to complete. These signatures were also useful to identify patterns and common factors while looking at crimes. These patterns became essential in linking crimes and
96 “Chapter9:EdKemper,”in Understanding Serial Killers (OpenAccessText),accessedMarch31,2026, https://csi.pressbooks.pub/uncserkill/chapter/chapter-9-ed-kemper/.
97 Ressler,Burgess,andDouglas, Sexual Homicide: Patterns and Motives
98 “Chapter9:EdKemper,”in Understanding Serial Killers
developing investigative strategies, further proving how useful and influential psychology researchhasbeentolawenforcementpractices.
Section3
As the understanding law enforcement hadofserialkillers,agenciesstartedcreatingnew tools and methods to identify, track, and catch them. In the United States, the FBI and local police departments developed behavioral profiling, forensic databases, and investigative technology, which reshaped how investigations of serial murder were performed. In responseto cases where crimes were left unconnected and law enforcement faced challenges investigating crimes, these tools were developed. In the 1970s, the rise in awareness of serial killers set in motion a spiral of different systems and agencies. One of the most significant institutional changes was the development of specific investigative units. In 1972, the FBI formally created the Behavioral Science Unit, ortheBSU,atQuantico,Virginia.99 Thisunitactedasaresponseto violent and repeated crimes. Local police officers had an influx of cases theywerestrugglingto solve; therefore, the FBI stepped in to assist and made the investigations easier and specific to serial crime. This marked the shift from traditional policing to proactive methods in relation to repeated crimes. Rather than treating these murders as single events,theBSUlookedatpatterns and motives with the ability to observe psychological traits. Interviews by FBI agents such as Robert Ressler and John Douglas show theearlyattemptsandusesofprofiling.TheBSUturned into the modern Behavioral Analysis Unit, also known as the BAU, a specialized group that worked withthenewlydevelopedskillsinprofiling.Manytermsandtoolswerecreatedwiththis team of specialized agents. The necessity of these specialized units was made clear after failed investigations that led to serial killers going undetected or not being caught. They used
99 “SerialKillers,Part2:TheBirthofBehavioralAnalysisintheFBI,”FederalBureauofInvestigation, accessedApril1,2026, https://wwwfbigov/news/stories/serial-killers-part-2-the-birth-of-behavioral-analysis-in-the-fbi
interviews and case studies to further their research and honeinonthespecifics.Theinterviews with incarcerated serial killers helped them further understand patterns, personality traits, and their decision-making process. The interviews with David Berkowitz gave helpful insights into certain rituals and compulsions that motivate serial killers. Berkowitz, commonly referred to as Son of Sam, was a serial killer whomurderedsixpeopleandinjuredmorefrom1976to1977.100 These interviews were extremely helpful in gaining a background understanding of different elementsofserialkillers.
The BAU was able to understand and develop terms and tools that helped move their investigations and research from reacting to crimes to proactively preparing and understanding potential crimes and suspects. Their formal use of behavioral profiling allowed investigators to predict patterns, motives, and evenpotentiallyidentifyfuturetargets.Theywereabletousetheir work to predict the behavior of the offendersandconnectcasesacrossmultiplejurisdictionsdue to their uniqueness. The term MO, which standsformodusoperandi,wasusedandexplainedby John Douglas.101 Before these developments, the MO was heavily relied on for connecting crimes; however, law enforcement only looked to see a consistent MO in every crime. Douglas determined that serial killers adapt the MO until they find the one that fitstheirfantasyandlaw enforcement has to take that into account while connecting crimes.102 Interviews with incarcerated serial killers set up an understanding of their psychology and how tointerpreteach offender and potentially predict their actions. The use and advancements of profiling were a
100 “NotefromSonofSam:SerialKillers,” Crime and Punishment: Essential Primary Sources, Encyclopedia.com,accessedApril1,2026, https://wwwencyclopediacom/law/educational-magazines/note-son-sam-serial-killers
101 Ressler, Burgess,andDouglas, Crime Classification Manual: A Standard System for Investigating and Classifying Violent Crimes
102 Ressler, Burgess,andDouglas, Crime Classification Manual: A Standard System for Investigating and Classifying Violent Crimes
significant development and step forward compared to thelinkageblindnesspolicingpreviously practiced.
Forensic science and technology advancedwithtime,andoverallsocietalchangesduring the late 1980s. With behavioral science being the groundwork, serial killers also accelerated forensic developments. Before the 1970s, thecapabilitiesofforensicscientistswerelimitedonly to fingerprinting and blood typing.103 Evenwiththesetools,forensicsciencewasonlysomewhat helpful to investigations. By the 1980s and 1990s, the DNA analysis and enhancements made significant differences in investigations. This development was made by Sir Alec Jeffreys in 1984, which made a significant impact very quickly.104 DNA analysis was usedtolinkevidence from crime scenes to a single offender and identify suspects. Gary Ridgeway was caught a decade after his period of operation because of DNA collected fromhisvictims.Ridgeway,also known as The Green River Killer, committed his first murder in 1982andwasnotarresteduntil 2001. He pled guilty to 48 counts of murder in 2003 after thecasemadeadvancementsasDNA testing and analysis became more commonly used.105 The Combined DNA Index System (CODIS) was used to identify his DNA. This system was used by law enforcement nationally starting in the 1990s, which allowed agencies to compare DNAwitheverysampleinthesystem rather than in a single jurisdiction.106 Ridgewaywassuspectedearlyoninthecase,buttherewas not enough evidence to arrest or question him. DNA evidence, saliva foundonthebodiesofhis victims in 2001 to him which led to his arrest. The use of DNA as evidence is a solid way to identify suspects and is undeniable proof. It can also be used to provetheinnocenceofsuspects
103 RichardSaferstein, Criminalistics: An Introduction to Forensic Science
104 AlecJeffreys,“GeneticFingerprinting,”
105 KingCountySheriff’sOffice,“GreenRiverHomicideInvestigation,”accessedApril1,2026, https://kingcountygov/en/dept/sheriff/courts-jails-legal-system/sheriff-services/investigations/green-river
106 FederalBureauofInvestigation,“CODISandNDISFactSheet,”FBILaboratoryServices.
when their DNA is tested, anditdoesnotmatchtheDNAfound.Fingerprintevidenceisanother piece of evidence often used to identify suspects, victims, or prove innocence. Starting in the early 20th century, fingerprints were used; however, the development of the Automated Fingerprint Identification System, also known as AFIS, in the 1970s and 1980s made matching fingerprints available much quicker and able to match across different jurisdictions.107 The Combined DNA Index System (CODIS), the National Integrated Ballistic Information Network (NIBIN), and the National Crime Information Center (NCIC)wereotherdatabasesdevelopedto assist federal and state agencies in sharing information and identifying patterns or suspects. In addition, the internet and media usage aided investigations and supplied information to these databases. The media and the internet could also take information from the databases provided and publicize it to bring awareness and potentially seek assistance from the public. These databasessingle-handedlysolvecoldcasesandlinkserialkillerstomultiplecrimes.
Advancements in psychology and understanding serial killers led to the development of national databases, DNA analysis, and communication, which helped catch offenders from both cold cases, active cases and predict/prepare for future suspects. Law enforcement was able to overcome earlylimitationsandconnectcrimesacrossjurisdictionsandsolvecasesthatoriginally would have been viewed as isolated incidents. Together, these advances made ahugedifference in reshaping how law enforcement handled serial killers and crimes. The use of psychological research demonstrates how the rise of serial killer investigations was a challenge and a turning point in modernizing investigation techniques and tools. Law enforcement was able to go from long-lasting investigations often ending with no arrest and facing challenges such as linkage
107 “AFIS(AutomatedFingerprintIdentificationSystem),”Innovatrics,accessedApril1,2026, https://wwwinnovatricscom/glossary/afis-automated-fingerprint-identification-system/
blindness to solving past crimes, predicting crimes, understanding serial killers' motives and patterns,andconnectingcrimesthatexistindifferentjurisdictions.
Section4
The developments in psychology, forensic science, and investigative technology did not simply solve specific cases but systematically reshaped the entire American criminal justice system.108 Law enforcement gained the ability to understand, identify,andtrackserialoffenders, which was a drastic change from before the 1960s, when most cases were seen as isolated incidents and linkage blindness prevented cases from being connected. Crimes that were left unsolved were connected, and serial killers who remained undetected were identified and arrested. These changes represent a larger shift from reactive policing to a coordinated system that uses evidence and psychology to understand and prevent serial killers from being unidentified.
One of the most significant outcomes of these changes is the increased ability to solve cold cases.BeforeDNAandfingerprintnationaldatabasesweredeveloped,manycaseswereleft unsolved due to a lack of evidence or inability to connect suspects to specific crimes.109
Approximately 242,000 murders wereunsolvedfrom1980to2016,withthedatabasesandDNA evidence, that number is increasingly dropping.110 With these new databases and technology, investigators have access to revisitcasesandcollectandtestevidencethatwasunusabledecades earlier. Testing based onbiologicalevidencewasnotconsideredreliableandforyearswasrarely
108 AliceGnesin, Serial Killer Terminology and Its Effect on Criminal Trials,Fla Atl U Undergraduate L.J.(June5,2025),https://digitalcommons.fau.edu/cgi/viewcontent.cgi?article=1020&context=ulj.
109 US DepartmentofJustice, Prosecuting Cold Cases Using DNA: Scientific and Investigative Approaches (Washington,DC:OfficeofJusticePrograms,accessedApril1,2026), https://wwwojpgov/library/publications/prosecuting-cold-cases-using-dna?utm
110 “BringingResolutiontoColdCases:TheProsecutingColdCasesUsingDNAProgram,”Bode Technology,accessedApril1,2026, https://bodetech.com/bringing-resolution-to-cold-cases-the-prosecuting-cold-cases-using-dna-program/.
used in investigation; however, now it is used regularly and has closed many unsolved cases. This provides many benefits, such as closure and justice forthevictims'families,dueprocessto the offender, and reinforces the idea that criminals can not act without being caught, which provides comfort and a feeling of security to society ThecaseofGaryRidgewayhighlightsthis because after years, he was connected tohiscrimesthroughDNAtesting,andthefamiliesofhis victims wereabletogetclosureknowingwhathappenedtotheirfamilymembers.111 Ridgewayis one of many cases that represent the benefits and outcomes of the significant advancements in foreignscience,andthoseresponsiblecanbeheldaccountable.
In addition to solving cold cases, these developments and advancements for law enforcement have increased the number of serial killers that are identified and arrested. With forensic evidence, behavioral profiling, and national databases, investigators are able to narrow the suspect pool for each case and build stronger cases with more evidence against suspects. Rather than relying on eyewitnesses and circumstantial evidence, modern investigations are supported by scientific data that is more reliable.112 This has directly improvedtheeffectiveness of law enforcement investigations and processes, as well as strengthened the prosecutionswhen cases are taken to court. With DNA evidence and analysis of patterns, a jury has less room to allowoffenderstoevadeconviction.
The ability to connect crimes across jurisdictions, which, as aforementioned, was a significant challenge and weakness of earlier policing strategies, with the issue of linkage blindness. Before the 1960s, police departments operated independently and did not communicate outside their departments. Crimes that were committed in different locationswere not lookedatorcomparedtogether.Thiscausedpatternsandimportantinformationtobemissed,
111 KingCountySheriff’sOffice,“GreenRiverHomicideInvestigation,”
112 “CODIS(CombinedDNAIndexSystem),”UniversityofNorthTexasCenterforHumanIdentification, accessedApril1,2026,https://wwwunthealthedu/center-for-human-identification/codishtml
which is how so many serial killers were not caught. Their crimes were not connected to one person but rather as single-time cases with no connection. With the development of national systems such as NCIC and CODIS, information can be shared across local, state, and federal levels. Investigators can identify patterns between crimes even if they took place in different locations. As a result, serial killers are not able to use jurisdictional boundaries to their advantage, which many used to be undetected for years, decades, and potentially never get caught. The systems on a grander scale represent how serial crime and repeat offenders are understood, shifting from viewing them as isolated crimes to looking for larger behavioral patternsthatcanbeanalyzedandidentified.
Beyond investigative changes, outcomes, and strategies, the advancements of psychological research and forensic science had a significant impact on courtroom procedures. Psychological research and behavioral analysis are frequently used in court to provide context for the defendant's actions, motivations, and mental state. Expert witnesses, including forensic scientists, psychologists, and profilers, may testify about patterns of behavior, personality traits, and the possibility of reoffending.113 The use of these witnesses introduces the understanding of mental illnessesandpsychopathy Inabout40to50percentofcourtcases,amentalhealthexpert testifies.114 Court systems and judges must consider the distinction between mental and psychological disorders and legal accountability.115 This idea also brings up important questions that many researchers, law enforcement officers, lawyers, and more are considering, whether
113 “WhatIsForensicPsychology?”AmericanPublicUniversitySystem,accessedApril1,2026, https://wwwapuapusedu/area-of-study/security-and-global-studies/resources/what-is-forensic-psychology/
114 AmericanPsychiatricAssociation, Resource Document on Mental Health Courts (2020) https://wwwpsychiatryorg/getattachment/b808a481-c996-4c88-8afe-41605412dd48/Resource-Document-2020-Me ntal-Health-Courtspdf
115 “WhenCourtsEmbracePsychologicalScience,” APA Monitor on Psychology,AmericanPsychological Association,September2017,accessedApril1,2026,https://wwwapaorg/monitor/2017/09/courts-decisions
offenders are fully responsible for their actions or influenced by underlying conditions. The debate between mental illness and criminal responsibility has become a central issue in serial killer cases. Some killers exhibit traits that are associated with psychopathy; however, the legal system does not automatically excuse their actions and dismiss their responsibility Theinsanity defense is used occasionally, yet it requires proof that the defendant is unable to understand the extent and wrongfulness of their actions at the time of the crime. In most cases, this standardis not met as serial killers demonstrate some sort of planning and attempt to avoid being caught. Psychologicalevaluationscaninfluencesentencingdecisionsregardinglifeimprisonment,parole eligibility, or placement in psychiatric facilities.116 This shows the shift in the criminal justice system and highlights how scientific and psychological evidence are being used to influence legaldecisions.
Sentencing laws have also been impacted due to the rise of serial killers in the late 20th century, and especially with the growing understanding of their actions and the severity of their crimes. The use of the life sentence and death penalty has increased in severe cases, and the threat of serial crime has pushed policymakers to advocate for harsher punishments. Serial murder is often viewed as the most heinous and violent crime, and people wish for extreme punishments. A life sentence without parole is the sentence used when an offender is convicted of multiple homicides. In the case of Gary Ridgway, he was sentenced to 48 life sentences without parole. This demonstrates how the severity ofhiscrimesandsimilarserialmurdercases are punished extensively. Severe sentences like this can also be imposed in cases where the jurisdiction has established laws and systems in place for other repeat violent offenders, not specific to serial killers. A significant benefit of the forensic developments and overall
116 “HowForensicPsychologyShapesSentencingOutcomes,”FCPsychExperts,accessedApril1,2026, https://www.fcpsychexperts.com/how-forensic-psychology-shapes-sentencing-outcomes/.
advancements in investigative strategies is that theabilitytoidentifysuspectshasimproved,and the likelihood of a wrongful convictionhasreduced.117 WithDNAevidence,asecureconnection to the crime and offender almost guarantees the correct suspect will be prosecuted. It is also important to note that DNA is not completely foolproof. ThereisalwaysthepossibilityofDNA being found at a crime scene, but not being the offender's. DNA can be less useful to investigations based on where and how it was found at the crime scene. Although DNA is an incredibly useful piece of evidence that, in most cases, can help solve a crime, it must be interpreted in relation to each case. This demonstrates how the advancements in investigative techniques and psychological research have shaped the court for individual cases, but also the policiesandstructuresofthecriminaljusticesystemoverall.
Overall, the combined impact of psychological research, forensic science, and technological advancements and developments has reshaped both the investigative and prosecution processes of serial killers in the United States. These developments have corrected many of the early limitations of law enforcement that allowed for serial killers to operate undetected for long periods of time. The systems are now interconnected and effective, all of which is based on the evidence provided from these advancements. Solving cold cases, improving identification methods, integrating scientific evidence, and having a deeper understanding of a serial killer's psychology have helped evolve the criminal justicesystemand respondtothemanychallengesposedbyserialkillers.Integratingpsychologyintoinvestigations specifically granted an understanding of their motives, traits, and behavioral patterns. Forensic science and technology advancements introduced DNA analysis, fingerprint databases, and
117 EricF Connolly,“NewRulesforBetterScienceinForensicScience andNowAIComesAlong,” Michigan Bar Journal (StateBarofMichigan),accessedApril1,2026, https://www.michbar.org/journal/Details/New-rules-for-better-science-in-forensic-science-and-now-AI-comes-along ?ArticleID=5206
national systems such as CODIS, NCIC, and NIBIN, which provide evidence thatisundeniable and could link cases across jurisdictions, solve cold cases, and identify killers. Behavioral profiling and the development of specialized units like the FBI’s BAU created investigative strategiesandmethodstounderstandserialkillersandapprehendthem.
These advancements not only influenced the process of solving crimes but also had a long-lasting impact on the criminal justice system. Courtrooms incorporate psychological expertise, behavioral analysis, and forensic evidence to ensure theaccuracyoftheevidence,and the mental state or motives of the offender are considered. Legal standards, including fair trials andsentencingpolicies,alsomadechangestocreateasystemthatprovidesstrongerprosecutions and prevents wrongful convictions. This provides society with some comfort and hope in our systemsandprocesseswhenconvictingcriminalsandkeepingthepublicsafe.
The rise and recognition of serial killers in the 1960s and 1970s, due to an increase in coverage in the media, did not simply expose the weaknesses in lawenforcementbutultimately drove the modernization of investigative practices, psychological background, and legal standards. Serial killers drove law enforcement and researchers to improve psychological understanding, update techniques, tools, and terminology, andstrengthenthejusticesystem.The serial killers in this time frame shaped law enforcement as we know it today, and our systems continue to improve with data from these cases. Crimes are identified more officially, investigations are more effective, and prosecutionsaremoredependable.Thestudyandresearch of serial killers in multiple fields has improved and reshaped the UnitedStateslawenforcement and justice system in response to violent and repetitive crimes. This research is incredibly important and useful because it provides law enforcement with knowledge and tools to prevent future crimes, protect possible victims, and respond in a proactive way when crimes occur
Understanding the psychological and behavioral patterns of serial killers allows investigators to connect crimes and identify potential threats. Thiscanalsobeusedtoconnectcrimesthatwould have originally remained unsolved and seen as isolated crimes. Beyond catching and investigating serial crimes, the legal systems can get a better sense of security with convictions and make fair and just decisions for sentencing. Ultimately, studying serial killers is a helpful resource for ensuring justice is served and cases that occur in both the present and future are handled most effectively. This paper contributes to the understanding of serial killers and their impact on law enforcement and the justice system. This highlights the importance of learning about the context and history of something, which can create a better understanding of why things are the way theyareandhowtheycouldpotentiallybeimproved.Thisresearchshowsthe backgroundandgroundworkofwhyourmodernsystemsexistthewaytheydo.
Acknowledgments:
IwouldliketothankGiadaMusto,KymanniBabb,andEseoseOlogboselefortheircomments, corrections,andadvicethroughoutthedraftingandwritingprocessofthispaper
IwouldliketothankMrs.Mustoforguidingmethroughtheresearchprocessandthesmalland bigcorrectionsduringthewritingprocess.
Aspecialshout-outtomyfriendsandfacultymembersinthePBAdormfortheirpatiencewhile Iworkedoutmytopicandaskedforadviceandmotivation.InadditionIwouldliketothank HarrisonO’ConnorforhelpwiththefootnotesandcommentsasIfinisheduptheprocess.
Bibliography
AmericanPsychiatricAssociation Resource Document on Mental Health Courts 2020
https://wwwpsychiatryorg/getattachment/b808a481-c996-4c88-8afe-41605412dd48/Resource-Document-2020Mental-Health-Courtspdf
AmericanPublicUniversitySystem.“WhatIsForensicPsychology?”AccessedApril1,2026.
https://www.apu.apus.edu/area-of-study/security-and-global-studies/resources/what-is-forensic-psychology/.
APAMonitoronPsychology.“WhenCourtsEmbracePsychologicalScience.”AmericanPsychologicalAssociation, September2017 AccessedApril1,2026 https://wwwapaorg/monitor/2017/09/courts-decisions
BiographycomEditors “HH Holmes’Victims:WhoWereThey?” Biography com
https://wwwbiographycom/crime/hh-holmes-victims
BodeTechnology “BringingResolutiontoColdCases:TheProsecutingColdCasesUsingDNAProgram”Accessed April1,2026
https://bodetechcom/bringing-resolution-to-cold-cases-the-prosecuting-cold-cases-using-dna-program/
Bonn,Scott. Why We Love Serial Killers: The Curious Appeal of the World’s Most Savage Murderers.Naperville,IL: Sourcebooks,2014.
Brown,Jerrod,EricHickey,andBlakeHarris.“H.H.Holmes:America’sFirstSerialKiller.” Forensic Scholars Today. ConcordiaUniversity,St.Paul.AccessedMarch31,2026.
https://digitalcommons.csp.edu/cgi/viewcontent.cgi?article=1007&context=forensic scholars today.
Cleckley,Hervey The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic
Personality St Louis:C V Mosby,1941
https://gwernnet/doc/psychology/personality/psychopathy/1941-cleckley-maskofsanitypdf
Connolly,EricF “NewRulesforBetterScienceinForensicScience andNowAIComesAlong” Michigan Bar Journal AccessedApril1,2026
https://wwwmichbarorg/journal/Details/New-rules-for-better-science-in-forensic-science-and-now-AI-comes-al ong?ArticleID=5206
CrimeandPunishment:EssentialPrimarySources.“NotefromSonofSam:SerialKillers.” Encyclopedia.com. AccessedApril1,2026.https://www.encyclopedia.com/law/educational-magazines/note-son-sam-serial-killers.
CriminalJusticePrograms.“TheHistoryandPurposeBehindCriminalProfiling.”AccessedMarch31,2026. https://www.criminaljusticeprograms.com/articles/the-history-of-criminal-profiling/.
Egger,StevenA “AWorkingDefinitionofSerialMurderandtheReductionofLinkageBlindness” Journal of Police Science and Administration 12,no 3(September1984):348–357 https://wwwojpgov/pdffiles1/Digitization/103445NCJRSpdf
FederalBureauofInvestigation “CODISandNDISFactSheet”FBILaboratoryServices
FederalBureauofInvestigation “SerialKillers,Part2:TheBirthofBehavioralAnalysisintheFBI”AccessedApril 1,2026.https://www.fbi.gov/news/stories/serial-killers-part-2-the-birth-of-behavioral-analysis-in-the-fbi.
Fox,JamesAlan,andJackLevin.“MultipleHomicide:PatternsofSerialandMassMurder.” Crime and Justice 23 (1998):407–55.http://www.jstor.org/stable/1147545.
FCPsychExperts “HowForensicPsychologyShapesSentencingOutcomes”AccessedApril1,2026
https://wwwfcpsychexpertscom/how-forensic-psychology-shapes-sentencing-outcomes/
Gnesin,Alice “SerialKillerTerminologyandItsEffectonCriminalTrials” Fla Atl U Undergraduate Law Journal, June5,2025 https://digitalcommonsfauedu/cgi/viewcontentcgi?article=1020&context=ulj
Gutmann,Philipp “JuliusLudwigAugustKoch(1841–1908):Psychiatrist,Philosopher,andChristian” Würzburger medizinische geschichtliche Mitteilungen 25(2006):215–30 https://pubmedncbinlmnihgov/17333864/
Hare,RobertD. Without Conscience: The Disturbing World of the Psychopaths Among Us.NewYork:GuilfordPress, 1993.
HoganAssessments “ThePersonalityofSerialKillers” Hogan Assessments Blog,October11,2022
https://wwwhoganassessmentscom/blog/personality-serial-killers/ Innovatrics.“AFIS(AutomatedFingerprintIdentificationSystem).”AccessedApril1,2026.
https://www.innovatrics.com/glossary/afis-automated-fingerprint-identification-system/. Jeffreys,Alec.“GeneticFingerprinting.”
KingCountySheriff’sOffice “GreenRiverHomicideInvestigation”AccessedApril1,2026
https://kingcountygov/en/dept/sheriff/courts-jails-legal-system/sheriff-services/investigations/green-river
NortheasternUniversity “WhyAreThereFewerSerialKillersToday?”April26,2023
https://newsnortheasternedu/2023/04/26/serial-killer-decline/
PsychCentral “OCDandCrime”June7,2016
https://psychcentralcom/blog/ocd-reflections/2016/06/ocd-and-crime#1
Ressler,RobertK.,AnnW.Burgess,andJohnE.Douglas. Crime Classification Manual: A Standard System for Investigating and Classifying Violent Crimes.Washington,DC:U.S.DepartmentofJustice,FBI,1992.
https://www.ojp.gov/pdffiles1/Digitization/134597NCJRS.pdf.
Ressler,RobertK,AnnW Burgess,andJohnE Douglas Sexual Homicide: Patterns and Motives Lexington,MA: LexingtonBooks,1988
Saferstein,Richard Criminalistics: An Introduction to Forensic Science
Samuel,DouglasB,andThomasA Widiger “DescribingTedBundy’sPersonalityandWorkingTowardsDSM-V” Independent Practitioner 27,no 1(2007):20–22
http://sampplpsychpurdueedu/~dbsamuel/Samuel%20&%20Widiger%20(2007)%20DIV42pdf
SanFranciscoCall.“HolmestheCastleSwindler.”May8,1896.LibraryofCongress.
https://www.loc.gov/resource/sn85066387/1896-05-08/ed-1/?sp=1.
Schechter,Harold The Serial Killer Files: The Who, What, Where, How, and Why of the World’s Most Terrifying Murderers NewYork:BallantineBooks,2003
Stacy,Taylor.“SerialKillerStatistics.” Putting Methods to the Madness (Blog),UniversityofMichigan,March4, 2023.https://sites.lsa.umich.edu/qmss/2023/03/04/serial-killer-statistics/. TheJournal.April11,1896.LibraryofCongress.
https://tile.loc.gov/storage-services/service/sgp/sgpbatches/batch dlc forsyth ver01/data/sn84031792/print2430/ 1896041101/0185pdf
Thomas,Heather “EarlyAmericanSerialKillers” Headlines & Heroes,LibraryofCongress,October22,2019
https://blogslocgov/headlinesandheroes/2019/10/early-american-serial-killers/
UniversityofNorthTexasCenterforHumanIdentification “CODIS(CombinedDNAIndexSystem)”Accessed April1,2026 https://wwwunthealthedu/center-for-human-identification/codishtml
U.S.DepartmentofJustice. Prosecuting Cold Cases Using DNA: Scientific and Investigative Approaches. Washington,DC:OfficeofJusticePrograms.AccessedApril1,2026.
https://www.ojp.gov/library/publications/prosecuting-cold-cases-using-dna.
Vronsky,Peter. Serial Killers: The Method and Madness of Monsters.NewYork:BerkleyBooks,2004.
LIVELONGANDPROSPER: HOWFANDOMSURVIVEDANDTHRIVED
ByGiadaReneeMusto
“Fandomcankeepsomethingalive,andfandomcantakeitdown”isaquotebytheactor ChristopherHeyerdahl,whoappearedinshowssuchas Supernatural, Stargate: Atlantis, Van Helsing, and Peacemaker Hisquotebeginswiththepositivepoweroffandom,onhowitcan keepashowalivejustthroughthefans'adoration.Thenheturnstothedarkersideoffandom, abouthowifthefansarenothappy,thethingtheyusedtolovecandie.Throughthisquotehe putsfansinapositionofabsolutecontrol,butthathasnotalwaysbeen,andstillisnot,thecase.
Fanshavehistoricallyhadtofighttobeheardbycreators,andforthelongesttimetheirvoice didnotmatteratall.Sohowdidwegethere,toamomentintimewherefans'voicesareloud andstudioshavebeguntolisten?
Itisdifficulttopinpointtheexactbeginningoffandom.Mainlybecausetheversionof fandomasweknowittodayhasbeenaffectedbymodernlife.Whatmakesfandomsodifficult totrackisthatfandomhasaplethoraofaspectsfromdifferenthistoricalcommunitieswhich havecombinedintomodernfanculture.Themostgroundedbeginningoffandomtracesitsstart tothe1800swithmusicandtheatre.Fanstudiesfrequentlyreferencestheriseintheatregoers duringthe19thcentury,whichbroughttheatretothegeneralpublicbutalsobirthedtheideaofa “matineegirl”,whowereaudiencemembers–mainlywomen–whofrequentlyattended performancestoseetheactorsandnotnecessarilytheproductionitself.Thesegirlswereseenas obsessiveandgenerallydisapprovedofbysociety.Matineegirlsshareafewqualitieswith modernfandom.Firsttheyfrequentedperformancesmorethantheaveragepersonalthoughthese earlyfansdifferfrommodernmediafansasmatineegirlsareseenasmoreloyaltoactorsthan
themediatheypresent.Second,bothgroupswouldcritiqueandcommentontheperformances theysaw,normallyinoneorganizedplace.Formatineegirlsthiswasfrequentlyascrapbook withreviewsandclippings.118 Theirscrapbookswereprivateandnotforpublicuse,whichis verydifferentfromthepubliccommentsanddiscussionsfanshavearoundmediatoday Thereforeitisevidentthespacesmediafansoccupyhaschangedovertime.Originallyreviews werepostedinmagazinesbutnowtheyaremostlypostedtotheinternetusingnumerous platforms.Modernfansandmatineegirlssharesomeaspectsoftheircommunity,butfan practicestendtoexpandoutsideofthoseofthematineegirls.Becauseoftheirsimilaritiesand differencesmatineegirlsareoftenseenasaprecursortomodernfandom.
Fanfictionisoneofthemostwell-knownfanpracticesanditreceivesitsoriginsfrom multiplegroupsthatwereprominentatthestartofthetwentiethcentury Mostnotablyfanfiction hastiestothe1920sand1930smovementofsciencefictionliterarymagazines,whichshare manycommonalitiestofanzinesofthesixties.Theybothincludecommentsonpopularworks, fanmadeart,andfanmadeshortstories.Sciencefictionwasbeginningtohaveconventionsinthe midtolate1930s.Inaddition,earlysci-fifans'vocabularyinfluencedmanywordsinmodern fandomsuchas filk119 , fangirl120,and BNF (BigNameFan)121 122 GuinnessWorldRecordsnames thefirsteditionofthefanzine Spocknalia publishedin1967asthefirstfanfiction,althoughthey donotethatscholarsoftendebatewhatpiecestrulydeservethattitle.123 AbigailDerechotraces fanfictionpracticeallthewaybacktotheseventeenthcenturywithtwowomen'scopiesof The
118 Scrapbookofamatineegirl. Chicago Public Library. https://wwwchipubliborg/fa-scrapbook-of-a-matinee-girl/
119 Astyleoffolkmusicwrittenbyfansandoftensungatconventions.
120 Anyfanofmedia
121 Fansthatarewellknownthroughoutfandomcultureandhaveaminifandomoftheirown
122 KarenHelleksonandKristinaBusse Fan Fiction and Fan Communities in the Age of the Internet North Carolina:Macfarland&Company,2006,11
123 “FirstFanFiction” Guinness World Records,[n.d.],accessedFebruary9,2026. https://wwwguinnessworldrecordscom/world-records/444366-first-fan-fiction
Countess of Pembroke’s Arcadia,whichincludedtheirhandwrittennotesandadditionstothe story.ShealsonotesthefirstpublishedEnglishplaybyawoman, The Tragedy of Mariam, the Fair Queen of Jewry, wassimilartofanfictionasitisaretellingofthestoryofKingHerod’s wife.124 Shefollowstheserewritingsofclassictalesallthewaytothemodernpracticeofwriting fanfiction.Anothermajorchangeinthistimeperiodistheintroductionofmovies.Peoplewere attendingmovietheatresinhigherquantitiesleadingtomagazinesdedicatedtomovies.These magazinessharedmanycommonalitiesofthemodernfanzine,especiallywhenitcomestothe catchallplacetogetinformationonyourfavoritemovieorcelebrity.Theriseofmoviesbrought alongariseofactorswiththeirlivesbeingopentopublicadorationbutalsopublicscrutiny.
HenryJenkins’ Textual Poaches: Television Fans and Participatory Culture,isoften notedasoneoftheforemostwritingsonfandoms.Hepositionsfansas“poachers”whoborrow piecesofexistingmediaandcombinethemtogethertomakesomethingnew.125 Henotesthat mostfans'drivetodothiscomesnotonlyfromaloveofmediabutalsoforslightdiscontentment onthedirectionthestoryhasgone,andthewishtoretellitthewaytheywantittobe.Mostfans dothisthroughfanfiction,whichhasaplethoraofstorytellingtricksandformulastohelpsatisfy fanswishes.Hethengoesontoexplorefandomasaculture,howfansinteractthrough conventions,fanzines,andinternetforums.Helooksatfandomasacommunityofpeopleunited byacommonloveofmedia.Jenkins’ideasaboutfandomasaculturearecontinuedinStevenE.
Charlotte’s Historical Binge-Watching: Marathon Viewing on Videotape,whichexploreshow bingewatchingisusedasasocialactivitywithinfandom.Shealsoexploresbingeingasfan labor,asfansspendhoursrewatchingashowtocompilealltheinformationtheycanonevery episodeinordertoaddtothefandomscollectiveinformation,withthehopethatthenew
124 KarenHelleksonandKristinaBusse Fan Fiction and Fan Communities in the Age of the Internet, 67
125 HenryJenkins, Textual Poachers: Television Fans and Participatory Culture NewYork:Routledge, 2013
informationtheyfindwillbeusedbyanotherfansomeday.Shearguesthatbingewatchingcan beaworkoffanlabor,andalsoaplaceforsocialconnectionandcommunitybuilding.126
Fandom Before “Fan” byDanielCavicchiexploreshistoricalfandomsinanattemptto connectthemtofandominthemodernday Heequatesextrememusiclovers,baseballfans,and theatregoerstomodernfandomwitheachpracticesharingafewsimilarities.Stillthereisno historicalfandomthatperfectlymatchesthefandomweknowtoday.Lastlyhepointsoutthat spottinghistoricalfandomsisdifficultasfanswereviewedasoverlyobsessedandmentallyill, makingithardforfandomstogrowduetofearofbeingdeemedinsane.127 Laterdowntheline,in herarticle Early Vidding and Its Precursors,FrancescaCoppadiscussestheriseofvids,which areclipsfromashowwithmusicplayedoverthem.Sheclaimsthe Star Trek fandomgavebirth tothevidbecauseoftheshow'sfeminineaestheticwhichmadeitadaptabletothefemalegaze. Inadditionthefandomwasactiveduringatimeoftechnologicaladvancementwhichallowed fanstocreateinnewways.
128 Lastly, “Thank the Maker!” George Lucas, Lucasfilm, and the Legends of Transtextual Authorship across the Star Wars Franchise byTaraLomaxanalyzesthe complexityofownershipandauthorshipinapopularpieceofmedia.SheusesGeorgeLucas’s relationshipto Star Wars anditsfandomtoexplorehowfanstreatasinglecreatorofafranchise, particularlybecauseGeorgeLucasveryadamantly“disowns”fanfictionofhiscreations.Inthe endshedeterminesGeorgeLucasbeingthesolecreatorof Star Wars puthimindirectopposition ofhisfans,especiallyduetotheircontrastingviews.129
126 CharlotteE Stevens,“HistoricalBinge-Watching:MarathonViewingonVideotape”In Binge-Watching and Contemporary Television Research,editedbyMareikeJenner,23–39 EdinburghUniversityPress,2021, accessedFebruary9,2026
127 DanielCavicchi,“FandomBefore‘Fan’:ShapingtheHistoryofEnthusiasticAudiences” Reception: Texts, Readers, Audiences, History 6(2014):52–72,accessedFebruary9,2026
128FrancescaCoppa,“EarlyViddingandItsPrecursors,”In Vidding: A History,67–92,Universityof MichiganPress,2022,accessedFebruary9,2026
129 TaraLomax,“‘ThanktheMaker!’:GeorgeLucas,Lucasfilm,andtheLegendsofTranstextual AuthorshipacrosstheStarWarsFranchise,”In Star Wars and the History of Transmedia Storytelling,editedbySean GuynesandDanHassler-Forest,35–48 AmsterdamUniversityPress,2018,accessedFebruary9,2026
Whilealotofresearchhasbeendoneonthefancommunitytherearestillplentyofgaps inthestudyoffandoms.Notalotofresearchhasexploredminoritycommunitiesotherthan womeninfanfiction.Inadditionnotalotofresearchhasbeendoneonthemorerecentchanges tofandomthattechnology,mainlyimprovementstotheinternethavecaused.Whilefandomis stillrecognizabletothe Star Trek fansofthe1960s,itvarieswidelyinmanyaspectsthathave notyetbeenresearched,partiallybecausethesechangesaresorecenttomemory.
ItiseasytoquestionwhyanyresearchintofandomisimportanttosocietybutIthinkits importanceboilsdowntoonesimplething:fandomcelebratespeoplewholovesomething.In thisworldthatmattersalot.Fandomishardlygoingtostopwars,curecancer,oreradicate oppression,butitdoesunitepeople,anditdoesthatthroughlove.Understandingtheconnection betweenfanshelpsusunderstandconnectionsbetweenpeople.Attheendofthedayeveryoneis afanofsomething.Maybetheyareafanof Harry Potter, BadBunny,ortheNewEngland Patriots,itdoesnotmatter.Whatmattersisthattheylovesomethingandtheyareproudofit.So attheendofthedayresearchingfandomisreallyresearchingloveandhowitmanagesto surviveinaharshworld.
Themostcommonthemesoffandomareownership,authorship,community,andsecrecy Fandomhashistoricallybeenacombinationofallthree,withfansstrugglingtomaintaincontrol ofmediatheydonotactuallyhavepowerover,andfansbuildingacommunitythatisrejectedby themainstream.Betweenthe1920sandtheearly2000smediafandomhaschanged,butone constantistheeverevolvingrelationshipbetweenmediafandomandcreators.Whileoriginally creatorsandcompaniesmaintainedcontrolovermedia,duetoasteadyriseoftechnologysince the1960sthepowerofafandomitselfhasgrowninnumerably,allowingfandomtorivalthe controlofcreators.Yetwhilefandomhasonlyrecentlyleveledtheplayingfieldbetweenfans
andproducers,fandomculturewouldnotexistinthesamewayifitwerepartofthemainstream media.
ThroughoutthispaperIwillbemovingchronologicallythroughhistorybysections, analyzingfandominthattimeperiodandthechangesthathaveoccurredfromthelast.Iwill beginfromthe1920stothe1950sandlookatsciencefictionfandomalongwithmoviefandom. BygoingfromthesetwoopposingsidesIhopetocaptureallaspectsoffandomsatthistimeand howtheymergeintothemediafandomsweknowtoday.Mostoftheanalysiswillfocusaround magazinesandtheirconnectiontotheearlyfandomculture.
NextIjumptothe1960sand1970s,whichisaveryimportanttimeforfandom.Iwill discusstheriseofStar Trek, touchingonsomeofthemonumentalachievementsthefandom madeduringitsfirsttwodecades.Themainfocuswillbeon Star Trek anditscreatorGene Roddenberry,andhowhepromotedthegrowthofthefandom.Inadditionthepaperwilltouch onfanconventions,fanzines,andvidsastheyallblossomintoexistence.Theninthe1970s Star Wars enterstheconversationandstartsawholenewsci-fimovementwithtvshowsand blockbustermovies.Thesedecadesalsobroughttheriseofthebuddycomedylike Starsky&Hutch whichdrewmany Star Trek fanswholovedKirkandSpock.Thesefanscause mediafandomtoexpandoutsideofthesci-figenreithadstartedin.
Movingontothe1980sto1990sweseeacontinuationofthepatternsetbythelasttwo decades.Thereisalottotalkaboutinthesedecadesincluding Cagney and Lacy, andmultiple new Star Trek shows.Inadditioncamethecontinuedriseofblockbustermoviessuchas The Terminator andthesecondtwo Star Wars films.I’lldiscusstheriseofAmericanswatching Britishtvasitbecomesmorewidelyavailable.LastlyI’lldiscusstheriseoftheinternetandhow itsearlydaysaffectedfandom.
Thepaper’slastsectionwillfollowthe1990stotheearly2000s,analyzingtheeffectsof easilyaccessibleinternetandhowthatcausedacollisionoffandoms.I’lldiscusshowthese advancementsintechnologyalteredpre-existingfandompracticessuchasviddingandfan fiction.I’lldiscussthemajorworksofthedecadelike X-Files, Buffy the Vampire Slayer, andthe prequel Star Wars movies.Thispaperwillemphasisethegrowthofmediafandomsinceits foundingduetochangesincultureandtechnologyovertime.LastlyIwilldiscusshowfandoms growthandchangeshavemadeitselfmorevisibletomainstreammediaandhowthataffectsits futuregrowth.
Duringthe1920sto1930sScienceFictionculturewasboomingwithshortstoriesin magazinesleadingtocreativewritinginthegenrebecomingincreasinglycommonand discussed.Atthesametimetheriseoffilmbegananeraofpeoplededicatedtowatchingfilms andtalkingaboutthem.Pastimeslikefilmsandsciencefictionmagazineswereincreasingin popularitybecausepeoplewishedtoescapefromtherealityoftheGreatDepressionbyusing media.Overthesedecadesfandomwastalkedaboutinmagazinesbutremainedhiddenfromthe publiceye.Aspectsofbothsciencefictionfandomandearlymovieculturearecombinedin presentdaymediafandom.
Duringthe1920smovieswereincrediblypopular,astheatreswerewidelyavailableand fairlyinexpensive,makingitanactivitythatpeopleofdifferingsocialclassescouldparticipate in.Inresponsemoviesmarketingincreasedtoputanemphasisontheactors,notjustthe characters,andmagazineswerecreatedtodiscussallthingsmovierelated.ClaraBowwasthe mostpopularactressofthelate1920sandearly1930s,especiallyafterhermostnotablemovie entitled It. Themoviefollowsadepartmentstoreemployeeassheattemptstodatetheownerof thedepartmentstorechain. It’ssignificancecomesfromitsideasaboutdesireandconsumption
asthemoviecontainsarolereversalofthenormasthefemalemaincharacter,playedbyClara Bow,isalwaysinactionandobservingthemalemaincharacterinorderto“havehim”.130 Dueto thecentralthemeoftheplotbeingseeingandhaving,themovieplaysintofansdesiresasthe viewingcommodifiestheobject.Byblurringtheselinesthemovieplaysintoaspectsofearlyfan cultureasmoviegoersoftendiscussednewmoviesinmagazineswhichalsosoldinformation abouttheactorsasiftheywerealsoaproduct.
Earlyfanmagazinesbridgedthegapbetweenviewer,artist,andproduct.Photoplaywas oneofthemajorfilmmagazinesinthefirsthalfofthe20thcentury,withpublicationsincluding reviews,tips,andscandals.Unlikefanzines,Photoplaywasnotpublisheddirectlybyfans.While somesectionsofferedplacesforfanstowriteshortreviewsofshows,mostofthemagazinewas written,edited,andpublishedbyaregularsetofstafflikea“normal”magazineatthetime.That isnottosaythatthecreatorsofthePhotoplaydidnotenjoyfilmsandcouldnotbefans themselves,itisjusttosaythattheywerenotallfans.A1931issueofPhotoplaycontainsan articleentitled“Clara’sMicrophoneFright”whichdiscussesClaraBow’srecentillnessthatno onecanidentify,andherminifeudwithanotheractressoverherown“stammer”,whichin contextreferstoastutter 131 Thearticleoutlinestheentireeventsoftheincidentandhowitcould affectBow’scareer Itisclearthemagazineisofferingspeculationandaddingfueltothefirein ordertokeepfansentertained.Theauthorprovidesprivatedetailstomakethereaderfeelthey haveinsiderknowledge,cementingthemagazineasthesourceformorepersonalinformationon fans'favoritecelebrities.Thisisaclearexampleofhowmagazinesprovidedaglimpsebeyond thescreenbutfallsclosertotheideaofcelebrityfandomthenthemodernmediafandom.
130 MarshaOrgeron,“Making‘It’inHollywood:ClaraBow,Fandom,andConsumerCulture,” Cinema Journal 42,no 4(2003):76–97,accessedFebruary13,2026
131 Photoplay[Jul-Dec1931]MediaHistoryDigitalLibrary. https://mediahistoryprojectorg/readerphp?id=photo41chic
EarlierPhotoplayissuesdisplayasectionentitled“Brickbats&Bouquets”which containslettersfromreaders,whoarefansofcinemaastheyhavetakentheirtimetowritetoa cinemamagazine.A1923Photoplayissue’s“Brickbats&Bouquets”sectionhasoneletter askingthemtowriteasegmentonMayMcAvoyassheisanunderratedactressinthemindof thewriter,anotherclaiming“TriflingWomen”isthebestpicturetheyhaveseeninsixmonths duetotheincredibleactingandthatwhenevertheyseeamoviemadebyRexIngram Productionstheyarereadytobeimpressed,andlastlyalettercritiquingthemagazineforcaring somuchabouttheagesofactorsbecauseitisirrelevanttotheirartform.132 Justafewpageslater isasectiondedicatedtoreviewofcurrentfilms,whichprovidesbriefreviewsofcurrentmovies beingreleasedsothatreaderscangetaglimpseofwhattheymightwishtowatch.Bothofthese sectionsdemonstratethefaninteractionandcommunicationthathappenedintheseearly magazines.Whilefansmightnothavebeenengagingindirectconversationovermovies,they participatedinwiderconversationsviatheirentriesinthemagazine.Theywerenottalking directlytoanyspecificfanbuttheirwordsdidnotgounsaid.Inadditionitisclearthemagazine ismeanttohelpfansdecidewhatmoviestowatchorwhichactortofollow,allowingthema guidetotheworldofearlymediafandom.Sowhilefandiscussionsandactivitieswereoccurring aroundcinema,itwaslesscommontooccurinpublicandinsteadoccurredviaindirectformsof contentsuchasmagazines.
Intandemwithearlymoviefandom,thesciencefictionfandomwasgainingtraction throughsimilarmeans.Thegenreofsciencefictionisolderthanthe1930’s,withMaryShelley’s Frankenstein beingnotedasoneofthefirstbooksofthegenre,butitisinthisdecadethatthe creationofthesciencefictionmagazineoccurs.Themostnotablemagazineis Astounding
132 Photoplay[Jul-Dec1923]MediaHistoryDigitalLibrary. https://mediahistoryprojectorg/readerphp?id=photoplayvolume22425chic
Stories,whichisoftenconsideredthefirstsci-fimagazineinprintalthoughitwasfollowedby manyothers.Thesemagazineswereslightlydifferentfromtheircinemacounterpartsasthey offeredlesscelebrityinsightandinsteadfocusedonpublishingstories.Eachstorywaspublished intheofficialmagazinesbuttheyallgeneratedtheirownfanfictionandfanarttogoalongwith it.Thesemagazineswereamodelforfanzineswhichbecamepopularduringthe1960s.
Fanzine’sfollowedasimilarformatbutinsteadofsharingcompletelyoriginalstories,fanzines sharedfanfictionstories.Inadditionscience-fictionmagazines,forthemostpart,werepublished byanofficialpublishinghouse,whilelaterfanzinesareselfpublished.Understandingthe commonalitiesanddifferencesbetweensci-fimagazinesandfanzines,helpstounderstandthe overallshiftoffandomtoberunbyindividualfansinsteadofonlybylargecompanies.
Itisclearthatduringtheseearlydecadesofthe20thcenturyfandomispresentwithin society.Yetfandomisnotcollectedintolargegatheringsofphysicalpeoplebutrathermadeup ofreadersofmagazineswhocommunicatewitheachotherthroughthewordsonthepage.This setsthebasisforfandomtobestrongbutstillhiddenfromthemainstreammedia.Whileearly fandomduringthesedecadesmightappeartobewidelydifferentfromwhatisgenerally consideredfandom,alotofthepracticestheyhadsuchaswriting,art,andsharingbehindthe scenesdetailsactedasmodelsformodernfanpractices.Understandinghowfandomcamefrom amoredisorganizedandundergroundcommunityinordertokeepitselfsafefromthejudgement ofthemainstream,helpstoexplainhowitwasformedintoitsmoderniteration.
Beginninginthe1960sfandombeginstoblossomas Star Trek bringssciencefictionfans togetherastheyfightforthelifeoftheshow.Itwasperfectlysituatedwithinthetimetogain fansfrommultipledemographics.Itdrewinsciencefictionfans,andhousewiveswhopreferred moreemotionaltelevision.Theshow'sthemesofhopeandexplorationworkedtocalmAmerican
fearsovertheColdWar.Inadditionduringthisdecadefanfictiongrowsasfanscreatetheirown magazineswitheasieraccesstoprintingtechnology.Bytheendof1970sthegrowthin technologyhasallowedfanstocreateoriginalworksotherthanfanfiction,suchasvids133 The smalltechnologicaladvancementsofthedecadesallowedforfandomtogrow
Thereisadebatearoundwhatshowhadthefirstfandombutmostwouldattributethe honorto Star Trek. Theoriginalshowranforthreeseasonsfrom1966to1969.Itfollowedthe crewoftheEnterprisewhichexploredthedepthsofspaceandalienplanets.Theshowearnsthe titleofthefirstfandombecauseitwasthefirsttimethatfandomwaswidelytalkedaboutand acknowledgedbymainstreammediaorproducers.Thisshiftoccurredbecausethefansofthe showbecamesovocalandusedtheircreativityinnewways.Forexample,thecredittothefirst fanfictionoftengoestoa Star Trek fanzinecreatedbytwofemalefansentitled Spocknalia. The magazine'sissuestellalotaboutthefandom.Forstarters,GuinnessWorldRecordsconsidersthe firstissueofthefanzineastheFirstFanFiction,althoughitiscleartheoriginsofthepracticego backfurther.
134 Eachissuecontainsworksoffanfiction,fanart,andalsoinsiderinformationabout thetvshow.InfacttheveryfirstissuecontainsabriefletterfromLeonardNimoy,theactorof Spock,andabiographyofSpockthathecreated.Alaterissueofthefanzineevencontainsa letterfromGeneRoddenberry,andportionsaboutSpockprovidedbywritersoftheshow Inthis waythefanzineallowsfanstogaininsightsabouttheshowthatcansupplementtheactual episodes,butisalsonotrequiredtounderstandtheshowitself.Thisiswhatseparatesfansfrom theaverageviewer,fansgooutoftheirwaytofindextrainformationabouttheshowinorderto enhancetheirenjoymentofit.
133 Avideoorcompilationofimagesfromamovieorshowsettomusictoconveyanewstoryormeaning
134 “FirstFanFiction” Guinness World Records,[n.d.],accessedDecember7,2025. https://wwwguinnessworldrecordscom/world-records/444366-first-fan-fiction
Thefanzinesofthe1960ssuchas Spocknalia showtheirprogressionfromsciencefiction magazinesasaddressedearlier.Themaindifferencebetweeneachmagazineisnotentirelythe content,astheybothcontainartandstories,butratherhowtheyarebeingeditedandpublished. Sciencefictionmagazineswereoftenpublishedthroughtraditionalpublishinghousesbut fanzinesarenot.Inthesecondvolumeof Spocknalia thetwoeditorsandpublishersintroduce themselvestotheirreadersanddeclarethemselvesasloversofthesci-fiandfantasygenres.135
Thefirstisa25yearoldwomannamedShernaComerfordwhowaswritinghermastersthesis andfocusedonbiologyandpsychologyincollege.Shenotesthatsheisengagedtoamanwhois afanhimself.Inadditionshetalksabouthowherneighborsinherroominghousedonotknow whatsci-fiisbuttheythinksheisniceanyways.Shefollowsthisstatementwithalaugh.136 This smalldetailmakesfandom’ssecrecytooutsidersobvious.YetComerford’ssmalllaughatthe endcommunicatestoheraudiencesomethingtheyallknew,ifherneighborsfoundoutabouther fandomlifetheywouldprobablythinkverydifferentlyofher.Thissmalldetaildisplayswhythe secrecyoffandomwassoimportanttofans,becausetheydidnotwanttobeostracizedby society. Spocknalia’s othereditorisa24yearoldwomannamedDevraLangsamwhoisa children’slibrarianwithamastersdegreeinlibraryscience.ComerfordandLangsamare examplesofcommon Star Trek fanswhowereoftenwell-educatedmiddleclasswomen.This meansthatmostfans,whiletheyhavesomepowerwithinsociety,oftenarenotthepeoplewho makelargerdecisions,particularlyinthe1960s.Everythingthesefansdoisself-madeandnot backedbylargeorganizations.Theyaredoingthispurelyfortheirloveofmediaandtheirwish tocontinuehavingitsstoriestold.Theymaynothaveanycontrolonwhatofficiallyhappens withintheshowof Star Trek andyettheyarestilltakingthetimetoexertsomeownershipover
135 DevraLangsamandShernaComerford,“OfftheTop”
136 DevraLangsamandShernaComerford,“OfftheTop,” Spocknalia Volume 2, 1968,accessedApril3, 2026,https://archiveorg/details/SpockanaliaV2/page/n5/mode/2up
thecharactersanduniversebypublishingstoriesinthe Star Trek universethatareauthoredby fansinsteadofthetelevisionindustry.
The5thissueof Spocknalia featuresafanfictionstoryentitled“ToSummontheFuture” byJaunitaCoulson.137 Thisstoryexemplifieshowalthoughfansoftenlovetheshowsthey watch,theyoftenendupdisagreeingwiththedirectionthewritersgoin.Tomakeupforthe dreamsnotbeingrealizedintheshowitself,theyturntotheirowncreativitytomakeithappen. Inherstory,CoulsonwritesfromtheperspectiveofNurseChapel,acharacterwhotheshow focusesonminimally.While Star Trek hadanincrediblydiversecastforthetime,thefemale characterswerecommonlyusedtoadvancetheplotofthemenandrarelyhadplotsoftheirown. Coulsonremediesthisproblembywritingherownstorywhichgivesaplottothe underrepresentedfemalecharactersoftheshow Before Star Trek popularizedfanzines, fanfictionsuchasCoulson’swascertainlybeingwrittenbutitdidnothaveaconvenientmeans ofmassdistribution.NowthatfanslikeComerfordandLangsamcanprintandcopytheirown works,itmakesiteasierforfanstoseeunderrepresentedcharactershavestoriesoftheirown throughfanfiction.Coulsonprovidesaclearexampleofhowtechnologyhelpedfansbecome authorsandallowedthemsomecontroloverthemediatheyconsumed.Whiletheymaynothave beenabletoeasilyaltertheactualeventsoftheshow,theywereabletosharetheiroriginalideas forhowthestoryshouldunfold.Whilefanswereunabletoowntheshowtheyloved,theywere stillabletobecomeanauthorofitsevents,evenifitwasinanunofficialmanner.
Fanzinesshowhowfandomspreadslongdistancebutfanconventionsarewhenfans begintocometogether,markingfandomasatruesocialcommunity.TheScienceFiction communityhadbeenholdingconventionssincethe1930sbutin1972thefirst Star Trek
137 JaunitaCoulson,“ToSummontheFuture” Spocknalia Vol5:13-19,accessedDecember8,2025. https://archiveorg/details/SpockanaliaV5/page/n17/mode/2up
conventionwasheld,drawingover3,000people.By1974theconventionhad15,000people attending,with6,000morepeoplebeingturnedawayatthedoor.138 Thesenumbersmorethan provethescaleandspeedwithwhichfandomgrewdueto Star Trek Thefandoms'growth occurredfornumerousreasons,amajorpartofitsimplywastheshow'scontent.Itssci-fi elementsdrewfrompre-existingsci-fifandom,itsdepictionofemotionandfemalecharacters appealedtowomen,anditssocialcommentarydrewinacademics.Theshowsimplyhitkey pointstodrawinmajortargetaudiencesbuttheonesthatmadeitexplodewerethewomen.The maindemographicofmediafanstendstobemiddleclasswhitewomen.Itisimportanttonote thatmenarestillinvolvedinfandombuttheymakeupagreaterpercentageofsportsfandomor simplysci-fifictionwritingfandomsratherthanthemediafandomthispaperhasfocusedon. Womenwerethemainfanlaborers,creatingfanfiction,makingfanzines,startingconventions, andinventingthevid.Onefanhistoriancalculatedthat83%offandomwritersinthe1970 Star Trek fandomwerewomen;thatnumberwentupto90%by1973.139 Thegrowthoffandomwas sodrasticthatin1975thebook Star Trek Lives! waspublished,whichexploredfandomshistory, whichonlyofficiallydatedbacklessthanadecade.Itsfinalchapterdescribedthefanfiction communityandactuallyopenedmanymoderatefansuptotheideaoffanfiction,causingthemto beginwritingaswell,andcausingthephenomenonthebookdepictedtogrow 140
Anotherformoffancreationsproutedduringthe1970sthankstoa Star Trek fannamed KandyFong,vids.Theseareimagesorvideoclipsfromapieceofmediastrungtogetherwith backgroundmusicinordertotellanewstory.Thefirstvidshemadewaspresentedviaamanual slideshowthatshetimedtochangewiththemusic.Shefirstmadeitforhercollege's Star Trek
138 FrancescaCoppa,“ABriefHistoryofMediaFandom,”in Fan Fiction and Fan Communities in the Age of the Internet, edbyKarenHelleksonandKristinaBusse(NorthCarolina:Macfarland&Company,2006),46
139 FrancescaCoppa,“ABriefHistoryofMediaFandom,”46
140 FrancescaCoppa,“ABriefHistoryofMediaFandom,”46-48
clubbutthenpubliclyshoweditataconventionin1975,andimmediatelybecamebelovedby thefandom,withalineoutthedooraspeoplewouldfinishandthengobacktotheendofthe linejusttoseeitagain.141 Thefirstpartofthevidisimagesfromtheshowwithherown Captain’slogrecordedoverit,thenthesecondsegmentendsthevidwithclipsfromtheshow playingasthefilk142 song“WhatDoYouDoWithaDrunkenVulcan”playsinthebackground.
Ayearlatershefolloweditupwithoneofthemostpopularvids,“BothSidesNow”which exploredthecharactersofSpock’sdichotomyofidentitythroughvisualsandLeonardNimoy’s, theactorofSpock’s,renditionof“BothSidesNow.”Thisvidexploredwhatisattheheartofa lotoffandom,andthat'stheideathatcharactersarenotasheternormativeastheyappear.Many Star Trek fanfictionwriterswriteaboutK/S,whichisKirkandSpockinarelationship,which foundedthegenreofslash,agenrewherehomosexualcouplesaretheheartofthestoryline.
“BothSidesNow”exploresSpock’sdualidentityashalfVulcanandhalfhuman,butalsothe subtextualelementsoftheshowthatindicatethecharactermightbebisexual.Whilefanfiction haswrittenabouthomosexualrelationshipsforquitesometime,Fongisbeingverydeliberate withhermusicandscenechoicestopulltheoriginallysubtextualelementsoutintotheopen wheretheycanbereadasclearlytextualideas.BydoingthisFongisexertingauthorshipand ownershipoverhercreation.Whileshedoesnotownanyoftheimagesoraudiosheused,the wayshemergedeachpiecetogethertocreatehervidisanewstorythatshehascompletecontrol over,verysimilartofanfiction.
WhileFongcreatedvids,therewerealotofpiecesthatfellintoplaceinordertokeepthe practicealive.Forstarters,GeneRoddenberry,thecreatorof Star Trek, broughthertothestudio
141 Fong,Kandy 2014 InterviewwithKandyFong ConductedbyFrancescaCoppa In"Materialityand Object-OrientedFandom,"editedbyBobRehak,specialissue, Transformative Works and Cultures, no 16 https://journal.transformativeworks.org/index.php/twc/article/view/535/431.
142 Songsmadebyfansthatcontainfanspecificlyrics
andletherpickoutslidestouseinordertomakevids.143 Bydoingthishewasextending ownershipoftheveryframesthatmakeup Star Trek, toafan.Hismotivationwasnotpurelyto helpfancreations,itwasactuallytoattempttoleveragethestudiotomake Star Trek movies, whichtheyeventuallydidin1979.Yetwhilehismotiveswerenotpure,hisintentionstellusa lotaboutfancultureatthetime.Mostsignificantisthatacreatorofashowbelievedthefans werepowerfulenoughtoleveragehisstudiotolistentohimandhewasright.Hekept Star Trek alivepartiallybecauseheprovedthattherewasanaudienceforitbyincreasingfanproduction whichincreasesfanvisibility.Inadditiontheriseofothersci-fimediaatthetime,like Star Wars, provedthattherewasalargeraudienceformoresci-fimovies.Thismomentinthe Star Trek fandomiswhenweseeafandommovefrombeingacommunityonlytalkedaboutwhenyouare init,toacommunitythatisknowntothelargerpopulation.
Whilefandomatthistimewasveryconcentratedinsci-fimedia,itisimportanttonote theexceptionstothat.Mostnotablystartingin1975 Starsky&Hutch,abuddycopshow,began airing.Despitebeingexponentiallydifferentfrom Star Trek innumerousways,itdrewalotof thesamefans.MostofthesefanswerethosewhoenjoyedtheduoofSpockandKirkin Star Trek,andfeltthatStarskyandHutch’srelationshipwassimilarinalotofways.Assuchfans wrotestoriesinwhichthetwoweredating,similartothefanfictionaboutKirkandSpock.The ideaoftherelationship,andinfactmostmalerelationshipsonscreen,cameaboutduetothe emphasisonemotionsthatclose-upshotscreates,andalsothe“specialbond”themainmale characterstypicallyshareviafriendship,whichfansfrequentlyinterpretassomethingmore.At thetimeshowsaboutmalefriendshipandadventurewerebecomingincreasinglycommon,and asfansbeganwatchingthemtheylearnedtoadapttheirfannishpracticesontothesenew
143 KandyFong,“InterviewwithKandyFong,”byFrancescaCoppa In"MaterialityandObject-Oriented Fandom,"editedbyBobRehak,specialissue, Transformative Works and Cultures, no.16, https://journaltransformativeworksorg/indexphp/twc/article/view/535/431
shows.
144 Theywouldanalyzeeachepisodeofabuddycopshowjustasmuchastheywould Star Trek.Theywouldwritefanfiction,createfanart,anddiscusseachepisode.Alljustliketheyhad donefor Star Trek Thiseasygenretransitionthatmediafandommakesprovesthatfandomwas notaonetimephenomenonbutsimplyawaysomeonecanperceivetheworld.Oncesomeone startsthinkinglikeafanitishardnotto.Afanmovesabouttheworld,analyzesstories,andonce thatdoorisopened,itisdifficulttoclose.Fandomcanoccurforanypieceofmedia,thegenreis nearlyirrelevant,theonlythingthatreallymatterswhendeterminingifashowcanhavea fandom,iswhetherpeoplelikeit,notwhetheritisgood.Fandom’sleapfromsci-fitocopshows isaclearexampleofthisfact.Whileitseemslikethetwoshowsshouldhavenothingin common,beingapartofthe Star Trek fandomprimedpeopletowatch Starsky&Hutch through thatsamelensandthereforeprovidingitwithafandomofitsown.Thishappensinfinitetimes throughoutfandomhistoryforfandomisalwaysmovingtowardthenewestpieceofmedia, eagertoseewhatstoriesarelefttoexplore.
Bythe1980sfandomculturehadgrownbeyondsci-fifandomforgood.Fanswere gainingpowerandinfluenceduetotheirnumbers,whichmadeithardertoignoretheirpower overmedia.Inadditionthetechnologicaladvancementsofthedecadeallowfanseasieraccessto media,increasingwhatfanscanwatchandwhatfanscanmake.Duetotheincreasein technologytheriseofblockbustersthatemergedinthemiddleofthe1970scontinuedonthrough thenextdecade.Majorfranchisessuchas Star Wars,whichgottwosequelswithinthedecade, and The Terminator whichwasfirstreleasedin1984beforealsogettingtwosequels, demonstratehowafewaspectsoffandomculturemakeitintothemainstreamduringthis decade,partiallybecausemediahasbecomesoaccessible.
144 FrancescaCoppa,“ABriefHistoryofMediaFandom,”48-50
ThemostsignificanttechnologicaladvancementforfandomatthatpointwastheVCR.It wasfirstonthemarketinthemidtolate1970sbutdidnotbecomewidelyavailableuntilthe 1980s,whenmostpeoplestartedusingVHS.Fansbenefittedexponentiallyfromthisnew technology,asnowtheycouldrecordepisodestowatchlater,tradeorgiftshowstofriends, analyzethoserecordingsinmoredetailastheypauseorfastforwards,andtakevideoclipsfrom episodestomakemoreadvancedvids.Withthesechangescametheideaofbingewatching, whichwascalledvariousothertermsbeforebingeingwascoined.Whilethecommonimageof fansdepictsindividualswatchingtvaloneinthedark,bingeingchallengedthisidea.Manyfans chosetobingewatchtheirfavoriteshowsingroups.Evenconventionshadweekendbinge viewingsofshowssuchasone1982 Starsky&Hutch conventionheldinWaleswhichismost notableforthefactthatitplayedanepisodethattheBBCwouldnotairinBritainuntil1999.145 InthiswaytheVCRallowedforfanstowatchinlargergroupsastheywerenotconfinedto people’slivingrooms,andallowedthemtosharemoreepisodesastheywerenotrestrictedby whattheirbroadcastingcompanieschosetoair.ThisismostnotablebytheamountofAmericans introducedtoBritishtelevisionviaVHS.BritishfanswouldrecordanepisodeofBritishtvand thenshareitwiththeirAmericanfriends.ThisworkedsowellthatPBSdecidedtoairtheBritish tvshow Doctor Who oncetheyrealizedhowpopularithadbecomewithAmericans.146 Networks wereclearlyrealizingthatlisteningtowhatfanswantedwasagoodideainordertomake money.
Fans'voicesbeingheardwasnotanexceptiontothedecade.Theshow Cagney and Lacy standsoutinalotofwaysfrommostfandoms,mostnotablybecauseitscopshowwherethetwo starsarewomen.Butmoreimportantlyitbecamethefirstshowbroughtbackfromcancellation
145 CharlotteE.Stevens,“HistoricalBinge-Watching:MarathonViewingonVideotape”
146 FrancescaCoppa,“ABriefHistoryofMediaFandom,”51
viaaletter-writingcampaignmadebyfans.147 Thismeantfanswereorganizedandvocalenough toconvinceanetworkthatcancellingwasabadidea,andthenetworkagreed.Giventhat Star Trek fanslaunchedasimilarcampaignafteritwasannouncedtobecanceledwhichdidnotwork nearlyaswell, Cagney and Lacy’ssurvivalisanincrediblefeatwhichisacredittothegrowthof fandom.
Thenetworksandfansstillneversaweachothercompletelyeyetoeyeduringthis period.Bingewatchingofshows,orgroupviewingsofvidscouldfrequentlyoccurinhotel roomsofconventions.Fanswouldbringtheirowntapesofvidsandthenplaythemfortheir friends,sometimesdistractingfromtheactualeventsoftheconvention.Althoughthe conventionsoftendidnotmind,becausetheywerehesitanttoshowtapesasanofficialeventdue tocopyrightlaws.Giventhatfandomrevolvesaroundusingcontentsomeoneelsecreated, copyrightlawwasatrickyconceptforfandomtonavigate.Copyrightisaconstantreminderthat fanshavenolegalownershipovermedia,eveniftheyareabletoauthorstoriesaroundit.
Technicallycopyrightlawsareonlyaproblemwithinfandomifcreatorsandcorporationschoose toenforcethem.WhileIhavepreviouslydiscussedGeneRoddenberrywhohelpedKandyFong createvidsusing Star Trek stills,notallcreatorswereasgeneroustofansashewas.Anotable exampleofthiswouldbeGeorgeLucas,whoduringthe1980swasfinishingthefirst Star Wars trilogyandwouldreturnattheendofthe1990sinordertoexpandhisempire.Lucasfocusedon gaininganincredibleamountofcreativecontrolthroughmultiplemediadeals.Atthesametime hedistancedhimselffromany Star Wars workthathedidnothelptocreate.148 Thisincludes novelsthatwereoriginallymarketedasofficial Star Wars stories,alongwithfanworks.
147 FrancescaCoppa,“ABriefHistoryofMediaFandom,”52
148 TaraLomax,“‘ThanktheMaker!’:GeorgeLucas,Lucasfilm,andtheLegendsofTranstextual AuthorshipacrosstheStarWarsFranchise”
Yetdespiteallofthesestruggles,fansstillfindenjoymentinthemediatheyconsume.
Conventiongoersreportontheirbinge-watchingactivitieswithpleasure,mostlystatingthat despitethesleepdeprivationthehappymemoriesofwatchingwithfriendsarewellworthit. Fansdonotfeelguiltyaboutstayinguplate,sincelonghoursofwatchingtvandtalkingis viewedasasuccessfulconvention.149 Fromtheseaccountsitiseasytoseethatinsteadof viewingtelevisionbeinganindividualandlonelyactivity,itisaspaceinwhichyoucanbuild friendshipsandcommunity.Duringthesedecadesfandomfollowsafamiliarrhythm.Fansgrow involumeandsodotheirvoices,butmediacompaniesarefailingtorespondtofandom’s growingpresencefastenough.Inthemid1990sthesedynamicsshiftedonceagain.
Fandominthe1990sandearly2000swasdominatedbyonething:theinternet,which pulledmediafandomfromtheshadows.Thedecade'snewtechnologymakesfandomeasily accessiblefornewusers,andeasilynavigabletopicktheaspectsoffandommostinterestingto theuser.Itisimportanttonotethatfanstendtobeaheadofthecurvewhenitcomestoaccessing newtechnologies,sotheyoftenhadaccesstotheinternetbeforetheaverageperson.Whatthe internetdidforfandomwasallowfanstodiscussmediawithoutactuallyhavingtomeetin person.Thisincreasedinteractionsincludingdiscussionsofongoingtvshows,andspreadingof fanfictionwithoutphysicalfanzines.
Beforenewfanpracticeswerecreatedfromtheinternet,theoldfanpracticeswere expandedupon.Thisismostevidentwithvids,whichareabletoexpandduetotheupgradesin videoeditingtechnologythatallowforfarmoreprecisecutsandcomplicatedtechniques.Thisis evidentbyafewofKandyFong’smorerecentvids.Sheisnowabletocreatemoredetailedvids andeasilyspreadherworktootherfansbecauseoftheinternet'sabilitytosharewithease. Viddinghasitsowngroupoffansandaconventiondedicatedtoitself,Vividcon.In2005ithad
149 CharlotteE Stevens,“HistoricalBinge-Watching:MarathonViewingonVideotape”
itstwentiethanniversarywhereKandyFongwashonoredasaspecialguest.150 YetFongis clearlynottheonlyonemakingmodernvidsasisevidentbythecreationofvidinggroupsthat popupinthe1990s,suchasMediaCannibalswhichmadevidsoncurrentlyairingshowslike X-Files,andoldshowslike The Professionals.151 Viddingwasgrowingintoitsownartformina similarfashiontofanfiction.
Fanfictionalsowentthroughasignificantshiftontotheinternet,asmoststorieswere spreadviawebsitesinsteadoffanzines.WebsitessuchasLiveJournalwereincrediblypopular withthefanfictioncommunitybecausefanscouldeasilyuploadandreadstories.Thisallowsan onlinetaggingsystemtodevelop,allowingfansamorepersonalizedexperience.Writingswere “tagged”bytypebecausefanfictionissuchavastgenrewithvaryingstylesandtropes,tagging wasaneasywayforfanstoonlyfocusonthethingstheywantedtoread.Tagscontainimportant informationabouteachstorysuchasthefandomitisfrom,theship152 itrepresents,theuniverse itoccursin,andthengenerallyanytriggerwarningslikeexcessivesex,violence,orcharacter death.Tagsornoteswouldoftenclarifywheretheficwasstartinginrelationtothesource media,whethertherewasaplotpointitignored,orwhetheritwassimplycreatingitsownstory withintheconfinesofthemedia’suniverse.Thisinturncreatedawholenewsetofvocabulary fanshadtolearn.Keytermsinclude gen whichisastorythatdoesnotfocusonaromantic relationship, het whichisastorythatfocusesonaheterosexualrelationship,and slash whichisa storythatfocusesonsame-sexrelationshipsoftennotpresentedintheoriginalmedia.153 These termsaremerelythetipoftheicebergastagsanddescriptionshavebecomeincrediblyspecific. Thisspecificityallowsforamorecuratedformoffaninteraction.Ontheinternetfanscaneasily
150 KandyFong,“InterviewwithKandyFong,”byFrancescaCoppa
151 “FallInTheLight-XFilesFanvidbyTheMediaCannibals(remastered),”1997,accessedFebruary24, 2026 https://archiveorg/details/x-files-fall-in-the-light-media-cannibals
152 Arelationshippairingofcharactersthatisusuallyromanticbutcanoccasionallybeplatonicincontext.
153 KarenHelleksonandKristinaBusse, Fan Fiction and Fan Communities in the Age of the Internet, 10
pickandchoosethecontenttheywanttoseebysimplysearchingforit.Thisallowsfansto easilystayintheirowncorneroffandomontheinternet,happilyreadingwithintheircomfort zone,butitalsoallowsforeasierexplorationofnewregions,andfornewfans.Alotofthetime withfandomthehardestplaceisthestart,buttheinternetmakesitsoifyouwanttostartreading fanfictiononanewshowyoucansimplysearchforit.Thismakesbecomingafansignificantly easier,asyouusedtohavetoknowafantohelpyoubecomeone.Nowallyouhavetodoishop onlineandmakeaLiveJournalaccount,orjoinoneofthethousandsofdiscussionboards appearingthroughoutthedecade.Theinternetcreatedasafespaceforthefancommunityto interactandmoveaboutwhichencouragedgrowthaspotentialfansfeltcomfortablejoiningthe community
Duetotheonlineshift,fandom'svisibilityincreasedonceagain,whichprovidedthe fandomwithevenmorepowerthantheyhadalreadydeveloped.Sinceitsbeginningfandomhad almostalwaysoperatedintheshadows,butbecauseofeasyaccesstotheinternetfandomwasno longerhidden.Eventhemostsecretiveaspectsoffandomlikeslashwerebeingbroughtoutinto theopen.Thissubsequentlychangedhowfansandcreatorsinteractedwitheachother.Oneof themostnotableinstancesoffanbacklashfromthistimeperiodwastheresponsetoGeorge Lucasandthenew Star Wars prequelsalongwiththetwentiethanniversaryeditionofthe originalmovies.Mostofthebacklashfromfansoccurredin1997withthereleaseofthe twentiethanniversaryeditionastheproductionteamdigitallyremasteredthefilmandchanged keydetailswhichalteredcharacterization.Thenwhentheprequelsbegantoreleasein1999, manyfansfeltthattheincreaseduseofnewdigitaltechnologytookawayfrom Star Wars’ originalaesthetic.TheyalsothoughttheprequelsweremadesolelybyLucaswithoutanyother creativeinput,whichwasafairlyaccurateclaim,leadingfanstobelieveLucascouldnolonger
betrustedwithcreativecontroloftheuniverseandmythos.154 Whatisimportantisthatfansfelt theyhadcontroloverthemythosfarmorethanthecreatorandtheywerenotafraidtosayit.Part oftheprobleminthisscenarioisthatLucashadbuilthimselfupasthesolecreatorofthe universewhichmeantallitssuccesses,butalsofailurescouldbedirectlyblamedonhim.Itis boundtohappenthatanycreatormakesadecisionthatfansdisagreewithbecausefandomworks byexploringtheendlesspossibilitiesofapre-existinguniversebuttheoriginalcreatormust alwayschooseonepossibilitytobetheofficialcanon.155 Yetnormallymediaismadebya collaborationofmultiplecreators,closertohowfandomitselfoperates,whichmakesdecisions morereasonable.Here Star Wars fansarguedagainstthefranchisefollowingonlyLucas’vision. Fanshadbeenarguingwithcreatorslikethisforyears,tellingthemthattheydidnotunderstand themediatheywerecreating,but Star Wars isthefirsttimeweseeitplayoutinavisibleand opensetting.
While Star Wars isanexampleofaverynegativecreatorandfanrelationship,some relationshipsweremorepositive.Inthelate1990s Buffy the Vampire Slayer createdbyJoss Whedonroseinpopularity.156 Atthetimeofitsairing,the Buffy fandomoperatedviaonline discussionboards,themostnotablecalledTheBronze,namedaftertheclubthatthemain charactersfrequentintheshow Whilethesespacesweremainlyusedbyfansonmultiple occasionsWhedonandtheothermembersofthecreativeteamentitledMutantEnemyresponded tofans'questionsandsuggestionsfromtheseboardsbyincorporatingthemintotheshowitself. Anotableexampleofthiswastheepisode“TheWish”whichexploredafan'squestionofwhat
154 TaraLomax,“‘ThanktheMaker!’:GeorgeLucas,Lucasfilm,andtheLegendsofTranstextual AuthorshipacrosstheStarWarsFranchise”
155 FrancescaCoppa,“WritingBodiesinSpace:MediaFanFictionasTheatricalPerformance,”in Fan Fiction and Fan Communities in the Age of the Internet, edbyKarenHelleksonandKristinaBusse(NorthCarolina: Macfarland&Company,2006), 241-242
156 Whedonandfanstypicallygotalongalthoughitisimportanttonotethatlaterinthe2010sduetonew informationaboutWhedon’smisconducttowardactorsfansturnedagainsthim,buttheseeventsoccurredafterthe showwasover
wouldhappenif Buffy nevermovedtothetowninwhichtheshowisset,orwhatifhertwo friends,WillowandXander,werevampires.157 Thisishardlytheonlyepisodeoftheshowtodo thisasisevidentbytheepisode“Dopplegangland”inwhichvampireWillowreturnsandfeeds intotheslash-fictionsubtextinaverytextualmanner Afewmonthspriortothereleaseofthis episodeWhedonrespondedtoafan’spostabouthomoerotictensionbetweenBuffyandFaith, anothervampireslayer.InsummaryhediscussesjustreadingapieceoffanfictionaboutBuffy andFaithandthathehadneverseentheirrelationshipthiswaybutnowheagreeswiththe interpretation.InadditionhesaidwhathelovesabouttheBuffyverseisthatpeoplecanin essencepicktheirownsubtexttosubscribeto.158 InonesimplepostWhedonvalidatedthe entiretyofthefancommunity,includingslashwhichisoftenthemostfrowneduponpractice withinthefandom.Itiscleartherelationshipbetweenfansandcreatorswasbecomingmore steadyandconnectedduetotheinternet.Obviouslyinteractionsbetweenfansvaryonacaseby casebasis,buttheinternetclosedthedistancebetweenfansandcreatorsregardlessofthestatus oftheirrelationship.
Theinternetalsoalteredfans'protestofcreators,whichcanbebestexemplifiedbythe Buffy fandom.WhilefanslovedWhedonandMutantEnemy,theywereoftenatoddswiththe productioncompany,Fox,duetoitsfocusonbusinessdecisions.TensionsboileduntilFox issuedaceaseanddesistordertomultiplefanrunwebsitesforusingcopyrightimages,sound, andcharacterizationfromtheshow.Inresponsefansparticipatedinaninternetcampaignagainst Foxbyorganizingaonedayshutdownandpostingdigitalbanners.159 TheFoxversusBuffyfans incidentmakesitevidenthowincreasedvisibilitygivesfansmorepower,butitalsomakesthem
157 JoshStenger,“TheClothesMaketheFan:FashionandOnlineFandomWhen‘BuffytheVampire Slayer’GoestoeBay,” Cinema Journal 45,no 4(2006):35,accessedMarch3,2026
158 JoshStenger,“TheClothesMaketheFan:FashionandOnlineFandomWhen‘BuffytheVampire Slayer’GoestoeBay”
159 JoshStenger,“TheClothesMaketheFan:FashionandOnlineFandomWhen‘BuffytheVampire Slayer’GoestoeBay”
morevulnerabletoattacks.Beforetheinternet,copyrightlawsonfanzinesandotherfan activitiesweredifficulttoenforceasitwashardtoobtainclearevidenceagainstthem,nowwith theinternetitiseasytoaccessplentyoffanwebsitesusingcopyrightedcontent.Still,because fandomhadgrownsomuchduetotheinternetitwouldbenearlyimpossibleforanycompanyto takedowneverycopyrightedworkfromeverywebsite,forthesecondonewastakendownthree morewouldpopup.
Theinternetsignaledamajorriseinvisibilityandpowerforfandom,whichinturn allowedthemmoredirectaccessintothecreativeprocess,butalsoopenedthemselvesuptothe vulnerabilitiesofcopyrightinfringement.Stilllookingbackatthefandomfromyearsbefore, mostfanswouldneverbelievehowfartheyhadcome.Thefactthattechnologyevenallowsfans andproducerstotalkdirectlyissomethinga1920moviegoercouldneverfathom.Soyes,the shiftoffandomtotheinternetincreasestheriskasitisnowvisible,butthatvisibilitymakesit stronger,asmanyfansrealizehowmanyofthemtheretrulyare.Nowfansareeasilyunitedwith theclickofabuttontojoinanycampaign,orwatchanyshow,orreadanypieceoffanfiction. Theopportunitiesarenearlyendlessandfansaretakingadvantageofit.Theyarecreatingand talkingandworkingharderthananygenerationbeforethem,readytogettheirvoicesheard,and readytoparticipateinacommunitythatprovidesthemwithsomuchjoy
Fandomhasclearlybeenstudiedasacommunityforpeopletodisplaytheircreativityand loveofmedia.Ithasalwaysbeenaspacewherepeoplecanunitebasedontheircommon interestsandloveofstories.Fanshavealwaysworkedinasafespacewheretheycanexpress theirinterestswitheachother,butsharingtheiropinionswiththewidercommunityhasalways provedtobeastruggle.Forstarters,fandomwasbuiltoutsideofthemainstreammedia,this meantthatitwasforcedtogrowintoatightknitcommunityinordertosurvive.Fromthere
fandomhasalwaysbeenindangeroflosingthemediatheyloveastheydesperatelytryto convinceproducerstokeepmakingthecontenttheywanttosee.Yetproducersfailtoplease everyonesofandomshiftedtoprivateworkwithintheshadowsasfanscreatedtheirowncontent toappeasetheirdesires.Thisresultedinagrowthoffandomastheyspreadandsharetheirown storieswitheachother.Nowthesesecretivedreamsoffans'owncreationsareseeingthelightof dayagain,asfandomhasriseninpowerbecauseofitssheernumbersandnewtechnology, boostingthecreativemindsintoamoreopensetting.
Afewmajorshiftshaveoccurredsince2006,whenmypaperstops,and2026,thepresent day.Oneofthemostnotablechangesisthecreationof Archive of Our Own (AO3)whichisone ofthemostnotoriousmodernfanfictionwebsites.WiththeintroductionofAO3theuseofmost otherfanfictionwebsitesdecreasedsignificantlymeaningthatanyfancanhopontoAO3and findcontentfromnearlyanyfandom.Somefanficshavegoneontobecomepublishedworksof theirown.Mostnotably Fifty Shades of Grey beganasafanficof Twilight.Whilemostfanfics arenotmadeintotheirownoriginalcontent,whichisaprocessthatinvolveschangingany detailssignificanttothesourcematerialtheywerebasedonbutkeepingthesamecharacter dynamicsandconflict, Fifty Shades ishardlytheonlyfanfictohavemadethejumpfromfan madetoofficiallyproduced.Mostrecentlyoneofthemostfamous Harry Potter fanficsthat focusesontheshippingofDracoandHermoineentitled Manacled,wasmadeintoitsownbook, Alchemised, whichhasreceivedsignificantapprovalfromtheonlinebookcommunity.
Inadditionthewayinwhichproducersandfansinteracthasshifted.Conventionshave growninpopularityandscalesomuchthateventhegeneralpublicisconsistentlyawareoftheir existence.ThemostnotableexampleofthisisSanDiegoComicConwhichhappensyearlyat theendofJuly Thisisamassiveconventionwherefanscreatecosplays,attendpanels,watch
content,buyfromvendors,getautographs,andreceiveexclusivecontent.Creatorshaveused thisconventionasaplatformtomakemajorannouncements,thisismostevidentfromthe MarvelCinematicUniverseandotherDisneyownedcorporations.TheMCUcommonly announcestheirupcomingreleasescheduleforthemovies,oftendroppingatrailerorrevealing castmembers,aswasshowninthe2025conventionweretheynotonlyletfansattendingthe panelwatchallofthe Deadpool&Wolverine moviebeingreleasedthatday,butthenalso announcedRobertDowneyJr.tobereturningtotheMCUasDoctorDoominatheatricalreveal. Clearlywithinthepasttwodecadesthespacewherefansandproducersmeetandcollaborate havebeguntooverlap,asproducershavebeguntorealizethatthefansaretheaudiencethey shouldbetryingtoappease.Producerssincehaveconsistentlymademajorannouncements availableexclusivelyateventslikeconventions,oraddedextracontentonlyfanscouldaccessin ordertomakethisaudiencefeelseenandappreciated,evenifstudioschoosetoactuallyignore mostofthefanswishes.
Thelastmajorchangeinfandomhasoccurredduetotheriseinstreamingservices.This hasstoppedthedecadesoldformatoftelevision,creatingstrangereleasepatterns,anddumbing downcontentaspeopletendtowatchtelevisionwhilealsodoingothertasks.Streamingservices helpfansaccesscontentlongafteritsaired,leadingtosomeshowsandtheirfandomstobe revived,asisseenwith The Office duringcovid.Thesebenefitshavehelpedfandomgrowinnew ways,asfanscanenjoymoremedia.Yetatthesametimestreamingserviceshavehurtfandom astheyconsistentlycancelshowsthatdonotairwellwiththeexacttargetaudiencetheywanted, orsimplythemainstream.Showsarefrequentlycanceledafteraseason,especiallythosewith uniqueplots.Lastly,timesbetweencontenthasincreasedsignificantly,tenyearsagooneseason ofashowwouldbereleasedeachyear,butnowoneseasonofashowwithonlyeightepisodes
oftentakestwotofiveyearstomake.Thisleadsfans'expectationstoincreaseandyettheshows alwaysfailtodeliverexactlywhattheywant.
Itisimportanttonotewhileitfeelslikestudiosandproducersaresolelyincontrol,fans arealsogettinglouderandmoretalkedabout.Thisismostevidentbytheriseofslash discussionsinmodernmedia.AfteryearsoffansshippingWillandMikeintheshow Stranger
Things theshowhadWillcomeoutasgayandadmittedhehadacrushonMike.Whilethepair didnotgettogethertheshowclearlylistenedtotheyearsoffansinordertocreateanendingfor Willtheyhopedwouldappeasethem.Yetitismorecommonforalotofstudiostoacknowledge fansbutneveractuallymaketheirwishesarealitywithintheshow'scanon.Thisisbest exemplifiedby Supernatural whichranforfifteenseasonsinwhichitdevelopedalargefanbase.
Supernatural breaksthefourthwallplentyoftimesbutoneofthemostimportantinstancesis whentheyhavetheirmaincharacters'livesactuallybewrittenintobookswithintheshow's universewithasmallbutmightyfanbase.Thesefansthencreatetheirfanworksinwhichtwoof theshow'smaincharactersareshipped.Thecreatorsneverhadtoacknowledgeanyofthefans wishes,itdidnotaddathingtotheplototherthanatouchofcomedy,butbyacknowledging fanswishestheyshowasignofrespect,eveniftheyaremakingfunoffansabit.Attheendof theday,fansknowthatalotoftheirideasfortheshowarenotrealisticinanywayforamyriad ofreasonsbuttheystillwantthestudiotohearthem,tounderstandtheirinterpretation,and understandwhytheylovetheshow.Smallacknowledgementsliketheones Supernatural made allowthefanstoknowthatstudiosareinfactlisteningandtheydocare,eveniftheyarenot goingtoimplementeverynewstorytheyhear.
Fandomandcreatorsarestillatodds,thatprobablywillnoteverchangecompletely,but technologicaladvanceshavecertainlyleveledtheplayingfieldalittlebitmore.Nowthegap
betweenthetwosidesisnotasvastasthe1920s,andfanshavefarmorespacestoexploretheir
owncreativityoutsidethecanonoftheoriginaltext.Attheendofthedayfandomisnotabout whohasthemostpoweroverthemedia,itisabouthowmuchpeopleloveit.Creatorslikewhen fanslovetheirshowandfanslovewhencreatorsenjoymakingtheshow Thisunderstandingof mutualloveofmediaiswhatkeepsthepeacebetweenmostfansandcreators,itisonlywhen thisbondisbrokenthatchaosbreaksloose.
Acknowledgements
IwouldliketoacknowledgeEseOlogbosele,ManniBabb,andMaddieMacallisterfortheirhelp editingmypaper InadditionIwouldliketothankMrs.Mustoforhelpingmeresearchandwrite thispaper,whilealwaysaddingpersonalinsightsfromherexperiencewithfandom.Iwouldlike toacknowledgeAlderHurleyandSamOblakforkeepingmecompanyintheWritingCenteron TuesdaynightsasIattemptedtowrite,andallthebrilliantsuggestionstheymadeevenifIended upignoringthem.LastlyIwanttothankeveryfancreatoroutthere,becausewithoutthemI wouldnothavebeeninspiredtowritethispaper.
Bibliography
Cavicchi,Daniel.“FandomBefore‘Fan’:ShapingtheHistoryofEnthusiasticAudiences.” Reception: Texts, Readers, Audiences, History 6(2014):52–72. https://doi.org/10.5325/reception.6.1.0052
Coppa,Francesca.“ABriefHistoryofMediaFandom.”in Fan Fiction and Fan Communities in the Age of the Internet, editedbyKarenHelleksonandKristinaBusse,41-59.North Carolina:Macfarland&Company,2006.
Coppa,Francesca.“EarlyViddingandItsPrecursors.”In Vidding: A History,67–92.University ofMichiganPress,2022.http://www.jstor.org/stable/10.3998/mpub.10069132.8
Coppa,Francesca.“WritingBodiesinSpace:MediaFanFictionasTheatricalPerformance.”In Fan Fiction and Fan Communities in the Age of the Internet, editedbyKarenHellekson andKristinaBusse,225-244.NorthCarolina:Macfarland&Company,2006.
Coulson,Jaunita.“ToSummontheFuture.” Spockanalia Vol5:13-19.AccessedDecember8, 2025.https://archive.org/details/SpockanaliaV5/page/n17/mode/2up.
“FirstFanFiction.” Guinness World Records [n.d.].AccessedDecember7,2025. https://www.guinnessworldrecords.com/world-records/444366-first-fan-fiction
Fong,Kandy.“InterviewwithKandyFong.”ByFrancescaCoppa.In"Materialityand Object-OrientedFandom,"editedbyBobRehak,specialissue, Transformative Works and Cultures, no.16.
https://journal.transformativeworks.org/index.php/twc/article/view/535/431
Hellekson,KarenandKristinaBusse. Fan Fiction and Fan Communities in the Age of the Internet. NorthCarolina:Macfarland&Company,2006.
InternetArchive.“FallInTheLight-XFilesFanvidbyTheMediaCannibals(remastered).” 1997.AccessedFebruary24,2026.
https://archive.org/details/x-files-fall-in-the-light-media-cannibals
Jenkins,Henry. Textual Poachers: Television Fans and Participatory Culture. NewYork: Routledge,2013.
Langsam,DevraandShernaComerford. “Off the Top.” Spocknalia Vol 2. 1968.AccessedApril 3,2026.https://archive.org/details/SpockanaliaV2/page/n5/mode/2up.
Lomax,Tara.“‘ThanktheMaker!’:GeorgeLucas,Lucasfilm,andtheLegendsofTranstextual AuthorshipacrosstheStarWarsFranchise.”In Star Wars and the History of Transmedia Storytelling,editedbySeanGuynesandDanHassler-Forest,35–48.Amsterdam UniversityPress,2018.
Orgeron,Marsha.“Making‘It’inHollywood:ClaraBow,Fandom,andConsumerCulture.” Cinema Journal 42,no.4(2003):76–97.http://www.jstor.org/stable/1566529.
Photoplay[Jul-Dec1923]|MediaHistoryDigitalLibrary https://mediahistoryproject.org/reader.php?id=photoplayvolume22425chic.
Photoplay[Jul-Dec1931]|MediaHistoryDigitalLibrary. https://mediahistoryproject.org/reader.php?id=photo41chic.
Scrapbookofamatineegirl. Chicago Public Library. https://www.chipublib.org/fa-scrapbook-of-a-matinee-girl/.
Stenger,Josh.“TheClothesMaketheFan:FashionandOnlineFandomWhen‘Buffythe VampireSlayer’GoestoeBay.” Cinema Journal 45,no.4(2006):26–44. http://www.jstor.org/stable/4137166
Stevens,E.Charlotte.“HistoricalBinge-Watching:MarathonViewingonVideotape.”In Binge-Watching and Contemporary Television Research,editedbyMareikeJenner, 23–39.EdinburghUniversityPress,2021. http://www.jstor.org/stable/10.3366/j.ctv27qzrrt.6.
VIOLATEDVAGINAS,SCALPELANDSPECULUM:THECOMMODIFICATIONOF
BLACKWOMENINAMERICANGYNECOLOGY
byEseoseMaureenOlogbosele
Conceivedontheplantationandextractedthroughviolence,Americangynecology transformedenslavedBlackwomen’sreproductivelivesintoaformofmedicalcapitalinwhich birthbecamelaborandcarebecamecontrol.Thisconversionisnotmetaphorical;under enslavement,Blackwomen’sreproductivecapacityfunctionedsimultaneouslyasassetsand property.
160 Longbeforehospitalsinstitutionalizedobstetrics,itwaspracticedthroughregulation andunconsentedexperimentationonAfrican-Americanwomen.Enslavedwomenwerevalued notfortheworktheyproduced,butfortheirfertilityandassistanceinmaintainingtheAmerican slavepopulation.AmericangynecologywasbuiltonthecommodificationofBlackwomen’s reproductivebodiesduringslavery,andtheseracializedlogicspersisttodaythroughforced sterilizationcampaigns,stereotypes,andhighmaternalmortalityrates,contributingtothefearof medicalpersonnel.
Longbeforetheformalemergenceofgynecologyasaprofessionalspecialtyinthe nineteenthcentury,historiansofslaverycontendthatreproductionfunctionedasaneconomic strategywithintheAtlanticworld.JenniferL.Morganhasshownthatfromtheseventeenth centuryonward,EuropeancolonialregimeslinkedAfricanwomen’schildbearingskillsto systemsoflaborextractionandimperialexpansion:Africanwomenwereimaginedasnaturally suitedforchildbearing,blurringthedistinctionbetweenworkandmaternity 161 Thisscholarship
160 DorothyRoberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (NewYork: VintageBooks,1997),23
161 JenniferL.Morgan, Laboring Women: Reproduction and Gender in New World Slavery (Philadelphia: UniversityofPennsylvaniaPress,2004)
situatesBlackwomen’sreproductiveexploitationnotasanaberrationofthenineteenth-century South,butasfoundationaltothedevelopmentofracialcapitalismacrosstheAtlantic.
Legalhistoriansfurtheranchorthistransformationinacolonialstatute.Thedoctrineof partus sequitur ventrum (1662VirginiaLaw)162 formalizedtheownershipofbondswomen’s childrentoslaveholders.Legallytranslatedas“thatwhichisbornfollowsthewomb,”the doctrineassuredthatpregnancydirectlyincreasedaslaveholder’spropertyandfurthertiedBlack women’sfertilitytotheplantationeconomy.163 AsscholarsofearlyAmericanlawhavenoted, thisstatutemarkedadecisivedeparturefromEnglishcommon-lawtraditions,linkingracial identityandreproductioninanunprecedentedway.Byembeddingheredityintopropertylaw, coloniallegislaturesconvertedthewombintoasiteofeconomicaccumulation,layingthe structuralgroundworkforlatermedicalintervention.Reproductionwasthusjuridicallyregulated beforeitwasmedicallymanaged.
AssociologistDorothyRobertsargues,underslavery,Blackwomen’swombsfunctioned aspropertyoftheirslaveholder,producingchildrenthatwouldeventuallybecomeaneconomic pawninthenecropoliticalstateoftheAntebellumEra.164 Pregnancywaspunishedyet incentivizedsimultaneously,providingadichotomyofcontrolthatregulatescontemporary medicine.Blackmothersweretaskedwithtryingtopreservethemselvesandthemoralityoftheir childwhilealsofightingagainsttheverysystemrenderingthempowerless.165 Roberts’sriveting book, Killing The Black Body: Race, Reproduction, and the Meaning of Liberty166 (1997),draws backthecurtainofAmerica’streatmentofBlackwomenthroughhistory,arguingthatBlack
162 SashaTurner,“TheInvisibleThreadsofGender,Race,andSlavery,” African American Intellectual History Society,April13,2017,https://www.aaihs.org/the-invisible-threads-of-gender-race-and-slavery/
163 JenniferL Morgan, Partus Sequitur Ventrem: Law, Race, and Reproduction in Colonial Slavery (Philadelphia:UniversityofPennsylvaniaPress,2018)
164 Roberts, Killing The Black Body, 23-25
165 Roberts, Killing The Black Body, 49
166 DorothyRoberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (NewYork: VintageBooks,1997)
women’sreproductionhaslongbeenusedasasiteofracialgovernanceratherthanautonomy.
Tracingpolicyfromslaverythroughtwentieth-centurybirthcontrolinitiatives,Roberts demonstratesthatreproductiveinjusticeisstructural,embeddedinlawandpublicpolicy ProgramssuchasNorplantdistributionandstate-sponsoredsterilizationoverwhelmingly affectedBlackmothers,whowerelabeled“unfit.”Centraltoheranalysisistheenduringideaof Blackwomenas“welfarequeens,”aderogatorystereotypethatisfrequentlyusedtojustifystate intervention.ForRoberts,reproductionhadbecomeapoliticalbattlegroundwheregovernment populationcontrolsupersedesmaternalhealth.
Twodecadeslater,DeirdreCooperOwens’s Medical Bondage: Race, Gender and the Origins of American Gynecology 167 (2017)historicizesthemedicaldimensionofgovernance.
FocusingonSouthernphysicianswhorefinedcesareansections,ovariotomies,andfistularepairs onenslavedwomen,CooperOwensemphasizesthecomplexrelationshipsbetweenenslaved womenandphysicians,asmedicalrelationshipswereinfluencedbycoercionandrestricted agency.Shedemonstratesthatplantationmedicinefunctionswithinapoliticaleconomywhere enslavedwomen’sbodieswerecommerciallyvaluabletoslaveholdersandmedicallyinestimable forphysicians.Byplacingrace,gender,andcapitalismatthecenterofgynecology,Cooper Owenssuccessfullyarguesthatmedicalinnovationisinseparablefromracialexploitation.
Together,OwensandRobertsestablishreproductionasbothapoliticalandmedicalsite ofcontrol.RobertsrevealshowBlackwomen’sfertilityhasbeenconstructedasasocialproblem requiringregulation.Atthesametime,Owensshowshowprofessionalmedicalauthoritywas builtthroughexperimentationonenslavedwomen’sbodies.Buildingontheirwork,thispaper arguesthattheseprocessesarebestunderstoodthroughcommoditization:thetransformationof
167 DeirdreCooperOwens, Medical Bondage: Race, Gender, and the Origins of American Gynecology (Athens:UniversityofGeorgiaPress,2017),1
Blackwomen’sbodiesintoaneconomicstakedeterminedbypoliticalregulation,racialcontrol, andmedicalignorance.
Commoditizationisusedasthecentrallenstoexaminehowthehistoricalextractionof Blackwomen’sreproductivelaborhasshapedcontemporaryobstetriccare.Bytracinghow Blackmaternityevolvedfrommedicalcapitalduringslaveryintoanecropoliticalcontrolunder theguiseofgynecology,itwillbecomeclearthatdisparitiesinhealthcarearenotaccidental failures,butarehistoricalbiasesnormalizedbyasystemthatusesBlackbodiesasinstrumentsof inspectionthatareconsideredlessofahumanlife.
Thequestionnowiswhetherthesehistoriesarebestunderstoodasmanifestationsof racialcapitalismorasproductsofsurgicalmodernity ScholarssuchasL.LewisWallemphasize theexperimentalcharacteristicsofmoderngynecology,arguingthatphysiciansoperatedwithina cultureoftrialanderror.168 WallcontendsthatDr.J.MarionSims–andothernineteenth-century doctors–operatedwithintheethicsoftheirtimeperiod.Tolookatthemwithacontemporary lensisimproper.169 ThiscontextualistapproachreframesthedevelopmentofmodernAmerican gynecologyasastoryofmedicalprogressemergingfromaharshyetwidelyacceptedsurgical culture.Yet,evenwithinthisframework,thequestionremainsunanswered:ifexperimentation wascommon,whywereenslavedBlackwomenthefocus?Itisinthisracialdistributionofpain andmaltreatmentthatentrenchedreproductivevaluationis.
First,understandingmodernmaternityandgynecologyrequiresaconcretepictureofthe antebellumpracticesthatshapedit.Therefore,slavery’splantationeconomymustbecritiqued anddissected.Longbeforegynecologyemergedasaformalmedicalspecialty,theplantation
168 L L Wall,“TheMedicalEthicsofDr J MarionSims:AFreshLookattheHistoricalRecord,” Journal of Medical Ethics 32,no 6(June2006):346–50,publishedbyBMJ,https://wwwjstororg/stable/27719646
169 EseoseOlogbosele, “Innovation or Injustice?: The Medical Ethics of J Marion Sims” (unpublished paper,AdvancedHistoryCapstone,BrooksSchool,December16,2025),2
economyhadsubduedBlackwomen’sreproductivecapacityintoameasurableformofcapital. Itspowerrestedontheconvergenceoflawandsocialcontrol,withtheformerreinforcingthe latter Throughthissystem,pregnancybecameaprofitablecalculation,withthewomb functioningasasiteoffinancialaccumulation.Examiningplantationlogicandreproduction revealshowcommodificationprecededandultimatelyshapedlatermedicaldevelopments.
Onplantations,pregnancywasnotenoughtojustifyaninabilitytowork;enslaved womenwereexpectedtoreproduceandwork,andwerepunishedformiscarriagesor complications.170 Bondswomen171 weredeniedagencyovertheirmaternityandweresubjectedto consistentsexualviolenceatthehandsofotherbondsmen172 andtheirslaveholdersalike.173 Physicians,whoaremeanttoprovidepreventativecare,becameperpetratorsofviolenceand mistrust.J.MarionSimsisrecognizedasthe“GodfatherofAmericanGynecology,”and perfectedhisworkonthebodiesofbondswomenwhocouldnotformallyconsenttoinvasive procedures.Thevesico-vaginalfistula,Sims’smostnotable“achievement,”wasperformedon enslavedwomenwithoutanesthesia.174 Whileanesthesiaexistedinthe1840sintheformof diethylether,175 SimsdeliberatelywithhelditfromenslavedBlackwomen,statingthattheir bodiescouldwithstandthepain,despiteusinganesthesiaforwhitepatientswhileperforming similarprocedures.176 Consistentwiththisrhetoric,mostantebellumAmericandoctorsbelieved
170 CooperOwens, Medical Bondage, 1.
171 AnenslavedBlackwoman
172 AnenslavedBlackman
173 Roberts, Killing The Black Body, 44-45
174 MonicaCronin,“Anarcha,Betsey,Lucy,andtheWomenWhoseNamesWereNotRecorded:The LegacyofJ MarionSims,” Anaesthesia and Intensive Care 48,no 3 suppl(November2020):6-13,accessed October20,2025,https://journalssagepubcom/doi/epub/101177/0310057X20966606
175 RavindraChaturvediandR L Gogna,“EtherDay:AnIntriguingHistory,” Medical Journal of Armed Forces India 67,no 4(October2011):306–308,https://pubmedncbinlmnihgov/25032386/
176 HarrietA.Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (NewYork:Doubleday,2006),34-36
thatblacknessprovidedastrongerpainthreshold.177 Essentially,theBlackbodybecamealab specimen,andwhitedoctorsignoredthehumanitythatlaywithin.
WhileeugenicsisprimarilyassociatedwithNaziGermanyandHitler’sadvocacyfora pureAryanrace,theslaveeconomyreliedonbreedingstrongwomenwithstrongmento producethebestfieldhands.178 Apracticecommonlyusedtobreedanimalsorplantswas transferredtoaracedubbed“chattel.”Theinabilitytochoosebreedingpartnersdenied bondswomentheluxuryofloveandsafetythatcomeswithpregnancy.Explicitly,anenslaved woman,Rose,recallswhenherslaveholder,MasterHawkins,commandedhertobeintimate withanotherbondsman,Rufus,despitenotknowinghim.WhenRoseattemptedtofendoffhis advances,MasterHawkinstoldher,
Woman,I’spaybigmoneyforyou,andI’sdonedatfordecauseI wantsyoustoraisemechillens.I’sputyoutolivewithRufusfor datpurpose.Now,ifyoudoesn’twantwhippin’atdestake,yous dowhatIwants.179
Toescapepunishment,RoseconsentedtoRufus’srequests.Rose’sexperiencedemonstratesthat enslavedwomen’sreproductivefunctionsservedaseconomicproductionratherthanaprivate orfamilialmatter.Unlikemanywhitewomen,whoretainedsomecontroldespitecoverture,180 couldbepresentmotherstotheirchildren.Enslavedwomenweredeniedsuchautonomy,as theirchildrenimmediatelybecamepropertyofslaveholdersandwerelefttomidwives–often poorlytrained–totakecareoftheirchildren.Rose’sbodywassealed,aninvestmentintendedto generatefuturefieldhands,revealinghowBlackwomen’sfertilityoperatedascapitalwithinthe
177 HarrietA Washington, Medical Apartheid, 34-36
178 Roberts, Killing The Black Body, 44-45
179 RoseWilliams,interview,in Slave Narratives: A Folk History of Slavery in the United States, From Interviews with Former Slaves,vol 16,TexasNarratives,pt 4(Washington,DC:WorksProgressAdministration, 1941),LibraryofCongress
180 Nineteenth-centuryEnglishcommonlawdoctrinewhereawoman’slegalidentitywastiedtoher husbanduponmarriage,strippingherofpropertyrightsandlegalstandings.Thisdoctrinewasabolishedinthe mid-nineteenthcenturyundertheMarriedWomen’sPropertyActs
plantation.Thisbiocapitalwasformallyembeddedinthelaw,aspreviouslymentioned,bythe doctrineof partus sequitur ventrum.
Moreover,slaveholdersprovidedroutineincentivesforBlackwomenwhogavebirthto sufficientfieldhands.181 Famously,ThomasJeffersonstronglybelievedthatafemaleslavewas “moreprofitable”than“thebestmanonthefarm,”asherreproductivecapacitiesadded4 percentannuallytothecapitaloftheplantation.182 Jefferson’sexplicitframingofchildbirthas aneconomicgainrepresentstheproliferationofwealththatbondagepresents.Thus,to incentivizechildbirth,plantationswouldgrantbondswomenextrarations,183 exemptionfrom labor,184 premiumsforlargerfamilies,and,inrarecases,freedom.185 Everyyearfrom1750until emancipation,oneineveryfiveBlackwomenofchildbearingagegavebirth.186 InJamaica, enslavedwomenwerepraisedfortheirchildbirthabilities.AstheBritishSlaveTradeendedin 1807withParliamentpassingtheSlaveTradeAct,andtheU.S.Congressfollowingsuitinthe sameyear,theCaribbeanandtheAmericasweretaskedwithfindingnewinputsforslavelabor supplychainsandincreasingillegalslavetrafficking.187 Thiscatalyzedeugenics-basedbreeding thatrampagedthroughtheWesternHemisphere.Thesesystemicincentivesforreproduction, whileframedas“rewards,”alsoreinforcedplanters’authorityoverenslavedwomen’sbodies, normalizingtheiruseasinstrumentsofwealthproduction.Sucheconomiclogiccreated conditionsinwhichsexualexploitationandproprietorshipwereinseparable:thewombhadthe
181 Roberts, Killing The Black Body, 26
182 ThomasJefferson, Farm Book, 1774–1824,manuscript,Monticello,quotedinLuciaC.Stanton, Those Who Labor for My Happiness: Slavery at Thomas Jefferson’s Monticello (Charlottesville:UniversityofVirginia Press,2012),124
183 FederalWriters’Project, Slave Narratives: A Folk History of Slavery in the United States from Interviews with Former Slaves,vol 17(Washington,DC:LibraryofCongress,1941)
184 Roberts, Killing The Black Body, 26
185CooperOwens, Medical Bondage, 16
186 HarrietA Washington, Medical Apartheid, 44-45
187 AlexanderFilippides,“HumanitiesResearchersRemembertheSlaveTradeandItsAbolition,” National Endowment for the Humanities,August23,2023, https://wwwnehgov/blog/humanities-researchers-remember-slave-trade-and-its-abolition
dualityofprofitandcoercion.ThisdynamicisstarklyillustratedthroughthelifeofSally Hemings,whosereproductivelaborandsexualexploitationunderThomasJefferson demonstrateshowthelegalandeconomicchassisofslaveryrenderedBlackmaternityatoolof bothpropertyandpower
Nomatterwhofatheredthechild,anyfetusesbornfromanenslavedwoman’swomb automaticallybelongtoherslaveholder.Usingthisfreedomgivenbylaw,slaveholders routinelysexuallyabusedbondswomen,andextendedenslavementtotheirchildren.188 Jefferson fatheredatleastsixchildrenwithSallyHemings,189 whowasaround15whenhercoercive relationshipwithJeffersonbegan,andworkedinhishomewhilepregnant.190 Hemings’story representsthepowerimbalancebetweenenslavedwomenandthemenwhoabusedthem. Jefferson’sstatusasPresidentdisempoweredHemings,andherstorywasnottolduntilafterher passingin1835.191 Jefferson’srelationshipwithHemingsillustrateshowsexualexploitationand ownershipoperatedintandem.
192 Sincethestatusofchildrenfollowedthemother,Jefferson’s paternitywasextraneous;infact,itstrengthenedtheholdofbondage.Hisbiologicalchildren withHemingsremainedlegallyenslaved,reinforcingtheprinciplethatBlackmaternity, regardlessofworkinginthefieldorthehome,functionedasamechanismofwealthproduction ratherthankinship.
BeyondtheHemingscase,sexualcoercionwasnotanabnormalitywithinslavery,buta routinefeatureofplantationmanagement.Thelegalityofenslavementandmaternalviolence producedinnumerableabusesagainstBlackwomen.Enslavedwomen’sfertilitywastherefore
188Roberts, Killing The Black Body, 29-33
189AnnetteGordon-Reed, The Hemingses of Monticello: An American Family (NewYork:WW Norton& Company,2008),quotedinThomasJeffersonFoundation, “Thomas Jefferson and Sally Hemings: A Brief Account,” Monticello – Thomas Jefferson’s Estate,accessedFebruary23,2026, https://wwwmonticelloorg/slavery/jefferson-and-sally-hemings/a-brief-account/
190 ThomasJeffersonFoundation, Thomas Jefferson and Sally Hemings
191 ThomasJeffersonFoundation, Thomas Jefferson and Sally Hemings
192 ThomasJeffersonFoundation, Thomas Jefferson and Sally Hemings
monitored,encouraged,andmanipulatedinwaysthatalignedwitheconomicinterests.
Reproductionwaseffectivelycapturedwithinthebroaderrecordofplantationprofitability.
DeborahGrayWhite’s Ar’n’t I A Woman provideskeyexamplesofthephysicalexploitationof bondswomen,notingthatpregnantenslavedwomenwereoftenrequiredtocontinuestrenuous fieldlaborwithoutaccommodation.193 Regardlessoftheircondition,bondswomenwere expectedtoperformas“primefieldhands,”demonstratinghowtheirbodieswereusedforboth laborandreproduction.
Theeconomiclogicofslaveryalsoreshapedthemeaningofmotherhood.Enslaved womenborechildrenwhocouldbesold,mortgaged,orinherited,severingbiologicalbondsin favoroffinancialtransactions.Familieswerefragmentedtosatisfymarketdemands194 and maternalgriefwassubordinatedtocommercialexchange.Inthissystem,Blackmaternity existedintension,beingexploitedforitsproductivecapacity,yetdeniedrecognitionasa human.Thewombwascommercialized,reinforcingtheplantation'sdependenceon reproductiveextraction.
Iftheplantationsoughttoconvertthewombintoproperty,enslavedwomenrespondedby assertingmotherhoodinwaysthatdefiedownership.Toenslavedmothers,thebestwayto protecttheirchildrenfromthebrutalityofslaverywastoemotionallydetachfromtheir children195 orincertaincases,murderthem.196 Particularly,inKentucky,enslavedwoman MargaretGarnerwastriedforkillinghertwo-year-olddaughterwithaknife,desperatelytrying topreventtheunfortunaterealityofenslavement.Garnerwasfoundguiltyofhercrimeandwas
193 DeborahGrayWhite, Ar’n’t I a Woman? Female Slaves in the Plantation South (NewYork:W W Norton,1985),121
194 Roberts, Killing The Black Body, 33-35
195 EricaS Lawson,“BereavedBlackMothersandMaternalActivismintheRacialState,” Feminist Studies 44,no 3(2018):717-18, https://www.jstor.org/stable/10.15767/feministstudies.44.3.0713
196 Roberts, Killing The Black Body, 36-37
forcedtoreturntoherslaveholder.Importantly,Garner’scasesparkedabolitionistcriestoend slavery,condemningitasabrutalinstitutionthatforcesmotherstoresorttohomicidetoprotect theirchildren.197 Whileunspeakabletoday,enslavedwomenwereforcedtoundercutthe economicinstitutionofslaveryanditscyclesbyendingitwhereitbegan,atconception.This realitynotonlyreflectsactsofresistancebutalsorevealstheprofoundpsychologicaltolland dehumanizationimposedbyslavery,aswomenareforcedtonavigatethecontradictionofbeing motherswhilealsolackingcontroloftheirchildren’sfate.Subjugatedbybondage, bondswomenwereforcedtowitnesstheirdaughters’rape198 andotherunspeakabletraumas.For many,severingemotionalbondswiththeirchildrenallowedthemtobetterfacetheinvoluntary realityofenslavement.
Somewomen,however,wereunabletokeeptheirfamilialandplantationrelationships separate,andchosetobringtheirchildrenalongsidethemonthejourneytofreedom.199 Inthe 1850s,whenenslavedwomeninNewOrleansescaped,nonelefttheirchildrenbehind.200 As documentedin The Underground Railroad Records, enslavedwomenfrequentlyfledwiththeir children,withentriesdescribingmothersasleavingwiththeirthreechildreninattemptsto secureapromisingfuture.201 Similarly,runawayslaveadvertisementsreportwomenescaping withtheirchildren,providingheftyfinancialincentivesforthosewhoreturnedthem.202 Additionally,HarrietJacobs’ Incidents in the Life of a Slave Girl revealsthatenslavedwomen
197 “ArrestofFugitiveSlaves:ASlaveMotherMurdersHerChildRatherThanSeeItReturnedtoSlavery,” Anti-Slavery Bugle (NewLisbon,OH),February2,1856
198 Roberts, Killing The Black Body, 37
199 Roberts, Killing The Black Body, 43
200 J K Schafer, “New Orleans Slavery in 1850 as Seen in Advertisements,” The Journal of Southern History 47,no 1(1981):33–56,ascitedby Stories of Care and Control: A Timeline of the Medical Industrial Complex,accessedFebruary28,2026, https://mictimelinecom/timeline/formerly-enslaved-black-women-refuse-to-leave-their-children-behind
201 WilliamStill, The Underground Railroad Records (Philadelphia:Porter&Coates,1872)
202 “RunawaySlaveAdvertisements,”UniversityofNorthCarolinaatGreensboroLibraries,accessed March29,2026
activelyresistedsexualexploitationbydirectlydecliningsexualintercourse,willingtosacrifice theirsafetyinsearchofhumanity,203 preventinginstancesakintothoseofJeffersonand Hemings.Despitetheseactsofresistance,however,thebodilycontrolofBlackwomen persistedinotherarenas.
Mid-nineteenth-centurymedicineoperatedinanenvironmentwhereformalizedpatient consentwasnonexistent,particularlyamongstthepoorandtransient.204 Charityhospitalswere filledwithimmigrantsandlaborers,andphysicianshadfreewilltorefinetheirprocedures.205 However,whilepovertycreatedvulnerability,enslavementcreateddispossessionanddisposal. Poorwhitepeoplewerenotlegalproperty.Theycouldnotbeboughtandsold,orpunishedfor refusingtreatment.Enslavedblackwomenandmen,however,werebodieswhoseownerscould authorizetheiruseformedicalexperimentation.206 Throughthislegalstructure,exploitation becameopportunisticinasystemicextensionofslaveholdingpower.
Bythenineteenthcentury,thisnormalizationofBlackwomen’sbodieshadextended beyondplantationdisciplineintomedicalpractice.Physiciansbeganexperimentinginamarket inwhichtheirsubjects–enslavedBlackwomen–weresociallyinvisible.Bondswomenwere obtainableforexperimentation,intervention,andexamination.Medicalauthoritiessuccessfully professionalizedthereproductivelogicofcontrolandexploitedthesysteminwhichtheywere grantedpower.ItiswithinthisenvironmentthatSoutherndoctorssuchasJ.MarionSimsand Dr.ThomasHamiltonconductedinvoluntarymedicalexperimentsonbondswomenand bondsmen,refiningtechniquesthatwouldlaterdefineAmericangynecologyandothermedical
203 HarrietJacobs, Incidents in the Life of a Slave Girl (Boston:PublishedfortheAuthor,1861),chap 10
204 Homeless
205 ToddL Savitt,“TheUseofBlacksforMedicalExperimentationandDemonstrationintheOldSouth,” The Journal of Southern History 48,no 3(August1982):334,accessedNovember18,2025, https://www.jstor.org/stable/2207450?.
206 Savitt,“UseofBlacksforMedicalExperimentation,”336-338
practices.207 Enslavedwomenwerealienatedfromtheirbodiesandbecamesubjectsofdetached medicalinquiry.Therefore,theconversionfromplantationoversighttomedicalsupervision servedasacontinuationofgovernanceundertheguiseofscientificadvancement.
ThroughtheworkofSimsandotherantebellumdoctors,Americanobstetricsand gynecologyemergedthroughthemanipulationofBlackwomen’sbodies,whowereusedas experimentalsubjectsthatproducedstereotypicalnotionsaboutpain,pregnancy,andbiological differences.Dr.SimswasinspiredbythebeliefthatBlackwomenwereimpervioustopain208,an ideacreatedbynarrow-mindedscientistswhosearchedfortangibleexcusestoexecute experimentationona“sub-human”race.Dr.CharlesWhiteproudlyproclaimsthatBlackmen bearthepainofsurgicaloperationsbetterthanotherraces,andthepainthatwouldcauseawhite manto“quiver”wouldgounnoticedbyaBlackman. 209 Dr Whitespewedconsistentracist rhetoricthroughouthisfieldofwork,asheconsideredBlackmenandwomenassexually promiscuous,untrustworthy,andfrequentcarriersofsexuallytransmitteddiseases.210 Likewise, in1847,Dr.JamesJohnsonclaimedthat:
Whenwecometoreflectthatallthewomenoperateduponin Kentucky,exceptone,wereNegressesandthatthesepeoplewill bearanythingwithnearlyifnotquiteasmuchimpunityasdogs andrabbits,ourwonderislessened.211
ResearchingBlackbodieswasnormalizedinAmericannineteenth-centurymedicine,and physiciansfoundthemselvesactivelypurchasingslavestohaveareadilyavailablesupplyof experimentalsubjects,withelderlyslavesbeingsoldoutrightbyslaveholders,nolongerholding
207 CooperOwens, Medical Bondage, 7-8
208 Washington, Medical Apartheid, 58
209 JohnDuffy,ed, The Rudolph Matas History of Medicine in Louisiana (2vols)(BatonRouge, 1958-1962)
210 Washington, Medical Apartheid, 58.
211JamesJohnson,“ReviewofSurgicalPractices,” The Medico-Chirurgical Review (London,1840s)
aneconomicstakewithinthebrutalplantationeconomy.212 Thisbiasedlogicwasepitomizedin Sims’sworkwiththevesico-vaginalfistula,213 whereenslavedwomenweresubjectedtoinvasive experimentswithoutanesthesia,theirpaindiscreditedduetoantebellumstereotypes.214 As previouslydiscussed,enslavedwomencontinuedworkingduringpregnancy,resultingina multitudeofcomplicationsbeforeandafterchildbirth.215 Enslavedwomenwerenotproperly clothedandsuccumbedtobugbites,theheat,andthesharpfeaturesofcottonplants,which addedtothegrowingstrugglesofpregnancy.Parturient216 enslavedwomencoulddolittleto escapethetrichotomyoftheplantation,physicians,andtheirenslavers.
Inhismemoir, The Story of My Life,Dr.SimsfirstdescribesawomannamedAnarcha, whohadbeeninlaborforseventy-twohours.Herbabyhadbreachedthepelvisandneededtobe deliveredassoonaspossible.Herslaveholder,Mr Westcott,signedoffonhertransfertoSims, andherpainsweretemporarilysolved.However,Anarchasoonlostcontrolofherbladderand rectum,andsoonformedavaginalslough–thedischargeofdeadepithelialcells;tissuesfroma degenerativeuterus–thatwasincurable.217 Undoubtedly,Anarchawasinseverepainandfaced socialexclusion,yetwastaskedwithcontinuingtoworkbyMr.Westcott.
Concurrently,BetseyandLucy,bondswomenfromneighboringplantations,facedsimilar challenges.Betsey,whowasaboutseventeenyearsold,hadgivenbirthtoherfirstchildandwas nowunabletoholdfluids.Thebaseofherbladderwas“completelydestroyed,”accordingto Sims,andshewassenthomewithaletterstatinghercondition.218 Lucy,whowaseighteen, reportedthesamesymptomsasBetseyandfacedthesametreatment.Bothyoungwomenwere
212 Washington, Medical Apartheid, 57
213CooperOwens, Medical Bondage, 35
214CooperOwens, Medical Bondage, 3
215CooperOwens, Medical Bondage, 45
216 Awomanwhoisinlabor
217 J.MarionSims, The Story of My Life (NewYork:D.AppletonandCompany,1884),227.
218 Sims, The Story of My Life,228
livingwithavesico-vaginalfistula.Thismedicalconditioncreatesanabnormalopening(fistula) betweenthebladder(vesico)andthevagina,achildbirthinjurythatleftthemincontinentand sociallyostracized.
Dr Sims,whohadgonearoundGeorgia“perfecting”hismedicaltechnique,contacted Betsey’sslaveholder,requestinghertocomebacktohisclinicfortreatment.Betseyisrecorded tohavewillinglyconsented219–althoughbondswomen,intheinstitutionofslavery,lackedbodily autonomy,andcouldnotlegallyconsent–andDr.Simsproceededwiththevesico-vaginal fistula.Thisprocedurerequiresthepatienttobendover,exposinghervaginaandrectumtoSims, adehumanizingmeasurethatstripsanalreadysociallysubduedwomanofthelittleshehasleft. Simsthenusesmedicalstudentstoholdthebuttocksapart,allowinghimtoseeinsideBetsey’s vagina.SimsintroducedabentspoonintoBetsey’svagina,whichheusedtoretractthevaginal wallsandvisualizethefistula.220 Whathelatercelebratedasamomentofscientificdiscovery was,forBetsey,anencroachingviolationofherbody.
SimssanctionedthereturnofLucyandAnarchatohisclinicandchosetoperformon Lucyfirst.Lucy’sbladderhadessentiallyfallenout,leavingatwo-inchdiameterbetweenher bladderandvagina.Thiswasbeforethedevelopmentofananestheticinanycapacity–atleast,as Simsclaims.SimsreportedthatLucyborethepainoftheexperimentwith“greatheroismand bravery.”221 Despiteherpain,Dr.Simscontinued.HeinsertedaspongeinLucy’svaginainan attempttosoakuptheblood,givinghersepsis.222 Whenhetriedtoremovethesponge,Lucy’s vaginabecameinflamed,andLucyenduredextremeagony.AccordingtoDr.Sims,she recoveredintendays,whichwasa“remarkablefeat.”223
219 Sims, The Story of My Life,234
220 Sims, The Story of My Life,235-236
221 Sims, The Story of My Life,236-237
222 Bloodpoisoning.
223 Sims, The Story of My Life,238
AsLucywasrecovering,SimsfocusedhisattentionbackonBetsey.Hefollowedthe sameprocedurementionedearlier.ForAnarcha,however,hercaseofvesico-vaginalfistulawas unprecedented.Notonlydidshehavealargefistulaatthebaseofherbladder,butshealsohad damagetothebackofhervagina,leavingherrectumexposed.Sheexperiencedcontinual incontinenceandsmelledofabadodor.224 Despiteherailments,Simscontinuestosaythat “patientsofthiskindneverdie.”225 Withhisreferencetobondswomenandmen,Simsreinforced theracializedbeliefthatBlackbodiespossessedextraordinaryresiliencetopain.
Simsdirectlyplayedintothereproductivelogicofcommodification,shapingenslaved women’ssufferingintodatathatadvancedhisprofessionalreputationwhilepreservingthe antebellumhierarchyintheSouth.Simsoperatedonatleast10-12enslavedwomeninthe 1840s,226 andonlynamedthethreewomenabovementioned.Thesewomenunderwent remarkableboutsofpain;Anarchawasoperatedonatleastthirtytimeswithoutanesthesia.227 Anarcha’srepeatedoperationswerenotincidentalfailuresbutpartofanexperimentalprocess. EachfailedattemptbySimsrefinedhistechnique,eventuallyleadingtothesuccessfulsilver suturemethodhecontinuedtouse.
Beyondtheexperimentalproceduresthemselves,Simsfurtherdehumanizedhispatients bykeepingthemanonymous.AlthoughSimsmeticulouslyrecordedhisexperimentsinhis autobiography,heidentifiedonlythreewomenbyname.Therestarelefttobeflattenedintocase descriptionsratherthanrecognizedasindividuals.Inmedicalliterature,namingconfersauthority andpresence;enslavedwomenhadneither.Bycontrast,anonymitycreatesdisposability.Sims’s
224 Sims, The Story of My Life,240
225 Sims, The Story of My Life,240
226 BrynnHolland,“The‘FatherofModernGynecology’PerformedShockingExperimentsonEnslaved Women,” History,August29,2017,updatedDecember3,2025, https://wwwhistorycom/articles/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves
227 MonicaCronin,“Anarcha,Betsey,Lucy,andtheWomenWhoseNamesWereNotRecorded:The LegacyofJ.MarionSims,” Anaesthesia and Intensive Care 48,no.3 suppl(November2020):8,accessedOctober 20,2025,https://journalssagepubcom/doi/epub/101177/0310057X20966606
narrativecentersonhisowninnovationwhilerelegatingthewomentointerchangeablesubjects, strengtheningtheantebellumracialorderinwhichBlackwomen’ssufferingwasinstrumental. Towithholdtheirnameswhilepreservingsurgicalintegrityandproceduralrefinementsreveals thehierarchyatwork.Thetechniquewasworthremembering,butthewomenwhomadeit possiblewerenot.The“GodfatherofGynecology”wascreatedbythesilencedpainofenslaved womendeniedanesthesia,consent,humanity,andthedignityofbeingremembered.
ThiserasureisnotuniquetoSims.Theobscurityofenslavedwomeninmedicalarchives reflectsabroadernineteenth-centurypatterninwhichBlackbodiesweredocumentedas experimentalmaterialratherthanaspatients.Fistulasurgerywasoneofmanymanifestationsof amedicalculturethatheavilyreliedonracializedvulnerabilitytogenerateprofessional advancement.
Besidespracticingphysicians,medicalstudentsalsousedenslavedpeopletostudythe humanbody.MedicalschoolswereexplicitintheirdesireforbothBlackandtransientwhite patients.228 Whenthecadaveravailabilitywasinsufficient,physiciansandstudentssometimes resortedtograve-robbingtomakeupfortheshortfall.229 Inthiscontext,obtainingbodiesbysuch meansposednomoralcompromiseforthoseinvolved,asenslavedpeoplewereneitherlegally recognizednorsociallyregardedasfullhumanbeings.Culturalmemorypreservesthisreality withraciallytargetedpoems,like The Dissecting Hall. SuchliteraturelamentedtheuseofBlack bodiesformedicalstudyinthenineteenthcentury.Thepoem,wordedinBlackdialect,likely camefromawhiteauthorandcirculatedintheearlymid-twentiethcentury,reflectingthe treatmentofBlackbodiesinmedicalspaces: Yuhseedathouse?Datgreatbrickhouse? Wayyonderdowndestreet?
228 Savitt,“UseofBlacksforMedicalExperimentation,”334.
229 Savitt,“UseofBlacksforMedicalExperimentation,”337
Deyusedtodeadfolkseendar Wrappedeenalongwhitesheet.
An’sometimeswe’ena[blackperson]stop, A-wonderingwhowasdead, Demstujentmenwouldtakeaclub An’bat‘imondehead.
An’dragdatpoordead[blackperson]chile Righteendat‘sectinhall Tovestigate‘itsliver–lights–Hisgizzardan’‘isgall.
Takeoffdat[blackperson]’shan’san’feet–Hiseyes,hishead,an’all, An’w’endemstujentfinish Deywasnothin’leftatall.230
Althoughtheauthorcannotbeidentified,thenormalizationanddehumanizationofenslaved cadaverssetthestageforthenextstepinantebellummedicine:liveexperimentation;notably,by thehandsofDr.ThomasHamilton,whoborrowedabondsman,Fed,fromaneighboring plantation.Fedenduredextremeabuseashewassubjectedtoprescriptionmedicineoveruse, forcedtostandinheatedholeswithhisheadwrappedintowels,blisteredtotesttheeffectsof heatonBlackskin,andrepeatedlyexposedtoconditionscausingheatexhaustion.Hamilton’s experimentsillustratehowthelogicofownershipextendedfromthedeceasedtothelivingasthe bodiesofenslavedpeopleweretreatedasinstrumentsofmedicalstudyratherthanautonomous humanbeings.231
Strikingly,bythemid-twentiethcentury,theexploitationofBlackwomenhadbecome commonwithingynecologicalandoverallmedicalinstitutions.Thesamerationalitythat permitteddoctorstoblisterBlackskintoexamineitsdepthwouldlaterjustifytheregulationof
230ToddL Savitt,“TheUseofBlacksforMedicalExperimentationandDemonstrationintheOldSouth,” Journal of Southern History 48,no 3(August1982):340,quoting Scribe 1(December1951):17
231 LouisA Chamerovzow,ed,SlaveLifeinGeorgia:ANarrativeoftheLife,Sufferings,andEscapeof JohnBrown,aFugitiveSlave,NowinEngland(London,1855),45-48,citedinF.NashBoney,"DoctorThomas Hamilton:TwoViewsofaGentlemanoftheOldSouth,"Phylon,XXVIII(Fall1967),288-92
Blackfertilitythroughcoercedsterilizationandcontraceptivesurveillance.Indoingso, contemporarygynecologyvaluedsurveillanceandcontrolovertrust,productivityover autonomy,andmanagementoverconsideration.Consequently,thestainofslaverywas essentiallyadoptedbyAmericanmedicine.
TracingbacktostudiesofheredityandSocialDarwinism,scientistsdiscoveredthat naturalselectionledtotheextinctionofinferiorgroups.Hence,eugenicswasborn.Coinedin 1883byFrancisGalton,Darwin’sdistantcousin,232 Galtondeclaredthatforhumanityto maintainitsintelligenceandsocialorder,societiesmustreproducethebestofthebest.Certain groups–Mongolians,Black,Jews,andAmericanIndians–wereconsideredinferior.233 Galton’s studieswerelaterusedtojustifylynchingsacrosstheUnitedStatesinattemptstotaperthe growingbirthrateamongstimmigrants.Theideathatsterilizationwasaconcretesolutionfor socialproblemsstemmeddirectlyfromhatredtowardsBlackAmericans.Undercapitalism,poor Blackwomenwereconsidered“burdens”onsocialwelfare,andcontrollingtheirreproduction wouldhenceforthreducefuturedependency.From1960to1961,socialwelfareexpenditures amountedto11.5%($58billion)ofthegrossnationalproduct.234 Nearly$22billioncovered socialinsurancebenefits.235 Centeringwelfareintermsofeconomiccostandburdenreinforced theperceptionthatdependentpopulationswerefinanciallyunsustainable,providingjustifications forpoliciesaimedattheirreproduction.
Withnotionslikethese,itisunsurprisingthatJohnKellogg,thefamousbusinessman, inventor,andphysician,supportedeugenics.Kelloggbelievedthatselectivebreedingwas necessarytosavesocietyfromdisaster.Hence,athis1913ConferenceonRacialBetterment,
232 Roberts, Killing The Black Body, 59
233 FrancisGalton, “Hereditary Talent and Characteristics,” Macmillan’s Magazine 12(1865),157
234 SocialSecurityAdministration,“EugenicsandtheSocialSecurityAct,” Social Security Bulletin 25,no 11(1962):1.
235 SocialSecurityAdministration,“EugenicsandtheSocialSecurityAct”
Kellogginvitedover400eugenicists.
236 Kellogg’sconceptsweresupportedbypoliticalfigures, likeTheodoreRoosevelt,whourgedwhiteAmericanstocontinueproducinglargefamilyunitsto avoid“racialsuicide,”237 asimilarsentimenttoKellogg,whoinsistedthatmiddleandupperclass whitepeoplewerebeing“outbred”byallotherraces,andwereatriskofextinction.238
Kelloggandothereugenicisttheoristsreshapedprejudiceintopolicybyembeddingracial hierarchyintoscientificandmedicaldiscourse.Theyactivelypromotedselectivebreedingasa necessitytosolvesocialinstability,andgatheredhundredsoflike-mindedpeoplewhoinfluenced socialthoughtaboutbirthcontrol.Eugenicsbecametheexplanationforsettlingpovertyand populationgrowth.Inthisframework,reproductionlostitsfamilialintimacyandbecame measurablesocialoutput,somethingthestatecouldmanipulate,encourage,and,inthisinstance, suppress.
Suchashiftmarkedacriticalturningpointinreproductivemedicine,asthematernal capacitiesofmarginalizedpopulations,particularlyBlackwomen,becameabstractedintosocial calculations.Theveryactofcomputingwelfareasapercentageofgrossnationalproductalters humanneedintoaneconomicliability,reducingentirepopulationstomeasurablecosts.Black women’sfertilitywasnowseenasexcessive,drainingtaxpayermoney,andoughttobe regulated.Inthisway,eugenicslaidthesubstructureforthecommercializationofreproduction, wherecertainbirthsareprotected,whileothersaresystemicallydiscouraged.Itiswithinthis contextthatgovernment-sponsoredbirthcontrolemergedasamechanismthroughwhichthe statecouldregulate,andultimatelycommodifyreproduction.
236 ElizabethStout,“ToRidSocietyofImbeciles:TheImpactofDr JohnHarveyKellogg’sStandfor Eugenics,” University of Michigan School of Public Health,December12,2022, https://sphumichedu/pursuit/2022posts/the-impact-of-dr-john-harvey-kelloggs-stand-for-eugenicshtml
237 Roberts, Killing The Black Body, 66.
238 Stout,“ImpactofDr JohnHarveyKellogg’sStandforEugenics”
Historically,birthcontrolhasbeenasymboloffemaleautonomy,allowingwomento controltheirreproductiveliberty.OrganizationssuchasPlannedParenthood,SisterSong,andthe NationalAbortionFederationhavepromotedcontraceptivesasameansofvoluntary motherhood.PlannedParenthood,specifically,isthenation’sleadingproviderandadvocateof equitablereproductivecare,andisthenation’sleadingeducatorinsafesexualrelationships. PlannedParenthoodwascreatedbyNurseMargaretSanger,whoopenedthefirstPlanned ParenthoodinBrownsville,NewYork,in1916.Sangerstrivedtocreateanaffordablewayfor womentoaccesscontraception,althoughitwasillegalatthetime.239 Sangerriskedherfreedom toprovidehealthcareaccessandbodilyautonomytowomen,empoweringthemtocontroltheir reproductivelives.Herworkwaslargelyaimedatexpandingaccesstocontraceptionforwomen broadly,particularlyworking-classandEuropeanimmigrantwomen,reflectingherbeliefthat smallerfamiliescouldimproveeconomicandsociallivingconditions.Atthesametime, reproductionissituatedwithinbenefits,wherefamilysizeislinkedtoeconomicproductivityand societalstability.
However,Sangerwasalsoaprofoundeugenistwhobelievedthat“lowerstock”people shouldberegulatedintheirreproduction.Whilethisbeliefreflectsthebroadereugenistthinking ofhertime,itisimportanttonotethatherwritingsoftenframetheseconcernsinthetermsof socialconditions,economicstrain,andaccesstoresources,ratherthanexplicitlycallingforthe sterilizationofspecificracialgroups.Inherbook, Women and the New Race,Sangerwritesthat immigrantsfrom“theslumsofEurope”havemovedtotheUnitedStatesandhavenearly doubledtheAmericanpopulation.
240 Whatisnexttocome,accordingtoSanger,is“ignorance
239 PlannedParenthoodFederationofAmerica,“TheHistory&ImpactofPlannedParenthood,”accessed March31,2026,https://www.plannedparenthood.org/about-us/who-we-are/our-history
240 MargaretSanger, Women and the New Race (NewYork:Brentano’s,1920),32
andwant”,alongside“seriousproblems.”241 Sangercontinueshertangentwithstatisticsstating that8.3millionoftheimmigrantswhoenteredtheUnitedStatesbetween1900and1910could notreadorwrite,andrendersthem“illiterateforeigners.”242 Sangerthenattackspredominantly BlackandHispaniccities,includingNewark,Buffalo,Worcester,Lowell,andmore,claiming thattheyareincreasingthebirthrateoftheUnitedStateswhilesimultaneouslyincreasingthe crimerate,wastingtaxpayermoney,andmustbesterilizedtoavoiddisasterinthefuture.243
Whilethislanguageisdeeplyproblematic,itcanalsobeinterpretedasreflectingherbeliefthat limitingfamilysizecouldimproveeconomicstabilityratherthanasanexplicitordertomandate racialtargeting.Thislensiscriticaltoreproductivecommoditization,ashumanfertilitybecomes treatedasaresourcesubjecttocontrol.Bylinkingreproductiontocrime,poverty,andmonetary burdens,Sangerreinforcestheideathatcertainpopulationsproduce“costly”livesthatmustbe reduced.
Infact,SangerdirectlysaysthattheUnitedStateshas“herded[lower-stockpeople] togetherlikerabbitstomultiplytheirnumbersandtheirmisery.”244 Whileonewouldassumethat sheisadvocatingforbetterlivingconditionstoincreasethebirthrateofimmigrantpopulations, Sangerisusingthisabstractideatopromotebirthcontrolformarginalizedpopulationssothat the“multiplication”and“misery”ofthe“unfit”canbeceased.245 Inthisway,birthcontrol functionsasamechanismthroughwhichreproductionitselfiscommodified.Dependingonits socialvalue,itcanbeincreasedorstifled.Ofcourse,withthedecreaseofthe“unfit,”the“fit” canincreasetheirpopulation,andAmericacanreturntoitseugenistroots,hencewhybirth controlbecameappealingtoeugenicistsintheirattackagainstBlackmothers.246 Ultimately,this
241 Sanger, Women and the New Race,32
242 Sanger, Women and the New Race,33
243 Sanger, Women and the New Race, 33
244 Sanger, Women and the New Race, 37
245 Sanger, Women and the New Race, 45.
246 Roberts, Killing The Black Body, 56
revealsthatreproductiveautonomyandcontrolarenotmutuallyexclusive,butintertwined withinanecropoliticalsystem,andcertainlivesaremorevaluablethanothers,reinforcingthe ideaofcommoditizedreproductivecare.
Followingtheearlytwentiethcenturyemergenceofeugenisttheory,theseideasbecame increasinglyinstitutionalizedthroughstateandmedicalsystemsbetweenthe1920sand1960s.In thisperiod,dozensofU.S.statesenactedeugenicsterilizationlawsaimedattheimpoverished, disabled,anddisproportionatenumbersofBlackandIndigenouswomen.The1927Supreme Courtdecisionin Buck vs. Bell (1927)upheldtheVirginiastatuteforthesexualsterilizationof inmatesininstitutionssupportedbythestateforanyonefoundtohaveahereditaryformof imbecilityorinsanity 247 JusticeOliverWendellHolmes,infamouslydeclaredthat“three generationsofimbecilesareenough,”248 effectivelylegitimizingsterilizationasaformofpublic good.Thisrulingsetaprecedentofnolongerbeinganideologicalregulation,butsomething activelyregulatedthroughlaw.Thestatereinforcedreproductivepolicinginlatercasessuchas Skinner vs. Oklahoma (1942),wheretheCourtupheldsterilizationfor“habitualcriminals”in Oklahoma,249 presumablytopreventapopulationincreaseamongstthe“condemned.”
Throughoutthemid-twentiethcentury,thesepracticesexpandedthroughstateinstitutions andpublichealthprograms,particularlythroughtargetingmarginalizedwomenunderthe justificationofsocialimprovement.Concurrently,reproductivecontrolbecameincreasingly medicalized,asphysiciansandgovernmentprogramsgainedauthorityoverwomen’sfertility decisions,oftenwithoutconsentorunderstanding.Thesedevelopmentsdemonstratethatthe logicofeugenicspersistedbeyonditsearlytheorists,evolvingintoasysteminwhich
247 Buck v Bell, 274US 200(1927)
248 Buck v Bell
249 Skinner v Oklahoma exrel Williamson,316US 535(1942)
reproductionwasmanagedasapublicresource,resultinginthelaterfederallyfunded contraceptiveinitiatives.
Startingin1965,theUnitedStatesgovernmentbegansponsoringfamily-planning programsaspartofthe“WaronPoverty,”250 butreacheditspeakwiththeformalizationofthe FamilyPlanningServicesandPopulationResearchActof1970,whichapprovedTitleXto providecomprehensivehealthcareservices.251 FollowingTitleX,Medicaidwasauthorizedto fundfamilyplanningin1972,effectivelyfocusingtheprogramsonearlyinitiativesthat prioritizedlow-incomefamilies.Specifically,whenwomenrequestedpubliclyfunded sterilization,itwasobligatorytocompletethe“ConsenttoSterilization”sectionoftheMedicaid TitleXIXform.252 AccordingtoNikkiZiteetal.(2007),theseformswerewrittenatalevelthat exceededtheaveragepatient’sreadingcomprehension,raisingseriousconcernsaboutinformed consent.253 Therefore,thesewomenweresigningdeceptiveforms.Thus,theyexperienced significanthardshipswhenattemptingtogettheircontraceptivesremoved.
Incontrast,individualswithprivateinsurancetypicallyhadstraightforwardaccessto familyplanningservices,withouttheextendedwaitingperiodsorcomplexconsent documentation.TheNewDeal’ssocialinsuranceprogramsprovidedpreferencetowhitemale wageearnersandtheirwives,anddeniedBlackAmericans’eligibilitytosocialinsurance claims.254 Thisdisparityreflectsasysteminwhichreproductivehealthcareisstaggeredacross
250 RachelBensonGold, Title X: Three Decades of Accomplishment,TheGuttmacherReportonPublic Policy4,no.1(February2001),5.
251 NancyA White, Family Planning Services and Population Research Act Extends Reproductive Rights, Law, Research Starters,EBSCOResearch(2023), https://wwwebscocom/research-starters/law/family-planning-services-and-population-research-act-extends-reprodu ctive
252 SamuelBorrero,N Zite,J E Potter,andJamesTrussell,“MedicaidPolicyon Sterilization AnachronisticorStillRelevant?” New England Journal of Medicine 370,no 2(2014):102–104, https://pmcncbinlmnihgov/articles/PMC4418554/#R2
253 N Zite,S Philipson,andL Wallace,“ConsenttoSterilizationSectionoftheMedicaid–TitleXIXForm: IsItUnderstandable?” Contraception 75(2007):256–260.
254 Roberts, Killing The Black Body, 206
socioeconomiclines,whereaccessandautonomyaremorereadilyavailabletothosewithmore economicprivilegeandflexibility.Whilefamilyplanninginthe1970swasincreasingly consideredafeministadvancement,especiallywiththereproductiverightsculminatingin Roe vs. Wade (1973),255 unequalimplementationofhealthcarepoliciesisobscured,particularlyfor low-incomewomen,regardlessofcolor.DorothyRobertshasrepeatedlydemonstratedthat reproductivepoliciesintheUnitedStatesdisproportionatelyimpactBlackwomen,reinforcinga patterninwhichreproductivecontrolisexercisedmostoveroppressedcommunities.
WhenexaminedalongsidethehistoricalregulationofBlackwomen’sfertility,federal family-planninginitiativesreflectafamiliarlogicofreproductionremainingamatterof state-managedcontrol,andBlackwomen’sbodiescontinuedtobevoidedofautonomouschoice. Thesediscrepanciesrevealthatwhilereproductiveaccessexpandedintheory,itspracticewas structuredthroughsystemsthatprivilegedsomegroupswhileconstrictingothers,effectively commodifyingreproductionbyassigningdifferentlevelsofaccessandcaretodifferent populations.
Moreconcretely,Enovid,thefirstFDA-approvedoralcontraceptivepill,wasintroduced inthe1960sandmarkedabreakthroughinreproductivefreedomformanywomen,butwas promotedthroughfamily-planningagenciesthatdisadvantagedwomenofcolor Thistrajectory continuedwiththeFoodandDrugAdministration’sapprovalofNorplantinthe1990s; administeredthroughTitleX,Medicaid,andstatewelfaredepartments,theseprograms functionedastoolsofracializedpopulationmanagement,pressuringBlackwomeninto long-actingsterilization.AclearexampleisgivenwithDarleneJohnson,aCaliforniamother chargedwithchildabusein1991.Aspartofherpleaagreement,Johnsonwassentencedtoone
255 Roev.Wade,410U.S.113(1973)(FourteenthAmendment’srighttoprivacyprotectsaperson’sliberty tochoosetohaveanabortion;overturnedinJuneof2022in Dobbs v Jackson Women’s Health Organization )
yearinjailandwasforciblyimplantedwithNorplant,asdirectedbyJudgeHowardBroadman.256
Suchjudicialconditioningrevealsthatreproductive“choices”werenotequallyavailable,but insteadshapedbysystemicpower Ratherthanaltogethercallingit“racialgenocide,”the Americangovernmentframedbirthcontrolpolicyas“welfarecontrol,”257 whileinreality, Norplantadministrationservedasaformofdemographicengineering.
BytargetingwomenonMedicaid,thegovernmentsuccessfullyadministered hysterectomies258 andothermedicalproceduresonBlackwomenwithoutconsent.Rangingfrom theDeepSouthtoNewEngland,deceitbydoctorswascommoninhospitalsthatattendedto Blackwomen.InAikenCounty,SouthCarolina,Dr.ClovisH.Piercedemandedthathispatients, predominantlyBlack,besterilizedafterchildbirth.MariettaWilliams,whowastwentyand pregnantwithherthirdchild,wasdeniedtheabilitytodeliverherchildbyPierceunlessshe agreedtobesterilized.Piercealsonotifiedotherwomenthathewouldnotbeusinghistax dollarstopayforillegitimatechildren,andthatsterilizationistheirbestchoice.259 Pierce’s demandsdidnotrepresentindividualprejudicebutratherabroaderinstitutionalacceptanceof reproductivecoercionunderthelanguageoffiscalresponsibilityandpublichealth.Caseslike Piercearenotisolated;infact,NialRuthCoxwaspregnantatseventeenwhilelivingwithher eightbrothersandsistersinNorthCarolina,andwastoldbyacaseworkerthatshemustbe sterilizedorelseherfamily’swelfarebenefitswouldbecutoff.260 Cox’sdoctortoldherthatthe procedurewould“wearoff,”yetCoxwasleftpermanentlyinfertilebythisoperation.Cox attemptedtosue,seekingdamages,arguingthatthesterilizationstatutewasunconstitutionaland involuntary.Unfortunately,thedistrictcourtruledthatherdamageclaimwasbarredbythe
256 People v Johnson,3Cal App 4th1390(Cal Ct App 1992)
257 Roberts, Killing The Black Body, 56
258 Theactofremovingone’suterus
259 Roberts, Killing The Black Body, 92
260 Weisbord, Genocide? Pp.159-61;Aptheker,“Sterilization,Experimentation,andImperialism,”40.See also Cox v Stanton, 529F2d47(4thCir 1975)
statuteoflimitations;Coxwassterilizedateighteenandbroughtthecourtsintohermattersat twenty-eight.261 Coxcontinuedtolivealifeinwhichherreproductivefreedomwasstolenfrom her
SterilizationpoliciesextendfartherthantheCarolinas,asFannieLouHamer,an Americanvotingandwomen'srightsactivistfromMontgomeryCounty,Mississippi,was sterilizedin1961whenshewenttothehospitalforcystremoval.262 Thisprocedurewas commonlyreferredtoasa“MississippiAppendectomy,”aninfamousprocedureknowntotarget low-incomeBlackwomen.263 Aspreviouslymentioned,thesemedicalprocedureswereatrend amongstwomeninlower-incomeareas.WhileMississippiAppendectomieswerealsodoneto “feeble-minded”whitewomen,theproceduredisproportionatelytargetedimpoverishedBlack womenintheAmericanSouth.Asaresultoftheprocedure,Hamerwasunabletohavechildren ofherownandadoptedtwolittlegirls.
InJulyof1973,WashingtonD.C.JudgeGerhardGesellfoundthatatleast100,000were sterilizedannuallyundergovernment-fundedprograms.Suchfindingswerepublishedasaresult ofGeshell’slitigationin Relf v. Weinberger (1974).Thelandmarkfederallawsuitexposedthe caseoftwosisters,MinnieLeeRelf(14)andMaryAliceRelf(12)ofAlabama,whowere sterilizedwithouttheirconsentwhentheirmotherwasdeceivedintosigningaformstatingthat herchildrenwouldbegettingbirthcontrolshots,whichwasroutinemedicalcareatthetime.264 Gesell’sadvocacysurroundingtheRelfsisters’caseledtofurtherfederalregulations surroundingthenumberofBlackwomencoercivelysterilized.ScholarshavenotedthatU.S. sterilizationpractices,whiledistinctfromNazipoliciesincontextandscale,nonethelessshared
261 Coxv Stanton,529F2d47(4thCir 1975)vi
262 PaolaAlonso, Autonomy Revoked: The Forced Sterilization of Women of Color in 20th Century America (Denton,TX:TexasWoman’sUniversity,nd),3
263 RosalindEarly,“TheSweatandBloodofFannieLouHamer,” Humanities 42,no 1(Winter2021),“The SweatandBloodofFannieLouHamer”|NationalEndowmentfortheHumanities
264 Relf v Weinberger,372F Supp 1196(DDC 1974)
aeugenicfoundationandinvolvedthelarge-scalestate-sanctionedauthorityofreproduction.265
InNaziGermany,the1933LawforthePreventionofHereditarilyDiseasedOffspringledtothe sterilizationofapproximately300,000to400,000individuals,266 ascalethathasbeencompared toextensivesterilizationpracticesintheUnitedStates.
SuchprejudiceextendsbeyondthemainlandUnitedStatesandintoPuertoRico,where theU.S.governmentbegan la operación inthe1930s,andcontinueduntilthelate1970s.267
Withinthistime,one-thirdofchild-bearingagewomeninPuertoRicoweresterilizedinefforts tocontrolthe“overpopulation”oftheisland.268 Law116,enactedin1937,269 legitimizedthe sterilizationofPuertoRicanwomenfor“healthreasons.”Atthetime,thebirthratewassteadily increasingwhilethedeathratewasdeclining,posingamajorissueforresourcecirculation.The 1937billwassignedbyMendezRamos,whosaid:
ThoseofuswhohavediscussedthemaldistributionofPuerto Ricanlandsanditsgrowingabsenteeownershipmustrealizethat theseproblemsaregrowingmoreandmoreseriousthroughour existingsurpluspopulationanditsconstantgrowth.Theinevitable consequencesareincreasingunemployment…270
Essentially,thegrowingpopulationbecameaproblemforPuertoRico,andtheintroductionof Norplantresolvedpublichealthconcerns.TheUSgovernmentusedthreemainjustifications withintheirfundingof la operación,includingbeneficialsecuritymeasuresfromsterilizingthe
265 AllanChase, The Legacy of Malthus: The Social Costs of the New Scientific Racism (Urbana:University ofIllinoisPress,1980),299-300
266 “Yale Study Shows U S Sterilization Movement More Prevalent than Believed at Time of Nazi Germany,” Yale News,February14,2000, https://news.yale.edu/2000/02/14/yale-study-shows-us-sterilization-movement-more-prevalent-believed-time-nazi-g ermany
267AniqueY Jones, “The Eugenic Sterilization of Puerto Rican Women: A Case of US Interests and Religious/Spiritual Freedom” (master’sthesis,ChapmanUniversity,2025),4-5
268 SamanthaGalarza,“SterilizationofPuertoRicanWomen,”InterculturalLeadershipInstitute,accessed April6,2026, https://weareiliorg/timeline/sterilization-of-puerto-rican-women/#: :text=The%20sterilization%20efforts%20were %20so%20prevalent%20that:,without%20them%20knowing%20about%20it%20until%20afterwards
269 CommitteetoEndSterilizationAbuse(CESA), “Sterilization Abuse of Women: The Facts,” Health/PAC Bulletin,no.62(January–February1975),89.
270 SterilizationandFertilityDeclineinPuertoRico(PopulationMonographSeries,No 13)
poor,limitingprolongedcontraceptiveuseofyoungcouples,andallowingtheCatholicChurch tolimitconfessionals;multipleusesofbirthcontrolmeantmultipleconfessions,whileNorplant onlyneededoneconfessionforitsuse.271 Allinall, la operación sterilizedalmost200,000 women.272 SimilartoinstancesinthemainlandUnitedStates,manywomenwereunawareofthe permanencyandlong-lastingeffectsthatcamewithsuchaprocedure,andasaresultof la operación,thePuertoRicanbirthratedroppedtoarecordlowof32.9%by1957.273 Whilethis paperdoesnotfocusonsterilizationoutsideofthemainlandUnitedStates, la operación serves asaprominentexampleofhowgovernment-fundedsterilizationcampaignscanserveas instrumentsofpopulationcontrol,disproportionatelytargetingmarginalizedgroupsunderthe guiseofpublichealthandmodernization.
Buildingonthislegacyofstate-controlledreproduction,Norplantwasadvertisedto Blackteenagersinlow-incomeneighborhoodsinanattempttolowerthenumberofchildrenthey hadinwedlock.Statistically,24percentofBlackteenbirthswereoutofwedlockin1965.274 Thus,thegovernment’sgoalforNorplantwastolowertheBlackbirthrate,therebyreducingthe amountofwelfarethattaxpayerswereobligatedtodisburse.Thegovernmentincentivized Norplantusebycoveringtheinsertion.Norplantistobeadministeredthroughlocalanesthesia, anefficienttentotwenty-minuteprocedure.However,onceNorplantwasinserted,Blackwomen
271 Jones, “The Eugenic Sterilization of Puerto Rican Women ” , 18-19
272 QuiaraAlegríaHudes,“#OurMothersToo:ReckoningWithMyAbuela’sCoercedSterilization,” The Nation,June17,2021, https://wwwthenationcom/article/society/ourmotherstoo-reckoning-with-my-abuelas-coerced-sterilization/#:~:text= She%20enjoyed%20bingo%2C%20cooking%20for,sterilization%20rate%20in%20the%20world
273 PeterKihss,“PuertoRicoFindsDipinBirthRate;FamilyPlanAideCallsDropaResultofMigration andIncreaseinSterilization,” New York Times,January25,1958
274 StephanieJ VenturaandMaryAnneFreedman,“TeenageChildbearingintheUnitedStates, 1960–1997,” Vital and Health Statistics 21,no.53(2000),NationalCenterforHealthStatistics,CentersforDisease ControlandPrevention
foundsignificantchallengesingettingitremovedonceithadserveditspurpose.275 An Oklahomadoctorechoesthisconcern,statingthat:
ItisnottheintentoftheDepartmenttocoverremovalofthe Norplantsystempriortotheexpirationoffiveyearsunlessthere isdocumentedmedicalnecessity.Paymentisnotintendedtobe madefortheremovalofthecontraceptivefortheconvenienceof thepatient,minormenstrualirregularities,orforthepurposeof conception.276
IfMedicaidcoversimplantationandnotremoval,financiallyunstablewomenareforcedto continuelivingwithNorplantanditssideeffects,whichweresoadversethatalawsuitwasfiled in1995againstitsparentcompany,Wyeth-AyerstLaboratories.277 Defendantsclaimedthatthe companydesigned,tested,andmanufacturedacontraceptivethatresultedinharmdueto inadequatewarnings.278 Patientssufferedfromnervedamage,amenorrhea,ovariancysts,andin severecases,osteoporosis.279
Thecaserevealsthatreproductivetechnologieswerenotonlydistributedthroughstate programsbutalsomarketedascommercialproducts,exposingwomentoheightenedmedical riskswhilereinforcingasysteminwhichreproductionitselfbecomesasiteofdemographic control.Thegovernmentwasgivencontroloverminoritypatients’reproductivefreedoms, placingthematthemercyofaninstitutionthatremainsindifferenttotheirpleas.The governmentcoercionofyoungBlackwomenintousingbirthcontrol,tothenturnitsback, precededadeliberatepopulationerasurecampaignthatsubvertedplantationeconomicpolitics; theplantationworkedtogainvaluefromBlackmaternity,whilethewelfarestatesoughtto curtailit.Inbothcontexts,however,reproductionremainedsubjecttoeconomicvaluation.What
275 Roberts, Killing The Black Body, 129
276 RaymondHaddock, Division Administrator for Medical Services, State of Oklahoma Department of Human Services, letter to physicians, January20,1993
277 Norplant Products Liability Litigation,915F Supp 845
278 In re Norplant Contraceptive Products Liability Litigation,915F.Supp.845(E.D.Tex.1996).
279 K Katoetal,“NorplantandItsSideEffects,” Zentralblatt für Gynäkologie 117,no 5(1995):260–62
wasonceseenasaneconomicopportunitybecameahindrance.Whethercultivatedforlaboror restrictedtoreducepublicexpenditure,Blackwomen’sbodiesweregovernedaccordingto shiftingmarketlogicsratherthanindependentchoice.
America’sabnormallyhighmaternalmortalityratesworkintandemwithinstitutional structuresthatreproducelongstandingracialandeconomicinequalitiesinhealthcare.Inthe UnitedStates,Blackwomen,regardlessofclass,facesignificantlyhigherrisksof pregnancy-relatedcomplicationscomparedtotheirwhitecounterparts.Thisdisparitydoesnot reflectbiologicaldifference,butsystemicissues,includingunequalaccesstohealthcare,implicit biasamongsthealthcareproviders,andthecumulativeeffectsofchronicstressproducedby structuralracism.Asaresult,maternalmorbiditynotonlybecomesapublichealthcrisisbuta manifestationofbroadersocialinequalitiesembeddedinAmericanmedicalinstitutions.
Intheyearsleadingupto2004,BlackwomenintheUnitedStatesfacedsubstantially higherrisksofpregnancy-relatedoutcomesthanwhitewomen,acontrastlinkedbypublichealth specialiststohealthcarediscrepancies,delayedtreatment,andracializedassumptionsaboutpain, ratherthanbiologicaldifference.By2000,thesedisparitiesbecamehorrifyinglyquantifiable. AccordingtoNationalVitalStatisticsReportData,thematernalmortalityrateforallracesin 2000was9.8deathsper100,000livebirths,withBlackwomen’smaternalmortalityratebeing 22.3deathsper100,000livebirths,awhopping3.28timestherateofwhitewomenof6.8deaths per100,000livebirths.280 Additionally,from2007-2016,Non-HispanicBlackwomen experiencedaPregnancy-relatedMaternalRatio(PRMR)of40.8,whilewhitewomen experiencedasignificantlylower9.7(SeeAppendixA).281 Whilethispaperfocuseson
280 ArialdiM Miniñoetal, Deaths: Final Data for 2000,NationalVitalStatisticsReports50,no 15 (Hyattsville,MD:NationalCenterforHealthStatistics,2002),13
281 EmilyE Petersenetal,“Racial/EthnicDisparitiesinPregnancy-RelatedDeaths UnitedStates, 2007–2016,” Morbidity and Mortality Weekly Report 68,no.35(September6,2019):762–765, https://doiorg/1015585/mmwrmm6835a3
developmentsthroughtheearly2000s,laterepidemiologicalevidencefromtheearlytwenty-first centurydemonstratesthatBlackwomencontinuetofacedisproportionatelyhigher pregnancy-relatedmortalitythanotherracialgroups,suggestingthatthelegacyofstructuralbias documentedearlierpersistsinracializedoutcomes.
ResearchbytheInstituteofMedicinefoundthatraceandethnicityremainedsignificant predictorsofthequalityofhealthcarereceived,withdisparitiesarisingfromprovider-patient interactionsshapedbybias,stereotyping,andclinicaluncertainty.
282 However,maternal mortalityreviewcommitteesoperatinginthelate1990sandearly2000sfrequentlyconcluded thatasubstantialproportionofpregnancy-relateddeathswerepreventable.Commonlycited factorsincludeddelayedresponsestohemorrhaging,failuretoescalatecareinhypertensive crises,andinsufficientresponsestopatientcomplaints.Suchfindingsrevealthatmortality disparitieswerenottheproductofbiologicalinevitabilitybutofinstitutionaldecision-making. Whenplacedalongsidedecadesofresearchdemonstratingracialdisparitiesinpainmanagement andclinicalurgency,thesecasessuggestthatthedevaluationofBlackbodilydistress,whichwas soexplicitinnineteenth-centurymedicine,remainedembeddedinobstetricspractice.Despite widespreadrecognitionofthesedistinctionsbyresearchersandmedicalprofessionals, meaningfulreformwaslimited.Institutionalresistance,implicitbias,andthebroaderstructural inequalitiesamongandwithinproviderestablishmentsallowthesepatternstopersist,while politicalprioritiesshadowtheoverallimportanceofmaternalhealthcare.Asaresult,the devaluationofBlackwomen’shealthhasremainedembeddedwithincontemporarymedical practice.
282 InstituteofMedicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington,DC:NationalAcademiesPress,2003)
Americangynecologydidnotemergesimplyfromantebellumsurgicalingenuity,norcan itsdevelopmentbeunderstoodasanisolatedstoryofmedicalprogress.Asthispaperhasshown, thefoundationsofobstetricsandgynecologywerelaidwithinaplantationeconomythat convertedBlackwomen’sreproductiveexperienceintocapital.Throughstatutessuchas partus sequitur ventrum,thecommercialincentivesattachedtochildbirth,andexperimentalprocedures performedonenslavedwomenwithoutconsentoranesthesia,reproductionwasrenderedbothan economicassetandaclinicalopportunity.
Althoughslaveryendedandoverteugenicrhetoricfaded,thelogicsurroundingBlack women’sbodiesandreproductionpersistedinanalteredform.Twentieth-centurysterilization campaigns,targetedcontraceptiveinitiatives,andmeasurabledisparitiesrevealthatreproduction continuedfunctioningasasiteofgovernanceinoppositiontoautonomy Thelanguageswitched fromtheplantationandthelabtabletocontraceptiveimplantsandwelfaremanagement.Where theplantationoncesoughttomaximizereproductiveoutput,themodernstatefrequentlysought toreduceit.Inbothcases,Blackwomen’sreproductivelivesweretreatedasmattersof institutionalconcernratherthanprivatedignity.
Thepersistenceofthispatternbecomesunmistakablecomparedwithcontemporary accounts.In2017,SerenaWilliamsnearlydiedfromapost-partumpulmonaryembolism283 after medicalstaffinitiallydismissedherself-reportedsymptoms.284 In2018,OlympicathleteAllyson Felixdescribedbeingpressuredintoanemergencycesareansectionaftercomplicationsrelated topreeclampsia,285 laterrevealingstructuralfailuresinmaternalcareandcorporatesupport.286 Felix’steammate,Frentorish“Tori”Bowie,diedinMay2023atage32duetochildbirth
283 Whenabloodclotgetsstuckinanarteryinthelung,blockingbloodflowtopartofthelung
284 MayaSalam,“SerenaWilliamsonPregnancyandMotherhood:‘IWasAlmostKilled,’” New York Times,January11,2018,https://wwwnytimescom/2018/01/11/sports/tennis/serena-williams-baby-voguehtml
285 Potentiallyfatalbloodpressuredisorderoccurringduringpregnancyorpost-partum
286 CentersforDiseaseControlandPrevention,“AllysonFelix:AStoryofResilienceinMaternalHealth,” CDC HEAR HER,lastreviewedMarch24,2023,https://wwwcdcgov/hearher/allyson-felix/
complications,specifically,respiratorydistressandeclampsia.287 Bowiewasoncethefastest womanintheworldandhadaccesstothehighestlevelsofcareduetoherathleticstatus. However,Bowie’sfameandrecognitiondidnotstopherfromfallingvictimtotheUnitedStates’ lackofcaresurroundingBlackmaternity 288 Allthreecasesresembleadeepercontinuityin whichBlackwomen’spain,despitetheirbackground,remainsunequallyacknowledged.Ifelite athletesmustadvocateforcefullytobeheard,theimplicationsforlessvisiblewomenare profound.
Recognizingthiscontinuitydoesnotcollapsepastandpresentintosameness.Antebellum physiciansspokeopenlyaboutracialbiologicaldifferenceandpaintolerance;however,the underlyingquestionpersists:whosesufferingisbelieved,whosestressisurgent,andwhose reproductionismanaged?Maternalmortalitydisparitiesinthetwenty-firstcenturydonotstand apartfromtheantebellumpast.TheyinsteadrevealthedurabilityofasysteminwhichBlack women’sbodieshavelongfunctionedassitesoflabor,experimentation,andcomputation.The actofbringinglifeintotheworld,anexperiencethatdeservescare,dignity,andadmiration,was weaponizedagainstBlackwomentobolstertheantebellumeconomy,andlater,reconfiguredina capitalistmedicalsystemthatsoughttotreatBlackreproductionassomethingtobesurveyed.In agynecologist’soffice,awomanismeanttofeelprotectedinhermostintimateandvulnerable state,yetBlackwomenhavegrowntofearthescalpelandtheclinicalgaze.Theirpainismeant tobeenduredratherthananesthetized,andtheyarelefttoconfronttheterrifyingrealitythat eveninseekingcare,theirlivesarenegotiablewithinasystemthathasneverfullyrecognized theirrighttosurviveit.
287 NPR,“Tori Bowie, an Elite Olympic Athlete, Died of Complications From Childbirth, ” NPR,June13, 2023
288 Tori Bowie’s death highlighted a devastating reality for Black women in the US, The Guardian,August 1,2023
Overall,tounderstandAmericangynecology,then,istorecognizeslaverynotas backgroundcontextbutasformativestructure.Thediscipline’scelebratedinnovationswere achievedwithinasystemthatcommodifiedBlackmaternity Untilthathistoryisacknowledged asfoundationalratherthanperipheral,contemporarydisparitieswillpersist.
Acknowledgments
GuidedbyPsalm90:17:“LetthefavoroftheLordourGodbeuponus,andprosperforusthe workofourhands—Oprospertheworkofourhands!” TheutmostloveandgratitudetoKiaraRiveraValdezandManuellaKiriza,mybestfriends. MysincerethankstoKymanniBabb,GiadaMusto,MadelineMacallister,SadhanaBery, ShamsudBery,LailaMcCain,and,mostimportantly,Mrs.Mustoforyourhelpfulguidanceand advicewhilewritingthispaper
Bibliography
Alonso,Paola.AutonomyRevoked:TheForcedSterilizationofWomenofColorin20thCentury America.Denton,TX:TexasWoman'sUniversity,n.d.
"ArrestofFugitiveSlaves:ASlaveMotherMurdersHerChildRatherThanSeeItReturnedto Slavery."Anti-SlaveryBugle(NewLisbon,OH),February2,1856.
Boney,F Nash."DoctorThomasHamilton:TwoViewsofaGentlemanoftheOldSouth." Phylon28,no.Fall(1967):288–92.
Borrero,Samuel,N.Zite,J.E.Potter,andJamesTrussell."MedicaidPolicyon Sterilization—AnachronisticorStillRelevant?"NewEnglandJournalofMedicine370, no.2(2014):102–104.https://pmc.ncbi.nlm.nih.gov/articles/PMC4418554/#R2.
Buckv Bell,274U.S.200(1927).
CentersforDiseaseControlandPrevention."AllysonFelix:AStoryofResilienceinMaternal Health."CDCHEARHER.LastreviewedMarch24,2023. https://www.cdc.gov/hearher/allyson-felix/.
Chamerovzow,LouisA.,ed.SlaveLifeinGeorgia:ANarrativeoftheLife,Sufferings,and EscapeofJohnBrown,aFugitiveSlave,NowinEngland.London,1855.
Chase,Allan.TheLegacyofMalthus:TheSocialCostsoftheNewScientificRacism.Urbana: UniversityofIllinoisPress,1980.
Chaturvedi,Ravindra,andR.L.Gogna."EtherDay:AnIntriguingHistory."MedicalJournalof ArmedForcesIndia67,no.4(October2011):306–308. https://pubmed.ncbi.nlm.nih.gov/25032386/.
CommitteetoEndSterilizationAbuse(CESA)."SterilizationAbuseofWomen:TheFacts." Health/PACBulletin,no.62(January–February1975):89.
CooperOwens,Deirdre.MedicalBondage:Race,Gender,andtheOriginsofAmerican Gynecology.Athens:UniversityofGeorgiaPress,2017.
Coxv.Stanton,529F.2d47(4thCir.1975).
Cronin,Monica."Anarcha,Betsey,Lucy,andtheWomenWhoseNamesWereNotRecorded: TheLegacyofJ.MarionSims."AnaesthesiaandIntensiveCare48,no.3_suppl (November2020):6–13. https://journals.sagepub.com/doi/epub/10.1177/0310057X20966606.
Duffy,John,ed.TheRudolphMatasHistoryofMedicineinLouisiana.2vols.BatonRouge, 1958–1962.
Early,Rosalind."TheSweatandBloodofFannieLouHamer."Humanities42,no.1(Winter 2021).https://www.neh.gov/article/sweat-and-blood-fannie-lou-hamer.
FederalWriters'Project.SlaveNarratives:AFolkHistoryofSlaveryintheUnitedStatesfrom InterviewswithFormerSlaves.Vol.17.Washington,DC:LibraryofCongress,1941. Filippides,Alexander "HumanitiesResearchersRemembertheSlaveTradeandItsAbolition." NationalEndowmentfortheHumanities,August23,2023. https://www.neh.gov/blog/humanities-researchers-remember-slave-trade-and-its-abolition
Galarza,Samantha."SterilizationofPuertoRicanWomen."InterculturalLeadershipInstitute. AccessedApril6,2026.
https://weareili.org/timeline/sterilization-of-puerto-rican-women/.
Galton,Francis."HereditaryTalentandCharacter."Macmillan'sMagazine12(1865):157–166.
Gold,RachelBenson."TitleX:ThreeDecadesofAccomplishment."TheGuttmacherReporton PublicPolicy4,no.1(February2001).
Gordon-Reed,Annette.TheHemingsesofMonticello:AnAmericanFamily.NewYork:W.W. Norton&Company,2008.
Haddock,Raymond,DivisionAdministratorforMedicalServices,StateofOklahoma DepartmentofHumanServices.Lettertophysicians,January20,1993.
Holland,Brynn."The'FatherofModernGynecology'PerformedShockingExperimentson EnslavedWomen."History,August29,2017.UpdatedDecember3,2025.
https://www.history.com/articles/the-father-of-modern-gynecology-performed-shocking-e xperiments-on-slaves.
Hudes,QuiaraAlegría."#OurMothersToo:ReckoningWithMyAbuela'sCoercedSterilization." TheNation,June17,2021.
https://www.thenation.com/article/society/ourmotherstoo-reckoning-with-my-abuelas-coe rced-sterilization/.
InstituteofMedicine.UnequalTreatment:ConfrontingRacialandEthnicDisparitiesinHealth Care.Washington,DC:NationalAcademiesPress,2003.
Jacobs,Harriet.IncidentsintheLifeofaSlaveGirl.Boston:PublishedfortheAuthor,1861. Jefferson,Thomas.FarmBook,1774–1824.Manuscript.Monticello.QuotedinLuciaC.
Stanton,ThoseWhoLaborforMyHappiness:SlaveryatThomasJefferson'sMonticello. Charlottesville:UniversityofVirginiaPress,2012.
Johnson,James."ReviewofSurgicalPractices."TheMedico-ChirurgicalReview.London, 1840s.
Jones,AniqueY."TheEugenicSterilizationofPuertoRicanWomen:ACaseofUSInterestsand Religious/SpiritualFreedom."Master'sthesis,ChapmanUniversity,2025.
Kato,K.,etal."NorplantandItsSideEffects."ZentralblattfürGynäkologie117,no.5(1995): 260–62.
Kihss,Peter."PuertoRicoFindsDipinBirthRate;FamilyPlanAideCallsDropaResultof MigrationandIncreaseinSterilization."NewYorkTimes,January25,1958.
Lawson,EricaS."BereavedBlackMothersandMaternalActivismintheRacialState."Feminist Studies44,no.3(2018):713–742.
https://www.jstor.org/stable/10.15767/feministstudies.44.3.0713.
Miniño,ArialdiM.,etal.Deaths:FinalDatafor2000.NationalVitalStatisticsReports50,no. 15.Hyattsville,MD:NationalCenterforHealthStatistics,2002.
Morgan,JenniferL.LaboringWomen:ReproductionandGenderinNewWorldSlavery. Philadelphia:UniversityofPennsylvaniaPress,2004.
Morgan,JenniferL.PartusSequiturVentrem:Law,Race,andReproductioninColonialSlavery. Philadelphia:UniversityofPennsylvaniaPress,2018.
NationalCenterforHealthStatistics.Deaths:FinalDatafor1998.NationalVitalStatistics Reports48,no.11.Hyattsville,MD:U.S.DepartmentofHealthandHumanServices, 2000.https://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf.
NationalCenterforHealthStatistics.Deaths:FinalDatafor1999.NationalVitalStatistics Reports49,no.8.Hyattsville,MD:U.S.DepartmentofHealthandHumanServices, 2001.https://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_08.pdf.
NationalCenterforHealthStatistics.Deaths:FinalDatafor2000.NationalVitalStatistics Reports50,no.15.Hyattsville,MD:U.S.DepartmentofHealthandHumanServices, 2002.https://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_15.pdf.
NationalCenterforHealthStatistics.Deaths:FinalDatafor2001.NationalVitalStatistics Reports52,no.3.Hyattsville,MD:U.S.DepartmentofHealthandHumanServices, 2003.https://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_03.pdf.
NationalCenterforHealthStatistics.Deaths:FinalDatafor2002.NationalVitalStatistics Reports53,no.5.Hyattsville,MD:U.S.DepartmentofHealthandHumanServices, 2004.https://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_05.pdf.
InreNorplantContraceptiveProductsLiabilityLitigation,915F Supp.845(E.D.Tex.1996).
NPR."ToriBowie,anEliteOlympicAthlete,DiedofComplicationsFromChildbirth."NPR, June13,2023.
Ologbosele,Eseose."InnovationorInjustice?:TheMedicalEthicsofJ.MarionSims." Unpublishedpaper,AdvancedHistoryCapstone,BrooksSchool,December16,2025.
Peoplev Johnson,3Cal.App.4th1390(Cal.Ct.App.1992).
Petersen,EmilyE.,etal."Racial/EthnicDisparitiesinPregnancy-RelatedDeaths United States,2007–2016."MorbidityandMortalityWeeklyReport68,no.35(September6, 2019):762–765.https://doi.org/10.15585/mmwr.mm6835a3.
PlannedParenthoodFederationofAmerica."TheHistory&ImpactofPlannedParenthood." AccessedMarch31,2026. https://www.plannedparenthood.org/about-us/who-we-are/our-history.
SterilizationandFertilityDeclineinPuertoRico.PopulationMonographSeries,No.13. Berkeley:UniversityofCalifornia,InstituteofInternationalStudies,n.d.
Relfv Weinberger,372F Supp.1196(D.D.C.1974).
Roberts,Dorothy KillingtheBlackBody:Race,Reproduction,andtheMeaningofLiberty New York:VintageBooks,1997.
Roev.Wade,410U.S.113(1973).
"RunawaySlaveAdvertisements."UniversityofNorthCarolinaatGreensboroLibraries. AccessedMarch29,2026.
Salam,Maya."SerenaWilliamsonPregnancyandMotherhood:'IWasAlmostKilled.'"New YorkTimes,January11,2018.
https://www.nytimes.com/2018/01/11/sports/tennis/serena-williams-baby-vogue.html.
Sanger,Margaret.WomenandtheNewRace.NewYork:Brentano's,1920.
Savitt,ToddL."TheUseofBlacksforMedicalExperimentationandDemonstrationintheOld South."JournalofSouthernHistory48,no.3(August1982):331–348. https://www.jstor.org/stable/2207450.
Schafer,J.K."NewOrleansSlaveryin1850asSeeninAdvertisements."JournalofSouthern History47,no.1(1981):33–56.
Sims,J.Marion.TheStoryofMyLife.NewYork:D.AppletonandCompany,1884. Skinnerv.Oklahomaexrel.Williamson,316U.S.535(1942).
SocialSecurityAdministration."EugenicsandtheSocialSecurityAct."SocialSecurityBulletin 25,no.11(1962):1.
Stanton,LuciaC.ThoseWhoLaborforMyHappiness:SlaveryatThomasJefferson's Monticello.Charlottesville:UniversityofVirginiaPress,2012.
Still,William.TheUndergroundRailroadRecords.Philadelphia:Porter&Coates,1872.
Stout,Elizabeth."ToRidSocietyofImbeciles:TheImpactofDr.JohnHarveyKellogg'sStand forEugenics."UniversityofMichiganSchoolofPublicHealth,December12,2022. https://sph.umich.edu/pursuit/2022posts/the-impact-of-dr-john-harvey-kelloggs-stand-for -eugenics.html.
ThomasJeffersonFoundation."ThomasJeffersonandSallyHemings:ABriefAccount." Monticello–ThomasJefferson'sEstate.AccessedFebruary23,2026.
https://www.monticello.org/slavery/jefferson-and-sally-hemings/a-brief-account/. "ToriBowie'sDeathHighlightedaDevastatingRealityforBlackWomenintheUS."The Guardian,August1,2023.
Turner,Sasha."TheInvisibleThreadsofGender,Race,andSlavery."AfricanAmerican IntellectualHistorySociety,April13,2017. https://www.aaihs.org/the-invisible-threads-of-gender-race-and-slavery/.
Ventura,StephanieJ.,andMaryAnneFreedman."TeenageChildbearingintheUnitedStates, 1960–1997."VitalandHealthStatistics21,no.53(2000).NationalCenterforHealth Statistics,CentersforDiseaseControlandPrevention.
Wall,L.L."TheMedicalEthicsofDr.J.MarionSims:AFreshLookattheHistoricalRecord." JournalofMedicalEthics32,no.6(June2006):346–350. https://www.jstor.org/stable/27719646.
Washington,HarrietA.MedicalApartheid:TheDarkHistoryofMedicalExperimentationon BlackAmericansfromColonialTimestothePresent.NewYork:Doubleday,2006.
Weisbord,RobertG.Genocide?BirthControlandtheBlackAmerican.Westport,CT: GreenwoodPress,1975.
White,DeborahGray.Ar'n'tIaWoman?FemaleSlavesinthePlantationSouth.NewYork:W. W Norton,1985.
White,NancyA."FamilyPlanningServicesandPopulationResearchActExtendsReproductive Rights."EBSCOResearchStarters,2023.
https://www.ebsco.com/research-starters/law/family-planning-services-and-population-re search-act-extends-reproductive.
Williams,Rose.Interview InSlaveNarratives:AFolkHistoryofSlaveryintheUnitedStates, FromInterviewswithFormerSlaves,vol.16,TexasNarratives,pt.4.Washington,DC: WorksProgressAdministration,1941.LibraryofCongress.
"YaleStudyShowsU.S.SterilizationMovementMorePrevalentthanBelievedatTimeofNazi Germany."YaleNews,February14,2000.
https://news.yale.edu/2000/02/14/yale-study-shows-us-sterilization-movement-more-prev alent-believed-time-nazi-germany.
Zite,N.,S.Philipson,andL.Wallace."ConsenttoSterilizationSectionoftheMedicaid–Title XIXForm:IsItUnderstandable?"Contraception75(2007):256–260.
MaternalMortalityRatebyRace,1998-2002
Maternalmortalityratesper100,000livebirths.DatacompiledfromtheNationalCenterfor HealthStatisticsandtheNationalVitalStatisticsReportsfortheyears1998,290 1999,291 2000,292 2001,293 and2002.294
289 EmilyE Petersenetal,“Racial/EthnicDisparitiesinPregnancy-RelatedDeaths UnitedStates, 2007–2016,” Morbidity and Mortality Weekly Report 68,no.35(September6,2019):762–765, https://doiorg/1015585/mmwrmm6835a3
290 NationalCenterforHealthStatistics, Deaths: Final Data for 1998,NationalVitalStatisticsReports48, no 11(Hyattsville,MD:US DepartmentofHealthandHumanServices,September28,2000),table32, https://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48 11.pdf.
291 NationalCenterforHealthStatistics, Deaths: Final Data for 1999,NationalVitalStatisticsReports49, no.8(Hyattsville,MD:U.S.DepartmentofHealthandHumanServices,June2001),table30, https://wwwcdcgov/nchs/data/nvsr/nvsr49/nvsr49 08pdf
292 NationalCenterforHealthStatistics, Deaths: Final Data for 2000,NationalVitalStatisticsReports50, no 15(Hyattsville,MD:US DepartmentofHealthandHumanServices,September16,2002),table38, https://wwwcdcgov/nchs/data/nvsr/nvsr50/nvsr50 15pdf
293 NationalCenterforHealthStatistics, Deaths: Final Data for 2001,NationalVitalStatisticsReports50, no 15(Hyattsville,MD:US DepartmentofHealthandHumanServices,September16,2002),table38, https://wwwcdcgov/nchs/data/nvsr/nvsr52/nvsr52 03pdf
294 NationalCenterforHealthStatistics, Deaths: Final Data for 2002,NationalVitalStatisticsReports53, no.5(Hyattsville,MD:U.S.DepartmentofHealthandHumanServices,June2005),table34, https://wwwcdcgov/nchs/data/nvsr/nvsr53/nvsr53 05pdf