“Saving Muslim Women”: How Language Justifies Intervention through USAID Family Planning Programs in Pakistan…
Posted under: Lucy Banion, University of Missouri – Columbia
“Saving Muslim Women”: How Language Justifies Intervention through USAID Family Planning Programs in Pakistan Between 1965-1979 and 2001-2018
While the “saving Muslim women” rhetoric employed in the so-called U.S. “War on Terror” has been widely studied, the origin of this narrative is less understood. This article argues that this rhetoric partly stems from the purported agendas of the United States Agency for International Development (USAID) in its early decades – especially those related to family planning and population control, which were reinvigorated as part of humanitarian interventions post-9/11. Using critical discourse analysis of 20 primary source publications by USAID, this research focuses on programming in Pakistan during two historical eras: 1965-1979 and 2001-2018. This analysis reveals how the “saving Muslim women” narrative justified foreign aid intervention through family planning for more than 50 years.
“It is problematic to construct the Muslim woman as someone in need of saving. When you save someone, you imply that you are saving her from something. You are also saving her to something.”
– Lila Abu-Lughod (2013, p. 46)
Humanitarian intervention programs sponsored by Western countries such as the United Stats have long been criticized for employing the “saving Muslim women” trope – that is, framing all Muslim women as inherently oppressed, as opposed to the liberated Western (non-Muslim) woman. This rhetoric allows non-Muslim/Western voices to speak for Muslim women, whose lived experiences and opinions are often ignored or under-valued. These projects centered on “saving” other women “depend on and reinforce a sense of superiority, and are a form of arrogance that deserves to be challenged” (Abu-Lughod, 2013, p. 47). While the post-9/11 “War on Terror” is often cited as the moment “saving Muslim women” became central to U.S. foreign policy, the legitimization of intervention as a means of “saving” has deep roots. The U.S. has consistently tried to “save” foreign nations for decades, and the centrality of women to this agenda is nothing new. To what extent has this “saving women” frame contributed to the U.S. neo-imperial agenda since World War II and how has it evolved? In this paper, I will argue that programs pertaining to “population control” and “family planning” in the 1960-70s also exemplify the discursive logic of the “saving Muslim women” rhetoric. For non-U.S. women, these programs were not just about health or empowerment, but a means of exerting political and social control with their reproductive bodies as the battleground. Constructed narratives of need and overpopulation positioned non-U.S. women as requiring the salvation of the West, often through relationships with the Western woman. These narratives targeted Muslim-majority countries, which were also seen as “less developed.”
The agency that employed this Western salvation and development rhetoric more than any other was the United States Agency of International Development (USAID). The U.S. State Department began formally managing foreign assistance programs in 1955 with the establishment of the International Cooperation Administration. This predecessor to USAID was dissolved in 1961 by the Foreign Assistance Act, which established USAID. Where, how, and to whom economic and developmental assistance was given reflects U.S. foreign relations and agendas. The Food for Peace Act of 1966 was the first official declaration of a U.S. “War on Hunger” by President Lyndon B. Johnson (1966), for instance. Emerging from a period of decolonization, “developed” countries feared there would not be enough food, and the burden would fall on their nations to support the “less developed” countries’ hungry populations – furthering the divide between “the West” and the “rest” (Hall, 2018, p. 209). Also during this time, the U.S. and the Soviet Union fought to establish alliances during the Cold War and to retain some of the social control lost by decolonization, fueled with increases in foreign aid and military support (Council on Foreign Relations, 2023). While some programs sought to expand the world’s food supply and enhance the country’s soft power, other programs sought to minimize global populations and therefore lessen the projected burden of care. To this end, the U.S. Population Council was established in 1952 and the Family Planning Association of Pakistan in 1953 – both of which partnered closely with USAID since its founding.
Pakistan has been a consistent recipient of U.S. foreign assistance since the creation of USAID in 1961 until its dissolution in January 2025. Pakistan gained independence from the United Kingdom in 1947 through the Indian Independence Act, which created India and Pakistan as separate, independent nation-states (see UK Parliament, 1947). The Act separated the land into dominions based on religion, resulting in a mass forced migration of Muslim, Hindi, and Sikh peoples. Since its independence in 1947, Pakistan has relied on U.S. military and economic assistance and the U.S. has relied on Pakistan’s geographic location for its counterterrorism efforts, but the diplomatic relationship lacks trust or transparency. India and Pakistan have gone to war in 1947, 1965, 1971, and 1999. Each time, the U.S.’s response as an alleged ally has been viewed as less than adequate by Pakistan, fostering a relationship of abandonment and distrust. As Daniel Markey (2013) notes, “the U.S. has been the fickler partner, its approach to Pakistan shifting dramatically across the decades. Pakistan, however, has been guilty of greater misrepresentation, claiming support for American purposes while turning U.S. partnership to other ends. Consequently, both sides failed repeatedly to build a relationship to serve beyond the immediate needs of the day.” The American perception of Pakistan changes under each administration, swinging like a pendulum between “extremes of ungrounded exuberance and overstated fear” (Markey, 2013). While the reason for U.S. involvement has changed over time, it remains that Pakistan has been a site of U.S. development for decades.
USAID programming in Pakistan offers a revealing case study for examining how the “saving Muslim women” rhetoric has operated and evolved – as a means of controlling women, but also as a link between development assistance and U.S. strategic interests. With some of the highest birth and poverty rates in the 1960s, Pakistan was a target for policymakers concerned with overpopulation. In the early 2000s, Pakistan was an important actor in the U.S. “War on Terror” as a Muslim-majority country and neighbor to Afghanistan. The financial assistance Pakistan received through USAID during these two eras – the Cold War (1965-1979) and the War on Terror (2001-2018) – shows how Muslim women’s bodies became the rationalization for intervention framed as humanitarian necessity. Their experience demonstrates that the language of empowerment, health, and education that justified invasive family planning programs functioned as a tool of control and established rhetorical patterns that would emerge into the explicit “saving Muslim women” discourse decades later.
Theoretical Framework
This historical comparative analysis examines USAID publications from two specific eras: 1965-1979 and 2001-2018. I employ critical discourse analysis to systematically analyze how language frames Pakistani Muslim women as subjects in need of saving and how humanitarian aid acts as a form of social control. This methodological approach reveals both how language functions and its effectiveness as a method of control and power. Critical discourse analysis offers a methodological approach for identifying how language, explicit and implicit, creates both the problem and solution. I can illuminate how the “saving Muslim women” discourse is applicable to both eras, not just during the “War on Terror” as previous scholars have noted. By asking the same questions of each source and looking for the same language or functionality, I explore continuities and changes in control mechanisms across the two eras.
My first question asks what problems USAID identified and constructed related to the issue of “population control,” and what solutions they proposed to solve this issue. Under the auspices of USAID, the problem was often framed as a lack of development, and the solution was modernization. Michael Latham’s (2011) work on “modernization” as a Cold-War ideology prompts this question and provides the necessary framework for understanding underlying geopolitical agendas that prompted family planning agendas. My second question asks about the positionality of the women as they are framed in USAID publications. Often the subject of population control, women represent and experience different “problems”; how they are described, or fail to be mentioned, reveals their assumed role in family planning advancement. Lila Abu-Lughod’s (2013) theory of “gendered orientalism” frames this question, as she speaks to the positionality of Muslim women and how control has operated in practice. Exploring these questions help reveal how the language used by USAID in their family planning programs positioned Muslim women in a way that legitimized intervention, before and during the U.S. “War on Terror.”
Modernization theory begins to explain the guiding beliefs behind USAID and its manifestations in social welfare programs, which recast older imperialistic ideologies into purportedly value-neutral, secular, scientific vernacular. The sociological theory first emerged during the Cold War as theorists sought ways to hinder the Soviet spread of communism in “developing” countries and to control newly independent states. In U.S. Cold War strategy, modernization became central to planning by determining how Americans would fight in a dangerous struggle – including making identity inseparable from how they defined security and strategy (Latham, 2011). As modernization expanded out of sociology and into political science, it brought with it a way to understand society as a series of patterns, an integrated system. It identified linear steps in societal and state development based on historical patterns used to order societies in accordance with their modernity. If the pattern could be identified, then a state’s progression of development could be impacted by more modern countries such as the United States. Thus, modernization theory not only justified overseas intervention, but required and supported it. If contact with modern societies was the only way to make traditional societies achieve “progress,” then the U.S. saw it as an obligation to turn other states toward democracy and away from communism. With its high birth rates and poverty in the 1960s, Pakistan fit perfectly into this framework as a “tradition-bound” society requiring Western rationalization, specifically through family planning programs designed to modernize reproductive practices. Community development programs relied on the personal relationships between American volunteers and aid recipients, which were implemented “not through large scale infrastructure projects but through interventions in the private domain of the family – in the lives of parents and children” (Fieldston, 2015, p. 144).
Since the 1960s, an area of intense concern for development agencies has been the growing global population and the need for it to be controlled. If over population and under development go hand in hand, then the birth rates of developing countries need to be decreased. Modernization justified this as a natural step of progress, spurred by widespread fears of starvation and anarchy that drove the creation of population control programs (Bureau for Technical Assistance, 1969, p. 104). Matthew Connelly (2008) criticizes the imperial roots of these programs and argues: “The great tragedy of population control, the fatal misconception, was to think that one could know other people’s interests better than they knew it themselves” (p. 378). This was the overarching logic of modernization: it is the duty of the most modern people to help those who cannot reach modernity. However, this logic was flawed because it assumed that everyone wanted to be “modern,” that those that did not want to be modern did not know better, and there was an obligation to correct the “backwards” ways of the “underdeveloped.” The modern woman had a manageable number of children and used contraceptives, while the traditional woman had too many children because she was uneducated about contraceptives and birth spacing (Connelly, 2008, p. 138). It was quickly decided: “Only massive birth control operating effectively throughout the world, can possibly restore the balance and save what is a deteriorating situation” (Bureau for Technical Assistance, 1969, p. 105).
Women were now positioned as the problem in overpopulated (underdeveloped) countries and their acceptance of birth control was the solution. To solve overpopulation, the country had to be developed – and no agency other than USAID was prepared to take on this task. Ultimately, the core issue was framed as a matter of “family planning.” This is a means of population control which advocated for birth spacing and contraceptive use, and it encourages women to believe “they were better off with fewer children” (Merrill, 2002). These programs often use empowerment language or position the issue alongside health, seemingly in line with feminist goals, but: “Was contraception a part of comprehensive healthcare or was healthcare a vehicle for population control?” (Connelly, 2008, p. 200).
Decolonial feminist theory reveals how a Western feminist rhetoric can serve as a means of control when applied to Muslim women. It requires an understanding of gendered orientalism and Western feminist complicity in imperial projects. “There is a long tradition of representing Muslim women in the West: Gendered Orientalism. Pictorial as well as literary, what is constant is that Muslim women are portrayed as culturally distinct, the mirror opposites of Western women,” writes Abu-Lughod (2013, p. 88). This representation has shaped U.S. foreign policy for decades, and U.S. opinion for centuries. Orientalism at its core is belief in Western superiority, and non-Western (Oriental) inferiority (Said, 1978, p. 42). This Western-constructed dichotomy justified colonization and developmental assistance in the nineteenth and twentieth centuries by creating a need for saving that only they provide. Gender orientalism takes this further, analyzing the unique experience of “Eastern” womenand how they are depicted by the “West.” They are constructed as oppressed not just by their culture, but also by the men around them. Building on Edward Said’s (1985) analysis of how the West constructed the “Orient” as culturally inferior to justify colonial domination, Abu-Lughod (2013) demonstrates how this Orientalist logic operates with particular force when applied to Muslim women.
Research Methods
For this project, I identified two specific eras using historical markers within nearly 80 years of relations between the United States and the independent state of Pakistan. Era I begins in 1965, with the creation of the Office of Population within USAID, under the direction of Reimert (Ray) Ravenholt. Ravenholt remained a key actor in family planning programs until he left the agency in 1979. His “contraceptive inundation” approach had lasting effects on hundreds of thousands of women in Pakistan and surrounding countries. This approach meant flooding the nations with birth control and condoms, through as many outlets as possible, to as many people as possible. From 1965 to 1979, population planning programs were implemented in dozens of countries in the “developing world” with the goal of lowering birth rates. Ravenholt’s departure from USAID signified the decline of the agency’s aggressive population control campaign (Gillespie, 2000). In the same year, the administration of U.S. President Jimmy Carter suspended all aid upon confirmation of Pakistan’s nuclear enrichment program, (This suspension of aid was in accordance with the 1976 amendment to the Arms Export Control Act, which barred the U.S. from providing economic and military assistance to any state involved in “nuclear-enrichment activities; Cookman & French, 2011). Era I ends in 1979.
Era II begins in 2001, with the declaration of a “War on Terror” by the U.S. President George W. Bush after the 9/11 terrorist attacks. Counterterrorism efforts were aimed at destroying al-Qaeda and driving the Taliban from power in Afghanistan, but affected many facets of U.S. foreign policy in neighboring countries – including Pakistan. Assets of known or suspected terrorists and terrorist organizations were closed, and the Foreign Terrorist Tracking Task Force was created to prevent terrorists from entering U.S. territory (Bush, G. W., 2001). Military operations increased on the ground, and so did humanitarian aid; the new “war” justified military, political, and social intervention overseas. U.S. First Lady Laura Bush was especially concerned about the experiences of women under the Taliban and placed them at the center of the war effort, stating: “The fight against terrorism is also a fight for the rights and dignity of women” (Bush, L., 2001). Here, Afghan women were positioned as needing to be saved from a harmful regime. This further justified military and social intervention in Afghanistan. In the U.S. National Security Strategy, development was placed alongside defense and diplomacy as key pillars, which called for new responsibilities for USAID. The agency already operated and had connections in many states considered “at risk” for terrorism (Baltazar, 2007, p. 39). Enhancing development programs meant enhancing national security, and the existing relationships that USAID had in these “at risk” countries provided a way in. Aid to Pakistan – a neighbor to Afghanistan and also a Muslim majority state – also spiked immediately following the attacks, after receiving no aid the previous decade (Center for Global Development, 2013). This meant more workers on the ground and a resurgence of funding for new and existing programs. In line with Laura Bush’s concerns about saving Muslim women, programs supporting child and maternal health (including family planning) were given special attention (Bhutta, 2004). Era II ends in 2018, with the cancellation of all military aid by the Donald J. Trump Administration, due to the Pakistani government’s “failure to take action against terrorists” (Sullivan, 2018).
These two, roughly 15-year periods, allow for a critical historical comparison between distinct administrative goals that influenced the allocation of USAID efforts. What problems did these goals address? How did women fit into the solution, or the problem? To answer my questions, I began researching publications written by USAID employees or financially sponsored by USAID.[1] My goal was to uncover the specific language used by the agency about women’s development and how it evolved over the 64 years of its existence. The recent dissolution of USAID and the subsequent decommission of the Developmental Experience Clearinghouse, an online repository of USAID documents, was the most challenging obstacle in my research for both eras. I relied heavily on the DECFinder database, created by the Institute for Development Impact (I4DI) as a “practical effort to preserve development knowledge and keep it in the hands of the people who need it” (Kacapor, 2025). Containing just over 110,000 of the original 220,000 documents published by USAID since 1961, the collaborative effort of I4DI and the scholarly community to rebuild an inaccessible archive provided me with valuable primary sources in my research. I began by narrowing my search filter to Pakistan, which included 2,935 documents. Filtering one year at a time, I reviewed the documents published from 1960-1980, and 2001-2019, and downloaded those with relevant subject matter. I expanded my search range past my defined eras to include summary reports of projects implemented in years prior. Relevant topics included: women, mothers, family planning, population control, contraceptives, child health, and development. This search returned over 25 relevant publications, which I reviewed and added to my literature collections for both eras. My analysis in this paper focuses on three within Era I (1965-1979) and nine within Era II (2001-2018). These documents employ the best examples of language and provide the best grounds for critical discourse analysis.
Additionally, I conducted archival research at the University of Missouri’s Ellis Library in the Federal Government Document collection. Filtering by the author, “USAID” or “United States. Agency for International Development,” I located a range of publications that included printed pamphlets, reports, and microfiche reports from 1955-1999 and digitized those with relevant subject matter. Again, relevant topics included: women, mothers, family planning, population control, contraceptives, child health, and development. I reviewed several hundred documents in the collection and closely analyzed 18. My analysis in this paper highlights seven of these which best exemplify the specific language pertaining to women that I wanted to investigate. These were placed into ‘Era I,’ which I define as 1965-1979.
Era I: USAID from 1965-1979
Era I begins in the first year of operations for the Population Council, a new division in USAID – an agency which, in 1965, was only in its fourth year. A year prior to the U.S. declaring a “War on Hunger,” concern was growing as the global population reached 3 billion people (Himelfarb, n.d.). Pakistan requested foreign assistance from USAID in 1964, amid struggling with their own family planning programs that began in 1953 (Office of Technical Cooperation and Research Health Service, 1967). Living in a developing country with a high birthrate and low literacy levels, Pakistani women were a target for population control. If the “problem” was too many births, then the target population was the birth givers, and the solution was lower birth rates.
Despite being the target population and the assumed focus of discussion, women are most often defined by their relationships to others in these selected documents. By shifting much of the focus to child health or wellbeing, women are positioned as mothers, and only as mothers. It assumes a failure on the part of the mother; that she cannot provide adequate levels of care for her child, especially when she has so many children. As noted in an American field motivator guide, “often babies die because their mothers were not looking after them well – carelessness and nonchalance” (quoted in Fieldston, 2015, p. 158). This ties infant mortality – an issue almost as prevalent as (yet also intertwined with) family planning – to the failure of the mother. High infant mortality rates were regarded as an “economic waste of manpower” that every country had an obligation to prevent (Extension Service of the Department of Agriculture, 1973, p. 12). Oftentimes, infant deaths were caused by lack of access to healthcare and medical resources for rural women. Family planning programs sought to increase access to healthcare, but prioritized access to contraceptives or sterilization over prenatal and postpartum care. If child rearing methods were considered inadequate, what then constituted a good mother? A 1973 field guide states: “A tired mother cannot make good milk. She also needs to be clean and happy. When she worries, she cannot make enough milk” (Extension Service of the Department of Agriculture, 1973, p. 22). If the mother was unable to keep herself clean and happy, USAID planned to educate her on proper nutrition, hygiene, and child-rearing and teach her how to make “living more satisfying” (Extension Service of the Department of Agriculture, 1973, p. 1). From the perspective of USAID, mothers represented two problems – infant mortality and overpopulation – because they “needed” to be properly educated in homemaking and convinced of the benefits of family planning methods. This implies a need for women to be saved from themselves, for the sake of their children and their happiness.
The burden of convincing and educating was dually placed on women through their roles as field motivators, U.S. home economic workers, and lady health visitors. Pakistani women were, reasonably so, hesitant to agree with family planning messages. A volunteer from the U.S. would arrive in Pakistan and make herself known in the community, getting to know the other women. Building upon her personal relationships, she would be tasked with persuading the women of the “benefits” of family planning. A USAID field report noted: “The field motivator should be the most mature and respected woman in the community. Thus, her dedication to the health care of the women in her community will give the necessary credibility to the program” (Balin & Tyrer, 1977, p. 11). The burden of persuasion creates pressure for the female field worker, who is expected to perform the emotional labor and use her relationships to convince others. She is told to convince herself that any situation can be improved and that any family will want to live more satisfying lives, given the proper incentives (Extension Service of the Department of Agriculture, 1973, p. 143). Her responsibilities included teaching women how to “make every motion count” by showing her what muscles to use when lifting children, preparing food, and making smooth motions with her hands. “Some women find pleasure in working in their houses and fields. Others find it drudgery. Sometimes drudgery comes from wasted time and energy. When a homemaker must care for her house, mind the child, prepare the food for her family and work in the fields, she must make every motion count” (Extension Service of the Department of Agriculture, 1973, p. 60). This reveals an attempt to control not just a woman’s reproductive system, but her body as a whole – down to the movement of her hands. Women are explicitly referred to as “acceptors” or “acceptors of control” across publications, signifying how control, sometimes birth control, was something they denied (see Bureau for Technical Assistance, 1969; Bureau for Population and Humanitarian Assistance, 1972; Fornos, 1976; Hamburg, 1977).
In a report on the population program in Pakistan in 1969, its remarkable progress is attributed to “incentive payments for village organizers and acceptors of control devices” (Bureau for Technical Assistance, 1969, p. 104). Village organizers, like American fieldworkers, were members of the community targeted for being influential and incentivized to persuade the women in her community. The field worker is given several warnings about her behavior: “She must avoid making any promises that cannot be kept or creating desires that cannot be fulfilled” (Extension Service of the Department of Agriculture, 1973, p. 8). (This report also emphasizes the delicacy of the on-site relationship between the American home economist and her local co-workers.). Those inside USAID knew they could not convince local women themselves, and the success of population control through lower birth rates relied on mutual trust between women.
In the early 1970s, population planning programs began targeting women where they were believed to be most easily persuaded: postpartum programming. The postpartum program was based on “the fact that in the period immediately following delivery or abortion, many women are highly motivated for fertility control and are more than usually responsive to family planning education,” (Bureau for Population and Humanitarian Assistance, 1972, p. 12). This “fact” cites no real evidence, and rests upon persuading women while they are emotionally extremely vulnerable. This logic positions women as subjects to be persuaded with their vulnerability an advantage, rather than being autonomous, educated agents making informed decisions about their bodies. They are passive recipients of contraceptives, who were not given the opportunity for decision, only acceptance. The assumed need for saving is implicitly increased as the woman is positioned as more vulnerable.
Despite being the most important stakeholder for program success, women are rarely the central focus of internal summary reports. While boasting of 2.2 million IUD insertions and 630,000 sterilizations in Pakistan, the only explicit mention of “women” in a 1969 report was the manner in which they were getting in the way: “Handicap to achieving birth rate reduction continues to be the shortage of women doctors to insert IUDs” because Muslim women traditionally are reluctant to be examined by male physicians (Bureau for Technical Assistance, 1969, p. 104). For USAID, this problem meant requiring more women actors and more funding to medical training programs. Little regard was given to the specific religious concerns of these women: “Fears based on religious beliefs arose from a staunch belief in predestination and in God’s wrath for those who attempted to interfere with His plans…In this way, all side effects, diseases, cases of insanity, deaths, or the birth of twins or triplets were seen as punishment from God and a warning for the people to refrain from entering into such confrontations with Him” (Fornos, 1976, p. 5).
By the mid-1970s, 74% of Pakistani women interviewed expressed “irrational” fears surrounding modern methods of birth control (Fornos, 1976, p. 5). Researchers noted: “Fear expressed ranged from ‘all women die or, at best, become invalid for life and susceptible to many diseases’ to ‘why should we pay to become ill?’ to ‘vasectomy means impotency, an attack on masculinity’” (Fornos, 1976, p. 5). Factors attributed to aversion of family planning included religion, irrational fears, illiteracy, economic consideration, and exaggeration of unfortunate experiences, reinforced by an inadequate service system (Fornos, 1976). The problem for USAID was that women were not being convinced fast enough. Why hadn’t they accepted birth control? If their fears were irrational, then it must be the fault of the field motivating force, who “lack the motivation to do their jobs” (Fornos, 1976, p. 3). Either way, motivators and acceptors were preventing the population control efforts of USAID. By framing women’s health concerns and religious beliefs as obstacles rather than a legitimate reason for caution, more funding and new programs were justified.
For some women, reluctance went beyond expressing fear. They recognized how fundamentally harmful family planning programs were to their communities and ways of life. One Pakistani woman described the efforts as a “murderous venture aimed at eradicating women and children” (quoted in Fornos, 1976, p. 6). This voice is absent from official reports but exists in the summary advice report, which was written in agreement with USAID but published by the American Public Health Association. Women who articulated their reluctance serve as recognition of harm being done. The gap between their own framing of their experience and how they were represented by USAID reveals whose knowledge played the larger part in shaping family planning programs, and who believed they were doing the “saving.”
The response to this resistance was to essentially intensify the programs through means of increased marketing, outreach to rural villages, and a stronger push towards contraceptive inundation. Ravenholt, head of the Office of Population, had what has since been described as a unique ability to work about the answer “no”. When women said no to contraception and family planning programs, they were targeted during postpartum vulnerability. When governments did not want to implement programs, he convinced NGOs to implement the activities themselves. When physician-dominated health programs did not make family planning easily available, Ravenholt ensured that community-based and social marketing programs would be (Gillespie, 2000). He worked to systematically circumvent resistance and eliminate obstacles, even when the obstacles remained the target population. The solution to resistance was to find an alternative to achieving the goal – population control – but not to question whether the programs should proceed. Consent was positioned as optional from women, governments, and medical professionals when it conflicted with program goals, and acceptance was inevitable.
This is further revealed through the case of the Dalkon Shield, an intrauterine device created by A.H. Robins and introduced in the U.S. in 1966. Arguably one of the most harmful contraceptives ever used on women, more than 160,000 American women filed personal injury claims after experiencing septic abortions and infections that resulted in sterility. Eighteen users had died by January 1971 and production had stopped by 1974. This left Robins bankrupt and with hundreds of thousands of unused Dalkon Shields. Before being pulled from the market in 1975, but after concerns began appearing in press and medical journals in 1973, Robins contacted Ravenholt. He marketed the device as a fine product that could be used throughout family planning programs and a 48% pricing discount if he accepted certain conditions. Already a known dangerous device, “each of the concessions demanded by Robins put women in the developing world at greater risk of infection, but Dr. Ravenholt inked the deal anyway” (Mosher, 2013, p. 27-28). If so many women had developed infections in the advanced medical facilities of the U.S., how much more harm would it cause for women in countries with grossly inadequate health care? In 1973, “hundreds of shoebox-sized cartons, each filled with one thousand unsterilized Dalkon Shields, one hundred applicators, and a single set of instructions” were shipped to over 40 countries, including Pakistan, totaling over 700,000 Shields to the developing world (Mosher, 2013, p. 28). We may never know how many women were implanted with these devices or how much harm was caused from poor medical treatment. The risks of inserting a Dalkon Shield, whether resulting in maternal or child death or permanent sterility, met the same goal of lower fertility rates. If fewer children were born, the population would be controlled. It did not matter if the means was safe, it mattered that it was effective in reducing a woman’s capacity to reproduce. Fear of population programs being a “murderous venture aimed at eradicating women and children” was hardly irrational, it was real.
Across Era I, women are commonly positioned as inadequate mothers, needing to be saved through education so they might accept “modern” contraceptives and family planning goals. To assist in this persuasion, the second positionality of women was their roles as field motivators, lady health workers, and village organizers in their own communities. The success of family planning programs relied on the personal relationships and mutual trust created between women. However, when Pakistani women expressed their reluctance, they were positioned as just another obstacle in lowering birth rates. The very harms that Pakistani women warned against materialized through devices like the Dalkon Shield. The side effects women feared – like infection, death, and complications – were not irrational fears or religious superstitions, but predictable results of unsafe medical technology. Summary reports assumed resistance was caused by a lack of education and market demand and assumed that it could not possibly come from real harm. Population control goals had far superseded women’s safety and wellbeing, as healthcare became a vehicle for bodily control. Ravenholt’s ability to override women’s bodily autonomy in service of U.S. political interests, which specifically meant a decrease in birth rates of developing countries, reveals the level of control that USAID had over the countries that received their financial assistance. The language of “barriers,” “resistance,” and “irrationality” constructed women’s self-protective refusals as problems requiring solution through more aggressive intervention. Implicitly, the documents construct the reluctant woman as so far from modernity, she did not even know she needed to be saved from tradition. The persistence of USAID during these decades reveals an assumed belief that more reluctance from the women meant there was more work to be done. This logic would persist into the “War on Terror” era, when Afghan and Iraqi women’s “no” to U.S. intervention would be similarly reframed as evidence they needed saving from themselves.
Era II: USAID from 2001-2018
Era II begins in 2001, shortly after the September 11 attacks. The “War on Terror” effort fueled the resurgence of U.S. aid dollars to Pakistan, after a decade of disengagement with USAID. Although aligned in the fight against Al-Qaeda and the Taliban, Pakistan-U.S. relations failed to establish mutual trust and bilateral economic assistance. The U.S. expected Pakistan to do more in Afghanistan and blamed the failure of war efforts on Pakistan’s inability to curb terrorism (Javed, 2023). In 2010, Pakistan received $1.4 billion from USAID, which was more assistance than in any year prior. The U.S. assassination of Osama Bin Laden the next year in northern Pakistan further deteriorated relations, as the act was interpreted as a violation of Pakistan’s national sovereignty (American Society of International Law, 2011). Anti-American sentiment increased throughout the country as the goals of aid and interference were questioned; “Pakistan wants US aid without any conditions attached to it, and the U.S. sees aid as a tool for attaining U.S. geostrategic goals” (Javed, 2023, p. 6). The mutual distrust between the two mutually reliant states is seen as a constant in Pakistan-U.S. relations since their beginnings. Like Afghan women under Taliban rule, Muslim women in Pakistan were positioned as oppressed by their culture, lumped together in the “saving Muslim women” trope despite having different experiences.
The resurgence of aid brought with it a renewed interest in family planning programs, believed to be a means of giving Pakistani women more autonomy. The population problem was still placed on women, specifically “the burden of high fertility and low contraceptive use remain challenges, and the intention to use contraception is low even among women who have attained their desired family size” (Agha & Williams, 2013, p. 9). Positioning the decisions of women as a “burden,” this reiterated the language and unsolved problem from Era I. The major difference from Era I was the dispersion of funds and information. Under cooperative agreements with USAID, programs like the Family Advancement for Life and Health (FALAH) and the Pakistan Initiative for Mothers and Newborns (PAIMAN) were created to carry out the same goals of increased contraceptive use and reduced fertility (Murphy, 2010). Official responsibility for providing family planning services was divided between the Health and Population Welfare Departments (Global Health Technical Assistance Project, 2008). How, then, did their methods of achieving these goals change, and what remained the same?
There was a new understanding of the religious positionality of Pakistani women. As sterilization was deemed not religiously permissible, attention was shifted towards other methods, (Kamran et al., 2015). Pakistan’s Ulema, Islamic religious scholars who were critical in shaping public opinion, were also engaged; “FALAH worked towards making them active promoters of birth spacing as a health intervention. This helped substantially in mitigating perceived religious opposition” (Ammad, 2012, p. 11). What were once “irrational” or superstitious religious beliefs were now goals to accomplish along the way. Women continued to be positioned as mothers having too many children, but the narrative shifts from lack of education to lack of social freedom. In addition to not being able to physically access health services:
[T]raditional social values often discriminate against women, lowering their status and affecting their food intake and nutrition, education, decision-making, physical mobility, and healthcare. Husbands, in-laws, and religious and community leaders all play significant roles in these customs. Societal pressures on women to have many children in quick succession, preferably sons, also increase their risk of morbidity and mortality” (Agha & Williams, p. 3).
These dynamics had been in play for decades and were an unidentified barrier to population control in the 1960-70s. By finally recognizing experienced social pressures, the problem was no longer uneducated women – it was their positionality. The woman is no longer seen as backwards or irrational, but rather as a symbol of oppression. If she could not act freely, then those who guided her decisions must become the new target population. The assumed solution was the mobilization of those that stood between the woman and her participation in family planning. Perhaps the best motivator was not another woman or religious leader, but the very patriarchy from which she needed to be saved from: her husband.
The most striking difference between Era I and II was the new role of men. Previously, husbands had been described as “interested bystanders at best, and at worst, as grudging gatekeepers impeding women’s use of contraception” (Kamran et al., 2015, p. 1). However, both FALAH and PAIMAN started finding evidence of men’s increased interest in family planning. Once exclusively women’s issue, contraceptive use now “involves two equal stakeholders – the man and the woman – and logically both need to be addressed by FP interventions” (Kamran et al., 2015, p. 2). This assumes equality of the man and woman in the relationship, as if they had equal say in the matter of birth spacing and contraceptive use. In reality, only about half of couples surveyed in Pakistan agreed on family size in the early 2000s (National Institute of Population Studies & Macro International Inc., 2008). Family planning had the face of a woman, and in some rural communities [t]here is opposition from the family and we [husbands] get taunted that you are a slave of the woman” (Kamran et al., 2015, p. 8). Men were not overly eager to get involved in family planning and if willing to use contraceptives, and they often felt as though there was no one to address their needs and concerns. The family planning sector had previously been dominated by women because the target population had been exclusively women. Men wanted their own male health workers to seek assistance, learn from, and purchase contraceptives from; “just as LHWs deliver FP information, counseling and contraceptives to women at their doorsteps, a cadre of male health workers (MHWs) should be developed for individual as well as group counseling of men, provision of condoms, and referral to appropriate health facilities where needed” (Kamran et al., 2015, p. 17).
Men’s new roles as MHW and motivators at the family level were widely available across Pakistan, but the Population Council still wanted to reach more people. A new set of motivators in the form of community-based volunteers were a team of selected married couples that used contraceptives themselves and advocated for family planning (Ammad, 2012, p. 12). These teams were incredibly effective because they fostered personal relationships between the wives and husbands, increasing the chance that the “target” couple would be convinced to start planning their families and using contraceptives (Ashfaq & Sadiq, 2015, p. 6). In these teams, the husband was not only the most effective convincer as the authority in most Muslim households, but he also demonstrated that an effective male wanted to learn. In one example, a man from the province of UmerKot advocated for two years’ birth spacing with his wife, who initially disagreed – but he noted “but then I convinced her and she agreed” (quoted in Kamran et al., 2015, p. 4). Notably, a common barrier to family planning acceptance in Era I was often the lack of willingness of women to be educated – but in Era II, the new target population sought out education. The men seemed far more willing to become “modern,” while women continued to be positioned as “backwards” and in need of correcting. If women were acceptors needing to be convinced, men were willing acceptors that wanted to be educated. Because of this, the Population Council of Pakistan began the task of “engaging the missing link: involving men in family planning in Pakistan” (Ashfaq & Sadiq, 2015, p. i).
Not all men were eager recipients of family planning education, and many had their own concerns. However, these concerns were not disregarded as “irrational” like those of women, but rather prompted change. In the case of the MHWs, men claimed that only having female health workers “severely limits men’s ability to access FP services and blinds the health system to their unique needs,” (Kamran et al., 2015, p. 17). This problem was acknowledged and the program was adapted to train MHW to meet the needs of men. In Era I, programs were rarely adapted to respond to the expressed concerns of women, and more often changed in accordance with USAID priorities. An additional concern of men was sterilization; “With the method of vasectomy, men have a fear of losing their manhood forever…[their] apprehension about vasectomies will need to be addressed through a comprehensive set of interventions ranging from counseling to service provision” (Kamran et al., 2015, p. 13). Again, the call for counseling and services (program adaptations) respected men’s concerns and sought effective solutions. But when women expressed health concerns, like bleeding or infections, more education was the solution. It appears that family planning programs favored men because of their willingness to accept. Because they had not been positioned as the problem of population growth since the 1950s, nor experienced the harms of early programs, and it’s not hard to understand why they were more eager to accept. If women were always the problem, neither they nor their ideas could ever be the solution. This reinforced a Western, male “saving” rhetoric by silencing the woman’s voice and calling her oppressed. It remained clear that the woman could never save herself.
Conclusion
The logic behind the “saving Muslim women” rhetoric can be seen in its infancy, hidden inside population control programs of the 1950-60s. The language USAID used in describing Pakistani women in both eras (1965-1979 and 2001-2018) positions women as in need of saving, but from whom they needed to be saved, and how they would be saved, changed over time. High fertility rates in the 1950-60s were understood as evidence of the backward ways that needed correcting. Family planning programs were positioned as the path to liberation of these “traditional” reproductive practices, by educating women on “modern” contraceptives. Functionally, this justified Western involvement in Pakistani women’s reproduction and served geopolitical interests. It allowed the U.S. to retain control in “developing” countries and exercise it to control population growth rates.
In Era I, women are assumed to be uneducated mothers, irrationally fearful and reluctant acceptors of control, needing to be saved by the modern, often Western, contraceptive-using woman. As birth givers, they were the problem with the growing population. As motivators, they were the solution. Women needed to be saved from themselves, and by other women. In Era II, women are assumed to be socially oppressed – by their husbands, government, and religion – again, needing to be saved by the modern, autonomous woman equal to her husband. It positions women as needing to be saved from the patriarchy, but by their husbands. In both eras, family planning is positioned as a matter of female empowerment, supposedly a means for women to “save themselves.” However, the way that language positions these women and functions in practice, as passive acceptors and obstacles to modernization, reveals that women were never intended to be saved by anyone other than the West.
It is impossible to know the extent of harm done to women across the globe because of family planning programs that strongly encouraged dangerous birth control devices and sterilization, and often ignored women’s voices. To prevent more harm from being done, we cannot afford to lose access to reliable information on the history of U.S. development practices, especially the worst parts of it. With the dissolution of USAID, it is more important than ever that we are aware of the functionality of language that overseas aid programs employ. Religious or secular, every organization has its own agenda. Even USAID, a purportedly secular organization, had to navigate the religious implications of birth control, and implicitly imposed its own moral beliefs.[2] The question is no longer, “When will the Muslim woman be saved?” but rather, when will we stop using “saving” as a justification for control? When will we center the experiences of Muslim women themselves, and listen to their articulations of need, knowledge, fear, and desire?
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Righting Wrongs: A Journal of Human Rights is an academic journal that provides space for undergraduate students to explore human rights issues, challenge current actions and frameworks, and engage in problem-solving aimed at tackling some of the world’s most pressing issues. This open-access journal is available online at www.webster.edu/rightingwrongs.
[1] Publications include those directly written by USAID, third party evaluators who were paid by USAID, or offices under their supervision or in agreement with Office of Population, Bureau of Technical Assistance, Office of War on Hunger, Department of Agriculture, and the American Public Health Association.
[2] For further research, I recommend an interrogation of the religious implications of birth control, in both Muslim-majority countries and other religions. In what other instances have religious beliefs, of either the recipient or provider of aid, impacted the way in which humanitarian programs operated? Does religious aid aligned with the country’s majority religion produce more harm or good? Is the world better off or worse without USAID?