A bill before the Maine legislature would allow women to
obtain a year’s worth of oral contraceptives at a time, rather than the
previous 3-month limit. This is a good thing, as argued by its sponsors and
supporters. Women typically take oral contraceptives for long periods of time,
and the requirement that they return to refill their prescriptions every 3
months is at best an inconvenience and at worst a burden. It is a burden women
should not have. Indeed, there is no good
reason to require a prescription for oral contraceptives at all.
This does not mean that there are no reasons put forward by
opponents; if there were none, there would be no opponents. Overall, the
opposing arguments fall into 3 categories: money, control, and wacko paranoia.
If women only have to fill prescriptions once a year there will be fewer
prescriptions being filled, which could be a small hit to pharmacies. The
bigger objection is from insurers, as addressed in an article
in the Portland Press-Herald of April 19, who worry that it could
become a “mandate” for coverage with no cost share for other contraceptives,
particularly those that are more expensive for insurers.
Control is a big and insidious issue. The idea that women
are incapable of making their own decisions, particularly with regard to their
reproductive systems, is as outrageous as it is persistent. For generations
women have fought and often won struggles to be considered legally as “people”
(implicit definition: men); to have the vote, to own property, to divorce. But
no area has been as fraught with (yes, “fraught” requires a preposition!)
opposition as the entire area of women’s reproduction. From before the time of
Margaret Sanger, every source of pressure – religious, economic, and legal –
has been brought to bear against the idea that women should have control of
their own bodies and particularly their reproduction. The struggle continues;
abortion rights are the most vulnerable today, but as the opposition to the
Maine bill illustrates, contraceptive rights are scarcely secure.
Even among the biggest supporters of contraception, there
can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood
advisory board, and many of its members were surprised that I strongly opposed
a requirement that women have a Pap smear before receiving a contraceptive
prescription. The logic of those who supported it was that the inducement of receiving
contraceptives would encourage women to get their Pap, which was then
recommended. My position was that the negative incentive of the Pap (and
associated pelvic examination, see below) would keep women, especially young
women and teens, from getting their contraceptives, and thus likely increase
unwanted pregnancies. I am sure that that Planned Parenthood, and other
contraceptive providers, no longer have such a requirement. Indeed, we no
longer recommend Pap smears for women under the age of 21, and for others, they
are recommended only every 3 years. Regarding the screening pelvic examination,
it simply violates the first criterion for a screening test – there must be
condition that can be screened for in an asymptomatic person. This has led the
American College of Physicians, having reviewed the evidence, to recommend
against it, while the US Preventive Services Task Force (USPSTF) somewhat
incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or
against) recommendation. This is summarized in a recent review from the Agency for
Health Research and Quality (AHRQ). The American College of Obstetricians
and Gynecologists still basically advocates it, although it suggests the
decision be made individually between the woman and her doctor, no real change
from when I discussed it on July 3, 2014 (”The
screening pelvic examination: not annual, not ever”).
Being a major provider of contraception does not save PP
from the wrath of Congressional Republicans; indeed, while abortion is the
flaming tip of the spear of conservative opposition, the right’s opposition to
PP is also against those that do not do abortions, but mainly provide
contraception and other women’s health services. The good news is that the
GOP may be unable to attach defunding PP to the “health” bill (Obamacare
repeal) because it is being done at a budget resolution. You might think that
providing contraception would be seen as a good thing, since fewer unwanted
pregnancies would lead to fewer abortions, but this is not their logic. [I
think that they are, basically, anti-sex, at least that practiced by others, as
demonstrated by all the patently false claims we hear constantly in
school-based clinics that prescribing contraception will “encourage” sex.]
Of course, it does not. Hormones encourage sex, yes. Social
pressure encourages sex, for sure. But not contraceptives; what they do is
prevent pregnancy. Amazing. And if the whole campaign against PP, as well as
opposition to allowing a year’s worth of OCPs, is grounded in a mindset that
wants to control women, the issue for young women (and their partners) is far
worse. They are seen as not only women, but immature and incapable of making
wise decisions. There is some basis for the idea that they are immature, as
parents know; the brain is not fully developed until at least the mid-20s and
the last part to develop is the ability to make “executive decisions” – taking the
information that you have, looking at it completely and objectively, and making
a smart choice. This is why teens and
young adults make poor decisions in driving and, conversely, make the best
soldiers.
But this is not a justification for restricting access to
contraceptives, condoms, or other health services that might prevent bad
outcomes. Because teens make not make the most mature decisions, and often
regret them later, it doesn’t mean that they won’t make them. So we need to
make it as easy as possible for them to not have long-lasting negative consequences,
like STIs and unintended pregnancy. There need to be as few barriers as
possible for young people to not get (or make another) pregnant, to not get
preventable sexually-transmitted infections (STIs). These would include making oral
contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman
(or man) come to a clinic for care, invite them in, see them quickly, meet
their needs. For goodness sake, don’t make it hard, don’t send them somewhere
else to register as they’ll walk out the door!
The editorial in the New
York Times, May 13, 2017, “The
health care bill’s insults to women”, documents the degree to which women
in rural and underserved areas, where more than half of PP’s clinics are, will
lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties,
PP is the only provider of reproductive health services. The editorial starts
with insensitive “sophomoric” quotes from several congressmen and senators,
including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my
mammograms!”. Sen. Roberts would be well advised to identify which of the areas
in Kansas, particularly in the very
rural “Big First” district he once represented as a congressman, would be
among those losing services. A lot, actually, especially since one OB/Gyn from
Great Bend is now busy representing the district in Congress. Of course, Dr. Roger
“the
poor just don’t want health care” Marshall probably didn’t take care of
many underserved folks.
This is not the way to go. Our goal must be to increase
health as much as possible, not to create obstacles to it.
