Pregnancy, contraception, and misinformation on social media

A recent article in the Washington Post, “Women are getting off birth control amid misinformation explosion” (March 21, 2024), by Lauren Weber and Sabrina Malhi, discusses a recent explosion of misinformation about contraception on the Internet. More important, it notes the more serious result – women getting pregnant when they didn’t want to be because they believed this misinformation and acted on it by not using effective contraception. In many cases, according to anecdotal reports, women have sought abortions but found themselves living in states that made this difficult or impossible.

The article is not paywalled but does require (free) registration to read, so I will include some of the other important points in it.        

•  Much of the misinformation is especially found on sites like TikTok and Instagram that are followed by young people.
• Many of these sites and posts are by people with no medical training or credentials, but who cite their personal experiences, and such ideas as “natural” (whatever that is or isn’t).
• Many of the latter are folks trying (or succeeding) in developing careers as social media “influencers"; in addition to the usual ways of making money (advertising or payment from companies for promoting their products) they also can actually sell their services (one “charges hundreds of dollars for a three-month virtual program that includes analyses of blood panels for what she calls hormonal imbalances.”).
• An OB/Gyn physician in DC says that many of the women he sees “have traveled from states that have completely or partly banned abortions, he said, including Texas, Idaho, Georgia, North Carolina and South Carolina.”
• A variety of experts have cited the particular vulnerability of “Women of color whose communities have historically been exploited by the medical establishment may be particularly vulnerable to misinformation, given the long history of mistrust around birth control in this country… [including] forced sterilizations of tens of thousands of primarily Black, Latina and Indigenous women happened under U.S. government programs in the 20th century”.
• Much of the misinformation is propagated by those with political, social, and religious agendas.

This is a lot of things. Some of them need to be addressed on an individual basis by doctors and other health professionals when beginning women on contraceptive treatment. Especially important is identifying, which requires asking about, any concerns women may have, what the source of that concern is, and honestly discussing potential side effects. The discussion should address what those side effects do, and do not, indicate, ways of treating them, and effective alternatives if they get too serious. The most important point about both hormonal (oral contraceptive pills, implants, and some IUDs) and long-acting reversible contraception (LARC, mainly IUDs and implants) is that they effectively prevent pregnancy and are generally are what women who are having sex and do not wish to become pregnant should use. But if there is not (or is insufficient) discussion about worries that women have about the other effects of contraception, and as a result they are not used, or not used appropriately (e.g., oral contraceptives must be taken daily), unplanned and undesired pregnancy may be the result.

It is true that there is a horrific history of medical experimentation (and exploitation) of Black people in the US. The most famous is the Tuskegee Study, which followed a group of Black men with syphilis to study its “natural history” for years after treatment was available – but not given to them. Black women were victims of forced sterilizations, long after slavery, carried out by leading American physicians such as J. Marion Sims, whose statue in New York City was recently taken down (photo in this excellent review in The Intercept) and continued until relatively recently. A New York Times article from 2022 focuses on two sisters who were only in their early 60s at the  time, and were sterilized in 1973 at 14 and 12. It is unsurprising that, given this history, that Black and other minority women may legitimately be suspicious of treatments that affect their reproductive capacity.

It is also important to remember that all pregnancies, even when desired, carry health risks greater than that from any contraception. A recent piece in The Hill reports that nearly 40% of Black women of reproductive age are very concerned about the risks to their health should they become pregnant, especially with the repeal of Roe v. Wade and the restrictions on or abolition of abortion in many states. There is a great disparity in maternal mortality. As the Hill article notes

Studies show Black people who give birth are three to four times more likely to die from pregnancy-related causes than their white counterparts, while Black infants are two times more likely to die within their first year than white infants. Reasons for the disparities are nuanced, but many point to systemic racism in the health care system that dismisses Black women’s symptoms.  

That these fears are not unwarranted is horrifying, but to the extent that people are aware of them suggests that the misinformation on social media is not the only message getting out, and that accurate information is being provided by knowledgeable and trusted groups such as In Our Own Voice.

There is no question that right-wing, anti-abortion forces are behind much of the misinformation about contraception that is rampant on social media. But why? After all, if their concern is limiting abortions, the most effective way is to limit the number of unintended pregnancies, and this is what contraceptives do. While I have heard this argument made by a number of organizations and individuals who work for funding of contraception but not (necessarily) abortion, it doesn’t seem to get much traction with the bulk of the right-wing “anti-abortion” movement, which is also frequently are anti-contraception. What is this about?

There are a number of possible reasons. Perhaps it is related to the fact that often those providing contraception, such as Planned Parenthood, also provide abortions so that, in the thinking of these groups, contraception becomes tainted by association. It may also be a revulsion to sex, especially if undertaken for any purpose other than conception – in marriage.

But if sex is only ok if it is for conception and within marriage, why would they want to deny contraception to women who are having sex when they are not married and are not desiring to be pregnant? One answer is that they have an overall intent to control, restrict, and punish women, who they believe should have no agency. Men, of course, are just men and can be forgiven their “lack of control”, and even rape (like some presidents) but women are guilty and sinful even when they are the victims of that rape.

It is likely that the misinformation on social media is a result of all these factors, from “influencers” who are seeking fame and fortune to those promoting right-wing political and social agenda. Or maybe it is just all about providing misinformation so people can not effectively do what they want to. Whatever the reason, however, women should not be forced to risk pregnancy when effective and safe contraception is available, and certainly not be forced to find themselves requiring, and unable to get, an abortion.

Whatever the intent of the “misinformers” is, the result is the same, and bad.

SCOTUS, Roe, Reproductive Rights, and All Our Freedoms: We must act

 

Politico, and now other outlets such as the NY Times,  have reported on a 98-page draft opinion from the Supreme Court that, in no uncertain terms, overturns both Roe v Wade and Casey and removes federal protection for abortion rights. While it is true that this is a draft and individual justices’ final decisions could change, the fact that 5 of the justices (Alito, who wrote it, Thomas, Gorsuch, Kavanaugh, and Coney Barrett) signed on to it makes it unlikely that the final decision will change. The only uncertain vote is that of Chief Justice Roberts, but he is no longer the swing vote he once was; the only difference is whether the vote to say that women have no Constitutional right to control their own bodies would be 6-3 or 5-4.

And, absolutely, let us be clear: that is what overturning the 50-year old Roe decision would mean, that the majority of the justices on the Supreme Court will have ruled that the control over a woman’s body, on whether she has to continue a pregnancy regardless of the circumstances, is in the hands of others. It may be Congress, state legislatures, governors, husbands or other relatives, churches that they may or may not belong to or believe in, petty pettifoggers, vicious misogynists, non-vicious misogynists (?), and folks with their own right-wing agendas, but not the women themselves. When Roe was decided, Justice Blackmun, who wrote the opinion, said abortion should be a decision made by a woman and her doctor. That was itself a bit paternalistic, but it was 50 years ago; I think the way that still should be read is “with adequate medical advice”, understanding the potential (or likely) risks involved in the decision that the woman makes. And ONLY the woman whose body involved should be able to make!

The majority of justices on the Supreme Court obviously do not believe this, along with a substantial minority – but definitely a minority – of the American people (most polls put support for Roe at about 70%). Their anti-abortion movement, well funded by multi-millionaires and billionaires, and supported by both the Catholic Church and many fundamentalist Protestant sects, seems to have finally won their cause after 50 years of reactionary fighting to impose their will on everyone else. It is a coup, be certain of that. It was, most immediately, made possible by the fact that Donald Trump got to name 3 Supreme Court justices, through the hypocritically evil behavior of Mitch McConnell the GOP Senate majority, which decided both to block President Obama’s appointment of Merrick Garland, not even holding hearings, 9 months before his term expired, and then approving Trump’s appointment of Amy Coney Barrett just weeks before the election he lost! This alone should be enough to make everyone who cares about reproductive rights, women’s rights, LGBTQ+ rights, voting rights, any rights, pull out all stops to make sure that the predicted Republican victory in November does NOT happen, that McConnell (and I make no analogies since anything you might compare him to would be insulted by the comparison) does NOT again become Majority Leader. The Democrats are far from perfect, but every justice who voted to repeal was appointed by a Republican, and it was the Republican majority in the Senate that facilitated the appointment of the last three. The SCOTUS opinion will say that the decision is Congress’ and there is no possibility that legislation maintaining women’s rights will get 60 votes in the Senate, or even 50 given Joe Manchin. The pundits and pollsters are all predicting a big INCREASE in GOP seats in November. Unless we do something about it.

Make no mistake: this SCOTUS decision is that the opinions of some people are worth more than the lives of others. No one who is opposed to abortion has ever been required to get one by the decision of Roe. Of course, there were many “mental disabled” people or others judged incompetent who were required to get them in the past, vicious abuse in itself. Ironically, the issue is that the same logic is now being applied to ALL women; they do not have the Constitutional right to make their own decisions about their own bodies.  As Susan Matthews in Slate writes, Justice Alito could not find a justification for the right to abortion in the Constitution because “The Constitution was not written for women”. It didn’t even give them the vote!

Although it does not change the core issue, the choice of words in the debate has been unfortunate; anti-abortion people use the term “murder” of “babies” while abortion rights advocates have used the term “choice”, as if it were a matter of convenience, or what color bedspread to get. It isn’t. It is about the decision to carry a pregnancy, something that is medically risky even in the lowest risk people (but a risk that most people who want to have a baby gladly accept), to give birth, to probably raise a child, to completely change their life, to possibly be unable to care for already-born children, to give birth to a child of a rapist (perhaps incestuous rapist), to give birth to a child already unable to survive because of genetic or other malformations occurring in utero, etc., etc., being only the right of the woman who is pregnant, and not that of anyone else. Consulting them – family, friends, doctors, is fine, but the decision needs to be that of the woman alone, not the state legislature.

This decision, if it stands, will not end abortion in the US, as it will send us back to pre-Roe times when the decision was left to the states (indeed, several states had legalized abortion before Roe). So, abortion will likely remain legal in states like NY, CA, MA, IL, etc. But other states, including of course TX and FL, which have already passed draconian restrictions on access to abortion, will almost undoubtedly make it illegal again, along with many others. It has been estimated that abortions will decrease by 14% (“only”) but if this is true, it has to be taken in the context of geographic access. Women with money from TX, FL, and other states that severely limit access to abortion may be able to travel to another state, but poor women, on whom the burden always falls the hardest, will find it much more difficult or impossible, as will teenagers, including those who are pregnant as a result of incestuous rape (see “Who gets abortions in America”, by Sanger-Katz, Miller and Bui, originally published in the NY Times Dec 21, 2021 and republished on May 3, 2022). Health and healthcare are already incredibly inequitable in the US, and this decision will make it much worse. Jill Filipovic, writing in Substack, provides a number of other concerning likely outcomes,  including that there will be a 21% increase in maternal mortality!

And if that were not enough – more than enough – to get your blood boiling,  get you out to the streets, the likelihood that this will end with abortion approaches zero. Many of the opponents of abortion rights also oppose other reproductive rights, including cheap and easy access to contraception and sex education in schools. This would be illogical if preventing abortions were truly their goal, as it is precisely access to these two factors that are universally associated with lower abortion rates – see ‘Scandinavia’. When abortions were illegal in countries such as Ireland, sex education and contraception were also severely restricted – and the abortion rate was higher than in say, Denmark. But the women receiving these abortions, illegally, were at much higher risk. These arguments, however, get little traction, since those who would restrict all reproductive rights are doing it for other reasons – maybe they hate sex, maybe they hate women, but they surely believe that they know better and freedom is not important to them. If this is hypocrisy – they will fight for the right to own and carry a gun or not wear a mask – hypocrisy is not important to them either.

And it will not end with reproductive rights and contraception. Certainly the rights of LGBT+ people will be even more infringed. And our rights to read books and have our children learn science and history. And our right to vote. Listen to the far-right carry on about restrictions on their freedoms, but think about the freedoms that are at the core of the US and on which we depend.

And most important, these are freedoms we can no longer can passively depend on. If you don’t fight for them, they won’t be there.

The Texas Abortion Law is contrary to women, to science, and to human values

The new Texas abortion law and the Supreme Court tacit endorsement of it is the latest (as of this writing – there will be more!) assault on science, medicine, and the will of the people, in an almost unbroken string of such actions. Another example of this process is the effort to spread COVID by opposing mandates for masking, vaccination, or social distancing, under the pretense of “individual liberty”, by a variety of jurisdictions, mostly at the state level and mostly in Republican-controlled states.

First, a quick review: the Texas law prohibits abortions after 6 weeks without exceptions for anything, including rape and incest, or ability of the fetus to survive outside the womb. It employs a cute (in the sense that the term “cute” can be applied to, say, a giant, mean, ugly, evil, violent ogre) trick to try to get around potential lawsuits that would be based on fact that the Roe v. Wade decision gives women a Constitutional right to abortion. The law does not mandate that state officials enforce it. Instead, anyone, from any state, is empowered to be a “whistleblower” and turn in anyone enabling the abortion (doctor, nurse, counselor, taxi driver) with the potential reward of $10,000 (from the state, of course) if successful.

Neat, huh? The Supreme Court majority thought so too, and, using another trick (called the “shadow docket”) declined to invalidate it. This method obviates the need for a hearing, presentation of arguments on either side, questions from the justices, and thought-out opinions which present the reasoning of the majority and the dissenters. It thus does not require the identification of those voting in the majority (we only know in this case that it was 5-4 and who the 5 and 4 were because each of the 4 issued their own dissenting statement). It also does not allow the lower courts to know what the reasons and arguments were, resulting in inconsistent interpretation of the decision by those courts. This, of course, was on purpose. Justice Sotomayor (one of the 4) put it succinctly “The court has rewarded the state’s effort to delay federal review of a plainly unconstitutional statute, enacted in disregard of the court’s precedents, through procedural entanglements of the state’s own creation.”

Several of the justices who created this problem have defended their action, and Justice Alito, in a speech at Notre Dame, not only defended the shadow docket but portrayed himself and the other members as the actual victims. This is another neat trick, which has been employed by the right, including former president Trump, and billionaires and corporations who have been criticized for such things as underpaying their workers and not paying taxes. The best defense, it is said, is a good offense.

 Let’s review the science:

1.      a large percentage of pregnant women do not even know that they are pregnant, particularly if they usually have irregular periods, before 6 weeks,

2.      the assertion in the Texas law that the fetus has a heartbeat at 6 weeks, thus why they chose that timeframe, is incorrect. In fact, the embryo is not even a fetus at 6 weeks.

There is in fact a lot more relevant science, but let’s move on, since the science is only an issue for those of us who believe in it.

The reason for the restrictive abortion law in Texas (and all the other states’) is not in the least because they have any respect for science or medicine. For different individuals, of course, there are different reasons. For some it is because of their religious beliefs, Catholic or otherwise, that all life is sacred and thus abortion is murder. That this may result in the death of the mother, or that it should then require the same level of commitment to helping the parents ensure that children have a reasonable chance at life (housing, food, clothing, education) may be positions supported by some Catholics, including the current Pope, but is not a corollary of opposition to abortion for most of these people. This is important, because in the case of taking a human life by say, murdering them with a gun, the public is not empowered to sue anyone who might have enabled them, like the gun dealers or manufacturers.

For others, the abortion restrictions are, explicitly or not, about restricting the rights of women and relegating them to their place. This is so essentially the results of such laws and policies that denial of it is virtually always disingenuous. Even those who take the “life is life” Catholic anti-abortion position find themselves in this situation (arguably, this position on women is part of the justification by an entirely male-run church). None of these laws or policies create any penalty or responsibility for the male whose role in creating the pregnancy was central. And 100% of unintended pregnancies are directly caused by men.

Finally, the reason for these laws is political. They garner support for a generally right-wing, pro-corporate political agenda from those who would not support it as such. This trend has always been part of US politics, but more explicitly so since Richard Nixon. Ultimately, of course, whatever the ostensible position of any individual is, the issue is essentially about politics. You put together a coalition, and then you implement the laws you want to. Make no mistake, this is what it is about. Nationally, a large majority of Americans oppose overturning Roe v. Wade (about 60%). In individual states, it may differ. A good history of the right-wing of the GOP looking for an issue that would mobilize the evangelical community in support of them, and their segregationist, pro-corporate agenda, is found in a recent issue of Politico. Abortion turned out to work after other issues didn’t, despite evangelical ambivalence on the issue at the time.

For nearly two decades, [right-wing activist and segregationist Paul] Weyrich, by his own account, had been trying out different issues, hoping one might pique evangelical interest: pornography, prayer in schools, the proposed Equal Rights Amendment to the Constitution, even abortion. “I was trying to get these people interested in those issues and I utterly failed.”

To the extent that the Texas anti-abortion law is about a rejection of science to achieve a political or religious or misogynist agenda, it is not entirely a separate issue from COVID and opposition to mask or vaccination or distancing mandates. The politicians want what they want – mainly power – and are willing to pander to whoever to get it, even fomenting anti-science agendas. Truth no longer matters, and it has gotten beyond an abstract concept to the point where people are dying, and yet others are still unwilling to believe in the cause-and-effect. A recent article in Rolling Stone notes that in parts of Oklahoma, hospitals are not only full of people with COVID and its complications but with people who are overdosing on ivermectin, an anti-parasitic drug that has widely -- and falsely – been promoted as a treatment for COVID. Since ivermectin requires a prescription for people (and it is indicated for certain kinds of worm infestations and actually does work to treat scabies), people are buying it at feed stores where it is sold for deworming horses! If the RS article is correct, many of these hospitals are even too full for gunshot victims!

COVID is a virus, and one that mutates and evolves (whether you believe in evolution or not) and can create more dangerous strains like the Delta variant. It is infectious. Immunization offers great, if not perfect protection; while it is possible to get infected after being immunized, it is less likely and, more important, it is much less likely that you will be hospitalized, ventilated, and die. This is  a fate reserved almost exclusively for the unvaccinated. Masks do help, although they are better at protecting others from being infected by you than protecting you from others – this is why OTHER people wearing masks makes a difference. This is science. On abortion – a “6 week” pregnancy is measured since the last menstrual period, which could easily mean 4 weeks since ovulation, 2-3 weeks since fertilization, and less since implantation, not to mention a positive pregnancy test. A very high percent of women don’t yet know that they are pregnant.

Scientific answers are arrived at through experimentation and re-experimentation; “truth” changes as more information becomes available. It is messy, not simple and easy to understand like a “belief”, or something you read on the internet. If it is one-dimensional and simple it is probably wrong.

But more important, it is usually out there to accomplish another agenda.

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4^th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4^th night and taking every 4^th admission, and the two interns on each service thus taking every 8^th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4^th night call was a big change from every other or 3^rd night, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.

And as people.

Contraception, women's health and dignity, teens, and stupid legislators

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.