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Vulnerable Women and Contraception: The Plan B Setback

Today's post is from Carole Joffe, author of Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients, and the Rest of Us. Joffe is a professor in the Bixby Center for Global Reproductive Health at the University of California, San Francisco (however, the views and opinions expressed here do not necessarily state or reflect those of the Regents of the University of California, UCSF, or the UCSF Medical Center). This post originally appeared at RHRealityCheck.

"For a woman to 'ask her physician' for a safe and effective contraceptive  presupposed that she had a physician, that she could afford a contraceptive, and that the physician would be willing to give it to her, regardless of her marital status."

These are the words of the historian Sheila Rothman, writing about the setbacks Margaret Sanger faced in the 1920s and 1930s in trying to realize her vision of making birth control widely available to all women, including the poorest—and about the ultimate “ownership” of contraceptive services during that era by physicians. Sanger’s original vision was a fleet of clinics, to be run by public health nurses. But as Rothman and others have documented, when she attempted to open such clinics, she experienced repeated arrests and the closures of her facilities, as contraception was then illegal. In the years leading up to the 1965 Supreme Court Griswold decision, which legalized birth control for married persons, only physicians were legally permitted to provide such services, and as the quote from Rothman implies, this situation put poor women at a tremendous disadvantage.

PlanbRothman’s critique, written in the 1970s about events in the ‘20s and ‘30s,  is remarkably relevant to today’s leading reproductive controversy: the Obama administration’s overruling of the FDA decision to allow over-the-counter status of Plan B, an Emergency Contraceptive product, for young women under the age of seventeen. If one substitutes “teenager” for “woman” and “Plan B” for “a safe and effective contraceptive” in Rothman’s quote, one can readily appreciate how, once again in America’s longstanding reproductive wars, the needs of the most vulnerable are willfully neglected.

Secretary of Health and Human Services Kathleen Sibelius and President Obama justified the Administration’s action because of concerns about pre-teens’ ability to use EC correctly. But as ha been repeatedly observed, only a tiny portion of this age group is sexually active. It is 15- and 16-year-olds who are sexually active in far greater numbers, and therefore, far likelier to have need of EC (and to be able to use it correctly). But many in this group do not have a primary health care provider to whom they can go for a prescription. Some of those who do have a relationship with a provider may be too embarrassed, or afraid of a breach of confidentiality, to ask for such a prescription.

To be sure, some things have improved in the contraceptive world since the dominance of private practice physicians in Margaret Sanger’s time. In 1970, Congress authorized the Title X program, which made federal funds available for family planning services for poor women including, notably, teenagers. (As a sign of how much the reproductive battle lines have hardened in the last 30 years, Title X was signed by a Republican president, Richard Nixon, and one of its most enthusiastic sponsors in Congress was a future Republican president, George H.W. Bush). A number of contraceptive products are available on the shelves of drugstores.

And it is no longer just physicians who can advise and dispense contraception. In public health clinics and Planned Parenthood facilities, nurses are in fact the main providers of contraception. We can hope that some portion of those teenagers who need EC can find their way to a Planned Parenthood or other Title X site in the three day window in which the drug is most effective.

But this recent decision of the Obama administration on EC occurs, of course, in an atmosphere in which Republicans in Congress are attempting to abolish Title X, and various states have defunded Planned Parenthood, leading to a closing of numerous clinics. The reproductive wars drag drearily on—and in our times, as in Sanger’s, the most vulnerable of women pay the greatest price.