Tennesseans for Choice Explores Topic of Access to Contraception

by Bob Stone

Access to Contraception: The Latest Battleground for Reproductive Rights?

This was the subject for TFC's last public meeting, held at Kern Methodist Church on November 18. The high profile battle to keep legal abortion available as a last ditch option has taken not only the spotlight, but even the porch light off the subject of contraception. Effective contraception can dramatically decrease the demand for abortion, but it does not follow that the antichoice zealots are taking up the banner for family planning. Instead, their view is that sex is only for procreation, and that any interference between cause and effect is immoral and unnatural.

The event that led us to choose this topic for a meeting was the political decision of Wal-Mart to refuse to allow their pharmacies to fill prescriptions for emergency contraception drugs ("morning after pills"). These drugs are guaranteed to inflame the passions of antichoice zealots since they consider such pills to be abortifacients. To explore this issue, as well as other barriers to effective birth control, we assembled a panel of knowledgeable speakers:

Ms. Corinne Ravetti worked for Planned Parenthood of East Tennessee (PPET) for several years and has been a family practice nurse at the Knoxville Center for Reproductive Health (KCRH) for 10 years.

Dr. Charles Darling is the Medical Director of PPET and has a private practice in Ob/Gyn.

Dr. Linda Rankin is a medical ethicist on the faculty in the philosophy department of the University of Tennessee.

Emergency Contraception

The panel discussion began with Ms. Ravetti discussing emergency contraception (EC). The use of high doses of estrogen to prevent ovulation and/or the implantation of a fertilized egg was pioneered by a Dutch physician in the early 1960's. DES (diethylstilbestrol --a synthetic estrogen) was used for the same purpose in the early 70's. The use of high doses of birth control pills for EC has been well known for 25 years. "Off label" use of many prescription drugs is common practice but such use of birth control pills for EC was not widely practiced. A group called Contraceptive Technology publicized the technique through an emergency hotline 888 NOT 2 LATE (1-888-668-2528) which provides information on doctors who would write the necessary prescriptions. There is a web site with a similar name.
KCRH dispensed these drugs for 25 years, but was not permitted to advertise that they did so. In February of 1997 the FDA, approved large doses of birth control drugs for EC, making it legal to advertise their availability. In 1998 Gynetics, Inc. introduced "Preven," a packaged emergency contraceptive kit which includes the necessary pills and a pregnancy test. (This is the product Wal-Mart won't sell.) In September 1999 the Women's Capital Corporation introduced "Plan B," a progestin-only pill for EC. This was not yet generally available as of November. Gynetics has submitted an application for approval of its own progestin-only pill. (This type of EC pill produces less nausea and is more effective.)
Why isn't this important resource more commonly used than it is?

1) Low awareness among women and their health providers.

1.3 million Preven kits have been sold. One year of marketing has increased knowledge of the product from 11% to 15%. The vendors want 50% awareness, and Gynetics plans a major ad campaign in 2000.

2) Low availability.

Many doctors don't know about it and have been reluctant to prescribe EC. As an example, a KCRH patient had a condom failure on a Friday. KCRH was closed her family doctor wasn't available and the physician on call advised her to take a birth control pill. Such a dose is useless for morning-after use.
A Knoxville walk-in clinic advised a patient to take one birth control pill a day for 21 days. Again useless, and this woman wasn't able to take birth control pills on a regular basis.
Emergency rooms are undependable. They don't consider a condom failure something they will deal with, but they will provide EC for rape victims. However, rape victim advocates have found that emergency room personnel often won't bring up the issue of pregnancy risk with rape victims they are treating, and some doctors refuse to provide EC.
Kaiser Permanente in San Francisco studied EC awareness among health care providers. 80% knew about it, but only 10% offered it, although 84% said they had no ethical issue with it.

3) Limited availability in pharmacies.

Preven is carried by 9 out of the 10 major pharmacy chains in the U.S. Wal-Mart is the exception, and they say "business considerations" led them to refuse. (They do carry high dosage birth control pills, which can be used for EC with the proper prescription.) Some individual pharmacists may reject prescriptions or overcharge for EC on "ethical" grounds.
In Knoxville, of 24 pharmacies checked, 11 had Preven and 13 did not. Some of the latter said they carried it, but were out. Among those that carried it there was an enormous range of prices for the same product.
TFC found that Preven was on hand in only 3 out of 14 Anderson County pharmacies contacted -- all 3 were local outlets of national pharmacy chains. A kit ranged in price from $21.59 to $31.79. Six of the 11 pharmacies that did not have it stock said they would order it for a patient and could have it the next day.

4) Political misinformation.

This is often deliberately disseminated by the same groups who spread falsehoods about abortion. A frequent ploy is to call EC an "abortifacient". Since the medication acts to prevent a pregnancy from starting it can't truthfully be said to terminate one. EC is sometimes confused with RU-486, which is an abortifacient. RU-486 could be used for EC, but at this time it isn't available for any purpose.
Detractors claim "Women will use this as birth control". Untrue. Most users of EC seek it because of contraceptive failure.

Dr. Darling: Local Issues

Dr. Darling was the next speaker. In preparation for this meeting he had asked Paul Erwin, Public Health Director for East Tennessee, about local availability of family planning. The answer was that resources are there, in every East Tennessee health department. But use of those services is diminishing, probably due to the limitations of TennCare. "We hope people are getting care, but it's harder to get data."
The most common contraceptive provided in the health departments is Depo-Provera (a long-lasting injection). This is also the method of choice in inner cities. There are several reasons for this. First, patients forget to take a daily pill. Second, inner city men often want to impregnate their partners so these women need a surreptitious method of avoiding pregnancy.
The health department has an outreach program for middle school teachers, with the emphasis on abstinence. There is no program for teachers of older students.
Dr. Darling said that education and income are the main determinants of birth control use in East Tennessee. Women tend to be born into poverty and stay there. Population control and discretion in their personal lives are alien concepts.

He gave a few statistics:

-- Half of U.S. pregnancies are unintended, and half of these end in elective abortion.
-- One-fourth of women have been sterilized.
-- One-fourth use oral contraceptives.
-- Of her approximately 36 years of reproductive capability a woman spends three quarters avoiding pregnancy.
Cost is definitely a factor in the use of contraception. Contraceptives have become a cash cow for the drug industry. For "The Pill," a package which was $2 in the 60's is now $25. After FDA approval, a Depo-Provera injection went from $12 to $40. An IUD was $15 in the 70's; it is now about $350.
Insurance often doesn't cover contraception or sterilization although a few states mandate contraceptive coverage. The American College of Obstetricians and Gynecologists (ACOG) supports federal legislation to that end.
A recent poll showed 20% of women thought oral contraceptives were dangerous. 10% thought they were very dangerous. These fears are unnecessary. Moreover, the medical profession has not stressed the non-contraceptive benefits to women, primarily easier menstrual periods.
Also, IUD's are no longer considered dangerous.
It once could be said that women of reproductive age were either pregnant, nursing, or dead. Control of reproduction now gives women power over their lives.
Of male methods for birth control:
-- 20% of men use condoms.
-- 10% are sterilized.
-- 3% say they practice withdrawal.

Most birth control interest has focused on the woman. It is time to bring men into the picture. This raises a number of questions.
1)Can contraceptive drugs be developed for men? (Probably yes.)
2) How can men be educated concerning women's right to contraception?
3) Should men (or a teen's parents) pay for a woman's birth control?
 

Dr.  Rankin:  Ethical Issues

The third speaker was Dr. Linda Rankin, who discussed the ethical issues involved.

She started by outlining some basic ideas about morality. People have a variety of bases for evaluating conduct. Some relate to such guidance as the Ten Commandments, where one's behavior follows regulations from external authority. Others evaluate the possible consequences of their actions -- the utilitarian concept.

Dr. Rankin doesn't feel that real morality is about rules and principles, but simply is measured by how harmoniously we live together. The Golden Rule doesn't always work in a heterogeneous society because different people have different values. Rankin suggested that one needs to do for others what you think they would want for themselves.

Perhaps our speaker was thinking of Ada Annie's song in "Oklahoma":
"I try to act refined and shy,
Asettin' on the velveteen settee;
But then I remember that ol' Golden Rule,
And do fer him what he would do fer mee."

Dr. Rankin went on to say, "The title for this meeting mentions 'rights', which is a defensive term. Why are we on the defensive?" She said that the question involves power and control issues for women. Why should sexuality be a problem for women? Contraception promotes equality. If we respect others, we should respect the fact that not all women want children or want the same number.

Some religious groups claim all life is sacred and sex is only for procreation. These are the views of Dr. Rankin's brother, an anti-abortion minister. "Fundamentally," she said, "he is wrong."  She went on to explain the flaws in her brother's logic, which can be rhetorically effective but is logically flawed. His view is that contraception is killing a human life. (Apparently, not only a fertilized egg, but even a potentially fertilized egg is human life.) Society generally believes it's wrong to kill another person. Those who hold her brother's views choose the term "human life" (not "person") for the protected group, and restate this as "It's wrong to kill human life." They then quickly define a fertilized egg as "human life" (which is biologically correct, but it is also biologically correct to call a human cancer cell "human life"), and conclude that it is wrong to kill a fertilized egg. In effect, these people start by assuming a that fertilized egg is morally valuable, neglecting to provide the slightest proof that such is the case.
According to Rankin, forcing such views on others requires them to practice a religion other than their own, which is something repugnant to this country's principles.

What about pharmacists? Some may say, "You're forcing me to violate my morals if I must dispense this drug." But by seeking a professional license, the pharmacist has taken the king's shilling. He/she is obliged to serve; they have that responsibility. The same may be said of a hospital nurse who won't help with a medically necessary third trimester abortion.  If you know you will refuse to fulfill a particular aspect of a job, you should tell a prospective employer up front. Certain jobs have certain requirements. Don't work on an ob/gyn floor or as the sole pharmacist in a small town if you can t deal with abortion or emergency contraception. In such a case you are forcing your views upon others.

Some argue that emergency contraception should be sold over the counter, as it is in Europe. Based on their experience elsewhere, some university students can't believe it's not openly available here.
 

Question and Answer Session

A discussion session followed.
In answer to a question about Norplant, it was said to be still available. Dr. Darling said that a group of lawyers is recruiting women for a class-action lawsuit against the manufacturer. He added that Depo-Provera has supplanted Norplant, being much more convenient.

Ms Ravetti added that we will soon see ads for emergency contraceptives. There is no conspiracy not to advertise, and women's magazines have been carrying articles on the subject,. Also, contraceptives are being promoted. One oral contraceptive is being advertised as "good for acne". ("It's just for my pimples, Mom.")

Dr. Rankin re opened the question of discussions with anti-choicers. "We need to get the issues underlying the argument out on the table. Find out if there is a common ground. We once thought contraception could be a common ground, but it doesn't seem to be." This is an emotional issue, not a rational one. One is up against the argument "Sex is for procreation." There is, however, a social justice issue on the right to quality of life, which the opposition never recognizes.

It wasn't mentioned at the meeting, but biologists figured out the purpose of sex a long time ago, and it isn't for procreation. If procreation were the goal, asexual reproduction is far simpler and more efficient. Biologically, the purpose of sex is improvement of the species. A mutation resulting in superior specimens will quickly spread through the population, since individuals who are bigger, stronger, smarter, or longer lived will succeed in mating with more partners and will successfully choose partners who are themselves superior. As a result, natural selection speeds up. Unfortunately, those who think the reason for sex is procreation generally don't believe in evolution, so the facts are probably irrelevant.

This was a good meeting with an important topic and expert and interesting speakers. If you weren't there, we missed you.
 

Written by Bob Stone, based on extraordinary notes by Ellen Smith.

 

 
 
 

Last Modified August 20, 2000.