The Pill: A Counter to “Over-the-Counter”

Amanda Marcotte

Should the pill be sold over-the-counter? While prominent advocates have argued for removing barriers to access like doctor's visits and prescriptions, it may not be as good an idea as it once seemed.

The birth control pill turned 50 years old this month, and to mark this anniversary, Kelly Blanchard took to the New York Times op-ed page and suggested that it’s time for the FDA to approve the pill for sale over the counter.  It’s been an argument that’s been floating around for awhile, now that we have low-dose formulations of the pill that are safer than aspirin, and because doctors basically rubber-stamp requests for the pill coming from consumers more than they prescribe it for those who came in to a doctor’s appointment unsure of what they needed. Newsweek followed up by fleshing out the arguments: requiring a prescription is paternalistic, the OTC version of the pill would be a mini-pill with fewer likely side effects, research shows that women who buy pills over the counter understand the contraindications better than women who have prescriptions do.  So now the question’s out on the table in a big way, and we should take a closer look at it: should the birth control pill be sold over the counter?

Despite being a fan of the belief that there’s no time like the present, I have to admit that this discussion couldn’t be more badly timed, coming in the middle of the gradual overhaul of our health care system.  It’s a sign of the perversity of American politics that discussions about making the birth control pill available over the counter open up right as the federal government is likely to move towards requiring insurance companies to make the pill free to customers with prescriptions, instead of using the current co-pay system.  In most circumstances, it would only be good news if the pill was something you could buy without having a prescription, but even if that happens, most women will probably still go through doctors just because the pill will be cheaper that way.  Additionally, much of the support for making the pill over the counter comes from women who don’t have health insurance, a category of women that supposedly will disappear within the next few years after the government starts requiring Americans to buy health insurance.  Leave it to Americans to finally start selling the pill over the counter right as much of the demand for OTC pills dries up.

But much isn’t all of the demand, and there are still groups of women that would benefit strongly from having access to OTC birth control pills.  Teenage girls are the biggest group to come to mind.  For many, going to the doctor equals telling your parents, and for obvious reasons, many teenage girls don’t feel comfortable or even safe letting their parents know they’re sexually active.  While it would be ideal if all teenagers were simply excellent and consistent condom users, there are many teenage girls who do just fine on the pill, or use it as back up, and they shouldn’t be deprived just because they’re worried about the doctor telling their parents that they’re on the pill.  (True, doctors aren’t supposed to reveal that kind of private information, but not all teenagers know this or trust that it’s true.)  Blanchard pointed out other reasons women might not want to go the prescription route—they forgot to get a refill until it’s too late, they don’t have time to go to the doctor right now for an exam, they went on vacation and forgot their pills.

It’s a smart idea to sell the pill over the counter, but I don’t see it happening in the United States any time soon for a couple of disturbing reasons: sexist paternalism and sex panic.  The first is well covered in the Newsweek article.  Right now, one of the major reasons that doctors hang tightly on to control over who gets the pill is that they believe it’s the lure they need to get women to come in for pelvic exams.  The thinking is that it’s unpleasant to go to the doctor and even more so for a pelvic exam, and so many women would put off gynecological visits if they weren’t in danger of losing access to the pill because of it.  But as Newsweek reported, a preliminary study in Washington showed that decoupling the pill from the pelvic exam didn’t actually cause women to stop getting pelvic exams.  Those women probably had a better time scheduling their doctor’s visits, though, since they didn’t have to worry about getting it done before there was a break in their pill prescription.

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Even if we can get the medical establishment to trust women to look after their own health without having to be bribed with contraception, the odds are high that a vocal section of the public would have a meltdown if the FDA even considered the question.  And yes, I blame sex panic.  Even on the left, you find a strong tendency to blow the dangers of the birth control pill way out of proportion, and find people freaking out about the pill in ways they never would over other commonly used but more dangerous drugs.  Not to be an armchair sociologist, but I suspect strongly that the widely-held but erroneous belief that the pill is dangerous is a direct result of the American ethos that holds that sex itself is dangerous, and that female sexuality in particular is dangerous.

This is certainly what drives the right wing hysteria and misinformation campaigns about the birth control pill, campaigns that would kick in to high gear if the FDA actually considered allowing over the counter sales.  As much as I’d like to dismiss the idea that right-wing hysteria about the pill has much effect on people—since a solid majority of women use the pill at some point in their lives—the ugly truth is that right-wing misinformation has a far reach.  They may not convince the public that the pill is so dangerous that it can’t be legal at all, but they’ll be able to convince the public that the pill is too dangerous to sell over the counter.  After all, they were able to bully the FDA into putting emergency contraception behind pharmacy counters, even though there’s absolutely no science-based reason to do so.        

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