Emergency contraception: The next frontier for our two-tier reproductive health system?

SharonMD

The new post-coital contraceptive, ulipristal (also known as ella), has been FDA approved. As a doctor who wants women to have as many choices as possible, I’m thrilled to have another option to offer to women.  But this particular new choice actually leaves me feeling queasy.

The new post-coital contraceptive, ulipristal (also known as ella), has been FDA approved.  As a doctor who wants women to have as many choices as possible, I’m thrilled to have another option to offer to women.  But this particular new choice actually leaves me feeling queasy.

Ella is being reported in the media as the new emergency contraceptive that works for 5 days, as compared with Plan B’s 3 days.  While it’s true that ella is FDA approved for 5 days, and Plan B for 3 days, it is well known that Plan B continues to be effective for up to 5 days after unprotected sex, though efficacy decreases with time.  Several months ago I wrote a post with my colleague Nick Fogelson at the Academic Ob/Gyn dissecting the evidence for ella’s claims of superiority as a post-coital contraceptive and found it lacking.  Yes, ella works as well as Plan B.  It may even be more effective than Plan B, but the studies that have been published to date do not provide conclusive evidence to support that.

Despite the inability to draw a definitive conclusion from the published study, the fact is that there is a trend towards superiority in preventing unwanted pregnancy after unprotected sex.  For the sake of argument, let’s assume that ella is, in fact, more effective.  Where does this leave us?

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Frankly, in a very problematic position.  For starters, Plan B is currently available over-the-counter, without prescription, for anyone over 16.  Ella will be available only by prescription and, although prices have not yet been released, it’s a safe bet to say that it will be more expensive than Plan B.  Add to this time off from work, paying for a doctor’s visit, and either a higher co-pay or no coverage of Ella due to the existence of a cheaper alternative, and you can start to see that ella will be an option only for the haves.  The have-nots will be tracked into the same two-tier reproductive health system that leads to poor women running out of their contraceptive pills, getting abortion procedures up to 3 weeks later than their more well-off peers, continuing unwanted pregnancies somewhere between 18 to 35 percent of the time, and resorting to do-it-yourself abortions.

As I’ve said, it remains to be seen if ella is indeed more effective than Plan B.  But even if it isn’t, it’s being marketed that way and reporting on it in the mainstream media has faithfully followed the formula set out by the pharmaceutical company.  Most women in need of emergency contraception don’t have time to read the journal article and take a statistics class to understand it.  Imagine you’re a woman (or part of a couple) in need of emergency contraception.  You google “emergency contraception” and come across an article reporting that of those who took ella within 72 hours of unprotected intercourse, 0.9 percent got pregnant, and of those who took Plan B within 72 hours 1.7 percent got pregnant.  As most rational people would, you decide that you would prefer the option more likely to work, because after all you really don’t want to be pregnant.  So, do you spend $10 to $70 for Plan B over-the-counter and hope that you’re in that 98.3 percent of people who don’t get pregnant, or do you spend $100 -$150 for that 99.1 percent chance?  Do you call your doctor for a prescription, setting ahead the clock another 12 to 24 hours and thereby leading to lower effectiveness?  Do you take a day off from work to go see a doctor if you’re unable to get a prescription over the phone?

While these seem like theoretical calculations, this could very well become a reality for some women and their partners.  We’re not talking about whether you should spring for the premium tires for your car; we’re talking about a very real biological event that can profoundly change your life.  Regardless of whether ella truly is more effective than Plan B, a very worrisome situation has been set up here, and I’m not sure how consumers will be able to navigate it.

Commentary Violence

This is Not The Story I Wanted—But It’s My Story of Rape

Dani Kelley

Writer Dani Kelley thought she had shed the patriarchal and self-denying lessons of her conservative religious childhood. But those teachings blocked her from initially admitting that an encounter with a man she met online was not a "date" that proved her sexual liberation, but an extended sexual assault.

Content note: This article contains graphic descriptions of sexual violence.

The night I first truly realized something was wrong was supposed to be a good night.

A visiting friend and I were in pajamas, eating breakfast food at 10 p.m., wrapped in blankets while swapping stories of recent struggles and laughs.

There I was, animatedly telling her about my recently acquired (and discarded) “fuck buddy,” when suddenly the story caught in my throat.

When I finally managed to choke out the words, they weren’t what I expected to say. “He—he held me down—until, until I couldn’t—breathe.”

Hearing myself say it out loud was a gut-punch. I was sobbing, gasping for breath, arms wrapped as if to hold myself together, spiraling into a terrifying realization.

This isn’t the story I wanted.

Unlearning My Training

I grew up in the Plymouth Brethren movement, a small fundamentalist Christian denomination that justifies strict gender roles through a literal approach to the Bible. So, according to 1 Corinthians 11:7, men are considered “the image and glory of God,” while women are merely “the glory of man.” As a result, women are expected to wear head coverings during any church service, among other restrictions that can be best summed up by the apostle Paul in 1 Timothy 2:11-12: Women are never allowed to have authority over men.

If you’ve spent any number of years in conservative Christianity like I did, you’re likely familiar with the fundamentalist tendency to demonize that which is morally neutral or positive (like premarital sex or civil rights) while sugar-coating negative experiences. The sugar-coating can be twofold: Biblical principles are often used to shame or gaslight abuse victims (like those being shunned or controlled or beaten by their husbands) while platitudes are often employed to help members cope with “the sufferings of this present time,” assuring them that these tragedies are “not worthy to be compared with the glory that is to be revealed to us.”

In many ways, it’s easy to unlearn the demonization of humanity as you gain actual real-world experience refuting such flimsy claims. But the shame? That can be more difficult to shake.

The heart of those teachings isn’t only present in this admittedly small sect of Christianity. Rather, right-wing Western Christianity as a whole has a consent problem. It explicitly teaches its adherents they don’t belong to themselves at all. They belong to God (and if they’re not men, they belong to their fathers or husbands as well). This instilled lack of agency effectively erases bodily autonomy while preventing the development of healthy emotional and physical boundaries.

On top of that, the biblical literalism frequently required by conservative Christianity in the United States promotes a terrifying interpretation of Scripture, such as Jeremiah 17:9. The King James Version gives the verse a stern voice, telling us that “the heart is deceitful above all things and desperately wicked.” If we believe this, we must accept that we’re untrustworthy witnesses to our own lives. Yet somehow, we’re expected to rely on the authority of those the Bible deems worthy. People like all Christians, older people, and men.

Though I’ve abandoned Christianity and embraced feminist secular humanism, the culture in which I grew up and my short time at conservative Bob Jones University still affect how I view myself and act in social situations. The lessons of my formative years created a perfect storm of terrible indoctrination: gender roles that promoted repressed individuality for women while encouraging toxic masculinity, explicit teaching that led to constant second-guessing my ability to accurately understand my own life, and a biblical impetus to “rejoice in my suffering.”

Decades of training taught me I’m not allowed to set boundaries.

But Some Habits Die Hard

Here’s the thing. At almost 30, I’d never dated anyone other than my ex-husband. So I thought it was about time to change that.

When I found this man’s online profile, I was pleasantly surprised. It was full of the kind of geekery I’m into, even down to the specific affinity for eclectic music. I wrote to him, making sure my message and tone were casual. He responded instantly, full of charisma and charm. Within hours, we’d made plans to meet.

He was just as friendly and attentive in person. After wandering around town, window-shopping, and getting to know one another, he suggested we go to his favorite bar. As he drank (while I sipped water), he kept paying me compliments, slowly breaking the touch barrier. And honestly, I was enthralled—no one had paid attention to me like this in years.

When he suggested moving out to the car where we could be a little more intimate, I agreed. The rush of feeling desired was intoxicating. He seemed so focused on consent—asking permission before doing anything. Plus, he was quite straightforward about what he wanted, which I found exciting.

So…I brought him home.

This new and exciting “arrangement” lasted one week, during which we had very satisfying, attachment-free sex several times and after which we parted ways as friends.

That’s the story I told people. That’s the story I thought I believed. I’d been freed from the rigid expectations and restraints of my youth’s purity culture.

Now. You’re about to hear me say many things I know to be wrong. Many feminists or victim advocates almost certainly know the rationalizations and reactions I’m about to describe are both normal responses to abuse and a result of ingrained lies about sex in our culture. Not to mention evidence of the influence that right-wing conservatism can have on shaping self-actualization.

As I was telling people the story above, I left out important details. Were my omissions deliberate? An instinctive self-preservation mechanism? A carryover from draconian ideals about promiscuity?

When I broke down crying with my friend, I finally realized I’d kept quiet because I couldn’t bear to hear myself say what happened.

I’m a feminist, damn it. I left all the puritanical understandings of gender roles behind when I exited Christianity! I even write about social justice and victim advocacy. I ought to recognize rape culture!

Right?

If only being a socially aware feminist was enough to erase decades of socialization as a woman within rape culture—or provide inoculation against sexual violence.

That first night, once we got to my car, he stopped checking in with me. I dismissed the red flag as soon as I noticed it, telling myself he’d stop if I showed discomfort. Then he smacked my ass—hard. I pulled away, staring at him in shocked revulsion. “Sorry,” he replied, smirking.

He suggested that we go back to my house, saying we’d have more privacy than at his place. I was uneasy, unconvinced. But he began passionately kissing, groping, petting, and pleading. Against my better judgment, I relented.

Yet, in the seclusion of my home, there was no more asking. There was only telling.

Before I knew it, I’d been thrown on my back as he pulled off my clothes. I froze. The only coherent thought I could manage was a weak stammer, asking if he had a condom. He seemed agitated. “Are you on birth control?” That’s not the point! I thought, mechanically answering “yes.”

With a triumphant grin and no further discussion, he forced himself into me. Pleasure fought with growing panic as something within me screamed for things to slow down, to just stop. The sensation was familiar: identical to how I felt when raped as a child.

I frantically pushed him off and rolled away, hyperventilating. I muttered repeatedly, “I need a minute. Just give me a minute. I need a minute.”

“We’re not finished yet!” he snapped angrily. As he reached for me again, I screeched hysterically, “I’M NOT OK! I NEED A MINUTE!”

Suddenly, he was kind and caring. Instead of being alarmed, I was strangely grateful. So once I calmed down, I fucked him. More than once.

It was—I told myself—consensual. After all, he comforted me during a flashback. Didn’t I owe him that much?

Yet, if I didn’t do what he wanted, he’d forcefully smack my ass. If I didn’t seem happy enough, he’d insistently tell me to smile as he hit me again, harder. He seemed to relish the strained smile I would force on command.

I kept telling myself I was okay. Happy, even. Look at how liberated I was!

All week, I was either at his beck and call or fighting suicidal urges. Never having liked alcohol before, I started drinking heavily. I did all I could to minimize or ignore the abuse. Even with his last visit—as I fought to breathe while he forcefully held my head down during oral sex, effectively choking me—I initially told myself desperately that surely he wouldn’t do any of this on purpose.

The Stories We Tell and The Stories That Just Are

Reflecting on that week, I’m engulfed in shame. I’m a proud feminist. I know what coercion looks like. I know what rape looks like. I know it’s rarely a scary man wearing a ski mask in a back alley. I’ve heard all the victim-blaming rape apologia you have: that women make up rape when they regret consenting to sex, or going on a date means sex is in the cards, or bringing someone home means you’re game for anything.

Reality is, all of us have been socialized within a patriarchal system that clouds our experiences and ability to classify them. We’re told to tend and befriend the men who threaten us. De-escalation at any cost is the go-to response of almost any woman I’ve ever talked to about unwanted male attention. Whatever will satiate the beast and keep us safe.

On top of that, my conservative background whispered accusations of being a Jezebel, failing to safeguard my purity, and getting exactly what I deserve for forsaking the faith.

It’s all lies, of course. Our culture lies when it says that there are blurred lines when it comes to consent. It violates our personhood when it requires us to change the narrative of the violence enacted against us for their own comfort. Right-wing Christianity lies when it says we don’t belong to ourselves and must submit to the authority of a religion or a gender.

Nobody’s assaulted because they weren’t nice enough or because they “failed” to de-escalate. There’s nothing we can do to provoke such violence. Rape is never deserved. The responsibility for sexual assault lies entirely with those who attack us.

So why was the story I told during and after that ordeal so radically and fundamentally different from what actually happened? And why the hell did I think any of what happened was OK?

Rape myths are so ingrained in our cultural understanding of relationships that it was easier for me to believe nothing bad had happened than to accept the truth. I thought if I could only tell the story I wanted it to be, then maybe that’s what really happened. I thought if I was willing—if I kept having him over, if I did what he ordered, if I told my friends how wonderful it was—it would mean everything was fine. It would mean I wasn’t suffering from post-traumatic stress or anxiety about defying the conservative tenets of my former political and religious system.

Sometimes, we tell ourselves the stories we want to hear until we’re able to bear the stories of what actually happened.

We all have a right to say who has what kind of access to our bodies. A man’s masculinity gives him no authority over anyone’s sexual agency. A lack of a “no” doesn’t mean a “yes.” Coercion isn’t consent. Sexual acts performed without consent are assault. We have a right to tell our stories—our real stories.

So, while this isn’t the story I wanted, it’s the story that is.

I was raped.

News Politics

Clinton in Friday Speech: ‘Fight Back Against the Erosion of Reproductive Rights’

Ally Boguhn

Just after the former secretary of state ended her speech, the presumptive Republican nominee Donald Trump took the stage at another event and struck a different tone.

Hillary Clinton defended reproductive rights in a Friday speech, following the news that the former secretary of state had become the Democratic Party’s presumptive nominee. Soon after Clinton’s comments, Donald Trump took the stage at a different event and vowed to protect “the sanctity and dignity of life.” 

In her speech, Clinton detailed her support of access to safe and affordable abortion and contraceptive care.

“It’s been a big week, and there’s nowhere I’d rather end it,” Clinton told the crowd while speaking at an event for Planned Parenthood Action Fund in Washington, D.C. Planned Parenthood Action Fund, the political arm of Planned Parenthood, endorsed Clinton in January, offering the Democratic candidate “its first endorsement in a presidential primary in the nonprofit’s 100-year existence,” according to the New York Times.

“Today, I want to start by saying something you don’t hear often enough: Thank you,” she said, offering her gratitude to the organization for caring for its patients “no matter their race, sexual orientation, or immigration status.”

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Clinton continued: “Thank you for being there for every woman, in every state, who has to miss work, drive hundreds of miles sometimes, endure cruel medically unnecessary waiting periods, walk past angry protesters to exercise her constitutional right to safe and legal abortion. I’ve been proud to stand with Planned Parenthood for a long time, and as president I will always have your back.”

Clinton then pivoted to discussing presumptive Republican nominee Donald Trump.

“When Donald Trump says, ‘Let’s make America great again,’ that is code for ‘Let’s take America backward,’” she said. “Back to a time when opportunity and dignity were reserved for some, not all. Back to the days when abortion was illegal, women had far fewer options, and life for too many women and girls was limited. Well, Donald, those days are over.”

Citing the upcoming Supreme Court decision in Whole Woman’s Health v. Hellerstedt as proof of the importance of nominating a new justice to the Court’s vacant seat, Clinton called on Congress to “give Judge [Merrick] Garland the hearing he deserves.”

Clinton went on to outline her vision for reproductive rights in the country should she be elected, noting: “If right-wing politicians actually cared as much about protecting women’s health as much as they say they do, they’d join me in calling for more federal funding for Planned Parenthood.”

Calling to “fight back against the erosion of reproductive rights at the federal, state, and local levels,” Clinton pushed for a host of related priorities, such as ensuring clinic patients and staff can safely access clinics; investing in long-lasting reversible contraception; acting to combat the Zika virus; and repealing the Hyde Amendment, which bans most federal funding for abortion care.

Just after Clinton ended her speech, Trump addressed the Road to Majority conference, hosted by the Faith & Freedom Coalition and Concerned Women for America, and struck a very different tone. “Here are the goals … and I wanted it to come from me, from my heart. We want to uphold the sanctity and dignity of life,” Trump told the crowd.

The Republican went on to reiterate his promise to nominate only “pro-life” justices to the Supreme Court should he be elected, before turning to attack Clinton. “She will appoint radical judges who will legislate from the bench, overriding Congress, and the will of the people will mean nothing,” said Trump before claiming Clinton “will push for federal funding of abortion on demand until the moment of birth.”

Though Clinton has championed reproductive rights during her presidential campaign, she told Fox News in March that she would be “in favor of a late-pregnancy regulation that would have exceptions for the life and health of the mother.”