Commentary Contraception

The Politics of Fat and Emergency Contraceptives

Jazmine Walker

It was reported recently that French drug manufacturer HRA Pharma had found that the emergency contraceptive Norlevo, which has a similar chemical makeup to Plan B One-Step, is ineffective for women over 176 pounds. Here's why I was not surprised.

This piece is published in collaboration with Echoing Ida, a Strong Families project.

I am a fat Black woman from the South. I exist at the intersection of multiple identities that medical research labels “vulnerable populations.” The label “vulnerable population” describes people who are frequently excluded from involvement in medical research, including clinical trials, because they are perceived as difficult to reach by the research community. Despite acknowledging that their research is not inclusive of all groups, the medical industry has a long exploitive history of attributing health disparities to patient behavior and economic inequality rather than admitting that their own prejudices also lead to differential outcomes for “vulnerable populations.” So when it was reported recently that French drug manufacturer HRA Pharma had found that the emergency contraceptive Norlevo, which has a similar chemical makeup to Plan B One-Step, is ineffective for women over 176 pounds, I was not surprised. Medical research, researchers, and commentary do not exist in a vacuum of objectivity; they are shaped by social assumptions and stereotypes that often end up having harmful consequences for “vulnerable populations.”

The labeling of one’s size and obesity status is not objective, nor are the factors isolated. Body mass index (BMI) has long been a magnet for fat-shaming and does not take into account differences in body composition between genders and racial and ethnic groups, and people of color are still disproportionately considered “obese.” Poverty exacerbates barriers to quality health care, thereby increasing the potential for obesity in these communities. With Black and Latino/a populations disproportionately living in poverty, they are at a much higher risk for obesity and more likely to be overweight, especially those living in the South. Poverty not only restricts access to nutrition and health care, but also appropriate reproductive health services and information. This means women of color are less likely to have access to appropriate emergency contraceptives.

According to Princeton’s emergency contraceptive web page, obese women (with a BMI of 30 or greater) became pregnant more than three times as often as non-obese women when using emergency contraceptives like Plan B. For women with a BMI greater than 26, the site recommends they contact a health-care provider for a copper intrauterine device (IUD) within five days after intercourse to prevent pregnancy. Confusion and misinformation already surround emergency contraceptives, especially more popular types like Plan B, but barriers mount depending on one’s race, body type, and class, resulting in often dire consequences for women of color seeking emergency contraceptives.

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These findings raise concerns about whether fat women are given adequate knowledge about the proper emergency contraceptives. The medical industry assumes that “obese” women know that a copper IUD would be a more effective alternative to oral emergency contraceptives, can find a physician, and have the device implanted. Though a copper IUD is among the most inexpensive long-term (lasting up to 12 years) and reversible forms of birth control, upfront cost can range from $500 to $900. This presents a potential hardship for these women, who are often unable to acquire such a large lump sum of money. Even with Planned Parenthood’s prorated costs based on income, or even Medicaid, cost is still a barrier for women in rural communities who lack access to health-care professionals and women living in red states that have rejected Medicaid expansion. Even when they gain access to a health-care provider, they may not receive accurate contraceptive information about weight and may encounter poor medical advice that is rooted in the provider’s own racial, gender, class, and fat biases. Additionally, despite the perceived long-term convenience of an IUD, it cannot be inserted or removed without medical assistance. This leaves the judgment to remove the device up to the medical provider, stripping women of their reproductive agency. Lack of adequate access to health care and medical information compounds disadvantage resulting in limited reproductive health options for many women who happen to be considered “obese”—a de facto determination of who is and isn’t deserving of various reproductive health options.

Though over a third of U.S. women are “obese,” they remain underrepresented in contraceptive clinical trials, and at this point there are no clinical trials for an emergency contraceptive scheduled for “obese” women. It is painfully obvious that the medical industry has yet to account for how “vulnerable populations” intersect with one another. “Obese” women included in clinical trials will likely represent the health concerns and needs of white women even though poor women of color are more likely to be “obese” and need to be accounted for, if the medical industry plans to be inclusive. But they seem to have no plans to be inclusive. For example, human papillomavirus (HPV) vaccine medical trials under-represent Black women, meaning the vaccine on the market is designed to fight HPV strands that are common in white women, rendering it less effective for Black women whose common strands differ. We see this happening in clinical trials for contraceptives as well. Historically, contraceptive research excluded “obese” and overweight women from clinical trials, resulting in a limited body of evidence regarding contraceptive effectiveness and safety in “obese” and overweight women. This means that overweight and “obese” women are prone to receiving improper birth control information largely because their under-representation results in a lack of accurate information about how they are affected. The problems of this lack of information fall disproportionately on the shoulders of women living at the intersections of blackness, poverty, and Southerness.

The irony here is that modern contraceptive knowledge is based on experimentation and forced sterilization of Black women and other women of color during the eugenics movement and its aftermath. Now, when we actually stand to benefit from our inclusion in these trials, the medical industry ignores us. Though “vulnerable population” should imply the increased likelihood of being exploited or mistreated by medical professionals and researchers as it has in the past, it has now come to signify our invisibility and negligent disregard by the medical industry.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

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