tag:theconversation.com,2011:/id/topics/birth-control-1018/articlesBirth control – The Conversation2024-02-25T14:16:37Ztag:theconversation.com,2011:article/2240402024-02-25T14:16:37Z2024-02-25T14:16:37ZWhy access to free prescription contraception is a crucial component of a national pharmacare program for Canada<p>A new federal pharmacare legislation agreement, <a href="https://www.cbc.ca/news/politics/liberals-ndp-pharmacare-deal-1.7123952">reportedly reached between the Liberal government and the NDP</a>, is an important opportunity to give all Canadians access to effective contraception.</p>
<p>Federal NDP leader Jagmeet Singh <a href="https://www.ndp.ca/news/jagmeet-singh-urging-liberals-cover-contraceptives-all-canadians-part-pharmacare-proposal">advocated for providing free prescription contraception for all Canadians</a> under the Canada Pharmacare Act. On Feb. 23, he announced that a pharmacare agreement had been reached that included coverage for <a href="https://globalnews.ca/news/10313661/pharmacare-ndp-liberals-deal-reached/">several types of prescription contraception</a>, including birth control pills, intrauterine devices (IUDs) and emergency contraception. </p>
<p>Singh was right on this point: it is vital that Canada’s national pharmacare program provides free prescription contraceptives for all Canadians. </p>
<p>Providing free contraception to all Canadians is a cost-effective way to reduce rates of unintended pregnancy and realize <a href="https://www.who.int/publications/m/item/investing-in-sexual-and-reproductive-health-and-rights-essential-elements-of-universal-health-coverage">the right to reproductive health</a>. By making it easier for women to plan their pregnancies, we can <a href="https://www.jogc.com/article/S1701-2163(16)39370-7/pdf">work toward gender equity</a> and <a href="https://doi.org/10.1001/jama.2022.19097">improving maternal and child health outcomes</a>.</p>
<h2>Access to prescription and emergency contraception</h2>
<p>Access to contraception reduces the incidence of unplanned pregnancy. Yet a 2006 survey found that <a href="https://doi.org/10.1016/s1701-2163(16)34242-6">only 65 per cent</a> of Canadian women at risk of unintended pregnancy always use contraception. <a href="https://doi.org/10.25318/1310038201-eng">National-level data from 2015</a> showed that 24 per cent of sexually active females not wanting to conceive did not use any form of contraception the last time they had sex with a male partner. </p>
<p><a href="https://doi.org/10.1186/s12884-015-0663-4">Moreover, 27</a> to <a href="https://med-fom-cart-grac.sites.olt.ubc.ca/files/2020/12/2015-BC-Sexual-Health-Indicators-CART-CSHS_2017-06-15.pdf">40 per cent</a> of pregnancies in Canada are unintended, and <a href="https://doi.org/10.1016/j.contraception.2011.06.009">one in three women have an induced abortion</a> in their lifetime. It’s important to acknowledge that <a href="https://doi.org/10.1016/S1701-2163(16)39370-7">Canada needs to implement routine surveillance of reproductive health indicators</a>, such as contraception use and rates of unintended pregnancy at the national level, to track changes in these statistics over time.</p>
<p>Avoiding unintended pregnancy is an important component of everyone’s right to reproductive health, which includes the ability to plan pregnancies. Furthermore, unintended pregnancy is associated with <a href="https://doi.org/10.1001/jama.2022.19097">adverse maternal and infant outcomes</a>, including depression during pregnancy, preterm birth and low infant birthweight. </p>
<p>The <a href="https://www.longwoods.com/content/24170/healthcare-policy/barriers-and-facilitators-to-family-planning-access-in-canada">cost of contraception</a> is an important reason for non-use in Canada. On April 1, 2023, <a href="https://news.gov.bc.ca/releases/2023HLTH0033-000430">British Columbia</a> became the first province to offer several types of free prescription contraception to all residents. <a href="https://www.cbc.ca/news/canada/manitoba/manitoba-throne-speech-birth-control-1.7035927">Manitoba is set to follow suit</a>. </p>
<p>In other provinces and territories, individuals without adequate private insurance coverage, or who are ineligible for public drug insurance, must pay out-of-pocket or seek help from <a href="https://www.canadahelps.org/en/explore/charities/category/social-services/sub-category/family-planning/">family planning organizations</a> for prescription contraception.</p>
<p>The <a href="https://www.cbc.ca/news/canada/north/canadian-doctors-want-ottawa-to-pay-for-birth-control-1.1295913">Canadian Medical Association</a> and the <a href="https://sogc.org/common/Uploaded%20files/Universal%20Contraception%20Coverage%20in%20Canada_ENG.pdf">Society of Obstetricians and Gynaecologists of Canada</a> both recommend that provincial/territorial and federal health care plans cover <em>all</em> contraceptives for <em>all</em> Canadian women. The <a href="https://doi.org/10.1093/pch/pxz033">Canadian Paediatric Society</a> also supports no-cost contraception for women of reproductive age and, in particular, suggest that no-cost contraception be provided under provincial/territorial and federal health plans until age 25.</p>
<p>New federal pharmacare legislation is an important opportunity to give all Canadian women access to effective contraception. </p>
<h2>The importance of free prescription contraception</h2>
<p>Highly effective contraception methods tend to be the <a href="https://news.ubc.ca/2019/11/05/birth-control-options-out-of-reach-for-many-low-income-women/">most expensive</a>. Prescription contraception options such as birth control pills and IUDs are <a href="https://www.nhs.uk/conditions/contraception/how-effective-contraception/#:%7E:text=Contraceptive%20pill&text=than%2099%25%20effective.-,Fewer%20than%201%20in%20100%20women%20will%20get%20pregnant%20in,get%20pregnant%20in%20a%20year.">more effective at preventing pregnancy than condoms alone</a>. However, these forms of contraception are also among <a href="https://news.ubc.ca/2019/11/05/birth-control-options-out-of-reach-for-many-low-income-women/">the most expensive and least used in Canada</a>. For example, <a href="https://ppt.on.ca/factsheets/hormonal-iud/#:%7E:text=best%20for%20you-,How%20to%20start%20using%20the%20hormonal%20IUD,%24270%20%E2%80%93%20%24400">IUDs can cost up to $550 in upfront payment</a>.</p>
<p><a href="https://www.jogc.com/article/S1701-2163(16)39370-7/pdf">Certain populations are less likely to use effective contraception methods</a> to prevent unintended pregnancy. These populations include youth, those with lower incomes and those who have recently immigrated to Canada. For example, <a href="https://doi.org/10.9778/cmajo.20190087">a 2019 study</a> reported that, among Canadians ages 15 to 24, lower income is associated with using condoms only, and with not using any contraception, compared to youth from higher-income households. </p>
<figure class="align-center ">
<img alt="An IUD and birth control pills" src="https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577690/original/file-20240223-18-jf1x79.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some of the most effective forms of birth control are also the most expensive.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Being able to access prescription contraception through a universal public pharmacare plan not only removes cost-related barriers, but <a href="https://www.actioncanadashr.org/sites/default/files/2022-11/Policy%20Brief%20Canada%E2%80%99s%20Pharmacare%20Plan%20Should%20Provide%20Access%20to%20All%20Forms%20of%20Contraception.pdf">allows women to confidentially obtain contraception</a> without having to claim it through a parent’s or partner’s insurance plan.</p>
<p>Recent research from the United States showed that <a href="https://www.brookings.edu/articles/increasing-financial-access-to-contraception-for-low-income-americans/">providing women who have low incomes with vouchers to cover 100 per cent of the cost</a> of their preferred form of contraception resulted in women choosing to use more effective contraceptive methods. The increase in effective contraception is estimated to reduce unplanned pregnancies by 32 per cent among this group of women, compared to those paying sliding scale prices. This study demonstrates the importance of removing cost-related barriers to contraception.</p>
<p>The benefits of providing free prescription contraception extend beyond preventing pregnancy and can include benefits for women who aren’t sexually active. Some forms of prescription contraception are also used to treat several painful and debilitating conditions common in women, <a href="https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661">such as endometriosis</a> (a condition where tissue similar to the lining of the uterus grows outside the uterus) and <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos">polycystic ovary syndrome, or PCOS</a>, which occurs when the ovaries produce an abnormal amount of male sex hormones.</p>
<h2>Cover several types of highly effective contraception</h2>
<p>It is essential that women be able to choose their preferred contraception method. Preferences may be influenced by several factors.</p>
<p>For example, women who recently immigrated to Canada may be more likely to have <a href="https://www.cfp.ca/content/59/10/e451.long">negative attitudes toward hormonal contraception</a>. Providing the option for copper IUDs, for example, would provide a highly effective non-hormonal option to women wanting to prevent pregnancy without taking hormones. Additionally, some types of prescription contraception are <a href="https://doi.org/10.1016/j.jogoh.2019.02.006">contraindicated (should not be used) for women with certain health conditions</a>. </p>
<p>It is important that several types of highly effective contraception be available cost-free so that all women can choose the safest and best option, <a href="https://www.jogc.com/article/S1701-2163(16)39370-7/pdf">based on contraindications, personal beliefs, culture, preferences and the ability to adhere to the chosen method</a> without cost-related barriers influencing their decision. Health-care providers can then <a href="https://cps.ca/en/documents/position/contraceptive-care">educate youth</a> and <a href="https://www.longwoods.com/content/25242/electronichealthcare/barriers-and-facilitators-to-family-planning-access-in-canada">adult Canadians</a> on contraceptive methods and their effectiveness without concern about cost as a barrier to access or adherence.</p>
<h2>Covering prescription contraception is cost-effective</h2>
<p>A single-payer universal pharmacare program will provide Canada with <a href="https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/implementation-national-pharmacare/final-report.html">better bargaining power to negotiate lower drug prices</a> for certain contraception products than Canada’s current patchwork system of public and private insurance plans.</p>
<p>Additionally, a national pharmacare program that provides free prescription contraception means that health systems and, in turn, individuals or taxpayers spend less on managing unintended pregnancies. We can turn to British Columbia for an example. <a href="https://cart-grac.ubc.ca/files/2021/04/Contraception-Cost-Effectiveness_CART-Report_2018-06-21.pdf">Researchers in B.C.</a> found that the cost to provide a universal subsidy to all women in the province is less than the cost to manage unintended pregnancies that would be preventable with improved contraception access. </p>
<p>This logic contributed to the provincial government’s decision to provide free prescription contraception to all residents. The policy is expected to <a href="https://www.med.ubc.ca/news/how-ubc-researchers-laid-the-groundwork-for-free-contraception-in-b-c/#:%7E:text=The%20evidence%20was%20conclusive.,approximately%20%2427%20million%20per%20year.">save the health system approximately $27 million a year</a> from the fourth year onward.</p>
<p>While there are other barriers to accessing effective contraception beyond cost, making prescription contraception free for everyone in Canada is undoubtedly a step in the right direction. It’s both cost-effective and a movement towards gender equity and realizing the right to reproductive health for all Canadians.</p><img src="https://counter.theconversation.com/content/224040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melina Albanese receives funding from the GROWW Program and the Ontario Government Scholarship.</span></em></p>New federal pharmacare legislation is an important opportunity to give all Canadian women access to effective contraception and realize the right to reproductive health.Melina Albanese, PhD Candidate (Epidemiology), University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2042302023-07-13T22:34:32Z2023-07-13T22:34:32ZFDA approves first daily over-the-counter birth control pill, Opill – a pharmacist and public health expert explain this new era in contraception<figure><img src="https://images.theconversation.com/files/537358/original/file-20230713-15-64cjm9.jpg?ixlib=rb-1.1.0&rect=49%2C35%2C4643%2C3067&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The progestin-only pill Opill could be available in early 2024.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/empty-shopping-basket-on-pharmacy-drugstore-counter-royalty-free-image/1013458454">Kwangmoozaa/iStock via Getty Images</a></span></figcaption></figure><p>On July 13, 2023, the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-nonprescription-daily-oral-contraceptive">U.S. Food and Drug Administration approved</a> a drugmaker’s application for the first daily over-the-counter birth control pill for people seeking to prevent pregnancy.</p>
<p>The pill, called Opill – the brand name for the tablet formulation of norgestrel – is an oral contraceptive containing only progestin hormone, which helps prevent pregnancy by thickening cervical mucus, preventing ovulation or both. Opill was initially approved <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/opill-0075mg-oral-norgestrel-tablet-information">by the FDA for prescription use in 1973</a>. Its approval for nonprescription use may spark other manufacturers of prescription-only birth control to follow. This highlights the importance of pharmacies as destinations for health care and pharmacists as facilitators of contraceptive care.</p>
<p>Opill is expected to be available through pharmacies, supermarkets, convenience stores and online retailers in early 2024. The FDA’s approval of an over-the-counter birth control pill can further expand options for people seeking hormonal contraception to all 50 states and U.S. territories. This expanded access could be a significant development in the post-Roe era as <a href="https://theconversation.com/one-year-after-the-fall-of-roe-v-wade-abortion-care-has-become-a-patchwork-of-confusing-state-laws-that-deepen-existing-inequalities-207390">individual states further restrict</a> women’s access to abortion. </p>
<p>Prior to the FDA’s approval of this pill, many U.S. states have allowed pharmacists to prescribe hormonal contraception. The process begins <a href="https://birthcontrolpharmacist.com/">with a pharmacist consultation</a> to screen patients for eligibility, collect a medical history and measure blood pressure. If the patient qualifies, the pharmacist can provide a prescription to the patient; if not, the pharmacist refers the patient to a physician. </p>
<p>We are a <a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">pharmacist</a> and a <a href="https://scholar.google.com/citations?hl=en&user=OIT2K2oAAAAJ">public health expert</a>. We see the move toward over-the-counter birth control as an important step toward accessible and equitable reproductive health care for all Americans. Even though this product will be over-the-counter, pharmacists will play an indispensable role in that effort.</p>
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<figcaption><span class="caption">The FDA’s approval of the first-ever over-the-counter daily birth control pill means that people could soon get them from the same aisles as aspirin, eye drops or condoms.</span></figcaption>
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<h2>Making birth control more accessible</h2>
<p><a href="https://doi.org/10.1016/j.japh.2022.07.003">With more than 60,000 pharmacies nationwide</a>, pharmacists are the most accessible members of the health care workforce. Nearly 90% of Americans live within <a href="https://doi.org/10.1016/j.japh.2022.07.003">5 miles of a pharmacy</a>. Throughout the COVID-19 pandemic, pharmacies have provided testing, vaccination and treatment for millions of people in the U.S., <a href="https://theconversation.com/how-the-test-to-treat-initiative-aims-to-get-ahead-of-the-next-wave-of-covid-19-179607">proving their worth</a> in supporting and sustaining initiatives that are important to public health. </p>
<p>Traditionally, hormonal contraception – also known as birth control, or when taken orally, “the pill” – has only been accessible after a comprehensive medical evaluation by a physician, physician assistant or nurse practitioner. </p>
<p>But in 2016, California and Oregon changed their legislation to allow pharmacists to prescribe birth control. That quickly expanded to 20 states, plus Washington, D.C., that now <a href="https://naspa.us/resource/contraceptives/">allow pharmacists to prescribe</a> some form of birth control, whether it be the pill, patch, ring or shot.</p>
<p>However, the move toward over-the-counter birth control is important because it will lessen some of the known barriers to birth control, especially if the products are offered at an affordable price point. These barriers include the inability to pay for medical office visits required to obtain a prescription, lack of insurance to cover the cost of prescription birth control or lack of access to pharmacist-prescribed contraception.</p>
<p>Over-the-counter birth control can also reduce access barriers by preventing the need for a scheduled appointment with a primary care physician during work hours, the need for a pharmacist to be present to dispense prescription birth control or the need to travel long distances to access these professionals. </p>
<p>But it is important to note that over-the-counter access to hormonal birth control does not replace the importance of regular office visits or discussion about reproductive health with physicians.</p>
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<figcaption><span class="caption">The use of contraception was illegal in the U.S. from the late 1800s until the 1960s.</span></figcaption>
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<h2>Addressing remaining barriers</h2>
<p>Even in states where pharmacists are currently allowed to prescribe birth control, over-the-counter hormonal birth control can make a difference.</p>
<p>For example, if state policies do not create payment pathways to reimburse pharmacists for their time to counsel and prescribe, pharmacists may choose not to participate in prescribing birth control. Additionally, pharmacist availability and time may be limited and more restricted than the hours a pharmacy is advertised as open to the public to sell over-the-counter birth control products.</p>
<p>Finally, there are notable cases of pharmacists who have denied patients access to emergency contraception, also known as the “morning-after pill,” and <a href="https://www.npr.org/2018/06/25/623307762/walgreens-pharmacist-denies-drug-for-woman-with-unviable-pregnancy">prescriptions for medication abortion</a> on the grounds of moral, ethical and religious beliefs. </p>
<p>For instance, in 2019, a pharmacist in Minnesota <a href="https://www.nbcnews.com/news/us-news/minnesota-pharmacist-trial-refusing-dispense-morning-pill-beliefs-rcna41030">denied a patient emergency contraception</a>, citing personal beliefs. As a result, the patient drove 50 miles <a href="https://www.washingtonpost.com/nation/2022/08/03/minnesota-pharmacist-contraception-lawsuit/">to gain access to the medication</a>. Ultimately, a jury found that the pharmacist did not discriminate against the woman by denying to fill her prescription.</p>
<p>This precedent suggests that pharmacists who object to the use of reproductive medications may further choose not to participate in prescribing hormonal contraception even when permitted to do so by state law. Individuals may also choose not to stock over-the-counter birth control when it becomes available.</p>
<h2>Pharmacist ‘conscience clauses’</h2>
<p>Notably, many states give pharmacists autonomy when dispensing medications. Currently, 13 states have laws or regulations known as “conscience clauses” that <a href="https://www.nbcnews.com/news/us-news/can-pharmacist-legally-deny-patient-prescription-it-depends-n894871">permit pharmacists to refuse to dispense a medication</a> when it conflicts with their religious or moral beliefs. </p>
<p>The American Pharmacists Association also recognizes an individual pharmacist’s right to conscientiously refuse to dispense a medication; however, the organization supports a system to <a href="https://aphanet.pharmacist.com/policy-manual?key=Pharmacist+Conscience+Clause&op=Search">ensure patient access to medications</a> without compromising the pharmacist’s right of refusal. In other words, pharmacists are encouraged to “step aside” but should not “step in the way” of dispensing or selling medications that conflict with their personal beliefs. </p>
<p>Some states with conscience clauses legally require pharmacists to refer patients elsewhere when they decline to dispense a medication for ethical and/or moral beliefs. In addition, company policies may require pharmacists with objections to arrange for another pharmacist – who does not have objections – to provide the medication and care requested by the patient. However, some states do not require a system to ensure this patient access as the American Pharmacists Association suggests.</p>
<p>Pharmacist conscience clauses are unlikely to interfere with over-the-counter birth control availability at large pharmacy chains, supermarkets and mass merchandisers due to top-down decision-making structures of these organizations. However, national pharmacy chains have recently faced <a href="https://www.nytimes.com/2023/03/07/business/walgreens-abortion-pill.html">complicated legal and political situations</a> when it comes to offering prescription abortion pills in the post-Roe era.</p>
<p>Ongoing <a href="https://www.guttmacher.org/state-policy">legislation seeking to reduce abortion access</a> in the post-Roe era across the U.S. only increases the importance of patient access to contraception. Geographical spatial analyses have found that people of low socioeconomic classes and of color <a href="https://read.dukeupress.edu/jhppl/article/46/2/277/166722/Affordable-but-Inaccessible-Contraception-Deserts">disproportionately reside in contraception deserts</a>, which are areas with low access to family planning resources. These contraception deserts could be reduced or eliminated altogether now that retailers may sell over-the-counter hormonal birth control at an affordable price. </p>
<h2>Pharmacists’ role in providing contraceptive</h2>
<p>Although patients may seek and purchase over-the-counter hormonal birth control at locations other than community pharmacies, when patients come to a pharmacy, pharmacists can help them understand how to use the product correctly, safely and effectively prior to purchase. Pharmacists are trained as medication experts and acquire unique knowledge and skills of self-care products and nonprescription medications. When a pharmacist feels it is necessary, they can refer patients who do not qualify for over-the-counter birth control use back to their primary care providers for further evaluation and care.</p>
<p>In our view, pharmacists can positively contribute to the safe, effective and accessible use of contraception across the country.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/with-over-the-counter-birth-control-pills-likely-to-be-approved-pharmacists-and-pharmacies-could-play-an-ever-increasing-role-in-reproductive-health-care-189216">article originally published</a> on Oct. 28, 2022.</em></p><img src="https://counter.theconversation.com/content/204230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is part owner of the consulting company, Embarx, LLC.</span></em></p><p class="fine-print"><em><span>Marian Jarlenski does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With the approval of the first over-the-counter oral contraceptive, pharmacists stand to play an ever-increasing role in helping expand access to reproductive health care in the post-Roe era.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghMarian Jarlenski, Associate Professor of Health Policy and Management, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2038642023-04-18T16:12:00Z2023-04-18T16:12:00ZBirth control study suggests oestrogen dosage could be drastically cut – here’s what you should know<figure><img src="https://images.theconversation.com/files/521575/original/file-20230418-26-e046v7.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5607%2C3715&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174199502">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>The amount of oestrogen the birth control pill currently contains is already <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520685/">substantially lower</a> than it was when the pill was first licensed more than 60 years ago. But a new paper has suggested that the doses of both oestrogen and progestogen in the pill could be significantly reduced and <a href="https://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1010073#abstract0">still work to prevent pregnancy</a>.</p>
<p>Given the many <a href="https://www.plannedparenthood.org/learn/birth-control/birth-control-pill/birth-control-pill-side-effects">side effects</a> that can come from using contraceptives, researchers wanted to know whether birth control could still work even if hormone dosages were lower. </p>
<p>To conduct their study, the team of researchers developed a very complex mathematical model using data on hormone levels from 23 women with normal menstrual cycles. They were then able to use this information to calculate what effect altering the timing and doses of certain hormones could have in preventing ovulation. </p>
<p>The model predicted that giving a very short, moderate dose of oestrogen around the seventh day of a 28-day cycle – either with or without a low dose of continuous progesterone – was capable of stopping ovulation. This meant that the dose of oestrogen needed to stop ovulation could be reduced by over 92%, while the dose of progesterone in progestogen-only methods could be reduced by 43%. </p>
<h2>Hormone dosages</h2>
<p>As exciting as these findings may be, there are a couple of major caveats to this research when it comes to real-world application.</p>
<p>First, it’s important to understand that these findings are based on computer modelling – not real-world data. Most new contraceptive methods are tried first on <a href="https://slate.com/news-and-politics/2011/08/how-they-run-clinical-trials-of-contraceptives.html">animal models, then in human volunteers</a>. It’s very possible that these computer models will reflect real-world results, but much more research will be needed in order to understand whether very precise low-dose hormonal contraceptives actually work in humans. </p>
<p>Second, the model was built using a simulated 28-day menstrual cycle. But menstrual cycle length can <a href="https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/">vary greatly between women</a>. As such, it’s uncertain whether these results will be true for women who have different menstrual cycle lengths. </p>
<p>Another limitation of the model that the researchers point out is that reducing contraceptive hormone levels only appears to work for about four simulated menstrual cycles. After that, the model predicts that ovulation will start to happen again. </p>
<p>This is because stopping ovulation in the previous cycle adjusts the length of the next cycle and the hormone levels associated with it. This in turn affects the time that the next dose needs to be given. So, for very low doses to work in real life, it’s likely that women would need to constantly adjust the time they take hormone dosages to keep the contraceptive working.</p>
<figure class="align-center ">
<img alt="A woman uses a menstrual calendar on her phone to track stages of her cycle." src="https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The simulation found ovulation was only stopped for a few months.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-tracking-periods-by-using-menstrual-1940658049">Kaspars Grinvalds/ Shutterstock</a></span>
</figcaption>
</figure>
<p>The researchers suggest that if a device could constantly sample the blood of the user and adjust the timing of a dose of oestrogen each month, this would overcome this problem and the problem of varying cycle lengths between women. Such a device does not yet exist, however.</p>
<p>The oestrogen found in current combined contraceptive methods (such as the pill and patch) also helps to regulate bleeding, and is taken for at least 21 days in every month. We don’t know what effect taking a lower dosage of oestrogen during a specific, much shorter time of the month would have on bleeding in the rest of the menstrual cycle. This is something that future studies will need to investigate. </p>
<h2>The future</h2>
<p>Despite these caveats, these results are exciting because of the benefits that lowering hormone doses could have for those who use birth control. </p>
<p>When the combined contraceptive pill was first introduced in the 1960s, doctors quickly realised that the high doses of oestrogen in the pill <a href="https://peopleshistorynhs.org/encyclopaedia/birth-control-on-the-nhs/">were causing clots, strokes and heart attacks</a> in some women. This led to a reduction of the amount of oestrogen the pills contained. </p>
<p>But although hormone levels are significantly lower now than they were in the past, a small number of women still experience harmful side effects when they take birth control, such as clots in the leg, <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">largely because of the oestrogen it contains</a>. Women at increased risks of clots, strokes or heart problems cannot use contraceptive methods involving oestrogen at all. </p>
<p>While many factors contribute to a woman’s risk of harmful side effects from the oestrogen and progestogen found in contraceptives (such as genetics, weight and whether she smokes), it’s generally assumed that some of this risk is due to the level of these hormones that contraceptives contain. That means that lowering the dose of hormones in contraceptive methods has the potential to reduce the small risk of harmful side effects in some women.</p>
<p>This is why the suggestion that the doses of both oestrogen and progesterone could be much lower and still stop ovulation is so interesting. If future research shows these findings to be true in human trials, the next step would then be developing technology that could help ensure women receive the precise hormone dosages at just the right time. This would ensure that her contraceptive worked but with the possibility of minimising the risk of side effects.</p><img src="https://counter.theconversation.com/content/203864/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has previously received funding from Bayer PLC. </span></em></p>A computer modelling study suggests that oestrogen levels could get lowered by as much as 92%.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2031312023-04-10T20:00:33Z2023-04-10T20:00:33ZBritish Columbia’s coverage of contraceptives should inspire the rest of North America<figure><img src="https://images.theconversation.com/files/520087/original/file-20230410-7003-jfzc31.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">British Columbia's move to provide free contraception is an act of defending and upholding reproductive rights and freedoms.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p><a href="https://bc.ctvnews.ca/access-to-free-birth-control-begins-in-british-columbia-1.6339248">As of April 1, 2023 all residents of British Columbia gained access to free prescription contraception</a>. This includes the birth control pill, injections and implants, IUDs and emergency contraception known as Plan B or the “morning after” pill.</p>
<p>The bold move makes good on a campaign promise of the NDP government. </p>
<p>It’s the focus of sustained activism of groups like <a href="https://www.accessbc.org/">AccessBC</a> and Action Canada for Sexual Health and Rights, and was ignited by the ongoing abortion politics south of the border, where a judge in Texas just <a href="https://www.nytimes.com/2023/04/07/health/abortion-pills-ruling-texas.html">issued a preliminary ruling invalidating the Food and Drug Administration’s 23-year-old approval of the abortion pill mifepristone</a>. That ruling was almost immediately followed <a href="https://apnews.com/article/washington-abortion-pills-lawsuit-fda-1857d1a4fd356c61ad76e00621e93b44">by a contradictory decision</a> by a judge in Washington state.</p>
<p>The <a href="https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/what-we-cover/prescription-contraceptives">B.C. policy</a> could serve as a model for other provinces — Ontario’s Progressive Conservative government, for example, has already said it’s “<a href="https://www.thestar.com/politics/provincial/2023/03/08/ontario-looking-closely-at-bc-plan-to-offer-free-contraception-health-minister-says.html">looking closely at what British Columbia has proposed</a>.” </p>
<p>Nonetheless, universal coverage of contraception beyond British Columbia is unlikely at the moment. It does not seem to be a serious proposal of any current provincial government. </p>
<p>While some provincial opposition parties have promised universal contraception, policy progress depends on whether they actually get elected. It will also depend on a number of factors that will shape their political agenda once in office.</p>
<h2>List not fully complete</h2>
<p>The new coverage in B.C. is extended to anyone with a provincial health card and requires a physician’s prescription until later this spring, when <a href="https://www2.gov.bc.ca/gov/content/health/accessing-health-care/pharmacy-services">pharmacists will be able to prescribe contraceptives</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A package of birth control pills." src="https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519991/original/file-20230409-6385-i30zeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A one-month dosage of hormonal birth control pills.</span>
<span class="attribution"><span class="source">(AP Photo/Rich Pedroncelli, File)</span></span>
</figcaption>
</figure>
<p>The list of contraceptives included in this plan <a href="https://www.timescolonist.com/local-news/bc-provides-list-of-birth-control-methods-to-be-covered-6668608">is comprehensive but not exhaustive</a>. Other forms of birth control and menstrual regulation, according to the B.C. government, might be considered in the future. </p>
<p>There seems to be no significant discussion of extending the coverage to B.C. residents who don’t have a provincial health card, such as undocumented residents and migrant workers for whom <a href="https://www.alternateroutes.ca/index.php/ar/article/view/22448">reproductive rights</a> are already sometimes inaccessible. </p>
<p>And accessibility will be dependent upon pharmacists’ willingness to dispense medication, something that might be particularly contentious, not to mention time-sensitive with emergency contraception. </p>
<p>Pharmacists are allowed to refuse to stock or dispense medication as a matter of conscience, something that has been a <a href="https://doi.org/10.1370/afm.2562">barrier for medication abortion access</a> in Canada, especially in rural areas. Yet despite these criticisms, the B.C. plan serves as an example of equitable primary sexual and reproductive health care delivered at the provincial level.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/roe-v-wade-canada-can-respond-to-u-s-bans-by-improving-access-to-abortion-care-here-185827">Roe v. Wade: Canada can respond to U.S. bans by improving access to abortion care here</a>
</strong>
</em>
</p>
<hr>
<h2>Opposition promises in other provinces</h2>
<p>Opposition parties in Alberta, Manitoba and Saskatchewan have all promised to implement the <a href="https://bc.ctvnews.ca/access-to-free-birth-control-begins-in-british-columbia-1.6339248">same policy</a> if elected. But at this point, such a commitment really just amounts to a progressive idea in the context of conservative provincial politics, with <a href="https://thecanadaguide.com/data/provincial-premiers/">centre-right parties in power in eight of 10 provinces. </a></p>
<figure class="align-left ">
<img alt="A man is seen in profile under a large golden ceiling light." src="https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=511&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=511&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519993/original/file-20230409-24-z3gijl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=511&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">B.C. Health Minister Adrian Dix is seen during a news conference with his provincial counterparts in Vancouver in November 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>This means that the B.C. policy might reflect the uniqueness of the province’s political dynamics and also demonstrates what is possible, given the right political conditions, in the realm of <a href="https://doi.org/10.1086/722896">reproductive rights</a>. </p>
<p>It’s also reflective of the broader North American <a href="https://doi.org/10.1177/14647001221114611">politics of abortion</a>, as the timing of the policy — a campaign promise of the NDP government, elected in 2020 — seems to respond to the reversal of reproductive rights in the United States with the <a href="https://www.nytimes.com/2022/06/24/us/roe-wade-overturned-supreme-court.html">overturn of <em>Roe v. Wade</em> </a> in June 2022.</p>
<p>The end of constitutional protection of the right to abortion in the U.S. created momentum for strengthening abortion policy and reproductive rights in Canada. </p>
<p>In response <a href="https://www.nytimes.com/interactive/2022/06/24/us/politics/supreme-court-dobbs-jackson-analysis-roe-wade.html">to the U.S. Supreme Court ruling</a>, the <a href="https://www.cbc.ca/news/politics/abortion-funding-expanded-roe-v-wade-1.6449487">federal Liberal government has increased and sustained commitments to ensuring access to abortion</a> and other areas of sexual and reproductive health and rights.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mexicos-help-to-american-women-who-need-abortions-should-inspire-canada-202117">Mexico's help to American women who need abortions should inspire Canada</a>
</strong>
</em>
</p>
<hr>
<h2>Reproductive justice</h2>
<p>Much of this work is carried out by organizations like <a href="https://www.actioncanadashr.org/">Action Canada for Sexual Health and Rights</a> and the <a href="https://nafcanada.org/">National Abortion Federation Canada</a>, with advocacy and information campaigns by the <a href="https://www.arcc-cdac.ca/">Abortion Rights Coalition</a>. </p>
<p>All insist that contraception and abortion are both matters of individual autonomy and <a href="https://www.sistersong.net/reproductive-justice">reproductive justice</a>. At the provincial level, <a href="https://montreal.ctvnews.ca/mobile/quebec-college-of-physicians-announces-new-guidelines-to-make-access-to-abortion-medication-easier-1.5988310">Québec reduced restrictions</a> on the dispensing of mifegymiso, the drug used in medication abortion. Other provinces, including <a href="https://www.thecoast.ca/news-opinion/how-to-get-an-abortion-in-nova-scotia-28911462">Nova Scotia</a>, created abortion self-referral networks.</p>
<p>But the B.C. government’s universal contraception announcement is the most recent positive policy response to the reversal of reproductive rights in the U.S.</p>
<p>Of course not all of the impact of the <em>Dobbs</em> decision on Canada has been positive. In the immediate aftermath of the overturn of <em>Roe</em>, the Manitoba legislature <a href="https://winnipeg.ctvnews.ca/ndp-bill-for-abortion-clinic-buffer-zones-defeated-in-house-1.5623693">defeated a bill</a> that would have provided buffer zone protection for abortion clinics. </p>
<p>The same organizations that benefit from increased federal funding — and use it to support women and other pregnant people — indicate that Canadian women who used to travel to the U.S. for certain kinds of abortions are finding it more difficult to do so due to increased restrictions and bans on the American side of the border.</p>
<p>The recent <a href="https://www.washingtonpost.com/politics/2023/04/07/abortion-pill-ruling-texas-washington/">duelling U.S. court decisions</a> concerning restrictions on mifepristone will only increase this difficulty and limit reproductive rights. </p>
<p>Policies like B.C.’s universal coverage of contraception will help to expand reproductive rights. That’s why it’s such an important decision.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sea of people carrying pro-choice signs." src="https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519992/original/file-20230409-16-dgu48i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People march through downtown Atlanta in June 2022 to protest the U.S. Supreme Court’s decision to overturn Roe v. Wade.</span>
<span class="attribution"><span class="source">(AP Photo/Ben Gray, File)</span></span>
</figcaption>
</figure>
<h2>Defending reproductive rights</h2>
<p>On a practical level, funding for contraception has the effect of making birth control available for everyone, with no privilege for those who have private insurance or can afford to pay and no disadvantage for those who have trouble affording it.</p>
<p>But beyond this, public support and payment for contraception serves to normalize birth control, Plan B and sexual health and reproductive rights as a public good and as a matter of public responsibility. </p>
<p>In an age of increased privatization in health care in general, and the increased stigmatization and criminalization surrounding abortion, the B.C. move is a positive step that fully embraces sexual and reproductive health and rights for everyone in post-<em>Roe</em> North America.</p><img src="https://counter.theconversation.com/content/203131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Candace Johnson receives funding from The Social Sciences and Humanities Research Council of Canada (SSHRC).</span></em></p>British Columbia’s move to provide free contraceptives is a positive step that fully embraces sexual and reproductive health and rights for everyone in post-Roe North America.Candace Johnson, Professor of Political Science, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2020872023-03-21T18:02:21Z2023-03-21T18:02:21ZBreast cancer: progestogen-only and combined birth control both increase risk – here’s what you need to know<figure><img src="https://images.theconversation.com/files/516644/original/file-20230321-1390-p2mixq.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C4947%2C3280&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The progestogen-only pill is more commonly known as the 'mini pill'.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-african-american-woman-holding-contraceptive-135468863">Samuel Borges Photography/ Shutterstock</a></span></figcaption></figure><p>Breast cancer is one of the <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/worldwide-cancer#heading-Zero">most common types of cancer</a> worldwide, with around <a href="https://www.who.int/news-room/fact-sheets/detail/breast-cancer">2.3 million women</a> diagnosed with the disease every year. In the UK alone, it is estimated that <a href="https://cks.nice.org.uk/topics/breast-cancer-managing-fh/background-information/prevalence/">one in seven women</a> will develop breast cancer at some point in their lifetime. </p>
<p>The biggest determinants for developing breast cancer are age and being female. But other lifestyle factors, such as weight, how much you drink, whether or not you exercise, and hormone levels, can also play a smaller part in elevating your risk.</p>
<p>It has also been known for many years now that women who are using or have recently used the combined oral contraceptive pill for more than five years <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/oral-contraceptives-fact-sheet#:%7E:text=Ovarian%20cancer%3A%20Women%20who%20have,contraceptives%20(16%E2%80%9318).">have a 25% greater risk</a> of developing breast cancer compared to their risk if they hadn’t taken the pill. But despite this small increase in risk, only about <a href="https://www.royalmarsden.nhs.uk/information-gps/gp-resources/breast-cancer/breast-cancer-incidence-and-risk-factors">1% of all breast cancers</a> in the UK are linked to the use of oral contraception.</p>
<p>Until now, it was thought that only the combined hormonal pill carried a greater risk of breast cancer. But a <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004188">recent study</a> suggests that the progestogen-only pill (also known as the mini pill) and other forms of hormonal contraception also carry the same increase in breast cancer risk as the combined pill.</p>
<p>The authors of the study looked at data from the GP records of more than 27,000 women in the UK, and combined this with data from 12 other published studies that had looked at the effect of different types of hormonal contraceptives (including the progesterone-only pill, hormonal IUDs, the implant and the injection) on breast cancer risk. </p>
<p>With this data, they were able to estimate whether women who had been diagnosed with breast cancer under the age of 50 were more likely to have used various forms of hormonal contraceptives, compared to women of the same age who had not been diagnosed with breast cancer. The study took into account other factors that may affect risk of breast cancer, such as body weight, alcohol intake and whether they had children. </p>
<p>The study found women who used progestogen-only hormonal contraceptives had between a 20-30% greater risk of developing breast cancer compared to women not using these methods. This increased risk disappeared ten years after stopping the method. </p>
<h2>Making individual choices</h2>
<p>To better put the study’s findings into perspective, it might help to look at the extra number of people who may develop breast cancer due to having used hormonal contraceptives, compared to the number of women who will develop breast cancer without having used birth control. </p>
<figure class="align-center ">
<img alt="A woman undergoes a breast examination using a machine operated by a male doctor." src="https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516647/original/file-20230321-22-7uvc0u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many factors may increase your risk of breast cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-doctor-checking-mammography-machine-scan-206670595">GagliardiPhotography/ Shutterstock</a></span>
</figcaption>
</figure>
<p>So for example, the <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004188">researchers in this study estimate</a> that in a group of 100,000 women aged 35-39, about 2,000 women will develop breast cancer over a 15-year period due to a range of factors unrelated to the use of hormonal contraception. But given that the study found birth control carries between a 20-30% greater risk of developing breast cancer, they estimate that an additional 265 women will therefore develop breast cancer over a 15-year period as a direct results of taking oral birth control. </p>
<p>If we were to look at women aged 50-54, we know from other research that about <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/incidence-invasive#heading-One">280 women per 100,000</a> are diagnosed with breast cancer each year. If birth control increases breast cancer risk by 20-30%, it would mean an additional 70 women per 100,000 would develop breast cancer each year. </p>
<p>This is one of the reasons women are not advised to take the combined pill <a href="https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/">over the age of 50</a>. The results of this latest study mean women may also want to consider the slightly increased risks of breast cancer with progestogen-only contraceptives over the age of 50. However, <a href="https://www.bhf.org.uk/informationsupport/support/practical-support/contraception">progestogen-only methods remain safer</a> in terms of cardiovascular risks – such as stroke and heart attacks – in this age group.</p>
<p>Obviously, breast cancer is a serious disease and a leading cause of death in <a href="https://www.gov.uk/government/publications/health-profile-for-england/chapter-2-major-causes-of-death-and-how-they-have-changed">younger women</a>, so anything which increases a person’s risk of breast cancer has to be considered carefully.</p>
<p>But one of the difficulties of deciding on whether a contraceptive method presents an acceptable risk is that many other common lifestyle behaviours <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer%23heading-Four">also increase cancer risk</a>. For example, it’s estimated that while 1% of breast cancers in the UK are caused by hormonal contraceptives, 5% are caused by not breastfeeding, 8% by being overweight and 8% by drinking alcohol.</p>
<p>This is further complicated by the fact that hormonal contraceptives can have some benefits. For example, the contraceptive injection can help ease symptoms in women who have <a href="https://endometriosisnews.com/depo-provera/">endometriosis</a>, while the intrauterine device is very effective in treating <a href="https://uk.mycontraception.com/contraception-methods/all-methods/ius">very heavy periods</a>. </p>
<p>The combined oral pill <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/oral-contraceptives-fact-sheet#:%7E:text=Ovarian%20cancer%3A%20Women%20who%20have,contraceptives%20(16%E2%80%9318).">reduces the risk</a> of endometrial cancer by about 50% and ovarian cancer by about 40%. It’s also beneficial in helping with <a href="https://www.gennev.com/education/birth-control-pills-for-perimenopause">hot flushes and other pre-menopausal symptoms</a>. Not to mention that contraception allows a woman to control her reproductive cycle and avoid unwanted pregnancy. </p>
<p>The decision about which contraceptive method to use is an extremely personal choice. The findings of this study provide important clarity on breast cancer risk, allowing women to make a more informed decision when it comes to using contraception.</p><img src="https://counter.theconversation.com/content/202087/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has previously received funding from Bayer PLC, and previously advised Natural Cycles.</span></em></p>It was previously thought that only combined hormonal contraceptives carried an elevated breast cancer risk.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1947962022-12-09T13:29:08Z2022-12-09T13:29:08ZWhat is voluntary sterilization? A health communication expert unpacks how a legacy of forced sterilization shapes doctor-patient conversations today<figure><img src="https://images.theconversation.com/files/499824/original/file-20221208-9366-xogfk5.jpg?ixlib=rb-1.1.0&rect=55%2C64%2C6132%2C3877&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Conversations between patients and their doctors about permanent birth control procedures can at times be fraught and influenced by long-standing stigmas.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-is-patient-in-hospital-clinic-royalty-free-image/1432735081?phrase=birth%20control&adppopup=true">Courtney Hale/E+ via Getty Images</a></span></figcaption></figure><p><a href="https://www.acog.org/womens-health/faqs/sterilization-for-women-and-men">Sterilization</a> is a <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization">safe and effective</a> form of permanent birth control <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization">used by more than 220 million couples</a> around the world. Despite its prevalence, however, patients seeking sterilization from their doctors often face a surprising number of challenges.</p>
<p>In men, the sterilization process is known as a <a href="https://www.mayoclinic.org/tests-procedures/vasectomy/about/pac-20384580">vasectomy</a>, which involves severing the tubes that carry the supply of sperm to the semen. In women, sterilization involves a procedure called <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">tubal ligation</a>. In this form of permanent birth control, the fallopian tubes are severed – or ligated – preventing eggs produced by the ovaries from traveling through the fallopian tubes to fertilize an egg. <a href="https://doi.org/10.4103/1008-682X.175091">Vasectomies</a> and <a href="https://doi.org/10.3389/fsurg.2018.00079">tubal ligations</a> can be reversed in some cases, although success rates vary widely.</p>
<p>A 2018 study found that female sterilization is the <a href="https://www.guttmacher.org/fact-sheet/contraceptive-method-use-united-states">No. 1 form of contraception in the U.S.</a>, used by nearly 1 in 5 women ages 15 to 49. And a partner’s vasectomy is the fifth leading contraceptive, relied on by 5.6% of women in that age group, after birth control pills, male condoms and intrauterine devices, or IUDs. </p>
<p>I’m <a href="https://comm.uconn.edu/person/elizabeth-hintz/">a scholar of health communication</a> with expertise in women’s health issues and <a href="https://scholar.google.com/citations?user=ByZ6qXEAAAAJ&hl=en&inst=9808383360503840251">interactions between patients and doctors</a>. My work explores how patients manage the stigma associated with seeking sterilization and communicate with others about their reproductive decisions. My research also illuminates why patients find talking about sterilization with their doctors so challenging. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustrated anatomical examples of vasectomy on the left and tubal ligation on the right." src="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=296&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=296&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=296&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=372&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=372&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=372&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The two common forms of sterilization, or permanent birth control, are vasectomy for men and tubal ligation for women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/male-and-female-sterilization-royalty-free-illustration/1133181391?phrase=vasectomy%20tubal%20ligation&adppopup=true">elenabs/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Access to sterilization</h2>
<p><a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">Ethical guidelines</a> from the American College of Obstetricians and Gynecologists recommend that doctors should respect a female patient’s wishes as a matter of “reproductive justice” when deciding whether to approve their request for voluntary sterilization. The <a href="https://www.auanet.org/guidelines-and-quality/guidelines/vasectomy-guideline">American Urological Association</a>, on the other hand, does not appear to offer ethical guidelines concerning the provision of vasectomy services for male patients.</p>
<p>Yet research has documented that patients seeking sterilization procedures, especially women, are sometimes told that their <a href="https://doi.org/10.1002/hast.216">doctors will not perform the procedure</a> because of the person’s age, number of children or potential risk of regret, among other factors. Providers may also refuse to perform sterilization procedures for other reasons, including <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">fear of legal culpability</a>, backlash from the medical community or <a href="https://doi.org/10.1016/j.jogc.2017.05.034">conscientious refusal</a>. The latter means that a doctor cannot be compelled to provide a medical service that goes against their best judgment or personal convictions. </p>
<p>This hesitancy to approve sterilization requests reflects the tension over forced sterilization in the past.</p>
<h2>How history has shaped views on sterilization</h2>
<p>Perceptions of sterilization in the U.S. have been marred by a <a href="https://www.genome.gov/about-genomics/fact-sheets/Eugenics-and-Scientific-Racism">dark history of eugenics</a>, in which racist ideas about who ought to have children have shaped reproductive policies and doctors’ reproductive counseling. And these views have given rise to the term “voluntary” sterilization, meant to contrast with the “involuntary” – or forced – sterilization of earlier decades.</p>
<p>From the late 1800s until the late 1940s, eugenicist movements sought to preserve racial purity by limiting the breeding of people who were considered “unfit” and promoting the proliferation of those who were white and of European descent, from middle or upper classes and <a href="https://doi.org/10.1016/0277-9536(91)90327-9">considered able-bodied and of sound mind</a>. Widespread federally funded involuntary sterilizations <a href="https://www.ecfr.gov/current/title-42/chapter-I/subchapter-D/part-50/subpart-B/section-50.205">continued in the U.S. until 1979</a>.</p>
<p>In contrast, women who were poor, disabled, immigrant, Black, Hispanic or Indigenous who sought to have children often <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">faced coercive or forced sterilization</a>, sometimes <a href="http://www.jstor.org/stable/40891307">without their consent or knowledge</a>.</p>
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<figcaption><span class="caption">Women of color were frequent targets of forced sterilization campaigns during the eugenics movement of the early 1900s in the U.S.</span></figcaption>
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<p>When women who were considered “desirable” sought to limit their family size or forgo having children altogether through voluntary sterilization, they were <a href="https://doi.org/10.1016/0277-9536(83)90161-2">sometimes denied the procedure</a>. That trend <a href="https://doi.org/10.5744/rhm.2022.50014">continues today</a> despite ethical guidelines recommending otherwise, since doctors cannot be compelled to perform medical procedures they find objectionable. Furthermore, sterilization services, like other reproductive health services, are often <a href="https://theconversation.com/a-growing-number-of-women-give-birth-at-catholic-hospitals-where-they-do-not-receive-the-same-reproductive-health-options-including-birth-control-provided-at-other-hospitals-184813">not offered at religiously affiliated hospitals</a>.</p>
<h2>Disparities in sterilization access</h2>
<p>These cultural views contribute to disparities in access to sterilization that persist today.</p>
<p>In 1979, <a href="https://opa.hhs.gov/sites/default/files/2020-07/consent-for-sterilization-english-updated.pdf">federal legislation</a> went into effect to halt Medicaid-funded involuntary sterilizations and to limit Medicaid-funded sterilization services to any person of sound mind over the age of 21. But ironically, this legislation – which was designed to prohibit involuntary sterilization – now restricts some patients who are <a href="https://doi.org/10.1002/hast.216">seeking sterilization</a>.</p>
<p>Laws vary widely from state to state, meaning that <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">where you live</a> dictates how accessible voluntary sterilization is to you. For example, in Kansas, the most <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">legally restrictive</a> U.S. state, individual doctors are not held accountable for refusing to perform sterilizations, even if they are medically necessary. In addition, medical facilities and individual doctors can also legally refuse to provide information or refer patients elsewhere to procure the procedure. </p>
<p>In contrast, in California – a state that has progressive reproductive health care rights – a right to voluntary sterilization is <a href="https://california.public.law/codes/ca_health_and_safety_code_section_1258">enshrined in law</a>. This means that patients cannot be discriminated against because of factors like age or the number of children they have. Yet forced sterilization is <a href="https://law.justia.com/codes/california/2017/code-prob/division-4/part-3/chapter-6/section-1952/">still legal</a> in California for patients with developmental disabilities who are under conservatorship. </p>
<p>This patchwork of policies across U.S. states creates room for bias in the patient counseling process. Today, when Black and Native American women seek sterilization voluntarily, they are still <a href="https://doi.org/10.1177/1557988309337619">more than twice as likely as non-Hispanic white women</a> to be approved for the procedure by their doctors. In my view, this shows that decisions about who can be sterilized are still inherently attached to <a href="https://doi.org/10.5744/rhm.2022.50014">racial bias as well as gender and class bias</a>.</p>
<h2>The implications of the fall of Roe</h2>
<p>In the aftermath of the <a href="https://www.brennancenter.org/our-work/research-reports/roe-v-wade-and-supreme-court-abortion-cases#">fall of Roe v. Wade</a>, which overturned nearly 50 years of abortion rights, people living in at least 13 U.S. states may now be in a double bind: unable to find a doctor who <a href="https://doi.org/10.5744/rhm.2022.50014">will grant them the permanent sterilization they desire</a> to prevent an unwanted pregnancy, and also unable to access an abortion should a pregnancy occur.</p>
<p>With abortion access reduced in many states after the Supreme Court’s ruling overturning Roe v. Wade, it’s more important than ever for patients to be able to discuss voluntary sterilization freely with their medical providers.</p><img src="https://counter.theconversation.com/content/194796/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Hintz does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The term voluntary sterilization, referring to the choice to receive permanent birth control, arose as a contrast to the involuntary, or forced, sterilization that stems from the eugenics movement.Elizabeth Hintz, Assistant Professor of Health Communication, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892162022-10-28T12:32:36Z2022-10-28T12:32:36ZWith over-the-counter birth control pills likely to be approved, pharmacists and pharmacies could play an ever-increasing role in reproductive health care<figure><img src="https://images.theconversation.com/files/487887/original/file-20221003-22-rx39dq.jpg?ixlib=rb-1.1.0&rect=395%2C0%2C5595%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The over-the-counter birth control pill will not require medical examinations or prescriptions prior to purchase.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cheerful-woman-in-modern-pharmacy-royalty-free-image/1360043428?phrase=pharmacy&adppopup=true">Sergey Mironov/Moment via Getty Images</a></span></figcaption></figure><p>The U.S. Food and Drug Administration is <a href="https://www.reuters.com/legal/us-fda-review-perrigos-birth-control-pill-otc-use-november-2022-09-12/">set to review</a> a drugmaker’s application for the <a href="https://www.statnews.com/2022/07/11/drugmaker-seeks-fda-approval-of-over-the-counter-birth-control-pill/">first over-the-counter birth control pill</a> in November 2022, with a decision expected in the first half of 2023. </p>
<p>An approved over-the-counter hormonal birth control product would not require a prescription and <a href="https://www.selfcarefederation.org/what-is-self-care">would be considered self-care</a>, defined as “the practice of individuals looking after their own health using the knowledge and information available to them.” </p>
<p>Currently, in many U.S. states, pharmacists can already prescribe hormonal contraception that requires a prescription. The process begins <a href="https://birthcontrolpharmacist.com/">with a pharmacist consultation</a> to screen patients for eligibility, collect a medical history and measure blood pressure. If the patient qualifies, the pharmacist can provide a prescription to the patient; if not, the pharmacist refers the patient to a physician. </p>
<p>The FDA’s approval of an over-the-counter birth control pill will further expand options for people seeking hormonal contraception to all 50 states. The first such over-the-counter pill – <a href="https://www.reuters.com/legal/us-fda-review-perrigos-birth-control-pill-otc-use-november-2022-09-12/">a non-estrogen, progestin-only contraceptive</a> – could become available by mid-2023. </p>
<p>We are a <a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">pharmacist</a> and a <a href="https://scholar.google.com/citations?hl=en&user=OIT2K2oAAAAJ">public health expert</a>. We see the move toward over-the-counter birth control as an important step toward accessible and equitable reproductive health care for all Americans, and pharmacists will play an indispensable role in that effort.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/0gzbFP09Eww?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The FDA will consider the application from HRA Pharma in November 2022.</span></figcaption>
</figure>
<h2>Making birth control more accessible</h2>
<p><a href="https://doi.org/10.1016/j.japh.2022.07.003">With more than 60,000 pharmacies nationwide</a>, pharmacists are the most accessible members of the health care workforce. Nearly 90% of Americans live within <a href="https://doi.org/10.1016/j.japh.2022.07.003">5 miles of a pharmacy</a>. Throughout the COVID-19 pandemic, pharmacies provided testing, vaccination and treatment for millions of people in the U.S., proving their worth in supporting and sustaining initiatives that are important to public health.</p>
<p>Traditionally, hormonal contraception – also known as birth control, or when taken orally, “the pill” – has only been accessible after a comprehensive medical evaluation by a physician, physician assistant or nurse practitioner. </p>
<p>But in 2016, California and Oregon became the first states to allow pharmacists to prescribe birth control. That quickly expanded to 20 states plus Washington, D.C. that now <a href="https://naspa.us/resource/contraceptives/">allow pharmacists to prescribe</a> some form of birth control, whether it be the pill, patch, ring or shot.</p>
<p>However, the move toward nonprescription-based, over-the-counter birth control is important because it will greatly lessen some of the known barriers to birth control. These barriers include the inability to pay for medical office visits required to obtain a prescription, lack of insurance to cover the cost of prescription birth control or lack of accessibility to pharmacist-prescribed contraception.</p>
<p>Over-the-counter birth control can also reduce access barriers by preventing the need for a scheduled appointment with a primary care physician during work hours or the need to travel long distances to get such care.</p>
<p>But it is important to note that over-the-counter access to hormonal birth control does not replace the importance of regular office visits or discussion about reproductive health with physicians.</p>
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<figcaption><span class="caption">The use of contraception was illegal in the U.S. from the late 1800s until the 1960s.</span></figcaption>
</figure>
<h2>Addressing remaining barriers</h2>
<p>Even in states where pharmacists are currently allowed to prescribe birth control, patients may still face barriers. </p>
<p>For example, if state policies do not create payment pathways to reimburse pharmacists for their time to counsel and prescribe, pharmacists may choose not to participate. Additionally, pharmacist availability and time may be limited and more restricted than the hours a pharmacy is advertised as open.</p>
<p>Finally, there are notable cases of pharmacists who have denied patients access to emergency contraception, also known as the “morning-after pill,” and <a href="https://www.npr.org/2018/06/25/623307762/walgreens-pharmacist-denies-drug-for-woman-with-unviable-pregnancy">prescriptions for medication abortion</a> on the grounds of moral, ethical and religious beliefs. </p>
<p>For instance, in 2019, a pharmacist in Minnesota <a href="https://www.nbcnews.com/news/us-news/minnesota-pharmacist-trial-refusing-dispense-morning-pill-beliefs-rcna41030">denied a patient emergency contraception</a>, citing personal beliefs. As a result, the patient drove 50 miles <a href="https://www.washingtonpost.com/nation/2022/08/03/minnesota-pharmacist-contraception-lawsuit/">to gain access to the medication</a>. Ultimately, a jury found that the pharmacist did not discriminate against the woman by denying to fill her prescription.</p>
<p>This precedent suggests that pharmacists who object to the use of reproductive medications may further choose not to participate in prescribing hormonal contraception even when permitted to do so by state law. They may also choose not to sell over-the-counter birth control when it becomes available.</p>
<h2>Pharmacist ‘conscience clauses’</h2>
<p>Notably, many states give pharmacists autonomy when dispensing medications. Currently, 13 states have laws or regulations known as “conscience clauses” that <a href="https://www.nbcnews.com/news/us-news/can-pharmacist-legally-deny-patient-prescription-it-depends-n894871">permit pharmacists to refuse to dispense a medication</a> when it conflicts with their religious or moral beliefs. </p>
<p>The American Pharmacists Association also recognizes an individual pharmacist’s right to conscientiously refuse to dispense a medication; however, the organization supports a system to <a href="https://aphanet.pharmacist.com/policy-manual?key=Pharmacist+Conscience+Clause&op=Search">ensure patient access to medications</a> without compromising the pharmacist’s right of refusal. In other words, pharmacists are encouraged to “step aside” but should not “step in the way” of dispensing or selling medications that conflict with their personal beliefs. </p>
<p>Some states with conscience clauses legally require pharmacists to refer patients elsewhere when they decline to dispense a medication for ethical and/or moral beliefs. In addition, company policies may require pharmacists with objections to arrange for another pharmacist – who does not have objections – to provide the medication and care requested by the patient. However, some states do not require a system to ensure this patient access as the American Pharmacists Association suggests.</p>
<h2>Contraception deserts</h2>
<p>Ongoing <a href="https://www.guttmacher.org/state-policy">legislation seeking to reduce abortion access</a> in the post-Roe era across the U.S. only increases the importance of patient access to contraception. Geographical spatial analyses have found that people of low socioeconomic classes and of color <a href="https://read.dukeupress.edu/jhppl/article/46/2/277/166722/Affordable-but-Inaccessible-Contraception-Deserts">disproportionately reside in contraception deserts</a>, which are areas with low access to family planning resources. These contraception deserts could be reduced or eliminated altogether in states that authorize pharmacists to prescribe contraception, or in areas with access to community pharmacies carrying hormonal birth control when available.</p>
<p>In our view, pharmacists can positively contribute to the safe, effective and accessible use of contraception across the country.</p><img src="https://counter.theconversation.com/content/189216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some states already allow pharmacists to provide birth control to patients with a prescription. But FDA approval of an over-the-counter birth control pill could greatly expand access.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghMarian Jarlenski, Associate Professor of Health Policy and Management, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1865372022-10-12T12:18:11Z2022-10-12T12:18:11ZMale birth control options are in development, but a number of barriers still stand in the way<figure><img src="https://images.theconversation.com/files/488588/original/file-20221006-22-mkhlv3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1999%2C1499&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lack of pharmaceutical industry interest has stymied the development of new male contraception options.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/lowering-sperm-count-royalty-free-illustration/825328902">filo/DigitalVision Vectors via Getty Images</a></span></figcaption></figure><p>In the wake of the reversal of Roe v. Wade, developing more contraception options for everyone becomes even more important.</p>
<p>Women and people who can become pregnant have a <a href="https://fphandbook.org">number of effective birth control methods</a> available, including oral pills, patches, injections, implants, vaginal rings, IUDs and sterilization. But for men and people who produce sperm, options have been limited. Two options, withdrawal and condoms, both have <a href="https://doi.org/10.1363/psrh.12017">high failure rates</a>. Withdrawal has a failure rate of about 20%. Condoms have a failure rate of only 2% when used correctly, but that rate rises to 13% based on how people typically use them. Vasectomies have a failure rate of less than 1%, but they require minimally invasive surgery and are seen as a permanent method of contraception. Neither vasectomies nor withdrawal protect against sexually transmitted infections.</p>
<p>There has not been a new form of male birth control since the introduction of the “<a href="https://www.healthline.com/health/mens-health/no-scalpel-vasectomy">no-scalpel vasectomy</a>” in the 1980s. <a href="https://lundquist.org/christina-chung-lun-wang-md">I, along with my team</a>, have been developing male contraception methods since the 1970s. I believe that new safe, reversible and affordable contraception options can help men participate and share contraceptive responsibilities with their partners, and <a href="https://doi.org/10.1016/j.contraception.2017.08.015">reduce the rate of unintended pregnancies</a>.</p>
<h2>Taking responsibility for family planning</h2>
<p>A <a href="https://www.malecontraceptive.org/uploads/1/3/1/9/131958006/mci_consumerresearchstudy.pdf">2017 survey</a> of 1,500 men ages 18 to 44 found that over 80% wanted to prevent their partner from getting pregnant and felt that they had shared or sole responsibility for birth control. </p>
<p>Men who are dissatisfied with condoms are more likely to either use withdrawal as a form of birth control or never use contraception. Of those dissatisfied with condoms, however, 87% percent are interested in new methods for male contraception. This translates to an estimated <a href="https://www.malecontraceptive.org/uploads/1/3/1/9/131958006/mci_consumerresearchstudy.pdf">17 million men in the U.S.</a> who are looking for new methods of contraception to prevent unintended pregnancies.</p>
<p>Similarly, a 2002 survey of over 9,000 men in nine countries over four continents found that <a href="https://doi.org/10.1093/humrep/deh574">over 55%</a> would be willing to use a new method of male birth control. Importantly, a 2000 survey across three continents found that <a href="https://doi.org/10.1093/humrep/15.3.646">98% of women</a> would trust their partner to use a male birth control method.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person displaying a variety of birth control methods." src="https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/488600/original/file-20221006-24-7c71p6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The onus of birth control has largely fallen on women and people who can become pregnant.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-explaining-contraception-royalty-free-image/602936017">Peter Dazeley/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<h2>Barriers to male contraception</h2>
<p>Strong interest in a new male contraceptive raises the question of why there haven’t been any new male birth control methods since the ‘80s.</p>
<p>Male contraception development has primarily been supported by governmental and nongovernmental organizations, including the <a href="https://www.who.int/publications/m/item/global-study-men-and-women-male-contraceptive-knowledge-using-mixed-methods">World Health Organization</a> working with academic medical centers. However, these agencies frequently do not have a <a href="https://doi.org/10.3389/fendo.2022.891589">drug development infrastructure</a> comparable to pharmaceutical companies, with programs typically run by only a handful of personnel assisted by clinical research organizations. Limited financial resources further slow down development.</p>
<p><a href="https://www.bloomberg.com/news/features/2017-08-03/why-we-can-t-have-the-male-pill">Lack of interest from pharmaceutical companies</a> may also play a role in deterring male contraception development, and there are a number of possible reasons the drug industry shies away from male birth control. One reason includes weighing the cost of development with uncertainties about the potential market. Other reasons include uncertainties about who would dispense these drugs and unclear <a href="https://pharmaceutical-journal.com/article/feature/overcoming-the-challenges-in-developing-male-contraceptives">regulatory requirements</a> for male contraceptive methods to receive FDA approval. Companies may also be concerned about liability if pregnancy occurs.</p>
<h2>New methods currently in development</h2>
<p>Researchers are currently looking into several different methods of male contraception.</p>
<p><a href="https://doi.org/10.1210/clinem/dgab034">Hormonal methods</a> are usually taken as a gel applied to the skin, injection to the muscle or oral pill. These methods typically contain testosterone and a progestin. The progestin suppresses two pituitary hormones that control the testes, the organs that produce sperm. While the testes require high concentrations of testosterone to make sperm, testosterone is typically included in hormonal methods to ensure that there is an adequate level of the hormone for other bodily functions. Counterintuitively, taking testosterone may also help <a href="https://doi.org/10.5534%2Fwjmh.180036">suppress sperm production</a>, because increasing circulating testosterone levels above a certain level suppresses the same two pituitary hormones. The addition of a progestin further enhances the suppression of sperm production.</p>
<p>The hormonal contraceptive candidate furthest along in development is currently in an ongoing <a href="https://clinicaltrials.gov/ct2/show/NCT03452111">second stage clinical study</a> that has recruited over 400 couples across four continents. I served as the principal investigator of this trial at the Lundquist Institute. The results of the study, sponsored by the <a href="https://www.nichd.nih.gov/about/org/dir/dph/officebranch/cdp">Eunice Kennedy Shriver National Institute of Child Health and Human Development</a> and the <a href="https://www.popcouncil.org/research/contraceptive-development">Population Council</a>, have so far been promising with minimal side effects, and the couples have found the gel acceptable to use.</p>
<p>My team and I are also developing drugs that function like <a href="https://doi.org/10.1210/clinem/dgab034">both testosterone and progestin</a>, but in a single compound. These drugs are currently undergoing early testing in people as a daily oral pill or a long-acting injection.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wYXI0Vt9oPU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scientists have been trying to develop male birth control pills for decades.</span></figcaption>
</figure>
<p><a href="https://doi.org/10.3389/fcell.2020.00061">Nonhormonal methods</a> typically involve drugs that specifically target sperm-producing organs to decrease sperm concentration or function. Nonhormonal drugs show efficacy in animal models, but preclinical toxicology results are needed before clinical studies to demonstrate safety, tolerability and efficacy in people can begin. <a href="https://doi.org/10.1210/clinem/dgab034">A few</a> of these methods are working toward first-stage clinical trials.</p>
<p>Another nonhormonal method involves reversibly blocking the vas deferens, an organ that transports sperm for ejaculation. Studies sponsored by the <a href="https://www.malecontraceptive.org">Male Contraceptive Initiative</a> and <a href="https://www.parsemus.org/humanhealth/male-contraceptive-research/">Parsemus Foundation</a> are testing <a href="https://doi.org/10.1210/clinem/dgab034">hydrogels</a>, a type of polymer that retains water, that block sperm from traveling through the vas deferens.</p>
<p>People are ready for new contraceptive methods. I believe that collaboration across academic, government, nonprofit and pharmaceutical sectors can help deliver new birth control methods that are safe, reversible, acceptable and accessible to all.</p><img src="https://counter.theconversation.com/content/186537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina Chung-Lun Wang receives funding from the Eunice Shriver Kennedy National Institute of Child Health and Human Development, National Institutes of Health, USA. She is a member of the International Committee for Contraceptive Development of the Population Council. She was a temporary consultant for the Research Group for the Study of Male Reproduction and previously named the Task Force for the Regulation of Male Infertility of the World Health Organization. She is currently an investigator at The Lundquist Institute and a Professor of Medicine in the Division of Endocrinology, Department of Medicine at the Harbor-UCLA Medical Center. </span></em></p>There hasn’t been a new form of male birth control since the 1980s. More contraception options for all partners could help reduce the rate of unintended pregnancies.Christina Chung-Lun Wang, Physician/Investigator at Lundquist Institute at Harbor-UCLA Medical Center and Professor of Medicine at David Geffen School of Medicine, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1912962022-10-07T14:51:15Z2022-10-07T14:51:15ZBirth control pill linked to greater risk of blood clots in women with obesity – here’s what you need to know<figure><img src="https://images.theconversation.com/files/486508/original/file-20220926-21-vtaud.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5615%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The combined pill contains both oestrogen and progestin. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174193232">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>Women who are obese and taking the combined oral contraceptive pill have 12 to 24 times greater risk of developing a leg-vein blood clot than those not taking the pill and who are not overweight, according to <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104">a recent review of research</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/12624633/">Other studies</a> have found a lower but still increased risk.</p>
<p>This kind of blood clot, known as a <a href="https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/">deep venous thrombosis</a> (DVT), can cause pain, swelling and redness of the affected leg. Usually this pain happens in the calf or thigh. Fortunately, most DVTs aren’t fatal – but they are serious and need to be treated urgently. In a small number of cases, part of the clot can break off and travel to the lungs which can be life threatening. </p>
<p>This increased risk might seem scary, and could even put some women off using contraception altogether if they’re overweight. But it’s important to understand where that risk comes from. And that not all types of contraception carry this increased risk. </p>
<p>The first thing to understand about the evidence around blood clot risk and contraception is that it only applies to <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">contraceptive methods that contain oestrogen</a>. These are the <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">combined oral contraceptive pill</a>, the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-patch/">contraceptive patch</a> and the <a href="https://www.nhs.uk/conditions/contraception/vaginal-ring/">contraceptive vaginal ring</a>. </p>
<p>That means that for <a href="https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/">all other methods available</a> the evidence doesn’t show an increased risk of developing a clot in healthy women who are not obese and don’t smoke. Smoking can also increase a person’s overall risk of blood clots, both in the leg and in the blood supply to the heart and brain. </p>
<p>The second thing to look at is the risk for all women of developing a clot, either while using contraception or not using it. </p>
<p>In general, the risk of developing a clot in the leg varies with age. But in young women worldwide, who are not using hormonal contraception, <a href="https://www.gov.uk/drug-safety-update/combined-hormonal-contraceptives-and-venous-thromboembolism-review-confirms-risk-is-small">around two in every 10,000</a> will develop a blood clot each year. This is very low.</p>
<figure class="align-center ">
<img alt="A clinician wearing blue surgical gloves holds a copper IUD between their fingers." src="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Contraceptives that don’t contain oestrogen (such as the copper IUD) don’t carry an additional risk of blood clots.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2074498042">New Africa/ Shutterstock</a></span>
</figcaption>
</figure>
<p>But the risk of developing a blood clot while on the combined oral pill is between <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">two and six times higher</a> than for women not using the combined pill. This works out at about five to 12 women per 10,000 each year – depending on the type of combined pill. Older pills containing <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">levonorgestrel have the lowest risk</a>.</p>
<p>The risk of developing a blood clot on the combined pill is about the same as the risk of developing a clot <a href="https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/treatment-of-venous-thrombosis-in-pregnancy-and-after-birth-patient-information-leaflet/#:%7E:text=it%20in%20pregnancy%3F-,Pregnancy%20increases%20your%20risk%20of%20a%20DVT%2C%20with%20the%20highest,including%20the%20first%203%20months.">during or immediately after pregnancy</a>. The <a href="https://www.bmj.com/content/344/bmj.e2990">patch and vaginal ring</a>, which both contain oestrogen, increase the risks by about the same amount as the combined oral pill. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039863/">contraceptive injection</a> seems also to increase the risk by a small amount – but this risk is still less than oestrogen-containing birth control methods.</p>
<h2>Obesity and DVT</h2>
<p>Being overweight increases everyone’s chance of developing a DVT, and this seems to be <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">especially the case in women</a>. People who are considered obese (a <a href="https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/">BMI of over 30</a>) are at about a <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">three to five times greater risk</a> of having a venous clot than those who have a healthy BMI. </p>
<p>There are two reasons that obesity increases risk of DVT. People who are obese have more abdominal fat, <a href="https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0031-1297369">which can slow the speed of blood flow</a> travelling from the legs and through the abdomen. This increases the chance of blood clotting. </p>
<p>Obesity also seems to cause <a href="https://www.webofscience.com/wos/woscc/full-record/WOS:000222655700008?SID=EUW1ED0AF0rjOMT19mVWZ8cXVTUpt">low-grade inflammation</a> in the body, which may make it easier for clots to form and may also make them <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">less likely to be dissolved naturally</a>.</p>
<p>Oestrogen has a similar effect to excess weight, also making the blood <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">more likely to form clots</a> and less likely to dissolve small clots when they happen. This is why obesity can put women taking oestrogen-containing contraceptives at even greater risk of DVT. </p>
<p>To lower your risk of a blood clot in general, it’s best to maintain as healthy a weight as possible, to avoid smoking and keep an eye on your blood pressure. Since both obesity and oestrogen can increase the likelihood of a blood clot in the leg, it’s not surprising the combination of these two factors increases blood clot risk substantially. </p>
<p>If you are worried about your risk of a blood clot, that doesn’t mean you can’t use contraception. There are still many safe contraceptives you can choose from which do not contain oestrogen, and therefore do not increase risk of a clot. This includes condoms, the copper IUD (which contains no hormones) or the progesterone-only pill, intrauterine system or implant (which only contain progestogen).</p><img src="https://counter.theconversation.com/content/191296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has receives funding from Bayer and NaturalCycles.. </span></em></p>Although the study found greater risk of blood clots for obese women taking the pill, the risk of developing one was still very low.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1862782022-08-11T12:15:09Z2022-08-11T12:15:09ZHow primary care is poised to support reproductive health and abortion in the post-Roe era<figure><img src="https://images.theconversation.com/files/478117/original/file-20220808-17-4g635q.jpg?ixlib=rb-1.1.0&rect=69%2C53%2C5048%2C3283&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Primary care providers comprise nearly a third of the U.S. clinician workforce.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/new-jersey-jersey-city-doctor-with-patient-in-royalty-free-image/140193309?adppopup=true">Tetra Images/via Getty Images </a></span></figcaption></figure><p>Just over a month after the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">Supreme Court struck down 50 years of federal protection of abortion rights</a> in the U.S., at least <a href="https://www.guttmacher.org/article/2022/07/one-month-post-roe-least-43-abortion-clinics-across-11-states-have-stopped-offering">43 abortion clinics in 11 states</a> have stopped offering abortion services. In states where abortion remains legal, abortion clinics are experiencing <a href="https://www.nytimes.com/2022/07/23/upshot/abortion-interstate-travel-appointments.html">excessive wait times</a> due to the influx of out-of-state patients. </p>
<p>Wait times are only expected to grow as <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">more states restrict abortion with regulations</a> such as gestational age limits, waiting periods and requirements for in-person visits, unnecessary clinical tests and required parental consent for minors. Abortion bans and restrictions are associated with higher rates of complications and are <a href="https://www.colorado.edu/today/2021/09/08/study-banning-abortion-would-boost-maternal-mortality-double-digits">harmful to the health of women</a> because they delay necessary care. </p>
<p>Although primary care doctors and clinicians are not typically associated with the abortion debate, they are a critical, untapped resource to help offset the abortion care crisis. Primary care is a key access point for patients, especially for adolescent, low-income and rural women. </p>
<p>And because almost all Americans <a href="https://www.fiercehealthcare.com/practices/89-americans-value-relationship-primary-care-doctor">value their relationship</a> with their primary care provider, primary care has a responsibility to ensure patients <a href="https://doi.org/10.1007/s11606-020-06245-8">maintain personal bodily autonomy</a>, including deciding when and how many children to have. </p>
<p>In the post-Roe era, primary care providers can help their patients prevent unintended pregnancy and avoid delays in abortion care by providing comprehensive contraceptive and family planning services, knowing how to counsel and refer individuals seeking pregnancy termination and providing post-abortion care. Due to various state restrictions, providers should <a href="https://states.guttmacher.org/policies/">familiarize themselves with their specific state regulations</a> to determine what is permissible in their current practice environment.</p>
<p>We are practicing <a href="https://www.uwmedicine.org/bios/emily-godfrey">primary care</a> <a href="https://www.uwmedicine.org/bios/adelaide-hearst">physicians</a> who include comprehensive family planning as part of our practices. We have written extensively about the feasibility of <a href="https://doi.org/10.1007/s11606-021-06863-w">including full-spectrum birth control</a> and first-trimester <a href="https://doi.org/10.1016/j.pop.2018.07.010">abortion services</a> in primary care.</p>
<p>Primary care providers make up 30% of the <a href="https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook2021.pdf">entire U.S. clinician workforce</a>. They include family physicians, general internists, pediatricians and advanced practice clinicians such as nurse practitioners, midwives and physician assistants, who are often the only source of care in <a href="https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html">underserved and rural areas</a>. </p>
<h2>Primary care’s role in preventing abortion</h2>
<p>One of the top reasons why patients go to their primary care provider is for birth control. Primary care clinics that provide all-inclusive birth control services <a href="https://upstream.org/results/">reduce unintended pregnancy</a> rates in their communities, which can help alleviate the demand for abortion services. </p>
<p>Primary care providers can talk with their patients about becoming <a href="https://beforeandbeyond.org/toolkit/reproductive-life-plan-assessment">pregnant now or in the future</a>, using <a href="https://powertodecide.org/one-key-question">clinical tools</a> that help patients decide <a href="https://www.mypathtool.org/en/intro_mp">which birth control method</a> to use. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic depiction of the variety of contraception and family planning methods." src="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Contraceptive methods range from IUDs and birth control pills to permanent sterilization.</span>
<span class="attribution"><span class="source">Centers for Disease Control and Prevention</span></span>
</figcaption>
</figure>
<p>Nationally based <a href="https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm">birth control clinical guidelines</a> empower clinicians to prescribe even the most effective birth control methods, such as an implant or intrauterine device – IUD – to patients with serious and chronic medical conditions. Primary care can also help patients with emergency contraception, either in the form of a pill or IUD, within five days after unprotected sex. </p>
<p><a href="https://acrobat.adobe.com/link/track?uri=urn:aaid:scds:US:750761d8-2138-3bd7-bcda-af1b07cc8404">Emergency contraceptive pills</a> are considered safe and effective. They are high-dose birth control pills that work by <a href="https://www.webmd.com/sex/birth-control/faq-questions-emergency-contraception#">interfering with the process of ovulation</a>, and thus will not affect a pregnancy if already pregnant. Emergency contraception is a last chance to prevent unplanned pregnancy.</p>
<h2>Abortion pill prescription falls within primary care</h2>
<p><a href="https://theconversation.com/how-to-navigate-self-managed-abortion-issues-such-as-access-wait-times-and-complications-a-family-physician-explains-186186">Abortion with medications can be safely and effectively used</a> up to the 11th week of pregnancy, with low rates of complications. Of the approximately 1 million legal abortions provided each year in the U.S., 90% occur in the first trimester, or through the 12th week of pregnancy. Thus, it’s no surprise that <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than half</a> of abortions are now managed with <a href="https://doi.org/10.1007%2Fs11606-020-05836-9">medicines that can be prescribed by a primary care provider</a>. </p>
<p>The <a href="https://nap.nationalacademies.org/catalog/24950/the-safety-and-quality-of-abortion-care-in-the-united-states">National Academies of Sciences, Engineering and Medicine</a> have issued evidence-based guidelines reiterating that trained, licensed primary care clinicians can safely and effectively provide medication abortion. Patients who have received abortions from primary care providers report that they are <a href="https://pubmed.ncbi.nlm.nih.gov/25646981/#">satisfied with the experience</a>. Studies show that patients <a href="https://doi.org/10.1007/s10995-010-0722-4">prefer abortion services in primary care</a> <a href="https://doi.org/10.1016/j.contraception.2009.01.017">because of the privacy</a>, convenience and <a href="https://pubmed.ncbi.nlm.nih.gov/26950663/">continuity of care</a>. </p>
<h2>How abortion care can be integrated into telehealth</h2>
<p>Despite the fact that first-trimester abortion care <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.301119?">fits well within primary care medical services</a>, it has not been widely offered in this setting. This is <a href="https://doi.org/10.3122/jabfm.2022.03.210266">due to roadblocks</a>, including lack of provider training, federal and state legislation, institutional barriers and administrative resistance. </p>
<p>However, there are now new, <a href="https://doi.org/10.1016/j.contraception.2017.11.005">more simplified medication abortion protocols</a> that allow primary care to safely offer abortion care remotely with a <a href="https://doi.org/10.1001/jamainternmed.2022.0217">history screening tool</a> that doesn’t require unnecessary clinical laboratory and ultrasound testing. Primary care’s expansion of telehealth abortion services has the potential to significantly reduce delays in care. This could help reduce abortions at more advanced gestational ages and the complications that come with them. Our study from 2021 conducted among primary care physicians providing telemedicine abortion <a href="https://doi.org/10.1016/j.contraception.2021.04.026">found that more than 85% of patients</a> were less than seven weeks pregnant when they sought care. </p>
<h2>Post-abortion ‘primary’ care</h2>
<p>In states with restricted abortion access, it is inevitable that patients will seek abortions on their own. Given the current legal landscape, clinicians are often confused about how to treat patients with pregnancy complications, including miscarriage. The World Health Organization stresses that even in settings where abortion may be outlawed, it is incumbent for clinicians to provide <a href="https://srhr.org/abortioncare/chapter-3/post-abortion-3-5/">compassionate, nonjudgmental post-abortion care</a>. </p>
<p>Post-abortion care includes managing residual side effects or complications of abortion, as well as the provision of comprehensive birth control services without discrimination or coercion. Complications from abortion or miscarriage are rare. However, complications like retained pregnancy tissue in the uterus, bleeding or infection can occur, most of which can be managed by primary care providers in the clinical setting. </p>
<p>Primary care providers who don’t offer abortion care can still counsel patients about <a href="https://www.abortionfinder.org/">where to seek</a> reliable, high-quality abortion services. The U.S. Department of Health and Human Services provides information about <a href="https://reproductiverights.gov/">Americans’ rights to reproductive health care</a>. </p>
<p>The short-term implications of the Supreme Court decision remain uncertain as state legislators weigh public opinion among their constituents. </p>
<p>What remains certain in the post-Roe era, however, is that primary care continues to be among the most reliable resources in the U.S. for accurate information and safe reproductive health care services.</p><img src="https://counter.theconversation.com/content/186278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily M. Godfrey receives funding from Cystic Fibrosis Foundation and Society of Family Planning Research Fund. She is a Nexplanon Trainer for Organon</span></em></p><p class="fine-print"><em><span>Adelaide H. McClintock is the named institutional PI for a grant from the Society of Family Planning. This grant was officially awarded to Nina Tan. </span></em></p>Primary care doctors have long played an important role in providing birth control. Now, with the fall of Roe, they could help fill a critical need for comprehensive family planning services.Emily M. Godfrey, Associate Professor of Family Medicine and Obstetrics & Gynecology, School of Medicine, University of WashingtonAdelaide H. McClintock, Professor of Internal Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869842022-08-05T12:10:37Z2022-08-05T12:10:37Z500K American men get vasectomies every year – a specialist explains the easy and reversible procedure<figure><img src="https://images.theconversation.com/files/475921/original/file-20220725-20-yvadro.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C4915%2C3664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This year, many vasectomy patients are young or single men concerned about unwanted pregnancy at a time when abortion care may not be as available as before.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-in-discussion-with-patient-in-exam-room-royalty-free-image/97863283">Thomas Barwick/Stone via Getty Images</a></span></figcaption></figure><figure class="align-center ">
<img alt="Green plate reading: 500,000 Number of men in the US who undergo vasectomies each year" src="https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=321&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=321&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474983/original/file-20220719-4704-cux94h.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=321&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
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<p>About half a million men undergo a vasectomy in the United States in any given year. The percentage of men getting them had been <a href="https://doi.org/10.1111/andr.13093">dropping for the past two decades</a>, but it looks like those numbers are going up in the wake of the June 24, 2022, Supreme Court <a href="https://www.oyez.org/cases/2021/19-1392">decision overturning Roe v. Wade</a>. </p>
<h2>Appointments up</h2>
<p>It’s too early for official numbers, but as a urologist and <a href="https://doctors.umiamihealth.org/provider/Ranjith+Ramasamy/526160">microsurgeon specializing in vasectomies</a>, I can report that more new patients are coming to see me. We used to perform about 20-25 vasectomies a month in our Miami clinic. But since the Dobbs v. Jackson decision came down, we’re now fully booked at 30 vasectomies scheduled each month through next year. I’m also seeing about 30% more online queries about vasectomies. It’s the first such increase I’ve seen in my 15-year career.</p>
<p>Other <a href="https://www.newsweek.com/male-contraception-vasectomies-inquiries-increase-roe-v-wade-supreme-court-1724739">urologists have rising numbers, too</a>. One Kansas City doctor said that he had <a href="https://www.cbs19news.com/story/46797913/urologist-says-vasectomy-consults-have-increased-by-900-since-roe-v-wade-decision">a 900% increase in vasectomy inquiries</a> in just the four days after the decision.</p>
<p>Most of our clinic’s new vasectomy patients are young or single men. They tell me they are concerned about getting a woman pregnant when abortion care isn’t as available as it was before. They also ask about <a href="https://doi.org/10.1007/978-3-030-47767-7_36">freezing their sperm first</a> in case they want biological children in the future. <a href="https://doi.org/10.1007/s10815-022-02545-6">Frozen storage is a viable option</a>, and some patients have even <a href="https://doi.org/10.1093/humrep/deac107.023">successfully frozen their own sperm</a>. </p>
<h2>Quick and simple</h2>
<p>Most vasectomies are straightforward, with 98% of them performed <a href="https://www.urologyhealth.org/educational-resources/vasectomy">in an outpatient clinic</a>. For the duration of the 15- to 20-minute procedure, most men are <a href="https://doi.org/10.1016/j.juro.2012.09.080">wide awake in a medical office</a>.</p>
<p>Only 2% of vasectomy patients get them in a hospital under anesthesia. That’s usually because of anatomical issues or previous surgeries complicating the procedure – or the personal preference of the patient to go to sleep.</p>
<p>The doctor starts by making a small opening in the scrotum. Then the doctor pulls out the vas deferens, the tube that delivers sperm out of the testes and to the ejaculatory duct. After placing permanent clips on the tube in two places, the doctor removes a small piece of tube between the clips. The clips remain in place, closing and permanently sealing the cut tube ends. Now there is no longer any connection between the testes where sperm is produced and the urethra, where it once exited the body. </p>
<p>Patients usually go home and recover for about four hours with some ice on the area. Most can go back to work a day or two later if their job doesn’t involve manual labor. We recommend no sex and no heavy lifting for about a week after the vasectomy.</p>
<p>The recovery period is a popular excuse for sports fans to plan their vasectomy around <a href="http://doi.org/10.21037/tau.2019.08.33">major sports events on TV</a> so that while they heal they can watch the Masters golf tournament, baseball’s World Series or the bowl games of American football. In fact, “March Madness vasectomy” promotions timed to college basketball playoffs are among the reasons <a href="https://doi.org/10.1016/j.urology.2018.03.016">March is a popular month</a> for appointments.</p>
<h2>More concerns than changes</h2>
<p>About two to three months later, the patient returns to the clinic. We take a sample of semen to check the sperm count. That tells us whether his vasectomy was successful. If any sperm are in the ejaculate, we might need to do a second one, but that happens in <a href="https://doi.org/10.21037%2Ftau.2017.07.08">fewer than 1% of cases</a>. Most of the time, we can give the patient the all-clear that their procedure is complete.</p>
<p>Of course, this is a surgery, so patients naturally have significant questions and concerns. A common one I’ll hear from a patient is that getting a vasectomy will make him “less of a man” because he is no longer able to father children. But that is absolutely not true. It won’t make you less of a man. </p>
<p>Some men fear it will damage their penis because the procedure is so close to it. But a vasectomy will not damage a man’s penis or any other surrounding structures. And he will not have any changes in sexual function or enjoyment after recovery from the procedure. </p>
<p>While everything else is the same as before, ejaculate volume obviously decreases slightly after a vasectomy. This worries some men. But it’s not a noticeable decrease, since <a href="https://onlinelibrary.wiley.com/doi/10.1111/andr.12983">sperm is only 5% of semen volume</a>. </p>
<p>If patients do change their minds, however, they can get their vasectomies reversed, and <a href="https://doi.org/10.1016/j.urology.2018.03.016">about 5% of U.S. patients do</a>.</p>
<p>Most commonly this involves a man with a new partner who wants to have biological kids. Nearly all vasectomy reversals succeed, with sperm returning to the ejaculate <a href="https://doi.org/10.1016/j.urology.2018.03.016">90% to 95% of the time</a>. And pregnancies follow vasectomy reversals about 50% to 60% of the time, depending on the age of the woman.</p><img src="https://counter.theconversation.com/content/186984/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ranjith Ramasamy receives funding from Acerus Pharmaceuticals (Consultant, Grant Recipient), Boston Scientific (Consultant, Grant Recipient), Coloplast (Consultant, Grant Recipient), Endo Pharmaceuticals (Consultant, Grant Recipient), Empower Pharmacy (Grant Recipient), Nestle Health (Consultant), Olympus (Grant Recipient), Hims, Inc (Advisory Board). </span></em></p>As more younger, single men ask for one following the Supreme Court abortion decision, a urologist explains what to expect with a vasectomy.Ranjith Ramasamy, Associate Professor of Urology, University of MiamiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1860052022-07-19T12:25:31Z2022-07-19T12:25:31ZWhat really drives anti-abortion beliefs? Research suggests it’s a matter of sexual strategies<figure><img src="https://images.theconversation.com/files/474127/original/file-20220714-32255-1j48rf.jpg?ixlib=rb-1.1.0&rect=0%2C101%2C3640%2C2562&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's an interesting evolutionary benefit for some women if the consequences of casual sex are high.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pro-life-marchers-participate-in-the-march-for-life-tens-of-news-photo/506527136">Albin Lohr-Jones/Pacific Press/LightRocket via Getty Images</a></span></figcaption></figure><p>Many people have strong opinions about abortion – especially in the wake of the U.S. Supreme Court decision that overturned Roe v. Wade, revoking a constitutional right previously held by more than 165 million Americans.</p>
<p>But what really drives people’s abortion attitudes? </p>
<p>It’s common to hear religious, political and other ideologically driven explanations – for example, about the sanctity of life. If such beliefs were really driving anti-abortion attitudes, though, then people who oppose abortion might not support the death penalty (<a href="https://doi.org/10.1080/07418829800093771">many do</a>), and they would support social safety net measures that could save newborns’ lives (<a href="https://www.npr.org/2022/07/13/1111244809/many-states-have-anti-abortion-laws-will-they-provide-a-social-safety-net-for-mo">many don’t</a>).</p>
<p>Here, we suggest a different explanation for anti-abortion attitudes – one you probably haven’t considered before – from <a href="https://scholar.google.com/citations?user=UEJqvFoAAAAJ&hl=en&oi=ao">our field of evolutionary</a> <a href="https://scholar.google.com/citations?user=CpXzPwgAAAAJ&hl=en&oi=ao">social science</a>.</p>
<h2>Why do people care what strangers do?</h2>
<p>The evolutionary coin of the realm is fitness – getting more copies of your genes into the next generation. What faraway strangers do presumably has limited impact on your own fitness. So from this perspective, it is a mystery why people in Pensacola care so strongly about what goes on in the bedrooms of Philadelphia or the Planned Parenthoods of Los Angeles.</p>
<p>The solution to this puzzle – and one answer to what is driving anti-abortion attitudes – lies in a conflict of sexual strategies: <a href="https://doi.org/10.1177/0963721412453588">People vary in how opposed they are to casual sex</a>. More “sexually restricted” people tend to shun casual sex and instead invest heavily in long-term relationships and parenting children. In contrast, more “sexually unrestricted” people tend to pursue a series of different sexual partners and are often slower to settle down.</p>
<p>These sexual strategies conflict in ways that affect evolutionary fitness. </p>
<p>The crux of this argument is that, for sexually restricted people, other people’s sexual freedoms represent threats. Consider that sexually restricted women often get married young and have children early in life. These choices are just as valid as a decision to wait, but they can also be <a href="https://doi.org/10.1016/S0049-089X(03)00012-7">detrimental to women’s occupational attainment</a> and tend to leave women more <a href="https://doi.org/10.2307/354020">economically dependent on husbands</a>.</p>
<p>Other women’s sexual openness can destroy these women’s lives and livelihoods by breaking up the relationships they depend on. So sexually restricted women benefit from impeding other people’s sexual freedoms. Likewise, sexually restricted men tend to <a href="https://global.oup.com/academic/product/the-oxford-handbook-of-evolutionary-psychology-and-parenting-9780190674687">invest a lot in their children</a>, so they benefit from prohibiting people’s sexual freedoms to preclude the high fitness costs of being cuckolded.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="two parents snuggle with four young kids" src="https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474128/original/file-20220714-33068-utuwgh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sexually restricted adults may feel that when casual sex has more potential consequences, it protects their own family relationships.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/happy-young-family-with-four-children-sitting-royalty-free-image/1354860953">Halfpoint Images/Moment via Getty Images</a></span>
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</figure>
<h2>Benefiting from making sex more costly</h2>
<p><a href="https://press.princeton.edu/books/paperback/9780691154398/why-everyone-else-is-a-hypocrite">According to evolutionary social science</a>, restricted sexual strategists benefit by imposing their strategic preferences on society – by curtailing other people’s sexual freedoms. </p>
<p>How can restricted sexual strategists achieve this? By making casual sex more costly. </p>
<p>For example, banning women’s access to safe and legal abortion essentially forces them to endure the costs of bearing a child. Such hikes in the price of casual sex can deter people from having it. </p>
<p>This attitude is perhaps best illustrated by a statement from Mariano Azuela, a justice who opposed abortion when it came before Mexico’s Supreme Court in 2008: “I feel that a woman in some way <a href="https://www.nytimes.com/2008/08/28/world/americas/28mexico.html">has to live with the phenomenon of becoming pregnant</a>. When she does not want to keep the product of the pregnancy, she still has to suffer the effects during the whole period.” </p>
<p>Force people to “suffer the effects” of casual sex, and fewer people will pursue it.</p>
<p>Also note that abortion restrictions do not increase the costs of sex equally. Women bear the costs of gestation, face the <a href="https://doi.org/10.1089/jwh.2020.8863">life-threatening dangers of childbirth</a> and <a href="https://doi.org/10.1016/j.copsyc.2021.07.020">disproportionately bear responsibility for child care</a>. When women are denied abortions, they are also more likely to <a href="https://www.ansirh.org/research/ongoing/turnaway-study">end up in poverty and experience intimate partner violence</a>.</p>
<p>No one would argue this is a conscious phenomenon. Rather, people’s strategic interests shape their attitudes in nonconscious but self-benefiting ways – a common finding in <a href="https://www.worldcat.org/title/challenge-of-democracy-government-in-america/oclc/449201193&referer=brief_results">political science</a> and <a href="https://doi.org/10.1017/ehs.2021.29">evolutionary social science</a> alike.</p>
<h2>Resolving awkward contradictions in attitudes</h2>
<p>An evolutionary perspective suggests that common explanations are not the genuine drivers of people’s attitudes – on either side of the abortion debate. </p>
<p>In fact, people’s stated religious, political and ideological explanations are often rife with awkward contradictions. For example, many who oppose abortion also oppose <a href="https://doi.org/10.1179/2050854914Y.0000000035">preventing unwanted pregnancy through access to contraception</a>. </p>
<p>From an evolutionary perspective, such contradictions are easily resolved. Sexually restricted people benefit from increasing the costs of sex. That cost increases when people cannot access legal abortions or prevent unwanted pregnancy.</p>
<p>An evolutionary perspective also makes unique – often counterintuitive – predictions about which attitudes travel together. This view predicts that if sexually restricted people associate something with sexual freedoms, they should oppose it. </p>
<p>Indeed, researchers have found that sexually restricted people oppose not only abortion and birth control, but also <a href="https://doi.org/10.1177/0956797615621719">marriage equality</a>, because they perceive homosexuality as associated with sexual promiscuity, and <a href="https://doi.org/10.1098/rspb.2010.0608">recreational drugs</a>, presumably because they associate drugs like marijuana and MDMA with casual sex. We suspect this list likely also includes transgender rights, <a href="https://doi.org/10.31234/osf.io/67vh9">public breastfeeding</a>, premarital sex, what books children read (and <a href="https://www.oif.ala.org/oif/drag-queen-storytime-continue-to-stir-up-controversy-as-well-as-excitement-among-library-patrons/">if drag queens can read to them</a>), equal pay for women, and many other concerns that have yet to be tested.</p>
<p>No other theories we are aware of predict these strange attitudinal bedfellows.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hazy-focus view of back of bride and groom in church with people in pews" src="https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474133/original/file-20220714-32258-kvrjag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">More sexually restricted people may in turn become more religious.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/focus-shot-of-flower-wedding-decoration-royalty-free-image/163346894">maximkabb/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Behind the link to religion and conservatism</h2>
<p>This evolutionary perspective can also explain why anti-abortion attitudes are so often associated with religion and social conservatism. </p>
<p>Rather than thinking that religiosity causes people to be sexually restricted, this perspective suggests that a restricted sexual strategy can <a href="https://doi.org/10.1037/0022-3514.89.1.78">motivate people to become religious</a>. Why? <a href="https://doi.org/10.1016/j.copsyc.2020.07.030">Several</a> <a href="https://doi.org/10.1016/j.evolhumbehav.2013.08.006">scholars</a> <a href="https://doi.org/10.1177/0963721419838242">have suggested</a> that people adhere to religion in part <a href="https://doi.org/10.1016/j.evolhumbehav.2008.03.004">because its teachings promote sexually restricted norms</a>. Supporting this idea, participants in one study reported being <a href="https://doi.org/10.1016/j.jesp.2009.10.017">more religious after researchers showed them photos of attractive people</a> of their own sex – that is, potential mating rivals.</p>
<p>Sexually restricted people also tend to invest highly in parenting, so they stand to benefit when other people adhere to norms that benefit parents. <a href="https://doi.org/10.1177/01461672221076919">Like religion</a>, <a href="https://doi.org/10.31234/osf.io/d3fg2">social conservatism prescribes parent-benefiting norms</a> like constricting sexual freedoms and ostensibly promoting family stability. In line with this, <a href="https://doi.org/10.1093/oxfordhb/9780190674687.013.27">some research</a> suggests that people don’t simply <a href="https://quoteinvestigator.com/2014/02/24/heart-head/">become more conservative with age</a>. Rather, people become <a href="https://doi.org/10.1016/j.paid.2018.05.045">more socially conservative during parenthood</a>.</p>
<h2>Restricting everyone to benefit yourself</h2>
<p>There are <a href="https://doi.org/10.1016/j.tree.2013.10.008">multiple answers to any “why” question</a> in scientific research. Ideological beliefs, personal histories and other factors certainly play a role in people’s abortion attitudes. </p>
<p>But so, too, do people’s sexual strategies.</p>
<p>This evolutionary social science research suggests that restricted sexual strategists benefit by making everyone else play by their rules. And just as <a href="https://www.politico.com/news/2022/06/24/thomas-constitutional-rights-00042256">Justice Thomas suggested when overturning Roe v. Wade</a>, this group may be taking aim at birth control and marriage equality next.</p><img src="https://counter.theconversation.com/content/186005/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some reasons people oppose abortion seem to be at odds with other positions they hold. Evolutionary social science points to a surprising motivation for anti-abortion attitudes.Jaimie Arona Krems, Assistant Professor of Psychology, Oklahoma State UniversityMartie Haselton, Professor of Psychology, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1848132022-06-29T12:05:44Z2022-06-29T12:05:44ZA growing number of women give birth at Catholic hospitals, where they do not receive the same reproductive health options – including birth control – provided at other hospitals<figure><img src="https://images.theconversation.com/files/471255/original/file-20220627-24-2ifhs7.jpg?ixlib=rb-1.1.0&rect=0%2C64%2C6114%2C4006&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that short spacing between childbirth and another pregnancy comes with heightened health risks.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-sees-a-positive-pregnancy-test-result-and-royalty-free-image/1386831922?adppopup=true">Aleksandr Kirillov/EyeEm via Getty Images</a></span></figcaption></figure><p>Now that the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">U.S. Supreme Court has eliminated</a> the constitutional right to an abortion, access to birth control has taken on new urgency. By moving the decision about abortion access to states, the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe v. Wade</a> means that it will be even more important for people to be able to prevent an unwanted or mistimed pregnancy. </p>
<p>Given the health risks of having a rapid repeat pregnancy, avoiding pregnancy is especially critical for those who have recently given birth. But not all health care providers offer birth control to their patients.</p>
<p>Over the past two decades, the number of <a href="https://www.communitycatalyst.org/news/press-releases/new-report-finds-rapid-growth-of-catholic-health-systems#">Catholic hospitals in the U.S. has risen dramatically</a>. But it might come as a surprise to many people to learn that Catholic hospitals are not allowed to provide health care that is considered by their religious leaders to be “intrinsically immoral.” </p>
<p>The Catholic religion holds that sex should only occur within marriage and that while it should be performed for the good of the spouses, each act must be open to procreation. Because of this, the U.S. Conference of Catholic Bishops has published <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a>, last updated in 2018, that prohibit Catholic hospitals from providing birth control, abortion and infertility treatments. There are no exceptions, even if the care is needed to protect a person’s life or health.</p>
<p>As a result, many people who want birth control before they leave the hospital after childbirth may not receive it. </p>
<p>One of the <a href="https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/intro.html">most effective methods of preventing pregnancy</a> is female sterilization, which is <a href="https://doi.org/10.1016/j.ajog.2021.12.261">used by 18% of women in the U.S.</a>. This permanent method of birth control usually consists of tubal ligation, a surgical procedure in which the fallopian tubes are cut or sealed. <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">Catholic hospitals are not permitted</a> to perform this procedure. </p>
<p>However, many people are not even aware that they are choosing a Catholic hospital when they decide where they will deliver. Others do not have an option or may not realize that where they give birth might affect the reproductive treatment options available to them.</p>
<p><a href="https://cph.osu.edu/people/mgallo">As a sexual and reproductive health epidemiologist</a>, I have carried out <a href="https://scholar.google.com/citations?user=xOQDyI8AAAAJ&hl=en">research on contraception and abortion</a> in countries throughout the world, including in the U.S., over the past 20 years. Much of my research involves studying disparities in people’s use of birth control.</p>
<h2>Avoiding a Catholic hospital can be difficult</h2>
<p>As a result of hospital mergers and acquisitions, between 2001 and 2016 the number of Catholic acute care hospitals grew by 22%. Overall, about 17% of acute care hospital beds in the U.S. <a href="http://static1.1.sqspcdn.com/static/f/816571/27061007/1465224862580/MW_Update-2016-MiscarrOfMedicine-report.pdf">belong to Catholic hospitals</a>. </p>
<p>Some people attend a Catholic hospital because they have limited choices. There are 46 Catholic hospitals in the U.S. that are the <a href="http://static1.1.sqspcdn.com/static/f/816571/27061007/1465224862580/MW_Update-2016-MiscarrOfMedicine-report.pdf">sole providers of short-term acute hospital care</a> in their geographic area, including in Santa Fe, New Mexico; Grand Junction, Colorado; and Bellingham, Washington. Others might be limited in where their health insurance will cover their care. </p>
<p>Some people are not even aware that they are attending a Catholic hospital. A 2018 national survey asked adult women of reproductive age where they go for their reproductive care; 16% named a Catholic hospital. However, over one-third of the women who named a Catholic hospital <a href="https://doi.org/10.1016/j.contraception.2018.05.017">did not know that their hospital was Catholic</a>. Furthermore, those who were wrong about their hospital’s Catholic status described themselves as being “sure” or “very sure” about their incorrect response. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6NpPmo-P8G0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘As U.S. hospitals are struggling, more and more are merging with Catholic institutions.’</span></figcaption>
</figure>
<p>In some cases, people might be unaware of their hospital’s status because its name does not sound religious. Also, people might not know that a Catholic network purchased their secular hospital and that their hospital is now required to follow its <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a>. A 2017-2018 review of hospital websites found that <a href="https://doi.org/10.1001/jama.2019.0133">21% of Catholic hospitals did not explicitly disclose</a> their Catholic status on their website.</p>
<p>Even if people know that their hospital is Catholic, they might not know that attending a Catholic hospital could restrict the scope of care that they are able to receive. A large survey of women found that <a href="https://doi.org/10.1363/psrh.12118">most did not expect restrictions on care</a> at Catholic hospitals, especially for services viewed as less taboo than abortion. Respondents did not realize that Catholic hospitals are restricted in providing birth control, including female sterilization methods such as tubal ligation.</p>
<h2>The need for birth control after childbirth</h2>
<p>Using birth control after childbirth is critical, because people’s fertility returns quickly. Having at least 18 months of spacing between childbirth and a new pregnancy is important to protect the <a href="https://doi.org/10.1016/j.ajog.2006.05.055">pregnant person</a> and the <a href="https://doi.org/10.1016/j.ajog.2014.11.017">infant’s health</a>. </p>
<p>Short birth spacing increases the risks of adverse outcomes such as preeclampsia, preterm birth and health problems for the newborn infant. Because of the health risks, the U.S. Department of Health and Human Services recognized birth spacing as a high priority in the <a href="https://health.gov/healthypeople">2030 Healthy People Objectives</a>.</p>
<p>For people who do not want to have more pregnancies, immediately after delivery can be the most convenient time to have a tubal ligation. For this reason, about half of all tubal ligations <a href="https://doi.org/10.1097/aog.0b013e318262e354">are performed after delivery</a>. <a href="https://doi.org/10.1016/j.ajog.2022.05.021">About 6.2% of deliveries</a> in the U.S. are followed by a tubal ligation. <a href="https://doi.org/10.1097/aog.0b013e3181f73eaa">Failing to receive a desired </a> postpartum tubal ligation increases the risk of having a rapid repeat pregnancy. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/3SqeSSQhu3o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A tubal ligation seals off the fallopian tubes, which carry eggs to a person’s womb, in order to prevent pregnancy.</span></figcaption>
</figure>
<h2>Birth control use following delivery at Catholic hospitals</h2>
<p>Our team decided to investigate whether women who recently delivered at a Catholic hospital were less likely to be using birth control during the postpartum period compared to women who delivered at a non-Catholic hospital. </p>
<p>Even if <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a> state that Catholic hospitals are not allowed to provide birth control, it is plausible that some hospitals might fail to enforce the rules or providers might find ways to work around them. For example, providers at Catholic hospitals might place an intrauterine device, or IUD, in a patient who desires one by justifying its use for noncontraceptive purposes. Or providers might perform an elective cesarean delivery in order to surreptitiously perform a tubal ligation. </p>
<p>My colleagues and I used survey data from the <a href="https://www.cdc.gov/prams/index.htm">Pregnancy Risk Assessment Monitoring System</a> from five states – Alaska, Illinois, Maine, Oregon and Wisconsin – over the period of 2015 to 2018. The Centers for Disease Control and Prevention and state health departments annually conduct this survey of women who gave birth in the last two to six months. We linked this survey data to birth certificates to know whether women had delivered at a Catholic or non-Catholic hospital.</p>
<p>Our study found that at two to six months postpartum, women who had delivered at a Catholic hospital were about <a href="https://doi.org/10.1363/psrh.12186">half as likely to have had female sterilization</a> as women who delivered at another type of hospital. This difference remained statistically significant after we adjusted for women’s age, race or ethnicity, education, insurance status and parity. </p>
<h2>Pregnancy carries health risks</h2>
<p>Legal abortion is <a href="https://theconversation.com/study-shows-an-abortion-ban-may-lead-to-a-21-increase-in-pregnancy-related-deaths-167610">much safer than childbirth in the U.S.</a>. Because people are <a href="https://doi.org/10.1097/aog.0b013e31823fe923">14 times more likely to die from pregnancy</a> than from a legal abortion, it is important that they are able to avoid an unintended pregnancy. </p>
<p>These studies illustrate the need for people to have access to the birth control method of their choice – a choice that is all the more important now that people have lost their constitutional right to an abortion.</p>
<p><em>Editor’s note: This story has been updated to clarify the Catholic religion’s stance on the purpose of sex; it holds that sex should only occur within marriage and be performed for the good of the spouses, but that each act must be open to procreation.</em></p><img src="https://counter.theconversation.com/content/184813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Gallo receives funding from Relias Media for consultant work and grant funding from the National Institutes of Health and non-profit foundations for research.</span></em></p>Many people do not realize they are delivering at a Catholic hospital, and others may not have a choice. But where one receives care has a profound impact on the birth control options they’re offered.Maria Gallo, Professor of Epidemiology, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1795362022-05-24T12:45:52Z2022-05-24T12:45:52ZProtestants and the pill: How US Christians helped make birth control mainstream<figure><img src="https://images.theconversation.com/files/464873/original/file-20220523-42302-xv0uq2.jpg?ixlib=rb-1.1.0&rect=22%2C7%2C999%2C723&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protestant Christians have been debating -- and more often than not, supporting -- modern contraceptives since they first appeared.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-government-and-doctors-have-decided-the-10-million-news-photo/514867588?adppopup=true">Bettmann/Bettman via Getty Images</a></span></figcaption></figure><p>Since the Supreme Court overturned Roe v. Wade, many Christians have celebrated the prospect of an America where abortion is someday <a href="https://religionnews.com/2022/05/19/as-roes-potential-fall-nears-abortion-abolitionists-turn-on-pro-life-elites-sbc-tom-ascol-women-murder-criminal/">banned entirely</a>.</p>
<p>Meanwhile, other conservative Christians have been working on a related target: <a href="https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/05/19/some-states-already-are-targeting-birth-control">limiting access to some contraceptives</a>.</p>
<p>In July 2020, when <a href="https://www.supremecourt.gov/opinions/19pdf/19-431_5i36.pdf">the Supreme Court</a> ruled that organizations with “sincerely held religious or moral objection” are not obligated to provide contraceptive coverage to their employees, many conservative Christians <a href="https://ministrywatch.com/supreme-court-rules-in-favor-of-little-sisters-of-the-poor/">applauded</a>. Six years before, the evangelical owners of crafting chain Hobby Lobby took their objections to covering the IUD in their health insurance plans all the way to the Supreme Court. Hobby Lobby argued – incorrectly, according to most <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices#:%7E:text=Copper%20Intrauterine%20Device&text=The%20available%20evidence%20supports%20that,which%20it%20remains%20highly%20effective.">medical authorities</a> – that it was <a href="https://www.theatlantic.com/health/archive/2014/03/heres-why-hobby-lobby-thinks-iuds-are-like-abortions/284382/">a form of abortion</a>, and therefore they should not have to cover employees’ health insurance for it. The justices sided with the chain’s owners.</p>
<p>Yet as access to both abortion and contraception <a href="https://www.today.com/health/womens-health/overturning-roe-v-wade-threaten-birth-control-access-rcna27092">comes under threat</a>, the vast majority of Protestants <a href="https://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">use or have used</a> some form of contraception. Their actions are supported by almost 100 years of pastoral advocacy on the issue. In my work as <a href="https://www.colorado.edu/wgst/samira-mehta">a scholar of religous studies, gender and sexuality</a>, I have researched the Protestant leaders who campaigned to make contraception respectable, and therefore widely acceptable, in the mid-20th century. </p>
<p>History, I have found, provides a different story about the relationship between Protestants and birth control.</p>
<h2>‘Responsible parenthood’</h2>
<p>As new contraceptive options emerged in the first two-thirds of the 20th century, from the <a href="https://www.popsci.com/story/science/contraception-diaphragm-history/">diaphragm</a> to the birth control pill, Christian leaders <a href="https://doi.org/10.2979/amerreli.1.2.02">wrestled with what to think</a>. Many came to see birth control as a moral good that would allow married couples to have satisfying sex lives, while protecting women from the health risks of frequent pregnancies. They hoped it could ensure that couples would not have more children than they could care for, emotionally and economically.</p>
<figure class="align-center ">
<img alt="A black and white photograph shows women with baby carriages lined up on a street." src="https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women with children stand outside Sanger Clinic, the first birth control clinic in United States, in Brooklyn, New York in 1916.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/women-with-children-outside-sanger-clinic-first-birth-news-photo/1347202932?adppopup=true">Circa Images/GHI/Universal History Archive/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>They looked inward, considering the consequences of birth control for their own communities, and hoped that “planned” or “responsible” sex would create healthy families and decrease divorce. They also looked outward, thinking about birth control’s wider implications, at a time of widespread concern that the global population <a href="https://www.smithsonianmag.com/innovation/book-incited-worldwide-fear-overpopulation-180967499/">was rising too quickly to handle</a>.</p>
<p>By the time <a href="https://theconversation.com/freer-sex-and-family-planning-a-short-history-of-the-contraceptive-pill-92282">the pill</a> came on the market in the 1960s, liberal and even some conservative Protestants were advocating for birth control <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">using new theological ideas about “responsible parenthood</a>.”</p>
<p>“Responsible parenthood” reframed debates about family size around “Christian duty.” To be responsible in parenting was not only to avoid having more children than you could afford, nurture and educate. It also meant considering responsibilities outside the home toward churches, society and humanity.</p>
<p>Protestant leaders supporting contraception argued that the best kind of family was a father with a steady job and a homemaker mother, and that birth control could <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">encourage this model</a>, because smaller families could maintain a comfortable lifestyle on one income. They also hoped that contraception would help couples stay together by allowing them to have satisfying sex lives.</p>
<p>Multiple denominations <a href="https://doi.org/10.2307/1190751">endorsed birth control</a>. <a href="https://www.nytimes.com/1958/08/26/archives/lambeth-bishops-for-birth-control-family-planning-described-by.html">In 1958</a>, for example, the Anglican Communion stated that family planning was a “primary obligation of Christian marriage,” and chastised parents “who carelessly and improvidently bring children into the world, trusting in an unknown future or a generous society to care for them.” </p>
<h2>The big picture</h2>
<p>Religious leaders’ support for “responsible parenthood” was not just about deliberately creating the kind of Christian families they approved of. It was also about heading off the horrors of <a href="https://www.nytimes.com/2015/06/01/us/the-unrealized-horrors-of-population-explosion.html">population explosion</a> – a fear very much front of mind in mid-century America.</p>
<p>In the middle of the 20th century, with increased access to vaccines and antibiotics, more children were living to adulthood and life expectancies were rising. Protestant leaders feared this so-called <a href="https://www.smithsonianmag.com/innovation/book-incited-worldwide-fear-overpopulation-180967499/">population bomb</a> would outstrip the Earth’s food supply, leading to famine and war. </p>
<p>In 1954, when the global population stood at <a href="https://www.eea.europa.eu/data-and-maps/daviz/data-visualization-40#tab-chart_1">about 2.5 billion</a>, Rev. Harry Emerson Fosdick, <a href="https://www.christianitytoday.com/history/people/pastorsandpreachers/harry-emerson-fosdick.html">one of the most prominent Protestant voices of the age</a>, framed overpopulation as one of the world’s “basic problems,” and the birth control pill, which was then being developed, as the best potential solution.</p>
<p>Richard Fagley, a minister who served on the World Council of Church’s Commission of the Churches on International Affairs, <a href="https://books.google.com/books/about/The_Population_Explosion_and_Christian_R.html?id=jhbaAAAAMAAJ">argued that</a> in family planning, science had provided Christians with a new venue <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">for moral responsibility</a>. Medical knowledge, Fagley wrote, is “a liberating gift from God, to be used to the glory of God, in accordance with his will for men.”</p>
<p>These “responsible parenthood” ideas held that religious couples had a responsibility to be good stewards of the earth by not having more children than the planet could support. In the context of marriage, contraception was viewed as moral, shoring up a particular form of Christian values.</p>
<h2>Yesterday’s arguments</h2>
<p>These ideas about “good” and “bad” families often rested on assumptions about race and gender that reproductive rights advocates find troubling today. </p>
<p>Early in the 20th century, predominantly white, Protestant clergy were very interested in increasing access to contraception for the poor, who were often Catholic or Jewish immigrants <a href="https://www.ucpress.edu/book/9780520303218/birth-control-battles">or people of color</a>. Some scholars have argued that early support for contraception was predominantly about eugenics, particularly before World War II. Among some white leaders, there was concern about so-called <a href="https://doi.org/10.2307/204082">race suicide</a>: the racist fear that “they” would be overwhelmed.</p>
<p>Apart from <a href="https://doi.org/10.1017/jme.2021.54">some eugenicists, however</a>, most of these clergy wanted to give people access to contraception in order to create “healthy” families, regardless of income level. Yet many were unable or unwilling to see how they were promoting a narrow view of the ideal family, and how that marginalized poor communities and people of color – themes I am studying in my current book project.</p>
<p>Moreover, many proponents were advocating for women’s health, but not reproductive freedom. Their priority was setting women up for <a href="https://uncpress.org/book/9781469636269/devotions-and-desires/">success to attain their ideal</a> of the middle-class, Christian motherhood. With fewer children, some hoped, families would be able to get by on just a husband’s salary, meaning more women at home raising children.</p>
<h2>A battle won – and lost?</h2>
<p>Over the decades, Protestant leaders have, in large part, disappeared from pro-birth control arguments.</p>
<p>There are many reasons. Mid-century agricultural technologies reduced fears of overpopulation – which have only recently been <a href="https://theconversation.com/curb-population-growth-to-tackle-climate-change-now-thats-a-tough-ask-153382">reawoken by the climate crisis</a>. Meanwhile, mainline Protestant churches, and their public influence, <a href="https://www.pewresearch.org/fact-tank/2015/05/18/mainline-protestants-make-up-shrinking-number-of-u-s-adults/#:%7E:text=Pew%20Research%20Center's%202014%20Religious,Study%20was%20conducted%20in%202007.">are shrinking</a>. Conservative leaders eventually grew concerned that birth control would lead to more working women, not fewer. And since the 1970s, evangelicals <a href="https://www.npr.org/2019/06/20/734303135/throughline-traces-evangelicals-history-on-the-abortion-issue">have grown increasingly opposed</a> to abortion, which was increasingly linked to birth control through the broad term “family planning.”</p>
<p>In other words, since the “population bomb” was no longer ticking, contraception no longer seemed like such an urgent necessity – and some of its other implications troubled conservatives, breaking an almost pan-Protestant alliance.</p>
<p>Meanwhile, liberal Protestants had so embraced contraception that they no longer viewed it as turf that needed defending. Today, 99% of American girls and women between the ages of 15 and 44 who have ever had sex <a href="https://www.cdc.gov/nchs/nsfg/key_statistics/c.htm#contraception">use or have used a contraceptive method</a>. Reproductive rights advocates turned their attention to abortion rights – largely leaving religious views on birth control to their opponents.</p><img src="https://counter.theconversation.com/content/179536/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samira Mehta does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Conservative Christians have cheered restrictions on some birth control. But many decades ago, Christian leaders’ support helped contraceptives become acceptable in the first place.Samira Mehta, Associate Professor of Women and Gender Studies & Jewish Studies, University of Colorado BoulderLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1829642022-05-17T10:01:42Z2022-05-17T10:01:42ZBirth control: what to expect if you choose to come off it<figure><img src="https://images.theconversation.com/files/463588/original/file-20220517-15-x18rn5.jpg?ixlib=rb-1.1.0&rect=35%2C11%2C7904%2C5285&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Your period will return quickly after you stop the pill.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-taking-birth-control-pills-2083070260">antoniodiaz/ Shutterstock</a></span></figcaption></figure><p>Deciding to stop using your regular birth control is a big decision. There are a number of reasons why you might be considering this – whether that’s to have a baby, or because of negative side effects you might be experiencing (such as mood swings). But while there’s plenty of discussion about what to expect when starting birth control, there’s less information out there about what to expect when you decide to quit. </p>
<p>One of the biggest things to consider if you do stop using your regular birth control is the possibility of <a href="https://www.nice.org.uk/guidance/cg156/chapter/Recommendations#initial-advice-to-people-concerned-about-delays-in-conceptio">becoming pregnant</a>. If you’re trying to avoid this, using a back-up contraceptive method is important. </p>
<p>But some women may also experience changes to their periods, skin or mood when they come off the pill and their natural cycle returns. This is because most contraceptive methods contain hormones – typically oestrogen and progesterone – which suppress the body’s normal hormonal changes. This not only prevents pregnancy, but may also have other effects – such as reducing period pain or affecting mood. </p>
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<img alt="Quarter life, a series by The Conversation" src="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><strong><a href="https://theconversation.com/uk/topics/quarter-life-117947?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">This article is part of Quarter Life</a></strong>, a series about issues affecting those of us in our twenties and thirties. From the challenges of beginning a career and taking care of our mental health, to the excitement of starting a family, adopting a pet or just making friends as an adult. The articles in this series explore the questions and bring answers as we navigate this turbulent period of life.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a></em></p>
<p><em><a href="https://theconversation.com/ivf-add-ons-why-you-should-be-cautious-of-these-expensive-procedures-if-youre-trying-to-conceive-180198?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">IVF add-ons: why you should be cautious of these expensive procedures if you’re trying to conceive</a></em></p>
<p><em><a href="https://theconversation.com/we-wont-have-a-male-contraceptive-until-we-change-our-understanding-of-risk-68375?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">We won’t have a male contraceptive until we change our understanding of risk</a></em></p>
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<h2>The pill</h2>
<p>The <a href="https://digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2020-21/data-tables">most common method</a> of birth control used by women in the UK is the pill. This includes both the combined pill (which contains both oestrogen and progestogen) and the progestogen-only pill (often called the “mini pill”). </p>
<p>If you decide you want to stop using the pill, it’s typically best to wait until <a href="https://www.nhs.uk/conditions/contraception/miss-combined-pill/">the end of a packet</a>. This will <a href="https://www.fsrh.org/standards-and-guidance/documents/fsrh-ceu-switching-document-feb-2019">lower the risk of becoming pregnant</a> from intercourse that took place just before stopping the pill. When using a combined pill, it’s safe to have sex during the pill free break, but only if you start the next packet on the correct day and take pills for at least the next seven days. That is why stopping in the middle of a packet is risky in terms of pregnancy.</p>
<p>The biggest change you’ll experience when stopping is the return of your normal menstrual cycle. Since the combined pill typically makes <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">periods lighter, less painful and more predictable</a>, you may find your periods are heavier and more painful in comparison when you stop the pill. Your periods will also return to their regular pattern (which for some may have been irregular). People who experienced mid-cycle pain (during ovulation) or pre-menstrual syndrome before starting the pill may also see these return.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/contraception-the-way-you-take-the-pill-has-more-to-do-with-the-pope-than-your-health-109392">Contraception: the way you take the pill has more to do with the pope than your health</a>
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</em>
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<p>If you were using the combined pill to improve acne or manage certain conditions (such as polycystic ovary disease) you will likely find these benefits are lost once you stop. </p>
<p>But if you were someone who took the mini pill, you may find your experience is slightly different when you stop. The <a href="https://www.nhs.uk/conditions/contraception/the-pill-progestogen-only">progestogen-only pill</a> does not provide the regularity of periods that the combined pill usually does – with many women often having irregular bleeding (usually light but unpredictable) while taking it. So when you stop the mini pill, your period will likely return to its natural pattern, which may be more regular and predictable. </p>
<p>Since progestogen has various side effects for some women – such as causing acne, mood changes or low libido – stopping both the combined and mini pill may <a href="https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-pop-mar-2015">improve all of these</a>. </p>
<p>It’s also important to note that your periods and your fertility return very quickly after stopping the pill and you could <a href="https://www.nhs.uk/conditions/contraception/when-periods-after-stopping-pill/">become pregnant</a> within weeks or even days of stopping. So use a back-up method immediately after stopping the pill if this is something you want to avoid. </p>
<h2>Longer-acting contraceptives</h2>
<p>Longer-acting hormonal contraceptive methods – such as the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-implant">implant</a>, <a href="https://www.nhs.uk/conditions/contraception/ius-intrauterine-system">hormonal intrauterine system</a> (IUS) and the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-injection">injection</a> – have similar effects on the menstrual cycle as the pill. This may include making periods lighter but more unpredictable, or even the absence of periods. </p>
<figure class="align-center ">
<img alt="A pair of hands wearing blue surgical gloves holds a copper IUD." src="https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Fertility will return to normal after having your IUD or IUS removed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2074498042">New Africa/ Shutterstock</a></span>
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<p>If you have your implant or IUS removed, your menstrual cycle will return to its previous pattern within weeks. Your fertility will also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055351/">return to normal</a> within days or weeks.</p>
<p>But with the injection, you might not have a period for several months after stopping – and the return of fertility can also be delayed <a href="https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/fsrh-guideline-contraception-young-people-may-2019.pdf">by a few months</a>. This is most likely because of the high dose of hormone in the injection, and how well it suppresses the natural cycle. However, most women typically get their period again <a href="https://www.nhs.uk/conditions/contraception/contraceptive-injection/">within a year</a> of stopping the injection, and these periods are as regular and heavy (or light) as before.</p>
<p>If you use the copper <a href="https://www.nhs.uk/conditions/contraception/iud-coil/">intrauterine device</a> (IUD), this does not contain any hormones. Though it’s long-acting and extremely effective against pregnancy, some women experience heavier and longer periods when using this method. Fertility returns immediately after having the IUD removed, so it’s important for women who don’t want to become pregnant to use back-up contraception. It’s also advised women with an IUD don’t have unprotected <a href="https://www.nhs.uk/conditions/contraception/iud-coil/">sex for a week before removal</a> because fertility returns so quickly. </p>
<p>You might be concerned about contraception having a long term effect on your periods or your fertility, but happily <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055351/">all the evidence</a> points to this not being the case. Some women may find they experience a slight delay in the return of their periods after stopping any form of hormonal birth control (though it’s most common with the injection). This is because it can take a few weeks for the body’s natural hormonal cycle to re-establish itself. This is not a cause for concern unless it goes on for many months. </p>
<p>The decision to stop using birth control is an extremely personal one, and will be influenced by whether you want to have a baby, your relationship and many other factors. Apart from sterilisation, all modern contraceptive methods are designed to be fully reversible. While you might notice some effects after stopping, these are typically due to the return of the natural rhythms of the menstrual cycle.</p><img src="https://counter.theconversation.com/content/182964/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has received funding from Bayer PLC and Natural Cycles. </span></em></p>Any effects you might notice after stopping birth control are typically due to the return of your natural menstrual cycle.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1824962022-05-05T14:05:46Z2022-05-05T14:05:46ZAbortion has been common in the US since the 18th century – and debate over it started soon after<figure><img src="https://images.theconversation.com/files/461388/original/file-20220504-19011-r3tbzx.jpeg?ixlib=rb-1.1.0&rect=8%2C8%2C5381%2C3571&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At New York City's Rockefeller Center, activists hold a series of signs that read 'Legalize Abortion' in March, 1968. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/in-front-of-the-atlas-sculpture-at-rockefeller-center-news-photo/939586500?adppopup=true">Bev Grant/Getty Images</a></span></figcaption></figure><p>these four men and one woman<a href="https://theconversation.com/abortion-right-guaranteed-by-roe-will-be-replaced-by-state-power-if-the-supreme-court-adopts-the-leaked-alito-opinion-182379">State-by-state battles are heating up</a> in the wake of news that the <a href="https://s3.documentcloud.org/documents/21835435/scotus-initial-draft.pdf">U.S. Supreme Court appears poised to overrule</a> landmark rulings - <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a> and <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a> - and remove constitutional protection for the right to get an abortion. </p>
<p><a href="https://www.pewtrusts.org/research-and-analysis/blogs/stateline/2022/05/04/more-states-shield-against-rogue-abortion-prosecutions">Now, pro- and</a> <a href="https://www.usnews.com/news/us/articles/2022-05-03/leaked-court-document-galvanizes-anti-abortion-activists">anti-abortion advocates</a> are gearing up for a new phase of the abortion conflict.</p>
<p>While many people may think that the political arguments over abortion now are fresh and new, scholars of women’s, medical and legal history note that this debate has a long history in the U.S.</p>
<p>It began more than a century before Roe v. Wade, the 1973 ruling that established that the Constitution protects a person’s right to an abortion. </p>
<h2>The era of ‘The Pill’</h2>
<p>On Nov. 14, 1972, a controversial two-part episode of the groundbreaking television show, “<a href="https://tv.avclub.com/10-episodes-that-show-how-maude-debated-american-cultur-1798278022">Maude</a>” aired. </p>
<p>Titled “Maude’s Dilemma,” the episodes chronicled the decision by the main character to have an abortion. </p>
<p><a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a> was issued two months after these episodes. The ruling affirmed the right to have an abortion during the first 12 weeks of pregnancy. “Maude’s Dilemma” brought the battle over abortion from the streets and courthouses to primetime television. </p>
<p>Responses to the episodes ranged from <a href="https://www.chicagotribune.com/news/ct-xpm-1992-11-13-9204130017-story.html">celebration to fury</a>, which mirrored contemporary attitudes about abortion.</p>
<p>Less than 10 years before “Maude’s Dilemma” aired, the Food and Drug Administration approved the first commercially produced <a href="https://www.pbs.org/wgbh/americanexperience/features/pill-us-food-and-drug-administration-approves-pill/">birth control pill</a>, Enovid-10. </p>
<p>Although various forms of birth control <a href="https://www.pbs.org/wgbh/americanexperience/features/pill-birth-control-pill/">predate</a> the birth control pill, the FDA’s approval of Enovid-10 was a watershed in the <a href="https://books.google.com/books/about/Birth_Control_Politics_in_the_United_Sta.html?id=it1LHbLKVpkC">national debate</a> around family planning and reproductive choice.</p>
<p>Commonly known as “The Pill,” the wider accessibility of birth control is seen as an <a href="http://www.cnn.com/2010/OPINION/05/06/pogrebin.pill.roundup/index.html">early victory</a> of the nascent women’s liberation movement.</p>
<p>Abortion also emerged as a prominent issue within this burgeoning movement. For many feminist activists of the 1960s and 1970s, women’s right to control their own reproductive lives became inextricable from the <a href="https://www.britannica.com/topic/womens-movement">larger platform</a> of gender equality. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278546/original/file-20190607-52789-jozddf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">19th-century advertisements for abortion-inducing items and abortion services.</span>
<span class="attribution"><a class="source" href="https://librarycompany.org/">The Library Company of Philadelphia</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<h2>From unregulated to criminalized</h2>
<p>From the nation’s founding through the early 1800s, <a href="https://www.ncbi.nlm.nih.gov/pubmed/10297561">pre-quickening abortions</a> – that is, abortions before a pregnant person feels fetal movement – were fairly common and even advertised. </p>
<p>Women from various backgrounds sought to end unwanted pregnancies before and during this period both in the U.S. and across the world. For example, enslaved Black women in the U.S. developed abortifacients – drugs that induce abortions – and abortion practices as means to <a href="http://www.civilwarmed.org/abortion1/">stop pregnancies</a> after rapes by, and coerced sexual encounters with, white male slave owners. </p>
<p>In the mid- to late-1800s, an increasing number of states passed anti-abortion laws sparked by both moral and safety concerns. Primarily motivated by fears about high risks for injury or death, <a href="https://www.theatlantic.com/magazine/archive/1997/05/abortion-in-american-history/376851/">medical practitioners</a> in particular led the charge for anti-abortion laws during this era. </p>
<p>By 1860, the American Medical Association sought to <a href="https://www.chicagotribune.com/sns-abortion-timeline-story.html">end</a> legal abortion. The <a href="https://law.jrank.org/pages/5508/Comstock-Law-1873.html">Comstock Law</a> of 1873 criminalized attaining, producing or publishing information about contraception, sexually transmitted infections and diseases, and how to procure an abortion. </p>
<p>A spike in fears about new <a href="https://daily.jstor.org/the-history-of-outlawing-abortion-in-america/">immigrants</a> and newly emancipated Black people reproducing at higher rates than the white population also prompted more opposition to legal abortion.</p>
<p>There’s an <a href="https://slate.com/human-interest/2017/05/susan-b-anthony-anti-abortion-heroine-how-activists-are-claiming-her-for-their-own.html">ongoing dispute</a> about whether famous women’s activists of the 1800s such as Elizabeth Cady Stanton and Susan B. Anthony opposed abortion. </p>
<p>The anti-abortion movement references <a href="https://www.feministsforlife.org/herstory/sbarevolution/">statements</a> made by Anthony that appear to denounce abortion. Abortion rights advocates <a href="http://time.com/4106547/susan-b-anthony-elizabeth-cady-stanton-abortion/">reject this understanding</a> of Stanton, Anthony and other early American women’s rights activists’ views on abortion. They assert that statements about infanticide and motherhood have been misrepresented and inaccurately attributed to these activists. </p>
<p>These differing historical interpretations offer two distinct framings for both historical and contemporary abortion and anti-abortion activism. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Huge and colorful crowd of anti-abortion protesters along a large boulevard, holding signs." src="https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461390/original/file-20220504-17-tnubq6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Thousands of anti-abortion activists from all over the U.S. gather on the Washington Monument grounds during the annual Right To Life March, Washington DC, January 22, 1985.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/thousands-of-attendees-from-all-over-the-united-states-news-photo/1293520742?adppopup=true">Mark Reinstein/Corbis via Getty Images</a></span>
</figcaption>
</figure>
<h2>Abortion in the sixties</h2>
<p>By the turn of the 20th century, <a href="https://billmoyers.com/story/history-of-abortion-law-america/">every state classified abortion as a felony</a>, with some states including limited exceptions for medical emergencies and cases of rape and incest. </p>
<p>Despite the criminalization, by the <a href="https://global.oup.com/academic/product/the-oxford-companion-to-united-states-history-9780195082098?cc=us&lang=en&">1930s</a>, physicians performed almost a million abortions every year. This figure doesn’t account for abortions performed by non-medical practitioners or through undocumented channels and methods. </p>
<p>Nevertheless, abortion didn’t become a hotly contested political issue until the women’s liberation movement and the sexual revolution of the 1960s and 1970s. These movements brought renewed interest in public discussions about reproductive rights, family planning and access to legal and safe abortion services.</p>
<p>In 1962, the story of <a href="http://news.bbc.co.uk/onthisday/hi/dates/stories/august/26/newsid_3039000/3039322.stm">Sherri Finkbine</a>, the local Phoenix, Arizona host of the children’s program, “Romper Room,” became national news. </p>
<p>Finkbine had four children, and had taken a drug, thalidomide, before she realized she was pregnant with her fifth child. Worried that the drug could cause severe birth defects, she tried to get an abortion in her home state, Arizona, but could not. She then traveled to Sweden for a legal abortion. Finkbine’s story is credited with helping to shift <a href="http://advocatesaz.org/2012/08/15/sherri-finkbines-abortion-its-meaning-50-years-later/">public opinion</a> on abortion and was central to a growing, national call for abortion reform laws.</p>
<p>Two years after Finkbine’s story made headlines, the death of <a href="https://www.vice.com/en_us/article/evgdpw/how-a-harrowing-photo-of-one-womans-death-became-an-iconic-pro-choice-symbol">Gerri Santoro</a>, a woman who died seeking an illegal abortion in Connecticut, ignited a renewed fervor among those seeking to legalize abortion. </p>
<p>Santoro’s death, along with many other reported deaths and injuries also sparked the founding of underground networks such as <a href="https://www.npr.org/2018/01/19/578620266/before-roe-v-wade-the-women-of-jane-provided-abortions-for-the-women-of-chicago">The Jane Collective</a> to offer abortion services to those seeking to end pregnancies.</p>
<h2>Expanding legal abortion</h2>
<p>In 1967, Colorado became the first state to <a href="https://denverite.com/2017/02/10/50-years-ago-colorado-became-first-state-liberalize-abortion-laws/">legalize abortion in cases of rape, incest, or if the pregnancy</a> would cause permanent physical disability to the birth parent.</p>
<p>By the time “Maude’s Dilemma” aired, abortion was legal under specific circumstances in 20 states. A rapid growth in the number of <a href="https://www.prochoiceamerica.org/about/">pro-</a> and <a href="https://www.nrlc.org/">anti-abortion</a> organizations occurred in the 1960s and 1970s. </p>
<p>On Jan. 22, 1973, the Supreme Court’s ruling in Roe v. Wade nullified existing state laws that banned abortions and provided guidelines for abortion availability based upon trimesters and fetal viability. The subsequent <a href="https://www.thirteen.org/wnet/supremecourt/rights/landmark_casey.html">1992 ruling known as Casey</a> reaffirmed Roe, while also allowing states to impose certain limits on the right to abortion. Roe remains the most important legal statute for abortion access in modern U.S. history.</p>
<p>Since Roe, the legal battle over abortion has raged, focused on the Supreme Court. If the draft opinion overruling Roe and Casey stands, the battle will end there and shift to the states, which will have the power to ban abortion without fear of running afoul of the Supreme Court. And the long history of conflict over abortion in the U.S. suggests that this will not be the last chapter in the political struggle over legal abortion.</p>
<p><em>This story is an updated version of <a href="https://theconversation.com/a-concise-history-of-the-us-abortion-debate-118157">an article published</a> on June 10, 2019.</em></p><img src="https://counter.theconversation.com/content/182496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Treva B. Lindsey does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With the Supreme Court likely to strike down constitutional protection for abortion, a centuries-old debate over its morality and legality has been reignited.Treva B. Lindsey, Professor of Women's, Gender and Sexuality Studies, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1740262022-01-18T13:56:23Z2022-01-18T13:56:23ZYes, it’s easier to get birth control than it was in the 1970s – but women still need abortion care<p>A historic ruling on abortion is likely to emerge from the U.S. Supreme Court this year as justices consider whether Mississippi can, in fact, impose a ban on abortions after 15 weeks of pregnancy. </p>
<p>The case, <a href="https://www.oyez.org/cases/2021/19-1392">Dobbs v. Jackson Women’s Health Organization</a>, challenges the landmark 1973 Roe v. Wade decision that protects women’s right to abortion. Meanwhile, Texas enacted its own restrictive abortion law in September – and <a href="https://jezebel.com/were-tracking-all-the-texas-style-abortion-bills-1848300080">other states</a> are working to follow suit. </p>
<p>Mississippi Solicitor General Scott G. Stewart <a href="https://www.supremecourt.gov/oral_arguments/argument_transcripts/2021/19-1392_4425.pdf">argued before the Supreme Court in December</a> that abortion is not necessary. </p>
<p>“I would emphasize that contraception is more accessible and affordable and available than it was at the time of Roe or Casey,” Stewart said, in reference to Roe v. Wade and Planned Parenthood v. Casey, two landmark abortion court decisions. “It serves the same goal of allowing women to decide if, when and how many children to have.”</p>
<p>So, is it actually easier than ever to get contraception in the U.S. – and does that mean that abortion is no longer necessary?</p>
<p>The short answers are, “no” and “no.”</p>
<p>Even if every person who needed it could obtain contraception, it wouldn’t completely eliminate the need for abortion. </p>
<h2>Why getting birth control in America isn’t always easy</h2>
<p>Total protection from unwanted pregnancy <a href="https://www.guttmacher.org/journals/ipsrh/2003/03/relationships-between-contraception-and-abortion-review-evidence">is impossible to achieve</a>, even with multiple, highly effective modern methods of contraception available. </p>
<p>No contraceptive method is 100% effective, and a need for abortion will always exist for several reasons. </p>
<p>First, most contraceptive methods still require a prescription and at least an initial visit to a clinic or a doctor’s office to initiate or maintain treatment. This step alone can be prohibitive for the <a href="https://www.guttmacher.org/fact-sheet/paying-contraception-united-states">21 million American women</a> who cannot afford to pay for family planning services.</p>
<p>This figure marks a 25% increase over the past two decades – in 2000, <a href="https://www.theatlantic.com/health/archive/2016/11/contraceptive-deserts/505577/">16.4 million American women</a> and girls needed help paying for contraception. This increase is outpacing the growth of the <a href="https://www.guttmacher.org/report/contraceptive-needs-and-services-2013-update">total number of sexually active women </a>and teens who need contraception since 2000. </p>
<p>Second, not all <a href="https://doi-org.offcampus.lib.washington.edu/10.1089/jwh.2020.8910">health care providers</a> are up to date on the <a href="https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm">latest evidence-based guidelines</a> for contraceptive use in people with particular medical conditions. As a result, patients may be unnecessarily denied their chosen contraceptive method or asked to return for multiple visits. </p>
<p>Third, many young people <a href="https://www.guttmacher.org/gpr/2018/02/new-name-same-harm-rebranding-federal-abstinence-only-programs">do not receive adequate sex education</a>, which would include information about contraception and how to get it. This is especially true among low-income or marginalized populations, including people of color and nonnative English speakers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A black and white photo shows a woman facing an open birth control package" src="https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440107/original/file-20220110-19-fj6pmq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In the 1970s, when Roe v. Wade was decided, oral contraception was one of the few effective methods of birth control available in the U.S.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/651976new-york-the-government-and-doctors-have-decided-the-10-million-picture-id514867588?s=2048x2048"> UPI wb/jl</a></span>
</figcaption>
</figure>
<h2>The evolution of birth control</h2>
<p>In 1973, the year of the Roe decision, doctors could offer only pills, diaphragms, IUDs or sterilization. Traditional methods, such as penile withdrawal, have been around since long before 1960 but are <a href="https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/family-planning-methods-2014.pdf">undeniably less effective</a> than more modern methods. </p>
<p>As a <a href="https://www.uwmedicine.org/bios/emily-godfrey#research-tab">primary care doctor and researcher</a> at the University of Washington Departments of Family Medicine and Obstetrics and Gynecology, I have <a href="https://www.researchgate.net/profile/Emily-Godfrey-2">two decades of experience</a> providing and teaching about full-spectrum contraceptive care.</p>
<p>I have been fortunate to offer my patients an increasing number of highly effective modern contraceptive methods. Today there are <a href="https://www.kff.org/womens-health-policy/issue-brief/minimum-contraceptive-coverage-requirements-clarified-by-hhs-guidance/">18 different methods</a> of contraception, ranging from intrauterine devices to vaginal rings. </p>
<p>Although almost all people in the U.S. use birth control at some point, not everyone is consistently using it all the time. On average, fertile women in the U.S. need effective birth control <a href="https://www.guttmacher.org/report/contraceptive-needs-and-services-2014-update">for 30 years</a> to avoid unwanted pregnancies.</p>
<h2>Measuring birth control availability</h2>
<p>While the number of birth control options has grown, it remains difficult for many women and teens to get contraception.</p>
<p>Today, an estimated <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">65% of women and teenage girls</a> use contraception, marking a <a href="https://www.cdc.gov/nchs/data/series/sr_23/sr23_012.pdf">10 percentage-point increase from 1982</a> rates.</p>
<p>And today, <a href="https://www.cdc.gov/nchs/products/databriefs/db388.htm">34% of women and teens are using the most effective forms</a> of birth control, compared with 23% of women who did so in 1982. </p>
<p>Approximately 17% of women and teens are using moderately effective methods, compared with 15% in 1982. The remainder are using less effective contraception, or none at all.</p>
<p>While the percentage of women and teenagers using contraception has increased since the 1980s, a closer look at data reveals an uneven picture. </p>
<p>Teenage girls ages 15 to 19 are much <a href="https://www.cdc.gov/nchs/products/databriefs/db388.htm">less likely to get contraception</a> than older women (only 38.7% of surveyed girls this age use it). Latina and Black women also have lower rates of contraception use than white women.</p>
<p>The COVID-19 pandemic has worsened these divides. Black, Latina and queer women reported higher rates of contraception appointment delays and cancellations. Approximately 29% of Black women, 38% of Latinas and 35% of queer women <a href="https://nwlc.org/wp-content/uploads/2020/08/NWLCIssueBrief_BCandCOVID-19.pdf">also reported</a> feeling worried about paying for contraception in July 2020. </p>
<p>One in 4 women report <a href="https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-health-services-key-findings-from-the-2020-kff-womens-health-survey/">not using their preferred method</a> of birth control because they cannot afford it. This matters, because patients are more likely to continue using a birth control method if they like it. </p>
<p><a href="https://opa.hhs.gov/research-evaluation/title-x-services-research/contraceptive-care-measures">One other way to measure contraceptive care</a> considers the percentage of women ages 15 to 44 who have unintended pregnancies.</p>
<p>The unintended pregnancy rate is 30% higher in the U.S., at <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">45 per 1,000 women</a>, than the average rate in all <a href="https://doi.org/10.1016/S2214-109X(20)30315-6">high-income countries</a>. </p>
<p>While unintended pregnancies in the U.S. reached the lowest rate in 2011 since at least 1981, lower-income women <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">remain five times</a> more likely than higher-income women to have a pregnancy they did not plan for.</p>
<p><a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30315-6/fulltext">More recent data</a> shows a 47% decrease in unintended pregnancies in Europe and North America, between the five-year period 1990-1994 and the five year-period 2015-2019.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women hug outside of a Planned Parenthood clinic, which has a sign that says 'still here' on the side" src="https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440114/original/file-20220110-17-1ljel33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pro-choice supporters embrace outside of the last Planned Parenthood location performing abortions in Missouri.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/prochoice-supporters-hug-outside-the-planned-parenthood-reproductive-picture-id1147201471?s=2048x2048">Saul Loeb/AFP via Getty Image</a></span>
</figcaption>
</figure>
<h2>Limits to getting birth control</h2>
<p>The use of public funds to fully cover family planning, which includes confidential contraceptive services, has long been established as <a href="https://www.guttmacher.org/gpr/2014/12/beyond-preventing-unplanned-pregnancy-broader-benefits-publicly-funded-family-planning">cost-effective intervention</a> in public health. </p>
<p><a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm?s_cid=rr6304a1_w">Family planning reduces unintended pregnancy</a>. Unintended pregnancy contributes to pregnancy-related deaths, preterm births and infant deaths, rates of which are <a href="https://www.vox.com/2020/1/30/21113782/pregnancy-deaths-us-maternal-mortality-rate">higher in the U.S.</a> than in other developed countries.</p>
<p>Congress <a href="https://opa.hhs.gov/sites/default/files/2020-11/opa-titlex-2020-timeline.pdf">passed two key mandates</a> in the 1970s that allowed the use of public funds for no- or low-cost family planning services for adolescents and poor and low-income women. </p>
<p>However, the budget for funding family planning is <a href="https://doi.org/10.1016/j.contraception.2013.12.005">less than half</a> of what it was in 1980. And the number of women who likely need public support for contraception is increasing. </p>
<p>Past programs in Missouri and <a href="https://onlinelibrary-wiley-com.offcampus.lib.washington.edu/doi/full/10.1363/46e1714">Colorado</a> that provided the full range of modern contraceptive methods <a href="https://www-ncbi-nlm-nih-gov.offcampus.lib.washington.edu/pmc/articles/PMC4000282/">at no cost</a> reduced unintended pregnancy and abortion rates. </p>
<p>Implementation of the Affordable Care Act in 2010 made contraception more accessible for millions of Americans using private and public health insurance by requiring <a href="https://www.hrsa.gov/womens-guidelines-2016/index.html">coverage of all contraceptive methods</a> without a copay. </p>
<p>Contraception is still not accessible to all, however, especially among those who live in states that <a href="https://www.guttmacher.org/report/publicly-supported-FP-services-US-2016">did not expand their Medicaid family planning services under the Affordable Care Act</a>, which lowered the criteria for low-income women to qualify for medical assistance coverage for contraception. </p>
<p>Additionally, <a href="https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-health-services-key-findings-from-the-2020-kff-womens-health-survey">1 in 5 privately insured women</a> report paying out of pocket for birth control, which is not possible for many women.</p>
<h2>Yes, we still need abortion care.</h2>
<p>Given the wide range of contraceptive choices available today, some Americans, including Mississippi’s Stewart, wonder whether abortion is still needed. </p>
<p>The short answer is, “yes.” </p>
<p>Despite America’s having the lowest abortion rate in 50 years, abortions in America are not rare.“ Approximately <a href="https://www.guttmacher.org/fact-sheet/induced-abortion-united-states">18% of the estimated 6 million pregnancies in the U.S. each year end in abortion</a>. </p>
<p>Access to contraceptive care from publicly supported providers in 2016 <a href="https://www.guttmacher.org/report/publicly-supported-FP-services-US-2016">helped delay or avoid nearly 2 million pregnancies</a>. Widespread access to birth control would reduce the number of abortions. </p>
<p>But expanding access will require definitive new federal and state action, including implementing policies that guarantee better health care access.</p>
<p>These changes won’t completely eliminate the need for safe abortions, which will remain a crucial health care service no matter what. </p>
<p>[<em><a href="https://memberservices.theconversation.com/newsletters/?nl=politics&source=inline-politics-important">Get The Conversation’s most important politics headlines, in our Politics Weekly newsletter</a>.</em>]</p><img src="https://counter.theconversation.com/content/174026/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily M. Godfrey receives funding from the Society of Family Planning Research Fund and the Cystic Fibrosis Foundation. She is a Nexplanon Trainer for Organon. She has written an Op-Ed about mifepristone by mail in the Seattle Times. </span></em></p>The Supreme Court is considering a case that could restrict abortions. One argument is that birth control eliminates the need for abortion. But contraception doesn’t offer an easy fix.Emily M. Godfrey, Associate Professor of Family Medicine and Obstetrics & Gynecology, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1739792022-01-06T14:39:16Z2022-01-06T14:39:16ZGreat balls of fire: How heating up testicles with nanoparticles might one day be a form of male birth control<figure><img src="https://images.theconversation.com/files/439249/original/file-20220103-36920-yu4j17.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C9485%2C5800&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Warming the testicles using nanorods affects sperm production.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/great-balls-of-fire--how-heating-up-testicles-with-nanoparticles-might-one-day-be-a-form-of-male-birth-control" width="100%" height="400"></iframe>
<p>Women have a variety of methods for contraception, but only two methods are commonly available to men: condoms and vasectomies. Both methods have their drawbacks. </p>
<p>Condoms can break, and some men <a href="https://doi.org/10.1111/j.1600-0536.1989.tb03173.x">are allergic to the latex in standard condoms</a>. Vasectomies are surgical procedures that can be <a href="https://dx.doi.org/10.4103/1008-682X.175090">painful</a> and <a href="https://dx.doi.org/10.4103/1008-682X.175091">difficult to reverse</a>. </p>
<p>So the search for <a href="https://dx.doi.org/10.4103/2230-8210.102991">alternative male contraceptive options continues</a>, and one method currently being investigated is <a href="https://doi.org/10.1038/nmat3701">nanocontraception</a>.</p>
<h2>An on/off switch</h2>
<p>Nanocontraception is based on the idea that nanoparticles — here, about 100 nanometres in diameter, or roughly one-thousandth the width of a piece of paper or of a strand of human hair — can somehow be delivered to the testicles, where they can be warmed.</p>
<p>If you could warm up the testicles just a bit, you would have a way to turn sperm production on and off at will because the warmer they get, <a href="https://doi.org/10.1530/jrf.0.1140179">the less fertile they become</a>. But it’s a delicate process because the testicles can be irreversibly destroyed if they become too warm; the tissue dies and can no longer produce sperm, even when the testicles return to their normal temperature.</p>
<p>Using nanotechnology to warm testicles was first studied in 2013 on mice by biologist Fei Sun and his multidisciplinary research team. His early experiments <a href="https://doi.org/10.1021/nl400536d">involved injecting nanoparticles directly into mouse testicles</a>. These nanoparticles were long nanorods (or nanocylinders) of gold atoms — imagine a tube 120 gold atoms long with a diameter of 30 gold atoms — coated with a few long polymer chains on their surface. They looked like oblong bacteria with hairs sticking out.</p>
<p>Infrared radiation was then used on the mice’s testicles. This caused the nanoparticles to warm from around 30 C to between 37 and 45 C. The exact temperature depended on both the concentration of nanoparticles injected and the intensity of the radiation.</p>
<p>The radiation caused heat lesions on the skin surrounding the mice’s testicles, so it was assumed that this procedure was painful for the animals, even though there was no reliable way to measure their pain. The researchers decided to look for other ways to inject the nanoparticles.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A hand wearing a latex glove holds a white lab mouse" src="https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439252/original/file-20220103-23-e6nw1u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Researchers used mice to test nanotechnology as a method of male birth control.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Iron rods</h2>
<p>In July 2021, Sun’s team <a href="https://doi.org/10.1021/acs.nanolett.1c02181">published a paper on their latest findings</a>. The nanorods in the new method are composed of magnetic iron oxide instead of gold, and they are coated with citric acid instead of ethylene glycol — but they have the same size and shape as the earlier nanorods.</p>
<p>These magnetic nanoparticles were injected into mice’s veins, and then the animals were anesthetized. A magnet was then placed next to their testicles for four hours, drawing the nanoparticles there.</p>
<p>This procedure — injection followed by magnetic targeting — was performed daily for one to four days.</p>
<p>After the last day of treatment, an electric coil was wrapped around the testicles, through which a current was passed. This induced a magnetic field that heated up the nanorods and, therefore, the testicles. Similar temperature increases — from a baseline of 29 C to between 37 and 42 C — were observed through this method. The more days a mouse had been injected with nanorods, the hotter its testicles became.</p>
<p>Hotter testicles led to their atrophy and shrinkage, but they showed gradual recovery both 30 and 60 days after treatment as long as testicle temperatures didn’t reach 45 C. Fertility was down seven days after treatment — in some cases, fertility was completely eliminated — but it also showed gradual (though not complete) recovery after 60 days.</p>
<p>Although fertility was not back to normal levels, there was no noticeable difference in the litter size of females impregnated by the treated mice and no morphological defects were observed in any of the mice pups. There seemed to be no difference in the sperm that did make it through.</p>
<p>And Sun and his colleagues found that, unlike the gold nanorods that stayed indefinitely in mouse testicles, the iron nanorods were gradually eliminated into the liver and spleen, and later fully eliminated from the body. This reduced the risk for long-term toxicity.</p>
<h2>Controlled breeding</h2>
<p>The cost and the irreversibility of surgical castration <a href="https://doi.org/10.1177/1098612X15594994">lead many pet owners to look for alternative methods of contraception</a>. Nanocontraception is ready to be used on household pets, says Sun, and adds that this method is already being used on cats in China. </p>
<p>Surgical castration is less popular in Europe than in North America, so nanocontraception might be of greater interest there, says David Powell, director of the Reproductive Management Center of the Association of Zoos and Aquariums in St. Louis, Mo. “There’s really not a big pet contraception market in the U.S.,” says Powell.</p>
<p>He adds that contraception is not typically used with agricultural animals like sheep and cows. “They are reared for consumption and slaughter, so the agriculture industry is not doing much, if any, research on animal contraception.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A male lion and a cub" src="https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439196/original/file-20220103-25-cxsk5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Viable contraception for animals can be a valuable tool for animal conservation and breeding programs.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>“Zoos are a very small market, and so drug companies don’t have a lot of motivation to make animal contraceptives,” says Powell. But some of them do, and the <a href="https://www.aza.org/reproductive-management-center/">Reproductive Management Center</a> collects data to evaluate how contraceptives work on different species.</p>
<p>Nanocontraception could be a part of zoos’ reproductive toolkit one day. But before this happens, says Powell, further studies would need to establish how painful it is and in which species the iron nanorods can be used. Research has indicated that some mammals — such as rhinoceroses, lemurs and dolphins — might accumulate iron, <a href="https://doi.org/10.1638/2011-0152.1">which can be toxic in larger quantities</a>.</p>
<h2>Reversible options</h2>
<p>One potential advantage of nanocontraception is its reversibility, as zoos often try to precisely time breeding events over animals’ life cycles. But just how reversible it is needs further study. All of Sun’s experiments treated mice only once; they were never subjected to a second injection of nanoparticles after their testicles had healed.</p>
<p>Sun’s ultimate goal is human contraception, although he admits that’s still a long way off. As with zoo animals, detailed studies will be required to establish that nanocontraception is not toxic for men. It is also more difficult to put a man under anesthesia for four hours and wrap an electric coil around his testicles than it is to do the same thing on a mouse. Instead, Sun hopes to be able to deliver the magnetic nanorods orally and find another way to direct them to the testicles.</p>
<p>And it is uncertain how many men will be comfortable with shrunken testicles, even if they recover their original size with time. </p>
<p>Until then, better get those condoms out.</p><img src="https://counter.theconversation.com/content/173979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey Mo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Growing applications of nanotechnology include using nanorods for male birth control. The technique has had some success in animals, and offers the potential of human male contraception.Jeffrey Mo, Global Journalism Fellow, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1736042021-12-14T18:35:24Z2021-12-14T18:35:24ZHow an independent tribunal came to rule that China is guilty of genocide against the Uyghurs<p>After 18 months of deliberations and three hearings of evidence from witnesses and experts – including anthropologists, political scientists and international lawyers – the London-based <a href="https://uyghurtribunal.com/">Uyghur Tribunal</a> has <a href="https://www.theguardian.com/world/2021/dec/09/uyghurs-subjected-to-genocide-by-china-unofficial-uk-tribunal-finds">ruled</a> that the People’s Republic of China (PRC) is guilty of crimes against humanity and genocide, by coercive birth control.</p>
<p>The Uyghur Tribunal is an independent people’s tribunal. Its <a href="https://uyghurtribunal.com/wp-content/uploads/2021/12/Uyghur-Tribunal-Summary-Judgment-9th-Dec-21.pdf">verdict</a> is not legally binding. The tribunal was chaired by the British lawyer, Geoffrey Nice, known for his role as prosecutor in <a href="https://www.icty.org/x/cases/slobodan_milosevic/tdec/en/11213JD516912.htm">the trial</a> of former Yugoslav president Slobodan Milošević for crimes against humanity.</p>
<p>The tribunal was established in June 2020, following the request of Dolkun Isa, president of the World Uyghur Congress, an advocacy group. Its purpose was to investigate crimes against humanity and <a href="https://theconversation.com/legal-expert-forced-birth-control-of-uighur-women-is-genocide-can-china-be-put-on-trial-142414">genocide</a> under international law, allegedly perpetrated by the Chinese state against <a href="https://theconversation.com/explainer-who-are-the-uyghurs-and-why-is-the-chinese-government-detaining-them-111843">Uyghurs</a>, Kazakhs and other Turkic-speaking Muslims in north-western China. </p>
<h2>Witness evidence</h2>
<p>In its investigations, the tribunal publicly requested evidence from witnesses, experts and governments. It did not judge Chinese values, citizens of the PRC, authoritarian governance, or Communist ideology. </p>
<p>Uyghurs turned to this civic forum because international courts and the Chinese legal system have no mechanisms by which Uyghur, or any minority peoples’ claims, can be heard without consent of the accused party – in this case, the PRC. </p>
<p>No government was willing to share evidence and the tribunal’s specific requests to the US, UK, and Japan were declined. This reflects how many governments’ policy decisions include trade-offs between economic interests and upholding human rights as established under international law. </p>
<p>The tribunal heard extensive <a href="https://uyghurtribunal.com/statements/">witness accounts</a> of children and families being routinely separated, women being subjected to <a href="https://jamestown.org/program/sterilizations-iuds-and-mandatory-birth-control-the-ccps-campaign-to-suppress-uyghur-birth-rates-in-xinjiang/">coercive birth controls</a>, the sexual torture of men and women and people being forced to take unknown medications.</p>
<p>One witness, Sweden-based data analyst <a href="https://edition.cnn.com/2020/12/16/china/uyghurs-silenced-abroad-intl-dst-hnk/index.html">Nyrola Elimä</a> testified to her family’s <a href="https://www.youtube.com/watch?v=7aI-wr9TtYo&ab_channel=UyghurTribunalUyghurTribunal">arbitrary detainment</a>. No official explanation was given for detainment of her cousin, <a href="https://shahit.biz/eng/viewentry.php?entryno=5417">Mahire Yaqup</a>, who, Nyrola said, looked “like skin stretched on a skeleton” when they last spoke three years ago. Echoing Uyghurs’ fears amid widespread family separations, Nyrola explained the risks she was taking by speaking publicly: “The Chinese government can take my parents”, she said, “I am scared. I can feel the threat closer and closer”. </p>
<p>Further witnesses described visceral experiences when questioned how they knew cellmates in the detainment camps were taken by guards to be gang raped after dark. <a href="https://uyghurtribunal.com/wp-content/uploads/2021/06/04-0930-JUN-21-UTFW-005-Qelbinur-Sidik-English-1.pdf">Qelbinur Sidik</a> could “hear the screams”. <a href="https://shahit.biz/eng/viewentry.php?entryno=5524">Zumret Dawut</a> could “see the guilt”, and “sense when they were taken and wouldn’t come back”. <a href="https://uyghurtribunal.com/wp-content/uploads/2021/06/04-1020-JUN-21-UTFW-018-Omir-Bekali-English.pdf">Omir Bekali</a> stopped to think, “are they human?”, while hanging upside down and tortured with thin wire. </p>
<p>The tribunal’s legal counsel verified case details using government documents and legal papers. They had to ask necessary but disconcerting questions to establish the facts. </p>
<h2>Expert evidence</h2>
<p>These testimonies correlate with evidence collected by social anthropologists on China’s <a href="https://www.penguinrandomhouse.com/books/696114/in-the-camps-by-darren-byler/">camp system</a>. They are familiar to researchers of Uyghur and Kazakh claims of <a href="https://lausan.hk/2021/camp-land/">settler-colonialism</a> and <a href="https://coremiddleeast.com/uyghur-people-in-the-concentration-camps-they-carry-out-various-types-of-torture-and-abuse/">genocide</a>. </p>
<p>China <a href="https://www.bbc.co.uk/news/uk-england-tyne-56545200">symbolically sanctioned</a> several academics and vocal politicians ahead of the tribunal’s first hearing. Nevertheless, the UK’s leading experts on the region (and myself) <a href="https://www.youtube.com/watch?v=AWCwLvUIV0g">presented</a> a co-authored <a href="https://uyghurtribunal.com/wp-content/uploads/2021/06/05-0940-JUN-21-David-Tobin-et-al-State-Violence-in-Xinjiang-English.pdf">report</a> to the tribunal, entitled State Violence in Xinjiang. </p>
<p>Our findings show that since 2017, the Chinese state has implemented planned, systematic, and co-ordinated practices of forced labour, <a href="https://www.hrw.org/news/2019/09/15/china-xinjiang-children-separated-families">child-separation</a>, coercive birth controls, <a href="https://www.hrw.org/report/2021/04/19/break-their-lineage-break-their-roots/chinas-crimes-against-humanity-targeting">sexual violence</a>, and repression of <a href="https://www.theguardian.com/world/2020/sep/25/thousands-of-xinjiang-mosques-destroyed-damaged-china-report-finds">religion</a> and culture. Together, these practices prevent intergenerational transmission of Uyghur identities. The key findings correspond with those of <a href="https://www.hrw.org/report/2021/04/19/break-their-lineage-break-their-roots/chinas-crimes-against-humanity-targeting">NGOs</a>, international <a href="https://newlinesinstitute.org/uyghurs/the-uyghur-genocide-an-examination-of-chinas-breaches-of-the-1948-genocide-convention/">thinktanks</a>, and <a href="https://barhumanrights.org.uk/bhrc-publishes-new-report-outlining-the-responsibility-of-states-under-international-law-to-uyghurs-and-other-turkic-muslims-in-xinjiang-china/">legal</a> bodies. </p>
<p>Chinese president Xi Jinping’s <a href="https://doi.org/10.1080/01419870.2021.2001556">assimilation policies</a> of “fusion” and “Sinicisation” are intended to solve what the party-state terms China’s “ethnic problem”. They have interned over <a href="https://www.chinafile.com/reporting-opinion/features/where-did-one-million-figure-detentions-xinjiangs-camps-come">one million</a> Turkic-speaking Muslims in <a href="https://atlantic-books.co.uk/book/in-the-camps/">“re-education” camps</a>, where they experience <a href="https://www.shu.ac.uk/helena-kennedy-centre-international-justice/research-and-projects/all-projects/laundered-cotton">forced labour</a> and <a href="https://www.hrw.org/report/2021/04/19/break-their-lineage-break-their-roots/chinas-crimes-against-humanity-targeting">sexual violence</a> and children are <a href="https://www.amnesty.org/en/latest/research/2021/03/the-nightmare-of-uyghur-families-separated-by-repression/">separated</a> from their parents. Outside the camps, Uyghurs live under <a href="https://www.hrw.org/report/2019/05/01/chinas-algorithms-repression/reverse-engineering-xinjiang-police-mass">hi-tech surveillance</a> and endure <a href="https://www.dpa-international.com/topic/memories-trauma-torture-follow-xinjiang-camp-survivors-urn:newsml:dpa.com:20090101:190311-99-328705">psychological trauma</a>. </p>
<p>Social anthropologists and political scientists have analysed how Uyghur history narratives are prosecuted by the Chinese state as <a href="https://www.hrichina.org/sites/default/files/PDFs/CRF.1.2004/b1_Criminalizing1.2004.pdf">terrorism</a>. Their research has shown how Uyghur language was gradually <a href="https://www.tandfonline.com/doi/abs/10.1080/02634930701517482">removed</a> from public life and religion had to be <a href="https://www.tandfonline.com/doi/abs/10.1080/14631360120017988">practised</a> in private. Uyghur <a href="https://www.cup.columbia.edu/book/the-uyghurs/9780231147583">speech</a> has been conflated with armed resistance and Uyghur identities treated as <a href="https://www.cambridge.org/core/books/securing-chinas-northwest-frontier/417E88E45DFE0D7E2800E7B94B25A019">security threats</a>. Scholars concluded these policies created <a href="https://www.etaa.org.au/wp-content/uploads/2018/06/Roberts_WorkingPaper_March2012.pdf">mass discontent</a> and exacerbated cycles of <a href="https://www.cambridge.org/core/journals/china-quarterly/article/abs/struggle-of-life-or-death-han-and-uyghur-insecurities-on-chinas-northwest-frontier/ACA97E9682101081E35CFE46518C9111">Han-Uyghur violence</a>. </p>
<h2>Genocidal processes</h2>
<p>To date, there has been limited open debate on how the genocide term applies to Uyghur experiences. The human rights scholar <a href="https://babel.hathitrust.org/cgi/pt?id=mdp.39015005077436&view=1up&seq=6">Rafael Lemkin</a> originally defined genocide in 1944 as “a coordinated plan of different actions aiming at the destruction of essential foundations of the life of national groups, with the aim of annihilating the groups themselves”. </p>
<p>In <a href="https://www.cambridge.org/core/books/confronting-evils/1BDD56BFFABFD218A011E86B11B97799">international law</a> today, genocide does not refer to the complete elimination of a group. <a href="https://digitalcommons.usf.edu/gsp/vol7/iss1/3/">Genocide theorists</a> tend to define genocide as planned <a href="https://www.cambridge.org/core/journals/hypatia/article/abs/genocide-and-social-death/E155AE3FDEB816A08D7FDD5D301FAF9C">social destruction</a>, not physical annihilation. </p>
<p>As Nice made duly clear in the tribunal’s <a href="https://www.youtube.com/watch?v=rbT_ctbEof0">detailed judgement</a> of crimes against humanity and genocide, the latter ruling was in respect of the UN Genocide Convention article 2D “imposing measures to prevent births within the group”. He noted that genocide in law remains broader than its misconception as mass killings. </p>
<p>Research interviews in Xinjiang are conducted anonymously to protect people’s safety. But since the emergence of the internment camps, Uyghurs have increasingly <a href="https://international.thenewslens.com/article/113718">spoken publicly</a> in desperation and <a href="https://www.bbc.co.uk/news/blogs-trending-47210039">in hope</a> of seeing family. As Nyrola Elimä explained to me in an interview: “While the world debates a word, we are dying”.</p>
<p>In his verdict, Nice reminded observers that universal rights are matched by personal duties. “It can never be right to look away,” he said. The judgement will vindicate Uyghurs’ and Kazakhs’ long-term experiences of state violence. </p>
<p>In response, a <a href="https://www.reuters.com/world/china/un-publish-xinjiang-findings-soon-2021-12-10/">UN spokesperson</a> noted “similarly identified patterns” and that the tribunal has “brought to light more information that is deeply disturbing”. The question now is, who will act?</p><img src="https://counter.theconversation.com/content/173604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Tobin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Governments declined to take part in the Uyghur Tribunal’s investigation. But the body of scholarly evidence for its claims, and its ruling, is thorough and extensive.David Tobin, Lecturer in East Asian Studies, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1624762021-12-02T14:21:34Z2021-12-02T14:21:34ZHow a Supreme Court decision limiting access to abortion could harm the economy and women’s well-being<figure><img src="https://images.theconversation.com/files/461289/original/file-20220504-15-r3tbzx.jpg?ixlib=rb-1.1.0&rect=137%2C73%2C6905%2C4624&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Supreme Court appears on the cusp of ending Roe v. Wade. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtAbortion/2194204e1a714554912fc438b10727d9/photo?Query=abortion&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=9770&currentItemNo=3">AP Photo/Jason DeCrow</a></span></figcaption></figure><p>A leaked draft <a href="https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473">suggests the Supreme Court</a> <a href="https://theconversation.com/abortion-right-guaranteed-by-roe-will-be-replaced-by-state-power-if-the-supreme-court-adopts-the-leaked-alito-opinion-182379">is ready to overturn Roe v. Wade</a>, the landmark case that gave women the right to terminate a pregnancy.</p>
<p>But reproductive health isn’t <a href="https://www.guttmacher.org/united-states/abortion/demographics">just about abortion</a>, despite all the attention the procedure gets. It’s also about access to family planning services, contraception, sex education and much else – all of which <a href="https://www.scientificamerican.com/article/it-rsquo-s-time-to-end-the-war-on-women-rsquo-s-health/">have also come under threat</a> in recent years. </p>
<p><a href="https://iwpr.org/wp-content/uploads/2020/07/B379_Abortion-Access_rfinal.pdf">Such access lets women control the timing</a> and size of their families so they have children when they are financially secure and emotionally ready and can finish their education and advance in the workplace. After all, <a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">having children is expensive</a>, <a href="https://www.usda.gov/media/blog/2017/01/13/cost-raising-child">typically costing almost US$15,000</a> a year for a middle-class family. For low-income working families, <a href="https://americanprogress.org/article/working-families-spending-big-money-child-care/">child care costs alone</a> can eat up over a third of earnings. </p>
<p>And that’s why providing Americans with a full range of reproductive health options is good for the economy, at the same time as being essential to the financial security of women and their families. As <a href="https://law.ubalt.edu/faculty/profiles/gilman/">a law professor who represents people experiencing poverty</a>, I believe doing the opposite threatens not only the physical health of women but their economic well-being too.</p>
<h2>The economics of contraception</h2>
<p>A <a href="https://www.oyez.org/cases/1991/91-744">Supreme Court majority acknowledged</a> as much in 1992, stating in its Planned Parenthood of Southeastern Pennsylvania v. Casey decision:</p>
<blockquote>
<p>“The ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives.”</p>
</blockquote>
<p>But in recent years, the right to control their reproductive health has become <a href="https://www.ansirh.org/research/research/novel-study-identifies-27-large-us-cities-abortion-deserts">increasingly illusory</a> for many women, particularly the poor. </p>
<p>Given their focus on limiting access to abortion, you might assume that conservative politicians would be for policies that help women avoid unintended pregnancies. But <a href="https://www.vogue.com/article/anti-birth-control-movement">conservative attacks on birth control</a> <a href="https://www.salon.com/2019/08/20/why-are-republicans-taking-away-birth-control-because-they-dont-want-women-to-have-it">are escalating</a>, even though <a href="http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">99% of sexually active women</a> of reproductive age have used <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">some form of it such as an intrauterine device, patch or pill</a> at least once.</p>
<p>In addition to its widely recognized health and autonomy benefits for women, contraception <a href="http://www.theatlantic.com/health/archive/2014/07/the-broader-benefits-of-contraception/373856">directly boosts the economy</a>. In fact, research shows access to the pill <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684076/">is responsible</a> for a third of women’s wage gains since the 1960s. </p>
<p>And this benefit <a href="https://iwpr.org/wp-content/uploads/2020/07/Contraception-fact-sheet_final.pdf">extends to their kids</a>. Children born to mothers with access to family planning <a href="http://www.nber.org/papers/w19493.pdf">benefit from a 20% to 30% increase</a> in their own incomes over their lifetimes, as well as boosting college completion rates. </p>
<p>Not surprisingly, in a 2016 survey, <a href="https://www.urban.org/urban-wire/women-want-effective-birth-control">80% of women said birth control had a positive effect</a> on their lives, including 63% reporting that it reduces stress and 56% saying it helps them to keep working. </p>
<figure class="align-center ">
<img alt="two hands hold a plastic package that's been ripped open showing a container containing many little white and green pills" src="https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not everyone has equal access to effective birth control.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TrumpBirthControl/04e57690d6e84317a1bd1698392fed3d/photo?Query=contraception&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=411&currentItemNo=9">AP Photo/Rich Pedroncelli</a></span>
</figcaption>
</figure>
<h2>Disparities in access</h2>
<p>Still, there is a class divide in contraception access, as evidenced by disparities in the 2011 rate of unintended pregnancies – the latest data available. </p>
<p>While the <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">overall rate</a> fell to 45% that year from 51% in 2008, the figure for women living at or below the poverty line, although also decreasing, was <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/FB-Unintended-Pregnancy-US.pdf">five times that of women</a> at the highest income level. </p>
<p>One reason for this disparity is the <a href="http://www.thenation.com/article/why-does-best-birth-control-cost-entire-months-wages/">cost of birth control</a>, particularly for the most effective, long-lasting forms. For instance, <a href="https://www.plannedparenthood.org/learn/birth-control/iud/how-can-i-get-an-iud">it typically costs women</a> over $1,000 for an IUD and the procedure to insert it, amounting to about <a href="http://dx.doi.org/10.1016/j.jadohealth.2013.01.012">one month’s full-time pay</a> for a minimum-wage worker lacking insurance coverage. </p>
<p>These costs are significant, given that the <a href="https://www.nytimes.com/2018/02/13/upshot/american-fertility-is-falling-short-of-what-women-want.html">average American woman will have</a> about two children and will thus need contraception for at least three decades of her life. Unfortunately, <a href="https://www.socialventurepartners.org/chicago/wp-content/uploads/sites/51/2013/04/Breaking-the-Cycle-of-Poverty-Expanding-Access-to-Family-Planning.pdf">publicly funded family planning</a> meets only 54% of the need, and these funding streams are under constant <a href="https://www.guttmacher.org/article/2020/06/seeing-whole-pattern-coordinated-federal-attacks-birth-control-coverage-and-access">attack by conservatives</a>.</p>
<p>Not surprisingly, <a href="http://www.scotusblog.com/2015/12/symposium-womens-compelling-need-for-contraception-met-by-insurers-not-objecting-employers/">health insurance makes a difference</a>, and women with coverage are much more likely to use contraceptive care. And yet about 6.2 million women <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7025a2.htm">who need contraception lack insurance coverage</a>. </p>
<p>Further, this coverage can be denied to millions of employees and their dependents who work for employers claiming a religious or moral objection <a href="https://www.supremecourt.gov/opinions/19pdf/19-431_5i36.pdf">under a Supreme Court ruling in 2020</a>. </p>
<h2>Sex education and the economic ladder</h2>
<p>Another key to reproductive health – and one that isn’t discussed enough – is sexual education for teenagers. </p>
<p>For years, the public has spent up to $110 million a year on abstinence-only programs, which not only <a href="https://doi.org/10.1016/j.jadohealth.2005.10.006">fail to reduce teen birth rates</a> but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens <a href="http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1084&context=bjalp">are particularly subject</a> to these programs.</p>
<p>Teens without knowledge about their sexual health <a href="https://www.guttmacher.org/news-release/2017/abstinence-only-until-marriage-programs-are-ineffective-and-harmful-young-people">are more likely</a> to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder. </p>
<h2>Access to abortion</h2>
<p>Then there’s the issue of abortion. Let’s start with the cost.</p>
<p><a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">Half of women who obtain an abortion</a> pay more than one-third of their monthly income for the procedure.</p>
<p>The longer a woman must wait – either because state law requires it or she needs to save up the money, or both – costs rise significantly.</p>
<p>Studies show that women <a href="http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?_r=0">who cannot access abortion</a> are <a href="https://www.law.berkeley.edu/php-programs/centers/crrj/zotero/loadfile.php?entity_key=5GDWVH35">three times as likely</a> to fall into poverty as women who obtained abortions.</p>
<p>In addition to the financial burden, <a href="https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers">many states are enacting laws</a> designed to limit abortion access. These laws hit low-income women particularly hard. Since Roe was decided, states have enacted 1,320 restrictions on abortion, including waiting periods, mandatory counseling sessions, and onerous restrictions on clinics. In 2021 alone, <a href="https://www.guttmacher.org/article/2021/07/state-policy-trends-midyear-2021-already-worst-legislative-year-ever-us-abortion">states passed 90 such laws</a>. </p>
<figure class="align-center ">
<img alt="A security guard opens the door to a brick building with a green hedge in front in Fort Worth, Texas. A sign on the wall says abortion is legal our clinic is open" src="https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In some states, abortion clinics are having a hard time staying open.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourt-Abortion/3803c31ca16044f580e5e3af65d8738c/photo?Query=abortion%20clinic&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1244&currentItemNo=113">AP Photo/LM Otero</a></span>
</figcaption>
</figure>
<h2>Hyde and health</h2>
<p>Another way in which U.S. policy on abortions <a href="https://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color">exacerbates economic inequality, especially for women of color</a>, is through the ban on federal funding.</p>
<p>It has been so since the <a href="http://billmoyers.com/content/five-facts-you-should-know-about-the-hyde-amendment/">1976 enactment of the Hyde Amendment</a>, which prevents federal Medicaid funds from being used for abortions except in cases of rape or incest, or when the life of the mother is at risk. </p>
<p>Denying poor women coverage for abortion under Medicaid contributes to the unintended birth rates that are <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">seven times as high</a> for poor women as for high-income women. </p>
<p>If Roe v. Wade is overturned by the Supreme Court – the chief justice <a href="https://www.nytimes.com/live/2022/05/03/us/roe-wade-abortion-supreme-court/leaked-draft-of-supreme-court-ruling-signals-a-seismic-shift-in-american-politics-and-law?smid=url-copy">confirmed the leaked draft’s authenticity</a> but said the decision wasn’t final – poor women would be affected the most. Women who are denied abortions <a href="https://doi.org/10.2105/AJPH.2017.304247">are more likely to end up in poverty</a>, be unemployed and turn to public assistance. </p>
<p>By contrast, economists have established that the <a href="https://www.brookings.edu/research/what-can-economic-research-tell-us-about-the-effect-of-abortion-access-on-womens-lives/">legalization of abortion</a> led to improved educational, employment and earnings outcomes for women, as well as for their children. </p>
<p>Politicians cannot promise to grow the economy and simultaneously limit access to abortion, birth control and sexual education. America’s economic health and women’s reproductive health are linked.</p>
<p><em>This article was updated on May 4, 2022, to add a reference to the leaked draft of the upcoming Supreme Court ruling. It’s a revised version of an <a href="https://theconversation.com/how-limiting-womens-access-to-birth-control-and-abortions-hurts-the-economy-57546">article originally published</a> on April 27, 2016.</em></p><img src="https://counter.theconversation.com/content/162476/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michele Gilman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In past rulings, the court has acknowledged that there’s a connection between the ability of women to control their reproductive lives and the economic health of the nation.Michele Gilman, Venable Professor of Law, University of BaltimoreLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1648442021-08-05T17:56:43Z2021-08-05T17:56:43ZCOVID-19 caused a global setback in reproductive and sexual health rights, especially for women<figure><img src="https://images.theconversation.com/files/412290/original/file-20210720-25-9qizql.jpeg?ixlib=rb-1.1.0&rect=14%2C2%2C784%2C591&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Measures to combat COVID-19 have affected sexual and reproductive health care around the globe, including maternal and newborn care, birth control and access to abortion.</span> <span class="attribution"><a class="source" href="https://www.usherbrooke.ca/medecine/faculte/cidis/projets/clefs/">Université de Sherbrooke, Centre interdisciplinaire de développement international en santé (CIDIS)</a>, <span class="license">Author provided</span></span></figcaption></figure><p>The exceptional measures governments and health authorities used during the COVID-19 pandemic, such as lockdowns, quarantine or reorganizing health services, <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS-continuity-survey-2021.1">directly affected the full realization of sexual and reproductive health and rights</a>. This was particularly the case for women and girls. These impacts are felt at many levels and require a major rethinking of international health development in order to make this issue a global priority.</p>
<h2>Access to birth control</h2>
<p>Access to birth control is one of the sexual and reproductive health issues that has been most impacted by the pandemic. According to the <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1">World Health Organization</a>, family planning and birth control have been severely disrupted during the pandemic, with seven out of 10 countries affected. </p>
<p><a href="https://www.unfpa.org/press/new-unfpa-projections-predict-calamitous-impact-womens-health-covid-19-pandemic-continues">According to the United Nations Population Fund (UNFPA)</a>, in 114 low/middle-income countries, more than 47 million women are unable to access contraceptives. With each three-month extension of the measures, up to two million more women would be unable to have access to modern birth control methods.</p>
<p>Confinement measures also <a href="https://www.guttmacher.org/print/article/2020/08/bad-worse-covid-19-pandemic-risks-further-undermining-adolescents-sexual-and">disrupted contraceptive supply chains and the ability to access health facilities</a>. Because of the focus on essential supplies to combat COVID-19, sexual and reproductive health-related products <a href="https://doi.org/10.1080/13625187.2020.1777398">became inaccessible or out of stock</a>, directly impeding sexual and reproductive health and rights for millions of women and girls. </p>
<figure class="align-center ">
<img alt="Infographic with two statistics: 650,000 additional unintended pregnancies in India, and 3.5 million additional unintended pregnancies in South Asia" src="https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=99&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=99&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=99&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=124&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=124&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=124&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19; UNICEF: Direct and indirect effects of the COVID-19 pandemic and response in South Asia.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Access to sexual health services</h2>
<p>The impacts of COVID-19 are also felt on access to sexual and reproductive health services, including on prenatal care, maternal and newborn health services, care related to sexually transmitted infections or sexual health counselling. In the United States, <a href="https://www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-2020-guttmacher-survey-reproductive-health#figure2">one in three women</a> reported having to delay or cancel a visit to a sexual and reproductive health provider, or had difficulty obtaining birth control. Closures of sexual and reproductive health clinics placed a disproportionate burden on women and girls with sexual and reproductive health needs. </p>
<p>School closures (a measure widely implemented globally) have also led to <a href="https://resourcecentre.savethechildren.net/node/18201/pdf/global_girlhood_report_2020_africa_version_2.pdf">reduced access to information and sexuality education, mostly for girls</a>. Not returning to school exposed these girls to lack of information and resources, high-risk teenage pregnancy and death (as Save the Children reports that <a href="https://doi.org/10.1016/S0140-6736(20)32112-7">childbirth is the leading cause of death globally for girls aged 15-19</a>).</p>
<p>Even modest barriers to sexual and reproductive health services can have major health effects. For example, the consequences of a 10-per-cent drop in pregnancy-related health coverage can be <a href="https://www.guttmacher.org/journals/ipsrh/2020/04/estimates-potential-impact-covid-19-pandemic-sexual-and-reproductive-health">disastrous for women and newborns</a>: 1.7 million women who give birth and 2.6 million newborns will suffer serious complications and not receive needed care.</p>
<h2>Access to abortion</h2>
<p>During the pandemic, access to abortion was declared in many states and health jurisdictions a “<a href="http://doi.org/10.1056/NEJMp2008006">non-essential” service</a>, hindering access for millions of women and girls. In May 2020, <a href="https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=25907&LangID=E">the Office of the United Nations High Commissioner for Human Rights</a> reported that some U.S. states were using the COVID-19 emergency situation to restrict access to abortion. In Italy, health <a href="https://www.hrw.org/news/2020/07/30/italy-covid-19-exacerbates-obstacles-legal-abortion">facilities have also suspended abortion-related services</a> or reassigned gynecological staff to anti-COVID-19 care, exacerbating barriers to legal abortion.</p>
<figure class="align-center ">
<img alt="Infographic with four statistics: 1 million unsafe abortions in India, 14-52% increase in maternal deaths in South Asia, 200% increase in maternal deaths in Nepal, 2,600 excess maternal deaths in India" src="https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=213&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=213&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=213&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=268&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=268&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=268&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19; Ipas: COVID-19 restrictions compromised abortion access for 1.85 M women in India; The Kathmandu Post 5/27/2020: a 200 per cent increase in maternal mortality since the lockdown began; Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Increase in gender-based violence</h2>
<p><a href="https://www.guttmacher.org/article/2020/08/bad-worse-covid-19-pandemic-risks-further-undermining-adolescents-sexual-and">Violence has also been exacerbated by the health crisis</a>, leading to an increase in gender-based violence threatening well-being and health. <a href="https://www.unfpa.org/fr/press/les-nouvelles-projections-de-lunfpa-pr%C3%A9voient-des-r%C3%A9percussions-d%C3%A9sastreuses-sur-la-sant%C3%A9-des">The UNFPA</a> has estimated, for example, that a six-month lockdown results in 31 million additional cases of gender-based violence. An additional 15 million cases would be added for each three-month extension.</p>
<p>Children are particularly impacted. <a href="https://www.wvi.org/sites/default/files/2020-05/Aftershocks%20FINAL%20VERSION_0.pdf">Save the Children</a> estimated in May 2020 that in the three months following their implementation, the stay-at-home guidelines resulted in a 20 per cent to 32 per cent increase in physical, sexual and emotional abuse of children. This means 85 million more girls and boys affected worldwide only for June, July and August 2020.</p>
<figure class="align-center ">
<img alt="Infographic with two statistics: 30-33% increase in domestic violence, 50% increase in gender-based violence" src="https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=98&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=98&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=98&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=123&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=123&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=123&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: UN Policy Brief: The Impact of COVID-19 on Women; African Union (CUAWGDD): La violence basée sur le genre en Afrique durant la pandémie de COVID-19.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Recommendations</h2>
<p>Progress on sexual and reproductive health and rights is a long-term endeavour that cannot afford to pause, even in a pandemic.</p>
<p>Millions of women and girls are affected globally — more than those affected by COVID-19. According to the <a href="https://www.guttmacher.org/fact-sheet/investing-sexual-and-reproductive-health-low-and-middle-income-countries">Guttmacher Institute</a>, there were for example, in 2020, 218 million women with unmet need for modern birth control method, 111 million unintended pregnancies, 30 million unplanned births and 35 million unsafe abortions, and this is only for low- and middle-income countries, compared to <a href="https://www.who.int/publications/m/item/weekly-epidemiological-update---29-december-2020">around 80 million cases of COVID-19 globally in 2020</a>. </p>
<p>The international community must mobilize with the same force as it did for the current pandemic. Sexual and reproductive health and rights must become a global priority.</p>
<p>To do so, we must:</p>
<ol>
<li><p>Establish a guaranteed base of sexual and reproductive health services that cannot be suspended, even in the event of a major crisis. This would help ensure a minimum supply of services, with continued funding, so that hard-won gains in sexual and reproductive health and rights are not lost.</p></li>
<li><p>Implement a gender and intersectional analysis for all health policies to assess short-, medium- and long-term effects in order to be sure that the negative impact of other health emergencies does not outweigh the expected policy benefits.</p></li>
<li><p>Continue to invest in international health development projects and ensure a significant budget to support the continuity of services despite other health emergencies and crises such as COVID-19.</p></li>
<li><p>Establish a specialization within the police and security services on gender-based violence so that people, especially women, can obtain support and protection without delay, even during emergency situations.</p></li>
</ol>
<p>The impact of the COVID-19 pandemic on the achievement of sexual and reproductive health and rights are multidimensional, direct and indirect, unevenly distributed internationally, and felt around the world. These impacts interact and intersect with other gender and/or economic and social inequalities that existed before the pandemic, adding to the complexity of the issue and the difficulties of responding adequately. The international community must make this a priority.</p><img src="https://counter.theconversation.com/content/164844/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>François Couturier receives funding from Global Affairs Canada. </span></em></p><p class="fine-print"><em><span><a href="mailto:michele.nicole.rietmann@usherbrooke.ca">michele.nicole.rietmann@usherbrooke.ca</a> receives funding from Global Affairs Canada (GAC). </span></em></p><p class="fine-print"><em><span><a href="mailto:sarah.stecko@usherbrooke.ca">sarah.stecko@usherbrooke.ca</a> receives funding from Global Affairs Canada - GAC. </span></em></p><p class="fine-print"><em><span>Gabriel Blouin-Genest, Natalia Torres Orozco, and Rosalie Émond-Tremblay do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The exceptional measures deployed around the world during the COVID-19 pandemic have impeded access to urgent services like birth control, abortion and maternal and newborn care.Gabriel Blouin-Genest, Associate professor, School of applied politics, University of Sherbrooke. Scientific codirector, CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke François Couturier, Professor, Scientific codirector, CIDIS (Centre interdisciplinaire de développement international en santé., Université de Sherbrooke Michèle Rietmann, Project manager and research professional, CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke Natalia Torres Orozco, Research Professional | LL.M, Applied International Law and Politics, Université de Sherbrooke Rosalie Émond-Tremblay, Auxiliaire de recherches, Université de Sherbrooke Sarah Stecko, Director of operations and partnerships - CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1641952021-07-14T15:03:20Z2021-07-14T15:03:20ZBirth control continues to fail women – so why has nothing changed?<figure><img src="https://images.theconversation.com/files/411195/original/file-20210714-25-1s4vtc6.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5607%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unpleasant side effects from contraceptives are experienced by many women.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gynecology-consultation-181677890">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>The hunt for a “<a href="https://sitn.hms.harvard.edu/flash/2021/a-potential-male-oral-birth-control-pill-may-be-on-the-horizon/">male birth control pill</a>” is a topic that often grabs attention. But so far no products have been licensed for use, either because they haven’t been effective enough, or because of <a href="https://www.newscientist.com/article/2110729-male-contraceptive-injection-works-but-side-effects-halt-trial/">negative side effects</a> – including depression, mood disorders and acne – that halted trials.</p>
<p>Current contraceptive options for men are <a href="https://pubmed.ncbi.nlm.nih.gov/10785217/">limited</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254803/">not always effective</a> – so it’s no wonder research continues in this area. But, while this is important, it’s critical that this isn’t at the expense of improving contraceptives currently available for women.</p>
<p>Since the female birth control pill first <a href="https://www.theguardian.com/society/2007/sep/12/health.medicineandhealth">became available</a> in the 1960s, it has allowed many to control their own fertility and manage conditions such as dysmenorrhoea (painful periods), non-menstrual pelvic pain and heavy menstrual bleeding. </p>
<p>But despite these benefits, birth control options are still failing women. This is largely because of the <a href="https://www.bbc.com/future/article/20180823-women-speak-about-side-effects-of-the-birth-control-pill">unpleasant side effects</a> many people experience when using them – which in some cases severely <a href="https://www.fertstert.org/article/S0015-0282(17)30247-9/fulltext">decreases quality of life</a>.</p>
<p>Women often have to put up with side effects when using contraceptives, such as irregular bleeding, bloating and headaches. In some cases, these side effects are more serious, and may include high blood pressure, <a href="https://www.bmj.com/content/373/bmj.n1159/rr-4">blood clots</a> and stroke. Research has also found a link between the pill and increased <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">risk of depression</a>, as well as <a href="https://pubmed.ncbi.nlm.nih.gov/16913282/">decreased sexual desire and libido</a>. </p>
<p><a href="https://apps.who.int/iris/handle/10665/75429">Side effects</a> are the reason around one-third of women stop their contraception in the first year of use. Perhaps as a result, use of the contraceptive pill in the UK <a href="https://digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2018-19">decreased from 45% in 2015 to 39% in 2019</a>.</p>
<p>It isn’t just the pill that needs improvement. Long-acting reversible contraceptives – such as inter-uterine devices (IUDs) and contraceptive implants – are used by around <a href="https://pubmed.ncbi.nlm.nih.gov/29972356/">12% of women</a> in the UK, but also come with their own side effects and disadvantages. </p>
<p>Like the pill, hormonal IUDs (a small device that is placed in the uterus, where it releases hormones) can <a href="https://pubmed.ncbi.nlm.nih.gov/24695563/">cause side effects</a> such as irregular or missing periods, headaches, nausea, hair loss, depression, and decreased libido. Even <a href="https://pubmed.ncbi.nlm.nih.gov/19341847/">non-hormonal IUDs</a> (such as the copper IUD) can cause heavier periods, longer menstrual cycles and increased pain – causing many women to have them removed early. Many women also report experiencing <a href="https://www.bbc.co.uk/news/health-57551641">painful IUD fittings</a> – often <a href="https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/intrauterine-contaception/">without the use</a> of local anaesthetic gels. </p>
<figure class="align-center ">
<img alt="An intrauterine device." src="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Both hormonal and non-hormonal IUDs can cause side effects.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/iud-174193595">Image Point Fr/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Finding a contraceptive method that works usually involves a lot of <a href="https://sexualhealthdorset.org/contraception">trial and error</a>. This is partly because clinicians don’t have access to large-scale and detailed data which could help them predict which method will work best for different people. The presence of side effects and their severity differs between women, depending on their sensitivity to hormonal changes – and <a href="https://www.sciencedaily.com/releases/2020/05/200512134532.htm">potentially because of genetics</a>.</p>
<h2>Need for improvement</h2>
<p>There’s a clear need for large-scale clinical trials into new and existing forms of birth control. Yet despite this, little investment is actually put into making this happen, and priority tends to be given to other areas of research. For example, between 2017 and 2020, there were only 23 <a href="https://clinicaltrials.gov/ct2/results?cond=contraception&strd_s=01%2F01%2F2017&strd_e=07%2F12%2F2020&recrs=b&recrs=a&recrs=f&recrs=d&recrs=g&recrs=h&recrs=e&recrs=i&age_v=&age=1&gndr=Female&type=&rslt=&phase=4&phase=0&phase=1&phase=2&phase=3&fund=2&Search=Apply">industry-funded clinical trials</a> into contraceptives, compared to <a href="https://pharmaintelligence.informa.com/resources/product-content/clinical-trials-2019-roundup">600 for cardiovascular drugs and 140 for treatment relating to eye disorders</a>. </p>
<p>Most shockingly, only 2% of the revenue made by pharmaceutical companies selling contraception goes back into <a href="https://www.bloomberg.com/news/articles/2019-08-08/better-birth-control-exists-but-big-pharma-isn-t-interested">research and development</a>. Even when methods are improved or refined, they’re often <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3136-4">not available worldwide</a> due to local regulations and health systems. </p>
<p>Access to preferred contraception in the UK (such as specific brands) is also largely dependent on commissioning systems (which assesses needs, and plan purchasing and monitoring of health services in the NHS) and contraceptive budgets – which were <a href="https://www.theguardian.com/society/2020/sep/10/women-in-uk-struggling-to-access-contraception-as-result-of-underfunding">cut by 13%</a> between 2015 and 2018. </p>
<p>Such budget cuts may mean a person has to switch from a brand they’re happy with to one that doesn’t work as well for them. And though the UK has now allowed <a href="https://www.gov.uk/government/news/first-progesterone-only-contraceptive-pills-to-be-available-to-purchase-from-pharmacies">progesterone-only pills</a> to be bought over the counter without a prescription, women still have limited ways to access birth control – and the costs associated with it may be too much for some.</p>
<p>Alongside these issues of access is a continued lack of research and development into women’s contraceptives for a variety of different reasons. For one, there’s little incentive to improve them, as it has already been proved that they prevent pregnancy. In addition, funding bodies are often interested in areas of research that affect all people – not just women – so funding will be prioritised to them. Many women will also continue using birth control despite side effects because they don’t want to get pregnant – so many developers may not see improving formulations as necessary. </p>
<p>Although there’s a clear need to develop better male contraceptives, much still needs to be done to address the inequalities women currently experience when it comes to sexual and reproductive health. The <a href="https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/womens-health-strategy-call-for-evidence">Women’s Health Strategy</a> has recently sought to collect views on women’s health to ensure that women’s voices are at the centre of new health agendas – which will hopefully help inform policies, strategies and healthcare. There are also numerous trials ongoing seeking to <a href="https://www.nature.com/articles/d41586-020-03532-6">improve contraceptive options</a> for women.</p>
<p>But it isn’t solely up to pharmaceutical companies to bring about changes – it will be up to regulators to listen to women when assessing the effectiveness of new contraceptive methods, and clinicians, to listen to patients’ concerns and questions.</p><img src="https://counter.theconversation.com/content/164195/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bethan Swift receives funding from Mustafa Bahceci (Bahceci Health Group, Istanbul, Turkey) for her Doctor of Philosophy at the University of Oxford (2019-2022).</span></em></p><p class="fine-print"><em><span>Christian Becker currently receives research funding from the European Comission and Bayer Healthcare. Both are not related to this article.</span></em></p>Despite side effects, women continue to take contraceptives because there are no better options available.Bethan Swift, PhD candidate in Women's and Reproductive Health, University of OxfordChristian Becker, Associate Professor, Nuffield Department of Obstetrics and Gynaecology,, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1544002021-02-03T14:21:34Z2021-02-03T14:21:34ZGrey squirrels: is birth control the solution to Britain’s invasive species problem?<figure><img src="https://images.theconversation.com/files/382224/original/file-20210203-21-kb8tu8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4020%2C2832&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/grey-squirrel-feeding-on-chestnuts-autumn-118390966">Scooperdigital/Shutterstock</a></span></figcaption></figure><p>There are thought to be 2.7 million grey squirrels in the UK, versus only 287,000 <a href="http://publications.naturalengland.org.uk/publication/5636785878597632">red squirrels</a>. The invasive greys, brought to Britain and Ireland from North America in the 1870s, are blamed for the disappearance of the native red throughout much of England and Wales, due to the squirrel pox virus they transmit and the fact that they compete for food and habitat with their smaller relatives.</p>
<p>As with the UK’s other invasive species, such as rabbits, signal crayfish and Japanese knotweed, introducing the grey squirrel has proved to be an expensive mistake. Not only do grey squirrels displace red squirrels, they strip bark from trees. <a href="https://rfs.org.uk/news/2020/1-2021/grey-squirrels-threatening-our-woodlands-to-tune-of-11bn/">A recent report</a> estimated that this could cost commercial forestry and native woodlands £1.1 billion (US$1.5 billion) over the next 40 years, including revenue lost to damaged timber, reduced carbon storage, tree replacement costs and squirrel control.</p>
<p>Despite efforts to kill grey squirrels over several decades, their populations remain large and widespread. So could <a href="https://www.bbc.co.uk/news/science-environment-55817385">government-backed plans</a> for using oral contraceptives to control their breeding be the turning point?</p>
<h2>Squirrel birth control</h2>
<p>Before we consider that question, let’s interrogate the idea that grey squirrels are bad for the environment because they damage trees. If we’re worried about carbon in the atmosphere then phasing out fossil fuels, not killing squirrels, is the top priority. And squirrels, even non-native greys, play an important role in woodlands by <a href="https://www.frontiersin.org/articles/10.3389/fevo.2020.00259/full">burying the nuts they find</a> and seeding new trees. If grey squirrels were to vanish overnight, then the natural regeneration of UK woodlands would probably slow.</p>
<p>Whether or not the damage caused by this invasive species is exaggerated, these reports inevitably encourage calls for bigger <a href="https://www.telegraph.co.uk/news/2021/01/21/royal-forestry-society-urges-grey-squirrel-cull-wake-1bn-woodland/">culls of grey squirrels</a>. Oral contraceptives might at least be a more humane alternative to live trapping and bludgeoning the animals to death.</p>
<p>Birth control has worked for keeping wildlife populations elsewhere in check. The method, which often involves injecting contraceptives, has proved successful in more than 85 species, including wild horses and elephants, according to <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0897.2011.01003.x">a 2011 review</a>. Contraceptives halved dense and destructive populations of North American <a href="https://pdfs.semanticscholar.org/7383/a4c2227392c16c8c6269fd3e91fa65c728a4.pdf?_ga=2.143665589.1480929846.1612138237-212678758.1612138237">white-tailed deer</a> in under 10 years.</p>
<p>Research into using oral contraceptives on grey squirrels in the UK has been ongoing for <a href="https://squirrelaccord.uk/squirrels/fertility_control/">several years</a>, and recent results show promise. Trials using feeders that only grey squirrels can access, baited with hazelnut spread laced with an <a href="https://www.humanesociety.org/resources/questions-and-answers-about-immunocontraception">immunocontraceptive</a> (a drug which tricks the body’s immune system into producing antibodies that interfere with reproduction, by blocking the sperm receptor sites on eggs, for example) indicate that <a href="https://squirrelaccord.uk/news/blog/fertility-research-news-from-the-field/">around 90%</a> of a local population can be treated using this method. Researchers hope this could induce infertility to such an extent that treated populations shrink substantially over time.</p>
<p>Contraceptives have their own <a href="https://conbio.onlinelibrary.wiley.com/doi/full/10.1111/csp2.171">ethical concerns</a> though. Being alive isn’t necessarily always better than being dead. We don’t really know what physiological and psychological effects an inability to breed will have on the welfare of grey squirrels.</p>
<p>It’s also important that this contraceptive doesn’t affect other species, though there are measures to ensure this. Bespoke feeding boxes that only grey squirrels can enter limit the risk to other species, in particular red squirrels, by weighting the door of the feeder so that the smaller red <a href="https://squirrelaccord.uk/news/blog/fertility-research-news-from-the-field/">cannot enter</a>. Providing the bait in a hazelnut spread, rather than nuts which squirrels may bury, prevents other animals inadvertently finding and eating the contraceptive. But what about predators? Will their fertility be threatened by eating prey dosed with contraceptives?</p>
<h2>The alternatives</h2>
<p>There are other ways to control grey squirrel populations, such as <a href="https://thebiologist.rsb.org.uk/biologist/158-biologist/features/2245-accelerating-evolution">gene drives</a>. These are altered genes that can be implanted in males and programmed to induce infertility in the genome of their female offspring. Female infertility spreads through the population as the gene drive is carried and inherited by males. Gene drives don’t carry the same risk of cross-contamination between species that contraceptives do, and they are cheaper and easier to implement.</p>
<p>But they still have a long way to go before they’re approved as a control method, as scientists worry that a gene drive could spread from invasive to native populations. Imagine a grey squirrel in the UK that had been treated with a gene drive somehow made it back into their native range in North America – it could mean their extinction.</p>
<p>Perhaps the most popular solution to the grey problem is the pine marten, a predatory mammal that is slightly larger than a ferret. Almost hunted to extinction in the UK, pine martens have made a comeback in recent years. <a href="https://royalsocietypublishing.org/doi/pdf/10.1098/rspb.2017.2603">Research suggests</a> that where martens return to woodland they reduce grey squirrel populations, while boosting the number of red squirrels. But pine martens aren’t going to colonise the entire country – and they are still predators which eat other wildlife and some domestic animals. Their return is likely to face <a href="https://www.scotlandbigpicture.com/rewilding-stories/the-return-of-the-taghan">resistance in some places</a>.</p>
<figure class="align-center ">
<img alt="A weasel-like mammal hugging a river bank to sip the water." src="https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pine martens are thought to hunt grey squirrels more readily than reds.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pine-marten-drinking-lake-forest-1798450855">Beata Farkas/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://reader.elsevier.com/reader/sd/pii/S0304380020304506?token=65D4E8A4AD5ED08A53E7A0359A31A65414B15AB18285A97E020D0CB976E7BF1A903F54EFACC860BFCCAEFAB5F95054B7">A recent study</a> suggested the most efficient way to control grey squirrels is a combination of culling and contraceptives. So no matter how effective an oral contraceptive is, culls are likely to continue. Animal welfare campaigners are <a href="https://petition.parliament.uk/petitions/562294">lobbying the government</a> to at least halt culls during the breeding season, when female grey squirrels have kits in the nest. As it stands, mothers can be killed and their offspring left to starve.</p>
<p>I’ve written <a href="https://theconversation.com/in-defence-of-the-grey-squirrel-britains-most-unpopular-invader-73983">in defence of grey squirrels</a> before, but I support controlling their populations with contraceptives. While I’d prefer nature to provide its own solution, I welcome methods of controlling so-called pest species that minimise pain and stress. Just because a species causes damage doesn’t mean that we can’t manage them with consideration for ethics and welfare.</p><img src="https://counter.theconversation.com/content/154400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Gilchrist does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Squirrel feeders laced with contraceptives could be used to suppress grey squirrels in the UK.Jason Gilchrist, Ecologist, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1334152020-08-18T19:46:17Z2020-08-18T19:46:17ZCondoms are the best defence against rising sexually transmitted infections<figure><img src="https://images.theconversation.com/files/353488/original/file-20200818-16-1v7faxy.jpg?ixlib=rb-1.1.0&rect=0%2C1056%2C6709%2C3410&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clear and accurate information about condoms and sexually transmitted infections is one of the best tools to avoid sexual health risks.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Rates of sexually transmitted infections in Canada have increased dramatically over the past decade, despite earlier public health and sexuality education interventions that reduced the rate of sexually transmitted infections (STI). Between 2008 and 2017, the rates of <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/report-sexually-transmitted-infections-canada-2017.html#f23">chlamydia increased 39 per cent, gonorrhea 109 per cent and infectious syphilis 167 per cent, according to the Public Health Agency of Canada</a>. </p>
<p>A variety of factors has contributed to the increase, such as changing societal and cultural norms, barriers to accessing condoms and changes in diagnostic and screening practices. </p>
<p>Although PHAC tracks STIs, it doesn’t track the most important tool we have in preventing the spread of STIs: condom use. Instead, occasional government surveys and university-based research fill the gaps. People may not be using condoms at the same rate as before, but it is difficult to know for sure because there is a lack of data. </p>
<p>As sociologists of sexualities, we collected data on condom use as a part of a larger, first-of-its-kind study on sex and sexuality in Canada. Our findings show that about <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228981">one-third of adult Canadians who engaged in penile-vaginal intercourse during their sexual encounters used condoms</a>. One survey can’t track changes over time, but it can be an important piece of the puzzle of understanding who uses condoms, in what types of sexual encounters they are used, and why. </p>
<h2>Sex in Canada study</h2>
<p>Younger adults use condoms more often than older Canadians, even when accounting for other demographic characteristics: 42 per cent of 19- to 29-year-olds used condoms in their most recent sexual encounters, compared to 31 per cent of 30- to 49-year-olds and 19 per cent of 50- to 64-year-olds. Seniors (65 and older) were the least likely to use condoms: 11 per cent.</p>
<p><a href="https://theconversation.com/older-people-still-have-sex-but-its-the-intimacy-and-affection-that-matters-more-70196">Seniors are often thought of as non-sexual</a>, but they continue to be sexually active. They may not, however, <a href="https://theconversation.com/think-teens-need-the-sex-talk-older-adults-may-need-it-even-more-103815">have access to the information about condoms and safer sex that young people have in school</a>. Older adults should use condoms to protect themselves from STIs, but not enough research, resources or public policy initiatives are encouraging safer-sex practices within this group.</p>
<p>We find that condom use is also higher (31 per cent) among those with university degrees compared those without (22 per cent). These institutions may be offering effective sexual health education and initiatives, such as providing free and easy access to condoms, which may lead to increased condom use among graduates.</p>
<p>Our results also suggest that when people use other forms of birth control, condom use decreases. This may be because pregnancy prevention is a greater concern for Canadians than avoiding STIs, or that sex education does not focus sufficiently on STI prevention. </p>
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Read more:
<a href="https://theconversation.com/fun-sex-is-healthy-sex-why-isnt-that-on-the-curriculum-81020">Fun sex is healthy sex: Why isn't that on the curriculum?</a>
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<p>Last, we find that informal and formal sexual health education is associated with increased condom use. This includes men who learn about condoms formally, such as through school-based sex education, or informally, such as through friends or the internet. Women’s increased condom use was only associated with formal sex education during middle and high school. Without formal sex education that covers condom use, women may be more at risk of STIs.</p>
<p><a href="http://educ.queensu.ca/sites/webpublish.queensu.ca.educwww/files/files/Research/SPEG/SPEG%20Canadian%20Youth%2C%20Sexual%20Health%20and%20HIV.pdf">Sex education advocates and public health experts consistently report</a> that clear and accurate information about condoms and sexually transmitted infections is one of the best tools to avoid sexual health risks. Our findings give credence to those experts who have advocated for increased sex education curriculum in schools. </p>
<h2>More data needed</h2>
<p>Keeping sexually transmitted infection rates low is an important public health goal. For example, PHAC recently launched a <a href="https://www.canada.ca/en/public-health/services/reports-publications/accelerating-our-response-five-year-action-plan-sexually-transmitted-blood-borne-infections.html">five-year action plan</a> to monitor sexually transmitted and blood-borne illnesses. Although condom use cannot prevent the transmission of STI’s in all types of sexual encounters, they are an important prevention tool. Our study focused on penile-vaginal sex, but <a href="https://www.healthline.com/health/lgbtqia-safe-sex-guide#Overview">many other groups, sexual pairings and sexual activities would benefit from using condoms</a>.</p>
<p>Even though condom use is a key part of the plan to reduce STI transmission, measuring it has not been. We should know whether Canadians’ use of condoms is increasing or decreasing over time, and the best way to get that data is to include questions on condom use every year on annual surveys like the <a href="https://www.canada.ca/en/health-canada/services/food-nutrition/food-nutrition-surveillance/health-nutrition-surveys/canadian-community-health-survey-cchs.html">Canadian Community Health Survey</a>.</p>
<p>Our research also emphasizes the need for more data on people’s attitudes about condoms, their knowledge of proper condom use and the conditions that promote or inhibit the use of condoms. Future research should assess the implications of sex education curricula on young adults’ use of and perspectives about condoms, access to ongoing sexual health education and age-specific resources, and gendered attitudes and beliefs about negotiating condom use during partnered sex between men and women.</p><img src="https://counter.theconversation.com/content/133415/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was supported by Social Sciences and Humanities Research Council of Canada Insight Grant 435-2017-0369: Tina Fetner (PI), Michelle Dion (co-I) and Melanie Heath (co-I).
</span></em></p><p class="fine-print"><em><span>Nicole Andrejek does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People may not be using condoms at the same rate as before, but it is difficult to know for sure because there is a lack of data.Nicole Andrejek, Research Assistant, Sociology, McMaster UniversityTina Fetner, Associate Professor, Sociology, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1396582020-05-31T11:57:50Z2020-05-31T11:57:50ZNexplanon, a 3-year birth control implant, is now approved for use in Canada<figure><img src="https://images.theconversation.com/files/338479/original/file-20200529-51509-1o7momt.jpg?ixlib=rb-1.1.0&rect=48%2C96%2C4537%2C3334&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The matchstick-size implant is shown here with an insertion device.</span> <span class="attribution"><span class="source">Unsplash</span></span></figcaption></figure><p>Already available in over 100 countries, <a href="https://www.flare.com/health/nexplanon-birth-control-implant-canada/">Nexplanon is now finally approved for use in Canada</a>. Nexplanon is a contraceptive implant: a small rod, inserted into the upper arm through a tiny incision, that prevents pregnancy for up to three years. </p>
<p>It works by releasing a very low continuous dose of a synthetic progesterone. The contraceptive implant offers an important and <a href="https://ojs.lib.uwo.ca/index.php/uwomj/article/view/1949/1253">overdue addition to contraception options for patients in Canada</a>. </p>
<p>Nexplanon’s long-awaited arrival could not be more opportune, as <a href="https://www.thestar.com/news/canada/2020/04/02/limited-sexual-health-services-during-coronavirus-crisis-could-lead-to-unplanned-pregnancies-advocates-say.html">COVID-19 has demonstrated</a> just how much patients need flexibility and choices to meet the essential need for access to contraception.</p>
<h2>Long-acting reversible contraception</h2>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338487/original/file-20200529-51516-1gpakr7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nexplanon is a small rod-shaped implant that is effective for three years.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<p>Up until now, <a href="https://www.healthlinkbc.ca/health-topics/tw9516">hormonal or copper intrauterine devices</a> (IUDs) were the only truly long-acting reversible contraception (LARC) available in Canada. </p>
<p>An IUD is a small T-shaped object inserted through the cervix into the uterus. Hormonal IUDs also work by slowly releasing synthetic progesterone. Both the IUD and Nexplanon are highly effective at pregnancy prevention when in place, and the potential to become pregnant resumes immediately when they are removed.</p>
<p><a href="https://doi.org/10.1016/j.ajog.2016.08.033">Patients may prefer LARC over other types of contraceptives</a> because life, school, work and other factors make daily or weekly options untenable at the best of times. Irregular work schedules can be incompatible with taking a pill every day at the same time. Seasonal employment and jobs away from home can limit physical and financial ability to seek prescription renewals. And contraceptives taken frequently are more difficult to hide from controlling sexual partners or disapproving parents. </p>
<h2>LARC benefits</h2>
<p>For some patients it is simply too hard to remember daily pills or weekly patches — the pandemic has demonstrated just how difficult some circumstances can make it to maintain a regular schedule. LARC offers three or more years of uninterrupted, effective pregnancy prevention.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338488/original/file-20200529-51449-8r3053.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Until the approval of Nexplanon, IUDs were the only long-acting reversible contraceptives available in Canada.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<p>The contraceptive implant also offers an alternative to a device that is inserted vaginally. Some patients have <a href="https://doi.org/10.1080/13625187.2019.1610872">concerns or anxiety</a> about the potential for pain during the IUD insertion process. </p>
<p><a href="https://www.health.harvard.edu/blog/when-a-pelvic-exam-is-traumatic-2019012915863">Pelvic exams may be triggering for survivors of sexual assault</a>. Some patients may be uncomfortable with the idea of having the IUD remain in place in their uterus. For these patients, Nexplanon provides an alternative.</p>
<h2>Timely and effective</h2>
<p>Nexplanon also provides an effective and timely long-term contraceptive option following an abortion. One of the optimal times to place an IUD is at the end of a surgical abortion procedure, when the cervix is dilated, medications have been provided to reduce anxiety and pain, and an IUD is easily inserted. However, this only works for patients seeking surgical abortion. </p>
<p>In 2017, <a href="https://nationalpost.com/news/canada/mifegymiso">Mifegymiso, the abortion pill, became widely available in Canada</a> as a method to induce abortion at home. Since then, an increasing proportion of patients are <a href="https://doi.org/10.1016/j.jogc.2019.01.009">choosing medical abortion (an abortion using medication) over surgical abortion</a>.</p>
<p>Patients who choose medical abortion and want an IUD need to return to clinic for the insertion after their abortion at home is complete. This results in a delay and the need to book a subsequent appointment. The wait increases their <a href="https://doi.org/10.1016/j.contraception.2010.10.006">risk of unplanned pregnancy</a>. </p>
<p>These patients may not ever get their chosen contraception, as many barriers impede following through with that followup visit. This is especially true in Canada, where <a href="https://www.actioncanadashr.org/news/2019-09-19-2019-launch-access-glance-identifies-realities-abortion-access-canada">rural and urban access to abortion</a> and reproductive health services remains decidedly unequal. <a href="https://thetyee.ca/News/2020/04/25/Pandemic-Abortion-Access/">During COVID-19, reproductive health patients have faced reduced service availability</a>, limited clinic hours, and a shift towards provision of care by phone. Nexplanon, however, could be inserted in the arm when the patient comes in for a prescription for medical abortion pills.</p>
<h2>Contraception costs</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338483/original/file-20200529-51516-1ua6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nexplanon is about the size of a matchstick and is implanted in the upper arm.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>We do not yet know how the cost of Nexplanon will compare to the IUD or other contraceptive options. Ideally, Nexplanon — and all contraception — <a href="https://www.cps.ca/en/documents/position/universal-access-to-no-cost-contraception-for-youth-in-canada">should be covered by provincial health insurance</a>. Such coverage would prevent the high costs — individual and system, direct and indirect — of accidental pregnancies. </p>
<p>One of the greatest <a href="https://www.doi.org/10.9778/cmajo.20190087">barriers to effective contraception use is cost</a> to the patient. Yet both surgical and medical abortion is almost universally covered in every province and territory in Canada. The arrival of the contraceptive implant is an opportunity for provinces and territories to step up and assume responsibility for making reproductive health options like LARCs financially accessible to all.</p>
<p>Nexplanon, like IUDs, will not prevent sexually transmitted infections (STIs). Barrier methods such as condoms remain necessary to prevent infection. Perhaps our enthusiastic embrace of infection prevention information and practices during COVID-19 will extend to understanding STIs, destigmatizing testing and encouraging effective prevention.</p>
<p>Like any medication, the contraceptive implant has side-effects and contraindications, and will not be suitable for everyone. All contraception, especially newly-introduced and long-acting options like Nexplanon, should be offered only with patients’ full and <a href="https://doi.org/10.1016/j.jogc.2020.02.007">informed consent</a>.</p><img src="https://counter.theconversation.com/content/139658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>As a doctoral candidate in Nursing, Martha Paynter receives funding from the Pierre Elliott Trudeau Foundation, CIHR, the Canadian Nurses Foundation and the Canadian Foundation for Women's Health. She is the volunteer Chair of Women's Wellness Within, a registered non-profit organization that advocates for reproductive justice and health for criminalized persons in Nova Scotia. She is a registered nurse. </span></em></p>Nexplanon, a long-acting reversible contraceptive that is implanted in the arm for up to three years, is a welcome addition to birth control options in Canada.Martha Paynter, PhD Candidate in Nursing, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.