2023-02-15
Birth Control Access May Get Easier. Here’s Why It’s Not Enough.
Just weeks after the Supreme Court overturned Roe v. Wade, Paris-based company HRA Pharma applied for Food and Drug Administration approval of the country’s first over-the-counter birth control pill. The application was a timely response to Justice Clarence Thomas’s concurring opinion in Dobbs v. Jackson Women’s Health Organization, where he suggested the Court “should reconsider” its 1965 ruling that codified rights to contraceptive access. If HRA Pharma’s petition is approved, people in the United States could purchase birth control pills from pharmacy shelves, next to condoms and menstrual products, without a prescription.
The possibility of an OTC birth control pill could remove key barriers to contraceptives, especially in the post-Dobbs era. And since one in three reproductive-aged women report difficulty obtaining a birth control prescription or refills, such an option may also help repair the U.S.’s fragmented state of reproductive rights.
But birth control has not always been synonymous with bodily autonomy. Contraceptives may allow people to manage their fertility, but they have also been pushed as a panacea for social problems like poverty, crime, and, more recently, climate change. Accordingly, tensions between the right to choose birth control and contraceptive coercion, or pressuring someone to use or not use a particular method of contraception, have influenced social policy since the birth control movement began in 1914.
Over-the-counter birth control is no exception. Removing the pill’s prescription requirement would be a historic advancement in reproductive health care. But the FDA’s decision, which is expected to be announced in mid-2023, isn’t enough to resolve disparities in access to contraception for communities of color and low-income women, who face long-standing barriers to contraceptive care, including out-of-pocket costs, pharmacy deserts, and medical mistrust.
The availability of an OTC pill means little if patients can’t afford or access the pill, or are simply suspicious of it. For the OTC pill to realize its potential for improved reproductive health and liberation, we must acknowledge contraception’s tangled history with reproductive coercion. It’s the only way to ensure equitable access, choice, and education.
Advocates from “Free the Pill,” the coalition that helped lay the groundwork for regulatory approval, emphasize that contraception is critical for family planning and reproductive health care in the U.S. The American Medical Association and the American College of Obstetricians and Gynecologists, or ACOG, have also voiced support for the over-the-counter option.
But historical lessons warn against hopes that mere approval of the OTC pill will have an equalizing effect for all people. While more than three-quarters of reproductive-aged women support the OTC pill, low-income women and women of color report greater concern over the contraceptive’s safety, showing a lingering distrust of birth control.
Indeed, researchers from the Bixby Center for Global Reproductive Health found that Black and Latina women were more likely to believe that the government encourages contraceptive use to limit minority populations. They were also more likely to use non-hormonal methods of contraception — or no method at all.
Such medical mistrust is well-founded considering the legacy of reproductive coercion and its ramifications for racial minorities in the U.S. For example, in the 1920s, American reproductive policies included eugenics-inspired programs aimed at decreasing the population of low-income, disabled, or non-White individuals. Indeed, sociologist Melissa Wilde argues that it was the eugenics movement — and its message of limiting the large family sizes of so-called “undesirable” Catholic immigrants from Ireland and Italy — that first pushed the Catholic church to ban artificial forms of birth control in 1930.
In the 1970s, U.S. doctors sterilized an estimated 25 to 42 percent of Native American women of childbearing age, often without their knowledge or consent. In the 1990s, lawmakers in many states proposed bills that would have forced poor women, primarily women of color, to use the long-acting contraceptive Norplant to qualify for welfare benefits — a proposal that continues to have cachet among politicians into the 21st century. Former Arizona state Sen. Russell Pearce was quoted in 2014 saying, “You put me in charge of Medicaid, the first thing I’d do is get [female recipients] Norplant, birth-control implants, or tubal ligations.”
Although the U.S. has made major advances in improving contraceptive access, including the Affordable Care Act’s 2011 mandate that insurance plans provide contraceptive coverage, it has not escaped its legacy of contraception and population control. Reproductive coercion exists on a spectrum, according to Leigh Senderowicz, an assistant professor at the University of Wisconsin-Madison who studies contraceptive autonomy. Although the term is typically used in reference to intimate partnerships, Senderowicz argues that reproductive coercion also includes the more quotidian and systemic restrictions that especially impact marginalized communities, including a lack of access to affordable, effective, and trustworthy contraceptive options.
Like the “Plan B” emergency contraceptive, the OTC pill would be sold by grocery stores and big box retailers, but pharmacies would serve as the primary distributor. Yet even access to pharmacies is not ensured for marginalized communities. In Los Angeles, for example, one-third of Black and Latino neighborhoods meet the criteria for a pharmacy desert. Pharmacy closures are also more common in these neighborhoods across the U.S., making residents and their reproductive health collateral damage in an already fractured network of contraceptive access. As Ebony Jade Hilton, an anesthesiologist based in Charlottesville, Virginia, noted on Twitter, “Options mean nothing [without] access.”
“Free the Pill” advocates have acknowledged these barriers and the long-term solutions they require. The more immediate concerns are the unresolved legal obstacles to OTC contraceptives, even if the FDA approves the new option.
Currently, 13 states have policies known as “conscience clauses” that allow pharmacists to refuse to provide medication when it conflicts with their religious or moral beliefs. These clauses have been invoked in notable cases of pharmacists denying patients emergency contraception or prescriptions for medication abortion. The U.S. Department of Health and Human Services recently clarified that, at least for prescription birth control, these refusals violate the ACA’s anti-discrimination provisions. But it’s unclear where OTC birth control would fall under these guidelines. Given that 10 of the conscience clause states have severe abortion restrictions or total bans, disparities in contraceptive access now carry bigger stakes.
Similar problems may prevent the OTC option from being affordable. The ACA allows insurance companies to require a prescription before covering OTC birth control expenses, which loops many patients back to the beginning of their contraceptive conundrum. For uninsured and low-income patients, a menu featuring only these two options — paying high out-of-pocket costs for the OTC option or obtaining prescriptions from a provider who may be geographically inaccessible — leaves the OTC pill firmly out of reach.
As the FDA considers OTC approval, health care providers and policymakers must recognize that women are responsible enough to decide whether this new option is right for them. Clinicians opposed to OTC contraceptives often report concerns with patients’ ability to correctly use the pill. But research demonstrates that women can effectively self-screen to make sure they are a good candidate for hormonal birth control and follow medication instructions. Misguided perceptions of patient incompetence compound on historical themes of favoring clinician expertise over women’s contraceptive preferences.
Additionally, dismantling the culture of fear surrounding birth control will require a lot more than recognizing historical inequities. People who can access OTC birth control should still have the option of supportive contraceptive counseling. ACOG has encouraged physicians to conduct such counseling with a reproductive justice framework — one that acknowledges historical and ongoing reproductive coercion and prioritizes the patient’s values and lived experiences. The American Pharmacists Association should encourage similar practices for pharmacists, who will play a key role in reproductive health care if the OTC pill is approved.
OTC birth control opens an important option for reproductive health care in the post-Dobbs era. But until we grapple with our past and present systems of reproductive coercion and their continuing effects on marginalized communities, the OTC pill will be unable to deliver on its promise of choice.
Lucy Tu studies sociology and the history of science at Harvard University. She is also a research fellow at Massachusetts General Hospital with a focus on health equity, public health law, and women’s health services.
Jocelyn Viterna is a professor of sociology at Harvard University, where she researches and teaches on topics related to gender, law, and reproductive health.
This article was originally published February 9, 2023 on Undark. Read the original article.
