[Anecdotes] Plan B – Got Another Option?

“ Is there a place for evidence-based health policy in repropreventive services?”

The Department of Health and Human Services (HHS) made history last week when Secretary Kathleen Sebelius overturned the Food and Drug Administration’s (FDA) decision to bring Plan B emergency contraception (EC) from behind-the-counter (BTC) to over-the-counter (OTC). This is the first time in history that HHS has overruled a decision by the FDA.

Plan B is currently available to men and women who are 17 years and older with identification or by prescription for those under 17 years.  (Several states allow healthcare providers the right to withhold emergency contraception (EC) from patients regardless of age, even in cases of rape.) The FDA, which oversees drug testing and safety, ruled that Plan B was safe for OTC availability without prescription. Sebelius, neither a physician nor a scientist, disagrees, stating that the studies are not sufficient to allow girls under 17 access to Plan B without consulting with a doctor.  Ironically, the  FDA’s decision was rendered by FDA Commissioner, Margaret Hamburg, MD, who, only a few years ago, had been accused of saying that emergency contraception would lead to promiscuity.

The topic of reproductive preventive (reproproventative) services is overshadowed by controversy.  The misconception that the availability of contraception promotes early age sexual activity is baseless.  It is the desire to prevent pregnancy that precedes the use of contraception.  Despite consistent evidence dispelling the myth that availability of repropreventive services causes high risk sexual behavior, this rhetoric continues to make its way into advocacy forums, policy debates, and even clinical decision-making.

In the early 1960s, debates around contraception included that access to “the pill” would promote promiscuity. Studies have shown no causal impact of contraception on high risk sexual behavior.  Rather, condom distribution programs have been shown to delay the onset of sexual activity amongst teens. Social factors such as type and length of relationships, income, education, and culture have shown to have more influence on sexual behaviors.  Now, we find ourselves in a debate that should have been put to rest decades ago.

Unlike the chicken and the egg, when it comes to sexual activity versus contraception, it is obvious which comes first. Yet, repropreventive opponents, policy makers, and even some health care providers continue to blame the availability of contraception for the choice to engage in sexual activity.  It is no more sensible that the availability of cholesterol-lowering agents promotes over-consumption of fatty food.  This line of thinking is not only counter-intuitive, but contradicts sound peer-reviewed research.

So, let us compare and contrast the uses of cold medicine, cigarettes, condoms, and emergency contraception.  Cold medicine, condoms, and EC are used to prevent or treat a condition, while cigarettes are used recreationally.  Cold medicine is OTC, available to all ages, used to treat cold symptoms, but can also be abused to get a high.  Cigarettes are BTC, available to those 18 years and older, used recreationally, and are known only to be detrimental to health. Condoms are OTC, available to all regardless of age, and are used during sexual intercourse to prevent sexually transmitted infections and pregnancy.   EC is used after sexual activity to prevent pregnancy, and without the Sebelius veto, would have been available to all ages OTC, like condoms.

Of these four items, only one is not used to prevent or treat, and limited access to cigarettes may actually prevent smoking.  Limiting access to cold medicine does not prevent a cold; similarly limiting access to condoms or EC does not necessarily prevent sexual activity.  Teens will engage in sexual activity regardless of the availability of contraception.   Limiting access to cigarettes, however, does prevent smoking. (Some may note that putting certain cold medications containing phenylephrine BTC does prevent abuse potential).  Nonetheless, even President Obama stands behind Sebelius in her decision which goes against the available evidence.

The real focus of this decision has been on the wrong outcome.  As in medicine, the right treatment for the right condition needs to be the approach.  If the condition with which Sebelius is truly concerned is young-age sexual activity, then, limiting EC is not the answer.  It is highly unlikely that readily available condoms and EC are to blame for a 17-year-old, sexually active Bristol Palin becoming pregnant.

EC prevents unwanted and unplanned pregnancies for those who have already decided to engage in sexual activity. The usual response to that statement from those who disagree is, “If they engage in sex, they deserve the consequences.”  But the consequence is not just their own; the burden of these pregnancies falls on society.

These comments in no way seek to promote or condone young-age sexual behavior; instead, reality dictates that young-age sexual behavior requires other approaches.  If this administration wants to tackle delay of sexual activity, it will need to take realistic steps towards that end.  It was reported this year, that the US experienced the sharpest decline in teen pregnancy since the 1990s.  This administration should concern itself with the factors that are contributing to this drop rather than snubbing evidence-based measures proven to prevent unwanted and unplanned pregnancies.

by

Renee Volny, DO MBA