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Last night I went to the pharmacy to see if I could pin down something that would speak to Abby's worry that Plan B might change teenage sexual behavior if/when it becomes available OTC to 17-year-olds. That would be the price. I knew the morning-after pill was expensive, and it's been my assumption that a contraceptive for which teenagers have to shell out a lot of money is not a contraceptive that is going to radically change teenage lifestyles. Turned out it is even more expensive than I thought: $49.50, according to the CVS pharmacist leaning discreetly toward me at the "consulting" alcove. "For a single dose?" I kept asking, my voice getting louder so that the man in the other alcove began to look alarmed. One might argue that the real danger of the morning-after-pill is that, at half the price of a pair of Uggs—OK, a third the price—teenagers won't use it at all. It's a little less expensive in some other stores, I think, but not much.
I've always thought Plan B is an important addition to the contraceptive array, because it does something no other pill or device does: contracept after the fact, rather than before. It's the only contraceptive that can stave off unintended pregnancy after a mishap has occurred, forestalling a lot of difficult decisions. This seems distinctive and invaluable—maybe especially for teenagers. The younger a girl is when she has sex, the more likely the sex is coercive rather than consensual, so younger teenagers might have particular need of this. If they can get that kind of money.
But I should also say that the pharmacist provided a gloss that might revive Abby's concerns. When I told her I was writing about girls younger than 18 having easier access, she said, "I think a lot of them are already getting it." She said she sees a number of males 18 and over buying it for their younger girlfriends, "sometimes more regularly than I would like." She thought it would be better if the girls got a prescription for the pill. When I voiced surprise that young men would pay $50 over and over for emergency contraception, she said maybe they were old enough that it didn't seem so much. I am way older than they are, and that sticker price certainly gives me pause. I think it would be interesting to report out how the price affects use.
As for Gardasil, like Megan I am bemused by the fact that sex educators and public health experts worry less about promiscuity among boys. In a way, boys have always seemed to me more vulnerable than girls. If a girl gets unintentionally pregnant, she, at least, has some control over the outcome. If a boy gets a girl unintentionally pregnant, he has none. I'm not saying he should have control, but the consequences, for him, are profound. Maybe that's why those 18-year-old boys are paying big bucks for those pills.
In answer to Jessica's question, I'm not sure whether Gardasil should be mandatory. I am not yet convinced that it should. I do have a problem making it mandatory too young. And I think that doctors who administer it should have some training in how to talk to the really still quite young children they are thinking about administering it to. As the parent of kids who have just recently survived their yearly dose of Family Life Education, I have always believed in erring on the side of too much information: When they come home looking shellshocked I listen, explain, correct, commiserate, whatever. But my frankness is nothing compared to the gory detail that one pediatrician went into when my daughter, who was barely older than 12, went for her last checkup. The doctor brought up the topic of Gardasil and when my daughter asked what it was, I was prepared to say simply that it is a shot that can prevent cervical cancer, which seemed to me, as her parent, really all she needed to know just then. But helpful Doc took this opportunity to go into an excruciating level of detail about genital warts, multiple sex partners, and how it would be good if you were always monogamous, but we all know how things work in reality, and my daughter's eyes kept getting bigger and more horrified, and I wanted to take one of those vaudeville crooks to TMI Doc's neck. I kept expecting the good doctor to add something like, "And then there are the nights when you get so drunk you don't even remember his name in the morning."
It's true that all these good innovations do have unforeseen consequences, in the case of Gardasil the possibility that young girls given the vaccine may end up scarred, in other ways, even as they're being protected. Their mothers, too.
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In all the XX Factor rejoicing of making Plan B available to 17-year-olds, no one has mentioned one peep about any of the possible consequences this change could bring about to high school sexual culture—we are talking about juniors and seniors in high school here, not adults, after all. Judge Korman's ruling is certainly a triumph of "science"—in the sense that there's no known greater physiological harm to 17-year-olds vs. 18-year-olds taking the drug. And from the research I've done, I haven't been able to find any distinct scientific reason that the limit is 17 and not 16 or 18—in fact, Judge Korman implied that the drug should be available to even younger women.
By definition, most of the legal age limits the government imposes are arbitrary in a scientific sense, but less arbitrary from a cultural sense. Why 16 to get your driver's license? Why 21 to drink? Why 65 to qualify for Medicare? Sure, there are basic principles that dictate the ballpark age-range for laws, but there's nothing usually medically or psychologically magical about any of those numbers. To me they're more a reflection of our cultural expectations and traditional chapters of American life.
So in this case we're talking about a law that takes control away from parents' rights to be involved in the lives of their not-yet-legal-age children. How you want to live your life once you're an adult is one thing, but laws like these make sex something completely private and of little physical consequence for high schoolers! I get that there's nothing "scientifically" wrong with this—but science is hardly the final promoter of happiness and mental health. So while Emily and Kerry seem to think the Plan B ruling is something to celebrate, I can't help but think that having easy access to this drug is going to have a serious impact in high school culture—and not necessarily in a way that empowers and encourages teenage girls to become confident and successful women down the road.
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Emily, thanks for the link to that meta-analysis in cautious support of over-the-counter birth control. For what it's worth, I certainly didn't mean to imply that annual cancer screenings are a waste of time. I am arguing that doctor's visits made solely for the purpose of obtaining permission to access a relatively safe form of contraception are pointlessly and harmfully burdensome. I've had to make quite a few such visits, in part because I move frequently and am incapable of getting an overworked doctor on the phone with an understaffed pharmacy. It's possible that I am overgeneralizing from my own deeply annoying experiences.
I've lived in countries where the pill is kept behind the counter and would be more than happy with such a compromise. But the FDA, unlike its counterpart agencies in England and Canada, only very rarely considers this third option due to complex regulatory barriers. (When the FDA rejected OTC status for Merck's Mevacor, for instance, several panelists said they'd be comfortable with the drug as it is sold in British pharmacies; in other words, behind the counter. They weren't given such an option, so the panel overwhelmingly voted down the application.) It's not clear that the FDA even has the authority to create a third class of drugs. But thanks in small part to Plan B, it looks like our binary classification system might be changing.
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Emily and Torie, my grasp of the regulatory issues is imperfect, but it’s my understanding that a drug company would have to apply for over-the-counter status through the FDA. (I've never heard a single plausible medical justification for keeping birth control prescription-only.) There are various reasons why drug companies would not want to attempt this; the most obvious being that pharmaceutical companies can charge much higher prices for prescription drugs covered by insurance. Companies would also see resistance from gynecologists, who rely on their prescription powers to keep women coming back for annual appointments.
Torie, I understand your concern about insurance refusing to pay for OTC drugs, but it seems to me that your logic applies to every single drug that has gone over-the-counter, from Prilosec to Nicoderm. Keeping birth control prescription-only actually raises the cost for the poorest women—those without insurance who must pay retail at that the pharmacy counter and pay out of pocket for the doctor’s appointment required to get the prescription. When drugs go OTC the price plummets, so the cost to the consumer without insurance falls. Here's a blurb from a 2006 survey by the Pharmacy Access Partnership, a group that advocates for wider emergency contraception access:
Women said convenience, simplicity and affordability were their highest considerations when choosing their current contraceptive. Fifty-four percent of women also chose their method because it did not require a prescription. African-Americans (65%) were more likely to choose a method because it did not need a prescription, compared to Caucasians (51%) and Latinas (54%). Importantly, 20% of women said the cost of a visit to the doctor was an obstacle in obtaining a prescription contraceptive. Overall, 28% of women have had problems with obtaining a prescription for contraception, filling the prescription or getting to their supplies when they needed them. Women who had fewer resources to manage an unintended pregnancy (uninsured women, single women and younger women) were more likely to have experienced problems with obtaining a prescription for contraception.
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I, too, applaud the move to make Plan B available over the counter for 17-year-olds, but, Kerry, I have to raise one problem that could accompany making hormonal birth control OTC: insurance. Many insurance plans don't cover OTC medication, unless it's a special program intended to keep costs down, like providing an incentive for people to use a specific OTC heartburn medication instead of an expensive prescription drug that's not more effective. Insurance companies like the checks and balances of going through a doctor and a pharmacist before shelling out. Yaz, which you mention, costs about $60 per month retail, I believe, depending on the store, the state, etc. Planned Parenthood and other resources might step in to help, but those of us who already have high copays on birth control would feel the hit if we had to start paying full price. Considering the battles waged over getting insurance companies to pay for birth control, I can't imagine that many plans would be willing to alter their OTC policies to cover the an over-the-counter pill.
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Kerry, interesting point about making regular birth-control available without a prescription. I wonder what the medical reasons for classifying it as a prescription drug are—do you know?
In the meantime, I'm relishing Monday's Plan B decision as a rare fact-based inquiry and denouncement, by a federal judge, of the kind of monkeying around with science that we've long heard pervaded Bush agencies. Federal judges don't interfere with the decisions of federal agencies unless those decisions really, really have no legitimate basis—in legal-ese, they have to be deemed "arbitrary and capricious." This is what Judge Edward Korman concluded in his ruling kicking the Food and Drug Administration for its denial of access to Plan B (the morning-after pill that prevents pregnancy) to girls who are 17 as opposed to women 18 and older.
Because of the FDA's stubborn insistence on its arbitrary age-based distinction, the Plan B pill, which is not a prescription drug, had to be stocked behind the pharmacy counter rather than out on the shelves. And 17-year-olds, of course, weren't allowed to buy it at all. I hear you, Rachael, in wondering whether feminism is broad enough to include women who are pro-life. But making birth control harder to get is a whole different ball game to me. I understand that Plan B falls into a tricky in-between zone because it's post-sex, but I'd like to think we could draw the line on the side that helps the girls and women who want to take it. I only wish Judge Korman's ruling had come earlier, when it would have forced the Bush FDA to get its act together.
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Back during the ridiculous brouhaha over access to the morning-after pill, regulators compromised by making the pill available without a prescription only to women of 18 years of age or older. A federal judge, noting that this restriction is arbitrary and without medical justification, has ordered the FDA to review the policy and make Plan B available to 17-year-olds in 30 days. I imagine that the policy will change pretty quickly; you know things are looking up when the Washington Post has to go to Concerned Women for America to find some quotable pushback.
All of which allows me to climb astride an old hobby horse: Regular old birth control ought to be available without a prescription. Hormonal birth control meets all of the FDA requirements for over-the-counter access; Plan B, after all, is just a mega-dose of the pill. We've all heard stories of women being denied birth control by squeamish doctors and pharmacists; there is no reason such women shouldn't be able to grab stacks of Yaz off the shelf at Walgreens. The aggregate burden of all those pointless doctor's appointments and hourlong pharmacy waits is surely massive.
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Emily, there's another decision from the Obama White House that women can cheer about: Word is they're rolling back the provider conscience rule today. Bush finalized the legislation in the waning days of his administration, and it allows medical professionals to refuse to do anything they object to on moral grounds, including, but not limited to, family planning services. The Chicago Tribune notes that seven states filed suit against the Bush rule, "arguing it sacrifices the health of patients to religious beliefs of medical providers."
According to the Trib, the Obama administration says they will look into a new, differently worded rule that will "clarify what health-care workers can reasonably refuse for patients." Hopefully the new rule will not include denying rape victims emergency contraception.
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