The XX Factor: What women really think.

The Pill Could Do You Wrong In Many Ways

If the blood clots and stroke risks don’t scare you off the pill, maybe this will: Women taking oral contraceptives are less attractive to the opposite sex and less likely to pick a good mate, according to a roundup of studies on the pill, published in this month's Trends in Ecology and Evolution, that Sarah Kliff at Newsweek reported on today.

When a woman is ovulating, her hormonal fluctuations affect her “facial appearance, her vocal pitch, even body odor,” Kliff writes. “And during ovulation, those changes increase a woman's attractiveness because they indicate fertility.” Hardly as dramatic as the potential side effect that terrified many of my friends when we started going on the pill: rapid weight gain. But apparently men—who, so the legend goes, don’t even notice a new outfit or restyled hair (or is that just my dad?)—pick up on these shifts, as shown in a study in the roundup that found that lap dancers make higher tips when they’re ovulating ... (Read more in DoubleX.)

The Complicated Calculus of Careers and Children

A guest post from Sharon Lerner:

Of course abortion and birth control have a large role in bringing down our fertility rate in America, as they have elsewhere. (I have spent much of the past decade-and-a-half writing about both.) But there is no need to be reductive; this is not an either/or issue. There are many factors contributing to the decline in fertility, including both the ability to control when and whether to become mothers and the policies that affect mothers’ quality of life ... (Read more in DoubleX.)

Preventing Babies, the Old-Fashioned Way

Quiverfull Feminism

"The threat of population decline," writes Michelle Goldberg at the American Prospect, "is one of the best arguments yet for socialized day care, family leave, and other dreamy Scandinavian-style policies.... I get why liberals have shied away from this discussion, since there's so many uncomfortable issues involved. But they really shouldn't, because the only solutions to the problem are liberal ones!"

I wrote a Reason feature on this issue for anyone who is interested in sociological and economic analysis of natalist policy. But for now I'll just say: Liberals ought to be very, very cautious about engaging natalist rhetoric in the promotion of social welfare policies. The claim that Western Civilization is on the brink of extinction might help sell universal daycare or any other policy that can be cast as an incentive to motherhood, but population alarmism lends credence to a number of wildly illiberal arguments. Once you've bought into the idea that a nation-state must defend its existence through native population growth, you've come uncomfortably close to arguing that a particular subset of women has a patriotic responsibility to reproduce. You've also legitimized some legislator's attempt to bribe women into using their bodies in a particular way. There is a reason that the producers of Demographic Winter are traditionalist Christians.

Gradual population decline of the kind we are seeing in Germany and Japan is, I think, manageable. But even if we insist on addressing population decline as some kind of crisis, it's not at all clear that liberal policies like paid family leave are going to turn the tide. The most obvious difference we see between developed countries with relatively high birth rates and developed countries with relatively low birthrates is cultural. Swedes and Americans are relatively more likely than, say, Singaporeans or Koreans, to believe that work and motherhood are compatible. The countries with the lowest birth rates in the world are countries in which childless women are integrated into the workforce but women with children are expected to stay home.

Such attitudes are distinct from redistributional social welfare policies. It may be that Sweden's welfare state is responsible for its near-replacement birth rate, but the evidence for this is not terribly compelling. In order to frame the story this way one needs to cast the high-fertility United States as an anomalous outlier rather than part of the general, culture-driven trend.

I am sympathetic to Goldberg in that population alarmism might be a useful way to argue for policies I happen to support; more open borders, for example. But there are better arguments for a humane immigration policy, and there are better arguments for an expansive welfare state.

Busted for Birth Control

A high school student gets caught popping a pill at the lunch table. Had she been taking an illegal drug, Fairfax County's "zero tolerance" policy would have called for a 5-day suspension. But she was taking birth control prescribed by her doctor and purchased by her mother. A student who brings a "controlled substance" into a Fairfax County high school is subject to the same penalties as a student carrying a gun. So the girl was suspended for two weeks and "recommended for expulsion." Last Thursday, The Washington Post reports, "a long table full of school officials weighed her case at a hearing."

I don't doubt that Ortho Tri-Cyclen is extremely dangerous to a certain social order—far more so than is, say, heroin. But it seems like the kind of thing public high schools should be encouraging. 

More Places To Put the Pill

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.

More on the Pill-Selling Over the Counter

An answer from Slate medical columnist Amanda Schaffer to my question about why the Pill is a prescription drug. Amanda supports, with caveats, Kerry's argument that oral contraceptives should be sold over the counter:

The downside risks of the pill (strokes, breast cancer) are pretty small, especially with newer formulations. And the upside of reducing ovarian cancer risk (as well as preventing unwanted pregnancy, of course), has led some researchers to argue for over-the-counter access; in fact, a meta-analysis in the Lancet from last year had an accompanying editorial making this case. The counterargument is that women who smoke or get migraines should not be on the pill, and a doctor's involvement might prevent that from happening. Plus, since women stay on oral contraceptives for long periods of time, it may be wise to have more medical oversight.

Amanda and I disagree with you, Kerry, that annual visits to the gynecologist are a waste of time. Breast exams, pelvic exams—that's trouble-catching time.

In Defense of OTC Birth Control

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.

The Trouble With OTC Birth Control

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.

Plan B and the Bush Science Monkeys

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.

For Women, Good Jobs Depend on Good Contraception ... and Yet ...

Dayo, I agree with you on a number of things about contraception and economic prosperity for the country and for women—and disagree with Rachael's contention that contraception isn't related to jobs.

Let's be real: Most women (with the exception of lesbians like me) couldn't be 21st-century workers without contraception. Helping poor women pay for contraception keeps them in the workforce (good for the economy), keeps down maternity-related health care costs down (ditto), helps poor women not have more children than they can support (TANF costs reduced), incrementally helps expand health care coverage, and all sorts of other things that are good for the economy, for women, for children, and for the country. Yes, I salute Medicaid coverage for contraception!

What's more, I agree with Ruth Rosen's more recent analytical post explaining the right wing's philosophical objection to family planning at all. Here's a snippet from her brilliant explanation of why Margaret Sanger was repeatedly arrested for opening her pioneering birth control clinics, why she and her fellows were attacked so ferociously by the forces of Comstock, and why contraception is still being attacked today:

... the religious right's real agenda is not just to eliminate abortion, but to end the historic rupture between sex and reproduction that took place in the 20th century.... If reproduction ceased to be the goal, sexuality might become yoked to pleasure and that is quite unsettling to many Americans. That is the legacy the religious right has fought against, and it's that agenda that cut funding for family planning.

As I explained in my book What Is Marriage For?, when women won the battle over contraception, it blazed the trail for the acceptance of lesbians and gay men. Hurray contraception, both practically and philosophically! What's more, there's some disguised racism in the opposition to Medicaid-funded contraception; all "welfare" supports for poor folks get a racialized tinge in the cultural imagination (however false the imaginary picture). 

And. Yet. I still don't get the angst over whether expanded Medicaid payments for contraception should or should not have been in the stimulus package. Can't we give Obama a chance to make this happen some other way? The man has been in office for all of nine days. One, two, three, four, five, six, seven, eight, nine! And in those nine days he has already done some amazing things for poor women—both symbolically resonant and immediately practical—like repeal the gag rule, appoint a female solicitor general, make Hillary Clinton (with her explicitly pro-women approach to foreign policy, dating back to the Beijing conference and beyond) our secretary of state, and support equal pay in the fabulous Ledbetter Act.

Look, Clinton went down in flames when he tried—right after he was inaugurated—to allow lesbians and gay men to serve openly in the military. The idea was right but the tactics were wrong—and the results were the disastrously restrictive Don't Ask Don't Tell policy. Can we give the Obamanauts another month or two—or call me crazy, three! —to work on Medicaid-funded contraception, which is so outrageously controversial, for the reasons Ruth explains, and more?

They Don't Call it a Majority for Nothin'

Republicans Drool

Dayo, it's giving a little too much credit where credit doesn't belong to say Republicans "ruled" by hissy fit on the contraceptive provision. You could claim that it was removed thanks, obliquely, to House Minority Leader John Boehner and the other GOPers who turned it into a big story, but at bottom (no jokes, please), it was removed for Democrats' sake. The Blue Dog Democrats, that is, who could have sunk the stimulus had they voted en masse against it and who—having run on heroic promises to crusade against fiscal irresponsibility—were feeling super antsy about the whole $819 billion bonanza.

Usually, the House GOP's bellyaching about being victimized by Nancy Pelosi and left out of the "process" strikes me as so many crocodile tears. Did any more vomitous image emerge from last fall's congressional session than that of Eric Cantor, then the GOP's chief deputy whip, waving a copy of a "partisan" speech by Nancy Pelosi in front of the cameras and claiming that it had so hurt his delicate-flower Republican colleagues' feelings they'd refused to vote for the financial bailout? But I actually think the Republicans performed a type of useful minority function in this whole contraceptive thing: publicizing a conservative objection to the bill so that more conservative-minded Democrats could consider whether it might sway them, too.

But "ruled" by hissy fit? No Republican voted for the stimulus, even after the contraceptive provision was yanked. But it didn't matter, because hey hey, it still passed the House! Some rule. I know it's considered a moral defeat for Obama that tonight's stimulus vote was party-line, but frankly, I kind of liked it. The GOP might have thought it was in "the minority" last year, but this New York Times lede is what it really feels like to be in the minority: "Without a single Republican vote, President Obama won House approval on Wednesday ..."

Maybe more of these ledes will finally prompt some soul-searching.

Jobs First, Please

Dayo,

Forgive me, but didn't we just spend eight years complaining that George Bush and Congress were saddling future generations with an unfair burden of debt? (I was no fan of the GOP-led Congress, believe me.) And wasn't one of the many complaints about the Patriot Act that it was rushed through and congressfolk didn't have time to read it? But now we have a proposal that will end up costing $1 trillion with interest and a president who says there is not a "moment to spare," and yet it's the Republicans with their concerns who are trying to "rule by ... hissy fit." (Um, also, aren't the Democrats in the majority here?) [Note: The NYT reports that the package has passed the House. It apparently went through without the contraceptives, but with $335 million for STD prevention.]

Now that they are out of power, the Republicans have an opportunity—and a responsibility—to start living up to their historical reputations for fiscal conservatism. House Minority Leader John Boehner had compiled a long list of concerns about the stimulus package, of which the complaint about contraceptives was just one item. For example, the creation of 32 new government programs that will cost $136 billion. What happens when they've spent their stimulus money? Will the programs go away? And then there's the fact that this is being sold as an "infrastructure" package, yet only 25 percent of the infrastructure dollars would be spent in the first year. (So, why the rush?)

I'm not an economist. I have no idea if the stimulus is going to work. It might be the only thing standing between us and a depression, or, as Politico pointed out today, even $1 trillion on stimulus might not be enough. But what I do know, is that if we're going to go ahead with this massive and hugely expensive project (the Senate takes it up next week), I want the focus to be on creating jobs quickly and getting money pumping through the economy. Whether that is through infrastructure or corporate tax breaks, I don't care. But I don't think that $200 million for contraceptives would create as many jobs as it could if directed toward some other purpose. There are lots of generic oral contraceptives, for example, which cost less (yay for Medicaid and our tax dollars) but reduce the incentive for pharmaceutical companies to have people out there selling (profitable) brand-name alternatives. And while $5 billion might sound like a big industry, it's comparable to what we spend on Halloween. Heck, the porn industry has asked for a bailout worth $5 billion. I'd much rather see that $200 million go as tax breaks to small businesses in return for hiring new employees, or a necessary infrastructure project (maybe a couple of bridges to SOMEWHERE, for a change). It's got nothing to do with scorn for women's health.

“Rule by Republican Hissy Fit”?

I’m a bit disappointed by President Obama’s rude expurgation of contraceptive planning from the “economic recovery package”—as we’re being asked to call the stimulus bill that’s working its way through Congress. Perhaps I’m just not down with all the euphemism on tap this week: Why not just call “Republican skepticism” here on the Hill what it is—an attempt to derail the future expansion of health coverage, couched in a puritanical queasiness with contraception. Lisa Lerer reports Minority leader John Boehner asking: “How can you spend millions of dollars on contraceptives? How does that stimulate the economy?” Well, John—hot button-ness aside—birth control is a commodity bought and sold like any other.

I agree with EJ that in many cases (I felt this way about Rick Warren) progressives should attempt to see the forest, not the offending tree. But here, it’s not just a bunch of women begging for their crazy pills! The Democratic White House’s concession of rhetorical and political ground—about whether contraception (a better than average return on public investment) and other Medicaid assistance counts as “stimulus” or not—could have outsized effects on the future of the universal health coverage debate. Over at the Washington Independent, Lindsay Beyerstein makes roughly this point. Harold Pollack and Nicholas Beaudrot at TAP make it explicit: We’re now, the latter writes, subject to “rule by Republican hissy fit.”

Who knows whether it’s the public climate that requires lifting of the odious global gag rule to be done under cover of media darkness, or the lightweight status afforded to “women’s health” in general—but birth control represents an arm of the pharmaceutical industry that nets drugmakers over $5 billion annually—perhaps even in a recession. I imagine the investors of $5 billion in any other American industry could, presumably, expect some back-scratching, be it through money kicked into the search for a better product, or strenuous lobbying to ensure access to said product is available to American women—especially those planning families, and seeking “economic recovery” from the new Congress.

More Stimulation

Rachael, it's lovely to agree with you ... at least partly. I too am vastly in favor of contraception being available to all, and yet agree that it shouldn't be in the stimulus package.

I've long found it amusing that Viagra, but not contraception, is regularly covered by health insurance: Why should men's sexual pleasure be underwritten but not women's? I don't know whether Medicaid covers Viagra without a waiver (according to MSNBC, 27 states' Medicaid programs do cover contraception, but they had to seek a waiver to do it.) If yes, obviously contraception should be, too. And I agree that underwriting contraception for poor folks seems like a no-brainer-except for the radicals (and yes, they do exist) who believe that all sexual activity should lead to babies.

And yet like you, Rach, I humbly disagree with my admired friend Ruth Rosen's position ... although for different reasons. I don't have any economic philosophical objections to its inclusion: After all, this stimulus package includes money for food stamps, the GAO, the census, the National Oceanic and Atmospheric Administration, unnamed projects for the Department of Homeland Security, information technology projects for the Department of State... and what's most relevant, Medicaid. If the Obamites deem a project good for the country, it's in this bill.

So why do I disagree with Ruth? Because the White House is already showing incredible savvy in making controversial changes about women's health. I was wowed by the fact that the controversial global gag was repealed on Friday at about 4:45 p.m. ... perfect timing for missing the American news cycles. Thursday's and Friday's news cycles were dominated by Gitmo closing; Monday, the news media were all over the plan to back higher fuel-emissions standards, a big symbolic move on environmental policy. Obama slipped through his move to improve women's lives by allowing women's health providers to talk freely about all options without losing U.S. funding with no controversy. (If Rick Warren's ghastly inaugural prayer was a fig leaf for this repeal of the gag rule, well, it was worth it.)

That's why I don't mind seeing this particular, um, withdrawal from the stimulus package: because I'm guessing that the Obamamites are being savvy—taking this fight out of the public eye so that they can handle it in a better way.

Is Birth Control, Um, Stimulating?

When I read this morning that President Obama was going to ask House Democrats to pull family-planning funds from the stimulus package, I breathed a sigh of relief. Not because I'm opposed to birth control (quite the contrary, actually), but because I was opposed to the stimulus package being used for such a purpose. (And yes, feel free to insert your jokes about the, har har, stimulating effects of birth control at any point.) Alas, and perhaps obviously, not everyone shares my sentiments. At Talking Points Memo, Ruth Rosen chides Obama for courting Republicans and calls his request "misguided."

This doesn't have to be an issue that divides women and brings Democrats and Republicans to blows so early in the new administration. I feel like there's a liberal argument for excluding the funds from the stimulus package, and a conservative argument for providing birth control for family planning.

First, not including the funds in the stimulus package: Despite Obama's pledge that there would be no pork in the legislation, Las Vegas' mayor has been trying to get stimulus bucks for a planned "Mob Museum" for his city, and conservatives are already having fun with such proposals as an extra $50 million for the National Endowment for the Arts. If family planning is so important, do we really want it to be reduced to comparisons to the Mob Museum?  Can't it stand on its own merits?

As for the (fiscally) conservative argument for funding family planning, well, as much as I rarely agree with Nancy Pelosi on anything, her comments to George Stephanopolous make a point. It's cheaper to provide birth control to poor families than it is to pay for unintended and sometimes unwanted children. And I'd rather fund birth control than abortion, a million times over. If we can give these parents the means to limit their family size, they will have an easier time taking care of themselves, meaning they will be less likely to need government assistance. And the parents will have more time and resources to devote to the children they already have, helping them with school and getting them involved in extracurricular activities, with the effect of helping them to break the cycle of poverty once they become adults themselves. (To me, that's a pretty important "family value.")

But both arguments lead me to the same conclusion: Make funding for family planning its OWN legislation. Get the debate out into the open. Obama promised hope and change. Congress shouldn't let him down with business as usual.

Rule Britannia

According to an article published in the London Times today, we Brits are now the most promiscuous nation in the world (of the western industrial nations, that is). In terms of one-night stands, total number of partners, and our "relaxed" attitude to casual sex, we beat Australia, the United States, Italy, and France. France! Where having extra-marital affairs is a favorite national pastime! If nothing else, at least now we might lose our reputation for being frigid and repressed.

In all seriousness though, Britain has the highest teen pregnancy rate in Europe as well as the highest teen STD infection rate in Europe (although both are significantly lower than here in the United States, where abstinence-only sex education doesn't seem to be helping much). Premature sex education in British schools (it can be taught to children as young as 4) has long been blamed for the epidemic, along with the inappropriate sexualization of children by toy manufacturers and the media. But here's a thought. In Britain, we also drink more than any other country in Europe (apart from Ireland and Finland, bizarrely), and our alcohol-related death rate has doubled since 1991. We've also, according to this reasonably insulting story in the New York Times, been causing havoc on summer vacations with our abhorrent, booze-soaked behavior. Could there be a correlation somewhere between the beer goggles and the newfound sluttiness?

Palin All for Condoms in Schools?

More on Sweaty T-Shirts

Meghan, I checked out that T-shirt sniffing study you flagged, and, well, it hardly implies a crisis for pill-users – or a pink slip for novelists.

To recap: The researchers asked women to rate the smells of T-shirts worn by different men. For each woman, they chose three men who were more genetically similar (in terms of a specific set of genes) and three men who were less similar. The genes in question were part of the major histocompatibility complex, or MHC, which plays a crucial role in immune function and is also linked to body odor (possibly because of interactions between the immune system and skin bacteria). The researchers found that when women began taking birth control pills, their smell preferences shifted somewhat toward men with more similar MHC profiles, though the difference was not huge.

Why might this matter? In the past, some research found that women tended to prefer the smell of men whose MHC makeup differed more extensively from their own. That result remains controversial, but from an evolutionary perspective, it makes for a good story. When women mate with less similar men, their kids may have more robust immune systems that can better fend off a wide range of diseases. In theory at least, that advantage may have helped to shape women’s tastes over time. As for the pill, if it were to skew preferences toward MHC similarity, women might smile on less genetically favorable partners, leading to problems in the long run. When women stop taking the pill, for instance, their tastes might shift again, resulting in “the breakdown of relationships," as one researcher speculated. Hence the maelstrom about women choosing the “wrong” men.

Strikingly, however, the current study fails to confirm the premise of that whole story. When women smelled men's T-shirts at the outset, before any of them took the pill, they showed no preference for men with more MHC difference. That is, they did not exhibit the supposed tendency that the pill supposedly disrupts. What’s more, when women taking the pill smelled the T-shirts again, they showed no preference for men with more MHC similarity. Yes, the pill-takers tended to rate the smell of MHC-similar men more favorably than they had before. But to repeat: They still didn’t prefer the similar guys overall. Despite the hype, then, this study’s findings are limited – and pretty messy.

Of course smell can play a role in romance. And the scent of MHC difference could turn out to be one factor – of many – that influences women’s choices. But really, when it comes to searing insight into longing and romantic crisis, T-shirt sniffing has nothing on Flaubert.