A Disastrous ''New Social Norm''
How EPICC Would Threaten Women's Health and Reproductive Freedom
Many of us in the various women's health and family planning specialties are alarmed about S. 104, the ''Equity in Prescription Insurance and Contraceptive Coverage Act of 2001'' (EPICC) bill being considered in the Senate. Essentially the bill would require all health plans to cover prescription contraceptives (the pill, IUD, Norplant, Depo-Provera, diaphragm, and so-called ''emergency contraception'') as well as outpatient contraceptive procedures, as a ''basic health care right'' for women. In support of this bill, various testimonies were given on Sep. 10, 2001 before Sen. Barbara Mikulski, who chaired the committee for Sen. Kennedy. (1)
The most important argument advanced by proponents of the bill is the “unintended pregnancy” argument. Dr. Anita Nelson, representing the American College of Obstetricians and Gynecologists, testified that 50 percent of U.S. pregnancies are unintended, and that 50 percent of these unintended pregnancies are aborted. Thus she urged the Senate to mandate coverage in the belief that prescription contraceptives can solve this problem. A lesser argument centers on alleged ''noncontraceptive health benefits'' of prescription contraceptives. This argument alleges that oral contraceptives are associated with reduced rates of certain diseases and therefore improve women's health apart from their contraceptive effects. (2)
What does ''unintended pregnancy'' mean?
Increasingly researchers question the meaning of ''unintended pregnancy''. Noting a troublesome subjectivity, changeability, and arbitrariness, few researchers agree on the definition of the terms ''unintended'', ''unwanted'', ''mistimed'', and ''unplanned''. The most prominent of these researchers are now calling for more careful study of this confusing question, especially before any practical policy decisions are made. (3) The EPICC bill would be a classic case of imprudent policy if based on this elusive concept. Why would the Senate take precipitous action based on such an ill-defined term, when the experts cannot agree as to what it means?
The 1995 report of the Institute of Medicine carries this fuzzy thinking to an extreme level, requiring that the nation adopt a ''new social norm. 'All pregnancies should be intended -- that is, they should be consciously and clearly desired at the time of conception.' '' (4) This is absurd. Most pregnancies throughout recorded history could not meet this standard. Moreover, the imposition of new social norms regarding pregnancy intentionality is contrary to reproductive freedom and gives the medical profession too much social control over the reproductive choices of women. This bill would become an instrument affording physicians an extraordinary and unprecedented level of social control of women. Quietly in development now are far more longer-acting ''contraceptives'' which become very hard to distinguish from sterilization, and which would essentially put the nail in the coffin of reproductive choice. We want to ask the bill's proponents why they are not clamoring for the Senate to mandate full coverage of surgical reversal for post-sterilization regret. Often poor and uninsured patients succumb to vasectomies and tubal ligations based on a subtle form of fiscal coercion, regretting them later but sadly not being able to afford the expensive and noncovered reversal.
And it is not the wealthy or the adequately-served who would find themselves under the control of physicians and planners; primarily, it is poor and underserved women, especially of certain ethnic groups -- those who currently cannot afford prescriptions -- who would be effectively giving up their right to refuse and choose. Once these draconian measures are fully covered in the insured, they would be inserted into public assistance programs and coercively marketed to the poor and uninsured, who still would be without health insurance for the diabetes, nicotine addiction, blood clots, strokes, birth defects, and other disastrous complications which are inevitably associated with these methods. Any cost analyses purporting to have found no increased costs with mandated coverage cannot have included appropriate assumptions about these common complications. Why would anyone call this reproductive health?
The EPICC approach does not work
(contraceptives do not reduce unintended pregnancy rates)
It is sad to see this contraceptive ideology consistently resurface. In layman's terms this repeatedly- failed belief system could be expressed thus: there are too many unwanted pregnancies, therefore we need more funding for contraceptives and indoctrination in their use. This indoctrination occurs irrespective of existing cultural, social, familial, moral, and religious norms which in many instances are violated.
In 1981 Susan Roylance, testifying before the United States Senate Committee on Labor and Human Resources showed conclusively that federal expenditures on family planning consistently produced greater, not fewer adolescent (unwanted) pregnancies. Given the extremely high correlation coefficient of 0.882, we could say in a statistically accurate way that expenditures for contraceptives are advisable only if unwanted pregnancy is the goal. (5) Similarly, Jacqueline Kasun offered corroborating testimony showing that these contraceptive programs actually increased the total pregnancy rate among adolescents, and that declining adolescent birthrates were only accomplished by a drastic increase in the abortion rates, rather than through any claim to reduction in unintended pregnancy. (6)
The true effects of contraception
(contraceptives increase abortion and unintended pregnancy)
Proponents of contraception had expected modern contraceptives to reduce abortion rates, especially since abortions constitute truly unwanted pregnancies. This hypothesis has been tested repeatedly in demographic analyses. These surveys consistently show that contraceptives increase abortion rates, thereby exacerbating the abortion/unwanted pregnancy syndrome. (7)
If we look at U.S. abortion statistics, we will see that while prescription contraceptives have been available since the 1960s, and most eligible women had obtained them by 1975, U.S. abortion rates still continued to climb until 1990. Among African-American women, rates continued to climb until 1997, and African-American pregnancies were aborted 30 to 100 percent more frequently than other U.S. pregnancies. This is a highly selective racial disparity and a clear inequity, all the more disturbing considering that before this trend African-Americans had by far the highest rates of fertility, thus the most to lose, of all U.S. ethnic groups. (8)
The same statistics overall show sustained increases in U.S. pregnancy rates until 1990. Declining birthrates were achieved only until 1982, predominantly because of large increases in abortion rates rather than contraceptive efficiency. Regardless of any theoretical efficacy, on the practical level contraceptive technology appears ineffective even for the relatively simple task of overall reduction in pregnancies. The more difficult task of selectively targeting only unwanted pregnancies would therefore seem beyond the grasp of this technology. We are not aware of any Western nation showing reduced abortion ratios in the years following the ''contraceptive revolution'', and would challenge the bill's proponents to provide such proof.
Why contraceptives fail
The failure of contraceptives can be more easily understood if we avoid narrowly focusing only on their pregnancy prevention characteristics, and instead recall their more hidden feature -- obstruction of and interference with reproductive function. This antagonism is most effectively highlighted when contraceptive methods are considered alongside methodologies which harmonize with, rather than antagonize, reproductive health. The evidence that exists suggests that not all pregnancy avoidance methods increase abortion rates -- only contraceptives do. Modern natural family planning (NFP) methods, while associated with unplanned pregnancy rates comparable to those seen with contraceptives, seem to have much lower abortion rates, (9) and preliminary data suggest high NFP satisfaction rates even when unplanned pregnancy occurs. (10) Pregnancies occurring in the contraceptive context seem more likely to be aborted, and this is not likely to be entirely explained by a pre-existing intentionality toward fertility control. (11)
Studies evaluating abortion decisions show pregnancies to be accompanied by shock, panic, and even denial; a nearly automatic and non-reflective abortion decision frequently is the result. In the minds of aborting women unwanted pregnancies can be the ''death of self''. Often, the decision is made even before the pregnancy test. (12) This suggests the influence of primitive, atavistic, and possibly preconscious motivations and points to the possibility of neurobiologically patterned or conditioned behavior in response to the pregnancy challenge.
While clearly needing adequate study, an inclination toward abortion may be a decisive characteristic of contraception which places a wide gulf between it and noncontraceptive pregnancy- avoidance methods (NFP). Such an enormously important contrast would have to be acknowledged honestly because of its impact on both maternal and child health. Certainly mammalian research shows that maternal behavior is not automatic, but rather must be prepared in advance by certain neurobiological and hormonal factors associated with ''attachment''. (13) If the most important of these factors are associated with sexual intercourse, as is likely, it is conceivable they are impeded by anticonceptive interventions. This would not be the case with NFP, since there is no interference with sexual and reproductive mechanisms.
Noncontraceptive health benefits?
EPICC's proponents point to alleged noncontraceptive health ''benefits'' such as prevention of anemia, ovarian cancer, dysmenorrhea, benign breast disease, and acne. (14) However, by definition contraceptive interventions can have no such ''health benefits''; those who say otherwise violently distort basic concepts of health and illness, reducing them to utterly meaningless concepts. According to this concept we would have to begin to consider disease and even death itself to have ''health benefits''. After all, the deceased never develop cancer or diabetes. For each of the diseases allegedly prevented, contraceptives have introduced a new disease which cancels out the possibility of the ''prevented'' disease, both diseases being at opposite ends of a single spectrum of function. As an analogy, the thyroid gland can secrete too much hormone or too little hormone, both disease states at opposite ends of the spectrum of thyroid function. However, we never consider hyperthyroidism to be a health benefit because it ''prevents'' hypothyroidism.
So, where the pill causes normal bleeding to stop there is a new disease, the absence of menstruation (secondary amenorrhea). A woman who cannot menstruate at all cannot menstruate excessively, but this cannot be considered healthy prevention of excessive or painful bleeding and anemia. Otherwise polycythemia (having too much blood) would be considered healthy prevention of anemia (having too little blood). (15) Similarly, the pill causes interruption in the cyclical ovarian function of ovulation, which includes multiplication of ovarian epithelial cells. Cells that cannot replicate normally also cannot replicate cancerously but this is ovarian insufficiency and premature senescence, rather than healthy prevention of ovarian cancer. This is the likely reason that users far more often require hormones in the menopause, (16) and this also explains cases of persistent amenorrhea which often occur after discontinuation of hormonal contraceptives. (17) Oral contraceptives are associated with breast cancer and fibrocystic disease, hardly a situation of benign breast disease ''prevention''. (18) Similarly, when the pill causes horrific and potentially fatal skin diseases such as porphyria, neurofibromatosis, and malignant melanoma, it is obvious skin health has declined. If less acne occurs, it is because the normal function of acne-producing glands is interfered with. (19)
The concept of ''benefit'' presented here is well illustrated by another analogy. Numerous studies could prove that removing both kidneys in healthy individuals would reduce the incidence of kidney cancer, but in no way would this intervention be a ''health benefit''. But perhaps a terminally lazy patient who preferred undergoing dialysis rather than undertake the effort to urinate might rationalize that this was beneficial. However, such a patient would be denied this ''therapy'' regardless of his personal preference and lifestyle choice. The noncontraceptive, so-called ''health benefits'' of modern contraceptives represent just this sort of rationalization.
When patients become unhappy with normal sexual function and want to disturb reproductive health, the clinical situation demands counseling, not contraceptives. Physicians should encourage patients to understand and accept the meaning and consequences of sexuality, rather than punish the body in order to nullify the human significance of freely-chosen acts, while evading reality.
Conclusion
The preceding information has been a very brief primer, a medical refutation of the arguments of EPICC's proponents, prepared by The Edith Stein Foundation. It is by no means exhaustive, and strong evidence of increased rates of cardiovascular death, blood clots, suicides, accidents, domestic violence, divorce, birth defects, prolonged and incurable infertility, STDs, autoimmune diseases, and some 60 other conditions which afflict women and stem gratuitously and unnecessarily from prescription contraceptives, could have been provided.
EPICC would have disastrous consequences for the health of America's women and children, and would disproportionately afflict African-Americans and the poor. Why would we mandate health coverage for a toxic intervention which impairs the health of women? From a different perspective, if prescription contraceptives constitute basic health care, why has the medical profession and the medical insurance industry traditionally considered them not to be so? If contraceptives constitute legitimate intervention, why is legislation now necessary? Why can't the insurance industry be persuaded of their legitimacy?
We propose a program of study and investigation as to the real role of contraceptives in women's health, a program which would have to resist an ideological attachment to contraceptives, and embrace an openness to noncontraceptive alternatives. EPICC would impose by finance what has not been successfully implemented by ''choice'' -- a debilitating surrender to the fear of pregnancy which is already the greatest threat to women's reproductive health and freedom, and we think this bill should be roundly rejected. We respectfully suggest to legislators that they demand scientific proof for the unrealistic and impossible claims made by EPICC's proponents.
References
(1) Transcript of testimonies available from C-SPAN, Sept. 10, 2001. Sen. Barbara Mikulski, Chair.
(2) ibid, testimony of Dr. Anita Nelson.
(3) Klerman, LV. The intendedness of pregnancy: a concept in transition. Matern Child Health J 2000 Sep; 4 (3): 155-62.
(4) Brown, SS and Eisenberg, L. From the Institute of Medicine. Unintended Pregnancy and the Well-being of Children and Families. JAMA, Nov. 1, 1995 -- Volume 274, No. 17, P. 1332.
(5) Roylance, S. Testimony before the United States Senate Committee on Labor and Human Resources, March 31, 1981; in Kasun, J. The War Against Population. The Economics and Ideology of Population Control. 1988, Ignatius Press, San Francisco. Page 142
(6) Kasun, J. Testimony before the United States Senate Committee on Labor and Human Resources, March 31, 1981; in Kasun, op. cit.
(7) Mohr, J. Abortion in America. 1978, Oxford University Press, New York; in Boyle, M. Re-thinking Abortion. Psychology, Gender, Power and the Law. 1997, Routledge, New York NY, page 83.
(8) Data obtained from the Web site of the National Center for Health Statistics. Health U.S. page, tables 3, 16, and 17. At www.cdc.gov/nchs/datawh/statab/unpubd/natality/natab97.htm.
(9
) Mikolajczyk, M. and Rauchfuss, M. Different concepts of dealing with fertility: a comparison of Berlin and Krakow. Geburtsh Frauenheilk 2001; 61: 121-126.
(10) Klaus H. et al. Use-Effectiveness and Client Satisfaction in Six Centers Teaching the Billings Ovulation Method. Contraception 1979 Jun; 19 (6): 613-29.
(11) Boyle, M., op. cit. page 83.
(12) Curtis J. Young. The Missing Piece. Adoption Counseling in Pregnancy Resource Centers. 1997, Family Research Council, Washington D.C.
(13) Kraemer, G. W. A Psychobiological Theory of Attachment. Behav. Brain Sci. 15: 493-511, 1992.
(14) Burkman, R.T. et al. Current Perspectives on Oral Contraceptive Use. Am J Obstet Gynecol volume 185. No. 2, supplement 5. August 2001. Pages S4-S12.
(15) Chasan-Taber, L. et.al. Oral Contraceptives and Ovulatory Causes of Delayed Fertility. Am J Epidemiol 1997; 146:258-65.
(16) McNagny, S. E., et al. Personal Use of Postmenopausal Hormone Replacement Therapy by Women Physicians in the United States. Ann Intern Med 1997 December 15; 127 (12 ): 1093-6.
(17) Bracken, M. B. et al. Conception Delay after Oral Contraceptive Use: the Effect of Estrogen Dose. Fertility Sterility 1990; 53: 21-7.
(18) Miller, D. R. et al. Breast Cancer before Age 45 and Oral Contraceptive Use: New Findings. Am J Epidemiol 1989; 129: 269-80.
(19) Neinstein, L. S. and Katz, B. Contraception and Chronic Illnesses: a Clinician's Sourcebook. 1986, American Health Consultants, Atlanta Georgia.
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