Contraception and population health: changing the narrative

Following up on a lecture on the determinants of contraceptive use by Prof. Jenny Higgins, Pop Health 795 student Katherine Brow comments on a recent executive order from the Trump administration affecting requirements for employer health plans to pay for contraception.  She writes:

During Dr. Higgins’ lecture today, I could not stop thinking about how relevant her discussion on changing attitudes regarding contraception use is to current legislation and policies being pushed by our current administration. On October 6, the Trump administration rolled back the Obama-era requirement that employer-health plans cover birth control methods at no additional cost to their women employees, on the basis that this requirement infringes on the employer’s rights to religious freedom. Although its predicted that many companies will continue to provide coverage for birth control, this new rule creates a huge loophole for any employer who doesn’t wish to provide coverage and thus many women will be forced to pay out of pocket for their prescriptions.

What I find to be the most devastating ramification of this new rule is the affirmation by our government that access to contraception and the basic tools for sexual and reproductive health is not considered to be an inalienable human right. It makes access to contraception and basic control over reproduction even more of a privilege – this policy won’t affect affluent women who can still afford insurance that covers contraception, but rather those who depend on their employer to provide coverage. The same administration is also launching attacks on organizations like Planned Parenthood that provide care to disadvantaged individuals who don’t have the insurance to cover birth control. After this new rule rolled out, the response on social media condemning this action was overwhelmingly based on the fact that many women go on birth control for a slew of reasons: including management of irregular, painful, or heavy menstruation, control of premenstrual symptoms and acne, prevention of bone thinning and anemia, among many others. These are all extremely legitimate reasons for a person to go on birth control but what stood out to me is that the majority of people didn’t talk about one of the major (if not THE major) reason women choose to go on birth control: to prevent unwanted pregnancy. Since the beginning of the reproductive rights movement, advocates have had to market the pill and other methods as being a medically relevant good in order to overcome the enormous stigma against positive female sexuality.

So, this leads me to my biggest question following Dr. Higgins’ lecture: how can we shift the overall narrative of contraception as a medical good to a sexual good when we are still fighting for the social and legal legitimacy of birth control? How can we assure the sexual acceptability of contraction for all women when it’s still a privilege simply to have access to quality birth control? As Dr. Higgins discussed in lecture, we can start this cultural shift within our own personal relationships with family members, clients, or patients, which can give a lot of hope in times where significant change seems futile. And going along with the general theme of this class; we do have evidence-based research and measures of the sexual acceptability of contraception – we just have to continue our work and empower others so that change is possible.

 

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9 thoughts on “Contraception and population health: changing the narrative

  1. I have recently been reading about this framing of “I use birth control because of X (some other reason than to prevent pregnancy”. It is extremely interesting. There are many instances were women are socially pressured into softening, couching, or framing legitimate actions or desires to avoid some adverse reaction.

    Call me extreme, but I think this is part of the patriarchy not recognizing women as fully human, able to make their own decisions and control their own bodies. The patriarchy wants to keep the current system in place, and the current American system professionally punishes women (again, you may call me radical, but this is a “sincerely held belief” just as “birth control is wrong” is a “sincerely held belief” of Hobby Lobby, etc).

    To put my two cents in with the questions you pose, I would say the first step is assuring birth control is available for everyone who wants it, and that it is not a privilege but a right. Once it is more accepted as something people should have access to, I think it will be so much easier to start changing the narrative. I don’t know if the other way around, as you suggest, would be easier. I sincerely hope no matter which way it occurs, birth control does not remain something for the economically comfortable!

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  2. I was also very much struck by many of the points that Professor Jenny Higgins brought up in her lecture regarding the “pleasure deficit” in contraceptive use research. I think the current administration’s narrative regarding birth control and access to sexual healthcare is troubling because, as you point out, it directly targets low-income and disadvantage populations. This is even more so troubling to me because I was recently a high school science teacher in Milwaukee Public Schools. I taught a Human Anatomy/Physiology course where inevitably, since I was teaching teenagers, the topic of sexual health would come up. Many of my students had been pregnant (and either given birth or undergone abortions) or were currently pregnant. While many had the stability in their families to be able to deal with an unexpected pregnancy and infant, many did not have these familial resources to rely on. What most struck me was these were essentially children who were attempting to raise children with (frequently) less than a high school or even middle school education. After what we have learned about the socioecological model and all of the factors that affect longterm health and especially brain development, I think, in many cases, it would be difficult for these teenagers and their children to be successful and healthy later in life. While I am not suggesting that it isn’t possible to break the cycle of poverty in this case, I just can’t imagine how difficult it would be to do so.

    This is exacerbated by the fact that, without access to proper sexual healthcare, this cycle is likely to continue. Studies have shown that abstinence only campaigns are unlikely to be successful; yet, there is research to suggest that a sense self-efficacy, knowledge, and motivation (both personal and driven by social norms) are likely models of success for intervention programs. However, this obviously requires access to care, knowledge of what is or is not available, and a change in the norms surrounding sexual health and wellbeing. As Professor Higgins pointed out, for a society that uses sex to sell almost anything, for some reason the narrative of sex as “good” is lost when it comes to the practice of sexual health and wellbeing especially with regards to contraceptives.

    My last point is simply that I am frankly at a loss for what to do. Lawmakers have made it so there is increasingly less access to general healthcare, contraceptives, and sexual health services, which seems to be a double whammy for those who are low-income and disadvantaged. These new policies just seem to be another tool in which we are increasing the inequity in our country, and I simply do not know what our options are to change these policies.

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    • Grace,

      I agree with your post, for me, the pleasure deficit was the point that resonated the most. Now every time that I see a Viagra commercial I remember this lecture. How contraception is portrayed is very patriarchal. It is unbelievable that the current administration is deciding to permit employers to deny the coverage of birth control in their healthcare plans.
      The solution is to be vocal about it and support planned parenthood, because in the end, the minority women are the ones affected the most, perpetuating the health disparities.

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  3. Dr. Higgins’ lecture also struck me in several ways. It was nice to hear her say all the hard things in the right way. So many of her comments resonated with me and I’m excited to keep following her research.

    While I think Dr. Higgins’ lecture brought up so many good point, I agree with Katherine that it’s hard to think about changing birth control from a medical good to a sexual good. It would seem to me that a sexual good would be a harder sell to keep mandatory in insurance coverage. I think looking at birth control as a sexual good in our research is the right direction, especially when taking into account the pleasure gap, but I’m not sure the political climate is ready for it to change elsewhere. I don’t know the answer, but I’m glad we are having the tough conversations and challenging each other to keep thinking.

    I wonder if just empowering women to have conversations with partner’s and family members to inform the male population of what is really going on when women take birth control would be helpful. I found this video (linked below) made a couple years ago where they interviewed men about birth control. Most of them don’t know the basics or really understand all the effort that goes into it. After the interview, they were asked if they would take a birth control if it was available. Most said yes and they would want to share in the effort (as long as the side effects were ‘not too bad’). I couldn’t find this other video, but I remember watching it where they interviewed men about certain side effects of birth control (without saying they were from birth control) and asked if they would be able to handle them if they were on a prescription. Most said they would not. At the end, they revealed all of the side effects they talked about were from birth control and many were shocked. I guess my point is here that we need to education the other half of the population of what birth control really looks like every day.

    Another thing I couldn’t get off my mind during the lecture was the use, or non-use, of contraceptives in animals. I am a dual degree DVM/MPH student and know that contraceptives are available for some species but as generally not used. In fact, most vets highly recommend NOT doing contraceptive for female animals as adjusting with the animal’s hormones can get messy and risky. That is not to say that animal contraception isn’t done, but it’s much rarer. I find it so interesting that in my field of health care, contraception carries so such risk, but there are so many women that are walking around with these risks every day.

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  4. This topic is very important to me considering this was a large part of my job for the last two years. Birth control has so many amazing benefits, and our patients would be on it for a variety of reasons including preventing unwanted pregnancy. I really like that she brought up the point women’s libido is a factor in which method women choose. Women should be able to find a method that works for them, and thankfully there are many options (unless medically indicated) for them to choose from. This definitely gets ignored I feel like in the conversation about birth control. Many women would ask, well what’s the best birth control? It really depends. Are you looking for the most effective at preventing pregnancy, or do you want your method to help with something else. It is important to understand everyone has a different idea of what is the best birth control for what purpose they want to use it for and if they are okay with side effects or not.

    As far as how to shift the narrative, I agree with Kelsey that it must be a right first for all women to have access first. Working in a clinic that relied heavily on Medicaid reimbursement, it is more than frustrating to see what our government is doing. With more access and education about contraceptives would comes acceptance. Until our government grants access, I sadly don’t think the conversation will shift.

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  5. My takeaway from Professor Higgin’s discussion on how to proceed with the conversation regarding birth control access echoes sentiments I experienced in my own research regarding reproductive rights and abortion. In an environment where some legislators don’t believe that birth control should be available as a medical good, it will be difficult to make progress in trying to discuss birth control as an important resource for women’s sexuality. This conversation is definitely worth having, but there is evidence to support that a realistic way to keep birth control accessible is to keep discussing it as a medical good in certain contexts. From my own management experience and from reading management literature, if you want people to agree and work with you towards your vision, you need to talk to them in terms of their goals. You will have a lot easier of a time getting people to agree with you if you incorporate their priorities into yours. So, if it is difficult to get some legislators to see the importance of birth control for women’s sexuality (which would be/is an unbelievably depressing reality), then continuing to work with them under the assumption that birth control is, first and foremost, a basic medical necessity might yield the desired results of making birth control more accessible.

    Birth control debates are not the only place we see advocates deploy specific rhetoric to further their agenda. In my research with pro-choice advocates, these activists used abortion’s medically necessary properties to bolster its legality. From conversations with activists, it was clear that many of them thought abortion should be legal because of their personal morals and feminist beliefs, however, when advocating for abortion access, they discussed it as a necessary medical service in an effort to communicate with their opponents in a way they thought would be more effective. This deliberate rhetoric is a tactic towards progress that we should not reject.

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  6. What baffles me about this topic and the rest of the pleasure deficit, is the double standard between men and women. I too thoroughly enjoyed Dr. Higgin’s lecture, and my opinions echo many of those who have already posted on this topic. Another example that comes to mind is the difference in approach to talking about Viagra and birth control, both in terms of coverage and research perspective. Trump speaks about taking away birth control coverage under his new health care plan, but yet no mention of funding cuts toward Viagra. Many providers can claim Viagra is prescribed for hypertension instead of erectile dysfunction, but apparently similar logic does not apply to birth control even though it is often prescribed for many other reasons besides pregnancy prevention. It’s yet another double standard contributing to the gender gap.

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  7. One idea to change the attitude about birth control in the current climate is to think about how we talk about birth control. Calling birth control, birth control may well be part of the current problem because with this name, birth control is linked to contraception and thus, indirectly linked to abortion in certain religions. What the above comments have already said is certainly true: women take birth control for a number of reasons besides preventing pregnancy. Thus, it would be factual and may be better to call “birth control” by another name. Without a clear understanding of the science behind birth control, I cannot posit a better name, but surely the drug name or the active ingredients would be a good place to start!

    The premise behind this idea is that if birth control is known by another name – one associated with the health benefits of the hormones – than it may start to be viewed differently over time. One major limitation to this idea is that its hard to change the way a population refers to a product that has been referred to as one thing colloquially for so long. However, this may not be determinative because we have seen major cultural shifts in attitudes and verbiage.

    Finally, it is important to note that the minutia of insurance law is reserved to the states, not the federal government. Thus, there is a difference between President Trump saying birth control will not be covered, and that actually happening. People who are part of federally-funded systems such as Medicare would be impacted, but, for private insurance plans, the decision would be made on a plan-by-plan basis within the states. The major legislative change would be not requiring insurance companies to cover birth control which is currently the case under the ACA. The impact of this has been predicted to disproportionately affect people in certain geographic regions of the United States and lower SES individuals which leads to a much broader discussion about insurance and population health!

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  8. I agree with Kathrine’s point of further creating the health disparity gap of socioeconomic privilges. Katherine states that this policy will cause an issue to women who may not be able to spend any part of their income (out of pocket) on contraceptive methods. This past summer I interned at the UW Public Health department on a Community Health Needs Assessment on low birth weight in African American babies. I wanted to tie this article into my experience. We also learned in this class about the wear and tear on the body due to stress – this ties to the health of African American mothers who have that wear and tear to their bodies and passing that down into their genes and having high rates of low birth weight babies. If a plan was in place to have reproductive couseling where mothers are not trying to get pregnant in a certain amount of years to become heathly to have a baby, this could be an issue if they cannot afford contraceptives.

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