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Emergency contraception: risk reduction at the Last Chance Saloon
Major health organisations want all teenage girls to have a supply of morning-after pills on hand. Are they crazy?
Recently the American Academy of Pediatrics called on all US pediatricians to counsel all their adolescent patients about post-coital contraception and make advance prescriptions for it available to girls under 17. The move came as no surprise. The AAP Committee on Adolescence has been advocating over-the-counter sales -- or, failing that, advance prescriptions -- of the morning after pill for all those in its purview for nearly a decade, as has the American College of Obstetricians and Gynecologists.
The main product in question (Plan B One Step) is a power-pack of the synthetic hormone progestin. It is designed to prevent ovulation but it can also act after ovulation and after fertilisation -- meaning that it can cause an early abortion. And that is not the only problem with “emergency contraception”.
With OTC provision already achieved for 17-year-olds -- and some states extending that to younger girls -- the AAP is now leaning on the profession to circumvent remaining restrictions. It has reiterated a 2009 policy according to which pediatricians “have a duty” to inform their patients about legal treatments such as EC, even if they have a conscientious objection. If they do, they must “refer patients to other physicians who will provide and educate about these services”. Failure to do so “violates this duty to their adolescent and young adult patients.”
The reckless teen years
One can understand where these health professionals are coming from. Emergency contraception is really Last Chance Saloon for the school of thought that says you can reduce the risks of teenage sex without tackling the sex itself.
It has long been obvious that teenagers, no matter how many lessons they have on the subject, are utterly unreliable when it comes to using ordinary contraception. Their brains, for one thing, are not up to it. The sexual liberation heralded by the pill meant never having to say no, but by the early 1990s the epidemic of “teenage pregnancies” had reached such proportions in the US that the federal government began -- what had been practically unthinkable for a couple of decades -- to support sex education programmes focussing on abstinence. This is probably the main reason that both birth rates and abortion rates among teenagers came tumbling down during the following decade, although the contraceptive brigade claim a greater share of the credit.
Still, popular culture is more and more sex-saturated, the experts’ messages are mixed (“It’s OK to say no but in the end it’s your choice -- so long as you use a condom and take your pill”) and many teens are sexually active. Studies cited by the AAP suggest that 43 percent of 15- to 19-year-old girls (42 percent of boys) have ever had sex -- though the proportion varies from 13 percent of 15-year-olds to 70 percent of 19-year-olds.
What worries the professionals, apparently, is not so much the juvenile sex but its the results. The most recent figures show that 57 percent of teen pregnancies ended in live births, 27 percent ended in abortion, and 16 percent ended in miscarriage or stillbirth. Behind these figures is a mixture of personal motives, morals and life-changing experiences, but to professional bodies like the AAP they represent above all a public health problem -- that is, a problem with a big price tag. The medical, psychological and financial support for all unwed mothers costs the US government more than $11 billion a year, according to the Brookings Institution.
As the AAP says in its recent policy statement, “Pediatricians have an important role, through their interactions with adolescents, to address the major public health objective of continuing to reduce adolescent pregnancy in the United States.”
Now, the most professional way to do this would be to spearhead another big campaign for abstinence education -- which the contraceptive lobby has done everything it can to destroy. But the AAP and similar bodies (the ACOG and the American Medical Association among them) clearly do not intend to deploy their considerable influence in that direction. For them, reducing pregnancies means reducing the risks of premature sex rather than prioritising avoidance of risks through delayed sexual initiation.
And since the condom and the pill won’t do it, emergency contraception is their last chance to show that the high personal and social costs of sexual liberalism can be contained. Even if it means getting young girls to medicate themselves with a dose of hormones up to 15 times the strength of ordinary contraceptive pills -- a treatment whose long-term effects are largely unknown.
How will emergency contraception affect girls' health?
Not all doctors dealing with adolescents think this is a good idea. The American College of Pediatricians represents some of the dissenters. It promotes “a society where all children, from the moment of their conception, are valued unselfishly”, and, among its core values, “Recognizes the physical and emotional benefits of sexual abstinence until marriage and pledges to promote this behavior as the ideal for adolescence.”
The reasons for their stance are summed up in an excellent paper published recently in the Journal of Human Sexuality: “At Risk Single Young Women Having Non-Marital Sex” (see ACP website: Recent Releases). Abstinent teens report no worries about pregnancy or STIs, they look forward to a good marriage, feel emotionally healthy, have more self-esteem than their non-abstinent peers, and avoid the emotional pain when a relationship fails -- as a teenage affair almost certainly will.
The alternative exposes young women to a multitude of risks. Along with unwed motherhood, there often comes failure to gain educational qualifications, and poverty for themselves and their children. They are likely to have more sex partners in their lifetime and are at greater risk of divorce or missing out on marriage altogether. Abortion -- which is actively encouraged by health providers -- carries risks of its own, psychological, spiritual and physical.
A risky business
Even if they avoid pregnancy, sexually active young women are at much higher risk of depression and attempted suicide than their non-active peers, because on the whole they are more emotionally involved in a relationship than their male counterpart and even more physically bonded thanks to the power of the much publicised “love chemical” oxytocin. They are more likely to be exploited by older boys and predatory men and to experience dating violence (10 percent of sexually active teens report being forced at first sexual intercourse). With a supply of Plan B at home a girl who has been sexually assaulted may avoid going to an emergency department for a forensic exam and counselling, thus putting herself at risk of further assaults while the perpetrator remains at large.
A major risk, obviously, is sexually transmitted infections. STIs are rampant in the US and many other developed countries. An estimated one in four girls aged 15 to 19 has a sexual infection. And then there are the boys.
Contraception other than condoms (which teenagers use erratically) do nothing to prevent STIs but rather increase the risk of infection for girls. Hormonal contraception increases the vulnerability of the immature cervix at a point known as the “transformation zone” -- a major reason for the alarming prevalence of the cancer-causing HPV virus among the young and the fortune being spent on immunising girls against it.
In the face of all these risks, emergency contraception can eliminate only two: birth or abortion. Given the social and fiscal implications of unwed motherhood, and the general acceptance of abortion in the public health establishment, experts in that field think that is enough to justify its widespread use. There will be fewer unsupported moms, less poverty, no knock-on effect to the next generation. Brilliant. All the downside of juvenile sex itself pales into insignificance.
Where's the evidence for lower teen pregnancy rates?
There is just one fly in the ointment, however. No-one has shown that emergency contraception can actually reduce unintended pregnancy rates in a country like the US, or virtually anywhere. In a very recent paper, “Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy”, one of the chief advocates of EC, James Trussell of the Office of Population Research at Princeton University, concedes that “only one of 15 published studies has demonstrated that increasing access to to ECPs can reduce pregnancy or abortion rates in a population”.
The one study that did show a population effect from advance provision of ECPs was carried out in Egypt among nursing mothers relying on breastfeeding to avoid pregnancy. When it comes to responsibility, such women are in an entirely different category to 16-year-old Americans who get drunk and sleep with someone they met at a party.
American studies show that even with advance provision of ECPs, up to 45 percent of women do not use them after unprotected intercourse. What seems to have happened in the studies is that women already diligent about using contraception began to use ECPs instead and to engage in riskier behaviour, whereas high risk women kept right on taking risks.
And yet… Dr Trussell, the AAP, the AMA, the ACOG and Co insist that even if emergency contraception has done no overall good, so far it has not done any overall harm, in the sense of increasing teens’ rates of sexual activity or STIs. Though its cost-effectiveness cannot be established and a “major public health objective” remains elusive they maintain that women (including girls) have a right to what is a “safe” and “effective” method of birth control if it is actually used.
They really seem to think there is no alternative. It’s risk reduction or public health Armageddon. Moreover, they intend to force all health providers into this mould with their talk of “duties” which may not be “violated” by doctors who conscientiously object to this scheme.
But risk avoidance through abstinence is a real alternative, if only the professional bodies would throw their weight behind it. As the American College of Pediatricians’ paper on the risks of non marital sex concludes, referring to some of the evidence, “This is not an impractical or unattainable goal… Both parents and professionals must raise the primary public health principle of risk avoidance to its proper place in the promotion of optimal sexual health.”
Nothing less is worth offering to young people, who have so much to lose from sex before marriage -- even without the babies.
Carolyn Moynihan is deputy editor of MercatorNet
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