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Contraception, and informed choice

March 24, 2010

In the interests of keeping the last post really Just the links, I’ve moved comments I couldn’t resist adding over to this new one. And expanding them a lot.

The article at AlterNet which prompted me:

*The Dark Side of Birth Control: The Pill Still Has Many Adverse Affects Glossed Over By Big Pharma
“Women have come to accept with little question that contraception should be their responsibility. . .If men were asked to take a hormonal therapy that would cut off the healthy production of their sex cells, would they take it? Would they take it if it would reduce their sexual appetite and adversely affected their moods? Would they take it if it increased their risks of developing high blood pressure, metabolic problems, certain cancers and having a stroke? Maybe. Yet, women everyday take on these risks to suppress ovulation without ever considering whether they are losing something essential when they do so.”

Here’s the ad I am talking about; I found it on YouTube.

Recently, I have been disturbed by a “know your options” PSA on British television, aimed specifically at young women (16-24), in which they have been pushing contraceptive implants (and IUDs)–presumably because they’re cheap and long lasting. NHS patient information on implants includes very little about risks. A “Disadvantages” page is not much more comprehensive, on implants and injections combined; they never mention cardiovascular risks nor metabolic changes such as insulin resistance, and gloss over bone loss. They do not mention that the very common weight gain could be a sign of insulin resistance, which could develop into diabetes if allowed to continue. These are all things that women should know about. Endocrine disruption that causes bone mineral loss is never a laughing matter, never mind the rest of it.

Pushing medications at young women, while deciding they don’t even need to know about potential risks, strikes me as particularly slimy. Who has the power here, even when we’re not talking about poor and/or minority young women? How seriously are young women generally taken?

Norplant was removed from the UK market due to adverse effects and lawsuits, and Implanon does not sound much better. Implanon can also cause diabetes, like Norplant and Depo-Provera. They are all very similar, long-acting, progestogen-only products. There are a lot of risks (a must read!), and CWPE rightly points out that these methods are highly provider controlled, not controlled by the woman. Where is the informed choice here?

CWPE also has a paper available on Implanon: Basic Information and A Feminist Perspective, Women’s Global Network for Reproductive Rights (WGNRR), in their Sex, Lies, & Contraception category. This confirms that there is very little difference between Norplant and Implanon in terms of side/adverse effects.

I was also concerned that the PSA seemed to be pushing Implanon as a convenient option for women whose partners might be pressuring them not to use this (any?) method, at 0:22. That does not seem to be the intended message, but hey, he doesn’t even need to know you have an implant at all! Someobody might suggest that I’m reading too much into things, but it’s more than a little disturbing in context: Partner Abuse and Unintended Pregnancy in Young Women, and When Partner Abuse Isn’t a Bruise But a Pregnant Belly. This happens, and young women know it even if the people making these ads don’t. This ad reinforces the idea that it’s OK for a male partner to voice objections to a young woman’s contraceptive choices, and it’s somehow up to her to convince him it’s a good plan.

Not to mention the idea that young women are totally responsible for making sure they don’t get pregnant. Whatever it takes.

I am also more suspicious of the levels of “choice” involved, based on personal experience with NHS doctors and birth control (especially once they had dismissed me as crazy). I can only think of the Mirena IUD episode as medical rape (and I have been raped). I had the shakes and was almost passing out from pain* for several days afterward, and could not make myself go back for any followup. This is a fairly extreme example of refusing to listen to what a woman has to say about her own contraceptive needs and experiences–much less wants–but it reflects a wider pattern all too well.

I was less than surprised to read about some of the ways other women using Mirena under the NHS** had been treated, and their side/adverse effects dismissed–if not outright blamed on things like their weight (i.e., if it’s a real problem at all, it’s your own damned fault). Some people’s systems just can’t tolerate any of the progestogen-only methods, and there seems to be very little recognition of this–or effects like nonstop bleeding and cramping are deemed “minor” by clinicians. Mirena is also cheap, requiring basically no provider effort over a 5-year time span. Especially if they just don’t want to know about any side/adverse effects the person experiences. Where’s the downside?!

The CWPE Dangerous Contraceptives: Norplant and Depo-Provera piece I mentioned earlier makes some excellent points about informed consent, specifically as it applies to women and contraception. Just a few highlights:

This “we need more choices” approach to contraceptives, however, ignores several important factors such as the fact that these methods have been associated with serious physical and societal risks. In addition, the methods have a history of unethical testing on poor and politically powerless women subjects. This history repeats itself as doctors and policy-makers market the methods to young, poor women of color and judges’ sentence women on trial to taking Norplant or Depo-Provera as part of their punishment. It is clear that taking Norplant or Depo-Provera is not a “choice” for many women. . .

Sacrificing Women’s Health to Pregnancy Prevention… By minimizing these potentially serious side effects, we are basically told that we, as women, are not entitled to sex and health, too. The message from providers and policy-makers is that if you have sex, you must pay the price in unwanted pregnancy or debilitating side effects. . .

The new “choices” of Norplant and Depo-Provera are administered by doctors rather than by women themselves. . .This decreases women’s autonomy and instead makes us depend on others when we are trying to control the most intimate detail of our lives—when and whether to have children. It also reinforces power imbalances between women (who are the actual experts about their own bodies) and their health care providers who are deemed the true experts on women’s bodies.

As has come up in other posts, I am all for true informed consent, and knowing what all your options are. Talking about the options is futile if you have very little information to base any decisions on. That is not informed choice, even if the clinician is listening to you.

______________

* I know pain. That was truly awful, at least in part because the GYN was very rough indeed.

** “Under the NHS” is an apt way of putting it, IME, with all the bad institutional stuff built up. The medical system in the US is crappy in too many ways to count, but the NHS demonstrates every bit of bad HMO behavior possible–including a rather strict formulary, numerous series of hoops, and hoping you will just go away instead of costing them anything. Being close to the only game in town has not helped. I have spent years uninsured in the US, several years under a privatized Medicaid managed care disaster, and six years with seriously inaccessible health care and shoddy treatment under the NHS; the results have been eerily similar, other than the amount of respect with which I’ve been treated. I even got treated more like a human being on disability-based Medicaid. In all of these situations, I’ve had to figure out how to live with poorly- or just plain untreated health problems.

The main practical advantage over being uninsured in a fee-per-service system? I’m probably not going to be allowed to die, receive only minimal lifesaving treatment, and/or wind up financially devastated if something really bad happens. (I have seen the financial consequences of an insurance company refusing to pay for my stepdad’s cancer surgery; my mom was actually better off totally uninsured.) If I get hit by a bus or have a heart attack, the NHS may not provide top-notch care, but they will treat me for free. I don’t have to worry that they will not provide coverage due to an amazing variety of preexisting conditions (unlike my very real concerns about the upcoming move back to the US). Yes, that is worth a lot, and it does ease my mind. It still does not make the system good.

I do not want comments to devolve into “Waah! But the very existence of the NHS is so grand, how can you possibly criticize it?!!” Health care should be accessible to everyone, period. The basic idea behind the NHS is sound, but the implementation is so terrible they have tried to pick up ideas from Kaiser Permanente, for goodness’ sake.

That Monkeys With Power post, over at The Tao of Chaos, is very applicable here.

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