HEALTH CARE/Joan Retsinas

Over-the-Counter Contraceptives: The Battle

We revel in sex. In movies, advertisements, and song lyrics, people “hook up.” The pornography of the 1930s is boring: today’s readers would yawn through Henry Miller’s widely banned, widely denounced Tropic of Cancer. As for Oscar Wilde’s “love that dare not speak its name,” this generation wonders at the homophobia. A subsequent generation will wonder what “out of the closet” meant. All those Puritanical strictures, those Victorian pronouncements evoke less-enlightened ages, beset by killjoys. Ditto for the Eastern cultures that cloak women in swathes of fabric, hiding their sexuality.

We 21st-century people are definitely not killjoys. We who have felt the earth move beneath our feet, the sap rise, the heart go flutter (those lyrics of desire really do signal the rush that makes us want to hold somebody’s hand) profess to enjoy sex more than our straiter-laced forbears.

So the brewing battle over the chance to market oral contraceptives over-the-counter, like condoms, evokes a Monty Python world.

“Easy (a.k.a. no-fault) sex,” whatever the media suggest, has always been a misnomer. The possibility of pregnancy – a possibility that shaped those antiquated strictures we mock – hovers. Indeed, contraception is the word that nobody speaks. Consider the movies: on stage, men don’t wrestle with condoms; women don’t wrestle with diaphragms et al. Yet implicitly off-stage, they have wrestled. The chance of one sperm uniting with one egg, yielding a bundle of joy that will need diapers, food, and eventually college (according to some economists, a million dollar bundle) is not sexy.

For men, contraception is cheap and convenient – as close as the nearby pharmacy. But for women, contraception is more expensive, more complicated. It starts with a physician – the gatekeeper. For some contraceptives, the physician is of course crucial: a woman cannot insert an intrauterine device herself. But for others, the woman needs a prescription.

One barrier for women has been the cost – not just of the contraceptive device, but of the physician’s involvement. So women cheered when the Affordable Care Act covered contraceptives, without a co-pay.

Yet must women go through a medical gatekeeper for all kinds of contraception? Two medical associations, weighing the data, the risks, and the benefits, have said “no.”

The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians suggest that birth control pills might sit beside condoms on pharmacy shelves. These pills carry health risks, but so does pregnancy. In particular, women over age 35 and smokers should probably not take them. Yet women can be made aware of those risks. The Food and Drug Administration must make the final decision.

Befitting Monty Python, groups have lined up, pro and con. On the con side are women’s advocacy groups. They deplore the higher costs, for women, of the switch to over-the-counter status. Since insurers don’t reimburse over-the-counter drugs, the women who buy them must pay the tab, which can reach a few hundred dollars a year. Having a physician-gatekeeper raises overall costs, but under the Affordable Care Act, the insurer – not the purchaser — bears that tab. The physician-gatekeepers limit access – but ironically, many of these advocates – the daughters of mothers who embraced “our bodies, ourselves” — are willing to keep gatekeepers. On the pro side are not just the medical societies, but Republican senators. They see themselves pioneering sexual freedom for women – a U-turn from their previous stance of restricting women’s access to insurance, to abortion, to contraception. If the government can withdraw from an obligation to pay for contraceptive pills, yet give women easier access, conservatives can count that as a victory.

Just as the FDA approved the reclassification of emergency contraceptives to over-the-counter status (a move initially blocked by the Department of Health and Human Services), the FDA must weigh the pros against the cons for the profusion of pills, each with a different chemical formulation.

The missing voice in this battle: women who want the kind of easy sex the media exult – which means easier access to contraceptives. Maybe we as a society are not as sexually liberated as we think we are. Henry Miller might be smirking.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, November 1, 2014