How Accessible Are IUDs?


Earlier this month Newsweek reported that IUDs are becoming more popular as a form of contraceptive. Reporter Meredith Melnick discussed how the 2005 FDA approval of IUDs among younger women who do not have children has affected the increase in usage. I was not surprised when Melnick reported that some doctors do not support this method for younger women for various reasons. As someone who got an IUD in 2007 before I was in my 30s, I had a very hard time accessing the method of my choice.

Growing up with Puerto Rican hippie parents, I remember my mother telling me that the birth control pill kills Puerto Rican women. And it did. I knew at an early age that condoms were the method I was going to use before even considering a hormonal method, which was not appealing, and still isn’t. Even when the morning-after pill/emergency contraceptive came out I wasn’t too into the option for myself. However, as someone who provided counseling on all options to young people, I also knew where my personal boundaries stopped; it was my obligation never to interfere with my client’s options counseling. Several of my female-identified clients opted for hormonal methods.

My graduate research in sexuality, Latino communities living in the U.S., and women’s health complimented my family’s narrative of forced sterilization of women of Color in the Caribbean and women with disabilities in the US. Knowing these facts and choosing to work in a field that has such a troubling history, I considered myself an educated consumer when it came to birth control and contraceptive options. When I found a steady sexual partner I decided to look into getting and IUD, the only method outside of condom use that I knew was for me.

As someone who has the privilege of having health insurance in the U.S., I made an appointment to see my private physician. At the time I was employed fulltime and was insured via the union of which I was a member. We had pretty good health care, or so I thought, as I rarely had to pay out of pocket for seeing a physician or for prescriptions. I met with him and I shared that I was interested in the IUD. He informed me that my insurance did not cover the IUDs (there are twp available in the U.S., a ParaGard which can be used for up to 10 years, and a Mirena which can be used up to five years and has hormones). I asked him what methods were covered by my insurance and he said all hormonal methods (besides the hormonal IUD) and sterilization.

I was in shock.

I told my doctor that we would need to talk further about my options and how much the IUD would cost out of pocket. He shared the IUD would be about $600 for insertion and for the actual IUD (apparently they are two different costs). I asked about sterilization and he shared that I had two options: a “traditional” tubal ligation which would require an overnight stay in a hospital and follow up appointments or a newer form of tubal ligation which is outpatient surgery called Essure. If I chose Essure I would have to also choose a hormonal birth control method to use as back up for three months. He also told me about the risks involved and the 30-day waiting period required for me to be sterilized.

As someone who knew the IUD would, basically, instantly work I was not too happy with these options. My physician and I continued to talk and he told me that before he would agree to perform any sterilization procedure on me that I would have to “prove to him I really wanted to be sterilized” because I had never been pregnant, was 28 years old, and he wanted to make sure I wouldn’t “regret” the decision. My response to his statement was honest, but it may have come off as me being flip. I asked him “how am I to prove to you I don’t want to be a parent?” I proceeded to share with him that I was not interested in pregnancy, childbearing, or parenting an infant child. I also shared that I was more committed to helping youth of Color age safely and successfully out of the child welfare system than I was to having a biological child.

What finally convinced him was when I told him that if I did decide to have a child I would come to him for fertility treatment. I signed the 30-day waiting period form for sterilization and made the decision to call my health insurance and ask how much of the $600 fee they would cover, if at all. To my surprise my health insurance said they would only cover $180 of my IUD. I asked how is it possible that they would cover 100 percent a tubal ligation which includes overnight stay in a hospital, general anesthesia (which has its own separate risks), antibiotics, and follow up examinations when an IUD, which takes less than 10 minutes to insert usually, costs significantly less, yet they do not cover in full. My insurance company said I could “appeal” their decision. When I asked how long that would take they said up to eight weeks (if that). I told the woman on the telephone that I did not want to be worried about my method eight weeks from now. I wanted the method sooner rather than later.

It made no sense to me. It still doesn’t make sense to me. How can we live in a country where we talk about “choice” and where anti-choicers love to say: “you should have used a method” or “been responsible” when people who are being as responsible as they can be cannot access the method of their choice? How was my choice to decide what went into my body and what affected me (and who got money based on my care) gone?

After some research I found a city hospital that agreed to insert the IUD for me for free as they had federal funding. I was at a hospital that worked with many sex workers and young women of Color in helping them maintain their reproductive and sexual health. It was the best place for me to get this method and I was extremely excited. I never thought I’d be as excited as I was. Perhaps that excitement stemmed from “getting over” on the insurance companies, or that I knew I was getting the method I always wanted, it felt good. My physician asked me if I minded having a resident sit in so they could watch the IUD insertion. I agreed and after 10 minutes I had the method of my choice and was instantly relieved at having one of the oldest methods, with the most longitudinal studies, and highest effectiveness rate.

To say the IUD has rocked my world is an understatement. There were some side effects that I was told about, but was not completely ready for, such as bleeding within the first two months, and difficulty feeling the thread to check the IUD after my menstrual cycle. I had never had to prepare or “clean up” the way I learned to the first several months of IUD insertion. At the same time I found it almost impossible to find and feel the thread of my IUD through my vaginal canal. However, my partner did confirm the thread was there, and also claimed to have “felt” the thread but it was not painful.

The Newsweek article presents the opinion of several doctors and researchers and their positions on providing the IUD to patients. The only doctor of Color mentioned, Dr. Hilda Hutcherson, is cautious about offering the IUD to younger patients because of what can happen if someone has an IUD and contracts an STI. She makes connections between IUDs, STI infection and how the two together can amplify infertility if the STI is untreated and that “fertility is really important.” That is true, if someone wanted to become pregnant. I understand this position, and realize that the IUD only prevents pregnancy not an STI, as every other hormonal method. We also know that infertility may be the result of many untreated STIs. What I’m not in agreement with some doctors completely against the method (which is different from being cautious about it) is that restricting our choices is not the most effective way to be a provider to a patient.

Have we not learned from what happens when patients are not given all of their options? Not told of all of the possible outcomes of a method? The idea that women have options when they choose to be responsible is very much an illusion for many. The idea that sterilization is no longer an option that doctors push for some women, especially as a woman of Color, and a Puerto Rican woman, seems difficult to believe from my personal experience.

Earlier this year I went to a book release event for Dr. Iris Lopez’s recent text: Matters of Choice: Puerto Rican Women’s Struggle For Reproductive Choice, which follows three generations of Puerto Rican women over 25 years who have decided on sterilization as their birth control method. Her findings are fascinating and I encourage readers to engage with the text beyond this article. Dr. Lopez provides readers the opportunity to hear Puerto Rican women share their own testimonies about why they chose sterilization, and their choices challenge how I view sterilization as well. Although I considered sterilization, I didn’t want to have to go through the procedure. The discussions of feeling liberated by some participants opens up dialogue about power, modes of survival for women in abusive and/or violent relationships, and “traditional” US ideologies around “liberation” and what liberatory sexuality means.

I’m excited to see the IUD becoming more popular. I also think it may be a useful long-term method for people who may need it the most. In comparison to other hormonal methods for young women, I think the IUD can be a realistic option. Not only do some hormonal methods take a while to work (about 30 days is the “safe” window period often mentioned for hormones to become effective), they can also alter the menstrual cycle of many young women.

For some of the young women I’ve counseled continuing to menstruate was essential to their ability to use a method while feeling safe in their home where parents and/or guardians monitor their cycle. For young people who are not comfortable touching their genitals (think using the NuvaRing), want a menstrual cycle (so Depo-Provera is not an option), don’t want a method others can see (such as the patch, which only comes in 1 color, a perfect example of the normalization of Whiteness and light skin in our society and around the world in reproductive and sexual health), that they have to remember each day (oral birth control pills,), or that can be checked discreetly by a physician (vaginal sonogram) if a parent/guardian remains in the exam room during a gynecological exam (this happens a lot more than some people might want to admit). I see the IUD as an option for transgender men as well, the discretion based on who their partners are is one that I may add a new understanding of safety and security to a community often exclude when discussing contraceptives and birth control options.

Even though the FDA has approved the IUD for all ages, there remain challenges even in obtaining information. Earlier this week my homegirl, reproductive justice activist and college student Bianca M. Velez shared on twitter: “When asking for a pamphlet of further info re: ParaGard on the website, it asks if the reader is 18 or older.” How accessible did you think IUDs were?

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Follow Bianca I. Laureano on twitter: @latinosexuality

  • nycprochoicemd

    Thank you for a thorough, thoughtful post on the barriers to increasing IUD use for young women.  You are right to cite the dubious history (and in some cases, present) of the medical profession with regards to giving Latinas (and all women) accurate, thorough information about all of the options available to them.  There remains a culture of paternalism in medicine, particularly when it comes to reproductive health.  Doctors seem to think they know better than their patients what will be best for them.

     

    I am glad to see that more young women are turning to IUDs.  Access remains a problem, as you report.  Many insurers don’t pay for it (it’s a side-effect of the for-profit, temporary nature of employer-based insurance; although an IUD is the most cost-effective birth control method, since women change insurers so often the insurer that paid for the method is unlikely to realize the cost savings), many physicians still refuse to insert them in women who have not had children or whom they perceive to be at high risk for STIs (FYI, preliminary data suggests IUDs may confer some protection against STIs due to changes in the cervical mucous! more studies needed, of course), and many physicians have not been trained in IUD insertion.

     

    I encourage you and your readers to visit http://rhedi.org/patients.php for some excellent fact sheets on different kinds of contraception options, the two kinds of IUDs, and some other information, available in English and Spanish.

  • dearface

    As someone who is gainfully employed full-time at a progressive health/advocacy organization, it’s somewhat comforting (and disturbing) to learn that I’m not the only one facing this contraceptive equity dilemma.

  • ksuchoice

    I’d have to report that IUD’s are not that easily accessible, even if you have insurance that is willing to pay for it!  I was 20 when I decided I wanted to get an IUD, and I called 15 gynecologists.  I asked over the phone (so as to save myself a lot of $40 copays) if the doctors would even consider an IUD for a woman who was 20, never pregnant.  The outright answer on a lot of them was “no”, “only if you’ve been pregnant before”, and I had one nurse even lecture me and tell me that’s not what I wanted, it’s long term birth control and I’d want to have kids someday so I shouldn’t get an IUD!  (There was a lot of “but you’re a white, middle class college student!”)

    I eventually gave up on the idea, but after a horrible episode with the pill last summer I started calling again, and finally found a doctor who was willing to consider it!  I went in for an office visit to convince her that, yes, I know what I’m talking about, and got a Paragard.  My insurance covered the entire thing.  So easy enough on the financial side, but really tough on the doctor side.  (Planned Parenthood was willing to do it when I first considered it, but they don’t take my insurance so it would have been $500 out of pocket, which was inaffordable).

  • crowepps

    I had one nurse even lecture me and tell me that’s not what I wanted, it’s long term birth control and I’d want to have kids someday so I shouldn’t get an IUD!

    This isn’t the only issue in which nurses decide they know best, but I for one am sure sick and tired of medical personnel take for granted that they are the authority on how other people should live their lives.

     

    It sure would be helpful if someone set up a continuing education course during which medical personnel could be given a little refresher in “wearing a white uniform does not give you psychic powers about whether people will “want to have kids someday”.  Maybe they could pair it with a list of “medical urban myths” and finally drive a stake in the heart of “the birth control pill works by causing abortion”.

  • ch

    I got the Mirena almost two years.  I didn’t and don’t need the contraceptive aspect but was looking for a way to alleviate very painful cycles and was hoping I would be one of the 20% whose cycle stops completely (I am not).  I was 36 at the time, had 1 child and knew I was done.  Because I only had one child my GYN did not want to give me the IUD.  I did my research and went back gave it to him and insisted.  Once he was onboard we set up an appointment only for the insurance to say it would not cover the IUD as a contraceptive method due to my age (too young!) and because I only had one child (the lawyers for the insurance compnay claim women should have 2 or 3 before being allowed to get one) but I could pay out of pocket ($1600-1800).  So we waited two more months, documented my cycle and pain and remade the appointment for insertion, this time claiming it was to help shrink my fibroids which the insurance company (same one) then approved and paid 100% of the cost (total was $1600).  I was pissed because barring any adverse health indications, I should not have had to spend nearly 6 months getting it, and I should not have to “create” an alternate illness or disorder to get it and all of that was with insurance.   

  • biancalaureano

    thanks for your comment! I agree w/you. many physicians do not have the training to insert IUDs which was one of the reasons I agreed to have the resident present to learn. It’s really important and shocking because it is one of the oldest methods with very little physician training/knowledge.

  • biancalaureano

    thank you for the perspective from someone who has health insurance that WILL pay for it and the challenges we all share. It’s so frustrating to hear the challenges from physician/provider side. I wonder if some physicians/providers have assumptions about IUDs that we are not privy to…

  • biancalaureano

    I LOVE your idea of the debunking “medical urban myths” because it is so necessary! I used to work at the same hospital Dr. Hilda is at as a Health Educator and there were some trainings for staff and NPs and Drs. but never like what you have suggested (unless they were about queer youth). I was trained 10 years ago by older sexologists re: biology & anatomy & physiology that since has been challenged by may activists who identify as intersex and transgender. It’s a lot ot unlearn, but I’m commited to that unlearning, not sure how open others are to it though.

  • biancalaureano

    Wow. Since when do lawyers get the training to know about IUDs and when women should get them inserted? What do they know about creating and sustaining a family and connections to birth control beyond their personal experience. That just enrages me! I’m glad your physician was active in supporting you and making sure your insurance paid what they should have to begin with!

  • squirrely-girl

    I considered an IUD but wasn’t the best candidate given some past cervical issues. I ultimately decided on Implanon which is good for three years and is implanted in the inside of my upper arm. 

     

    I’m not sure what miracle occurred, but my insurance company covered 100% of the cost (a little over $1000) which FLOORED me. Then again, I got pregnant while on the pill so maybe they saw it as an “investment.” :)