The Pill: A Counter to “Over-the-Counter”


The birth control pill turned 50 years old this month, and to mark this anniversary, Kelly Blanchard took to the New York Times op-ed page and suggested that it’s time for the FDA to approve the pill for sale over the counter.  It’s been an argument that’s been floating around for awhile, now that we have low-dose formulations of the pill that are safer than aspirin, and because doctors basically rubber-stamp requests for the pill coming from consumers more than they prescribe it for those who came in to a doctor’s appointment unsure of what they needed. Newsweek followed up by fleshing out the arguments: requiring a prescription is paternalistic, the OTC version of the pill would be a mini-pill with fewer likely side effects, research shows that women who buy pills over the counter understand the contraindications better than women who have prescriptions do.  So now the question’s out on the table in a big way, and we should take a closer look at it: should the birth control pill be sold over the counter?

Despite being a fan of the belief that there’s no time like the present, I have to admit that this discussion couldn’t be more badly timed, coming in the middle of the gradual overhaul of our health care system.  It’s a sign of the perversity of American politics that discussions about making the birth control pill available over the counter open up right as the federal government is likely to move towards requiring insurance companies to make the pill free to customers with prescriptions, instead of using the current co-pay system.  In most circumstances, it would only be good news if the pill was something you could buy without having a prescription, but even if that happens, most women will probably still go through doctors just because the pill will be cheaper that way.  Additionally, much of the support for making the pill over the counter comes from women who don’t have health insurance, a category of women that supposedly will disappear within the next few years after the government starts requiring Americans to buy health insurance.  Leave it to Americans to finally start selling the pill over the counter right as much of the demand for OTC pills dries up.

But much isn’t all of the demand, and there are still groups of women that would benefit strongly from having access to OTC birth control pills.  Teenage girls are the biggest group to come to mind.  For many, going to the doctor equals telling your parents, and for obvious reasons, many teenage girls don’t feel comfortable or even safe letting their parents know they’re sexually active.  While it would be ideal if all teenagers were simply excellent and consistent condom users, there are many teenage girls who do just fine on the pill, or use it as back up, and they shouldn’t be deprived just because they’re worried about the doctor telling their parents that they’re on the pill.  (True, doctors aren’t supposed to reveal that kind of private information, but not all teenagers know this or trust that it’s true.)  Blanchard pointed out other reasons women might not want to go the prescription route—they forgot to get a refill until it’s too late, they don’t have time to go to the doctor right now for an exam, they went on vacation and forgot their pills.

It’s a smart idea to sell the pill over the counter, but I don’t see it happening in the United States any time soon for a couple of disturbing reasons: sexist paternalism and sex panic.  The first is well covered in the Newsweek article.  Right now, one of the major reasons that doctors hang tightly on to control over who gets the pill is that they believe it’s the lure they need to get women to come in for pelvic exams.  The thinking is that it’s unpleasant to go to the doctor and even more so for a pelvic exam, and so many women would put off gynecological visits if they weren’t in danger of losing access to the pill because of it.  But as Newsweek reported, a preliminary study in Washington showed that decoupling the pill from the pelvic exam didn’t actually cause women to stop getting pelvic exams.  Those women probably had a better time scheduling their doctor’s visits, though, since they didn’t have to worry about getting it done before there was a break in their pill prescription.

Even if we can get the medical establishment to trust women to look after their own health without having to be bribed with contraception, the odds are high that a vocal section of the public would have a meltdown if the FDA even considered the question.  And yes, I blame sex panic.  Even on the left, you find a strong tendency to blow the dangers of the birth control pill way out of proportion, and find people freaking out about the pill in ways they never would over other commonly used but more dangerous drugs.  Not to be an armchair sociologist, but I suspect strongly that the widely-held but erroneous belief that the pill is dangerous is a direct result of the American ethos that holds that sex itself is dangerous, and that female sexuality in particular is dangerous.

This is certainly what drives the right wing hysteria and misinformation campaigns about the birth control pill, campaigns that would kick in to high gear if the FDA actually considered allowing over the counter sales.  As much as I’d like to dismiss the idea that right-wing hysteria about the pill has much effect on people—since a solid majority of women use the pill at some point in their lives—the ugly truth is that right-wing misinformation has a far reach.  They may not convince the public that the pill is so dangerous that it can’t be legal at all, but they’ll be able to convince the public that the pill is too dangerous to sell over the counter.  After all, they were able to bully the FDA into putting emergency contraception behind pharmacy counters, even though there’s absolutely no science-based reason to do so.        

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  • hmprescott

    You present some sound arguments in favor of making the pill available without a prescription, but I think it’s simplistic to attribute opposition to this measure solely to “sex panic.”  The story is much more complex than that.  I’ve written about this at length on my own blog:

    http://bit.ly/anAtMZ

  • amanda-marcotte

    Doesn’t say anything about the science of the situation. It’s entirely possible—and in fact likely—that sex panic-driven fears over the birth control pill cause women to attribute many symptoms that are likely unrelated to their pill. Class action lawsuits where the folks on the lawsuit have “everything under the sun” complaints, many without a shred of evidence to back them up, are pretty iffy in my book. The class action lawsuits against tobacco companies were backed up with hard science. I’m just not seeing that going on here.

    And yes, I do think that drugs related to sexuality get way more attention and fears than ones not. And that’s because we still have a lingering desire in our culture to say, “Just shut your legs!” I’ve found, for instance, that when you’re arguing with someone who thinks NFP is a great method for a wide range of women—and that our resistance to it could only stem from ignorance, not real desires—eventually you get to an end game of “shut your legs”. They pat themselves on the back for being sex positive because they only want you to abstain half the time, but the tone of judgment against women who might want to have sex a lot more than that is fascinating to me.

  • hmprescott

    It seems to me that by attributing women’s symptoms while on oral contraceptives to “sex panic driven fears” is just as paternalistic as saying women need a prescription for the Pill.   This same argument was made in the 1960s when the first serious side effects from the Pill were reported.

    I also think you misrepresent Laura Eldridge’s work, which is more complex than “freaking out about the pill.”  What’s wrong with giving women the information to make informed choices?  Or respectiing the choices they make?

     

     

  • sweetchild92

    Seems not good though. With all the different types of progestin, it just doesn’t seem good side-effect wise. It seems a girl/woman could easily get a pill that’s high dosage and more androgenic when that’s not what’s gonna work well for her.

  • amanda-marcotte

    A lot of tactics that come straight from the anti-science handbook, such as “just asking questions”, a tactic where you pretend that you’re just raising important questions, but all the questions you raise actually are arguments that you don’t have the courage to make straightfowardly. She’s obviously against the pill and everything she does is about convincing women it’s especially dangerous. It’s interesting that it’s the pill and only the pill that gets this treatment. Why not other more dangerous drugs sold OTC?

  • arekushieru

    I am concerned about any drugs that are sold over-the-counter, though.  I am concerned that, like many drugs that are sold over-the-counter, the instructions and methods of use will be far more ignored than their prescriptive counterparts.  One person brought up an interesting point on FB, though, that might actually address both of these issues.  Expand pharmacists powers of prescription…?  Just a thought.  ^^;

  • hmprescott

    To answer Amanda’s question — actually there have been criticisms of other OTC switches and/or attempts to change certain drugs to nonprescription status.  For example, see Jeremy Greene’s discussion of the anti-statin drug Mecavor in Prescribing by the Numbers.  I suppose these kinds of criticisms don’t get much attention in the popular press because they aren’t as “sexy” a topic as contraception.

  • amanda-marcotte

    But if you use your same wording with different chemicals, you can see how simply using chemical words to scare isn’t really an argument:

     

    Seems not good though. With all the different types of acetylsalicylic acid, it just doesn’t seem good side-effect wise. It seems a girl/woman could easily get an aspirin that’s high dosage and more antiplatelet when that’s not what’s gonna work well for her.

     

    Seems not good though. With all the different types of lotradine, it just doesn’t seem good side-effect wise. It seems a girl/woman could easily get a Claritin that’s high dosage and more inverse agonistic when that’s not what’s gonna work well for her.

     

    See?  Big words aren’t really an argument.  I just used your same strategy to argue against selling aspiring and Claritin over the counter.

  • amanda-marcotte

    But you yourself admit that they don’t get play because there’s no sex panic angle.

    Also, there’s no indication of how good these arguments are. That someone is a leftist doesn’t make him right, and in fact, a lot of leftists are anti-modernity, anti-science, and anti-medicine. Think, for instance, of anti-vaccination types who pretend that the measles and whooping cough aren’t deadly.

  • hmprescott

    Jeremy Greene is an M.D. as well as a historian and he outlines the various scientific and medical arguments that FDA weighed in their decision to reject the OTC switch for Mevacor. Marcia Angell, another M.D., does the same for other OTC drugs in The Truth About Drug Companies

    Regarding aspirin — Jeremy and other physicians have told me that there are so many contraindications that have been discovered through clinical case stuides over the past half century that it’s unlikely that aspirin would be approved by FDA even as a prescription drug.

    I agree that the anti-vaccination movement is a crock and the physician who first touted the MMR/autism link has been found guilty of scientific misconduct.  I also agree that there is a lot wrong with various alternative medical therapies — not the least of which is that they are not subject to FDA oversight because they are sold as dietary supplements rather than drugs.

     

  • ibis-reproductive-health

    Thanks, Amanda, for your thoughts on this issue!  We really hope that health care reform will mean more women are covered and that contraception is included as free preventive care (but we need to still keep the pressure on!).  Even if that all comes to pass though, it will be some time until women get the insurance coverage promised to them, and there are other costs for the pill on prescription besides the co-pay, such as the doctor’s visit, childcare, transport to the office, and time off work to name a few.  Many women might choose an OTC pill because it is convenient, and they should be able to make that choice.  We also need to think about the women who will be left out as health care reform moves forward.  Young women as you mention might have challenges accessing confidential care (particularly if they are on a parent’s plan); immigrant women and women who move in and out of eligibility for subsidies or move on and off insurance plans because of life changes like marriage, moving, changing jobs, etc., may struggle to keep continuous coverage of their contraception (which we have already observed in Massachusetts under health reform).  We also want to see more states and federal Medicaid rules changed to cover all effective OTC contraceptive methods–like EC and condoms and hopefully someday soon the pill–so that women on Medicaid have consistent access to effective contraception and STI prevention without a prescription.  The pill meets all the FDA criteria for an OTC medicine and more than 80% of women will use the pill at some time in their lives.  Years of experience and research show that OTC access to the pill would be safe and women are more than capable of correct use.  Let’s set the pill free from unnecessary medical restrictions and give women more options for conveniently accessing their contraception.

  • arekushieru

    Yes!  Your point about the OTC option makes a lot of sense, IRH.  Thanks for the clarification!  :)

  • sweetchild92

    I’m not trying to be against wider access to the pill, but if a woman gets a pill that she has a bad reaction to because of the hormone, or if it’s triphasic/mono, that might just put her off of it entirely. I’d rather increase access to doctors, so that a woman can decide which type of pill might be best.

     

    Or labels about the different types of progestin, the levels of estrogen, and if the pill is mono/bi/triphasic.

  • kimberly3

    Amanda,

     

    You hit on a critical point when you suggested we take a closer look at the question of an over-the-counter (OTC) switch now that it’s on the table. In some ways, the availability of an OTC birth control pill could transform the way we think about contraception, and how we access it. It’s understandable and even expected that women’s health advocates are bringing to light questions and concerns about an OTC switch. At the Reproductive Health Technologies Project, we have been evaluating the question of an OTC switch for over a decade. Throughout that time, we have tracked the safety and efficacy data, political climate, and cost/coverage in order to assess whether and when to pursue a switch.

     

    For us, the bottom line is—we know that cost, patient education, and preventive healthcare are important pieces of the puzzle, AND we are still interested in moving forward with a switch. Oral contraceptives have a decades-long track record of safety, and an OTC progestin-only pill would be more effective at preventing pregnancy then any other method available without a prescription.

     

    As a member of the Working Group on Oral Contraceptives Over-the-Counter, we welcome the input, collaboration, and concurrent efforts of reproductive health, rights, and justice advocates in ensuring that an OTC switch is ultimately “a good thing” for women. We know that a collective effort will be needed to overcome the very hurdles you named in your piece. We are excited to be working at this frontier, and we are mindful to proceed cautiously and thoughtfully.

     

    As a side note—we’re with you on the EC age restriction, and we’re not backing down until we see it removed!

  • goddessangel

    I vote in favor of OTC birth control. I was in the situation where I was FORCED into having a pelvic exam every year in order to get the pill. It think it’s wrong for anyone to have to pay for the right to use birth control, on top of cost of the pills themselves. For me being without the pill wasn’t an option due to heavy, painful periods (despite tests no explained medical reason, like PMDD or endrometreosis) since I was 16 yrs old. Finally now I have an IUD in now and don’t have to deal with this for the next five years. As a bonus my IUD has almost stopped my peroids (YAY!) and even though insurance wouldn’t cover the IUD, paying for that was actaully cheaper than what I would pay for the pills (not including the doctor visits) over the same time span.