Contraception and the Changing Role of Medical Providers in an Over-the-Counter World


Changes were made to this article on November 29th, 2012, at 3:57 p.m. to correct a factual error regarding basal body temperature and ovulation. The correction is clearly marked in the body of the piece.

Earlier this month, the American College of Obstetricians and Gynecologists (ACOG) put forward a bold position that might seem logical: allow birth control pills to be sold over-the-counter without a prescription. The benefits are obvious. Improve access by removing financial and logistical barriers for women using the pill. No more scheduling doctor’s visits carefully in advance of the last pack of pills running out. No more buying six months at a time to decrease hassles: simply head to the pharmacy when you’re running low and throw the box of pills in with your other casual pharmacy purchases.

There is another reason it was a bold move by ACOG: Besides the fact that it’s unlikely such a thing would come to pass without a fight since it requires approval from the Food and Drug Administration (FDA) which is lobbied by religious and conservative anti-contraception groups, a group of physicians is now arguing that we no longer need their services for a specific health intervention. As CNN quoted Dr. Daniel Grossman on the decision: “‘It is a pretty bold move on the part of ACOG,’ he said. ‘I really respect that the organization decided to make this statement after reviewing all the evidence. It’s not very common where you hear a physician organization say, ‘We think there should be a change so that our patients don’t have to see us anymore.’ ”

This is the change that is likely to have the biggest impact on women’s health overall if birth control does eventually go over the counter. Improved access to those contraceptives will indeed result, but I think it will mark a bigger change in how we interact with providers, particularly in the arena of women’s health and gynecology.

Obviously not everyone uses birth control pills to begin with—so this might not change a thing for those people who either use other birth control methods (IUD, Depo shots, condoms, etc) or who are not concerned with pregnancy prevention (queer people, the post-menopausal, etc). But according to the Guttmacher Institute, an estimated 11.2 million U.S. women ages 15 to 44, or 18 percent of all women, currently use oral contraceptive pills. That’s 11 million women who now will have one less reason to visit their medical provider on an annual basis. Coupled with new recommendations steering us away from annual pap smears, we’re heading into an era that might actually indicate less frequent visits to our gynecologists.

In many ways this is a good thing. One less yearly expense for women without health insurance, or those whose health insurance doesn’t cover the full cost of an annual appointment. One less thing to schedule around work, child care, and other life responsibilities. One less interaction with a provider that might not be friendly, or affirming, or even helpful. And in a health care system with ballooning costs, fewer required medical visits is also good news.

But there is a potential downside as well. One less opportunity to be screened for STIs, just because you’re already there for an exam. One less chance for a breast exam that you might not be doing at home. One less chance for the provider to ask you about emotional health, or your sexual satisfaction, or anything else that might come up in a routine appointment that would otherwise go unexamined. 

The ideal interaction outlined above is not, of course, what everyone currently experiences with their providers. How many of you have ever been asked about sexual satisfaction during a gynecological visit? Or emotional health? Or anything at all, for that matter? With some exceptional providers excluded, there remains much to be desired when it comes to medical care in this country. I know few people who are satisfied with their medical providers. 

Selling birth control pills over the counter is just another step toward putting responsibility for our own health care back in our own hands. It says you are capable of making these decisions about what brand or method is right for you—no need for an expert opinion beyond your own.

It’s just the latest possible development in what I think is an exciting trend of people, especially women, taking back a much larger role in their own health care. So many of my friends now have applications on their phones where they chart their menstrual cycles (and even those of their partners, if they are in queer relationships). There are women who are taking their basal temperature on a daily basis, entering that information as well into those handy apps. A technique generally used for measuring fertility when trying to get pregnant, some are now using it to better understand their own rhythms and cycles (your basal temperature, measured with an extra sensitive thermometer, shows a slight uptick when you are ovulating) (your basal temperature, measured with an extra sensitive thermometer, shows a slight uptick right after ovulation). Others are even bringing back the seventies-era tradition of whipping out the speculum and looking at your own cervix as a way to better know your body and your own health via changes in your cervical fluid. One crusader for this practice, doula Pati Garcia, has started an entire institute, The Shodhini Institute, to bring back this and other self-care practices, training others in the methods that they can then use in their work. 

I welcome this change in our relationship with medical providers as long as it comes along with individual people stepping in to fill that gap. Armed with the knowledge of our own bodies, rhythms, cycles and changes we can much more effectively partner with medical providers when necessary. We could go to them with knowledge that will help them know how to treat our illnesses, rather than expecting them, from seeing us once or twice a year, to have all the answers. Then we won’t need these prescription-filling visits to remind us to take care of our health—we’ll be taking that responsibility on ourselves.

But this utopic vision of self-care requires new learning for all of us who have never bothered to look at our cervix, or if we did, wouldn’t know what we were looking at. Could we imagine sex education including this kind of self-exam knowledge? Could we imagine health class actually teaching us tools to be our own health care providers, rather than just scaring us with pictures of extremely advanced sexually-transmitted infections? This knowledge is something many of us have lost in the past century, as medical experts have become the keepers of this information. It’s going to take work for us to take it back. 

Our health care system is expensive, often ineffective, and something with which few people are satisfied. In some instances, it might make sense for doctors to step out of the way to make room for new health experts: ourselves. Then we might actually stand a chance of partnering with providers effectively to improve our lives, coupling their knowledge with our own to work collectively toward better health for all of us.

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  • kls5734

    Hi Miriam, I’ve been a fan for a long time. I wanted to point out a slightly misleading remark. You state “(your basal temperature, measured with an extra sensitive thermometer, shows a slight uptick when you are ovulating).” That actually isn’t the case. You don’t see a thermal shift until after you have ovulated due to the increase in progesterone released from the corpus luteum. In fact, many women experience a dip in the their temperatures just prior to ovulation. 

  • miriam-perez

    Hi–

    Thanks for the correction! More about this distinction is here, but you are correct that there is actually a slight dip in temperature and then an uptick. Measuring over a few cycles will help people identify ovulation days based on these patterns.

    I will ask the editor to issue a correction to the original article.

     

  • miriam-perez

    The issue of cost of birth control if it moves over the counter is a big concern. Insurance companies don’t cover OTC medications (like when you buy advil, or monistat, or anything else).

    So the question becomes whether going OTC will also bring down the cost of birth control significantly, so that it’s not prohibitively expensive.

    Someone on twitter pointed out that this recent push might be a result of changes in health care from the Affordable Care Act, where contraception is now required to be covered without copay. Moving it over the counter could push those costs from the insurance companies on to consumers themselves.

     

  • crowepps

    There are many things available both ways — diabetic test strips can be prescribed (so Medicare will pay for them) or over the counter.  Ibuprofen is available over the counter in 200 mg tablets, and available by prescription in 800 mg tablets.

    There’s also the possibility that having them available over the counter would increase competition and the price would drop.