The Politics of Fat and Emergency Contraceptives

This piece is published in collaboration with Echoing Ida, a Strong Families project.

I am a fat Black woman from the South. I exist at the intersection of multiple identities that medical research labels “vulnerable populations.” The label “vulnerable population” describes people who are frequently excluded from involvement in medical research, including clinical trials, because they are perceived as difficult to reach by the research community. Despite acknowledging that their research is not inclusive of all groups, the medical industry has a long exploitive history of attributing health disparities to patient behavior and economic inequality rather than admitting that their own prejudices also lead to differential outcomes for “vulnerable populations.” So when it was reported recently that French drug manufacturer HRA Pharma had found that the emergency contraceptive Norlevo, which has a similar chemical makeup to Plan B One-Step, is ineffective for women over 176 pounds, I was not surprised. Medical research, researchers, and commentary do not exist in a vacuum of objectivity; they are shaped by social assumptions and stereotypes that often end up having harmful consequences for “vulnerable populations.”

The labeling of one’s size and obesity status is not objective, nor are the factors isolated. Body mass index (BMI) has long been a magnet for fat-shaming and does not take into account differences in body composition between genders and racial and ethnic groups, and people of color are still disproportionately considered “obese.” Poverty exacerbates barriers to quality health care, thereby increasing the potential for obesity in these communities. With Black and Latino/a populations disproportionately living in poverty, they are at a much higher risk for obesity and more likely to be overweight, especially those living in the South. Poverty not only restricts access to nutrition and health care, but also appropriate reproductive health services and information. This means women of color are less likely to have access to appropriate emergency contraceptives.

According to Princeton’s emergency contraceptive web page, obese women (with a BMI of 30 or greater) became pregnant more than three times as often as non-obese women when using emergency contraceptives like Plan B. For women with a BMI greater than 26, the site recommends they contact a health-care provider for a copper intrauterine device (IUD) within five days after intercourse to prevent pregnancy. Confusion and misinformation already surround emergency contraceptives, especially more popular types like Plan B, but barriers mount depending on one’s race, body type, and class, resulting in often dire consequences for women of color seeking emergency contraceptives.

These findings raise concerns about whether fat women are given adequate knowledge about the proper emergency contraceptives. The medical industry assumes that “obese” women know that a copper IUD would be a more effective alternative to oral emergency contraceptives, can find a physician, and have the device implanted. Though a copper IUD is among the most inexpensive long-term (lasting up to 12 years) and reversible forms of birth control, upfront cost can range from $500 to $900. This presents a potential hardship for these women, who are often unable to acquire such a large lump sum of money. Even with Planned Parenthood’s prorated costs based on income, or even Medicaid, cost is still a barrier for women in rural communities who lack access to health-care professionals and women living in red states that have rejected Medicaid expansion. Even when they gain access to a health-care provider, they may not receive accurate contraceptive information about weight and may encounter poor medical advice that is rooted in the provider’s own racial, gender, class, and fat biases. Additionally, despite the perceived long-term convenience of an IUD, it cannot be inserted or removed without medical assistance. This leaves the judgment to remove the device up to the medical provider, stripping women of their reproductive agency. Lack of adequate access to health care and medical information compounds disadvantage resulting in limited reproductive health options for many women who happen to be considered “obese”—a de facto determination of who is and isn’t deserving of various reproductive health options.

Though over a third of U.S. women are “obese,” they remain underrepresented in contraceptive clinical trials, and at this point there are no clinical trials for an emergency contraceptive scheduled for “obese” women. It is painfully obvious that the medical industry has yet to account for how “vulnerable populations” intersect with one another. “Obese” women included in clinical trials will likely represent the health concerns and needs of white women even though poor women of color are more likely to be “obese” and need to be accounted for, if the medical industry plans to be inclusive. But they seem to have no plans to be inclusive. For example, human papillomavirus (HPV) vaccine medical trials under-represent Black women, meaning the vaccine on the market is designed to fight HPV strands that are common in white women, rendering it less effective for Black women whose common strands differ. We see this happening in clinical trials for contraceptives as well. Historically, contraceptive research excluded “obese” and overweight women from clinical trials, resulting in a limited body of evidence regarding contraceptive effectiveness and safety in “obese” and overweight women. This means that overweight and “obese” women are prone to receiving improper birth control information largely because their under-representation results in a lack of accurate information about how they are affected. The problems of this lack of information fall disproportionately on the shoulders of women living at the intersections of blackness, poverty, and Southerness.

The irony here is that modern contraceptive knowledge is based on experimentation and forced sterilization of Black women and other women of color during the eugenics movement and its aftermath. Now, when we actually stand to benefit from our inclusion in these trials, the medical industry ignores us. Though “vulnerable population” should imply the increased likelihood of being exploited or mistreated by medical professionals and researchers as it has in the past, it has now come to signify our invisibility and negligent disregard by the medical industry.

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  • cpolis

    From the point of view of someone who works in contraceptive research, I can understand (some of) these frustrations (others I disagree with completely), and am glad to see a piece raising attention to some of these issues. At the same time, I am frustrated when people loosely throw around the term “medical industry” and cast harsh accusations towards the people involved in that “industry” – which I see happening an awful lot.

    In this article, for example, it is posited that it is due to “social assumptions and stereotypes” that obese women and others are excluded from medical research. While we should continually use a critical lens to examine which key populations are underrepresented in studies, we might want to simultaneously recognize the context in which some contraceptive research occurs: not always with a boatload of research dollars, which translates to smaller study budgets, potentially less ability to recruit diverse populations, smaller sample sizes, and less ability to obtain a final dataset that includes a sufficient number of individuals of every conceivable permutation (race, age, weight, socioeconomic status, health status, etc.), translating to a limited ability to definitively know a given product works for each kind of person. To the best of my understanding (though it’s still not entirely clear) the recent finding on obesity seems to have emerged as a result of a meta-analysis of data that pooled together existing smaller datasets, allowing a larger number of “types” of individuals to be assessed.

    I also appreciate the point made by Amber below, which points out the extremity of equating a medical provider needing to remove an IUD with women being stripped of their reproductive agency. I think it’s fair to say that that’s a bit over the top. But the nugget of truth that you raise is that more long-term, women-controlled contraceptive devices ARE needed. Consider that the folks working to bring those devices to you might benefit from your constructive criticism, particularly if backed up by elbow grease to help improve the situation.

    For example, I’m sure you know that participation in research is voluntary, and that a (historically justified!) distrust of the medical community is more prevalent in certain communities. So, rather than assuming that folks in the “medical industry” whom you are accusing of “negligent disregard” (!) are systematically excluding certain people because they are bigoted, evil scientists, perhaps you can work with them to improve engagement with and outreach to underserved, understudied populations to help them understand why their participation in research is important to science and the world. Or, you could use your excellent writing and advocacy skills to help the “medical industry” to spread the word (which, trust me, they are trying VERY HARD to do) that IUDs are more effective as EC than EC pills. Or, you could help advocate for increased funding for contraceptive research, so trials are better situated to collect robust information.

    In my opinion, those kinds of activities would better serve (y)our purposes than unfairly dehumanizing the many good people who work tirelessly to provide information about and access to products that all women of all shapes, colors, sizes, geographic locations, socioeconomic classes etc. can use to control the course of their (reproductive) lives.

    • Arekushieru

      Perhaps they should be doing the outreach themselves? Perhaps THAT was the point? Why should those who are historically justified (as YOU, yourself, put it, I should remind) in distrusting the medical community be the ones to affect change? Is the medical community too lazy to do so? Just because they are trying very hard doesn’t mean they are trying the right way, after all. And many of these minorities and even their own clientele are less financially comfortable than they are.

      And the medical community, once it HAS affected change, would probably be considered more inclusive if they actually targeted their advertising AT minority populations, rather than just doing the same thing over and over, again, then blaming lack of funding or apathy in those selfsame minority populations for the disparity. It’s the same problem many women encountered. They need safe spaces, but they should NOT be the ones required to create them. Kthx.

      Finally, just because the medical community does not ‘intend’ to be exclusive, it doesn’t mean that their lack of effort to BE inclusive are not contributing to and affected by the politics of exclusivity. It’s much the same with racism, after all.

  • Guest

    Actually, both you and the author are incorrect. The IUD does NOT require a medical provider for removal. They tell you it does, and there may be some safety issues if you do it yourself, though I can’t see what those could possibly be, but it it is not only possible but incredibly simple to remove by yourself and I know many women who have done so after having problems with it.

    Personally, I think the implication women are too stupid to pull on a cord is the most limiting and ridiculous bit of the whole “must be removed by a doctor” nonsense.

  • Bonzai

    Both you and the author are incorrect. The IUD does NOT require a medical provider for removal. They tell you it does, and there may be some safety issues if you do it yourself, though I can’t see what those could possibly be, but it it is not only possible but incredibly simple to remove by yourself and I know many women who have
    done so after having problems with it. I know a few others who have had it simply fall out on its own, too.

    Personally, I think the implication women are too stupid to pull on a cord is the most
    limiting and ridiculous bit of the whole “must be removed by a doctor”

    • Arekushieru

      Um, if it needs to be inserted, medically, it also needs to be removed, medically. I’ve heard of women who caused injury to themselves by doing that. Either because their uterus was too small, the cord disappeared, or because of other issues. So, why are you ignoring those women, again?

      There IS a reason that people are told not to pull out items lodged in their skin, because it might injure them more than the insertion did, y’know?

    • Sarah B

      the COPPER IUD is inserted at the base of your fallopian tubes… I don’t know anybody who is able to reach up, past their cervix, through the uterus,and into the base of the fallopian tubes in order to remove the copper coils.

  • superlizzard

    there are soo many problems with this, i don’t even know where to start, but he one thing i have to bitch about is the continuing use of bmi for anything all it is is a height/weight ratio even if they narrowed the issue down to “excess body fat” bmi would still be useless, because it has nothing to do with determining body fat percentages im over 176 lbs, my bmi is 30.6, and i am not obese would ec work for me? i have no idea the problem is, nobody does they are just assuming that ‘x>176lbs’ equals “obese”, and it doesn’t i’m overweight, yes, but not by that much i have a very stocky build, a lot of muscle, and am extremely busty the medical field’s continued reliance on bmi ratios to determine obesity is disturbing to me, as it demonstrates a bias against anyone that doesn’t fit the cookie cutter mold of what they’ve decided to call “normal”, and biases in the medical field can easily become deadly fortunately for me, it has yet to be an issue i use long term contraceptives, and medical providers generally have told me not to worry about my weight; that ten or fifteen extra pounds is no big deal but there are women who don’t have the same good fortune, and they will most likely suffer a great deal over this nonsensical attitude about weight >:(

  • sometimesdee

    If the medical provider refuses to remove the IUD, it does indeed strip the woman of her reproductive agency.

    • Abbé Faria

      And do you have you any evidence that has ever happened? (Edited for spelling)

    • Mindy McIndy

      I had a nurse practitioner try to refuse to remove my IUD when it was causing me terrible pain and bleeding. I told her that if she didn’t take it out, I would rip it out myself. Then she tried to scare me away from getting back on Depo Provera, saying that I would bleed for months on it and have even worse problems. (I did not.) So finally, after over an hour of crying and pleading ,she took it out. Oh, and I was also lied to about it when they put it in, being told that the same drug in Depo is what is in the Mirena IUD. I found out it was a lie the hard way.