Op-Ed Piece: EC access for young teens

Hi there! For this entry I have decided to post an assignment I did for my reproductive health advocacy course that just ended. Our charge was to write an op-ed piece about a topic in reproductive health that is controversial, and work on framing the issue in a thoughtful way. I very much enjoyed writing about emergency contraception access for young teens, so here you are:

The Nature of Evidence: Emergency Contraception Access for Young Teens

Bonnie, Guest Columnist

A fictitious newspaper like the New York Times, March 8, 2012

It is fascinating to examine the nature of evidence. As humans and consumers, we trust the medical system to keep us healthy by providing us with the right service at the right time. It is sound evidence, we hope, that allows providers to do this in a way that maintains our health and well-being. We like evidence because it helps us know that “cold-hard-science” is behind the decisions that get made about what is best for us. Yet evidence can also be used as a political tool to decide who gets what kind of medical services, and the time at which they can access them. In no other recent event has this happened more obviously than in US Health Secretary Kathleen Sebelius’s decision to veto the FDA’s recommendation to allow women under 17 access to emergency contraception.

Emergency contraception (EC) is a hormonal contraceptive pill that prevents pregnancy. Not to be confused with medication that causes abortion (such as RU-486), it does nothing to harm an existing pregnancy.  A woman can take it up to 5 days (120 hours) after unprotected intercourse, though its effectiveness declines with time. It has been behind the counter for women (and men) over 18 since 2006, and over 17 since 2009. It has few side effects, and is not known to cause lasting problems. The efficacy of EC in preventing pregnancy and other knowledge about its use is gleaned from the results of many sound scientific studies. These studies address medical side effects, access patterns and need for the drug, and consumers’ ability to read and understand the drug packaging.

In Ms. Sebelius’s statement regarding her decision to maintain current FDA guidelines and restrict access to EC for teens 16 and under, she wrote that a small percentage of girls in the US are able to bear children by 11.1 years of age, therefore the evidence presented to the FDA council was not sufficient to justify providing behind the counter access to women between the ages of 11 and 16. Indeed, the studies considered by the council only provided data for women 12 years of age and older. However, it is difficult to believe that Ms. Sebelius, with her previous experience as an insurance lobbyist, legislator, and governor, has the scientific authority to demand evidence on such a minuscule subsection of the population, a subsection least likely to be having sexual intercourse. If safety is her primary concern, might it instead be more prudent to study the health effects of childbearing in 11.1 year olds?

Let us consider the evidence that does exist, that which was considered adequate by the medical and scientific experts from the FDA Center for Drug Evaluation and Research (CDER). Remember, this is the body that came to the original conclusion that EC was safe for all women of childbearing age.  These studies showed that younger teens experience the same mild side effects from EC as older teens and adults. They showed that teens are able to read and understand EC packaging. They showed that EC does not cause an increase in risky behavior among teens. And they showed that teens can use EC correctly without medical advice or counseling. While it is perhaps true that the body and brain of an 11 year old is physiologically different from that of a 12 or 13 year old, do we truly believe that this difference is profound enough to cause earth-shaking changes in the way we allow them to prevent pregnancy?

It is clear that Ms. Sebelius has used a scientific argument to maintain the status quo of EC access in the United States, and this kind of argument is difficult to counter. No person wants to claim we do not need more evidence, especially not in a world which holds evidence to such high esteem. She is correct in her statement that data is absent for this subpopulation, but do we truly believe that evidence to support every combination of factors in the universe is our task? Have we specifically tested all headache medications on 11 year olds? Should we? In considering the larger picture of what is at stake for teens, this is an instance where more evidence may not be the answer, and we are instead blinded by politics in a scientific disguise.

Abortions, mental health, and the problem with bad science

Hello everyone! I hope you are all doing well and finding happiness in your lives. I am certainly happy that spring break is upon me, meaning that I only have to work and study for my healthcare finance midterm. Actually, I'm sort of stressed out. But at least I don't have to go to class.

What is on my mind lately in the world of reproductive health politics is the recent de-bunking of the Coleman et. al. study that claimed there was a causal link between abortion and mental health problems in women. The study was published in 2008 in the Journal of Psychiatric Research, which I'm not familiar with but would assume is a legitimate and hopefully peer-reviewed journal. I had heard about this study before, and wondered about how it came to its conclusions. The other research on the same topic was unable to find a causal link, so I found it odd that this one did.

According to the Guttmacher Institute, the study was officially found to be void based on analytic errors. Apparently, Coleman and her fellow researchers did not identify whether the mental health disorder was diagnosed before or after the abortion procedure, and proceeded to lump these women into the same group. They then found that a large number of women with mental health disorders had also had abortions (diagnosed before or after the procedure), and after controlling for current life situations that could account for the disorders, they concluded that the abortions caused the mental health diagnoses.

Uh, what?

There is a lot more detail to get into about the events surrounding this de-bunking, but such information can be found elsewhere (see the bottom of this post for some links). What makes me the saddest about all of this is that we base so much of our decisions as a country on science, and hold "evidence" that is published in journals in the highest regard. We create legislation and programs from this evidence that in turn affects millions of people. Of course, we need to support women in their decisions to have abortions and understand their mental health needs both before and after the procedure, but we can't allow this kind of bad science to dictate how we think about women who have had, or will have abortions.

Yes, abortion is an incredibly difficult decision that nobody wants to make, and such a situation can definitely have repercussions for some people. However, the body of evidence that already exists about mental health and abortion (and physical health and abortion for that matter) shows that abortion really does not cause marked distress in women. In public health school we learn that it is a body of evidence that allows us to conclude that something has a causal relationship, not one or two studies by the same author.

Other studies have shown that the women who do have complicated mental health reactions after their abortions were struggling with mental health issues prior to having the procedure. According to further research on populations who have mental health diagnoses, these same reactions occur after other difficult events in their lives. This is telling, as it shows that it is not so much about the abortion as it is about a person whose coping abilities may be compromised. We need to re-frame this issue as supporting women with mental health issues through all of the difficult times in their lives, not just abortion.

Of course, women without mental health diagnoses who have abortions need support too, because it can often be a difficult, guilt-inducing, and isolating experience. We should be offering support for every woman who has an abortion to help her maximize her recovery, whether she is having a reaction complicated by a prior diagnosis or a more common mix of contradictory emotions. But, we should absolutely not be operating on the premise that abortion is an experience that will always lead to complicated outcomes.

To conclude, scaring women with junk science is bad. Not making a distinction in your study between diagnoses made before an abortion and after an abortion, and then claiming that abortion causes mental health problems is abhorrent indeed. I am so glad this study has been debunked, but what of others? It is my most sincere wish that this example motivates journals to re-evaluate their screening processes, to make sure that science stays as unblemished as possible for the benefit of all of us. What do you think?

Further reading:

Read the Guttmacher article here
And the original Coleman study here
And the letter from the scholars who found the study to be flawed here
And another Guttmacher article about abortion reactions and the evidence behind them here

Why I deleted my Pinterest account

The web would be nothing without social media. Given the explosion of online content in the past several years, platforms charged with the organization and display of this content are imperative in order to make sense of it all and allow users to find and share what matters most. I love trying new platforms, and am consistently motivated to pioneer some of these contemporary offerings, motivated by a search for improved quality and relevance.

When my dear friend Georgia got engaged last year, she took to Pinterest to organize and manage all of her wedding ideas. For my parents and others of you unfamiliar, Pinterest is a social media platform that operates sort of like a virtual corkboard. Users create "pinboards" organized by theme and then "pin" content onto them from the Internet. The interface is photo-based, meaning that the image associated with the content is displayed for other users (your own friends or strangers) to click on and "like" or "repin" to their own boards. It is very visually appealing and easy to use, and can draw you into a mind-bending chasm of wasted time. Unlike me, Georgia used it constructively to compile ideas for wedding hair, dresses, invitations, flowers, and decor, which has allowed her to slowly build a holistic theme for her upcoming ceremony.

It was she who turned me onto the idea in the first place, and I gladly made my own boards. My first red flag came when I had to use my Facebook or Twitter account to sign up, but when I found that I didn't have to publish my Pinterest activity on Facebook, I settled down and began pinning to my heart's content. I slowly began to notice that strangers were repinning my pins, and that more and more people were following my updates that I didn't approve, some of them strangers. While I'm not completely opposed to the idea, it was the systematic lack of my permission that made me the most uneasy. All of a sudden, my content was public to all Pinterest users who could view and share my pins to their hearts content, with my only notifications coming after the fact.

Now, you may be wondering what the big deal is. The internet is public, you say. Pinterest is about sharing, you say. Now, that is all well and good. And while I do not believe the Internet is a private place, I do feel that an online personality within the context of a social media site is something you should expect to be able to control, especially if the platform is a password-protected user community. You should at least be asked if you'd like your content to be available to all users, and you should be able to control who follows your content preemptively, not after the fact. Perhaps I'm getting old, but the whole thing was making me a little queasy. Perhaps I was too used to the older platforms that asked you if you wanted to add someone as a friend beforehand. But all of this was not quite enough to make me stop using Pinterest.

The final straw came last week when I googled myself, as I do from time to time, to see what comes up from my name for the world to see. I was not signed in to any of my accounts, as I wanted to simulate what a stranger or potential employer might see. I was aghast to see my Pinterest account on the first page, attached to my full name. When I clicked on it, all of my boards were public, and you could even follow me with one click. Not that I had anything to hide on the site, but the idea that a stranger could access the totality of the content I intended for friends hit me right in the gut. I then found that I could remove my account from search results, but since cached pages could still lead users to the same destination, I opted to delete my account entirely.

Georgia can do what she wants without judgment from me. After all, she is using hers in a much more productive way than I ever did. Also, she may have completely different views on internet privacy, rendering my argument completely irrelevant, as it could also be for many others. But I am finished, and without a single tinge of regret. I have learned something from all of this, which is that I plan to pay much closer attention to terms of service in the future, and be wary of platforms that link to existing accounts. Linked accounts are a great way to get tons of information about me from the start, information that I want to be more guarded about as I thoughtfully cultivate my online identity.

ALSO: The copyright buzz around Pinterest is pretty fascinating. Read this to learn more, including how it seems that users are solely responsible for the legal expenses incurred against them and against Pinterest in the event of copyright infringement, something the site seems to enable.

What are your thoughts?

Coverage parity: Are the health needs of women medical or something else?

A lot has been in the news about coverage parity for women's health and what it means for insurance companies and employers with healthcare coverage. Yesterday, the aptly named Blunt amendment was defeated in the US Senate, which would have allowed insurance companies to refuse to cover certain services like birth control. Under the yet-to-be-implemented Affordable Care Act, this would greatly reduce the amount of protected essential services, and provide yet another obstacle between women (especially those without means) and their access to legal health services in our country.

As you can tell from that introduction, I happen to hold a certain stance on this topic already. However, it is the reasons for such a stance that hold the most importance. My thought process is thus:

The discussion about the receipt of legal medical services (like birth control) belongs between a woman and her healthcare provider. I know this amendment would not directly infiltrate that relationship in any way, but if a woman knows that her health insurance does not cover medications that some feel are immoral, for her, there is a cost factor in that discussion that could lead to a different decision, a factor has nothing to do with her health. I find this problematic, especially when there is no other segment of medical care that is disputed in the same way. Other kinds of procedures that come close are more elective, and insurance companies often will make coverage exceptions for what is deemed "medically necessary."

Let's talk for a moment about medical necessity. Pregnancy is not a disease, but it is a condition of health that causes physiological changes that are life-changing in scope. Pharmaceuticals have been developed to prevent this condition for women who do not feel their lives or bodies can handle it at any particular time. The medication is prescribed by healthcare professionals, and can be medically indicated for more than just pregnancy prevention (birth control can be very helpful for conditions such as endometriosis and anemia). This sounds pretty medical to me. There is also strong evidence that women who put more space between pregnancies have better health outcomes, including both physical and mental health.

Regarding the moral argument, republican heterosexual married women who only have sex with their husbands need birth control too. That is what makes this argument so interesting to me. If we take a small slice of the population who in the eyes of some are the only ones doing the right thing, and determine they need these services also, the entire argument self-destructs. This is a universal concern, not only for women, but for the men who love and support them, and who are planning or not planning to have families of their own. When I am faced with the medical argument, this whole thing merely becomes an arbitrary decision to cover some services over others, and such practices just don't make sense.

Of course, I know that just because the Blunt amendment failed does not mean that individual states will decide to add birth control to their list of essential services. But at least we do not have a preemptive platform for such "medical discrimination" to take place everywhere. That to me is an excellent step. What do you think?

Read more about the Blunt amendment here.