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Protection or control? The debate over emergency contraception

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The final weeks of 2019 witnessed considerable, rancorous debate over the accessibility and social effects of emergency contraception (EC). Should access to it remain contingent on mandatory consultations, with either GPs or pharmacists? Is its retail price too high? Are regulatory and financial barriers intended as deterrents? And if so, is that legitimate?

This is not the first time we have had this debate. In 2017, in the wake of a pricing campaign by the British Pregnancy Advisory Service (BPAS), Boots refused to reduce the cost of EC, claiming that doing so would encourage reckless use and risky sexual behaviour. BPAS criticised Boots’ decision to set deliberately prohibitive prices as ‘patronising and insulting’. But Boots’ decision—motivated, apparently, by customers’ objections to easy access to EC—was also the product of embedded historical ideas about the acceptable boundaries of women’s sexuality.

Even into the twentieth century, a woman’s ‘natural’ sexual impulses consisted in and only in her presumed inherent yearning for motherhood. In a society still buttressed by the sexual double standard, women who sought or expressed sexual pleasure beyond these narrow boundaries were vilified as insane or immoral. Likewise, women who sought or received information about their sexual and reproductive health were believed to be debased by that knowledge. Their innocence or purity was therefore contingent on ignorance of such matters.

The uncoupling of women’s sexual pleasure from childbirth and child rearing has not been an uncontested process. And it is far from complete. Boots eventually yielded to public pressure and reduced the price of EC in some of its stores. But the underlying assumptions about women’s sexual fecklessness have not gone away. A common refrain is that EC should not be made ‘as readily available as sweets’, the implication being that women are incapable of making serious, rational decisions about their own health. We saw such infantilisation in the responses to the journalist Rose Stoke’s recent article about the morning-after pill. Like many women for whom EC has failed, Rose was criticised for shirking her ‘personal responsibility’ by not doing ‘proper’ research. But women seeking pharmaceutical advice about EC regularly receive only partial or erroneous information. Even NHS England’s official guidelines do not address the relationship between ovulation and EC’s effectiveness. And although the guidelines do emphasise that ‘you can use emergency contraception more than once in a menstrual cycle’, they fail to mention that EllaOne should not be used in the same cycle as Levonelle. For this cautionary information, women must comb through leaflets produced by the Family Planning Association. How, then, can women make informed choices about their health if accurate information is not readily available?

A cursory glance over the social-media responses to this latest round of contentious debate reveals that women are overwhelmed with misinformation. A common misconception is that EC is harmful if taken ‘too many times’ (though precisely how many times constitutes ‘too many’ is rarely specified). Yet the medical evidence is clear: EC has been available in the UK for decades and there is nothing to suggest that regular use endangers health or future fertility. We accept—even expect—consultation-free access to many drugs whose safety profiles are comparable to EllaOne and Levonelle. And armed with the right information, consumers can easily understand these drugs, as demonstrated by women in other parts of Europe where EC is available off the shelf. So why in Britain does EC remain subject to regulatory controls, with the women who try to access it surveilled?

The answer lies perhaps in one of the most pernicious and long-standing fallacies surrounding women’s reproductive health: that easier access to contraceptive information and services would encourage promiscuity, especially among young women. This was the same argument deployed by the National Council for Combatting Venereal Diseases and the Medical Women’s Federation in the 1920s when both organisations opposed medical prophylaxis, believing that it would be misconstrued as the state promotion of ‘moral degeneration’. Such arguments were still being used in the 1950s and 1960s by conservative pressure groups to stop unmarried women accessing contraceptive services. Even married women in some Local Authorities could access family planning services only on medical grounds—a decision motivated by the persistent belief that women’s sexuality was inextricable from the literal and emotional labour of reproduction. It was not until the National Health Service (Family Planning) Act in 1967 that Local Authorities were empowered to make arrangements for the provision of contraceptive services to all women, regardless of their marital status, via voluntary organisations like the Family Planning Association. But despite the opening up of service provisions, women’s sexuality and the choices they make about their reproductive health continue to be scrutinised, challenged and subjected to the same condescending, conservative rhetoric.

The majority of women in England continue to pay up to £35 for access to something that is already available free of charge and without prescription in Scotland and Wales. And these regional disparities will likely get worse. Sexual and reproductive healthcare is often among the first services to be affected by cuts to Local Authorities health budgets. Indeed, half of all Local Authorities in England have already frozen or reduced spending on contraceptive services. According to the Advisory Group on Contraception, the majority of these Local Authorities are among those with the highest social deprivation. Consequently, abortions in those areas have increased by fifty-three per cent. And as other forms of contraceptive support are rolled back, women will increasingly turn to EC. These sorts of inequalities have a long history. Despite concentrated opposition to the ready availability of contraceptive services, a proliferation of private clinics had been in operation since the interwar years. And even after family planning services became part of socialised healthcare in the late 1960s, regional disparities necessitated ongoing support from a network of non-profit clinics run by charitable organisations.

In its December 2019 Report, the Royal College of Obstetricians and Gynaecologists recommended that oral EC be reclassified to the General Sales List to enable it to be sold free of charge and without consultation. Currently, women wanting access to EC must complete a mandatory consultation with a pharmacist. According the RCOG, ‘this adds a further barrier to access since many girls and women report that this consultation leaves them feeling uncomfortable, embarrassed or judged.’ The decision in many pharmacies to hide EC from sight—which, as BPAS points out, has ‘no clinical justification’—not only creates a physical barrier to access. It also reinforces, sometimes deliberately, a barrier of shame and stigma.

Objections to EC—often motivated by spurious claims about compromised health or reckless behaviour—mask a troubling fetishization of women’s bodies. If history teaches us anything about the battle over women’s reproductive health, it is that measures designed to ‘protect’ women, whether from themselves or others, usually have the opposite effect. Regulatory mechanisms, misinformation and prohibitively high price points do not discourage women from having sex. But they do discourage them from seeking support afterwards.

Please note: Views expressed are those of the author.

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