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Bargaining With My Birth Control

Many doctors are denying birth control to those who won’t take cervical screenings — even though it’s not medically necessary.

Monik Markus/flickr

Every tin foil pocket in my month’s supply of Mylan birth control pills had blossomed open, punctured and empty. I was ready to puncture the face of the pharmacist who wouldn’t refill my birth control prescription, two days since my last pill.

“Sorry, we can’t refill your prescription until your doctor gives authorization. We haven’t been able to get a hold of her,” she said.

“Can’t you just refill it while I settle whatever is going on with my doctor? My insurance covers it, and I’ve been taking this prescription daily for the past 10 months,” I pushed.

Her voice hardened, as if I had asked her to spot me an extra supply of oxycontin.

“No. We can’t just give you any prescription. We can’t do anything until a doctor signs for authorization.”

I’ve always been sensitive to hormonal changes. A pimple emerged on my chin and a burnt sienna stain greeted me on my underwear the next morning, both signs that my body was weaning itself off the birth control hormones and settling into the rhythm of its natural menstrual cycle. I hadn’t had a period in 10 months, and its unexpected arrival wasn’t helping my rage.

The Strange Sad Tale Of The Death Of The Diaphragm

When I finally got through to my doctor’s office the next day, a nurse informed me that the prescription couldn’t be refilled because of how long it had been since my check-up.

I balked. My last doctor’s appointment had been less than a year ago, and no one had contacted me to say I needed to come in or else say goodbye to my birth control.

Apparently, the doctor decided I needed a pelvic exam and pap smear before she, the gatekeeper to my contraceptives, would give her coveted signature. To be fair, I’d long considered the duo of a pap smear and pelvic exam another necessary burden of womanhood, and made peace with the fact that I needed to be an adult and grit my teeth through all the poking and scraping like my mother had before me. It would be a dreaded annual ceremony, cringingly tolerated so I could keep taking my birth control.

But my last pap smear was a year and a half ago and came back completely normal, and as a woman with the same sexual partner for the last six years, I was not a high-risk patient for a sexually-transmitted infection. There was no medical reason that I needed to get this cervical screening before getting my birth control. This barricade, built by doctors between people with vulvas and their contraceptives, isn’t uncommon. Around one-third of doctors always require a pelvic exam before prescribing or refilling oral contraceptives, despite the lack of connection between birth control and pelvic exams.

Around one-third of doctors always require before prescribing or refilling oral contraceptives.

Requiring people with internal reproductive systems to take annual pap smears can actually do more harm than good. In 2015 the Journal of Research in Medical Science published an article that followed 334 women for two years after receiving an abnormal pap smear. The women received biannual pap smears and annual colposcopy and biopsy exams. Twenty-four months after the abnormal pap result, 308 women had a normal pap smear, leading the authors to conclude that abnormal lesions can spontaneously and naturally regress, and annual pap smears are linked to a high rate of false positives.

That false positive comes at a cost to the patient, who must endure more speculum-spreading interventions.

The U.S. Preventive Screening Task Force, along with the American Cancer Society, considered the high false positive rate when they recommended pap smears occur at an interval of three to five years for asymptomatic women aged 21 to 65. As they wrote in the Annals of Medicine in 2012, “Treatment of lesions that would otherwise resolve on their own is harmful because it can lead to procedures with unwanted side effects, including the potential for cervical incompetence and preterm labor.”

The debate surrounding the benefits of the pelvic exam is a more tempestuous discussion. The American College of Obstetrics recommends a pelvic exam once a year for all people with internal reproductive systems 21 and older. In rebuttal, the American College of Physicians argues against a pelvic exam unless a someone has symptoms of a disease or infection, because more frequent intervention can cause more harm to their health than good. And in the neutral corner, the U.S. Preventive Screening Task Force decided to stay out of the debate completely, citing a lack of evidence necessary to form an opinion for or against pelvic exams.

As recently as 2002 and for decades before then, the American Cancer Society recommended that pelvic exams and pap smears occur at an annual rate to effectively catch cancer. But once a deluge of evidence showed that a majority of HPV infections resolve on their own, they changed their official recommendation in 2012 to a pap smear every three to five years and stopped recommending the pelvic exam altogether.

So why do doctors persist in pushing for annual exams? Sometimes the medical community is slow to accept new findings that change a decades-old process. Some have spent the majority of their professional lives administering annual cervical screenings, and are hesitant to change the habit.

Less altruistically, there’s a monetary gain that may entice doctors to ignore the new recommendations. It would be easier on the doctor to just prescribe and refill birth control prescriptions for their patients. But requiring every birth-control-taking person to come into the office and have their feet in the stirrups guarantees an annual check from each one, either out-of-pocket or from the insurance company.

Why Do We Doubt And Police Those Seeking Permanent Contraception?

Even if the intent is not malicious, keeping individuals from their birth control for no other reason than to enforce a screening is inherently coercive, since the two aren’t at all connected.

Withholding birth control harms a person’s reproductive health and stigmatizes the practice of taking oral contraceptives. As Drs. Felicia Stewart, Cynthia Harper, and Charlotte Ellertson explain in a 2001 article published in the Journal of American Medicine, requiring these exams “may reduce access to highly effective contraceptive methods, and may therefore increase women’s overall health risks. These unnecessary requirements also involve ethical considerations and unwittingly reinforce the widely held but incorrect perception that hormonal contraceptive methods are dangerous.”

Suspending a person’s access to their birth control for any reason, beside it being harmful to their health, is backward. The World Health Organization and the American College of Obstetricians and Gynecologists agree that hormonal oral contraception can be prescribed safely without a pelvic exam. Dr. Anita Nelson, professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA, calls the practice of only provisioning birth control after cervical screenings “a tragic leftover of the past.”

I don’t want to compromise my control over the reproductive hormones that go into my body, no matter how beneficial and ‘for my own good’ the test is.

The point is not to abolish pap smears or tell people to stop getting pelvic exams. In the past 50 years cervical cancer deaths have diminished by 60%, due in large part to the early detection from pap smears. Cervical cancer used to be the number one cancer killer of people assigned female at birth; now it’s 14th.

But whether it’s a screening test for cancer, a swab for sexually transmitted diseases, or my annual dental cleaning, I don’t want to compromise my control over the reproductive hormones that go into my body, no matter how beneficial and “for my own good” the test is.

If you want to complete a pelvic exam every time you sneeze funny, then I encourage you to, and want people with vulvas to have that choice. But tying the screenings to birth control is unethical and scientifically unfounded. It’s the equivalent to requiring a cis man to undergo a urethra swab and prostate exam prior to buying condoms. It also takes away the ability for those with internal reproductive systems to make decisions about their own health and body.

That’s why I canceled my pap and pelvic exam appointment with my doctor. I couldn’t spread my body open for procedures that were being performed at a frequency unsupported by the science and medical authorities, and fundamentally, I couldn’t support a doctor who would use birth control as a coercive measure for any reason. So I left my doctor permanently. I’m not interested in begging, negotiating, or bargaining with my health care provider in order to obtain my birth control.

What You Need To Know About Reproductive Coercion

I was off birth control for a month as I searched for a doctor that would both accept my health insurance and was OK with committing to a cervical screening once every three to five years. Then I found a better alternative. As the issue of “doctors holding birth control hostage” gains more attention, people are finding ways around the in-person doctor visit to obtain prescriptions.

Lemonaid is a virtual doctor visit. It costs $25 out-of-pocket for an online assessment, then a doctor can prescribe your birth control to be mailed directly to you or picked up at your local pharmacy. Lemonaid only operates in 18 states right now, but hopefully more are to come. Similar resources include Nurx, Virtuwell, and Pandia Health.

The pioneer of the pill and Planned Parenthood clinics Margaret Sanger once said, No woman can call herself free who does not own and control her body. No woman can call herself free until she can choose consciously whether she will or will not be a mother.As long as birth control is “given,” “prescribed,” and “permitted” to us, that sovereignty over our bodies, free from obstruction and coercion, is still on the horizon.

Two days after I signed up with LemonAid, answered a questionnaire, and messaged with a doctor about my medical history, I received a package in the mail. It was three months of birth control, delivered directly to my mailbox. I’d never been so excited to take my daily pill.

When I opened the package the familiar yellow containers fell out, followed by two Starburst candies, and a thank you note. After my excitement settled, I realized that this is how easy it’s supposed to be. The “control” in birth control should be possessed solely by the individual taking it. Their contraceptives should never be a bargaining chip.

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