battle over birth control: the oral contraceptive pill

contraception: not a new concept

• egypt 1850 BCE

  • arcadia leaves and honey

  • animal dung

• greece 4th century

  • spermicides: olive and cedar oil

• 17th century, condoms

• pre-industrial

  • douches

  • elixir to miscarry

changes in modern contraceptives

• 1839: Goodyear improves condom manufacturing through the vulcanization of rubber

• early 1870s: contraceptives available by mail, vendors, pharmacies

  • condoms, douching materials, vaginal sponges, cervical caps, “womb veils”

anti-contraceptive laws

• 1873: created the New York Society for the Suppression of Vice

• sale and distribution of obscene materials since the 19th century

• Comstock Law

  • illegal to send an “obscene, lewd, and/or lascivious” materials through the mail, including contraceptive devices and information

  • defined contraceptives as obscene

comstock laws

• 24 states enact their own comstock laws

• massachusetts

  • anyone disseminating contraceptives, or information about contraceptives faced a fine and imprisonment

• connecticut

  • the act of using birth control is prohibited

  • married couples could face one year in prison

  • looked away in many cases, but laws on the books

• challenges

  • 1916: Margaret Sanger arrested for opening the first birth control clinic in the US

  • 1918: women could use birth control for therapeutic purposes

  • 1936: amendment, physicians could send now contraceptives across state lines. paved the way for more relaxing of birth control laws

margaret sanger

• grew up in poverty

• mother had 18 pregnancies, 7 miscarriages. died at 49 of TB and cervical cancer

• 1916 founded the first birth control clinic in Brooklyn

• coined the term “birth control”

• Women Rebel 1914

• dream of creating “the pill”

enter the pill

• why do we need the pill?

  • gender inequalities

  • higher efficacy

  • empowerment for women

  • sexual revolution

    • enter the workforce

    • control over motherhood

    • sexual freedom

gregory pincus

• sanger meets gregory pincus

• harvard scientist

• 1934, in-vitro fertilization of rabbits

• Brave New World recently published

• pincus labeled “Dr. Frakenstein” by new york times

• denied tenure

john rock

• medical doctor

• devout catholic

• seen as skeptical at first by sanger

• later, critical advocate

• believed the pill should be accepted by the church

• took great risk to his career

• witnesses problems in his practice

• taught birth control to med students in the 1940s

katherine McCormick

• graduated from MIT with a degree in biology

• married stanley mccormick, heir to international harvester fortune

• suffrage movement

• committed to birth control with sanger

• financed the pill research

initial studies

• pincus conducts animal trials with progesterone. ovulation inhibited

• population needed for a trial

• GD Searle already had progesterone medications developed

• large scale study conducted in Puerto Rico

  • no comstock laws

  • dense population

  • science seen as a good thing

catholic church rejects pill

• rock argues hormones same as in the woman naturally

• increasing “safe period”

• Rock authors The Time Has Come: A Catholic Doctor’s Proposals to End the Battle Over Birth Control

• church released Of Human Life

the pill

• pill receives FDA approval in 1960

• within 2 years, 500,000 prescribed

• by 1965- 6 million on the pill

• key component of the sexual revolution

• by 1970, two-thirds of all catholic women and three-quarters of those under 30 were using the pill and other birth control methods banned by the church

pill decent

• by the late 1960s, thousands of women were complaining of side effects

• power and doctors at the time

• 1969 expose by barbara seaman

• 1970 hearings. no women to represent women

Alice wolfson

• “why are 10 million women being used as guinea pigs?”

philip ball

• “they used a sledge hammer to drive small nail.”

contraceptives as a social issue

social determinants of health

• education access and quality

• healthcare and quality

• neighborhood and built environment

• social and community context

• economic stability

benefits (guttmacher, 2013)

• a large and growing body of literature explores the health benefits related to services received at family planning clinics

• research indicates that family planning, including planning, delaying and spacing pregnancies, is linked to improved birth outcomes for babies, either directly or through healthy maternal behaviors during pregnancy

• contraceptive methods have a range of benefits other than their primary purpose of pregnancy prevention

  • contraception reduces pregnancy-related morbidity and mortality, reduces the risk of developing certain reproductive cancers

  • used to treat many menstrual-related symptoms and disorders

• in addition to contraception, a range of other beneficial health services are available to clients at family planning clinics. services to prevent, screen for and treat diseases and conditions such as chlamydia, gonorrhea, HIV, HPV, and cervical cancer, as well as to address intimate partner violence, benefit both female and male clients who visit these clinics

• because not all women have equal access to the many benefits of contraception and other health services, there is more work to be done in implementing programs and policies that advance contraceptive access and improve health outcomes for all women

contraceptive use in the US

• nearly half of pregnancies in the US are unintended

• intended, 51%

• unintended: occur earlier than desired, 29%

• unintended: occur after women have reached their desired family size, 20%

contraceptive need (guttmacher, 2018)

• there are 61 million US women of reproductive age (15-44). about 43 million of them (70%) are at risk of unintended pregnancy- that is, they are sexually active and do not want to become pregnant, but could become pregnant if they and their partners fail to use a contraceptive method correctly and consistently

• couple who do not use any method of contraception have approx. an 85% chance of experiencing a pregnancy over the course of a year

• in the US, the average desired family size is two children. to achieve this family size, a woman must use contraceptives for roughly three decades

contraceptive use (guttmacher, 2018)

• more than 99% of women aged 15-44 who have ever had sexual intercourse have used at least one contraceptive method

• some 60% of all women of reproductive age are currently using a contraceptive method

• 10% of women at risk of unintended pregnancy are not currently using any contraceptive method

• the proportion of women at risk of unintended pregnancy who are not using a method is highest among those aged 15-19 (18%) and lowest among those aged 40-44 (9%)

intersectionality

• unintended pregnancy rates are highest among low-income women (i.e., women with incomes less than 200% of the federal poverty level), women aged 18-24, cohabiting women and women of color

  • rates tend to be lowest among higher-income women (at or above 200% of poverty), white women, college graduates and married women

• the rate of unintended pregnancy among women with incomes less than 100% of the poverty was 112 per 1,000 in 2011, more than 5 times the rate among women with incomes of at least 200% of poverty (20 per 1,000 women)

• when used correctly, modern contraceptives are very effective at preventing pregnancy

• among U.S. women at risk of unintended pregnancy, the 68% who use contraceptives consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies

• in contrast, the 18% who use contraceptives inconsistently account for 41% of unintended pregnancies, and the 14% who do not use contraceptives at all or have a gap in use of at least one month account for 54% of unintended pregnancies

• in 2008, the 2/3 of us women at risk of pregnancy who used contraceptives consistently accounted for only 5% of unintended pregnancies

women report a variety of reasons for contraceptive nonuse

• 40%- problems accessing or using methods

• 19%- infrequent sex

• 18%- do not care if pregnancy occurs

• 7%- underestimate pregnancy risk

• 16%- other

dr. butler’s study

• dr. butler conducted a study among 2,800 college students, 1584 had used a condom in the last year

• variables

  • condom and safe sex product use

  • embarrassment

  • attitudes towards condom distribution programs

  • errors and problems

  • condom acquisition

• most students were sexually active in the last year, 73% had vaginal sex, 76% oral sex, and 17%

• 58% had used a male condom in the last year, less than 1% female condoms, and 1% latex dams

errors and problems

• 57% wanted to have sex but did not have a condom available

• 56% does not typically squeeze the air out of condom

• 51% did not check the condom for visible damage

• 50% added condom after sex had begun

• 47% started sex with condom, removed condom, and continued having sex

• 43% problems with how condoms feel

• 30% condom slipped off during sex

• 30% condom broke during sex

• 26% initially applied condom the wrong side up and flipped it over

• 20% does not typically leave a space at the tip

• 20% problems with how condom fit

• 11% used a sharp object when opening condom package

• 8% used an oil-based lubricant

condom embarrassment

• 45% were embarrassed to ask a pharmacist about condoms, 27% embarrassed to purchase condoms at a drug store near campus, 21% to acquire them at the student health center, and 17% embarrassed to acquire them at the local health department

the condom as dual protection

• some 5.5 million women rely on the male condom. condom use is most common (i.e., at least 25% greater than the national average of 15%) among 15-19 year olds, those who report their religious affiliation as “other,” those born outside of the U.S., college graduates, those who are uninsured and those who are nulliparous or are expecting at least one (more) child

• ever-use of the male condom increased from 52%in 1982 to 93% in 2006-2010

• dual method use offers protection against both pregnancy and STIs. some 8% of women of reproductive age simultaneously use multiple contraceptive methods (most often the condom combined with another method)

emergency contraceptives

• 1 in 9 sexually experienced women of reproductive age have used emergency contraception, as of 2010. the majority of these women used emergency contraception only once (59%)

• use is highest among 20-24 year olds and never-married women, of whom 23% and 19%, respectively, report having ever used emergency contraception

ACHA, 2023

• college students who reported having vaginal intercourse (penis in vagina) within the last 12 months were asked if they or their partner used emergency contraception (“morning after pill” or “plan b”) in the last 12 months:

  • 17% cis men, 21.5% cis women, 21.3% trans/gender non-conforming

• college students who reported having vaginal intercourse within the last 12 months were asked if they experienced an unintentional pregnancy or someone got pregnant within the last 12 months

  • 0.9% cis men, 1% cis women, 1.9% trans/gender non-conforming

title x

• health policy started by richard nixon in 1970

• specifically designed to subsidize family planning and health services

• grants provided to 4,500 health centers serving 5 million people

• designed to help low income families, including those not eligible for medicaid

• FY2016, congress appropriated around $327 million for the title x family planning program

• funds cannot be used for abortions

• nearly 90% also received preventive gyno attention, and over 50% were treated for STIs or reproductive tract infections or related conditions

• in 2006, publicly funded family planning services (Medicaid, title x, and state funds) helped women avoid 1.94 million unintended pregnancies, thus preventing about 860,000 unintended births and 810,00 abortions

• without publicly funded family planning services, the number of unintended pregnancies and abortions in the U.S. would be nearly two-thirds higher among women overall and among teens; the number of unintended pregnancies among poor women would nearly double

impact of public funding

• altogether, the services provided at publicly funded family planning visits in 2010 resulted in a net savings to the federal and state governments of $13.6 billion. the services provided at title x-supported centers accounted for $7 billion of that total

• in 2010, every $1.00 invested in publicly funded family planning services saved $7.09 in medicaid expenditures that would otherwise have been needed to pay the medical costs of pregnancy, delivery and early childhood care

scabies

what is scabies?

• scabies is a mite which causes a skin rash, very itchy

• the mite burrows its way into the skin

• considered contagious, spreads easy among partners, families, schools, nursing homes, prisons, etc.

• typically, you treat everyone who may have been exposed

key point

• scabies is easily treated. medicated skin creams or pills kill the mites that cause scabies and their eggs

• but itching may not stop for many weeks after treatment

typical locations on infections (adults)

• between the fingers and toes

• in the armpits

• around the waist

• along the insides of the wrists

• on the inner elbows

• on the soles of the feet

• on the chest

• around the nipples

• around the belly button

• around the genitals

• in the groin area

• on the buttocks

typical locations of infection (children)

• fingers

• face, scalp, and neck

• palms of the hands

• soles of the feet

causes (mayo clinic)

• scabies is caused by a tiny, eight-legged mite. the female mite burrows just under the skin and makes a tunnel where it lays eggs

• the eggs hatch, and the mite larvae travel to the surface of the skin, where they mature. these mites can then spread to other areas of the skin or to the skin of other people. itching is caused by the body’s allergic reaction to the mites, their eggs and their waste

• close skin-to-skin contact and, less often, sharing clothing or bedding with a person who has scabies can spread the mites

• pets don’t spread scabies to humans. the scabies mites that affect animals don’t survive or reproduce in people

• however, coming in contact with an animal that has scabies may cause a brief itching if the mite gets under the skin. but within a few days, the mite will die, so treatment isn’t needed

complications

• scratching too much can break your skin and cause an infection, such as impetigo

• impetigo is an infection on the skin’s surface that’s caused most often by staph bacteria (staphylococci) or sometimes by strep bacteria (streptococci)

crusted scabies

• a more severe type of scabies, called crusted scabies, may affect certain people including:

  • young children

  • people with developmental disabilities

  • people with weakened immune systems, such as those with HIV or lymphoma, or people who have had organ transplants

  • people who are very sick, such as people in hospitals or nursing facilities

  • older people in nursing homes

• crusted scabies makes the skin crusty and scaly, and affects large areas of the body. it’s very contagious and can be hard to treat. quick treatment with both a prescription pill and a skin cream is needed

• typically, someone with scabies has about 10 to 15 mites. but someone with crusted scabies may have millions of mites. yet itching may not occur or may be mild

prevention

• to prevent scabies from coming back and to keep the mites from spreading to other people, take these steps:

  • wash all clothes and linen. heat kills the mites and their eggs. use hot, soapy water to wash all clothing, towels, and bedding used in the last three days before beginning treatment. dry with high heat. dry-clean items you can’t wash at home

  • starve the mites. place items you can’t wash in sealed plastic bags and leave them in an out-of-the-way place, such as your garage, for a week. mites die after a few days without food

  • clean and vacuum. it’s a good idea to clean your home to prevent scabies from spreading. this is especially true for people with crusted scabies. vacuum furniture, carpets and floors to remove scales and crusts that may have scabies mites

women’s health epidemiology: cervical cancer and the HPV vaccine

types of cervical cancer

• the type of cervical cancer that you have helps determine your prognosis and treatment. the main types of cervical cancer are:

  • squamous cell carcinoma- this type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. most cervical cancers are squamous cell carcinomas

  • adenocarcinoma- this type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal.

  • sometimes, both types of cells are involved in cervical cancer. very rarely, cancer occurs in other cells in the cervix

• pre-cervical cancer conditions are extremely common

• the american cancer society estimates for cervical cancer in the u.s. for 2020 are: about 13,800 new cases of invasive cervical cancer will be diagnosed

• about 4,290 women will die from cervical cancer

survival rates

• SEER stage → 5-year survival rate

  • localized- 92%

  • regional- 56%

  • distant- 17%

  • all SEER stages combined- 66%

causes of cervical cancer

• healthy cells grow and multiply at a set rate, eventually dying at a set time. the mutations tell the cells to grow and multiply out of control, and they don’t die. the accumulating abnormal cells form a mass (tumor)

• cancer cells invade nearby tissues and can break off from a tumor to spread (metastasize) elsewhere in the body

• the role of human papillomavirus (HPV)

  • the common sexually transmitted infection

    • “normal” to be infected

    • incidence- 17 million

    • prevalence- 79 million

    • not always linked to cancers, it’s very confusing

signs and symptoms

• early-stage cervical caner generally produces no signs or symptoms

• signs and symptoms of more-advanced cervical cancer include

  • vaginal bleeding after intercourse, between periods or after menopause

  • watery, bloody vaginal discharge that may be heavy and have a foul odor

  • pelvic pain or pain during intercourse

risk factors

• many sexual partners- the greater your number of sexual partners- and the great your partner’s number of sexual partners- the greater your chance of acquiring HPV

• early sexual activity- having sex at an early age increases your risk of HPV

• other STIs- having other STIs- such as chlamydia, gonorrhea, syphilis and HIV/AIDS- increases your risk of HPV

• a weakened immune system- you may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV

• smoking- smoking is associated with squamous cell cervical cancer

• exposure to miscarriage prevention drug- if your mother took a drug called diethystilbestrol (DES) while pregnant in the 1950s, you may have an increased risk of a certain type of cervical cancer called clear cell adenocarcinoma

• long term use of oral contraceptives

age and cervical cancer

• cervical cancer is most frequently diagnosed in women between the ages of 35 and 44 with the average age at diagnosis being 50

• it rarely develops in women younger than 20

pre-cancer

• cells in the transformation zone do not suddenly change into cancer. instead, the normal cells of the cervix first gradually develop abnormal changes that are called pre-cancerous

• doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia

• when the pre-cancers are checked in the lab, they are graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal

• in CIN1 (also called mild dysplasia or low grade SIL), not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer

• in CIN2 or CIN3U (also called moderate/severe dysplasia or high-grade SIL) more of the tissue looks abnormal; high-grade SIL is the most serious pre-cancer

treatment (pre-cancer)

• cryosurgery to freeze off the abnormal cervical tissue

• LEEP (loop electrosurgical excision procedure) to burn off the abnormal cells with an electrical looped wire

• surgery to remove the abnormal cells with a laser, scalpel, or both

treatment (cancer)

• depending on the type and stage of the cancer, need more than one type of treatment may be needed

• for the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. for later stages, radiation combined with chemo is usually the main treatment. chemo (by itself) is often used to treat advanced cervical cancer

the HPV vaccine 527 emory and gc students

• a study by gc alum for her masters thesis at emory

• more than half (55.8%) of students reported they had initiated the HPV vaccine series (received at least one dose), and 80% of initiators completed the three dose series. among students who did not receive the HPV vaccine (non-initiators), only 4.5% reported they were planning to get it within the next year, while 50% reported they don’t plan to get it, and 45.5% were undecided

• factors that would influence whether they got the vaccine

  • if a doctor encouraged you to

  • if a parent/guardian encouraged you

  • if the CDC guidelines recommended it

  • if there was an HPV vaccine awareness program on campus

  • if you talked to someone who had a good experience with it

our recent study

• we assessed condom use among 2,809 students from 6 colleges and universities. we also measured other sexual health outcomes

  • 47% of students have had a gynecological/testicular exam in the last year

    • 54% of women vs 32% of men (p<.001)

  • 70% have been vaccinated for HPV

    • 73% of women vs 63% of men (p<.001)

  • 37% have been tested for STIs in the last year

    • 42% of women vs 26% of men (p<.001)

HPV vaccine

• there were originally two different vaccinations (bivalent and quadrivalent)

• currently there is a 9 valent vaccine (which is the one you want)

• protection against cervical, vaginal, and vulvar cancers in females, anal cancer, certain head and neck cancers, such as throat and back of mouth cancers and genital warts

• HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 (18 and 18 account for 70% of the cancers)

Abortion: Social Issues and Considerations

Abortion Issues

Abortion in the US

• at 2014 abortion rates, about one in four (24%) women will have an abortion by age 45

  • in 2017, there were 862,000 abortions in the US

• more than half of all US abortion patients in 2014 were in their 20s: patients aged 20-24 obtained 34% of all abortions, and patients aged 25-29 obtained 27%

• some 75% of abortion patients in 2014 were poor (having an income below the federal poverty level of $15,730 for a family of two in 2014) or low-income (having an income of 100-199%) of the federal poverty level)

when abortions occur

• in 2016, two-thirds of abortions occurred at eight weeks of pregnancy or earlier, and 88% occurred in the first 12 weeks

abortion rates are at historic lows

• the US abortion rate reached a historic low in 2017 (13.5)

closures in clinics

• between 2011 and 2017, closures of clinics offering abortion were concentrated in the south and midwest, regions also enacted a slew of new abortion restrictions

roe v wade is overturned

• dobbs v. jackson women’s health organization, in a 6-3 decision, the SCOTUS decides abortion is not a guaranteed right by the US constitution

before dobbs, georgia abortion law

• in georgia, the following restrictions on abortion were in effect as of september 1, 2019:

  • a patient must receive state-directed counseling that includes information designed to discourage the patient from having an abortion, and then wait 24 hours before the procedure is provided

  • health plans offered in the state’s health exchange under the affordable care act can only cover abortion in cases of life endangerment or severely compromised physical health

  • abortion is covered in insurance policies for public employees only in cases of life endangerment

  • the parent of a minor must be notified before an abortion is provided

  • public funding is available for abortion only in cases of life endangerment, rape or incest

  • an abortion may be performed at 20 or more weeks postfertilization (22 weeks after the last menstrual period) only cases of life endangerment, severely compromised physical health or lethal fetal anomaly