Plan D

Many in the public health community are dismayed by the administration’s decision to overrule the Food and Drug Administration’s recommendations regarding plan B. I certainly am. Emergency contraception indeed raises knotty issues regarding how young people or others might misuse it, whether there are unintended behavioral effects that might create health harms, and more. Analogous health issues arise in the case of home HIV tests, which may lead some people to misuse them or to avoid (needed) medical attention.

These are precisely the kinds of questions that medical and public health professionals are paid to address.  Margaret Hamburg is one of the nation’s outstanding leaders in this field. FDA officials have spent many years examining these questions. I’m dismayed to see her and her team overruled by her political overseers. Aaron’s recent postings examined these issues very well. However we might wish things to be different, the reality is that the majority of American teenagers are having a variety of sexual experiences, sometimes under circumstances that create serious risks to their physical health and their emotional well-being. American society is much less effective than other wealthy democracies are in helping young people navigate these issues. Improving access to emergency contraception is one element in a set of policies that could help.

I emailed this weekend with several experienced clinicians in this area. They report that Plan B has an award-winning easy-to-read label, that there are very few medical contraindications to this medication. My colleague Melissa Gilliam is section chief for the Section of Family Planning and Contraceptive Research at the University of Chicago. She has extensive experience treating sexual and reproductive health issues that arise among young women. Gilliam comments: “We seem to be saying that a young teen can increase her risk of becoming a parent (which entails lots of reading and complex tasks) but not read a label.”

She went on to note evidence of how poor access to care is for teens, how many teens present late for prenatal care, late for contraception following initiation of sexual relationships,  and, yes, late for abortion if that is their choice. Plan B is designed for people who are motivated to prevent pregnancy, who should be supported and not hindered. This debate is especially ironic in light of evidence that teens who have had unprotected sex typically do not access emergency contraception, when these medications are free or distributed to them in advance.

As a father of two teenage girls, I share the view held by millions of parents that young teens are wise to wait to engage in sexual intercourse. I certainly understand the moral and political calculations that led Secretary Sebelius to decide as she did. Leaving aside any issues of unintended pregnancy and sexually-transmitted infection, I just don’t see that (say) 14- and 15-year-old girls derive much of value from many of the sexual relations they are likely to have. This is especially true when these relationships are conducted with older teenage boys or young adult men. My public health research judgment: many of these relations are pretty exploitative and crummy.

Both boys and girls marinate in a crummy popular culture that combines prudishness about many aspects of sexuality with the commercial exploitation of sex to sell teens everything from Ax deodorant to the Sports Illustrated swimsuit issue. I am less terrified by the prospect that my daughters will have sex before I would like them to than I am by the prospect that their boyfriends or sex partners will have learned what they know about female bodies and female people from pornography and MTV.

The best plan B (or plan C or plan D) is to create an environment in which young people are supported in pursuing relationships of greater mutual respect, safety, and intimacy. We–their parents and other adults—have much work to do in making this happen. This issue goes far beyond emergency contraception.

Postscript: On a related important matter, I received an email this weekend from AIDS United, which alerts me to the possibility that the ban on syringe exchanges may be reinstated in some form during last-minute congressional negotiations over Fiscal Year 2012 appropriations.


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