Plan…C?

The U.S. Secretary of Health, Kathleen Sebelius, just overruled the FDA and decided to keep morning-after contraception (“Plan B”) accessible to girls younger than 17 by prescription only.  The FDA had recommended, in a split vote, to make the agent available over-the-counter.

This is simply the latest chapter on a long-simmering controversy, and one on which I have opined before.  There are plenty of opinions swirling in cyberspace about Secretary Sebelius’ decision- so I won’t belabor that.  Reposted below from 2009 is a blog I wrote addressing some of the historical controversy- all clearly still relevant.  My opinion on the right course is as it was in 2009.

 

Preventive Medicine Column

April 24, 2009

plan b for Plan B

 

Last week, in accord with a ruling by a federal judge, the FDA lowered the age requirement for over-the-counter access to Plan B – morning after contraception- from 18 to 17.  And thus Plan B, conceived in controversy, gestates in controversy still!

In 2005, the controversy was whether to make this last-ditch defense against unintended pregnancy available over the counter (OTC) to anyone.  At that time, the product- essentially a concentrated dose of the hormones used in oral contraceptives that prevents implantation, and thus pregnancy, if taken within 72 hrs of intercourse- was available by prescription only.  Making Plan B available OTC was recommended by a scientific advisory committee to the FDA, the agency’s regulatory staff, and the head of the agency’s drug center.

But instead, the FDA Commissioner at that time announced that a decision on Plan B would be postponed indefinitely while the agency wrestled with the unprecedented policy implications.  The real story, however, was all about political contamination of what should have been science-based action.

Dr. Susan Wood, who was assistant FDA commissioner and director of the agency’s office of women’s health at that time, resigned in protest over the agency’s handling of the Plan B issue.  Dr. Wood contended that abortion politics, rather than science, were behind FDA decisions regarding Plan B, which was self-evident to anyone paying attention.

We have come a long way since.  Eventually, Plan B was made available over the counter, but to women 18 and older.  With the official lowering of the age restriction to 17 last week, Plan B re-entered the news, and re-ignited controversy.

Age, in fact, was always the centerpiece of the Plan B controversy, or at least the pseudo-controversy used to stall any action.  The FDA acknowledged in 2005 that OTC Plan B was appropriate for those over age 17, but not for anyone younger.  The contention then was that it could not be made available over the counter at all without the risk that younger girls would buy it.

But that reasoning would suggest that cigarettes and alcohol should be sold by prescription only, since they, too, come with an age restriction!  Yet both are, of course, sold ‘over the counter.’   The notion that placing an age restriction on an OTC product had “unprecedented policy implications” was eventually exposed as the nonsense it always was.

But that left us with age-restricted access to Plan B, and still does- just a lower cut point as of last week.  Whether Plan B should have any age limit is a debatable issue in its own right.  Personally, I don’t think so.  Don’t get me wrong- I am not advocating sexual licentiousness.  As the father of five, four of whom are young women and teenage girls, I find my views on juvenile sexual activity to be quite conservative!

But it seems self-evident to me that if and when an injudicious sexual encounter does take place, compounding it with a safely preventable, unwanted pregnancy –or an abortion- makes little sense.  Plan B is quite safe, and fairly effective, having been used by millions of women in the US and Europe.  Once a girl is old enough to decide to have sex, however ill advised her decision may be, then it seems to me she is old enough to buy and take Plan B.  The more portentous of these two decisions is the former, not the latter.

Make no mistake, Plan B is NOT an early abortion.  Immediately after intercourse, there may not even be an egg, let alone a fertilized egg, in the fallopian tube.  But even if there is, prior to implantation, there is no embryo.  This is contraception, just applied a bit late.  Earlier contraception is better for many reasons, the most significant of which is that the right kind protects not only against pregnancy, but also against sexually transmitted diseases, including HIV.  Plan B does not.  That’s exactly why it IS plan B, and not plan A.

Plan A is either abstinence from sex, or the use of barrier contraception (e.g., condoms) that can safely prevent both pregnancy and sexually transmitted disease.  Plan B is just what it should be; a contingency plan when better options are no longer available.  Plan B is far from ideal, but once it becomes a relevant consideration, the other options are decidedly less so.

There is, as one would expect, conservative opposition to making plan B available to 17-year-olds.  The principal argument I have found is that young girls will rely on it as their preferred form of contraception.

While I can generally see the merits on both sides of such arguments, and am respectful of the range in perspectives on ethical matters, I really think this opposition is feeble.  It defies reason to think that girls will be sufficiently well informed about Plan B to rely on it for contraception, yet not informed of its clear limitations relative to the better methods of Plan A.  Pharmacies that sell Plan B also sell condoms, and at lower cost.

The considerable research on the topic of teen sex indicates that informing young people about sex and its consequences, and empowering them to avoid those consequences, are associated with lower, not higher, rates of sexual activity.  Any messaging associated with the marketing of Plan B should be an opportunity to highlight the hazards of unprotected sex.

Which makes a strong case for Plan A.  I support Plan A for the prevention of unwanted pregnancies among teenage girls.

But when the chance for Plan A has come and gone, I support the availability of Plan B to any girl old enough to have made the decision that makes contraception a relevant issue in the first place.  In moving to plan b for Plan B, the FDA has done the right thing.  Better still would be the removal of an age restriction altogether.  I guess that will be plan c.

 

 

-fin

Dr. David L. Katz; www.davidkatzmd.com

 

 

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