Medical Paternalism & Women’s Birth Control   4 comments

Some Planned Parenthood clinics offer a program called HOPE (Hormonal Option without Pelvic Exam) that allows women to obtain a prescription for birth control pills without submitting to a pelvic exam. The idea is to reduce barriers to contraception as young women in particular are often very uncomfortable with a full gynecological exam. While I commend the program, there is no reason why hormonal birth control should be tied to pelvic exams in the first place. As long as the patient is asymptomatic, taking her blood pressure and medical history is all the information the doctor needs to determine whether she’s a candidate for hormonal birth control. Which is why many other countries don’t require pelvic exams to get birth control pills.

In the US, however, doctors frequently refuse to prescribe the pill unless the patient is willing to strip naked and spread her legs for a gyno exam and Pap smear. It’s an outrageously paternalistic practice that would never fly if the patients were men. Can you imagine doctors withholding a dude’s Viagra unless he submitted to a prostate or rectal exam? Me neither. But it makes about as much sense as requiring a pelvic exam and Pap test to get birth control pills.

Cancer screening should be a choice, not a requirement. And for men, that’s the way it is. Women, however, are coerced into annual cervical cancer screening starting at age 21, often even younger, if they want access to the most reliable forms of birth control. On top of that, there is usually no discussion of the pros and cons of screening all women regardless of risk factors, no information on the test’s reliability, no mention of the percentages of false positives and false negatives, no data on the cancer’s prevalence compared to other cancers that we do or don’t worry about, and nothing about the potential health risks of biopsies performed due to false positives. Nor are American women told that doctors in many other countries warn against screening women under 25-30 because cervical cancer is extremely rare in that age group, while the likelihood of a false positive is extremely high (in Holland, for instance, even high risk women are told to wait until they’re 30 to get their first Pap smear). Hence, no informed consent is possible. But that’s okay; we wouldn’t want women to worry their pretty little heads about these things.

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4 responses to “Medical Paternalism & Women’s Birth Control

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  1. If an Australian doctor refused a woman the Pill UNTIL she agreed to a pap test (routine pelvic and breast exams are not recommended here, although some doctors will tack them onto the birth control consult) – he/she could be reported to the Medical Board. A doctor using coercion to force testing IMO, could also amount to an assault, a police matter.
    Of course, our doctors receive undisclosed target payments from the Govt for pap testing, so some GP’s will present the pap as a requirement, a try-on, but if challenged, they back down…others will warn a woman of the risks if she declines the test, BUT don’t explain the much higher risk WITH screening. A false positive is vastly more likely than cervical cancer or something that would progress to invasive cervical cancer, a rare cancer that was in natural decline before testing started…so our program is also coercive, unethical and dishonest. Papscreen also encourage doctors to ambush women in unrelated consults – get them to do their dirty work – they call it “opportunistic screening”. If a woman stands firm and declines screening though, she can find a GP who’ll respect her decision, I did…
    Astonishingly, some women don’t understand they CAN say NO. All cancer screening is elective and can only be an offer, as all screening carries risk to the healthy body.

    Why is there so much fuss about this rare cancer that affects 0.65% of women? When you screen for a rare cancer, you need at least 70% of women screened to stand any chance of bringing down the death rate and justifying the huge expense of screening. Now that may be the case, but when you use an unreliable test, you end up harming and distressing in large numbers the healthy population of women – in Australia the lifetime risk of referral after an “abnormal” pap test is a whopping 77% – almost all are false positives and some women are left worse off with cervical damage after cone biopsies and LEEP – cervical stenosis, cervical incompetence – miscarriages, premature babies, more c-sections, infertility etc
    So much damage caused by an unreliable screening program for a rare cancer – it makes no sense.

    Of course, the screening target is only achieved by violating the legal rights of women – they cannot risk only 50% of women agreeing to screen. IMO, this means the program is unsuitable for population screening, as it can only work outside of informed consent – which is unethical. It means they must coerce, pressure, scare or mislead women into the program to achieve the target of at least 70%.
    We are supposed to be providing informed consent for cancer screening, yet it’s not respected for women. You cannot make an informed decision to test when you’re coerced or pressured into testing, provided with no or incorrect/incomplete/misleading information – these programs are unethical and operate outside ethical standards and the law.

    Sadly, few doctors speak up and warn women or challenge these authorities – many profit from the over-treatment and target payments, others are afraid to take on the powerful screening authorities, cancer charities and women’s pressure groups. One way of getting away with this is to silence critics and the programs (breast screening as well) have been very effective in that department – of course, their concern is about politics, their jobs and protecting the programs, they don’t give a damn about women, their rights and health.

    I’ve been concerned for nearly 30 years and only now am I seeing a change – more women speaking out, becoming informed and demanding their rights. In the States you have several doctors alerting women to the fact they should change doctors if they are required to have anything more than a blood pressure test to get the Pill (and provide your medical history) – others are informing women that the routine pelvic, breast and rectal exams are not helpful in asymptomatic women and expose you to risk. The information is out there…sadly, many of your women are now so afraid and brainwashed that some will climb into stirrups every year for the rest of their lives, but hopefully, these harmful and paternalistic attitudes and practices are on the way out….
    The well-woman exam should be called the sick-woman exam, it is far more likely to harm you – 1 in 3 US women will have a hysterectomy by age 60!
    95% of you will be referred after an “abnormal” pap test at some point thanks to extreme over-screening and inappropriate screening. The US is the only country who tests virgins….and many women who’ve had full hysterectomies for benign conditions are still having pap tests.

    As a low risk woman I rejected pap tests almost 30 years ago and more recently rejected breast screening – both decisions made on the basis of information that is not released to women. ALL women have the right to make their own screening decisions.
    If women wants pap tests, 5 yearly from age 30 provides some protection from false positives, but it also seems women could have a HPV test at age 30 and if negative for high risk HPV and in a monogamous relationship, could forget pap testing. Women are only tested endlessly “in case” their risk profile changes – given testing means risk, the decision to screen should rest with the woman. Women under 30 don’t benefit from pap testing, but produce lots of false positives. IMO, many pap tests are unnecessary…

    Take a look at this article: “Cervical cancer screening” in “Australian Doctor” July 2006 by Assoc Prof Margaret Davy and Dr Shorne.
    The Blogcritics site and the thread, “Unnecessary Pap smears” has 6000 posts from women who’ve been harmed by testing and over-treatments or concerned/angry at the lack of respect for informed consent for women.
    Dr Joel Sherman’s medical privacy forum has a section on womens’ privacy issues – in the side bar you’ll find all of the information your doctor doesn’t want you to read – I’d recommend anything by Dr Angela Raffle and Prof Michael Baum.
    “Why I’ll never have another smear test” by Anna Saybourn (“Guardian”) talks about Dr Raffle’s research that was published in the BMJ in 2003/4.
    “1000 women need regular smears for 35 years to save one woman from cervical cancer”. Now take a look at how many women are referred over those years!
    Do your reading, get informed and protect your healthy body from harm – screen, don’t screen or screen on your schedule, the best decision is an informed decision.

  2. Frankly, I consider the coercive practice of requiring women to submit to a pelvic exam and Pap smear to obtain birth control pills a form of sexual assault. There is nothing between my legs that will tell the doc anything about my suitability for hormonal birth control, so why make a gyno exam part of obtaining the pill? But it’s for my own good, right? Even if that were so (and whether the pros outweigh the cons is far from clear when it comes to Pap tests), the choice should be mine. Anything else is outrageously paternalistic and coercive and would never fly if the patients were men.

    While Planned Parenthood’s HOPE program is a small step in the right direction, there are two big problems with it:

    1. It’s not available at every PP location.
    2. It’s intended only as a temporary measure to get young women in the door. As soon as you try to refill your prescription, they’ll start pressuring you to submit to a complete “well woman” examination. This is presented as something all women must get used to sooner or later, which is infuriating because it really ought to be a choice.

    And not just a choice, but an informed choice. Most women have no idea how unreliable Pap tests are, especially for young women, who have almost no cervical cancer risk, but a sky high chance of a false positive resulting in a painful and needless biopsy that can leave them with long-term health problems. There’s a reason why countries such as Holland discourage Pap tests before the age of 30.

    While false positives and the needless pain and suffering they cause are the biggest problem with cervical cancer screening because of the near certainty that a woman who follows standard medical advice and has a Pap smear every year starting at age 18 will have an abnormal result at some point in her life, false negatives are a problem too. The Guardian piece you mention references a UK audit that found that one-third of women who did develop cervical cancer had normal smear results. Talk about an unreliable test. Every woman should be provided with this information and the opportunity to carefully weigh the pros and cons based on her risk factors and priorities.

    The hysterectomy stats for the US are frightening as well. Obviously there’s big money in pathologizing women’s bodies.

  3. Sasha,
    I’d urge all women to go into these consults armed with their references. Dr Robert Hatcher from the Managing Contraception site has raised his concerns about doctors locking away birth control until women submit to unnecessary exams and tests.
    More and more your doctors are speaking out – if a woman produces this information and says NO, hopefully more of your doctors will back down – I’ve heard of American women getting up to leave and the doctor relenting or women seeking legal advice and the script arrives VERY quickly.
    Your doctors KNOW this is unethical (and I’d say illegal) – they rely on woman giving in and accepting this treatment – complaints and legal action even up the playing field.
    http://www.managingcontraception.com/newsevents/dr-bob/pelvic-exam-necessary-for-contraception-rx/ (Dr Hatcher)
    http://www.reuters.com/article/2010/11/22/us-birth-control-idUSTRE6AL67X20101122 (“Women after birth control get unneeded pelvic exams)
    http://www.law.harvard.edu/students/orgs/jlg/vol27/dixon.php (this is an excellent article on the pelvic exam requirement for birth control)
    http://www.mailman.columbia.edu/academic-departments/epidemiology/research-service/routine-pelvic-examination-obsolete
    (comments by Dr Carolyn Westhoff)

  4. It’s also astonishing that women would be denied birth control to force them to have totally unnecessary breast and pelvic exams and to force an elective screening test that has nothing to do with birth control – the consequences are severe – unplanned pregnancies, abortions, miscarriages, ectopic pregnancies, relationship issues etc
    To suggest these restrictions are about our health is absurd – the consequences of tying up birth control are severe…while the rest is potentially harmful for no benefit and pap tests are unreliable and for a rare cancer. Few women (if any) benefit from pap tests….
    It says to me this is about controlling women – maximizing income and satisfying vested and political interests. IMO, they have little to do with our health care. The debate that is raging in the UK shows breast cancer screening has the same problems – no informed consent, risk is hidden from women, benefits are inflated…it’s just disgraceful.
    I’ve passed on mammograms as well – due to concerns about over-diagnosis. Prof Michael Baum, UK breast cancer surgeon has called for breast screening to be scrapped….
    http://www.guardian.co.uk/commentisfree/2011/aug/02/breast-cancer-screening?INTCMP=SRCH

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