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About That “Free” Birth Control …

by Kait Scalisi | Apr 24, 2015 | News, Sex Stories

By Kait Scalisi, MPH

From the start, the Obamacare contraceptive coverage provision has been controversial. Now, a new report shows that the promise of free birth control may, in fact, be too good to be true.

The provision itself requires most private insurance plans to cover all FDA-approved contraceptive devices without any cost-sharing (e.g., co-pays). Federal guidelines, however, state that individual plans may apply limitations in an effort keep costs down and care efficient. Additionally, carriers should have a process for waiving coverage limitations for patients who need a form of contraception that the plan either limits or does not cover.

The Kaiser Family Foundation recently released a report exploring these limitations. They looked at the insurance coverage policies of 20 insurance carriers for twelve forms of contraception, not including oral contraceptive. Information was gathered by interviewing plan officials and reviewing publicly available coverage documents. The short version of their findings? Most insurers do not cover all forms of birth control. More specifically:

There is a lot of variation in how carriers are interpreting and implementing the contraceptive provision. In many cases, the limit coverage of certain methods by either denying coverage completely or requiring policy holders to cover a portion of the method’s costs.
NuvaRing is the method that is the least likely to be covered by carriers. They report they do not want to cover multiple forms of birth control with the same chemical formulation, such as the ring and at least one birth control pill, despite the fact that the ring is defined as a distinct form of contraception.
There is a lot of variability in whether and how IUDs, the implant, and the patch is covered. Some plans cover all of the methods without any limitations while others cover some with limitations and some without.
Plan B is widely covered but ella, which has a longer window to work and is recommended for women with BMIs above 25 is not.
Half of the plans cover sterilizations completely, including associated services such as anesthesia and follow-up visits.
None of the carriers have an established process for policy holders to appeal limitations based on medical need.

The goal of the Affordable Care Act is to provide coverage to anyone who needs it, and especially those who need it the most. However, these limitations in contraceptive coverage mean that many women still do not have full access to contraception, including the method that might be best for them.

The lack of a formal appeals process specific to contraception is particularly alarming. Susie Poppick wrote about her experience with these limitations and though she eventually got her birth control, she had to make several calls to her carrier. More importantly, she knew how to and had the time to do so. This is a privilege not everyone has, whether its the wherewithal to ask for a manager, the cell minutes and time to spend making multiple phone calls and waiting on hold at least once, or even that contraception is supposed to be covered.

All of this is not to diminish the fact that the ACA did increase birth control access for many women. Confusion, bumps, and negative outcomes are bound to happen, making reports such both vital and valuable. Now that we know the state of contraceptive coverage limitations, it is up to the government to clarify the guidelines related to different forms of contraception and for insurance companies to take the next steps in making their policies clear and accessible.

Other Sexual Health News This Week

Gonorrhea and chlamydia are on the rise in one CA county (Times Standard). An increase has also been reported in Montana. (KRTV)

Research Informs HIV Treatment Policy for Inmates (Medical Xpress)

Poll: Gay-Marriage Support at Record High (Washington Post)

Sex and Orgasm Makes You More Likely to Reveal Deep Secrets (The Daily Mail)

Bill to Allow More Sexual Abuse Suits in NY, Cites Syracuse University Scandal (Syracuse.com)

Culture’s Transgender ‘Moment’ (CNN)

Upcoming Conferences

The following conferences take place in April. Click on each name fore more information and to registers.

YTH Live 2015, April 26-29

Sexual Assault Summit, April 29-May 1

American Conference for the Treatment of HIV, April 29-May 2

Why Aren’t Women Using Condoms?

by Kait Scalisi | Apr 10, 2015 | News, Sex Stories

By Kait Scalisi, MPH

Nearly 4,000 women divulged their sexual health habits in a new survey given by Planned Parenthood and Women’s Health magazine. The results will either totally surprise you or confirm what you already knew: women aren’t using condoms, getting tested for STIs or talking to their sexual partners about safe sex.

More specifically, the survey found the following results.

Condom Use

58% of women rarely or never use condoms.
16% say they always do.
95% rarely or never use condoms during oral sex.

STI Testing

One-third of women have never been tested for any STD.
3% of women are not sure if they have.
38% of women have never been tested for HIV.
6% are unsure if they have.

Talking to Partners About Safer Sex

37% report they’ve never talked to a partner about STD prevention

The magazine does not provide information on the survey’s methodology or the respondents’ demographics. This information is extremely important as age is known to influence condom use with rates of it decreasing over time. It is somewhat safe to assume that respondents have similar characteristics to the magazine’s readership. This would place most of the respondents in their 20s and 30s, the ages when condom use begins to decline from adolescence.

The results of this are alarming if not totally surprising to those of us in the field. They support past findings from the National Survey of Sexual Health and Behavior as well as anecdotal evidence from our colleagues, peers, and family members. As Planned Parenthood’s Vice President for External medical affairs said:

Unfortunately, it’s not uncommon for smart, educated, otherwise safe-playing women to forgo all caution when it comes to STD prevention. (Source)

The Women’s Health piece does a decent job of outlining why condom use, regular STD testing, and talking to partners is important. Instead I’ll focus on what else the results offer: an opportunity to make change. Condom rates seem to be static, if not declining. This implies that public health’s efforts to promote safer sex practices need some reworking. Scare tactics, shame, and “come on you should no better” clearly aren’t working. Our questions then should shift from simply describing what’s happening to exploring, in-depth, the motivations behind these behaviors. For example, why aren’t women talking to their partners about safer sex? What practical strategies can we teach them to normalize this conversation and make it easier and less awkward? Can we eroticize safer sex in some way so that it becomes, in fact, sexy? How can we better market safe sex? How can healthcare providers be better trained to talk about sex with patients? These questions are where the true value of this survey lies.

In my opinion, the whole point of research is to influence policy and programming. It is fairly useless to simply state the facts and move on. Will Women’s Health use this data to influence the content that will appear in their magazine and website? Will Planned Parenthood and other sexual health organizations, which already do fabulous and extensive outreach during STD Awareness Month, focus a bit more on sex education for adults? I recognize this all is much easier said than done but looking into new ways to approach this issue is vital if we want to make long-lasting, macro-level changes.

Lastly, I hope the organizations conduct follow-up surveys that not only ask these questions again but also delve into the why behind this data. As the condom landscape changes and becomes more female-friendly (brands like Sustain and Loveability focus almost exclusively on millenial women), it will be interesting to see if and how the data changes.

Other Sexual Health News This Week

The US Healthcare System Isn’t Doing Enough for Vulnerable LGBT Communities (Quartz)

Domestic Violence Deters Contraception (ScienceDaily)

Gay Hookup Apps: Survey Reveals Some Things That Might Surprise You (WEHOville)

For Gay and Bi Blood Donors, New Rules but Same Ban (Huffington Post)

For Millenials Making Sexual Health Decisions, There is No Black and White (News OK)

Democrats in North Dakota Ask Governor for Executive Order Prohibiting Sexual Orientation Discrimination (Valley News) while San Diego Adds Gender Identity, Expression to Nondiscrimination Policy (San Diego Gay & Lesbian News).

CDC: Teens Unfamiliar With Most Effective Form of Birth Control (US News)

Conference Proposals Due

The following conference proposals are due in April. Click on each name for more information.

National HIV Prevention Conference, April 19.

Upcoming Conferences

The following conferences take place in April. Click on each name fore more information and to registers.

From Abortion Rights to Social Justice: Building the Movement for Reproductive Freedom, April 10-12

Gender Matters Conference, April 17-18

National Transgender Health Summit, April 17-19

Building Healthy Futures Advanced Training – Re-imagining Men’s Role in the Movement to End Sexual and Intimate Partner Violence, April 22-23.

SOPHE 66th Annual Meeting, April 23-25

YTH Live 2015, April 26-29

Sexual Assault Summit, April 29-May 1

American Conference for the Treatment of HIV, April 29-May 2

Is Birth Control Bourgeois?

by Kait Scalisi | Apr 3, 2015 | News, Sex Stories

By Kait Scalisi, MPH

Socioeconomic status (SES) matters when it comes to unintended pregnancy and birth rates. Individuals whose income falls below the federal poverty level (FPL) are more likely to have sex without any sort of protection and less likely to have an abortion compared to those with higher incomes.

These results come from a new study by the Brookings Institute (PDF). Using data from the National Survey of Family Growth (NSFG) 2011-2013, researchers sought to answer one question:

How much do gaps in contraception and abortion matter in terms of explaining variation in unintended birth rates by income?

From the more than 10,000 men and women who responded to the NSFG, researchers focused on 3,885 single women who were not trying to get pregnant. Women fell into this category if they fell into one of the following three categories:

Using contraception
Not using contraception for a reason other that trying to get pregnant (e.g. cost)
Classifying a pregnancy as unintended

The sample was then placed into one of five income categories.

At or below FPL
100-200% FPL
200-300% FPL
300-400% FPL
400%+ FPL

The researchers used these categories to make comparisons on four measures: sexual activity, contraception, abortion, and birth.

Sexual Activity was defined as having at least one opposite sex partner in the last year. There were no differences in rates by income level. Researchers also looked at sexual activity in the last month and total number of sexual partners in the last year and found no relationship. Sexual frequency is not captured in any of these measures and could account for some of the differences in rates of unintended pregnancy. However, past research supports the idea highlighted here that there is no connection between SES and how much sex people are having.
Contraception was defined as any contraception use in the last year. Women with the lowest income were twice as likely to have sex without contraception compared to those with the highest income. No analyses were done by type of contraception used which can also be related to the differences in unintended pregnancies.
Abortion rate was calculated by dividing the the women who reported their last pregnancy ended in abortion by the women who reported a pregnancy in the last year. Women with the lowest income were more than three times less likely to have an abortion than those with the highest income. Access to abortion services was not explicitly examined although it is implied that those with higher incomes would have the means to travel even if they lived in an area without one.
The birth rate was almost five times higher for women with the lowest income compared to those with the highest.

The authors went on to determine how the gap would be different if lower income women adopted the same rates as the highest income women. Their findings are twofold:

If all single women adopted the high SES rates of contraception use, the gap in unintended births would be cut in half.
If all single women adopted the high SES rates of abortion, the gap in unintended birth would be reduced by a third.

These are tabulations, however, and may not tell the whole story.

Other Factors Influencing the Contraception and Abortion Gaps

Several other factors may come into play when discussing the differences in pregnancy rates by SES.

Access to better methods of contraception. Currently 24 states do not cover long acting reversible contraceptives (LARCs), the most effective form of birth control. These states tend to be in the public health hotspots of the US including the Bible Belt where there are corresponding higher rates of poverty.
Distrust of healthcare. Due to abuses throughout history, people of color and low income individuals tend to feel distrustful of the healthcare field. This has been shown to delay seeking medical attention. From my own experience working in medicare/medicaid clinics, there also are racial and generational differences in what forms of birth control are accepted.
Limited access to sex education. Only about half of the states (PDF) require information on contraception be taught during sex or HIV education. Many of the states that do not cover LARCs also do not have comprehensive sex education. How can we expect people to use protection if they don’t even know about it?
Less access to a safe abortion. Women with lower SES are less likely to have the means to get to an abortion clinic and pay for an abortion. The Washington Post reports that primary deterrent to safe procedures is financial with women in the highest income brackets being three times as likely to have had an abortion in the past year that poor women.
Desire to have children. Some sociological research hows that having children, intended or otherwise, provides great fulfillment to women of lower income resources. As said in the study: “[it may be that] women with limited economic prospects will control their fertility less carefully because they have less to lose.” Data from the study does not show clear differences by income level in preferences for children; however it does show that a third of single women not trying to get pregnant would not be bothered by an unintended pregnancy.

Policy Implications

Since sexual frequency does not seem to contribute to differences in birth rates, policy should focus on increasing access to contraception and abortion, especially long-acting reversible contraceptives (LARC) such as the IUD or implant. Past research shows that when money is no issue, most women choose this option; however, for many the cost is prohibitive. This alone

From a practical standpoint, contraceptive access is a slightly easier product for public health to “sell.” It lacks some, if not all, of the moral controversy of abortion. Additionally, increased contraceptive use, particularly of LARCs, leads to a decrease in abortion rates as well. Lastly, expanding access to birth control makes economic sense. Unintended pregnancies cost taxpayers $21 billion each year according to a recent analysis (PDF) by the Guttmacher Institute.

This quote from the study’s co-author Richard Reeves, policy director of the Center on Children and Families. sums things up nicely:

“In a sense, inequality starts before birth,. An important part of the policy story is helping parents have children when they’re ready. The life chances of those children will be better as a result.” Source

Other Sexual Health News This Week

Adequate Sleep Tied to Women’s Sexual Function (Reuters)

Black Market Breast Milk Could Spread HIV (Vocativ)

This Experimental Vaccine Could Mean The End Of Herpes (Refinery 29)

Dating Research from OkCupid: Race and Attraction, 2009 – 2014 (OK Cupid)

Do I Have an STD? Spring Break Edition (GQ)

Millennial Attitudes on Reproductive and Sexual Health Show Promise for Advocates (RH Reality Check)