Opinion: Sexual chemistry
The news that emergency after-sex contraceptive pills (ECPs) are to be provided by pharmacists in Manchester is welcome and long overdue. Until now, emergency contraception - commonly misnamed the 'morning after pill' - has only been available on prescription from GPs, family-planning clinics and some hospital accident and emergency departments. This was about as irrational as it was possible to get.
To be effective, emergency contraception (two doses of special contraceptive pills) has to be started within 72 hours of sex - and it is best if the regimen is started within 12 hours. This makes obtaining it from your average doctor pretty difficult. Phone for an appointment and you are more than likely to find that your GP is already fully booked with patients half-dead with flu. Even if you can get an appointment, you have to be pretty motivated to take time out of your life to trudge along to the surgery, and (some would think) have a high embarrassment threshold to risk a lecture from your doctor, once you admit that you had unprotected sex the night before.
British Pregnancy Advisory Service (BPAS) tried to take the sting out of doctor-provided ECPs by advertising its willingness to prescribe the pills in advance of your need to use them. The rationale was sound. Women wanting to 'be prepared for the unexpected' could drop into a BPAS branch and pick up a packet of pills to keep at home along with aspirin, thrush cream and those sachets of stuff you dissolve in water and drink when you feel the first twinge of cystitis. But BPAS would be the first to admit that advance-prescribed ECPs never really took off. Probably this was still too much hassle, and relied too heavily on women's desire to plan for something they may not intend to happen. In these risk-obsessed times we are all supposed to plan and prepare for safer sex. Planning and preparing for sex that is unplanned and unprepared for might, just might, seem too weird for many women.
Providing ECPs in pharmacies is the obvious and most sensible means of making them available. If a woman has risked pregnancy she can drop into the pharmacy and pick up a pack on her way into work. There is no medical reason for a doctor's involvement. The risk of the drug causing problems is far smaller than many other drugs sold over the counter. ECPs are safe for almost any woman to use.
Yet even in Manchester, there seems to be a reluctance to face up to the fact that obtaining ECPs should be as easy and straightforward as getting antihistamines when you have hayfever. On the one hand those who devised the project seem keen to extend access to ECPs, but on the other they seem determined to lay a trail of obstructions in a woman's way. There have been approving reports of women needing to answer a detailed questionnaire and undergo a 10-minute consultation, to ensure that it is appropriate for them to use emergency contraception. The need to prevent women from using it repeatedly instead of regular contraception has been raised. The Express sensibly welcomed pharmacy provision in an editorial but cautioned, 'It is essential that the recipients are recorded, that the frequency of their requests is measured and that the scheme does not turn into an alternative to proper contraception'.
This caution reflects an absurd reluctance, even on the part of family-planning professionals, to see emergency contraception promoted and used.
Emergency contraception is 'proper contraception'. The only sound reason why it would be inadvisable for a woman to use ECPs repeatedly to prevent pregnancy is because they are less effective than most regular methods. But condoms are less effective than the pill, yet you would be pretty surprised to find your pharmacist advising you against using Durex repeatedly. And a woman does not need to be quizzed about when she had sex or about the date of her last period to determine whether ECPs are for her. She simply needs to know the 72-hour time limit of effectiveness, and that the pills will not cause an abortion if she is pregnant. Pharmacists do not need records of how often women have used ECPs. The medical issues for a woman using them for the sixth time are the same as when she used them first.
It seems likely that all the palaver with questionnaires and records has more of a moral purpose than a medical purpose. It becomes a means of underscoring what many in authority believe: that unprotected sex should not happen, and women should not be let off too lightly when it does.
An over-the-counter means of preventing unwanted consequences of a night of spontaneous, carefree passion may be just a little bit too amoral for policymakers to stomach. Contraceptive provision today, it seems, does not just have to help women prevent pregnancy - it has to give the right message about sex. The 'right message' is that sex is okay as long as it is anticipated, and ECPs are okay as long as they are used to sort out a genuine one-off mistake. Passionate abandon is definitely not an excuse for use. Shame!
Reproduced from LM issue 127, February 2000