Saturday, October 29, 2005

Oh My Nashville: EC and Rape

An interesting discussion has been going on at Nashville is Talking regarding emergency contraception, particularly a case in Tucson in which a woman was refused EC at a pharmacy after being raped. This was one of the most remarked upon stories on NiT for a couple of days, starting here, followed by a compelling and colorful response (as usual) from Aunt B., and continuing here. I've stayed out of the fray for a few days, wanting to collect my thoughts. I try to stick to information provision, but politics seem to frequently intrude into the world of women's health, and there is no doubt that prescription refusals have an impact on women's access to healthcare. I was surprised by some of the comments from other area bloggers/blog commenters. Let's take them point by point, and try to provide some info in each area:
(Warning: this is a long post, but it's a topic that merits attention and informed discussion)

First, the basics of the story that sparked so much discussion. Regarding the sexual assault victim - "While calling dozens of Tucson pharmacies trying to fill a prescription for emergency contraception, she found that most did not stock the drug. When she finally did find a pharmacy with it, she said she was told the pharmacist on duty would not dispense it because of religious and moral objections." You can read the full story here.

Some of the arguments:
  • Point: If you wouldn't be worried about an obstetrician refusing to provide abortions, you shouldn't be worried about this.
  • Information: Obstetrics is a specialized field, and abortion provision is even more specialized. A 2003 survey of US OB/GYN department chairs (78 of 126 responding) found that only 45% offered clinical experience in abortion during the 3rd year OB/GYN clerkship. In the 3rd year, 23% provided no formal education on abortion, and many covered abortion only via lecture. The topic is not covered at all in 17% of US medical schools. Essentially, abortion education is not only not required for obstetricians, it is not necessarily even available. As a result, expecting any and all obstetricians to provide abortion services (regardless of any moral stance) is not only misguided, it would be dangerous, negating the analogy. Pharmacists, on the other hand, are expected (with the exception of conscience clauses) to be able to dispense any medication in stock in a knowledgeable way, and are trained to do so. An MD is not an obstetrician is not an abortion provider, but a pharmacist is a pharmacist.

  • Point: A woman could just go to another pharmacist.
  • Information:
    1) Not every place has a pharmacy on every corner. Let's assume it's reasonably easy for a woman to obtain EC if there is a provider in her county, as a proxy for being within a reasonable distance. The 2002 Economic Census reports that there were 40,530 pharmacies and drug stores in the US. 39,282 of these offered prescription drugs. As of 7/7/2001, there were 3,141 counties in the US. That works out to an average of 12.5 pharmacies providing prescription drugs per county. Of course, some have many more. A quick search of for Nashville returns 152 results for pharmacies and drug stores. For the average to work out, for every city like Nashville, teaming with pharmacies, there must be ~12 counties with 0-1 pharmacies.

    2) Many pharmacies don't stock the drug. A study based on site vists conducted in Albuquerque, NM found that of 89 pharmacies, only 19 (11%) had emergency contraception in stock. Another report,based on a survey of pharmacists in Pennsylvania found that only 35% would be able to fill the prescription that day. Of those who couldn't fill the prescriptions, 79% reported that it was because the drug was not in stock; others reported that it was against store policy (6%), it conflicted with personal beliefs (7%), or they gave no reason (8%). Several of the pharmacists in the same study provided incorrect information about EC drugs, such as stating that they are not available in the US. Limited access is not only an issue in rural or small metro areas: a 2004 report to the New York City Council found that in NYC, 25% of pharmacies still do not stock EC.

  • Point: If she had gone to a hospital, she could have obtained the drug.
    Information: A 2002 study published in a recent issue of Annals of Emergency Medicine reports on a survey of a sample of emergency rooms nationwide found that 42.2% of non-Catholic and 54.9% of Catholic hospitals reported that EC was unavailable under any circumstances. 37.3% of non-Catholic and 28.8% of Catholic hospitals only provided EC under restricted circumstances, such as sexual assault. Of those who did not provide EC, 47.7% (Non-Catholic) and 53% (Catholic) either refused to provide a referral or provided an invalid referral. Another 2003 study of Oregon emergency departments published in the American Journal of Public Health found that only 61.1% routinely offered EC to rape victims. As a result, it seems that EC provision is not part of routine care of sexual assault patients in all hospitals.

  • Point: The victim had an obligation to visit the hospital and report the incident to the police.
    Information: It's a valid concern that women who don't report rapes leave the rapists free to commit future assaults. However, this particular victim is certainly not alone in not reporting the crime. According to this CDC fact sheet, only 39% of rapes and sexual assaults were reported to police in 2002. It also lists psychological consequences of rape, which include denial, withdrawal, guilt, and distrust of others, which may affect reporting. Regardless of the police reporting, it should not affect her access to legal medical care. The DSM-IV futher lists acute stress disorder as occurring immediately after 14-33% of all traumas, lists hopelessness as a symptom, and states, "Individuals with this disorder often perceive themselves to have greater responsibility for the consequences of the trauma than is warranted. Problems may result from the individual's neglect of basic health and safety needs associated with the aftermath of the trauma." Also among the diagnostic criteria are "Marked avoidance of stimuli that arouse recollections of the trauma" and "impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience." According to these definitions, psychological response may be a major factor in underreporting of sexual assault.

  • Point: The victim's actions (drinking, going home with a stranger) were the cause of the assault.
    Information: The responsibility for rape rests with the victimizer. This page of myths and facts from the Office of Violence Against Women directly addresses these issues. A 1995 study found that individuals were more likely to put the blame for rape partly on the victim when she had been consuming alcohol. One wonders if society's attitudes such as this contribute to rape underreporting by making the victim feel responsible for the perpetrator's actions. One of alcohol's biological effect is to impair judgment. I doubt that many people one look their daughter or wife in the eyes and say, "Well, you sort of asked for it." This type of accusation against strangers is hypocritical and does nothing to increase reporting, but may confirm the victim's fears. Additionally, other types of preventive care are available to individuals whose actions could be thought to lead to the incident, such as antiretrovirals for needle sticks, trauma care for drunk drivers who get into car wrecks, and oncology care for long-time smokers.

  • Point: Pharmacists shouldn't be forced to dispense something they're morally opposed to.
    Solutions? Let's ignore for a moment EC's mechanism of action. What are the solutions that allow women to receive treatment, and pharmacists to adhere to their personal beliefs? Some ideas:
    1) Require physicians to know which pharmacies stock and dispense the drug. In any other physician referral, it is certain that the place they send you will provide the care they advise. If you need an X-ray, they send you somewhere that does X-rays. If you need surgery, they send you to a surgeon that performs that procedure.
    2) Require pharmacies that stock the drug to have at least one staff member who will dispense it on duty at all times.
    3) Construct a nationwide database of pharmacies willing to fill the prescriptions, with an indication of the limitations.
    4) Make EC available over the counter.

    Which of these solutions are morally acceptable, financially agreeable, and serve women's needs in the most efficient way? Again, sorry this was so long - it's a complex topic. That's all for now!

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    MeSH Tags: Contraception, Postcoital; Pharmacists/ethics; Rape/psychology
  • Tuesday, October 18, 2005

    Homespun Breast Solutions

    Beryl Tsang has a simple, DIY solution for women who have undergone mastectomy and want to even things out with a breast prosthesis - knit your own. This breast cancer survivor found the entrepreneurial spirit and founded Tit Bits after being unsatisfied with expensive commercial prostheses, and began knitting her own devices, which are cheaper and can be worn inside a regular bra. Beryl's story, along with directions for making your own, can be found here, or you can purchase one from the Tit Bits website. Your options include "everday" (flesh colors), "fancy" (patterned), or "floosie" (hot pink!); there are also choices for size, nipple, piercing, weighting, and yarn type. It sounds a little crazy, but after looking at the product online, I don't see why this couldn't work. And you'd never be without a hacky sack. :)
    Thanks to Boing Boing for the heads up
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    Sunday, October 09, 2005

    Search Request Roundup #1

    On occassion, I'll post resources as a result of searches that led to my site when I haven't already listed much on the topic. It's difficult to tell what the individual intended, so I'll provide some general information.

    Ovary Removal
  • What is Ovarian Cancer? - American Cancer Society
  • Ovarian Cancer Home Page - National Cancer Institute
  • Ovarian Cyst - American Academy of Family Physicians
  • Hysterectomy - Benefits and Alternatives -

    Methods of Mammography
  • Screening Mammograms: Questions and Answers - National Cancer Institute
  • Mammography - Radiological Society of North America
  • Mammograms and Other Breast Imaging Procedures - American Cancer Society
  • Breast Cancer Screening - National Cancer Institute
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  • October is National [blank] Month

    October is Domestic Violence Awareness Month and National Breast Cancer Awareness Month.

    Domestic Violence Resources:
  • Domestic Violence Toward Women: Recognize the Patterns and Seek Help -
  • Checklist for Leaving an Abuser - what to take with you, from the National Women's Health Information Center
  • Violence Against Women - NWHIC
  • Important Phone Numbers
  • YWCA of Nashville info and local resources

    Breast Cancer Resources:
  • All About Breast Cancer - American Cancer Society
  • What You Need to Know About Breast Cancer - National Cancer Institute
  • Breast Cancer Treatment - National Cancer Institute
  • Breast Cancer Glossary - Cleveland Clinic
  • Y-ME National Breast Cancer Organization

    While I'm at it, it's also National Medical Librarians Month. (list of Nashville medical libraries)
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  • Vaccine for Cervical Cancer?

    Merck presented the results of a clinical trial indicating that the GARDASIL vaccine "completely prevented early-stage cervical cancer and precancerous cervical lesions caused by the two most common forms of a virus linked to such cancers." The study was conducted on more than 12,000 women aged 16-26 from various countries. The study results were announced at a conference; as such, a full publication that can be evaluated for study design and methods is not yet available. The vaccine would work by preventing HPV infection, the main risk factor for the cancer.

    Merck Cervical Cancer Vaccine Prevents Lesions
    Experimental Cancer Vaccine Shows Promise
    Merck's press release
    What you need to know about cancer of the cervix - from the National Cancer Institute

    That said, there are groups and individuals who oppose such a vaccine. HPV is a sexually transmitted infection, and vaccination is needed before sexual activity begins. Bridget Maher of the Family Research Council was quoted as saying, "Giving the HPV vaccine to young women could be potentially harmful, because they may see it as a licence to engage in premarital sex." Kristin Hayes of the Abstinence Clearinghouse likewise said "We're against vaccinating children [for HPV]. We don't know what this will do to children psychologically," for a 2005 piece in the journal Cancer Spectrum. Meanwhile, the Amercian Cancer Society estimates that in 2005, 10,370 cases of cervical cancer would be diagnosed in the US, and 3,710 women would die from the disease.
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    Sunday, October 02, 2005

    Who Needs Rights?

    An article in today's New York Times addresses the drug, misoprotol, covered in yesterday's post on miscarriage treatment. The piece is entitled, "Abortion Might Outgrow its Need for Roe v Wade," but the content of the article suggests otherwise. The article explains that in Brazil, where abortion is largely illegal, women began using misoprostol to end pregnancies (and suggesting it to other women) because miscarriage is listed as a side effect. If the drug fails, a surgical abortion may still be needed and/or birth defects can result, so the government restricted access to the ulcer drug. As a result, a black market developed. The article does mention the side effects of the drug, but the poor choice of title suggests that if Roe were overturned, women could move on just popping a pill, easy as pie. In reality, the piece suggests that in the absence of legal abortion, women still terminate pregnancies, but do so by resorting to dangerous self-medication practices without proper medical supervision, guessing at dosages and trying drugs that may be entirely inappropriate. The article also says that when the drug fails, Brazilian women turn up at hospitals for miscarriage treatment, potentially resulting in suspicions about whether they intentionally caused it. I imagine that if this became a trend in the US, women would experiment with any number of drugs that have miscarriage as a side effect, and those who prescribe them would come under the same scrutiny as those prescribing pain killers. Ultimately, we may add to the costs of healthcare, add to the size of the drug war (and the black market for drugs) by including women and physicians whose choices have been taken away, and create a new criminal class where all women who miscarry are under a cloud of suspicion. None of this will do anything to correct the situations that cause women to choose to terminate pregnancies, and the NYTimes article does women a disservice by suggesting the overturning abortion legislation would have limited consequences.
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    Saturday, October 01, 2005

    Drug Alternative to Surgery for Early Miscarriage

    A study in the August 25 New England Journal of Medicine examined the use of the drug Misoprostol (normally used for stomach conditions) compared to vacuum aspiration for early miscarriage. 652 women with 1st trimester miscarriage were assigned to either the drug (491 women) or the surgical procedure (161 women), and followed for whether expulsion was complete at a certain number of days after treatment. 84% of women were sucessfully treated with the drug, and 97% were successfully treated with aspiration. Women receiving the drug were more likely to experience reduced hemoglobin, nausea, vomiting, and diarrhea. However, 83% of women receiving Misoprostol would recommend the drug (compared to 83% for aspiration) and 78% would use the treatment again (compared to 75% for aspiration).

    A summary is available from NIH News, and the abstract is available from NEJM.
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