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!

    Technorati Tags: ; ; ; ; .
    MeSH Tags: Contraception, Postcoital; Pharmacists/ethics; Rape/psychology

    Blogger theogeo said...

    Thank you for this post. A breath of fresh air on this topic was very much needed.

    2:41 PM  

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