Sunday, January 02, 2005

Emergency Contraception: Enough Is Enough

The latest entrant into the, apparently irresistible, world of issuing reproductive health treatment guidelines is ...*stunned pause*... the U.S. Department of Justice:

The U.S. Department of Justice has issued its first-ever medical guidelines for treating sexual-assault victims - without any mention of emergency contraception, the standard precaution against pregnancy after rape.


The risk of pregnancy after rape is small - less than 5 percent - but the vulnerable group is large. Of 333,000 sexual assaults and rapes reported in 1998, about 25,000 resulted in pregnancies - of which 22,000 could have been prevented, estimated James Trussell, a Princeton University population researcher.

I'm not going to correct the inaccuracies in the article (emergency contraception is *not* a dangerous drug, etc.) and I apologize for that, but I have bigger fish to fry.

As usual, the cited newspaper article doesn't provide a link to the actual DoJ document. For something of this magnitude (one step beyond malpractice, into actively-hurting-patients territory) the responsible thing to do is to look at the primary source before commenting. So, I went Googling for the DoJ guidelines.

I won't bore you with the search details, but just keep in mind that this is not an easy document to locate [go ahead, give it a try and see how long it takes you]. With the proviso that, to the best of my knowledge, this is the document in question, I read the relevant portion of the National Protocol for Sexual Assault Medical Forensic Examinations (pdf), a 141 page document issued by the Department of Justice, Office of Violence Against Women, and dated September 2004.

Here is the entire section on pregnancy prevention (page 111):

9. Pregnancy Risk Evaluation and Care

Recommendations at a glance for health care providers to evaluate and treat pregnancy:

  • Discuss the probability of pregnancy with female patients.
  • Administer a pregnancy test for all patients with reproductive capability.
  • Discuss treatment options with patients, including reproductive health services.

  • Patients of different ages, social, cultural, and religious/spiritual backgrounds may have varying feelings regarding acceptable treatment options. Examiners and other involved health care personnel must be careful not to influence patients' choices of treatment.

    Discuss the probability of pregnancy with female patients. The risk of pregnancy from sexual assault is estimated to be 2 to 5 percent. However, pregnancy resulting from sexual assault often is a cause of great concern and significant additional trauma to the victim, so victims' fears should be taken seriously.282

    Conduct a pregnancy test for all patients with reproductive capability (with their consent).283 An exception is if a patient clearly is pregnant. If a patient is pregnant, the pregnancy may affect what medications can be administered or prescribed in the course of or after the exam.

    Discuss treatment options with patients.284 In cases of sexual assault, pregnancy is often an overwhelming and genuine fear. Therefore, discuss treatment options with patients, including reproductive health services.

    282 L. Ledray, SANE Development and Operation Guide, 1998, p. 75.

    283 Preexisting pregnancy may raise patient privacy issues. If the case is prosecuted, the prosecutor should work to address concerns such as this one.

    284 The National Sexual Violence Resource Center (877–739–3895 or 717–909–0710) offers more detailed information about sexual assault and pregnancy on their Web site at

    THIS. IS. IT.

    I will refrain from commenting on the actual text because I've done too many rape exams (from virginal pre-teens, to lawyers and housewives, to street prostitutes) to maintain a dignified tone. I'll only say this: Just because a woman has been raped, does not mean you have to treat her like an idiot! Neither should you assume the examiners and other involved health care personnel are idiots!

    Let me get back on track here. So, the DoJ's stated treatment options for pregnancy as a result of sexual assault are:

    1) discussion

    2) a reference (284) to a Web site

    I checked out the reference; it leads to a National Sexual Violence Resource Center (NSVRC) site. When you go to that site, there's no information about preventing pregnancy from sexual assault.

    If you enter "pregnancy" in the search box, you come to a page with 4 documents. After clicking on the right one [#2] (you figure out which is the right one by clicking on, and reading each one of the 4 documents), you come to a page with 7 options. Fortunately, one of them actually contains the "Preventing Pregnancy from Sexual Assault" in its description, so you're able to click on that link (pdf) directly, without having to wade through all the rest.

    Once on the site of interest, you get a 124 page document, mostly to do with policy and logistics. In case you blink and miss it, a general mention of the actual EC regimen is found on page 9 of the document:

    Facts About Emergency Contraception for Rape Victims

    Rape and Pregnancy

  • An estimated 25,000 U.S. women become pregnant as a result of sexual assault each year. EC could be used to prevent as many as 22,000 of these pregnancies.

  • 12% of all women experience sexual assault in a lifetime and 4.7% of those assaults result in pregnancy.

  • An estimated 3 million unintended pregnancies occur in the U.S. each year. EC could prevent as many as 1.5 million, including as many as 800,000 pregnancies that result in abortion.

    Safe and Effective Pregnancy Prevention

  • Emergency contraception is a safe and effective, FDA-approved method of preventing pregnancy after unprotected intercourse.

  • EC is time-sensitive. The sooner it is given, the better it works.

  • EC pills can be given in different ways. One approach requires giving a first dose within 72 to 120 hours of unprotected intercourse and a second dose 12 hours later. The second approach, which applies uniquely to progestin-only medications, entails giving the entire course of medication at one time within 72 to 120 hours after unprotected intercourse.

  • The side effects of EC are temporary and may include nausea, vomiting and breast tenderness. Plan B® appears to be associated with the fewest side effects.

  • According to the World Health Organization, EC will have no effect on an established pregnancy. It is not the same thing as RU-486, the "abortion pill."

    EC in the ER: Care for Rape Survivors

  • The American Medical Association, the American College of Emergency Physicians and the American College of Obstetricians and Gynecologists all recognize EC as part of standard rape treatment.

  • Yet only 20% of rape victims receiving treatment at hospital ERs actually received EC over a seven-year time period in the 1990s, according to a national study.

  • Surveys in several states have found wide variation in hospital policies on provision of EC to rape survivors.

  • As of this printing, four states - Washington, California, New Mexico, and New York - have enacted laws requiring hospitals to offer emergency contraception to rape victims. Illinois' law requires counseling of rape victims about EC, but not on site provision of the medication.

  • Before we go on, I want you to take a moment and do the following. Go back and time how long it takes you to read my account of looking for, and finally locating the page with the mention of the EC regimen. Now, figure it took me, at a minimum, double that time to find the information. And, because it usually takes a lay person a bit more to orient themselves in these searches, double my search time.

    Now, imagine you've just been raped and beaten and you need to conduct the exact search I did in order to figure out the treatment options for pregnancy as a result of sexual assault. How long do you think the search will take you? [Needles to say, my question is beyond sarcasm!]

    OK, before the Department of Paving the Roads and Collecting Highway Tolls decides to get in on it, and starts issuing reproductive health medical guidelines, it's time to say: Enough is enough! Forget the politicians, the bureaucrats, assorted fundamentalists, and your neighbors.

    If you are sexually active, or plan to be, and you do not wish to become pregnant, you, and only you are to insure you have instantaneous access to emergency contraception (EC). How do you accomplish that?

    A. You call your Ob/Gyn and ask for an advanced prescription [x2, with refills] for EC, and you fill that prescription now! [It's always a good idea to have an extra full dose available, just in case.]

    B. You also make sure to keep the EC handy. Think of an item that you can't be without 24/7 and associate it with the EC. You can also delegate the responsibility to your partner. [Unfortunately, men can't help with obtaining EC because their doctor won't prescribe meds for an unknown patient--you. However, if they travel outside the US, they can help. Ask them to stock up.]

    Let me repeat this: you obtain EC now, and keep it handy 24/7. This might require a change in how you think about EC--instead of waiting for the problem to occur and then scrambling to obtain EC, you prepare and have EC handy before you actually need it. Of course, it's quite possible you won't need EC at all. It doesn't matter. The risks of an unintended pregnancy far outweigh any drawbacks (time spent obtaining it, the cost, never having to use it) associated with the advance purchase of EC.

    C. Once you have your EC, you also have to spread the word. How many reproductive age, sexually active women/men do you know? Make sure each and everyone of them knows about EC and actually has it handy.

    Of course, just knowing that you should have EC handy isn't enough if your doctor won't prescribe it to you because of non-medical reasons, or your pharmacist refuses to fill the rx and/or steals it. So what do you do? You have three options: 1) ask your doctor/pharmacist for a competent referral; 2) if you, or someone you know travels outside the US, get it from there [in any pharmacy, OTC]; 3) purchase it online.

    A few words about buying EC online. There are several sites offering EC. I haven't checked them out, so I don't know how reliable they are. I'm just using them as an example. If you just can't get EC from your doctor/pharmacist, or, directly, form a pharmacy abroad, you should know you have this option. One thing I can tell you is that, even with the horrible exchange rate, one dose of EC shouldn't cost more than ~$25. [I'm a bit busy now, but I'll try to look into this and find something I can point you to.]

    Bottom line: Enough is enough. To insure you have access to a minimum of appropriate health care, change the way you think about EC. EC is not something you get if, and when you needed it. It's something you get and keep handy, period.

    Note: I think the shelf life for one EC dose is ~ 1 year; If you buy EC online, to verify you received the correct meds ask a doctor/nurse/pharmacist, and/or check the PDR; Although EC use stands on its own, for those who think this is relevant: I have no financial connection to any EC manufacturers.

    (via Mouse Words and atrios)


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