An Overlooked, Stigmatized Risk Factor for HIV/AIDS In Women

Posted on August 2, 2008

As the opening of the XVII International AIDS Conference was upon us, the highly respected medical journal, The Lancet, published an editorial titled, “HIV/AIDS in Latin America and the Caribbean” (The Lancet - Vol. 372, Number 9635, 26 July 2008, Pages 263). Once again, however, anal intercourse was ignored as an HIV/AIDS transmission category for women. I wrote a comment on this issue, which was published by The Lancet online. I invite you to read the letter.

In fact, the CDC just released new data showing that the number of new cases of HIV/AIDS in the US is higher than previously thought. A recent article in the Washington Post, reported on a study by the Black AIDS Institute which found that if the African American population of the U.S. was a nation unto itself, that nation would rank 16th in the world for the number of people living with HIV/AIDS!! More than 1/4 of those with HIV/AIDS in this country are women, predominantly black women. Hispanic women also have disproportionately high HIV/AIDS case rates. AIDS continues to be a leading killer of young women of color in the U.S.

Furthermore, and to its credit, The Lancet just published an article online that examines  the old belief that heterosexual intercourse is not as risky as intercourse between men (i.e. anal intercourse). The researchers found that infectivity (the likelihood that someone will become infected with HIV) varies. Astonishingly, while HIV infection is estimated to occur  in as few as 1 in 1,000 episodes of vaginal intercourse (that may be a low estimate!) when there are no other risk factors present, HIV infection occurs in as many as 1 out of 3 episodes of heterosexual anal intercourse. You do the math!!

Women are not getting the education they need to protect themselves from this disease. The nation, and the world, are still silent on anal intercourse as a risk behavior for women. Please spread the word, however, you can — because the public health and medical communities are not doing their jobs, and women continue to contract HIV/AIDS. In some areas the epidemic already has a female face. Education is a key to prevention.

Teen Pregnancy, the Abortion Rate Set to Increase if Bush Has His Way

Posted on July 16, 2008

Abortion and birth control are facing a new attack by the Bush Administration, under the guise of allowing health care providers to exercise their religious beliefs on the job. The Administration is proposing a new rule that would require any health facility that receives funding from the Department of Health and Human Services (that is a lot of facilities!!) to certify that they would not fire a worker who has religious objects to providing any particular “health service” – read “reproductive health service”. Ominously, according to the New York Times, the regulation broadens the definition of abortion to include “any of the various procedures — including the prescription, dispensing and administration of any drug or the performance of any procedure or any other action — that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation”. Yet, there are already regulations that prevent employers from firing employees who refuse to perform tasks that go against their religious or moral beliefs. But, what about the patients? There are federal laws that protect their right to obtain needed health services. It seems that if the patients are female their needs do not count for quite as much as employees, according to this Administration.

Let’s get real. If health care providers do not believe in contraception, they should not work in a setting where contraception is dispensed. If you refuse to write prescriptions for birth control, then don’t become a gynecologist – or at least advertise your beliefs so your patients do not come to you expecting to get a prescription for something you consider immoral.

Beyond that, there are many reasons women use contraception –not all of which have to do with preventing pregnancy. For example, women with polycystic ovary syndrome often do not menstruate at all – and they need birth control pills to regulate their periods. Many of my young adolescent patients (who are not sexually active) would really suffer without birth control pills. It is not unusual for a young teen to have very heavy or frequent periods that can lead to severe anemia. The only way to deal with that problem is to prescribe oral contraceptives. Should we just let those women deal with their conditions without the benefit of treatment?

There will be additional public health problems if we allow providers to refuse to provide contraceptives. For example, the teen pregnancy rate went up for the first time in over 15 years. Why? Well, there are several reasons why the teen pregnancy rate was going down, the primary one being better access to contraception. Now that it is becoming more difficult to get contraception, the teen pregnancy rate is on the rise. If teens cannot get birth control, they still have sex – only without contraception. Duh!!

Moreover, while the abortion rate overall has gone down, the abortion rate among poor women (those most affected by regulations making it more difficult to get birth control) has gone up. No birth control = more abortions. As a nation, we must take a comprehensive public health approach to reproductive health, and not tailor policy for individuals who do not believe in contraception. There are plenty of places where they can work without harming the greater good.

What I consider immoral is jeopardizing women’s health. When women cannot control their fertility, they suffer and so do their children (see Reproductive Health Care Can Reduce Child Abuse, April 4 post). Women’s health is a family value.

Contraceptive Free Drug Stores – In the Name of Preventing Abortion!!

Posted on June 18, 2008

On June 16 the Washington Post published an article detailing a new assault on reproductive rights — - pharmacies that don’t stock contraceptives.   They are doing this in the name of promoting their so-called pro-life agenda.As a nurse practitioner, I have often diagnosed pregnancy in young women for whom that pregnancy was disastrous.  One typical patient became pregnant when the condom broke and she was not able to buy emergency contraception because the pharmacist she turned to did not believe in it.  Her future was cut short.  She was to have been the first in her family to attend college.  The pharmacist had no right to do that to her.  If he does not want to fill the full range of prescriptions, he should find another place to work, such as a senior citizens’ residence. Incredibly, one pharmacist quoted in the Washington Post said that he decided that contraceptives “could hurt the woman and possibly hurt her unborn child”, so he does not provide them. That statement is disingenuous to say the least. Any medication can cause harm, even something as common as Penicillin. People die every year from allergic reactions to Penicillin.  Maybe these pharmacies should just stop providing antibiotics also.  Moreover, the risk of dying during pregnancy or delivery is exponentially higher than the risk of dying from complications of birth control use.   Just as antibiotics prevent illness and death from infections, so contraceptives  prevent morbidity and deaths from complications of pregnancy and childbirth.  Moreover, the data show over and over that when women cannot get contraception, the abortion rate goes up.  Duh!!  If women cannot prevent conception, they are left to deal with an unwanted pregnancy –  

In addition, contraceptives are used to treat a range of health problems, including endometriosis, an extremely painful condition and dysfunctional uterine bleeding which can cause severe anemia.  Why would anybody consider it alright to deny patients treatment for these conditions? 

 

At a minimum, pharmacies that do not provide contraceptives, should be required to advertise that fact, in bold letters, on their store sign, so that no woman wastes valuable time entering a pharmacy that will not serve her needs.  Many other consumers, no doubt, would simply wish to avoid patronizing a store that refuses to provide essential medications for women.  I wouldn’t walk in there.

 

Gagging American Women – And Wreaking Havoc in the Process

Posted on May 23, 2008

 

            The Wall Street Journal today (5/23/08) published an article, Antiabortion Groups Push Bush on Clinics’ Subsidies, by Stephanie Simon, which describes in some detail the continuing efforts of groups such as the Family Research Council, the Eagle Forum and Concerned Women for America to impose the Gag Rule on American Women.  In brief, the Gag Rule (which was enacted by Reagan, rescinded by Clinton, but reinstated by Bush on his first day in office) bans nongovernmental organizations outside the US from receiving US family planning assistance if they use funding — from any other source — to perform abortions except in cases of rape, incest, or a threat to the life of the woman. (For more on the Gag Rule see An Attempt To Impose the Gag Rule on American Women, posted on May 6).
            These groups had planned to give Bush a petition on May 7, asking him to impose the Gag Rule in this country.  I guess they haven’t gotten around to it yet.  They do not want tax dollars, in the form of Title X funds, to go to facilities where abortions may be performed. They are therefore targeting clinics where abortions are provided, such as Planned Parenthood.  However, the Planned Parenthood Programs I am familiar with spend most of their time providing services such as contraception, Pap smear screening and breast exams to poor and near-poor women; and many Planned Parenthoods now have clinic hours for men as well!!  But, the pro-Gag Rule folks want to separate out abortion facilities from those that provide other types of care, for example by erecting new walls around the abortion facilities.  Of course, that would be very expensive.  Some of the women’s health facilities are considering not accepting Title X moneys (an important component of their funding), rather than going through these expensive shenanigans.
            As I was reading the article, I felt as though I was transported back in time about 20 years, at a time when I was working in an agency that had Title X funding (and during the brief time when the Gag Rule did apply in the U.S.).  We had to be very careful about separating our activities when we were counseling pregnant teenagers.  We were not allowed to mention abortion in a Title X funded exam room although it would really have been malpractice not to provide patients with complete information.  In fact, The Hill reported yesterday that Rep. Mark Kirk, a Republican from Illinois said that if the new Gag Rule regulations took effect, “it would mean that a number of doctors, nurses and hospitals that operate under [American Medical Association] guidelines to inform a patient of all their options won’t be able to do so if they accept federal funds.”
In our facility we were supposed to say to a tearful, frightened 16 year-old who asked about abortion, “That is outside the purview of what I can discuss.”  Furthermore, our inclination was to refer them to the OB-GYN Department; but that too would have been illegal if there was a chance that a gynecologist might mention abortion. Can you imagine?!
            So, what the Family Research Council et al will accomplish is to further increase the number of poor women who cannot get Pap smears, breast exams or birth control.  The abortion rate for poor women will continue to increase.  And, the hardships for these women and their families will go on.  The desire for a domestic Gag Rule is clearly not family-friendly. 

NPR Gets It Wrong On Abstinence-Only Education

Posted on May 18, 2008

I was disappointed to hear John Jemmott, a very highly respected HIV-prevention researcher, say that abstinence education was OK. On Weekend Edition Sunday (5/18/08), he spoke about a study he did which showed that abstinence-only does not have ill effects. I am sure that the abstinence program he designed was factual, and based on appropriate theory.

However, most abstinence education, as he alluded, is based on ideology and inaccurate information. For example, teens are told that condoms don’t work. (Why in the world would adolescents bother to use a condom if they think condoms are ineffective?) Major evaluations, even those sponsored by the government, have shown that these programs may result in a slight delay in the onset of intercourse, but once the teens begin having intercourse, those who received abstinence-only education are less likely to use condoms, more likely to contract an STD, and more likely to engage in unprotected heterosexual anal intercourse. Readers of this site know how dangerous that is.

The distinction between most abstinence-education, and a program designed by John Jemmott, should have been made clear to the audience.

An Attempt To Impose The Gag Rule On American Women

Posted on May 6, 2008

Will there be a new Gag Rule in the U.S.? Yes, if nearly 80 conservative groups have their way! The Gag Rule, which is properly called the Mexico City Policy, was initially instituted by Reagan at a world population conference in Mexico City in 1984. It bans nongovernmental organizations (NGOs) outside the US from receiving US family planning assistance if they use funding — from any other source — to perform abortions except in cases of rape, incest, or a threat to the life of the woman. These NGOs are also prohibited from providing counseling and referral for abortion, or lobbying to improve access to abortion in their own countries.

The policy hurts poor women and children around the world. The United States has been an important donor to international health programs. However, we have also implemented policies that stifle health care. For example, if an organization is working to legalize abortion in its own country the Gag Rule mandates that aid to that organization is cut off. The end result is that the women and men who rely on that NGO will not have condoms and other birth control methods that we would have shipped to them. Ultimately, obviously, this is likely to result in more unwanted pregnancies and HIV transmission as well.

And now, the same groups who cheered the Global Gag Rule are apparently hoping to implement our own domestic version of it. The Family Research Council has prepared a petition for President Bush. Its website asks readers to: Please join the tens of thousands of citizens who have already signed the petition to President Bush, which FRC will deliver to the White House on May 7, asking the President to approve new Title X regulations ensuring that no taxpayer money subsidizes the abortion facilities of groups like Planned Parenthood. (Note to readers: according to the FRC, if abortions are performed on the same premises as family planning services, then any money given to the family planning organization also supports abortion.) Ask the President also to ensure that legitimate clinics are not forced to refer for abortions.

Title X is a lifeline for many uninsured women because it pays for their contraception. To make matters worse, the number of uninsured Americans has grown tremendously during the Bush years. More women need Title X-funded contraception, but fewer can get it. I was just reading a story about a woman who became pregnant because she could not afford birth control and could no longer get free contraception at her clinic due to cutbacks in Title X. She terminated her pregnancy.

In essence, if Bush accedes to this request, the new domestic Gag Rule will, no doubt, result in an even greater increase in abortions among poor women. Is that what these people want?

Laws Enacted at The Expense of Women

Posted on April 25, 2008

The need to place reproductive health, women’s health, in a public health context grows more urgent by the day. Almost every day I receive a report about another state that is in the process of passing legislation that will be harmful to women and to children. The two most recent are Arizona and Oklahoma. The Arizona House just passed its own “partial-birth” (I choke on that term) legislation on April 22, which now goes to the Senate. Governor Janet Napolitano had earlier vetoed a similar bill because it included a harsher penalty for physicians who perform abortions than the federal legislation permitted. The new bill does, however mete out punishment for physicians — a maximum two-year prison sentence as allowed under the federal law.

The Oklahoma Health Care Authority approved a rule allowing undocumented pregnant women to receive prenatal care — as long as their infants become citizens upon birth. (I am not sure what would happen if the babies happened to be born in Mexico, for example. Would the women have to reimburse Oklahoma for the care?) The rule allows undocumented pregnant women to receive coverage for prenatal care services that are needed to protect the health of the fetus, although the women, themselves, still do not qualify for full Medicaid benefits. This is not a unique regulation. A number of other states, including Arkansas and Texas, have similar regulations.

I have to ask: to help the fetus, not the mother – how can you separate them? If the mother has a dental abscess that goes untreated for lack of insurance, the fetus will be affected. If the mother becomes septic and dies for lack of treatment, the fetus will die too, unless the fetus is viable and a C/Section is done pronto. Under these laws, then, do we allow an undocumented pregnant woman to suffer the infection, and only intervene when she is moribund, so as to save the fetus? How can anybody think that these policies make sense?? And yet, every week another state tries to enact similar policies – that harm women, and thus, children. Where are their family values?

PS: It is interesting that I used the example of a dental infection. After writing this, I went to the Oklahoma Health Care Authority website to see what else was there – and there was a prominently displayed banner that reads: Pregnant? Don’t forget to think about Perinatal Dental Services.

Reproductive Health Care Can Reduce Child Abuse

Posted on April 4, 2008

An article in the Washington Post on April 4 discusses the grim statistics on child abuse in the U.S. Fully 91,000 infants under the age of 1 are abused. A remedy suggested in the article is counseling pregnant women. That might certainly be helpful. But, there is another important solution which may not be so palatable in the present political environment — providing reproductive health services to all women.

Two major risk factors for child abuse are large family size and unplanned pregnancies. Studies have shown that the risks appear to come not only from having a lot of children, but from having children too closely spaced. Children from families with two unplanned births are almost three times more likely to have been abused than children in families with no unplanned births; and children from families with three unplanned births are almost five times more likely to suffer from abuse!

Further, the government’s own research ( the U.S. Department of Health and Human Services’ 1996 publication: “Third National Incidence Study of Child Abuse and Neglect”), concluded that children from large sibling groups are more likely to be neglected as well as abused.

If women could decide when (and if) they wanted to become pregnant, their children would be much better off. This holds true for infant mortality as well. That information will come in another post.

Women’s health is a family value!

Full disclosure: I am the mother of 6 and a huge fan of big families — but only when those children are wanted and planned.

To read the Washington Post article go to: http://www.washingtonpost.com/wp-dyn/content/article/2008/04/03/AR2008040301895.html?wpisrc=newsletter

© Copyright 2008, Carol Roye, All Rights Reserved.