The Rhythm Method as Abortifacient: A Response to John B. Shea
Monday August 28, 2006
Category: Gender and Sexuality
On Friday, our U.S. Conservatives Guide, Amy Hess, blogged a conservative response to the FDA's recent decision to make Plan B available behind the counter for women 18 and up. Most of Amy's post sounds reasonable in and of itself, and her argument falls apart not due to any failings on her part--her own writing is, as usual, pretty cogent--but rather because she is forced to prop up incredibly bad source material that has no life of its own.
Her blog entry, in other words, is the rhetorical equivalent to Weekend at Bernie's, and in this case le cadavre encerclé is John B. Shea's "Candy That Kills," a remarkable example of now-you-see-it, now-you-don't pseudoscientific presdidigitation. Shea's tirade can be broken down into a series of misleading propositions that fall into two categories: misleading use of data, and misleading statements about what Plan B does. Although he marbles the two with great effect, the limitations of his argument become clearer if we deal with his propositions point-by-point.
1. Shea: Several studies have been unable to correlate increased use of EC with a reduction in the number of abortions.
The author refers here to a broad-spectrum study of Swedish adolescent sexual behavior, which doesn't deal directly with EC, and to a remark a business professor once made at a conference in Scotland. If he wants to make a case that EC doesn't reduce the number of abortions, there are better studies out there that he could have used dealing with the distribution of EC. But even in those cases (which, again, Shea didn't cite), there has never been any study conducted regarding the actual widespread use of EC and its effect on pregnancy--just its distribution. Obviously, simply having access to Plan B isn't going to prevent a pregnancy. You have to actually take the medication for it to work.
In any case, there is no mechanism in place by which Plan B could increase the number of abortions. One of the few areas where conservatives agree with emergency contraception proponents is on the issue of its efficacy: 89% if taken orally (as in the case of Plan B), 99.9% if used in IUD form. So if everyone who is sexually active takes Plan B, at least nine times as many people would have to suddenly become sexually active in order for this to have a net zero effect on the rate of unplanned pregnancy.
2. Shea: Availability of Plan B encourages promiscuity.
Before looking at the data, let's step back for a moment and realize that sex is a choice. There are various reasons why one might choose to have sex, and there are various reasons why one might choose not to have sex. If the only or primary reason someone isn't having sex is because they're afraid of getting pregnant, then it's not insignificant that a combination of a ParaGard IUD (reducing odds of pregnancy by 99.9%) and correct condom use (reducing odds of pregnancy by 98%) reduces the odds of pregnancy to 1 in 50,000 over a year of sexual activity. Because many of the things we do every day have a greater than 1 in 50,000 chance of killing us, and even abstinence (because of the possibility of rape) is not 100% effective, it's understandable if some people consider pregnancy avoidance a better argument for conscientious safe sex than it is for abstinence and make their personal decisions accordingly.
But why is this an argument in favor of restricting medical options? If we develop a cure for every major sexually transmitted disease, should we withhold these cures simply because they would reduce the consequences of sex (and make all gay sex intrinsically safe)? Why not put all the options on the table, and stop trying to socially engineer abstinence with the threat of unplanned pregnancy or disease?
All that aside, there is strong statistical evidence that Plan B does not encourage promiscuity. A slew of peer-reviewed studies--see items 1-9 and 11 in this bibliography--have uncovered no link between Plan B and increased sexual behavior, safe or unsafe.
Now let's look at Shea's data. He cites a 2000 study from the British Medical Journal which found that teenagers with unplanned pregnancies were more likely to have been given access to emergency contraception and other forms of birth control than members of the general population. What he did not address was how many of the 223 pregnant teenagers in his study had actually used these medical options, which seems relevant. One can imagine citing a second study of pregnant teenagers asking how many of them had been consulted by abstinence educators in order to show a correlation between abstinence and unplanned pregnancy.
Shea also cites data from Lothian County, Scotland which found a 10% jump in the number of pregnant 13-15 year olds in the year following availability of emergency contraception. What he neglected to mention was the reason that relatively conservative Lothian County had taken this bold step to begin with: Because they were (and still are) in the middle of a teen pregnancy epidemic.
Lastly, he cites "a study ... [which] has shown [that] an increase in family planning services and availability of the MAP without a physician's prescription was associated with an increase in the rate of sexually transmitted infections." But if you look at the footnotes, you'll find that Shea's source is an unpublished speech given by David Paton, a business professor. We have absolutely no way of independently determining how, or even if, Shea's source came to this conclusion when the international medical community has been unable to do so.
Now that we've addressed the fallacies in Shea's data, let's look at the most ludicrous part of his argument:
3. Shea: Emergency contraception causes abortions.
Before we proceed further, it's important to acknowledge a U.S.-British terminology difference. In the United States, pregnancy is defined at implantation, a process that takes place 5-12 days after sexual contact. It is during implantation that the fertilized egg (blastocyst) is lodged in the uterus, that independent DNA is formed, and (most importantly, from a medical standpoint) when the placenta begins to develop and the hCG (human chorionic gonadotropin) hormone begins to appear in the bloodstream. It also begins to appear in urine, which is how pregnancy tests work.
The U.S. model is not based on emergency contraception; it is based on the fact that 60 to 80 percent of blastocysts naturally fail to implant (as observed by OB/GYN professor John M. Opitz of the University of Utah, in remarks to the President's Council on Bioethics, among others). In Britain, pregnancy is determined based on fertilization of the egg.
So when Shea, who (in his defense) is British, writes...
But let's pretend for a moment that this is the case--that every microscopic blastocyst is, in fact, a tiny, self-aware human being. If that's the case, then the most prolific killer of innocent blastocysts isn't emergency contraception--it's the rhythm method (this article, like Shea's, is British, so note the use of the word "embryo" to describe pre-implanted blastocysts):
In any case, there is one sure way to guarantee that Plan B prevents fertilization rather than blocking implantation: by administering it as early as possible after sex. Implantation does not occur until at least five days after sexual intercourse, and sometimes takes as long as twelve days; Plan B is ideally administered within the first 72 hours, but patients who are unable to obtain Plan B, due to prescription requirements or "conscientious" pharmacists who refuse to keep it in stock, often have to wait longer. By delaying access to Plan B by requiring prescriptions for minors, the "pro-family" movement increases the odds that the pill will block uterine implantation.
The duplicity of the alleged pro-life movement astonishes me. If these people were really concerned about the abortion of second-trimester fetuses, they would not introduce legislation to delay abortions with waiting periods, parental and spousal notification requirements, ultrasound requirements, and so on and so forth, and they would certainly disapprove of using verbally abusive picketers to force women to postpone their abortions. If these people were really concerned about first-trimester embryos and fetuses, then they would be handing out Plan B in the streets to prevent unplanned pregnancies from developing in the first place. And if these people were really concerned about the unproven possibility of blastocyst rejection in the uterus as the result of Plan B use, then they would work to see to it that Plan B is administered as early as possible so that it prevents fertilization instead.
And they would certainly try to do something about that awful rhythm method.
See also:
On Friday, our U.S. Conservatives Guide, Amy Hess, blogged a conservative response to the FDA's recent decision to make Plan B available behind the counter for women 18 and up. Most of Amy's post sounds reasonable in and of itself, and her argument falls apart not due to any failings on her part--her own writing is, as usual, pretty cogent--but rather because she is forced to prop up incredibly bad source material that has no life of its own.
Her blog entry, in other words, is the rhetorical equivalent to Weekend at Bernie's, and in this case le cadavre encerclé is John B. Shea's "Candy That Kills," a remarkable example of now-you-see-it, now-you-don't pseudoscientific presdidigitation. Shea's tirade can be broken down into a series of misleading propositions that fall into two categories: misleading use of data, and misleading statements about what Plan B does. Although he marbles the two with great effect, the limitations of his argument become clearer if we deal with his propositions point-by-point.
1. Shea: Several studies have been unable to correlate increased use of EC with a reduction in the number of abortions.
The author refers here to a broad-spectrum study of Swedish adolescent sexual behavior, which doesn't deal directly with EC, and to a remark a business professor once made at a conference in Scotland. If he wants to make a case that EC doesn't reduce the number of abortions, there are better studies out there that he could have used dealing with the distribution of EC. But even in those cases (which, again, Shea didn't cite), there has never been any study conducted regarding the actual widespread use of EC and its effect on pregnancy--just its distribution. Obviously, simply having access to Plan B isn't going to prevent a pregnancy. You have to actually take the medication for it to work.
In any case, there is no mechanism in place by which Plan B could increase the number of abortions. One of the few areas where conservatives agree with emergency contraception proponents is on the issue of its efficacy: 89% if taken orally (as in the case of Plan B), 99.9% if used in IUD form. So if everyone who is sexually active takes Plan B, at least nine times as many people would have to suddenly become sexually active in order for this to have a net zero effect on the rate of unplanned pregnancy.
2. Shea: Availability of Plan B encourages promiscuity.
Before looking at the data, let's step back for a moment and realize that sex is a choice. There are various reasons why one might choose to have sex, and there are various reasons why one might choose not to have sex. If the only or primary reason someone isn't having sex is because they're afraid of getting pregnant, then it's not insignificant that a combination of a ParaGard IUD (reducing odds of pregnancy by 99.9%) and correct condom use (reducing odds of pregnancy by 98%) reduces the odds of pregnancy to 1 in 50,000 over a year of sexual activity. Because many of the things we do every day have a greater than 1 in 50,000 chance of killing us, and even abstinence (because of the possibility of rape) is not 100% effective, it's understandable if some people consider pregnancy avoidance a better argument for conscientious safe sex than it is for abstinence and make their personal decisions accordingly.
But why is this an argument in favor of restricting medical options? If we develop a cure for every major sexually transmitted disease, should we withhold these cures simply because they would reduce the consequences of sex (and make all gay sex intrinsically safe)? Why not put all the options on the table, and stop trying to socially engineer abstinence with the threat of unplanned pregnancy or disease?
All that aside, there is strong statistical evidence that Plan B does not encourage promiscuity. A slew of peer-reviewed studies--see items 1-9 and 11 in this bibliography--have uncovered no link between Plan B and increased sexual behavior, safe or unsafe.
Now let's look at Shea's data. He cites a 2000 study from the British Medical Journal which found that teenagers with unplanned pregnancies were more likely to have been given access to emergency contraception and other forms of birth control than members of the general population. What he did not address was how many of the 223 pregnant teenagers in his study had actually used these medical options, which seems relevant. One can imagine citing a second study of pregnant teenagers asking how many of them had been consulted by abstinence educators in order to show a correlation between abstinence and unplanned pregnancy.
Shea also cites data from Lothian County, Scotland which found a 10% jump in the number of pregnant 13-15 year olds in the year following availability of emergency contraception. What he neglected to mention was the reason that relatively conservative Lothian County had taken this bold step to begin with: Because they were (and still are) in the middle of a teen pregnancy epidemic.
Lastly, he cites "a study ... [which] has shown [that] an increase in family planning services and availability of the MAP without a physician's prescription was associated with an increase in the rate of sexually transmitted infections." But if you look at the footnotes, you'll find that Shea's source is an unpublished speech given by David Paton, a business professor. We have absolutely no way of independently determining how, or even if, Shea's source came to this conclusion when the international medical community has been unable to do so.
Now that we've addressed the fallacies in Shea's data, let's look at the most ludicrous part of his argument:
3. Shea: Emergency contraception causes abortions.
Before we proceed further, it's important to acknowledge a U.S.-British terminology difference. In the United States, pregnancy is defined at implantation, a process that takes place 5-12 days after sexual contact. It is during implantation that the fertilized egg (blastocyst) is lodged in the uterus, that independent DNA is formed, and (most importantly, from a medical standpoint) when the placenta begins to develop and the hCG (human chorionic gonadotropin) hormone begins to appear in the bloodstream. It also begins to appear in urine, which is how pregnancy tests work.
The U.S. model is not based on emergency contraception; it is based on the fact that 60 to 80 percent of blastocysts naturally fail to implant (as observed by OB/GYN professor John M. Opitz of the University of Utah, in remarks to the President's Council on Bioethics, among others). In Britain, pregnancy is determined based on fertilization of the egg.
So when Shea, who (in his defense) is British, writes...
Human embryologists everywhere agree that a human being, a human person, comes into existence at fertilization. This is an objective scientific fact, known to embryologists for over one hundred years....he simply isn't telling the truth. Embryologists do not even agree that pregnancy begins at fertilization, and there is certainly no widely accepted scientific view that "a human being, a human person, comes into existence" at that point. The view that a human person comes to be when it is a microscopic cluster of cells, before the woman's body has even begun to produce pregnancy hormones, is certainly radical and is in no way representative of the state of medical science.
But let's pretend for a moment that this is the case--that every microscopic blastocyst is, in fact, a tiny, self-aware human being. If that's the case, then the most prolific killer of innocent blastocysts isn't emergency contraception--it's the rhythm method (this article, like Shea's, is British, so note the use of the word "embryo" to describe pre-implanted blastocysts):
Rhythm method users try to avoid pregnancy by aiming at the period in which conception is less likely to occur and in which viability is lower. So their success rate is due not only to the fact that they manage to avoid conception, but also to the fact that conceived ova have reduced survival chances ... [E]ven if the latter mechanism has only limited effectiveness, it remains the case that millions of rhythm method cycles per year globally depend for their success on massive embryonic death.All of this may be irrelevant to the emergency contraception debate. A recent study by the Population Council's International Committee for Contraception Research has found that, at least in rats, emergency contraception works only by preventing fertilization and does not create a uterine environment hostile to implantation. To be honest, I wasn't aware of this study until recently myself--I've been saying for quite some time now that EC works in two ways, by preventing fertilization and preventing implantation--but, if its conclusions check out, then religious conservatives concerned about potential blastocyst non-implantation would be well advised to forget the rhythm method and use Plan B instead.
Let us try to make the argument more vivid. Pro-lifers oppose IUDs because their main mode of operation is to make embryonic death likely. Now suppose that we were to learn that the success of the rhythm method is actually due, not to the fact that conception does not happen—sperm and ova are much more long lived than we previously thought—but rather because the viability of conceived ova outside the [heightened fertility] period is minimal due to the limited resilience of the embryo and the limited receptivity of the uterine wall. If this were the case, then one should oppose the rhythm method for the same reasons as one opposes IUDs. If it is callous to use a technique that makes embryonic death likely by making the uterine wall inhospitable to implantation, then clearly it is callous to use a technique that makes embryonic death likely by organising one’s sex life so that conceived ova lack resilience and will face a uterine wall that is inhospitable to implantation.
In any case, there is one sure way to guarantee that Plan B prevents fertilization rather than blocking implantation: by administering it as early as possible after sex. Implantation does not occur until at least five days after sexual intercourse, and sometimes takes as long as twelve days; Plan B is ideally administered within the first 72 hours, but patients who are unable to obtain Plan B, due to prescription requirements or "conscientious" pharmacists who refuse to keep it in stock, often have to wait longer. By delaying access to Plan B by requiring prescriptions for minors, the "pro-family" movement increases the odds that the pill will block uterine implantation.
The duplicity of the alleged pro-life movement astonishes me. If these people were really concerned about the abortion of second-trimester fetuses, they would not introduce legislation to delay abortions with waiting periods, parental and spousal notification requirements, ultrasound requirements, and so on and so forth, and they would certainly disapprove of using verbally abusive picketers to force women to postpone their abortions. If these people were really concerned about first-trimester embryos and fetuses, then they would be handing out Plan B in the streets to prevent unplanned pregnancies from developing in the first place. And if these people were really concerned about the unproven possibility of blastocyst rejection in the uterus as the result of Plan B use, then they would work to see to it that Plan B is administered as early as possible so that it prevents fertilization instead.
And they would certainly try to do something about that awful rhythm method.
See also:
Comments
The real trouble I have with so many of these conservative positions is that they place an ideal over real benefit every time, regardless of actual human outcome. Thus, when the abortion and pregnancy rates go up because they have restricted sex education, it is always the fault of the ’sinner’ who ‘chooses’ the bahavior in spite of their disapproval. The won’t compromise on the use of birth control ebven if it means a reduction in abortion because it requires a sacrifice of ideals.
(JUst as with the marijuana vs. hard drugs issue, or the prison issue- better to promote the ideal that all drugs are bad or that all crime must be punished than to admit that some drugs are not as harmful or that society actually benefits from programs that aid prisoners and reduce recidivism, etc ad nauseum- being right is always more important than doing right.
Have you ever know Amy to base a decision on science? Afterall, she graduated from a college where speaking in tongues and phony faith healing is taught.
Actually, D, I have immense respect for Amy and have known her to base decisions on science.
And Northwest is an excellent little school. I can’t agree with its philosophy or its politics, but I have known many people to come out of very conservative schools with a solid understanding of science. Remember, Francis Collins–one of the scientists most responsible for decoding the human genome–is a fairly conservative Christian.
Cheers,
TH