The [Inclusive] Contraception Project
Interview 1 - An urban physician
Question: To start, please tell me a little bit about yourself
I am a family physician currently practicing in Vancouver, BC and do a mix of general family medicine as well as women’s health including contraception, abortion, and a larger focus on obstetric care. I do have extra training in women’s reproductive health, and before medicine completed a Master’s in Women’s Studies and worked to support access to sexual health in Ontario. Overall, I am passionate about women’s health!
Question: From your experience, what barriers are patient’s experiencing when trying to access contraception? We hear a lot about financial barriers, are there other barriers?
First, the COVID-19 pandemic has made it really challenging for people to access contraception. It’s become more difficult to physically visit doctors, both transport-wise in getting to appointments, as well as scheduling an in-person (vs. telehealth) appointment necessary for some forms of contraception like an Intrauterine device (IUD) insertion. In addition, I’m finding many patients are worried about going out due to the pandemic restrictions. This is especially impacting people with existing mental health concerns, for example anxiety, or people with family members who are immunocompromised that need to be protected.
Second, patients from rural or remote communities have unique barriers in accessing contraception. In small communities where everyone knows everyone, patients are burdened with needing to find out which physicians are safe to discuss contraception options, as well as worrying about their privacy in general. This worry prevents patients from speaking with their doctor about contraception. The pharmacies also don’t always carry enough stock for contraception, limited by quantity and type of contraceptive method, so even if a patient has a prescription they may not be able to get it filled right away and may have to wait for stock to come in. In some communities, there may not even be a health professional able to prescribe contraception! For youth in rural communities, it can be especially hard to get around town without a vehicle or reliable public transit. This means they either have to walk (which carries some risk) or get a ride from family/friends (less private). Even if a patient lives just outside of a larger center, access to contraception can still be difficult where it might take time to travel and, for example, an IUD appointment can last 1-2 hours so that could be almost a half-day off work/school.
Third, patients are often concerned about the confidentiality and privacy of their visit, most notably youth who may still be dependents. This situation is really tough because some young patients have insurance through their family and worry their parents will see the transaction on their account. I, myself, remember being afraid of this when I was younger too! So, some young patients will opt to pay out-of-pocket which can get expensive, especially if working part-time or at a minimum wage job.
Fourth, contraception is still heavily stigmatized with many different values attached to access. For some patients, they don’t want their families or romantic partners to know they are taking contraception. This can become hard to hide, and acts as a barrier for people needing a more concealable option of contraception.
Fifth, the sexual health space is dominated by white women and racism is a barrier for people of colour to access contraception. For example, assumptions can be made around ‘cultural values’ where some cultures are assumed to be against birth control and patients may not be asked about their contraceptive needs. There can also be assumptions made about the purpose of the contraception (i.e. to prevent pregnancy or as therapy for another medical condition) based on skin colour, assumptions that people of colour are not educated around this topic, assumptions that if you come from a ‘traditional’ background you are ‘backwards’, and assumptions their partner is against contraception based on religion. These assumptions are very harmful and create distrust that prevents people from seeking contraceptive care.
Sixth, language may be a barrier to accessing contraception when the patient may have difficulty with communicating in English. As a physician I have access to language translation services to assist in these patient encounters, but all too often I notice health providers not utilizing this service out of convenience – it takes more time to organize translator services, and takes longer getting through the appointment. To get around this, often a family member will be present to help translate for the patient, which comes with its own risks. I find the omission of utilizing translation services in order to turn over appointments faster and thus make more money as a physician is inherently racist and violent – we have a long way to go to provide truly equitable care. It is especially unethical when children are used to translate because it brings doubt to the information collected and may impede the parent’s privacy.
Seventh, health professionals can have a hard time trusting patients to make decisions about their health, especially for reproductive choices. Unfortunately, I’ve seen this all too often across medicine and it impacts patient autonomy. As health experts, it can be easy to think we know best but patients might have different goals for their care and life. We need to trust their choices. It can also be disturbing sometimes in clinic to catch how patients are spoken about, with judgement regarding their choices. The issue of autonomy in reproductive health spheres is longstanding, political, and racist because it impacts vulnerable women and youth where a potential new life is also concerned. In BC and Alberta, there is a horrific history of sterilization of Indigenous women, poor people, single/teen parents, and those suffering from mental illness rendering them infertile. This only stopped in the 1960’s and 1970’s so it was not long ago that people had their autonomy taken away and suffered forced sterilization. This in part reflected the eugenics movement at the time. There are still more recent cases today of Indigenous women being coerced into sterilization procedures.
Lastly, access to contraception is hindered by the lack of publicly funded prescriptions through Pharmacare. This obviously brings to mind all of the financial barriers to contraception access. But I do think the concept behind the policy is interesting, it’s like as a society we would rather focus more on preventing the bad things (i.e. wanting less teen pregnancy) so we don’t have to deal with the consequences, rather focus on the good things (i.e. family planning allows people to reach their life goals and supports patient autonomy). Ultimately, contraception should be publicly funded by Pharmacare to support people’s goals for their life, including education and autonomy, and for their families benefit.
These are all barriers that people face when trying to access contraception that go beyond financial challenges.
Question: Can you share a specific patient experience that still sits with you? Hoops a patient might have had to jump through?
Sure, I had a patient once who lived in another province but was in BC for seasonal work. She was working in a smaller community that had some pretty strong negative values around contraception and had trouble accessing birth control. She became pregnant during the COVID-19 lockdown in this unfamiliar community and decided to seek care to learn more about abortion, but was unaware of the community’s values. Because of this, she was given poor and inaccurate abortion information that ultimately delayed receiving her abortion care. Luckily she managed to find good information on her own and it worked out ok. After the abortion, the patient wanted to go on birth control but struggled to take time off work to properly access medical appointments. It is not right that this much labour and onus is on the patient to advocate for themselves – this disparity of care shouldn’t happen in Canada in 2020! Unfortunately, this is a common example and a variation of it exists frequently.
Question: Talk to me more about communities with negative values regarding contraception? What can be done?
Yes, this is an on-going challenge that isn’t specific to BC. As physicians, we have a professional duty to advocate for our patients- negative attitudes about accessing contraceptive care among health professionals is unacceptable. Why does the Canadian Medical Association (CMA) allow attitudes like that to continue among its members? Why wouldn’t a physician believe in birth control? I think if you have strongly held values when it comes to contraception you shouldn’t work in that area of medicine (e.g. OB/GYN, family medicine). Contraception is a core aspect of care in these fields. And if you do choose one of these fields, physicians should not have the choice to not prescribe contraception. Yes, it is a requirement to refer a patient you don’t want to prescribe contraceptives to, but this is not very enforceable, and patients do not always know their rights. So, the burden to access contraception always falls back on the women (already facing numerous barriers) to make up for inappropriate care. This shouldn’t be the case.
With the expansion of telemedicine, and now more comfort using virtual health services due to COVID, this can hopefully alleviate some of this burden from women struggling to access care. It might also offer more confidentiality to be able to speak to your physician on the phone somewhere private. Telemedicine might also lift some of the financial barriers associated with travel and time-off, but hopefully public coverage will be increased in current political discussions. I do also think that there is a new era of physicians entering the field of medicine now where there is more patient advocacy and alignment with women’s reproductive autonomy compared to some of the older generations – not prescribing birth control is so old-school! This same cohort of entering physicians also have different values when it comes to patient partnership in care, so patients feel more empowered to ask their physician questions and explore other options within the health system.
Question: Speaking of patient advocacy and contraception, how much of your time is dedicated to this on behalf of your patients?
Well, one example is that many physicians keep ‘unofficial stock’ of birth control pills and IUDs for patients that can’t afford to pay; these are given from companies on a compassionate basis. We also have ‘unofficial groups’ we can network with to get access to contraceptive resources if we need to. We really need to improve access for people, and de-stigmatize contraception.
Question: What is one thing you would like people to know about accessing contraception?
I want people to know that there are still many challenges, which go beyond just financial barriers. Even people living in urban areas can face substantial barriers accessing contraception. This fight isn’t over and advocacy for universal contraception will continue across Canada. All of the barriers I highlighted above can intersect and compound on one another, it isn’t just a matter of rural v. urban or white v. racialized, and ultimately leave people without access to safe care or accurate information.
Question: If you could create your dream contraception policy, what would that look like?
Ultimately, we should have Pharmacare and all birth control options should be available for free. The Medical Services Plan should not only be available to citizens and permanent residents, it should be available for all, including temporary workers and international students. We would benefit from an expansion of health coverage in general as well as specifically related to contraception. For example, in BC the Ministry of Health has partnered with BC Women’s Hospital and Health Centre to offer the SMART Program (Safe Methods at the Right Time) which aims to reduce subsequent unintended pregnancies by providing contraception at no cost to women at the time of abortion. This program offers contraception, either an IUD, 1 package of pills, or 1 shot of Depo-Provera, at no cost. However, there are some caveats, in addition to the fact that 1 month of pills is not enough, the marketing of the program as being “smart” is problematic. Why should it be required to have had a surgical termination of pregnancy in order to qualify for free contraception? It would be “smarter” to be proactive and offer contraception so unwanted pregnancies could be avoided in the first place. It would be nice if individuals have more access to avoiding abortion.
Question: What do you consider to be the biggest flaws or what is being missed in the talks of the policy currently being proposed?
The features of the proposed policy are a good start. I am unclear as to why there potentially could be a cut off for coverage after age 25. It seems fairly arbitrary – why not 30? Or just anyone who needs it? It could be presented that those under 25 are less likely to be working in established “careers,” however it seems like many people in our current economy, of all ages, are in temporary positions and COVID has increased unemployment rates.
Some of my patients fall within the targeted demographic and have the potential to benefit from a policy of this type, but a lot of my patients are over 25. While I was training in Ontario there was a similar program – you could use a parent’s insurance until age 25. But what happens after that? There is still a gap of working poor who might never have insurance – why create more barriers for these people? Some may live in areas where accessing healthcare is challenging, they may have limited access to transportation, or work long hours in difficult situations like overnight or on weekends which makes getting into the clinic harder. Others don’t have sick pay and may be over 25; these people need contraception too despite not being poor enough to receive Pharmacare and living paycheck to paycheck. So, while the policy components that have been proposed are a step in the right direction, and a policy of this type would help some, it would not help all. Ultimately it should be that… and more.
Question: What has your contraceptive journey been like?
Thankfully, my personal contraceptive journey has been pretty easy due to consistent access to healthcare and living in big cities. I have also always been interested in being involved with sexual health organizations, so this gave me access to educate myself on contraception. I don’t remember learning much about sexual health or contraception in high school, but through volunteering and work experiences I was exposed to a lot of sexual health information. I have also always had an interest in sexual health organizations, so I often used those resources to educate myself. My knowledge in this area was largely self-taught through circles in university, and as a white middle-class woman I had limited issues with access to contraception. During that time, it seemed like the institutions were made for me and I easily had access to insurance through school, which helped cover costs. Also, I have always had access to big cities, so when I learned more about IUD as an option, I was able to have access in the large cities.
Things changed when I started working at a non-profit - wages were low, I had no benefits, and no access to Pharmacare. I didn’t have the money to pay for birth control and I relied on the provided birth control that was offered at a reduced cost. This is generally the only time that there was an inherent barrier to my journey in accessing contraception.
Question: Something you wished you started earlier?
I don’t remember any sexual education taught while I was in high school. If it was, it would have been brief but in reality, sexual education ought to be taught more than once throughout high school. Any conversations I do remember were centred around condoms and birth control pills, and largely just in the context of pregnancy. This type of education is not enough for people and in my experience, it led to a lot of negative conversations about people who got pregnant. This also fed into a culture that didn’t provide supportive information for individuals who wanted to avoid pregnancy, which is a part of reproductive health.
Question: What has supported your access to contraception the most?
My access to contraception has been supported by the fact that I never felt worried about my anonymity or not getting the right information. However, the most significant thing that has supported my access to contraception is having insurance. Since I have been able to physically access contraception, having lived in larger cities with the ability to visit specialty clinics or family doctors, the most significant challenge I have faced is a lack of coverage. During times when I did not have insurance and could not afford it, rather than opting out of using contraception, I ended up stealing it from work.
Question: How has access to contraception affected different areas of your life?
I have had an IUD since 2014 and without it I truly don’t think that I could have worked towards and achieved the education, career, and personal goals I have set for myself. I have used an emergency contraception pill in the past and had I not had access to it my life could look very different than how it does now. Contraception has helped me to be more secure in my financial future, it has provided me and my partner with the flexibility to be able to frequently move in recent years, and ultimately it allows me to decide when I feel ready to be a parent. My life would be fundamentally changed if I did not have access to contraception.