Diversity and InclusivenessMedical Sexism in Prescribing Birth Control

Medical Sexism in Prescribing Birth Control

Practically everyone who is eligible to use birth control chooses to use it at some point in their life. And the availability of contraception to those who want it is central to our autonomy and equality. Angela Davis writes, “Birth control—individual choice, safe contraceptive methods, as well as abortion when necessary—is a fundamental prerequisite for the emancipation of women.” So why is birth control still so difficult to obtain? Why do Americans struggle to access contraception when it is over-the-counter in over 100 countries? Why is it so challenging to receive prescriptions and prescription refills when doctors agree that birth control is safe, effective, and medically necessary? And why do some individuals still face obstacles to contraception due to the imposition of what amounts to irrelevant and often unnecessary yearly testing for unrelated conditions like STDs and cancer?

The answer to these questions is tied to what I call, “medical sexism,” in which medical means or medical ends are used to uphold, assert, or achieve a gendered hierarchy of maleness and masculinity over femaleness and femininity.

Ask almost anyone seeking hormonal control in the United States what they need to do to get a prescription and they will likely say that they are required to undergo a Pap test or pelvic exam first. A practice so common must be medically related to hormonal birth control, you ask? Well, no. Doctors routinely deny patients birth control prescription refills until patients comply with Pap tests or pelvic exams, even though birth control judgments are in no way affected by the outcome of a Pap test or pelvic exam. In that case, you might suppose, these tests must be recommended by the relevant medical oversight societies and associations? Again, no. The Centers for Disease Control (CDC), the U.S. Preventive Services Task Force, and The American Cancer Society, among others, all recommend against added tests for contraception access and recommend against testing every year if previous results have been negative.

Birth Control Pills
Source: BruceBlaus, CC BY-SA 4.0, via Wikimedia Commons

Nearly all cervical cancer is caused by certain types of an incredibly common sexually transmitted disease called human papillomavirus (HPV). Cervical cancer was the deadliest cancer for women before the advent of the Pap test in the 1920s, in which medical providers take cells from a patient’s cervix to test for cervical cancer. Thanks to widespread Pap testing, which allows for early detection, and a vaccine that prevents dangerous strains of HPV, cervical cancer rates in the United States are on the decline. But just because cervical cancer is caused by an STD does not mean that all sexually active people need HPV testing or cervical cancer screenings. HPV has a long latency period, and young women and girls under the age of 21 are so likely to clear any abnormal cells without medical intervention that cancer rates in that age group are negligible.

Today, Pap tests and pelvic exams pose far too great a limitation on birth control accessibility, with many patients unable to obtain prescriptions without these added tests. As a result, these exams are done at rates that far exceed scientific evidence or medical necessity. When doctors hold birth control ransom to STD testing and cancer screenings, they objectify and infantilize their patients, placing their own health priorities and values over those of the patient in a paternalistic fashion. Even if yearly Pap tests and pelvic exams were medically indicated for the average patient, their irrelevance to the safety and efficacy of birth control would make them impermissible as prerequisites to contraception access.

If doctors require Pap tests when they give unrelated prescriptions to anyone with a cervix, they must be requiring prostate exams when they give unrelated prescriptions to anyone with a prostate, right? After all, like Pap tests, prostate exams are part of a complete health care regimen and can lead to early detection of cancer. Consider the case of a patient with high cholesterol who is prescribed statins. Do doctors routinely withhold refills on statins for cholesterol until patients undergo prostate exams? Further evidence that the Pap test requirement is an instance of medical sexism is that the answer is no. In this case, the statins are part of ongoing care for a chronic condition and should not be contingent on a cancer screening, however strongly the doctor wants the patient to submit to added tests. Yet, this type of reasoning is exactly what is going on in the birth control case. 

A requirement of yearly testing in order to be prescribed birth control violates primum non nocere or “first, do no harm” for a number of reasons. For one, Pap tests and pelvic exams are invasive procedures. Doctors enforcing these tests in particular for birth control access raises red flags in part because the Pap tests and pelvic exams are sometimes unnecessary, irrelevant, and unwanted. For another, overtesting imposes its own costs in time and planning and can lead to false positives, overdiagnosis, and risks in overtreatment. Furthermore, withholding birth control imposes its own harms. Safe, effective contraception methods within the user’s control are essential for family planning and they treat a wide variety of conditions, including endometriosis. Hormonal birth control can decrease the likelihood of certain cancers during continued use, such that doctors are actually withholding a cancer-preventing treatment in favor of an intervention that merely screens for cancer. Withholding birth control prescription refills imposes serious risks to patients who need it.

Photo of pink sign with white lettering reading, "Don't take away my birth control," held by two hands in front of the Supreme Court.
Source: Women’s eNews via Flickr (CC BY 2.0)

If we aim to maximize the best consequences in the aggregate, as consequentialist and utilitarian ethical theories would encourage us to do, these medical and physical harms are essential to the moral analysis. These harms also point to potential legal issues. Withholding oral contraceptives in the manner described may constitute medical malpractice. The legal case for medical malpractice is met when there is a duty of care (established by the doctor-patient relationship), a standard of care (established by the best practices in the field), a breach of that care (established by the violation of evidence-based recommendations), and resulting damages (established by the above potential harms). This practice violates the most basic standards of the field, and can result even in legal negligence.

But risks and harms don’t fully capture the ethical issues involved. Denying birth control prescription refills is a violation of informed consent, whether or not any harms arise from the practice. Each condition of informed consent must be met for the procedure to be morally legitimate: the doctor must disclose the relevant information, the patient must understand the relevant information, the decision must be freely made, and the patient must be competent to decide. Patient surveys suggest that the first two conditions are not met. That’s not surprising. If a doctor were to disclose to a patient that another pelvic exam or Pap test after last year’s negative results is not indicated by medical institutions or scientific evidence, and it is a personal policy to require it before the release of a birth control prescription, patients might not comply with the testing.

What about the third condition of informed consent, that the decision be voluntary? The patient has expressed a preference for birth control access, and the doctor has recommended the treatment for the patient. Withholding ongoing medical care for a chronic condition in service of unrelated tests reduces the patient’s choices artificially and eliminates the “opt-out” element of undergoing an invasive medical procedure such as a Pap test or pelvic exam. The limitation of options undermines the voluntariness of the action. When doctors withhold prescriptions, telling patients they can only get needed medical care if they undergo a test unrelated to its safety or efficacy, they put the patient under duress.

This practice became standard in a field that never had evidence to back it up and persisted decades after it was explicitly opposed by major organizations due to medical sexism born out in this case by paternalistic behavior. Paternalism survives in areas generally deemed “women’s health.” This fact is not an accident. Paternalism is the expected response to patients who are not thought to be fully autonomous or who are infantilized, as women often are. That’s why we should call it out for being scientifically unfounded, medically dangerous, and unacceptably immoral. Doctors treat patients as less than fully developed moral agents when they require unrelated STD testing to allow patients to obtain the birth control they need, casting aspersions on the last condition of informed consent—competency—and using it to justify the failure to meet the other three. That STD testing and birth control are in question underscores the ways in which doctors aim to monitor women’s bodies precisely at the point where we are seeking to control our own reproductive capacities. Naming medical sexism is the first step towards ending it, and ending it is essential to protect patient health and well-being.

Medical sexism explains certain practices in the medical field, especially those that violate standards of care, are not financially advantageous to the physician, and increase the risk of mortality and morbidity for patients. Examples that meet these conditions abound, both historically and today. They are found in reproductive care, such as what happens when medical providers prescribe bed rest, deny abortion, or perform pelvic exams on unconscious patients without their prior consent. They are also found in areas outside of reproductive health, such as when doctors send women home from the hospital during a heart attack, misdiagnose autoimmune diseases, or fail to perform or overlook research on women.

Take pelvic exams in another context: gynecological surgeries. Even when these are medically necessary, a lack of consent still attends the practice, making them morally impermissible. In some situations, they are not medically indicated and used instead as training practice with no benefit to the patient. In such cases, they violate standards of care and impose risks to the patient on top of the violation of patient rights and autonomy. Just seven states make it illegal to perform a pelvic exam on anesthetized patients without their consent. Medical sexism is the best explanation for why this practice is still tolerated today. Medical sexism explains why patients’ autonomy would be denied, their preferences ignored, their rights sacrificed, and why the equal protection of the law does not extend to practices primarily impacting women.  

Medical sexism is not confined to reproductive health. Twice as many women as men have auto-immune disorders, and some are also more prevalent in women of color, though the reason for these differential impacts is not known. While so much is unknown about autoimmune disorders that the lack of knowledge about them poses its own dangers, another serious danger women face is being dismissed and belittled in the doctor’s office. Instead of contending with the fact that they don’t know what ails their patients, doctors tell 40% of those with autoimmune disorders that nothing is wrong with them and that their symptoms are imaginary.

The exclusion and erasure of women from biomedical research is also an extension of this phenomenon and creates a vicious cycle. Maya Dusenbery writes, “Women’s symptoms are not taken seriously because medicine doesn’t know as much about their bodies and health problems. And medicine doesn’t know as much about their bodies and health problems because it doesn’t take their symptoms seriously.” Medical sexism means that women’s symptoms are taken less seriously, doctors know less about their health, and new treatments are viewed as less urgent.

Medical sexism also intersects with other systemic hierarchies like medical racism and medical classism exacerbating and compounding injustices in the health care field. For example, the maternal mortality rate in the United States for non-Hispanic Black women is twice the national average, which is already the highest in the developed world and rising. It is impossible to address maternal health, then, without both the lenses of gender and race.

So what needs to change? First, we have to connect the dots. If we try to address contraception access without understanding its relationship to reproductive medicine or if we try to improve reproductive medicine without addressing contraception access, we run the risk of overlooking the underlying causes of the injustice. Violating patient preference in contraception is intimately connected to violating patient preference in abortion policy, labor, and delivery practices. Although the moral status of the fetus is often held up as an explanation for overriding patient preference in abortion, labor, and delivery, it can’t explain overriding patient preference in contraception. We do a disservice to the discussion when we claim otherwise.

Medical sexism is the instantiation of broader hierarchies in society and does not exist in a vacuum. Nothing short of dismantling systemic injustices like sexism, racism, ableism, and classism is required to address it, by focusing on laws, norms, and customs in addition to individual action. Telling patients how best to advocate for ourselves in the doctor’s office runs the risk of blaming the victim; our efforts at eradication should be aimed at those perpetrating injustice and not those receiving it. Still, we can provide support to those experiencing injustice by amplifying their voices, validating their experiences, and changing our institutions. Doctors and other health care providers are just one part of larger, systemic frameworks that can be oppressive or liberating. Let’s aim for liberation.   

The Women in Philosophy series publishes posts on women in the history of philosophy, posts on issues of concern to women in the field of philosophy, and posts that put philosophy to work to address issues of concern to women in the wider world. If you are interested in writing for the series, please contact the Series Editor Adriel M. Trott or Associate Editor Julinna Oxley.

Jill Delston

Jill B. Delston is associate teaching professor of philosophy at the University of Missouri-St. Louis. She is the co-editor of Applied Ethics: A Multicultural Approach (editions 5 and 6). Her monograph, Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care (Lexington Books, 2019), is out now in paperback.

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