Boots chemist should not have capitulated to pressure from BPAS over emergency contraception

Last night I waded into the debate on whether Boots should reduce the price of the so-called ‘morning-after pill’ and criticised the high street chemist for ‘capitulating in the face of political pressure’. 

Let me explain why.

Boots had originally defied calls to slash the price of ‘emergency contraception’ – with its chief pharmacist saying it did not want to ‘incentivise inappropriate use’.

But late on Friday night Boots released a statement to say it was ‘truly sorry’ about its ‘poor choice of words’, and was looking at cheaper alternatives (see here, here, here, here and here).

The about-face was the result of a high-level campaign on social media by abortion provider BPAS and a group of 35 Labour women MPs.

It all began when BPAS (the British Pregnancy Advisory Service) wrote to Boots’ head pharmacist, Marc Donovan, pointing out that generic versions of the Levonelle brand of emergency hormonal contraception can be bought cheaply by pharmacies and can retail for as little as £5.50 in France. By comparison, Boots charges £26.75 for its own version.

Mr Donovan wrote back to say that if Boots did make the pill cheap it could be ‘accused of incentivising inappropriate use’.

This led to an explosion on social media from Labour women MPs calling for women to boycott the chemist and forcing Boots to back down.

I have three main concerns about this whole furore.

First, public policy decisions about women’s health should not be made on the hoof after twitter rants especially when these are strongly ideologically motivated. They should rather be made after proper and robust debate on the facts. The knee-jerk assumption of most people is that making emergency contraception readily available either free or cheap over the counter without prescription will reduce unplanned pregnancies and safeguard women’s health. In fact there is no evidence to suggest that this is actually true (see below).

This latest broadside needs to be seen for what it is – part of a high level campaign by  abortion industry leader BPAS – which receives £30miliion of taxpayers money annually – to advance its agenda of abortion on demand up to birth and free contraception for all. They are prepared to bully, blackmail and boycott to achieve their agenda and sadly few are willing to stand up to them. If MPs wish to influence pharmacy practice they should raise it in the House of Commons in a responsible way, not form a social media lynch mob.

Second, all the evidence suggests that ready availability of emergency contraception does nothing to reduce abortion rates and actually increases rates of sexually transmitted diseases.

For a start levonelle is not 100% effective in any given case.  Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours). 

A 2012 study in Washington State showed that free access to emergency contraception caused a statistically significant increase in STI rates (specifically gonorrhoea rates) and no change in birth and abortion rates.

The results were almost identical to those of a British study published in the Journal of Health Economics (full text) in December 2010 and reported in the Daily Telegraph in January 2011. (See my previous blogs on this here and here).  The researchers found that rates of pregnancy among girls under 16 remained the same, but that rates of sexually transmitted infections increased by 12%.

In fact, in a systematic review published in 2007, twenty-three studies published between 1998 and 2006 measured the effect of increased EC access on EC use, unintended pregnancy, and abortion. Not a single study among the 23 found a reduction in unintended pregnancies or abortions following increased access to emergency contraception (see also fact sheet here).

The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’. The term has been applied to the fact that the wearing of seatbelts does not decrease the frequency of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly. In the same way ready access to emergency contraception encourages young people to take more risks and can also be used as a tool by abusers to negotiate for sex.

In 2015 the total number of new STI diagnoses in England was 434,456. This included more than 129,000 diagnoses of chlamydia (a major cause of infertility) in 15-24-year-olds.  Young females are more at risk of a diagnosis than young males. The male diagnosis rate among 15 to 19-year olds was 824.4 per 100,000 population and 1,693.8 among 20-24-year-olds compared to 2,436.8 among 15 to 19-year-old females and 2,557 among females aged 20-24. Gonorrhoea is also most common among the 20-24 age group, with a rate of 269.5 per 100,000 population.

So making the emergency contraceptive pill available over the counter free or cheap, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.

Third, the emergency contraceptive levonelle is already available free from Brook centres, some pharmacies , most sexual health clinics, most NHS walk-in centres,  most GP surgeries and some hospital accident and emergency (A&E) departments. For pharmacies it is a free market. Boots’ own  price tag was based on the cost of the medicine and the regulated mandatory consultation with the pharmacist. It is surely only fair that as a retail pharmacy they don’t compromise or undervalue this professional service.

It is regrettable that Boots has capitulated in the face of political pressure and failed to support its chief UK pharmacist in his legitimate concerns over incentivising the inappropriate use of emergency contraception. It is settled science that making so-called emergency contraception more easily available does not reduce pregnancy rates in a population and actually raises rates of sexually transmitted diseases. 

By appeasing this cartel of radical feminist MPs Boots is encouraging more reckless sexual behaviour and thereby exposing young people to an increased risk of sexually transmitted infections. They are also encouraging MPs and sections of the media to force changes in medical practice through bullying, name calling and blackmail rather than sound evidenced-based argument. The same campaign is going to target Lloyd’s Pharmacy next. This is bad medicine, bad leadership and bad public policy.

But perhaps the most frightening aspect of this whole episode is the deafening silence of other sitting MPs at Westminster who by their failure to speak out have signalled complicity with both process and practice.

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.

Church-based programmes such as Love for Life (Northern Ireland), Love2last (Sheffield), Challenge Team, Romance Academy or Lovewise (Newcastle) are getting great results and have much wisdom to pass on.

New study confirms that making morning-after pill free without prescription increases sexually transmitted infections and fails to reduce pregnancy rates

Half of all pregnancies in the United States are unintended.

One might therefore assume that making the morning-after pill (MAP) more widely accessible would cut the unplanned pregnancy rate.

Not so.

A new recent US study is the first to estimate the impact of making the morning-after pill available over the counter without prescription on abortions and risky sexual behaviour as measured by sexually transmitted infection (STI) rates.

Dr Karen Mulligan, associate professor of economics and finance at Middle Tennessee State University, found that providing individuals with over-the-counter access to emergency contraception (EC) leads to increased STI rates and has no effect on abortion rates.

Moreover, risky sexual behaviour such as engaging in unprotected sex and number of sexual encounters increases as a result of over-the-counter access to EC.

Mulligan’s analysis estimated that over the counter access increases STI rates by approximately 12% for women aged 15-44 and 9% for teenagers; these numbers are also consistent with the 12-17% increase in gonorrhea rates found in Washington as a result of expanded access.

She concluded that switching EC to over the counter status has three main effects on behaviour: individuals are more likely to have sex, they have a higher number of sexual encounters, and are less likely to use condoms.

The FDA approved access to emergency contraception, or Plan B (equivalent to Levonelle in the UK), through US pharmacies without a prescription in 2012 nationally. This followed pilot programmes in several states starting with Washington in 1998. 

But the US’s persistence with this unproven strategy is apparently driven more by ideology than evidence.

In the light of Mulligan’s research, Dr David Paton, professor of industrial economics at Nottingham University Business School, today called on local and national governments in the UK to review their current policy of aggressive promotion of emergency contraception (EC) to young people in schools, pharmacies and sexual health centres.

‘It is very interesting to see further confirmation that access to emergency birth control (EBC) does not seem to reduce abortions but leads to higher rates of STIs. This paper is one of the first to explore the mechanisms whereby EBC affects STIs, finding that both rates of 'unprotected' sex and numbers of partners increase in response to over-the-counter EBC. Although this paper uses US data, it is consistent with evidence from the UK’, he said.

A previous 2012 American study showed that making emergency contraception available free over the counter without prescription leads to an increase in rates of sexually transmitted infections and does not decrease pregnancy or abortion rates. 

Christine Durrance, Assistant Professor of Public Policy at the University of North Carolina, Chapel Hill, used county-level data as well as specific timing of changes in pharmacy access to consider the intended and unintended consequences of pharmacy access to emergency contraception in Washington. 

The results were almost identical to those of a British study published in the Journal of Health Economics (full text) in December 2010 and reported in the Daily Telegraph in January 2011.

This research, by professors Sourafel  Girma and David Paton of Nottingham University, compared areas of England where the scheme was introduced with others that declined to provide emergency contraception free from chemists (See my previous blogs on this here and here).

The academics found that rates of pregnancy among girls under 16 remained the same, but that rates of sexually transmitted infections increased by 12%.

In fact, in a systematic review published in 2007, twenty-three studies published between 1998 and 2006, and analyzed by James Trussell’s team at Princeton University, measured the effect of increased EC access on EC use, unintended pregnancy, and abortion. Not a single study among the 23 found a reduction in unintended pregnancies or abortions following increased access to emergency contraception (see also fact sheet here).

The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.

The term has been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly.

In the same way it has been argued that making condoms readily available actually increases rather than decreases rates of pregnancy and sexually transmitted infections because condoms encourage teenagers to take more sexual risks in the false belief that they will not suffer harm.

Whilst condoms offer some protection against sexually transmitted infections the morning-after pill offers none.

Britain has the highest rate of teenage pregnancy in Western Europe.  But international research has consistently failed to find any evidence that emergency birth control schemes achieve a reduction in teenage conception and abortion rates.

Now there is growing evidence showing that not only are such schemes failing to do any good, but they may in fact be doing harm.

Making the emergency contraceptive pill available over the counter free, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.

Is the RCOG breaking the law by preventing pro-life doctors from receiving its degrees?

Last week I highlighted the fact that a faculty of the Royal College of Obstetricians and Gynaecologists (RCOG) is barring doctors with pro-life views from receiving its degrees and diplomas. The story has been picked up by the Telegraph today. 

Doctors and nurses who have a moral objection to prescribing those ‘contraceptives’ which can act by killing human embryos are to be barred from receiving diplomas in sexual and reproductive health even if they undertake the necessary training according to updated FSRH guidelines .

The Faculty of Sexual and Reproductive Health (FSRH) is also barring such doctors from membership of the faculty and from specialty training.

Or to put it bluntly – if you refuse to fit coils or prescribe the morning after pill (MAP) then you can’t train to treat infertility, cervical cancer or HIV either. This effectively means that many thousands of doctors will not be able to pursue a career in gynaecology and sexual health. 

And yet the use of emergency contraception and IUCDs like the coil makes up only a tiny part of the specialty of sexual and reproductive health (SRH) which also encompasses the following long list of conditions, treatments and procedures: screening for cancer of the cervix, ovary, breast, bowel, prostate and testes; all methods of contraception which act before fertilisation; reproductive endocrinology; SRH epidemiology; miscarriage and ectopic pregnancy; forensic gynaecology (management of sexual assault); genitourinary medicine (sexually transmitted infections, HIV, AIDs);  infertility/subfertility (male and female);  medical gynaecology (menorrhagia, dysmenorrhoea, dyspareunia, endometriosis, PCOS, amenorrhoea, pelvic pain, PMS ,continence, menopause); management of menopause; postnatal depression; prenatal diagnosis and psychosexual issues.

So the effect of this RCOG ban will be to drive those with a moral objection to interventions which kill early human embryos (including Christians, Muslims and others) not just out of family planning but out of all these other areas of medical care as well.

This is an extraordinary case of taking a sledge-hammer to a walnut more worthy of gulag or gestapo than what David Cameron has called a ‘Christian country’. Surely reasonable accommodation could be made for pro-life doctors? Can the RCOG really argue that there is no creative alternative to these draconian measures?

After all, allowance is already made by the RCOG for doctors who have a moral objection to abortion to train in sexual and reproductive health because the Abortion Act 1967 has a conscience clause. 

But the RCOG, it appears, is exploiting the fact that no similar legal provision exists for fitting coils or prescribing the MAP, by punishing doctors who want to abide by the Declaration of Geneva (which enjoins the utmost respect for human life from the time of conception).

This action by the RCOG is not just profoundly discriminatory but may also be illegal. Under equality legislation, it is unlawful to discriminate against people who have ‘protected characteristics’ - treating someone less favourably because of certain attributes of who they are. This is known as ‘direct discrimination’.

Examples of direct discrimination include dismissing someone because of a protected characteristic, deciding not to employ them, refusing them training, denying them a promotion, or giving them adverse terms and conditions all because of a protected characteristic.

These protected characteristics include religion or belief. It’s also possible to be discriminated against for not holding a particular (or any) religion or belief. Imagine the outcry if the College were to bar from training doctors who wished to prescribe the morning after pill.  But the belief that killing embryos is OK, is a belief, just like the belief that it is not OK.

So it appears, at least on the surface, that the RCOG might well be guilty of direct discrimination. The RCOG is claiming in the Telegraph today that these guidelines are not new as if that somehow justifies their position. But the key issue is that the guidelines are not just and fair and now that the news is out I'm sure that many will be concerned. 

I expect that some serious questions will be asked in parliament and elsewhere about this matter in the coming days and I would not be surprised if some government ministers got very angry as a result, or if a doctor, or a group of doctors and nurses, contemplated bringing a legal case against the College. 

RCOG faculty bars prolife doctors from receiving its degrees and diplomas

Doctors and nurses who have a moral objection to prescribing ‘contraceptives’ which act by killing human embryos are to be barred from receiving diplomas in sexual and reproductive health even if they undertake the necessary training according to new guidelines.

Under new rules issued by the Faculty of Sexual and Reproductive Health (FSRH) earlier this year these doctors and nurses are also to be barred from membership of the faculty and from specialty training.

The FSRH is a faculty of the Royal College of Obstetricians and Gynaecologists established on the 26th March 1993 as the Faculty of Family Planning and Reproductive Health Care. In 2007 it changed its name to the Faculty of Sexual and Reproductive Healthcare.

Whilst many contraceptives act by preventing the union of sperm and egg, some, including most IUCDs (intrauterine contraceptive devices) and the morning-after pill EllaOne (ulipristal acetate), also act by preventing the implantation of an early embryo. In other words they are embryocidal or abortifacient, rather than truly contra-ceptive.

Many doctors, of all faiths and none, have a moral objection to destroying human life and wish therefore to avoid using drugs or methods which act after fertilisation.

In fact this position was once held by the British Medical Association (BMA) when it adopted the Declaration of Geneva in 1948. This states, ‘I will maintain the utmost respect for human life from the time of conception even against threat’.

But in 1983 the words ‘from the time of conception’ were amended to ‘from its beginning’ due to sensitivities about increasing medical involvement in abortion. The word 'beginning' was left undefined, giving doctors the opportunity to argue, contrary to the biological reality, that early human life was not actually human life at all. 

Now it seems that doctors who wish to abide by the original wording of the Declaration of Geneva are to be barred from practising in certain medical specialties. This is an extraordinary about face. 

The Faculty may argue that they are not barring doctors and nurses from practising, but simply from obtaining certain qualifications. But as many job appointments will be conditional on applicants having these qualifications this is effectively also a bar on practice.

Interestingly doctors who have a moral objection to abortion are still able to complete the Faculty’s qualifications because the Abortion Act 1967 contains a conscience clause which protects them. But there is no law protecting those who object to destroying human embryos. 

Many Christians believe that every human life, regardless of age, sex, race, degree of disability or any other biological characteristic, is worthy of the utmost respect, wonder, empathy and protection.

This is based on the idea, taught in the Bible, that human beings are made in the image of God. In a society which is becoming more hostile to Christian faith and values it is perhaps not surprising that we are seeing institutional discrimination of this kind.

Perhaps it is time for Christian doctors and nurses, and others who share their prolife views, to set up an alternative training programme.

What people should know about the ‘once-a-month contraceptive pill’

The Guardian and other news outlets have highlighted a new journal article arguing that a ‘once-a-month contraceptive pill’ is ‘scientifically possible’.

Writing in the Journal of Family Planning and Reproductive Health Care, the researchers say such an advance would be welcomed by many women but the biggest hurdle to development is likely to be ‘political opposition’.

The new pill, they say, could be routinely used after, rather than before, sex. The idea would be that women wouldn’t have to take any precautions against pregnancy at all other than popping a pill whenever their period is delayed and they think they might possibly be pregnant.

What the Guardian doesn’t tell us is that such a pill would not be a ‘contraceptive’ (literally ‘against conception’) at all but rather an abortifacient (destroying an implanted human embryo). This is abortion and not contraception.

Nor does it tell us that a pill that acts in this way in the first few days after conception, ellaOne (ulipristal acetate), has already been available on prescription in the UK since 2009. Another similar drug, mifepristone (RU 486), is already used in Britain to procure medical abortions up to several weeks, but only under the auspices of the Abortion Act.

What is really being advocated is the deregulation of early abortion, by making it available over the counter. And there is no doubt that if such a move took place some women would stockpile the drugs and also use them in higher dose to procure their own later ‘do it yourself abortions’ at home. The thought of young girls disposing of their pregnancies at home – with all that might involve – is really quite horrifying. 

There are other huge dangers with such a strategy. British and American studies have already clearly demonstrated that  making emergency contraception available free over the counter without prescription leads to an increase in rates of sexually transmitted infections and does not decrease pregnancy or abortion rates. If this new pill were to be made available we would expect it to be at least as bad (see note on 'risk compensation below).

Britain already has the highest rate of teenage pregnancy in Western Europe.  Rates of sexually transmitted diseases are also rising. In 2009 there were 12,000 more cases than the previous year, when 470,701 cases were reported. The number of infections in 16-to 19 year-olds seen at genito-urinary medicine clinics rose from 46,856 in 2003 to 58,133 in 2007.

The availability of such pills would also expose women to greater risks of sexual abuse. The fact that one is not using contraception is a strong argument to avoid being coerced into having sex by a strong-willed boyfriend or someone wanting to cover up abuse. Having such a pill available for use by would-be abusers - ‘It doesn’t matter; if you miss a period you could just take this pill’ – actually makes women more vulnerable.

This latest ‘advice’ is not just another ill-conceived non evidence-based knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease. It is also an attempt to smuggle in even more abortion by the back door.

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are very low, especially Christian faith communities, to learn about what actually works.

Note on risk compensation 

The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’. The term has been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly.

In the same way it has been argued that making condoms readily available actually increases rather than decreases rates of pregnancy and sexually transmitted infections because condoms encourage teenagers to take more sexual risks in the false belief that they will not suffer harm.

But whilst condoms offer some protection against sexually transmitted infections the morning-after pill offers absolutely none. Rather it encourages more risky behaviour in the false belief that one is safe.

Other blogs on related issues

What economics can tell us about teen pregnancy rates 
School contraceptives to 13 year olds 
Three false presuppositions about teenage pregnancies 

Doctors should not be forced to provide emergency contraception if they have an ethical objection to it

The Independent has run the story of a ‘Christian-run NHS GP surgery’ which has apparently ‘attracted criticism for posting a notice warning that some of its doctors refuse to prescribe the morning-after pill to patients on grounds of conscience’.

The message on the door of The Links Medical Practice in Mottingham, south London advises patients that if ‘a consenting doctor is not available’ to prescribe contraception they should contact a local clinic or chemist.

One of the practice’s patients was apparently so outraged by this that she opted to leave the practice and Audrey Simpson, chief executive of the Family Planning Association, has said that other women should also think about leaving the surgery in response to the notice.

She is reported as saying: ‘Leaving will send out a message to them that women have the right to access emergency contraception.’

Women can of course legally access ‘emergency contraception’ in the UK and can buy the ‘morning-after pill’ levonelle over the counter without prescription from most pharmacies as well as accessing it free on prescription, from sexual health clinics and from NHS walk in centres.

But according to General Medical Council guidelines published just recently (see my full review of them here), doctors can also refuse to prescribe certain treatments as a matter of conscience.

The Guidance ‘Personal Beliefs and Medical Practice’ states:

‘You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients.’

It goes on to describe how this is to be done:

‘If, having taken account of your legal and ethical obligations, you wish to exercise a conscientious objection to particular services or procedures, you must do your best to make sure that patients who may consult you about it are aware of your objection in advance. You can do this by making sure that any printed material about your practice and the services you provide explains if there are any services you will not normally provide because of a conscientious objection.’

This seems to be exactly what these doctors have done.

The guidance adds that doctors who do not provide a certain treatment should ‘tell the patient’, tell them ‘that they have a right to discuss their condition and the options for treatment with another practitioner’ and ‘make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

Why might doctors have an objection to prescribing ‘emergency contraception’?

There are three main reasons.

Some doctors may have an objection to prescribing contraception in principle. Many Catholics take this view.

Some doctors object to prescribing a drug which might in some circumstances act by preventing an early embryo from implanting in the womb as they see this as an early form of abortion. Although there is not firm proof that levonelle acts in this way there is at very least a degree of uncertainty and no absolute proof that it does not (more on this here – note levonelle in the UK is the same drug as Plan B in the US).

Finally some object because they are unconvinced that levonelle is an effective intervention. Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours).  Also in clinical trials its ready availability has been shown not to reduce pregnancy rates in a population and actually to raise rates of sexually transmitted diseases. 

This is thought to be due to the phenomenon of ‘risk compensation’ – people taking more risks because they believe there is a safety net.

But regardless of the reasons for a given doctor’s objection to prescribing ‘emergency contraception’, the fact that a patient can legally access it does not mean that every doctor thereby has a legal or ethical duty to supply it.

Doctors should not be forced to provide treatments or interventions that they believe are unethical, ineffective or inappropriate. To force them to do so would be to undermine their professional integrity. They are not simply rubber stamps.

Instead reasonable accommodation should be made. And thankfully both the law and the GMC guidance currently allow for that. 

As the recent CMF File on the doctor's conscience concludes: 

The right of conscientious objection is not a minor or peripheral issue. It goes to the heart of medical practice as a moral activity....  The right of conscience helps to preserve the moral integrity of the individual clinician, preserves the distinctive characteristics and reputation of medicine as a profession, acts as a safeguard against coercive state power, and provides protection from discrimination for those with minority ethical beliefs.

(Listen to my BBC London Interview with Vanessa Phelps here)

New study shows free emergency contraception increases rates of sexually transmitted infections

A new American study published this week has shown that making emergency contraception available free over the counter without prescription leads to an increase in rates of sexually transmitted infections and does not decrease pregnancy or abortion rates.

The FDA recently approved access to emergency contraception, or Plan B, through US pharmacies without a prescription. While this change is only now occurring nationally, several states had previously allowed pharmacy access to emergency contraception. In particular, Washington State was the first state to implement such a program in 1998.

In the new study, Christine Durrance, Assistant Professor of Public Policy at the University of North Carolina, Chapel Hill, used county-level data as well as specific timing of changes in pharmacy access to consider the intended and unintended consequences of pharmacy access to emergency contraception in Washington.

The results indicated that while county-level access to emergency contraception was unrelated to trends in STIs and abortions before access changed, access afterwards caused a statistically significant increase in STI rates (specifically gonorrhea rates), both overall and for females, and statistically significant decreases in abortion rates for some ages. These results were robust to several specification tests and falsification tests.

The results are almost identical to those of a British study published in the Journal of Health Economics (full text) in December 2010 and reported in the Daily Telegraph in January 2011.

This research, by professors Sourafel Girma and David Paton of Nottingham University, compared areas of England where the scheme was introduced with others that declined to provide emergency contraception free from chemists (See my previous blogs on this here and here).

The academics found that rates of pregnancy among girls under 16 remained the same, but that rates of sexually transmitted infections increased by 12%.

In fact, in a systematic review published in 2007, twenty-three studies published between 1998 and 2006, and analyzed by James Trussell’s team at Princeton University, measured the effect of increased EC access on EC use, unintended pregnancy, and abortion. Not a single study among the 23 found a reduction in unintended pregnancies or abortions following increased access to emergency contraception (see also fact sheet here).

The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.

The term has been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly.

In the same way it has been argued that making condoms readily available actually increases rather than decreases rates of pregnancy and sexually transmitted infections because condoms encourage teenagers to take more sexual risks in the false belief that they will not suffer harm.

Whilst condoms offer some protection against sexually transmitted infections the morning-after pill offers none.

Britain has the highest rate of teenage pregnancy in Western Europe. In 2008, the latest year for which figures are available, more than 7,500 girls in England and Wales became pregnant. Nearly two thirds of these pregnancies ended in abortion.

Rates of sexually transmitted diseases are also rising. In 2009 there were 12,000 more cases than the previous year, when 470,701 cases were reported. The number of infections in 16-to 19 year-olds seen at genito-urinary medicine clinics rose from 46,856 in 2003 to 58,133 in 2007.

International research has consistently failed to find any evidence that emergency birth control schemes achieve a reduction in teenage conception and abortion rates. But now there is growing evidence showing that not only are such schemes failing to do any good, but they may in fact be doing harm.

Making the emergency contraceptive pill available over the counter free, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.

Church-based programmes such as Love for Life (Northern Ireland), Love2last (Sheffield), Challenge Team, Romance Academy or Lovewise (Newcastle) are getting great results and have much wisdom to pass on. How about financing some serious research into examining them in more depth?

School contraceptive jabs to 13 year-olds without parental consent - a dangerous and ill-informed strategy

School nurses have given implants or jabs to girls aged between 13 and 16 more than 900 times in the past two years, a survey by The Daily Telegraph has found.

Girls aged 13 have been given contraceptive jabs and implants on more than 20 occasions.

A further 7,400 girls aged 15 and under have been given contraceptive injections or implants at family planning clinics.

Under the patient confidentiality rules, nurses are banned from seeking the permission of parents beforehand, or even informing them afterwards, without the pupil’s permission.

The implants, which prevent pregnancy for up to three years by releasing hormones into the blood, are inserted into girls’ arms. The injections are effective for up to three months.

Using Freedom of Information laws The Daily Telegraph has discovered that these implants and contraceptive injections are being offered in schools in Bristol, Northumbria, Peterborough, Co Durham, the West Midlands and Berkshire. They give much more detail about individual trusts in their article today.

The number of girls given implants and jabs is likely to be higher as many trusts claimed they did not keep records or said releasing information would breach patient confidentiality.

I was phoned by the Telegraph yesterday about this and they have just used one sentence of a fairly lengthy quote I gave them so I’m giving a more lengthy response here.

Why should we be concerned about this?

First, sex under 16 is not only illegal, it can also be profoundly damaging – physically, emotionally and spiritually. To facilitate such behaviour behind parents’ backs is unprofessional, irresponsible and morally wrong.

When this story first came to light earlier this year there were understandably a lot of angry parents who felt that their responsibility for their own children had been undermined and that their children were being exposed to risk and encouraged to experiment.

Children under 16 cannot drink in a pub, drive, vote or watch certain films and parental consent is required for any other medical or surgical procedure. Why is this issue so different, especially when contraceptive implants pose health risks – in particular the danger of them ‘going missing’ and damaging later fertility.

Second, young people who feel that they are secure and protected by contraception will take more risks sexually. The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’. The term has been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly. In the same way it has been convincingly argued that making contraception readily available to vulnerable people can actually increase rather than decrease rates of pregnancy and sexually transmitted infections because teenagers are thereby encouraged to take more sexual risks in the false belief that they will not suffer harm.

Third, there are other real risks to the health and well-being of young people in this strategy. A contraceptive implant or jab will protect you to some degree against unplanned pregnancy but it will not protect you against sexually transmitted infections or sexual exploitation. If a young teenage girl is in an abusive relationship or has pressure put on her to have sex then she can be very easily manipulated especially if she is emotionally involved with the boy or man who is trying to coerce her. I am concerned that this contraceptive provision has been moved from the safety of the doctor-patient relationship. Who is taking a detailed history from these girls to ensure that they are not being exploited, coerced or absued?

Fourth, this new strategy is not evidence-based – it is effectively an untested strategy paid for by tax payers’ money and promoted by the government. There is, by contrast, real evidence that making contraceptives more widely available does not reduce unplanned pregnancy rates in a population and may actually increase the incidence of sexually transmitted infections.

The current government teenage sex strategy is not working. Although teenage pregnancy rates in Britain have fallen to their lowest level since 1969, they are around twice as high as those in France and Germany and five times the rate in the Netherlands. That is because the strategy is based on two false premises – that contraceptives are 100% effective and that abstinence is impossible.

Contraceptive provision alone will never address Britain’s epidemic of promiscuity and its consequences. More needs to be doing more to dissuade young people from having sex and promoting abstinence as a good lifestyle choice. The government also needs to be upholding the law about sex with girls under 16 and doing more to curb easy access to pornography. In a pornography-saturated culture many young people have very unrealistic ideas and expectations about sex and will end up making decisions they later regret.

There are communities in the UK – both ethnic and faith communities – which have very low levels of promiscuity and accordingly very low levels of unplanned pregnancy and sexually transmitted disease, divorce and broken relationships. These groups are getting it right and the government should be learning from them rather than basing their strategy on a non-evidence-based ideology involving more and more contraceptives to younger and younger people.

Christian pharmacists under threat from new guidelines on morning-after pill provision

Christian pharmacists who object to dispensing the morning-after pill are facing pressure from their professional regulator to recommend other outlets to customers.

Many pharmacists – not just Christians – have moral objections to the morning-after pill because the drug may in some cases act after fertilisation by preventing the implantation of an early embryo. It is thereby technically abortifacient. There is also strong evidence that its ready availability over the counter without prescription does nothing to decreases the number of unplanned pregnancies in a community and actually increases the level of sexually transmitted disease.

Those with moral objections argue there is little difference between being forced to recommend another outlet for the pill and being forced to sell it themselves.

The regulator, the General Pharmaceutical Council (GPhC), has issued ‘non mandatory’ guidance on the matter which they say the guidance will be open to review after one year. ‘Our guidance is advice for pharmacy professionals and explains how our standards might be met, or provide additional suggestions for practice,’ a spokeswoman said.

According to the Daily Telegraph, the guidance was circulated last week. However the latest guidelines on the GPhC website, ‘Guidance on the provision of pharmacy services affected by religious and moral beliefs’, are dated September 2010. They state:

‘If you do not supply Emergency Hormonal Contraception (EHC), (either over the counter or against a prescription) women should be referred to an alternative appropriate source of supply available within the time limits for EHC to be effective.’

The guidance adds that pharmacists should also phone ahead to check that the product is in stock. It also says that conscientious objection on religious grounds must take second place to contractual demands of employers, like the NHS.

As human rights lawyer Neil Addison points out, ‘What many people do not seem to grasp is the fact that if you are refusing to do something because it is morally objectionable you cannot be obliged to recommend someone else’.

And Anna Sweeting-Hempsall a pharmacist in Sunderland said the new guidance ‘forces pharmacists to act against their consciences’ and would cause legal conflicts between staff and employers.

The Telegraph reports her as saying: ‘Now the employers have the right to impose any contractual obligations that take precedence over the right of conscience. The need to notify people beforehand makes you virtually unemployable. Anybody who values the sanctity of life from the moment of conception will be forced from the profession.’

The controversial General Medical Council Guidance, ‘Personal Beliefs and Medical Practice’ leaves doctors with a similar obligation to refer for practices to which they have a conscientious objection:

‘Patients may ask you to perform, advise on, or refer them for a treatment or procedure which is not prohibited by law or statutory code of practice in the country where you work, but to which you have a conscientious objection. In such cases you must tell patients of their right to see another doctor with whom they can discuss their situation and ensure that they have sufficient information to exercise that right. In deciding whether the patient has sufficient information, you must explore with the patient what information they might already have, or need. If the patient cannot readily make their own arrangements to see another doctor you must ensure that arrangements are made, without delay, for another doctor to take over their care.’

These cases rarely come to court and so often the legal precedents are not clear. Although emergency contraception is technically abortifacient, its provision is not covered by the conscientious objection clause in the Abortion Act 1967.

However it may be that equality law might have a bearing on cases like this. In a very recent case a hospital backed down from forcing two Christian nurses to participate in abortion after it received a letter from a lawyer saying that in so doing they could be in breach of the Equality Act 2010.

UK retailers are not being honest about the mode of action of new morning-after-pill ellaOne (ulipristal acetate)

Earlier this week the news broke that a new ‘morning-after pill’ was being sold online in Britain by a London-based company called HealthExpress.

In fact ellaOne (Ulipristal acetate) has been available on prescription in the UK since May 2009. It was granted marketing authorisation by the European Medicines Agency (EMEA) in March 2009 and the FDA in the US approved the drug on 13 August 2010.

According to the UK EllaOne website the drug can actually be bought from at least four UK sources by filling out a simple on-line questionnaire. Prices vary from £21.36 up to £129.99.

This in itself has fuelled controversy as there is no way of knowing whether the personal or health information supplied by anyone buying ellaOne on line is actually true. What would prevent underage girls buying it or, for that matter, a man intending to cover up sexual abuse?

But the specific concern I wish to raise is that retailers are being dishonest about the mechanism of action of the drug.

Hormonal contraceptives prevent pregnancy by one of three mechanisms – by suppressing ovulation (the release of the egg form the ovary), by preventing fertilisation (the union of egg and sperm – usually by interfering with egg and/or sperm transport) and by preventing the implantation of the early embryo in the lining of the womb.

Some women only choose to use those hormonal contraceptives which they know act before rather than after fertilisation. Stopping egg and sperm coming together is one thing. Causing the death of an early embryo is quite another.

How then does Ellaone act? If we rely simply on what the retailers of the drug are saying we might conclude that its action is solely directed at suppressing ovulation and preventing fertilisation.

Typical amongst these is HealthExpress who describe it as follows:

‘(EllaOne) delays the release of the egg, preventing pregnancy. In the event that an egg has already been released, ellaOne works by increasing thickness of the mucus at the cervix. This additional effect reduces the chances of sperm entering the womb and also reduces the chances of pregnancy.’

Similarly 121doc claims that ‘ellaOne works by altering the activity of the body’s natural hormone progesterone, which can stop your ovaries from releasing an egg and prevent pregnancy.’

Pharmaplex Direct and Online Clinic give no information about mode of action at all.

However if we look at the scientific literature on the drug it is very clear that ellaOne also acts by preventing the implantation of the early human embryo. In other words it is embryocidal, or abortifacient.

This simple fact is not mentioned by any of the UK retailers but was made powerfully by Donna Harrison, President of the American Association of Pro Life Obstetricians & Gynecologists (AAPLOG) in evidence presented to the FDA’s Advisory Committee for Reproductive Health Drugs in June 2010. AAPLOG’s full submission goes into much more detail.

This embryocidal mode of action accounts for ellOne’s 98% effectiveness in preventing pregnancy even up to 120 hours (5 days) after intercourse and also explains why it is contraindicated in pregnancy – because of the chance that it might cause an early abortion.

By contrast Levonelle, the emergency contraceptive pill is 95% effective within 24 hours of unprotected sex, 85% between 25 - 48 hours and 58% if taken between 49 - 72 hours.

Unlike the morning-after pill Levonelle (levonorgestrel), but like the abortion drug mifepristone (RU 486), ellaOne is embryotoxic in animal studies. In practice it is actually very unlikely that ellaOne could be used to cause abortions, since it is used in much lower doses (30 mg) than the roughly equipotent mifepristone (600 mg). But killing early embryos is another matter entirely.

According to Wikipedia the EMEA proposed to avoid any allusion to a possible use as an abortifacient in the package insert in order to stop people misusing the drug.

EMEA’s wording is slightly more honest than the UK retailers but again lacks full transparency:

‘For pregnancy to occur there has to be ovulation (release of eggs) followed by the fertilisation of the egg (fusion with a sperm) and implantation in the womb. The sex hormone progesterone plays a role in the timing of ovulation and in preparing the lining of womb to receive the fertilised egg… Through its actions on the progesterone receptors, ellaOne prevents pregnancies mainly by preventing or delaying ovulation.’

One has to read carefully between the lines to understand that this is actually saying that the drug could act by preventing an embryo implanting.

The Faculty of Sexual and Reproductive Healthcare (FSRH) of the UK’s Royal College of Obstetricians and Gynaecologists (RCOG) also hints at this mode of action.

The NHS is a little less ambiguous:

‘EllaOne stops or delays ovulation and makes it more difficult for a fertilised egg to be implanted into your womb.’

Most honest is ‘Netdoctor’ which simply and clearly states:

‘Ulipristal is also thought to alter the lining of the womb, preventing it from being prepared for a fertilised egg. This means that if an egg is released from the ovaries and is fertilised, it cannot implant into the womb and therefore pregnancy is avoided.’

EllaOne’s significantly higher cost than levonelle means in effect that in practice it will only be used in circumstances where there is a high risk that levonelle will not work – that is 2-5 days after sexual intercourse. At this stage it will almost certainly be acting almost exclusively by killing embryos rather than by preventing fertilisation.

Many women believe that life begins at fertilisation and may think twice if told that a drug worked by killing embryos. But how is properly informed consent even possible if retailers and the EMEA itself will simply not tell the truth about how ellaOne actually works?

We have to accept that EllaOne is already legal and available in the UK. But we can nonetheless insist that retailers are honest about its real mechanism of action.