The Other Birth Control Debate

Not directly related to – but probably not completely independent from – the raging debate over birth control coverage in Roman Catholic college health plans, the availability of the emergency contraceptive Plan B One Step, or the morning-after pill, has been making news on a number of campuses across the country, and not all of them are religious.

Some colleges have been criticized for not making Plan B easily available; others, for expanding access or accommodating it in unusual ways. But, playing out against the backdrop of the latest culture war, each case reinforces the considerable impact colleges can have in this area of student health.

In most cases, Plan B is not particularly difficult to obtain. Under federal law, it’s available at pharmacies to anyone 17 or older, regardless of gender, without a prescription. However, some states maintain a “conscience clause,” by which pharmacies can refuse to sell Plan B for moral reasons. And colleges that employ nurse practitioners rather than pharmacists might be subject to additional state laws restricting how they can distribute emergency contraception.

By making it more difficult for the sperm to fertilize the egg or by preventing fertilization altogether – not by aborting an already established pregnancy, as is sometimes assumed – Plan B can reduce the odds of pregnancy by 89 percent when taken within 72 hours after unprotected sex, though its effectiveness decreases with time. (The "abortion pill," known as mifepristone, medication abortion or RU-486, ends early pregnancies and is available from physicians at clinics, medical offices and hospitals.)

A survey by the American College Health Association in fall 2010 showed that 83.3 percent of ACHA member institutions that responded either prescribed, sold or dispensed emergency contraception. Because it is so widely available, Plan B distribution at the collegiate level is generally not particularly controversial, said Heather Eastman-Mueller, chair of ACHA’s Sexual Health and Clinical Care Coalition and a health educator at the University of Missouri at Columbia. The bigger issue among health officials has been confusion over federal guidelines.

After President George W. Bush reluctantly agreed to allow Plan B without a prescription for people 18 and older, the Obama administration in 2009 lowered the age to 17. Then, late last year, U.S. Health and Human Services Secretary Kathleen Sebelius overruled a Food and Drug Administration decision that would have given over-the-counter access to all women regardless of age; as a result, women under 17 must have a prescription to get Plan B.

“I think that oftentimes where [controversy] comes into play is the misunderstanding about what emergency contraception is actually intended for and how it should be used and who has legal access to it,” Eastman-Mueller said. “Just having 83 percent of the universities who responded dispensing or making emergency contraception accessible says something right there, I think.”

But it’s not always as simple as providing it or not providing it. An online petition late last year accused Ramapo College in New Jersey of unduly restricting access to Plan B.

Ramapo requires students to make an appointment with campus health services, look over and sign a fact sheet explaining how Plan B works, and answer nine questions detailing their contraceptive use and the instance of unprotected sex that led to the need for Plan B.

"As more students are having complications in obtaining Plan B from their health services, great concern has arisen on the campus of Ramapo College,” the petition reads. It requests a guarantee that students be seen within 24 hours for Plan B; a shuttle to Planned Parenthood when the center is closed; the elimination of mandatory appointments, which entail the "unnecessary and invasive interview process"; male student access to the contraception; and “open communication and transparency” between Health Services and students.

“Health Services views their role as one of education. Therefore, the questionnaire helps the student to put in place a Plan A, so that Plan B is not being used as their sole form of birth control,” Ramapo spokeswoman Cynthia Burns said in an e-mail. “If indicated, Plan B One Step will be dispensed to the female student.”

Last semester, 10 students requested appointments, half of whom were seen that day; the rest were seen within 24 hours. Students can take a shuttle to off-campus pharmacies when the Health Center is closed, and pharmacists can distribute Plan B to anyone, regardless of who will end up using it. While U.S. law allows anyone 17 or older to get Plan B with no prescription, New Jersey state law prohibits the nurse practitioners who staff the center from dispensing medication to anyone other than the patient – hence the male students not being able to pick up emergency contraception. 

Ramapo is not alone in making its own rules on Plan B.

"I can’t really say that there is a ‘standard campus pharmacy procedure.’ We have a little joke in college health that goes something like, ‘If you’ve seen one college health center, you’ve seen one college health center,’ ” Deborah Hubbell, chair of the ACHA Pharmacy Section, said in an e-mail. “My general impression is that health centers on larger campuses that have an in-house pharmacy are providing Plan B without a prescription, while smaller centers without a pharmacy require an appointment. This may or may not be related to their philosophy around sexual health.” But it could also depend on state regulations, she said.

For instance, at the University of Connecticut, where Hubbell is assistant director of business and ancillary services, Plan B is available without a prescription in the pharmacy for any student 17 and over. And to address the time element, the university has a “walk-in clinic med room” where students can buy Plan B, along with other non-prescription items, when the pharmacy is closed.

Washington University in St. Louis recently started distributing Plan B to male students. Alan Glass, assistant vice chancellor and director of the university’s Health and Wellness Center, wasn’t available for an interview, but told the student newspaper. "I do think it is effective and the right thing to do.” But few male students have picked up the pill, he said.

While Ramapo has drawn some criticism for its more restrictive procedures, Shippensburg College in Pennsylvania this month drew a firestorm of media attention when somebody caught wind that it distributes Plan B for $25 through a vending machine.

Unique, maybe. But not new (Shippensburg’s been doing this for two years), or particularly controversial, given that the machine is manned by an employee, as a pharmacy or nurse practitioner’s office would be. The contraception is still available only to students of age, and staff are there to answer questions.

Shippensburg installed the machine after 85 percent of students who responded to a survey three or four years ago said that Plan B should be available on campus.

“We understand this is a personal decision. If the student wants to make that decision, we have made what is an over-the-counter medication available without a prescription,” Shippensburg spokesman Peter M. Gigliotti said. “We’re sort of caught in this overall debate.”

Still, in response to a flood of questions about the method, the university is assembling a group of students, faculty, administrators and counselors to revisit the idea of the vending machine.

Meanwhile, some colleges are standing their ground even when the press comes knocking about birth control issues. Take Fordham University, a Jesuit institution in New York that was the subject of a Los Angeles Times article last week chronicling the pains one student went through trying to get birth control pills, which she took to reduce her risk of ovarian cancer, through the institution’s health care plan. (Editor's note: This sentence has been updated to correct a fact error.) A Fordham spokesman defended the university’s decision to follow Catholic doctrine. Asked this week to comment further, he referred Inside Higher Ed to the Association of Jesuit Colleges and Universities, which declined to comment, as did the Association of Catholic Colleges and Universities.

James Trussell, faculty associate of Princeton University’s Office of Population Research and creator of its educational emergency contraception website, reasoned that students at the Catholic colleges fighting against a mandate to cover contraception aren’t speaking out much about Plan B because it’s widely available elsewhere.

“It’s really hard to say how much access is really impeded because it would depend entirely on where college campuses are located,” said Trussell, the Charles and Marie Robertson Professor of Public and International Affairs at Princeton. In other words, a student in New York City would have a much easier time accessing Plan B off-campus than one in a rural town with no public transportation and only one or two pharmacies. But Trussell said he hears much more about pharmacies refusing to distribute Plan B than colleges.

Recent polls have shown 58 percent of Catholics support Obama’s policy requiring Catholic employers to provide free access to contraceptive health care, and that 98 percent of American women use birth control at some point in their lives.

“The ones who are providing it with a bunch of barriers are putting barriers there just for the sake of putting barriers. They have no medical reason for being there; they have no legal reason for being there,” Trussell said. “It’s not about contraception; it’s about sex. The social conservatives don’t want people to need it because they don’t want them to be having sex in the first place.”