How Accessible Are IUDs?

Cross posted from my RH Reality Check blog

Earlier this month Newsweek reported that IUDs are becoming more popular as a form of contraceptive. Reporter Meredith Melnick discussed how the 2005 FDA approval of IUDs among younger women who do not have children has affected the increase in usage. I was not surprised when Melnick reported that some doctors do not support this method for younger women for various reasons. As someone who got an IUD in 2007 before I was in my 30s, I had a very hard time accessing the method of my choice.

Growing up with Puerto Rican hippie parents, I remember my mother telling me that the birth control pill kills Puerto Rican women. And it did. I knew at an early age that condoms were the method I was going to use before even considering a hormonal method, which was not appealing, and still isn’t. Even when the morning-after pill/emergency contraceptive came out I wasn’t too into the option for myself. However, as someone who provided counseling on all options to young people, I also knew where my personal boundaries stopped; it was my obligation never to interfere with my client’s options counseling. Several of my female-identified clients opted for hormonal methods.

My graduate research in sexuality, Latino communities living in the U.S., and women’s health complimented my family’s narrative of forced sterilization of women of Color in the Caribbean and women with disabilities in the US. Knowing these facts and choosing to work in a field that has such a troubling history, I considered myself an educated consumer when it came to birth control and contraceptive options. When I found a steady sexual partner I decided to look into getting and IUD, the only method outside of condom use that I knew was for me.

As someone who has the privilege of having health insurance in the U.S., I made an appointment to see my private physician. At the time I was employed fulltime and was insured via the union of which I was a member. We had pretty good health care, or so I thought, as I rarely had to pay out of pocket for seeing a physician or for prescriptions. I met with him and I shared that I was interested in the IUD. He informed me that my insurance did not cover the IUDs (there are twp available in the U.S., a ParaGard which can be used for up to 10 years, and a Mirena which can be used up to five years and has hormones). I asked him what methods were covered by my insurance and he said all hormonal methods (besides the hormonal IUD) and sterilization.

I was in shock.

I told my doctor that we would need to talk further about my options and how much the IUD would cost out of pocket. He shared the IUD would be about $600 for insertion and for the actual IUD (apparently they are two different costs). I asked about sterilization and he shared that I had two options: a “traditional” tubal ligation which would require an overnight stay in a hospital and follow up appointments or a newer form of tubal ligation which is outpatient surgery called Essure. If I chose Essure I would have to also choose a hormonal birth control method to use as back up for three months. He also told me about the risks involved and the 30-day waiting period required for me to be sterilized.

As someone who knew the IUD would, basically, instantly work I was not too happy with these options. My physician and I continued to talk and he told me that before he would agree to perform any sterilization procedure on me that I would have to “prove to him I really wanted to be sterilized” because I had never been pregnant, was 28 years old, and he wanted to make sure I wouldn’t “regret” the decision. My response to his statement was honest, but it may have come off as me being flip. I asked him “how am I to prove to you I don’t want to be a parent?” I proceeded to share with him that I was not interested in pregnancy, childbearing, or parenting an infant child. I also shared that I was more committed to helping youth of Color age safely and successfully out of the child welfare system than I was to having a biological child.

What finally convinced him was when I told him that if I did decide to have a child I would come to him for fertility treatment. I signed the 30-day waiting period form for sterilization and made the decision to call my health insurance and ask how much of the $600 fee they would cover, if at all. To my surprise my health insurance said they would only cover $180 of my IUD. I asked how is it possible that they would cover 100 percent a tubal ligation which includes overnight stay in a hospital, general anesthesia (which has its own separate risks), antibiotics, and follow up examinations when an IUD, which takes less than 10 minutes to insert usually, costs significantly less, yet they do not cover in full. My insurance company said I could “appeal” their decision. When I asked how long that would take they said up to eight weeks (if that). I told the woman on the telephone that I did not want to be worried about my method eight weeks from now. I wanted the method sooner rather than later.

It made no sense to me. It still doesn’t make sense to me. How can we live in a country where we talk about “choice” and where anti-choicers love to say: “you should have used a method” or “been responsible” when people who are being as responsible as they can be cannot access the method of their choice? How was my choice to decide what went into my body and what affected me (and who got money based on my care) gone?

After some research I found a city hospital that agreed to insert the IUD for me for free as they had federal funding. I was at a hospital that worked with many sex workers and young women of Color in helping them maintain their reproductive and sexual health. It was the best place for me to get this method and I was extremely excited. I never thought I’d be as excited as I was. Perhaps that excitement stemmed from “getting over” on the insurance companies, or that I knew I was getting the method I always wanted, it felt good. My physician asked me if I minded having a resident sit in so they could watch the IUD insertion. I agreed and after 10 minutes I had the method of my choice and was instantly relieved at having one of the oldest methods, with the most longitudinal studies, and highest effectiveness rate.

To say the IUD has rocked my world is an understatement. There were some side effects that I was told about, but was not completely ready for, such as bleeding within the first two months, and difficulty feeling the thread to check the IUD after my menstrual cycle. I had never had to prepare or “clean up” the way I learned to the first several months of IUD insertion. At the same time I found it almost impossible to find and feel the thread of my IUD through my vaginal canal. However, my partner did confirm the thread was there, and also claimed to have “felt” the thread but it was not painful.

The Newsweek article presents the opinion of several doctors and researchers and their positions on providing the IUD to patients. The only doctor of Color mentioned, Dr. Hilda Hutcherson, is cautious about offering the IUD to younger patients because of what can happen if someone has an IUD and contracts an STI. She makes connections between IUDs, STI infection and how the two together can amplify infertility if the STI is untreated and that “fertility is really important.” That is true, if someone wanted to become pregnant. I understand this position, and realize that the IUD only prevents pregnancy not an STI, as every other hormonal method. We also know that infertility may be the result of many untreated STIs. What I’m not in agreement with some doctors completely against the method (which is different from being cautious about it) is that restricting our choices is not the most effective way to be a provider to a patient.

Have we not learned from what happens when patients are not given all of their options? Not told of all of the possible outcomes of a method? The idea that women have options when they choose to be responsible is very much an illusion for many. The idea that sterilization is no longer an option that doctors push for some women, especially as a woman of Color, and a Puerto Rican woman, seems difficult to believe from my personal experience.

Earlier this year I went to a book release event for Dr. Iris Lopez’s recent text: Matters of Choice: Puerto Rican Women’s Struggle For Reproductive Choice, which follows three generations of Puerto Rican women over 25 years who have decided on sterilization as their birth control method. Her findings are fascinating and I encourage readers to engage with the text beyond this article. Dr. Lopez provides readers the opportunity to hear Puerto Rican women share their own testimonies about why they chose sterilization, and their choices challenge how I view sterilization as well. Although I considered sterilization, I didn’t want to have to go through the procedure. The discussions of feeling liberated by some participants opens up dialogue about power, modes of survival for women in abusive and/or violent relationships, and “traditional” US ideologies around “liberation” and what liberatory sexuality means.

I’m excited to see the IUD becoming more popular. I also think it may be a useful long-term method for people who may need it the most. In comparison to other hormonal methods for young women, I think the IUD can be a realistic option. Not only do some hormonal methods take a while to work (about 30 days is the “safe” window period often mentioned for hormones to become effective), they can also alter the menstrual cycle of many young women.

For some of the young women I’ve counseled continuing to menstruate was essential to their ability to use a method while feeling safe in their home where parents and/or guardians monitor their cycle. For young people who are not comfortable touching their genitals (think using the NuvaRing), want a menstrual cycle (so Depo-Provera is not an option), don’t want a method others can see (such as the patch, which only comes in 1 color, a perfect example of the normalization of Whiteness and light skin in our society and around the world in reproductive and sexual health), that they have to remember each day (oral birth control pills,), or that can be checked discreetly by a physician (vaginal sonogram) if a parent/guardian remains in the exam room during a gynecological exam (this happens a lot more than some people might want to admit). I see the IUD as an option for transgender men as well, the discretion based on who their partners are is one that I may add a new understanding of safety and security to a community often exclude when discussing contraceptives and birth control options.

Even though the FDA has approved the IUD for all ages, there remain challenges even in obtaining information. Earlier this week my homegirl, reproductive justice activist and college student Bianca M. Velez shared on twitter: “When asking for a pamphlet of further info re: ParaGard on the website, it asks if the reader is 18 or older.” How accessible did you think IUDs were?