Well, Actually is a weekly column by Slate’s Shannon Palus. Each week, she’ll test health and wellness products to help readers figure out what they should try, what they should skip, and why.
You can order anything online these days—including, it turns out, hormonal birth control. In the past few years, some dozen options for buying the pill without the need to sit in a cold exam room have popped up. Among them are Hers, with ads that look like they could be for a trendy clothing company; Nurx, which also offers patches, rings, and shots, which you can apparently administer yourself; and the Pill Club, which sends chocolate, stickers, and samples along with meds. At first blush, they all strike me as pill mill outfits meets Birchbox beauty sample subscriptions—which is to say, the whole thing feels a little weird.
The sketchy patina is not helped by the suite of other medicines now sold through slick direct-to-consumer interfaces. Along with birth control, Hers offers prescription anxiety medication for public speaking and prescription “female Viagra,” along with skin and hair care products boasting specialized active ingredients. Sibling site Hims offers pills for erectile dysfunction and male-pattern baldness. Other companies include Roman, which sells ED meds; Kick, which sells propranolol, a beta-blocker; and Keeps, which sells potions for hair loss.
In all of these cases, acquiring a prescription seems to go in the wrong order: You select your meds and then do a consultation with a doctor. In many cases, you don’t even have to speak to a doctor; a medical professional will just review the information you’ve provided on blood pressure and family history before approving your purchase. This allows the doctor consultations to cost just a few bucks or nothing at all. The setup feels more akin to shopping than health care. “It’s restaurant-menu medicine,” Arthur Caplan, a bioethicist at New York University told the New York Times in a piece on the trend. Writing on Undark, medical student Vishal Khetpal was critical of these companies as well, questioning “whether direct-to-consumer medicine is truly safe for patients.” Performance jitters onstage or penis problems in bed can be symptoms of other problems; an old-fashioned and open-ended conversation with a pro can better help you untangle exactly what all is going on and how to treat it.
How is this allowed? Laws around telemedicine are young, often vague, and vary from state to state. That means these companies are creating questions that states and professional societies will eventually have to hash out, just as Uber and Lyft did with transportation (as this is all shaking out, many of the companies only operate in a smattering of states). But my question is simple: Since it currently seems that you can order birth control on the internet, should you?
As a human who ovulates and dates, I find the birth control offerings most intriguing—and in my opinion, birth control is in a different ethical order from some of the other medicines. So I set out to find out if, medically speaking, it’s a good idea to buy it online. In the course of speaking to two OB-GYNs and one reproductive health researcher and consulting a slew of papers, I found that if you are interested in taking the pill and in good health—yes. Buy the pill on the internet.
Birth control access has long been tough in the U.S. A mere century ago, it was an actual crime for doctors to even mail contraception (back then, diaphragms) across state lines. When the pill was rolled out in 1957, it was first only approved by the Food and Drug Administration as a medicine for severe menstrual disorders. Even as its uses have obviously expanded, today, about a third of women who have tried to get access to prescription birth control have faced barriers of some kind, according to a 2016 study co-authored by Kate Grindlay Kelly, a researcher at Ibis Reproductive Health, a nonprofit focused on advancing sexual autonomy. Chief among these pill barriers are cost, difficulty getting an appointment, getting to that appointment, and the fact that an appointment might require other screenings—which, in turn, can cost more in time, money, and discomfort. The study’s survey was completed before the Affordable Care Act, which requires most plans to cover birth control with no out-of-pocket cost, but the health care legislation still doesn’t help you navigate the sea of confusion around finding a doctor who takes your insurance in the first place—to say nothing of finding one who would be able to fit you in on your lunch break.
Birth control is a critical way for many women to manage their menstruation and reproductive health. The pill has been around for decades without causing any major health issues, and the current iterations use low doses of hormones that cause fewer bothersome side effects compared with earlier versions. It sure would be great if women didn’t have to shuttle themselves to a doctor (or, in a few states, a pharmacist) to get it. The price of buying the pill online varies depending on the company and your insurance, but it’s pretty cheap—Hers, which doesn’t accept insurance, sells it for $30 a month, while the Pill Club sells it for as little as $7 a month after your $15 consult (that’s also without insurance; insurance will often lower the cost to “free”).
Doctors themselves have been clamoring for freer access for decades. They often point to the much more dangerous alternatives that are much more available to people to buy. A 1993 editorial in the American Journal of Public Health illustrates just how weird it is that we can’t buy the pill without permission: “Cigarettes, which are readily available even to children, kill over a thousand persons each day,” OB-GYN David A. Grimes wrote all those years ago. Plus, the thing contraception aims to prevent—unwanted pregnancy—actually does have a proven track record of upending women’s lives and threatening their health.
“We sell all kinds of things over the counter that have risks, and people are adults,” points out Jen Gunter, a San Francisco–based OB-GYN and author of the forthcoming Vagina Bible. “I mean, aspirin?” (Aspirin, which comes with a small risk of bleeding for some people if taken daily, is allowed over the counter, and we all manage just fine.) “Birth control is really quite safe.” It seems like medicine because it’s been medicalized, but it’s important to remember that when used to prevent pregnancy, it’s not treating anything that might require more scrutiny, in the way ED or anxiety meds are. Being able to get pregnant isn’t an illness; it’s a human condition.
“An over-the-counter birth control pill is long overdue in the United States,” says Grindlay Kelly, who leads the Free the Pill Campaign, an effort to make the pill available without a doctor. Grindlay Kelly’s research suggests a third of women currently using no contraception or less effective contraception said they were likely to take the pill if it were available over the counter. In a study of over 1,000 women in El Paso, Texas, those who got the pill over the counter from a Mexican pharmacy—Mexico is one of over a hundred countries where the pill is already available sans doctor—were more likely to continue taking it compared with those who got it via prescription in the States.
Unfortunately, whether or not the pill becomes over-the-counter accessible does not depend on what would serve the best interests of women, but on whether companies are willing to put their corporate energies behind the task. In order to sell the pill over the counter, a drug company has to get approval from the FDA for the drug and particular packaging; it’s not enough to show that the pill has been safely deployed without a prescription to millions of women around the globe. That means doing (and paying for) studies to show that women can read and interpret the company’s specific packaging for the pill to determine if they have any conditions that would clash with the meds (like blood clots and breast cancer), and then take the pill correctly. Ibis is partnering with one pharmaceutical company doing this research, but it could be years before you can walk into a CVS and grab it off the shelf.
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Which brings us back to the websites. Grindlay Kelly and her team noticed them popping up and did a study to examine their prescribing practices, pretending to be patients with various conditions and seeing if they were effectively counseled against the meds. Her team found that the nine options available as of February 2018, including the Pill Club, Planned Parenthood Direct, and Nurx, all asked the right questions about blood pressure and family history (though in a few instances, some overlooked some relevant questions, like if the patient would have a major surgery soon after starting the pill). Free the Pill breaks down the 13 quick-prescription websites that are currently offering the pill in a very useful chart, which notes the states each company serves and whether they take insurance. It may not be as accessible as over-the-counter birth control, but it’s an improvement that stands to help people who might not otherwise be on birth control. Pill Club founder Nick Chang told me via email that half of the company’s customers are getting a prescription for birth control for the first time.
I tried going through the process at a few different sites myself, ultimately placing an order with the Pill Club because of the aforementioned stickers and chocolate. The survey even asked if I would like some Plan B and female condoms thrown in, provided they are covered by my insurance. Sure! A few minutes later, I got a lengthy text message running down the potential side effects and an offer to speak to the medical team (I was not required to reply, but when I did one evening several days later, I got a response early the next business day). “This concludes your medical visit,” the text said. It’s strange. But it works: When the pills arrive a week later in a pink envelope, the instructions even note to skip the placebo week, sparing me from my period as I had indicated I’d like on the questionnaire. It makes me think this just might be a step toward an even easier future.