Clinic escorts at a Washington, D.C. Planned Parenthood. Photo: Bruno Sanchez-Andrade Nuño via Flickr

Serving as the medical director of a reproductive health clinic made Dr. George Tiller a lightning rod for constant vitriol — and more than once a target of violence. Picketers routinely gathered outside his clinic in Wichita, Kansas, a site of their protests because it provided abortions, including late-term abortions. In 1986, Tiller saw the clinic firebombed. Seven years later, in 1993, he suffered bullet wounds to his arms when an anti-abortion extremist fired on him outside the property. Finally, in 2009, he was fatally shot while attending worship services at a Wichita church.

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Anti-abortion extremists can create life-threatening scenarios for those who seek reproductive health care.

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In the wake of Dr. Tiller’s death, many reproductive rights advocates argued that his assassination could have been avoided. The shooting was not the first time his murderer, 51-year-old Scott Roeder, broke the law.

Roeder could have been stopped prior to the shooting under a federal law, the Freedom of Access to Clinic Entrances (FACE) Act, which was enacted in 1994 — 19 years ago this Sunday — to protect the exercise of reproductive health choices. The FACE Act makes it a federal crime to intimidate or injure a person who is trying to access a reproductive health clinic. It also makes it unlawful to vandalize or otherwise intentionally damage a facility that provides reproductive health care.

Roeder’s ideology was the root of his criminality. Roeder subscribed to a magazine, Prayer and Action News, that posited that killing abortion providers was “justifiable homicide.” Roeder also had ties to a right-wing extremist movement that claimed exemption from U.S. laws and the legal system. Members of the same movement had been involved in a three-month standoff with the FBI in 1996.

Roeder’s extremism, though, didn’t stop at his views. Prior to murdering Dr. Tiller, he had threatened another abortion provider and vandalized both a Kansas City clinic and Dr. Tiller’s clinic. In 2007, someone identifying himself as Scott Roeder posted a message online that advocated confronting Dr. Tiller at his place of worship, Reformation Lutheran Church — the place where Roeder later carried out his assassination.

The FACE Act was enacted under the Clinton administration in response to mounting violence against reproductive health care providers in the 1980s and 1990s. The law, which allows both civil and criminal prosecution of violators, helped end an escalation of violence that had reached an unprecedented height with the 1993 murder of Dr. David Gunn, a physician and abortion provider who was shot to death at an anti-abortion rally in Pensacola, Florida. Upon signing the FACE Act into law, Bill Clinton stated, “We simply cannot — we must not — continue to allow the attacks, the incidents of arson, the campaigns of intimidation upon law-abiding citizens that [have] given rise to this law.”

The FACE Act was used aggressively during Clinton’s presidency. His administration prosecuted 17 defendants under the law in 1997 alone, and an average of 10 per year since the law was enacted. But in the years immediately prior to Dr. Tiller’s murder, under the George W. Bush administration, the legal climate had changed. “[W]e’ve heard that providers during that time would call [the Department of Justice] for help and get no response,” commented Janet Crepps of the Center for Reproductive Rights.

According to Daphne Eviatar of Human Rights First, “under the Bush administration, criminal enforcement of the [FACE Act] had declined by more than 75 percent.” The drop-off in prosecutions wasn’t due to a lack of need. The National Abortion Federation, which compiles data on violence and disruption against abortion providers, documented more than 3,000 incidents of violence in the United States and Canada from 2000 to 2008. (Data for the United States alone is not available.) Reproductive rights advocates reported roughly the same number of incidents in the two decades prior to George W. Bush’s presidency.

The department’s inaction against violators of the FACE Act can be explained by its makeup during the Bush years. As Eviatar reported in the last weeks of the Bush administration, “internal government reports and congressional hearings have documented [that] the Bush Justice Department over the last eight years expelled or ignored attorneys that it didn’t agree with and replaced them with inexperienced lawyers hired more for their ideology than their qualifications.” The Bush Justice Department had disqualified potential new hires if they had “liberal affiliations” — including connections to civil rights groups. Predictably, civil rights enforcement suffered, along with protection of patients and health care providers under the FACE Act. Thus, when Barack Obama took office in 2009, he inherited a Department of Justice staffed with people who lacked the will — and, in some cases, even the know-how — to enforce the FACE Act.

Faced with that legacy of hiring decisions, at the same time Obama was faced with the need to implement a tougher stance against anti-abortion extremists. After the murder of Dr. Tiller on May 31, 2009, just five months into Obama’s presidency, enforcement of the FACE Act became a renewed priority. The Civil Rights Division of the Obama Justice Department pursued eight civil cases and six criminal cases under the FACE Act by the end of 2011. Some of the civil cases, according to the Associated Press, included “a woman who blocked a car from entering a clinic in West Palm Beach, Fla.; a Texas man who threw his body across the door of a patient waiting area in San Antonio; and a Pennsylvania man who posted on the Internet the names and addresses of abortion providers and extolled his readers to kill them.”

Last month provided an ominous reminder of the need for continued vigilance. A new women’s health clinic, South Wind Women’s Center, opened in the same facility as Dr. Tiller’s former clinic. Anti-abortion extremists have already targeted the clinic — and its director, Julie Burkhart — with harassment and death threats. Burkhart, a former colleague of Tiller, filed a stalking protection order after one extremist appeared at her home with a sign reading “Where’s Your Church,” alluding to the circumstances of Tiller’s death.

To continue protecting patients and providers, the FACE Act will need the kind of vigorous enforcement it has seen under Clinton and Obama. But some argue that the law itself needs careful revision, including stiffer penalties for violators. When the Government Accountability Office surveyed U.S. Attorney offices, respondents pointed to a need for “stiffer treatment under other applicable statutes.” Some respondents also saw a need for clarification over jurisdiction and the role of local authorities.

To complement the federal law, California, New York, and Washington have passed state versions of the FACE Act, and other states have passed laws that deal more generally with harassment at health care facilities.

In Arizona, however, a new senate bill challenges protections for people seeking reproductive health care services. In March, conservative lawmakers introduced a strike-everything amendment to Senate Bill 1178, which would require “strict scrutiny” before legal action could be taken against anyone claiming religious freedom. As the Arizona Republic reported, “The legislation was … given a hearing on one of the last days allowed for public hearings of bills. No one showed up to testify against it and civil rights groups were left scrambling to figure out what it actually does.”

Anti-abortion groups have long claimed that the FACE Act violates their religious rights, so although the bill doesn’t specifically protect them, the broad protections it does promise could draw their attention — and galvanize them into action. Commenting on the bill, the ACLU of Arizona’s Anjali Abraham said, “What you’re doing is creating an entirely new path for people to sidestep laws they don’t like by claiming religious freedom.”

Even when they stop short of violence, the actions of anti-abortion extremists can create life-threatening scenarios for women who seek reproductive health care. They can prevent or deter women from seeking the care they need — or send them toward unsafe providers. When the story of Kermit Gosnell and his illegal medical practices broke two years ago, a question it immediately spawned was what drove women to seek his services, most notoriously the abortion services that led to multiple murder charges — and convictions — in a two-month trial that ended last week.

One patient who underwent an abortion at Gosnell’s clinic explained that she had first sought services at a Planned Parenthood health center in downtown Philadelphia, only to be scared away by the protesters outside: “The picketers out there, they just scared me half to death.” After entering Gosnell’s clinic, she says she immediately changed her mind when she saw another patient who was disoriented and surrounded by blood, but Gosnell allegedly restrained her and proceeded with the abortion.

Protecting patients and providers is necessary not just for those under fire by extremists, but for virtually everyone. The fear that threats and violence induce isn’t confined to those directly targeted, and when that fear influences the career choices of providers and the personal choices of patients, health care suffers. Costs increase when facilities require repair, higher insurance, or increased security after vandalism or other attacks. Threats also impact the availability of services. The Guttmacher Institute, a research organization focused on reproductive health issues, reports that only 2 percent of abortion providers offer late-term abortions, the service most intensely targeted by anti-abortion extremists.

One of those providers offering late-term abortions was Dr. Tiller’s clinic, which provided abortions past the 25th week of pregnancy. The new clinic opening in its space, according to its director Julie Burkhart, will not provide abortions past the 14th week of pregnancy.

Phoenix Gay Pride Parade, 2010. Photo: Fritz Liess via Flickr

I’m certain everyone read yesterday’s post on the International Day Against Homophobia and Transphobia (that’s today) and thought, “I’m so glad I live in Arizona, where the state legislature and judiciary would never further oppress an already marginalized group of people!”

Right?

Right?

Of course, the reality is that even recent Arizona lawmakers have established a trend of creating legislation that further harms women, people of color, and poor people. Sadly, we can add gay people and trans* people to that list as well.

Adoption Law — While the state’s current adoption statute allows unmarried people, regardless of sexual orientation or gender identity, to petition to adopt, only a “husband and wife” may jointly adopt children. It does not provide for joint adoption by people in other domestic partnerships. In fact, if other factors are equal, current law gives explicit placement preference to “a married man and woman.” Moreover, additional legislation has been introduced at least twice — once in 2006 and once in 2010 — to attempt to require adoption agencies to give “primary consideration” to married couples seeking to adopt.

Speaking of Marriage — Queer folk can’t do that here. If they do get married in a place where the local legislation allows it, the state of Arizona won’t recognize the marriage.

Birth Certificates — The statute does allow for an amended birth certificate if the person applying for such has had “a sex change operation” (sex reassignment surgery) and a note from their doctor saying as much. Certainly this is preferable to not having the option. However, it ignores some of the realities of sex reassignment surgery — that it can actually be a number of surgeries, that it comes with risks (e.g., general anesthetic) that can make it unworkable for some people, that it’s expensive and generally not covered by insurance, that providers are few and far between. Additionally, a birth certificate is one of the most common primary forms of identification for obtaining an Arizona driver’s license or state identification card — and it can be critical for individuals to have ID that matches their gender presentation, even if sex reassignment surgery has not been completed (if it’s even something the individual wants in the first place).

Hate Crimes — While “gender” is included in Arizona’s delineation of what constitutes a hate crime, “gender identity” is not. In practice, this means that the state collects data about crimes that “manifest evidence of prejudice” toward women — but not on crimes that manifest evidence of prejudice toward trans* people, whether those people are also women or not.

Health Care Decisions — Arizona law does allow domestic partners to act as health care surrogates for people who may be incapacitated or otherwise unable to make those decisions for themselves. However, unless the patient has created an advance health care directive (such as a living will or other document specifying health care power of attorney), the statutory default gives priority to spouses, adult children, and parents.

Other Discrimination — Arizona prohibits discrimination based on sexual orientation in public employment only. It does not ban discrimination in private employment, nor does it ban public employment discrimination based on gender expression or identity. In fact, everyone’s favorite representative, John Kavanagh, has recently introduced a gutted and reworded SB 1045, which would prohibit state municipalities from passing anti-discrimination legislation to protect transgender people. Because, um, the “bathroom bill” was not a sufficiently hateful and extreme edition?

These issues are a big deal. The presence of harmful legislation and absence of protective legislation interfere with people’s rights to create and safeguard families, to receive the most appropriate medical care, to seek employment free from discrimination, and to live their lives free from harassment.

Sadly, I’m sure that a substantial portion of private groups and individuals will continue to display anti-trans and anti-gay prejudices and actions for the foreseeable future. Changing legislation will not always change minds. However, changing legislation would provide some recourse for some victims of such marginalization. At the very least, it would not perpetuate intolerance and hate.

That’s tomorrow — May 17.

The International Day Against Homophobia and Transphobia.

Homophobia and transphobia — or rather, anti-gay and anti-trans thoughts, words, and actions — are deeply rooted in many cultures, including inside the United States. In reality, they need far more than one day of discussion and recognition. One day is not enough.

When I started thinking about this post, I thought of all the ways such sentiments show up in everyday life. It’s so much that I couldn’t possibly write everything. Then I thought some more — this was when Arizona SB1432, the “show your papers to pee” bill, was topping my newsfeeds — and it occurred to me how very much of this discrimination has been coded into law, is being encoded into law even now.

Even then, I had to narrow my search parameters — to the United States, to the relatively recent past. Otherwise, it’s just too much.

And even then, a lot of the bias remains in what’s not covered — people and situations for which the law does not provide. For groups of people who are still discriminated against, harassed, threatened, assaulted, killed by individual citizens or private organizations — this lack of necessary legislation still causes active harm.

This first set examines a number of laws — some national, some state — and Supreme Court rulings from the recent past.

1960 — Is as good a place to start as any. This is because in 1960, every state in the United States maintained laws against sodomy. Illinois was the first state to repeal its statute in 1961; Arizona followed suit 40 years later.

1967 — In Boutilier v. Immigration and Naturalization Service, the United States Supreme Court held that gay folk were included under those “afflicted with psychopathic personality.” They could thus be refused admission — or deported — simply for being gay. This remained in effect until immigration law was reformed in 1990.

1974 — Kentucky enacted an anti-sodomy law that explicitly targeted same-sex encounters. That is, oral or anal sex with a person of a different sex was legal; oral or anal sex with a person of the same sex was a crime. Additionally, since the law did not mention how “sex” was defined, it added an extra layer of uncertainty for gender-nonconforming individuals. The law was struck down in 1992.

1977 — Arkansas enacted a similar sex-specific anti-sodomy law that had the charming bonus of likening same-sex oral and anal sex to bestiality. It was overturned in 2002.

1986 — In Bowers v. Hardwick, the Supreme Court — a post-Griswold, post-Eisenstadt, post-Roe court — held that the right to privacy did not extend to the sex in which same-sex couples engaged in their own bedrooms. The decision in Lawrence v. Texas overturned Bowers v. Hardwick in 2003. At that time, 14 states still criminalized oral and/or anal sex between same-sex partners.

1996 — Congress passed the Defense of Marriage Act (because, you know, there’s a gay war on marriage — or something), which prohibits the federal government from recognizing same-sex marriages and the benefits that would be accorded to them. The U.S. Supreme Court is currently deciding the constitutionality of this law.

2012 — Representative John Ragan introduced a bill into the Tennessee legislature that would have made it illegal for elementary and middle school teachers to discuss sexual activity not “related to natural human reproduction” — which would have effectively banned discussion of non-straight sexual attractions or orientations. The infamous “Don’t Say Gay” bill died in the 2012 legislative session, only to be resurrected in 2013. The new, unimproved version of the bill would require school personnel to inform the parents of students they think might be gay, regardless of whether the students wanted their parents to know. Fortunately, the bill never made it out of committee this year.

Although many of these laws — this list, by the way, is not exhaustive — have been repealed, they help demonstrate that many LGBTQ people have lived substantial portions of their lives in a United States where the government has been actively hostile to their rights and to their very humanity. Many of the judges who ruled in these decisions still sit on their bench. Many legislators who enacted these statutes still hold office. Many of the people who first put them there still vote.

Tomorrow, we’ll be looking at current and proposed Arizona statutes and bills.

Gregory Pincus, Min-Chueh Chang, and John Rock were hired by Margaret Sanger and Katharine McCormick to develop the birth control pill.

Welcome to the fifth installment of our series chronicling the history of the birth control pill. In the previous installment, Margaret Sanger and Katharine McCormick envisioned and bankrolled the development of the birth control pill. Now it had to be tested in large-scale trials.

John Rock, Gregory Pincus, and Min-Chueh Chang had collaborated in the Pill’s development; now it was time to conduct clinical trials. The first study observed 60 women, some of whom were infertility patients while others were nurses. These small trials involved daily temperature readings, vaginal smears, and urine samples, as well as monthly endometrial biopsies. Although the initial results seemed promising, the sample size was small and few of the subjects complied with the protocol.

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The approval of the Pill in 1960 marked a turning point in our history.

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More test subjects were needed. At this point, historians’ accounts differ. Elaine Tyler May claims that, unable to locate an acceptable pool of volunteers, the researchers tested the Pill on subjects who could not give their consent, such as psychiatric patients. According to Bernard Asbell, however, Rock was scrupulous when it came to informed consent, despite it not being a legal requirement — or even much of a concept at all at this time in history.

Willing participants notwithstanding, conducting such trials in the United States posed a challenge, due to laws against contraception. So the first large-scale clinical trials were conducted in Puerto Rico in 1956. Puerto Rico was densely populated and there was a high demand for alternatives to permanent sterilization, which was widespread on the island due to funding from a wealthy eugenicist named Clarence Gamble, who advocated sterilization for the world’s poor. The clinical trials in Puerto Rico were conducted by Drs. Edris Rice-Wray and Adaline Sattherthwaite; the brand of birth control pill tested was named Enovid. Volunteers were so easy to come by that some clinics had waiting lists.

Test subjects’ health was meticulously monitored. Side effects included nausea, headaches, and dizziness, reported by 17 percent of volunteers. Rice-Wray considered these side effects to be unacceptable, even though the Pill proved completely effective in preventing pregnancy. Rock and Pincus, however, did not think these symptoms were alarming — Pincus, for his part, claimed that they were psychosomatic. In any case, the side effects may have been responsible for many subjects dropping out of the study, always a problem in clinical trials. According to May, others dropped out of the study under pressure from “priests and disapproving husbands,” and there was some concern that “Nordic whites” were using “the colored races as ‘guinea pigs.’”

In 1956, data on 221 subjects had been collected. The report stated, “Enovid gives one hundred percent protection against pregnancy in 10-milligram doses taken for twenty days each month … However, it causes too many side reactions to be acceptable generally.” Rock wondered if the side effects were actually nocebo effects — a phenomenon in which the expectation to experience side effects makes a subject more likely to notice or experience these side effects. A placebo-controlled trial seemed to confirm this, as 17 percent of subjects in the placebo group reported side effects, compared to the 6 percent of subjects who experienced side effects in an experimental group to whom no warning about side effects was given. It is interesting that being given advance warning of possible side effects correlated with an increased chance of experiencing these side effects, and shows how our expectations can shape our experiences.

Test groups were composed of mothers who were for the most part less than 40 years of age, and those who took the Pill as instructed did not get pregnant. After a propaganda campaign by a Catholic group, 10 percent of subjects dropped out of the study, and all of them became pregnant soon after. These dropouts were tracked, and their subsequent babies were examined to ensure that earlier use of the Pill did not have consequences for offspring. The sex ratio was evenly divided between male and female, and infant health was fine.

All told, the trials spanned three countries with more than 20,000 test subjects. Clinical trials in Puerto Rico and Haiti saw 1.7 pregnancies for every 100 women per year. Another field trial in Mexico City reported a failure rate of 0.6. In 1957, the Pill was approved as a treatment for “various gynecological disorders” (such as infertility and menstrual disorders), after which its developers sought to have it approved as a contraceptive.

The FDA began to investigate the Pill’s safety. While most physicians surveyed found the Pill to be “safe and effective for short-term use in treating gynecological problems,” there were some dissenters, including Dr. Edward Tyler, a researcher and head of the Planned Parenthood Clinic in Los Angeles. He was concerned about the Pill’s safety, as the side effects had been, in his experience, often severe: abnormal bleeding, weight gain, fluid retention, and more. In 1958, an FDA official heard Tyler’s concerns at a meeting. Because Tyler was considered to be a more neutral source than either Rock or Pincus, his concerns were given a lot of weight, and the approval process was slowed.

Eventually, however, in 1960 the Pill was approved as a contraceptive. Due to lingering concerns about the safety of long-term use, prescriptions were limited to two years. But 1960 marked an incredible turning point in our history — able to control their reproductive destinies, people with uteruses could choose their family sizes, choose not to have children at all, and have easier access to higher education and find futures in the labor force. Truly, thank goodness for the Pill!

Stay tuned for the next installment of this series, in which we learn about the people whose invisible labors provided the raw material for hormonal contraceptives. Mexican peasants were integral to the synthesis of progesterone, and some say they were exploited.

Becoming a mother is a wondrous event. It is also a lifelong commitment to another special human being, your child. To provide your new baby with the best start in life, taking care of yourself in your childbearing years is essential. When you think that half of all pregnancies in the United States each year are unintended, it’s very important to follow a healthy lifestyle every day to ensure a good pregnancy and a good start for your baby.

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Sunday is Mother’s Day. To those of you planning a pregnancy or hoping to be a mother someday, this is for you.

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The United States does not fare as well as many other industrialized countries when it comes to the health of its newborns. Preterm births and low birth-weight babies are often the result of unhealthy pregnancies and a lack of prenatal care. New information and research has given us lots of good information about what is important to do before and during your pregnancy to increase your chances of having a healthy baby. Having a plan about when you want to start a family and what you intend to do to get yourself in the best health possible is a good start. This is called preconception health care, and it can make a big difference in the well-being of you and your baby.

At Planned Parenthood Arizona, you can see us for preconception health checkups. In addition to pregnancy planning services and fertility awareness education, we provide other services that can help you be in the best health possible before you conceive. We offer physical exams as part of our general health care services. You also might be interested in STD screening, to ensure that you receive treatment before you become pregnant. Additionally, we offer smoking cessation, to help you quit smoking for a tobacco-free pregnancy.

Here are some guidelines for ensuring your preconception health:

1. Plan when you want to have a family and space your pregnancies. Be sure you are ready for the responsibility and expense of a child. If it’s not your first child, wait 18 to 24 months before having an additional child to allow your body to recover and prepare for another pregnancy.
2. Enter pregnancy as healthy as possible. This means eating healthfully and maintaining a healthy weight. Exercise regularly.
3. Make an appointment with your health care provider for a check-up. Treat and control any chronic health conditions, including sexually transmitted diseases. Learn your family history.
4. Don’t smoke. Don’t use alcohol excessively and never while you’re pregnant. Don’t use street drugs or recreational drugs. Any of these may harm your developing child. Talk with a doctor about medications you take regularly, because some medications may cause birth defects.
5. Take a prenatal vitamin daily that contains 400 micrograms of folic acid to prevent major birth defects. Take these vitamins for a month or more before you try to get pregnant and throughout your pregnancy.
6. Have your vaccinations up to date. Discuss these with a doctor.
7. Stay away from toxic substances such as bug sprays or other environmental substances that could harm your developing baby.
8. Stay emotionally and mentally healthy, and get treatment if you need help.
9. See a doctor throughout your pregnancy for checkups and prenatal care.

Even though people who were born male cannot get pregnant, they can also follow healthy practices so the child they father is as healthy as possible. These include:

• Prevent and treat sexually transmitted diseases.
• Stop smoking, using street drugs, and drinking alcohol excessively.
• Stay healthy mentally and get treatment for violence if needed.
• Support your partner.

Following these guidelines before you get pregnant is a good start to having a healthy baby someday. And then it will be a happy Mother’s Day for all!

Planned Parenthood health centers across the country can help you stay healthy and refer you to the resources you need when you decide to become a mother. Planned Parenthood Arizona also offers smoking cessation, and our Title X centers can provide you with prenatal vitamins if you qualify.

Should you stop taking your pills? What is a VTE and why should you worry? VTE is a blood clot that usually starts in your leg, but may break loose and travel to your heart or brain and cause a heart attack or stroke. It can be life-threatening, so it is a serious side effect to be concerned about. All birth control pills may increase your risk for a VTE, but it has always been considered so small that most women can safely take the pill. About 3 to 9 women in 10,000 who use birth control pills for more than one year may have a VTE compared to 1 in 5 women out of 10,000 who are not pregnant and not on the pill.

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Birth control pills are considered very safe for the majority of women, but all medications carry some risk of adverse effects.

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When oral birth control pills were first developed, they contained much higher doses of estrogens and progestins — types of hormones — especially estrogen. It was also noticed that there was a higher risk for developing a blood clot while using birth control pills than in nonpregnant women who didn’t take the pill. It was thought that the high dose of estrogen was responsible for this risk. So, with continuing research and development, eventually the dose of estrogen was decreased to the lower level used today to minimize the chance of a clot. The type of estrogen in pills today is almost exclusively ethinyl estradiol.

Over the years the other hormone in the pill, a progestin, was also studied, and different progestins were developed to lessen uncomfortable side effects linked to that group of hormones, such as bloating, acne, and mood changes. We now have third and fourth generation progesterone hormones that have decreased these side effects greatly. For example, drosperinone is the fourth generation of progestin developed.

However, the risk for blood clots seemed to go up with each new generation of progestin hormone developed. So studies were done, some good and reliable, others with too small a group of participants to be reliable, others with mixed results. Studies are still being done in the United States and in Europe to accurately assess the risk of clots with these new products, including the patch and vaginal ring. As a result of these studies, the Food and Drug Administration (FDA) decided in April 2012 to add a special warning about blood clot risk for contraceptives containing the hormone drosperinone, the hormone in Yaz, Yasmin, and some others. The general thought was that drosperionone increases the risk of a blood clot to 10 women in 10,000 taking contraceptives with drospirenone. That’s double the risk of other pills, but still a small percentage of all women.

Pregnancy also increases your risk of having a VTE — between 5 and 20 women in 10,000 may develop a blood clot during pregnancy. And after delivery, when hormones fluctuate greatly, that risk goes up to somewhere between 40 to 65 women per 10,000.

How do you decipher this information? First, it’s a good idea to know which hormones are in your birth control pill. A good list of contraceptives and their ingredients is available on Medline. Remember, all medications carry some risk of adverse effects. And birth control pills are still considered very safe for the majority of women. The American Congress of Obstetrics and Gynecology is even recommending that they be considered for purchase without a prescription to make contraception more available to women.

How can you decide what your risk is for taking or not taking a birth control pill? A few important suggestions have come from all these studies.

• It is widely recommended that women over 35 years of age who smoke should probably not use birth control pills. And, no matter your age, you should not smoke while taking any birth control pill. Sometimes your family history or your own health issues might make you a poor candidate for the Pill, and sometimes the risk of pregnancy can be more dangerous to your health than taking the Pill.
• People with polycystic ovary syndrome (PCOS) might have an even higher risk for blood clots while on the Pill, with blood clots diagnosed in 24 out of every 10,000 pill users with PCOS.
• Birth control pills are still an excellent choice for many women. It’s important that you discuss your health history and personal needs with your health care provider to decide what is right for you.

There are many contraceptive choices and many birth control pills that contain older formulations of hormones. There are implants, IUDs, and barrier methods. Planned Parenthood is able to help you find the best choice for you. Stop by your local Planned Parenthood health center for more information.

Click here to check out other installments of “Let’s Talk Contraception”!

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It’s common for STDs not to have symptoms, and infections can cause tissue damage — unbeknownst to you!

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Fertility can be impacted in several ways. The ability to become pregnant and bear children can be affected by a condition called pelvic inflammatory disease, which is usually caused by untreated gonorrhea or chlamydia infections. If you have a cervix, an infection with a high-risk strain of HPV can require invasive treatment, which in some cases might affect the ability to carry a pregnancy. If you have a penis, an untreated STD might lead to epididymitis, which in extreme cases can cause infertility.

Pelvic Inflammatory Disease (PID)

Many sexually transmitted infections are localized; for example, the bacteria that cause gonorrhea usually just hang out on the cervix. But untreated infections can spread on their own, and bacteria can also hitch a ride on sperm or the upward flow of a douche, which can take them into the cervix, through the uterus, down the fallopian tubes, and to the ovaries. At any of these locations, microbes can stake claim on your reproductive real estate, establishing colonies deep in your reproductive system. As these colonies grow, the bacterial infections become more widespread, and can cause scarring and other tissue damage. To keep these interlopers from getting through the front door, sexually active people can use barrier methods, such as latex condoms — especially with spermicides. There’s no need to host an open house for sexually transmitted bacteria in your uterus.

One result of a widespread STD, like chlamydia or gonorrhea, is pelvic inflammatory disease (PID), which can cause tissue damage to the uterus, cervix, fallopian tubes, ovaries, and other reproductive organs. About 10 percent of adults with this collection of reproductive organs suffer from PID at some point, and complications include infertility, ectopic pregnancy, and chronic pain. According to the Centers for Disease Control and Prevention, of the 750,000 annual cases of acute PID in the United States, up to 15 percent of these sufferers will become infertile as a result.

Cilia in fallopian tubes help transport eggs, but can be damaged by a gonorrhea infection. Image: Human Reproduction Update

The formation of scar tissue in the fallopian tubes can block the path that your eggs would otherwise be able to follow from your ovary to your uterus. A gonorrhea infection can also damage cilia, which are hairlike projections that help transport an egg down the fallopian tubes. Given such obstacles, it’s no surprise that PID increases risk for infertility or ectopic pregnancies. One large Swedish study found that the more often someone had PID, the greater their chances of infertility: One episode of acute PID led to an 8 percent infertility rate; two episodes led to a 19.5 percent infertility rate; three episodes led to a 40 percent infertility rate.

About 10 to 15 percent of the time, untreated chlamydia in females will progress to PID, possibly causing permanent damage to the fallopian tubes and uterus. If a gonorrhea infection progresses into PID, it can wreak similar havoc — in fact, before antibiotics, gonorrhea was incurable, and most ladies with gonorrhea saw their fertility affected as a result. Unfortunately, it’s very common not to experience symptoms of chlamydia or gonorrhea, so without regular STD screening, an infection can silently work its way up your reproductive tract, causing tissue damage that might not be reversible.

Cervical Cancer

The sexually transmitted virus human papillomavirus (HPV) can cause cervical cancer, but regular Pap testing usually catches it early enough to be treated before it can do significant harm. An abnormal Pap test might lead to colposcopy, with or without biopsy, which is more invasive than a Pap test but shouldn’t affect your ability to have children.

If your colposcopy results are abnormal, your health care provider might suggest followup procedures, including cryotherapy, loop electrosurgical excision procedure (LEEP), or a cone biopsy. Cryotherapy shouldn’t affect your fertility either, unless there is a very rare complication. LEEP might have some risks for future fertility, including increased chances of preterm birth. A cone biopsy can be performed either by LEEP or by treatment with a laser, and it comes with a few risks, including the possibility that your cervix will be unable to remain closed during pregnancy (incompetent cervix). It could also increase risk for miscarriage or preterm birth. Rarely, a cone biopsy can lead to infertility by causing narrowing of the cervix (cervical stenosis). In very rare cases, cervical cancer is treated by hysterectomy — the total removal of the uterus.

Luckily, there is now a vaccine (Gardasil) that can protect you from the strains of HPV that are together responsible for 70 percent of cervical cancers. Vaccination, the consistent use of latex condoms, limiting sex partners, and regular Pap testing can all combine to dramatically lower your risk of cervical cancer and invasive treatments that might compromise your fertility.

Epididymitis

Sometimes, an untreated STD can cause scarring that blocks sperm’s movement out of the testes, resulting in infertility. While this isn’t nearly as common (or as well studied) as other fertility-affecting conditions like pelvic inflammatory disease, it is a possibility.

An inflammation of the epididymis is called epididymitis. The epididymis is a tube that is connected to the testicle, and is where sperm are stored before ejaculation. When sperm enter the epididymis, they are “immature” — as they travel through the coiled tube, they gain the ability to swim. It is thought that epididymitis might affect sperm as they travel through the epididymis, possibly limiting their mobility and making them less able to swim toward an egg. It has also been shown that severe cases of epididymitis can cause enough scarring to block the sperm’s progress through the epididymis and the vas deferens (also called the ductus deferens). Lastly, it is postulated that acute epididymitis can affect sperm production.

An acute epididymitis case in which both testes have been affected (bilateral epididymitis) can lead to sterility in some. Chlamydia is the leading cause of epididymitis in heterosexuals 35 years old and younger, accounting for about 70 percent of epididymitis cases in that population. Because chlamydia is so often asymptomatic — half of men with chlamydia have no symptoms — it can be easy for an infection to spread undetected.

Planned Parenthood health centers offer STD screening, including urine tests for chlamydia and gonorrhea. If you are sexually active and have a cervix, we recommend regular Pap testing to catch cervical cancer before it starts. We also offer the preventive HPV vaccine, Gardasil, to decrease cervical-cancer risk. Furthermore, we can evaluate you for pelvic inflammatory disease or epipdidymitis. Finally, you can drop by any time to pick up condoms!

Click here to check out other installments of our monthly STD Awareness series!

This scanning electron micrograph from 1989 reveals HIV particles (colored green) emerging from an infected cell. Image: CDC’s C. Goldsmith, P. Feorino, E.L. Palmer, W.R. McManus

We’ve all heard various conspiracy theories; we may or may not find them credible, and we might chalk up opposing viewpoints to simple differences in opinion. Sometimes, however, conspiratorial narratives are woven around matters of life and death — and in such cases, the spread of such ideas can influence dangerous changes in behavior and even government policy.

AIDS denialism is based on the idea that human immunodeficiency virus (HIV) does not cause AIDS. Although the existence of HIV and its causal connection to AIDS has been thoroughly demonstrated by scientists, denialists either reject the existence of HIV altogether, or cast it as a harmless virus that doesn’t cause illness. Denialism often relies upon rhetorical strategies that are superficially convincing but intellectually hollow, including the cherry-picking of evidence, appeals to unreliable “experts,” and untestable claims. Denialists also might cite early AIDS research from the mid-1980s while ignoring more up-to-date findings and improved medical procedures. Such rhetoric creates a sense of legitimate debate in an area where there is none, and the only new evidence welcomed into the discourse is that which confirms preconceived notions.

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Health decisions must be shaped by the best available evidence, and when denialism misinforms, one cannot make an informed decision.

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If AIDS isn’t caused by HIV, what do denialists claim is behind the unique symptoms that characterize it? Some say that conditions such as malnutrition, or diseases that have been around for a long time, are simply being labeled as AIDS. Other denialists cast antiretroviral drugs as the cause, rather than the preventive treatment, of AIDS. Some claim that AIDS is caused by behavior, such as drug use or promiscuity — with some even saying that an accumulation of semen in the anus can cause AIDS. None of the claims is true — while AIDS can leave someone vulnerable to a wide variety of diseases, and while sharing IV equipment and engaging in unprotected sex can increase risk, there is only one cause: HIV.

Most denialists are not actual HIV experts — in fact, the only prominent denialist with a background in retroviruses (though not specifically with HIV) is Peter Duesberg, whose groundbreaking work with cancer-causing genes and retroviruses brought him fame in the 1970s. In the 1980s, however, when his views on HIV strayed ever further from scientific consensus, he became a pariah in the scientific community — a fact that fits perfectly into the “rebel” narrative that comes up so often in conspiracy theories. However, his claim that HIV does not cause AIDS, which rather is caused by drug use and other lifestyle factors, is not backed up by the huge body of evidence that scientists have amassed since the 1980s.

Such views become harmful when they are translated into advice: Denialists tend to downplay the importance of condoms and discourage HIV testing and the use of antiretrovirals. They often claim that life-saving antiretroviral drugs are toxic poisons, a Big Pharma conspiracy to rake in cash while killing innocents. Ironically, by fostering doubt in medicine and science, denialists create a market for dubious alternative treatments that allows them to rake in quite a bit of cash as well. Their customers’ suspicions toward mainstream medicine are often exploited by self-proclaimed “experts” selling disproven (and often expensive) alternative AIDS therapies, ranging from potions, herbs, and vitamins to electronic gadgets. These treatments are unevaluated for efficacy — and often ingredients are kept secret or are different from what is claimed (some contain industrial solvents, pesticides, and other harmful chemicals). And, if the promoter of these treatments insists that their product only works when antiretroviral therapies are discontinued, patients might put their health at risk.

One peddler of an alternative treatment, Matthias Rath, claims that HIV medicines are toxic and that his vitamins should be taken instead. He conducted unethical trials of his treatment in South Africa, and in 2008 was found guilty of unlawful human studies. Rath, in a pamphlet promoting his program, claimed that his vitamins were “safe because they are natural” (seemingly oblivious to many natural yet dangerous chemicals, such as ricin, strychnine, and arsenic). While a balanced diet is important for everyone, vitamin megadoses are not supported by good evidence, and Rath’s regimen was no exception.

Encouragement to forgo antiretroviral medication is most insidiously directed at pregnant people. When proper treatment is initiated early in pregnancy, there is less than a 2 percent chance of delivering a baby with HIV — compared to a 25 percent chance when HIV is not correctly managed. One tragic example lies in the case of Christine Maggiore, a prominent HIV-positive denialist who refused treatment during pregnancy and breastfed her baby. Eliza Jane was 3 years old when she succumbed to AIDS in 2005. The United States has seen a dramatic drop in pediatric HIV infections since the widespread use of antiretroviral medication and HIV screening during pregnancy. Maggiore, however, remained an outspoken denialist until her death in 2008. As an activist, she gained a fair amount of media attention, even promoting her views via a film whose publicity was aided by a Foo Fighters soundtrack.

Marginalized populations are a target for denialist ideas, as such communities might experience more widespread suspicion toward the medical establishment. In many cases, this wariness is understandable — the Tuskegee syphilis study is considered to have sown distrust toward medicine among many African Americans, and the deeply entrenched homophobia that marred mainstream psychiatry until relatively recently might render some in the LGBTQ community suspicious of medical authority. According to one large study, AIDS-related conspiracy theories are fairly widespread among African Americans, and the acceptance of denialist ideas has also been preliminarily documented among gay and bisexual men. Such beliefs might have an impact on a person’s sexual behaviors or likelihood to seek testing or treatment.

In the United States, the movement doesn’t have much political clout, but its key players have international influence. Denialism is at its deadliest when it infects public policy, as it most notoriously did in South Africa under the presidency of Thabo Mbeki. Mbeki’s policy was driven by his denialist minister of health, Manto Tshabalala-Msimang, and an AIDS advisory committee skewed by denialists like Duesberg, resulting in a ban on antiretrovirals in public hospitals. Evidence for antiretrovirals’ efficacy didn’t sway Tshabalala-Msimang, who recommended plant-based treatments such as lemon, potatoes, and garlic instead.

In South Africa, HIV rates skyrocketed from almost zero in the early 1990s to around 20 percent of the adult population in 2007 (even more grim, an estimated 1 in 3 women in the 25-to-29 age group is estimated to be HIV positive). By the time Mbeki resigned in 2008, 2.6 million South Africans had died of AIDS; Harvard researchers attributed 365,000 deaths to Mbeki’s policies. (The new president immediately fired Tshabalala-Msimang; South African AIDS policy is being modernized.)

Conspiracy theories that arise from suspicions toward science and medicine undermine prevention, screening, and treatment of disease. Whether this suspicion is aimed toward HIV medications, vaccines, cancer treatments, obstetrics, or other evidence-based medicine, the result is the same: Patients are disempowered from making decisions based on the most complete and reliable information. When denialism misinforms, one cannot make an informed decision. Freedom of choice and bodily autonomy aren’t worth as much when we fall prey to junk science and pseudoscience, myth and misinformation.

More information about AIDS denialism can be found at Science magazine’s website. Avert.org provides tips for spotting bogus HIV treatments. HIV testing can be obtained at any Planned Parenthood health center.