Op-Med is a collection of original articles contributed by Doximity members.
- The Trump Administration’s return to a failed Reagan-era “gag rule” at Title X facilities is part of a broader attack on women’s preventative and reproductive health that he has been waging for over a year.
- Ill-informed policy and funding shifts targeted at Title X programs, Teen Pregnancy Prevention Programs, and sexual education will increase the number of patients with preventable cancers, sexually transmitted disease, and unintended pregnancies in both teens and adults.
I opened a CT scan to reveal a massive tumor filling a woman’s pelvis in which I could not make out any normal structures like the uterus. The tumor was invading the back of the bladder and encircling the ureters causing a blockage which will hurt the kidneys if not treated promptly. When I glanced at the age of the patient, she was only 34 years old.
This is advanced cervical cancer. I have seen this many times over the years. Cervical cancer is a sexually transmitted disease caused by contracting the human papilloma virus (HPV) through unprotected sex with an infected individual. There were many steps along the way that could have prevented this diagnosis: a childhood immunization for HPV, barrier contraception, and early detection with a PAP smear. Prevention requires access to contraception, medically accurate information, and preventative health care services — all of which are being eroded under President Trump.
As a female physician, birth control, comprehensive sexual education, and preventative health care is something that I have almost taken for granted as a right throughout my lifetime, but I have seen this right being quietly, methodically eroded by the Trump-Pence Administration over the last year. This week Trump’s administration announced a plan for Title X changes to effectively cut Planned Parenthood funding.
The new guidelines for Title X are expected to require both “physical” and “financial” separation between entities that receive Title X funds and those that provide abortions. Title X funds cannot and have never been available for use for abortions at any facility, including Planned Parenthood, but this move will effectively defund the organization from being an efficient provider of a vast array of preventative health care services for women who receive health care at these clinics.
The Trump administration’s attack on women’s preventative health turns back the clock on women’s reproductive health: 1) from contraception to the rhythm method; 2) from comprehensive sexual education to abstinence-only sexual education; and 3) from comprehensive women’s preventative health care to a defunded, dismantled federal women’s health program. We should be past this point in American history and should strive to protect women’s access to medically accurate information and health care.
Through residency and early practice, I carefully planned the spacing and timing of my own three children around education, training, and career. This required consultation with my husband, my own doctor, and of course, contraception. I was fortunate. All women should be afforded the information and tools to plan the timing, spacing, and number of children they choose as a fundamental and basic human right.
I have taught my own children the basics of sex and human reproduction in a matter-of-fact, age-appropriate way as they were old enough to understand. I have gradually imparted both facts and my own personal ethics to them. I knew they would learn more specifics about sexually transmitted diseases and contraception including how to prevent unintended pregnancy and disease as part of their curriculum in health classes at school. They will need this information in their journeys through life for future health and wellbeing. I have occasionally spot checked their knowledge with “did you know…” style questioning.
As a radiologist in a busy urban practice, I see teenage pregnancies, cervical cancer, hepatitis C, HIV, other sexually transmitted diseases with their associated complications like infertility, metastatic disease, abscesses, and cirrhosis. I know that all of these conditions are preventable.
I want my daughters and my patients to have the knowledge and tools they need to protect their health and wellbeing. Lately, as I have read the news, I have been feeling dismayed at how contraception and sexual education is being politicized by our leaders with real public health policy changes that will hurt women, particularly the most vulnerable.
The Trump-Pence Administration is systematically rolling back the clock on access to basic contraception and comprehensive sexual education for American women and teenagers through attacks on Title X funding and grant priorities, the Teen Pregnancy Prevention Program, and comprehensive sexual education in schools. All of these policy changes erode women’s preventative health and will ensure that I see more cases like the young woman with cervical cancer.
This week’s announcement that Trump is planning Title X changes to cut Planned Parenthood funding is part of a broader attack on women’s preventative health that he has been waging for almost a year.
1. Trump-Pence issued a rule to allow employers to deny birth control coverage to their employees
President Trump set these wheels in motion on May 4, 2017, with an executive order in which he ordered his three cabinet secretaries from the Departments of Treasury, Labor, and Health and Human Services to devise a policy to allow employers with religious objections to birth control to exclude contraception from their group plans. This maneuver was designed to convert birth control from a legally-guaranteed right to an optional fringe benefit wholly at the discretion of the employer. He instructed Attorney General Jeff Sessions to provide formal legal guidance to his cabinet secretaries in this undertaking.
At the time of the executive order, there were already religious and moral exemptions in place. Churches were specifically exempt from the ACA birth control requirement. Religious schools, hospitals, charities, and even religiously-motivated private companies were exempt as long as the insurer or third-party administrator made separate payments for the covered person’s contraceptive services.
In short order, his cabinet secretaries carried out his orders issuing a joint, multi-agency policy in October 2017 that would allow employers to exclude contraceptive coverage from their group health plans under new rules. They took a shortcut in issuing the policies as interim final rules, jettisoning the requirement for public notice and public comment. They put the rules into effect immediately: any employer who declared either a religious and moral objection to birth control could scrap birth control coverage from their policies after notifying their employees of the change to their health plans.
House and Senate leaders from the Democratic Party responded immediately by introducing “Protect Access to Birth Control” bills, to nullify and repeal these policies. There is little chance of the bill passing in either chamber.
At the same time, several lawsuits were filed across the nation. In one suit on behalf of five states, Judge Haywood Gilliam restored contraceptive coverage to American women under the earlier ACA rules through a nationwide preliminary injunction in his ruling on December 21, 2017.
Judge Haywood’s decision will help to protect women in this country because access to contraceptives improves women’s health, reduce health care costs, and allows women to complete their educations to pursue careers — all of which is integral to the wellbeing of American women, their families, and society.
2. Trump-Pence are dismantling the women’s preventative health care infrastructure through attacks on Title X and Planned Parenthood.
Title X is the only federally funded grant program with a solitary mission of providing comprehensive family planning in the United States. The clinics that receive Title X funding also dispense preventative care service to indigent individuals including breast exams, pelvic exams, and other tests to help women screen themselves for breast and cervical cancer, sexually transmitted diseases, and HIV. The Title X program offers health care to over 4 million people in the US, largely women without health insurance. As many as 60% of women who use these clinics, report using the clinics as their usual source of health care, including many women who have been left out of coverage in states that did not expand Medicaid. Planned Parenthood provides health care to 1.6 million people under Title X federal funding.
The fact that Planned Parenthood is a large recipient of Title X funds has put the grant money squarely within the crosshairs of Vice President Pence, even though the funds cannot be used for abortion services in any manner whatsoever. On March 29, 2018, Vice President Pence issued a tie breaking vote in the Senate, sending a bill to President Trump that would give states permission to withhold Title X funding from Planned Parenthood.
To be clear, Title X funds cannot be used for abortion — EVER! Since the program began with bipartisan support under Nixon, the use of Title X funds has been strictly prohibited for programs that use abortion as a family planning method. The Hyde Amendment passed in 1976 solidifies the fact that federal funds including Title X cannot be used for abortion.
Vice President Pence is leading the charge, but he has helped put in place some strong allies in his mission. Valerie Huber, acting deputy assistant secretary of population affairs at the Health and Human Services Department, will have the final say on which groups receive the $286 million allocated for Title X funding. She was recruited from an advocacy group called Ascend in which she has tirelessly advocated for abstinence until marriage as well as abstinence-only education in lieu of the more traditional comprehensive sexual education that is now used in most schools. With Pence and Huber at the helm, the types of Title X funded programs are about to change drastically.
The Title X grants have new emphasis on abstinence is the exact opposite of what sensible public health policy requires to protect the health and well being of women in our nation. Individuals can make their own choices about personal behavior and contraception use, but the broader concerns for public health and safety dictates the need for dissemination of medically accurate information so that each individual can make his or her own informed decisions based on facts.
Shockingly, the unintended pregnancy rate in the United States is already one of the highest in the developed world with a staggering 45% percent of all pregnancies being unintentional. And, it should be noted that 40 percent of all unintended pregnancies end with an abortion. To prevent abortions, women need access to reliable contraception, and Planned Parenthood is highly effective in providing contraception to its patients to prevent unintended pregnancy. In the year 2015, Title X funding helped women prevent 822,3000 unintended pregnancies, which resulted in 387,200 fewer unplanned births and 277,880 fewer abortions.
The accidental pregnancy rate has fallen by 18 percent in recent years and is now at the lowest level in 30 years, mostly due to better use of birth control and comprehensive sexual education. We are about to see a reversal of the curve with the new Trump-Pence policy changes.
I see all of the diseases that Title X money is designed to prevent in women frequently within my practice. I see breast and cervical cancer that is far advanced because many of my patients have no access to screening or care. I see women with advanced tumors, sometimes metastatic when we first see them, that are difficult and expensive to treat with poor prognosis. I see sexually transmitted diseases like chlamydia and gonorrhea when they have become complicated with abscesses in the tubes and ovaries that require procedures rather than just antibiotics to treat.
I know that I will see more teen pregnancies, accidental pregnancies, herpes, chlamydia, gonorrhea, syphilis, hepatitis, breast cancer, and cervical cancer with increased frequency and with more advanced disease when underserved patients come to me for diagnosis and care as a result of the changing face of these women’s health prevention programs under the Trump Administration.
3. Trump-Pence tried to eliminate the Teen Pregnancy Prevention Program (TTP).
In 2010, the Teen Pregnancy Prevention Program was started with an $81 million budget funding 81 organizations across the United States. The grants funds scientific research by institutions like Johns Hopkins to find effective way for teens to make healthy decisions to avoid unintended pregnancies. The Program was renewed for five years in 2015. On July 3, 2018, Health and Human Services mailed each funded organization a letter, out of the blue, with the news that the Trump Administration had cut $213.6 million of funding without warning and that the program would end prematurely in June 2018, not 2020 as planned.
The goal of the program was to helps teenage girls avoid pregnancy and to collect research data to understand through the scientific method how to best prevent early sexual activity, teen pregnancy, and sexually transmitted disease in teen girls.
Many doctors credit the program with bringing the teen pregnancy rate to a 30-year low. For 30 years, teen pregnancy and childbirth in the United States has been declining — from an annual teen birth rate of 1 in 16 in 1990, to 1 in 45 today.
The premature termination of scientific studies that have been collecting data for three years means that there will be no valid publications without funds to analyze the existing but incomplete data. Once again, to be crystal clear, the funds were allocated exclusively for teen pregnancy prevention. Funding was never used for abortion under federal law.
Three separate federal judges have blocked President Donald Trump’s administration from terminating grants issued through a teen pregnancy prevention program. The HHS cut the funding to all 81 programs a month after Trump appointed Valerie Huber as chief of staff for the Office of Assistant Secretary of Health. Huber has repeatedly and publicly expressed her unsubstantiated, scientifically disproven belief that comprehensive sexual education encourages sex amongst teenagers. Actual scientific research demonstrates clearly that the opposite of of what she believes to be true.
Research studies show that teaching about contraception is not associated with increased risk of adolescent sexual activity or sexually transmitted diseases (STDs) as suggested by her and other abstinence-only advocates. Teens who received comprehensive sex-ed had a lower risk of pregnancy and STD infection than teens who received abstinence-only or no sex education at all in the U.S. Even more staggering, “the more strongly abstinence is emphasized in state laws and policies, the higher the average teenage pregnancy and birth rate.”
Comprehensive sexual education has broad support nationally. Approximately 82% U.S. adults support comprehensive programs that teach students about both abstinence and other methods of preventing pregnancy and sexually transmitted diseases. In contrast, abstinence-only education programs, received the lowest levels of support (36%) and the highest level of opposition (about 50%)
Fortunately for teens and families in the US, a federal judge has issued a permanent injunction blocking the Trump administration from cutting grants that pay for Teen Pregnancy Prevention Program in numerous states. U.S. District Court Judge Thomas Rice ruled “The Court finds that HHS arbitrarily and capriciously terminated the (teen pregnancy prevention) Program,” Rice wrote. “The Court determines that the public interest weighs in favor of (Planned Parenthood), as it would prevent harm to the community and prevent loss of data regarding the effectiveness of teen pregnancy prevention.” The lawsuit also notes the success of the program. Specifically since its inception in 2010, the teen birth rate in the United States has dropped by 41 percent.
The Trump-Pence administration has waged a multi-pronged attack on access to basic birth control and comprehensive sex education through executive orders and policies produced by Trump’s cabinet secretaries and other federal department leaders that is laser focused on those initiatives and is systemic. At every turn, the courts have overruled the Trump-Pence Administration’s attempts to roll back the clock on women’s access to birth control and comprehensive sexual education because 1) of the improper “shortcut” procedures that cut the public out of the loop for comment, 2) failure to follow proper due process, or 3) because the judges found that the policy changes would harm society.
These attacks on Title X programs, TPP, and sexual education will increase the number of patients that I see with preventable cancers, sexually transmitted disease, often at late stages, and will result in increased numbers of unintended pregnancies in both teens and adults.
Physicians have spent decades obtaining education and training and even more time building the science behind our evidence-based medical and public health policy practices. Physicians are held to high ethical, educational, and professional standards. Perhaps it is time that we held our elected public officials to a high standard in enacting public health policy that will impact the health of millions of women, too.
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