We rarely talk about the labour that goes into accessing contraception – but when Stylist’s Moya Crockett tweeted about “contraceptive admin”, she went viral. So why are so many women finding it difficult to get hold of the birth control they need?
I almost screamed on the street on Monday.
It had just gone 7pm, and I was on the phone to my local doctor’s surgery. The man on the end of the line had just suggested that I go back to the pharmacy I’d left minutes earlier, a pharmacy that was now shut for the night.
“If they don’t have Loestrin, you could just ask the pharmacist for a different kind of pill,” the man suggested, not unkindly. (Was he a receptionist? A nurse? He didn’t say, and I was too tired to ask.) I looked at the scrap of paper crumpled in my hand, which said I was owed three months’ worth of Loestrin 20, the contraceptive pill I’d been on for two and a half years. A vaguely childish mix of emotions – helplessness, frustration, anger, humiliation – washed over me. I suppressed the urge to sit down on the pavement and cry.
I’d left work early that afternoon to get to the pharmacy before closing time, a two-bus, flustered journey in the dusty heat. But when I arrived and showed my prescription to the man behind the counter, he’d simply shrugged. They didn’t have Loestrin 20 in stock, he told me. No, he had no idea when it would next be available. Something about a manufacturing issue? Go back to your GP, he said, already turning away to speak to another customer. Get a different prescription.
But now I was talking to my GP, or at least someone who worked at my local surgery, and he was telling me to go back to the pharmacist. It was the latest instalment in my personal version of the long, dull, infantilising saga that is – all too often – the process of trying to access contraception in the UK in 2019.
In recent years, much has been written and discussed about the negative side effects of hormonal contraception. In feminist circles, at least, we are now acutely aware of the unpleasant impact that contraceptives such as the pill, the coil and the implant can have on the bodies and minds of women and people who menstruate: mood swings, anxiety, a flat-lined libido.
But one major downside to contraception that is still rarely discussed is the admin. The faff. The sheer inconvenience. It’s the endless GP appointments that are near-impossible to book outside of regular working hours. It’s having to travel miles to a clinic to get the coil fitted, then waiting for hours to be told to come back another day. It’s discovering that our usual pill is mysteriously out of stock at a pharmacy, and being offered no information about why this might be or when we can expect it to be available again. It is a form of labour that is astronomically time-consuming, extremely disorientating and – usually – shouldered by women in grim silence.
By Monday, though, I’d had enough of silence. Once I got off the phone with the man at my GP surgery – after telling him firmly that no, I did not want the pharmacist to simply pick a new pill for me, and him promising that someone would call me for a consultation the next day – I opened the Twitter app on my phone.
“LONG THREAD,” I began. “I really, really want men to understand what a fucking HASSLE all the admin around female contraception can be.”
Over the course of 16 tweets, I relayed how hard I’ve always found it to obtain the pill in a timely, convenient way. I thought I might get a few likes, perhaps a handful of sympathetic responses. But overnight, my story went viral. Thousands of people liked and retweeted my thread, and for days afterwards, replies and direct messages poured in from women with similar tales to tell.
Some women said they’d never struggled to get hold of contraception. But I also heard from women who, like me, had had to comb their cities to find a pharmacy that stocked the pill they’d been prescribed. Women who had to beg their doctor for over a year, in phone calls and emails and in person, to get their implant taken out. Women who had to bear the burden of contraceptive admin while dealing with childcare responsibilities, a lack of public transport in their area and physical and mental health problems.
Worryingly, many women said they had eventually stopped taking the pill altogether – not because it screwed up their skin or their psyche, but because of the endless work involved in getting hold of it. I thought I’d been unlucky. But as it turns out, my experience was disturbingly normal.
Do you really need a check-up every three months for the contraceptive pill?
The UK likes to think of itself as pretty socially and sexually liberal. So why is accessing contraceptive services such a drag? For me, much of the frustration stems from the fact that I’ve rarely been allowed a prescription for more than three months’ worth of the pill, despite the fact that I’ve never experienced any problems with it (on this count, I’m lucky: others report unhappy side and after-effects when taking Loestrin 20, including acne, headaches and low mood).
As a result, I’ve attended appointments at my GP surgery roughly every nine weeks for the last two and a half years. At these check-ups, a nurse checks my weight (the NHS considers it risky for women with a BMI of 35 or over to take the pill) and blood pressure (because the combined contraceptive pill has been linked to blood clots). My BMI and my blood pressure are fine, but whenever I’ve asked for a longer prescription, I’ve almost always been turned down.
Given the potential negative side-effects, it is of course important that healthcare professionals keep an eye on how women are getting on with hormonal contraception. This is particularly true if someone is starting a new form of birth control, or has a specific mental or physical health history that puts them at a higher risk of complications. But if you’re happy with your chosen contraceptive, and there is no cause for concern about your health, it feels frustratingly futile to be dragged in for a check-up every three months.
“Not only can the pill have side effects that make women feel negative in all sorts of ways, having to go back every three months puts even more [pressure] on us,” says Alice Pelton, the founder of The Lowdown, an online platform where people can share honest reviews of different kinds of contraception.
“You’re constantly having to think ‘oh shit, I’m going to run out’, or needing to take the morning off work. It’s just another thing to add to our already busy to-do lists, and I don’t think men see or appreciate it.”
There also seems to be little consistency as to when people are allowed to progress from a three-month to a six-month or year-long prescription. According to updated guidelines issued by the Faculty of Sexual and Reproductive Healthcare (FSRH) in January, healthcare professionals can prescribe up to a year’s supply of the combined hormonal contraceptive pill at one time instead of the current three month supply.
But these guidelines aren’t mandatory – and what GPs and nurses are actually prepared to prescribe varies from surgery to surgery, clinic to clinic, appointment to appointment. One doctor told me that there is still some difference of opinion among GPs about what length of prescription should be written at a time, in part because by the instructions on some pill packets does not yet reflect the updated FSRH guidelines.
Dr Sara Kayat, a practising NHS GP at Gray’s Inn Medical Practice and private consultant who works in sexual health, says that healthcare professionals should generally call you back in for a three-month check-up after you’ve started a new pill. After that, they should write you a longer prescription.
“Anyone going against those guidelines is not necessarily following best practice,” she says. “It’s awful, because we’re already trying to encourage people to take the pill regularly.
“Young women are busy, we have jobs, we can’t come in every three months. The guidelines were changed specifically to reflect that. But unfortunately a lot of the public still doesn’t know that – and from the sound of it, a lot of professionals don’t either.”
The pain of trying to get an appointment
It’s not just the interminable check-ups that can make procuring the pill a struggle. Many women find it difficult to get seen by a healthcare professional at all – and often, these seemingly contrasting issues are tangled up together. More than once, I’ve found myself in the Kafkaesque position of knowing I have to book an appointment if I want a repeat prescription, but then being told that none are available for weeks.
The explanation for this? There was some difference of opinion among the healthcare professionals I spoke to for this piece, but it seems to be a complex, toxic combination of ruthless budget cuts, the chaotic fragmentation of some services and the sometimes unhelpful integration of others. In England, responsibility for sexual health and contraceptive budgets was taken away from the NHS and handed to local councils in 2013. And in recent years, central government funding for local authorities has been slashed dramatically. Analysis by the Local Government Association (LGA) shows that councils in England will have suffered an overall 77% decrease in government funding between 2015/16 and 2019/20.
And when councils are struggling to keep financially afloat, sexual health services suffer. Last autumn, a BBC investigation found that half of councils in England had cut or were planning to cut the number of sites providing contraception services between 2015 and 2019.
A recent survey by the British Association of Sexual Health and HIV (BASHH), meanwhile, found that six in 10 medical professionals working in sexual health services in England were having to turn patients away each week. (In Scotland, Wales and Northern Ireland, sexual health services are still overseen by the NHS. However, women in the Republic of Ireland have told me say their services are similar to those in England – with the added sting of having to pay for the pill and GP visits.)
Dr Asha Kasliwal is president of the FSRH and the clinical director for Manchester’s contraception and sexual health service. “We now have more than 8 million women of reproductive age living in an area where the council has reduced funding [to contraceptive services],” she says. “When there are big cuts in budgets, you can build in some degree of efficiency. But you cannot maintain the same level of services.”
Also making it harder for women to access appointments, Dr Kasliwal says, is the fact that sexual health clinics are facing an unprecedented level of demand and slots tend to get booked up by people seeking help for urgent problems like sexually transmitted infections.
As a result, someone with important but less immediately pressing contraceptive needs – a woman who wanted to get her coil changed, for example – might be discouraged by how hard it is to get an appointment. Dr Kasliwal’s concern is that “more vulnerable people – [such as] a woman with a pram, or a young teenager with a chaotic lifestyle” – are the most likely to put up with inadequate contraception, or give up trying to get hold of it entirely, because of the sheer time and effort involved in accessing care.
What do you do if your pill is out of stock?
I wish I was almost finished, but there’s one important point still to make. Let’s say you’re really lucky. You experience no negative side-effects on the pill, and you’re able to secure contraceptive check-ups without much trouble. In this situation, you may still be turned away from a pharmacy because your pill isn’t available.
If my Twitter DMs are anything to go by, this is an alarmingly common experience. I have become intimately familiar with the girly, sci-fi names of brands that women haven’t been able to get hold of in recent months: Micronor, Microgynon 30, Mircette, Cerazette, Ovranette. Many older women, who rely on hormone replacement therapy (HRT) to help them manage the symptoms of the menopause, report the same struggle to access medication.
These shortages are usually due to issues in the manufacturer’s supply chain. But sometimes, a brand of pill is not available because it has been totally discontinued. And all too often, patients will not discover this information until they’ve already travelled to a pharmacy. Personally, I have spent hours traipsing around pharmacies looking for Loestrin 20, feeling increasingly desperate and humiliated and angry. This week, I learned that the pill is currently out of stock across the UK, with no anticipated resupply date. But I didn’t hear this from my GP, or a nurse, or a pharmacist; I learned it from kind women on Twitter, who had done their own digging and sent me what they’d found.
Similarly, another woman messaged me to say that she and her friend had recently been prescribed Cilest, but couldn’t find it anywhere. I have since learned that Cilest is being discontinued this month, something that was announced back in November. But why should this woman have to rely on my information? Why were she and her friend blithely prescribed medication that was on its way out?
Dr Kasliwal of the FSRH is clear that doctors and nurses should not be blamed for prescribing medication that is experiencing shortages or will soon be discontinued. “It may be that the person prescribing had not received that information, but once they are told, they won’t make that mistake again.” She adds that even if your specific pill is out of stock, you can be offered a different brand containing the same ingredients.
I have a lot of sympathy for this view. I know how much pressure NHS staff are under, through no fault of their own. It’s not like doctors and nurses are deliberately withholding information from patients; if a pharmaceutical shortage doesn’t get communicated to them, they can’t communicate it to anyone else.
But I also understand why so many women feel profoundly anxious at the prospect of being suddenly switched over to another pill. And a lack of effective communication doesn’t just make us feel like we don’t know what’s going on with our medication – it leaves us thinking that nobody else has a clue what’s going on, either. It is hugely unnerving and disempowering to feel like your body is at the mercy of machinations that you cannot control or even fully comprehend, because nobody’s bloody telling you anything.
So is Brexit affecting contraception supplies?
What happens when people aren’t provided with adequate information? They start drawing their own conclusions about why they can’t access what they need. One theory I have heard, again and again, is that contraception shortages are being caused by Brexit. It’s not hard to understand why they might think this: according to a report by the Pharmaceutical Journal in April, worsening medicines shortages are currently “an undeniable reality for pharmacists across the UK”. Some NHS England bosses have linked this “unprecedented” scarcity to the ongoing upheaval around our exit from the European Union, and the Pharmaceutical Services Negotiating Committee (PSNC) has also previously said that Brexit chaos could be exacerbating drug shortages.
When I contacted the PSNC directly, though, a spokeswoman took a measured tone. “In general, shortages are not a new phenomenon and the sector is experiencing significant problems at the moment,” she said. “The manufacture of medicines is highly regulated, and materials and processes must meet rigorous safety and quality standards, so difficulties can arise for various reasons.”
Similarly, a spokesperson for the Department of Health and Social Care told Stylist: “There is no link between delays in the manufacturing process of some oral contraceptive pills and our exit from the EU. The vast majority of patients experience no issues but in the rare instances there are shortages those affected can access several alternatives and should discuss these options with their clinician or pharmacist as soon as possible.”
However, Alix Fox, the host of BBC Radio 1’s Unexpected Fluids and the resident sex educator for Superdrug and sex toy brand Womanizer, says that people’s concerns about how Brexit might affect contraception should not be dismissed.
“Lots of contraception is made in Europe, and no one is quite sure what’s going to happen if there’s no negotiation deal in place to keep those supply chains open,” she says. “As much as I don’t want anyone to freak out, it is right that we take this seriously and put back-up systems in place to avoid a situation where women’s health is thrown away.”
This sense of uncertainty is what defines many women’s experience of contraceptive care in England. It’s not the fault of individual doctors, or individual nurses, or individual pharmacists: I have every faith that the vast majority genuinely want to help women access the reproductive care they need. But neither should ordinary women be left feeling exhausted, confused and angry simply for trying to get hold of basic contraception.
What it is abundantly clear is that the system, as it stands, is broken. And women are being screwed as a result.
Images: Getty Images