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    Why Coverage of Prescription Contraception Matters for Men As Well As Women

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    Though the federal Affordable Care Act requires health insurers to cover many types of contraception, a vasectomy is not one of them.

    Contraception – who should be able to use it, and the role of government in its provision – has become a contentious issue, in part due to disagreements over the Affordable Care Act mandate positing that all private insurance plans must cover prescription contraception for women. The issue is not trivial, because nationally representative surveys show that more than 10 million women in the United States use the pill as their current method to prevent pregnancy. The pill is the most popular form of reversible birth control.

    Across the political spectrum, both citizens and public officials tend to understand birth control as a “women’s issue” rather than as a healthcare or social policy issue. Usually, birth control is discussed as a matter of reproductive health and rights or treated as an aspect of women’s personal responsibility for managing their own sexuality.

    But where do men fit? How do they benefit from the availability and use of prescription birth control coverage? Could a better understanding of the ways prescription birth control coverage benefits heterosexual couples improve bipartisan discussions about coverage for contraception? My research provides insight into both of these questions.

    Women’s Contraceptive Use and Couples’ Protection from Pregnancy

    Contraception presumes the sexual involvement of couples, but surveys typically ask individual people about what method(s) they as individuals use to prevent pregnancy. By default, a woman who uses the pill for contraception also provides her partner with protection from pregnancy; and if her partner wears a condom, then both participants benefit. Contraception and condoms can be used together, but research shows that, in practice, couples in long-term relationships often move from using condoms to relying solely on prescription contraception.

    Notably, interviews I conducted revealed that women who use prescription contraception for long periods of time rarely receive financial help from partners in purchasing it. Thus, although women’s birth control covers men, too, the men do not have to pay for this coverage and its benefits.

    Men reap the positive effects of women’s use of prescription contraception in at least three ways: they gain protection from pregnancy without much effort; they avoid using condoms when couples transition to solely using prescription contraception, and they can spend money they might have spent on contraception on other items and pursuits.

    There is also another way that men benefit from female contraceptive use that is not often mentioned. Women must deal with the downsides of whatever type of prescription birth control they use – including downsides such as physical side effects like nausea or depression and hassles like having to repeatedly refill prescriptions at the pharmacy. Their male partners are freed from such issues.

    Contraceptive Use and the Unequal Burdens of Dissatisfaction

    Preventing pregnancy is generally not something that couples enjoy, because it can be stressful, costly, and bothersome. Although public attention focuses on men’s dissatisfaction with condoms, much less attention is paid to women’s dissatisfaction with prescription birth control methods. My research using survey data finds that nearly 40% of women ages 23 to 44 who had ever used hormonal contraception had stopped using it at some point because they were dissatisfied.

    Yet even though many women stop using a particular type of prescription contraception, they rarely stop contraception use altogether. They try various methods – different pills, or long-acting reversible contraception devices like implants and intrauterine devices – until they find something that feels right for them. As my in-depth interviews show, although many women experience dissatisfaction with side effects of particular birth control methods, they still believe that they should continue using some kind of prescription method.

    Discussions that focus only on the benefits that prescription contraceptive coverage provides to women hide the ways that prescription birth control is very much like other medications – it can cause unpleasant and consequential side effects. By persisting despite dissatisfactions in their search for effective ways to prevent pregnancy, women provide tangible benefits for their partners, who get to avoid pregnancy without sharing such costs.

    Even when women find it difficult or unpleasant to use certain methods, they cannot always count on getting male partners to wear condoms – or otherwise take responsibility for the couple’s contraception. This may explain why data from nationally representative surveys show that women who experience dissatisfaction with contraception are at higher risk of unintended pregnancy. When the burden of responsibility for birth control is too great, male partners cannot be counted on to pick up the slack.

    What Does the Full Picture Mean for Debates about Contraception Coverage?

    Recognizing that men as well as women benefit from prescription birth control coverage is crucial for appropriately evaluating the costs of rolling back the Affordable Care Act mandate for prescription contraception coverage. A nationally representative survey shows that only a very small percentage of people recognize that married women are the most likely to use prescription birth control. This may be because many of us are conditioned to see birth control as something affecting women rather than couples.

    Public debates might very well change if more Americans understood all the ways that women, men, and society at large benefit from women’s access to prescription birth control – and their willingness to use it despite dissatisfaction. Too often, pundits and partisan debates treat contractive coverage as simply a women’s issue or benefit.

    But if women, especially married women or women in long-term relationships, lose access to the most popular form of reversible contraception, so will men. Both men and women will experience new frustrations and costs.

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    Krystale Littlejohn is an Assistant Professor of Sociology at Occidental College. Her research examines how culture shapes reproductive health outcomes in contraception and abortion. Her work lies at the intersection of health and medicine, race and gender, and social inequality. Two of her current projects investigate gender and women’s experiences using birth control across relationships and how medical providers talk about birth control in contraception counseling visits (with Katrina Kimport).

    Health

    Study Shows Immune Cells Against Covid-19 Stay High in Number Six Months After Vaccination

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    A recent study by Johns Hopkins Medicine researchers provides evidence that CD4+ T lymphocytes — immune system cells also known as helper T cells — produced by people who received either of the two available messenger RNA (mRNA) vaccines for COVID-19 persist six months after vaccination at only slightly reduced levels from two weeks after vaccination and are at significantly higher levels than for those who are unvaccinated.

    The researchers also found that the T cells they studied recognize and help protect against the delta variant of SARS-CoV-2, the virus that causes COVID-19. According to the U.S. Centers for Disease Control and Prevention, the delta variant — currently the predominant strain of SARS-CoV-2 in the United States — causes more infections and spreads faster than earlier forms of the virus.

    The study findings were first reported online Oct. 25, 2021, in the journal Clinical Infectious Diseases.

    “Previous research has suggested that humoral immune response — where the immune system circulates virus-neutralizing antibodies — can drop off at six months after vaccination, whereas our study indicates that cellular immunity — where the immune system directly attacks infected cells — remains strong,” says study senior author Joel Blankson, M.D., Ph.D., professor of medicine at the Johns Hopkins University School of Medicine. “The persistence of these vaccine-elicited T cells, along with the fact that they’re active against the delta variant, has important implications for guiding COVID vaccine development and determining the need for COVID boosters in the future.”

    To reach these findings, Blankson and his colleagues obtained blood from 15 study participants (10 men and five women) at three times: prior to vaccination, between seven and14 days after their second Pfizer/BioNTech or Moderna vaccine dose, and six months after vaccination. The median age of the participants was 41 and none had evidence of prior SARS-CoV-2 infection.

    CD4+ T lymphocytes get their nickname of helper T cells because they assist another type of immune system cell, the B lymphocyte (B cell), to respond to surface proteins — antigens — on viruses such as SARS-CoV-2. Activated by the CD4+ T cells, immature B cells become either plasma cells that produce antibodies to mark infected cells for disposal from the body or memory cells that “remember” the antigen’s biochemical structure for a faster response to future infections. Therefore, a CD4+ T cell response can serve as a measure of how well the immune system responds to a vaccine and yields humoral immunity.

    In their study, Blankson and colleagues found that the number of helper T cells recognizing SARS-CoV-2 spike proteins was extremely low prior to vaccination — with a median of 2.7 spot-forming units (SFUs, the level of which is a measure of T cell frequency) per million peripheral blood mononuclear cells (PBMCs, identified as any blood cell with a round nucleus, including lymphocytes). Between 7 and 14 days after vaccination, the T cell frequency rose to a median of 237 SFUs per million PBMCs. At six months after vaccination, the level dropped slightly to a median of 122 SFUs per million PBMCs — a T cell frequency still significantly higher than before vaccination.

    The researchers also looked six months after vaccination at the ability of CD4+ T cells to recognize spike proteins atop the SARS-CoV-2 delta variant. They discovered the number of T cells recognizing the delta variant spike protein was not significantly different from that of T cells attuned to the original virus strain’s protein.

    Although the study was limited because of the small number of participants, Blankson feels it pinpoints areas that merit further research.

    “The robust expansion of T cells in response to stimulation with spike proteins is certainly indicated, supporting the need for more study to show booster shots do successfully increase the frequency of SARS-CoV-2-specific T cells circulating in the blood,” says Blankson. “The added bonus is finding that this response also is likely strong for the delta variant.”

    Along with Blankson, the members of the study team from Johns Hopkins Medicine are study lead author Bezawit Woldemeskel and Caroline Garliss.

    This study was supported by the Johns Hopkins COVID-19 Vaccine-related Research Fund.

    The authors do not have financial or conflict of interest disclosures. 

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    Health

    Poverty, Racism and the Public Health Crisis in America

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    Although extreme poverty in the United States is low by global standards, the U.S. has the worst index of health and social problems as a function of income inequality. In a newly published article, Bettina Beech, clinical professor of population health in the Department of Health Systems and Population Health Sciences at the University of Houston College of Medicine and chief population health officer at UH, examines poverty and racism as factors influencing health.

    “A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe,” Beech reports in Frontiers in Public Health. “Racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. The U.S. has one of the highest rates of poverty in the developed world, but despite its collective wealth, the burden falls disproportionately on communities of color.” The goal of population health is to achieve health equity, so that every person can reach their full potential.

    Though overall wealth has risen in recent years, growth in economic and financial resources has not been equally distributed. Black families in the U.S. have about one-twentieth the wealth of their white peers on average. For every dollar of wealth in white families, the corresponding wealth in Black households is five cents.

    “Wealth inequality is not a function of work ethic or work hour difference between groups. Rather, the widening gap between the affluent and the poor can be linked to unjust policies and practices that favor the wealthy,” said Beech. “The impact of this form of inequality on health has come into sharp focus during the COVID-19 pandemic as the economically disadvantaged were more likely to get infected with SARS CoV-2 and die.”

    A Very Old Problem 

    In the mid-1800’s, Dr. James McCune Smith wrote one of the earliest descriptions of racism as the cause of health inequities and ultimately health disparities in America. He explained the health of a person “was not primarily a consequence of their innate constitution, but instead reflected their intrinsic membership in groups created by a race structured society.”

    Over 100 years later, the Heckler Report, the first government-sanctioned assessment of racial health disparities, was published. It noted mortality inequity was linked to six leading causes of preventable excess deaths for the Black compared to the white population (cancer, cardiovascular disease, diabetes, infant mortality, chemical dependency and homicide/unintentional injury).

    It and other reports led to a more robust focus on population health over the last few decades that has included a renewed interest in the impact of racism and social factors, such as poverty, on clinical outcomes.

    The Myth of Meritocracy

    Beech contends that structural racism harms marginalized populations at the expense of affording greater resources, opportunities and other privileges to the dominant white society.

    “Public discourse has been largely shaped by a narrative of meritocracy which is laced with ideals of opportunity without any consideration of the realities of racism and race-based inequities in structures and systems that have locked individuals, families and communities into poverty-stricken lives for generations,” she said. “Coupled with a lack of a national health program this condemns oppressed populations such as Black and Hispanic Americans, American Indians, and disproportionately non-English speaking immigrants and refugees to remain in poverty and suffer from suboptimal health.”

    Keys to Improvement

    The World Health Organization identified three keys to improving health at a global level that each reinforces the impact of socioeconomic factors: (1) improve the conditions of daily life; (2) tackle the inequitable distribution of power, money and resources; and (3) develop a workforce trained in and public awareness of the social determinants of health.

    The report’s findings highlight the need to implement health policies to increase access to care for lower-income individuals and highlight the need to ensure such policies and associated programs are reaching those in need.

    “Health care providers can directly address many of the factors crucial for closing the health disparities gap by recognizing and trying to mitigate the race-based implicit biases many physicians carry, as well as leveraging their privilege to address the elements of institutionalized racism entrenched within the fabric of our society, starting with social injustice and human indifference,” said Beech.

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    Culture

    What Do You Know About Disability Cultural Competence?

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    Recently, I had the opportunity to give a webinar on disability cultural competence to social service workers, but was met with many blank stares. As a disabled social worker myself, I often notice that the disability community is not recognized as a cultural group. Disability is also not considered as a social identity in diversity considerations, despite the ways the community feels about it. Frankly, our field has a long way to go when it comes to developing disability cultural competence. Let’s see if we can change that.

    Why the We Need to Prioritize the Disability Community

    You may be asking yourself, why all the focus on disability? Well, the disability community comprises 26 percent of the adult U.S. population – that’s one in four Americans according to the Centers for Disease Control. Among children under the age of 18, estimates suggest that 4.3 percent of the population is disabled according to the U.S. Census from 2019. This means that social services workers are interacting with the disability community all over! It’s also important to note that disability transcends race, ethnicity, gender and other social identities, as seen in the graphic below (courtesy of Courtney-Long, Romano, Carroll, et al., 2017). So we need to remember to be intersectional in our  practice – these are not siloed communities.

    Courtesy of Courtney-Long, Romano, Carroll, et al., 2017

    Importance of Disability Identity

    I’d like to transition now to talking about the importance of having a disability identity. Some people identify as disabled from a cultural perspective. Some people are not even aware that this is an option and you can open their eyes to the world of disability as a resource for them. In other words, for some, this is a missed opportunity to connect to a supportive network. For others, it’s a choice not to identify as disabled either due to stigma, internalized ableism or other beliefs. The idea is that developing a strong disability identity is super helpful with your long-term well-being. And in order to do this, you have to both connect with the disability community and with disability culture. So what is that?

    What is Disability Culture?

     

    In short, disability culture is the “sum total of behaviors, beliefs, ways of living, & material artifacts that are unique to persons affected by disability.” It’s essential for social service workers to be tuned in to disability culture so they can leverage it to connect with their clients. And let’s be clear, disability culture does NOT consist of disability service programs. Where we really see disability culture come alive is on social media sites, such as Twitter and Instagram. You can follow some of the major disability culture hashtags to see the dialogues and debates that are hot in our community right now, such as: #DisabilityTwitter; #DisabilityVisability; #DisabilityAwareness; #IdentityFirst; #DisabilityLife; #Spoonie,#SpoonieLife, and more.

    You may notice that the last two hashtags included the word “spoonie.” This derives from “spoon theory,” which is an actual theory based on a metaphor about how much mental and physical energy a person has to accomplish their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The disability community talks about how many “spoons” they have as a unit of measurement of energy – and sometimes refers to themselves as spoonies. Please note that in teaching you this, I am helping you to develop your disability cultural competence.

    How Build Disability Cultural Competence

    Other ways to build up your disability cultural competence are to check out the Disability Visibility Project, which tells the stories of diverse members of the community in wonderful ways. And there are a range of organizations, such as Sins Invalid, which founded the disability justice movement. You can also read the 10 principles of that movement in this short document. This will help you to tune in to the disability pride movement. We have a pride month and a pride flag too, it happens in July.

    When it comes to engaging in disability competent practice, we need to develop knowledge about disability culture and disability history. We can also consider taking the following steps to round out this competence:

    First, we need to examine our own attitudes about disability and engage in reflective practice around that. You can consider your own implicit bias about the disability community through Harvard University’s Project Implicit test about ableism, or through social worker Vilissa Thompson’s guide to checking your own ableism.

    Second, developing disability cultural competence over time also includes a careful look at the terminology we are using and respecting disabled people’s choice of identity-first language in many cases. You can read more about that here and throughout that site. The Harvard Business Review also has a thoughtful essay on why you need to stop using particular words and phrases. It’s a great resource and helpful read for many.

    Third, we also need to think respectfully about disability etiquette and how ideas play out in different parts of the disability community. One should presume competence about us – all of us! We ask that you respect our bodily autonomy, speak to the person and not their companion/interpreter, ask before you help, be sensitive about physical contact/equipment contact, don’t make assumptions about capacity, listen to us, don’t assume you know better and if you are in doubt about what to do, ask! Writer Andrew Purlang sums up his disability etiquette request as follows:

    • Don’t be afraid to notice, mention, or ask about a person’s disability when it’s relevant — but don’t go out of your way!
    • Offer to help, but make sure to listen to their response, respect their answer, & follow their directions
    • Don’t tell a disabled person about how they should think about or talk about their own disability
    • Don’t give unsolicited medical, emotional, or practical advice
    • Don’t make a disabled person responsible for managing your feelings about their disability, or for your education on disability issues
    • If you make a mistake, just say you’re sorry and move on. Don’t try to argue that you were right all along.

    Now What?

    Taken together, these steps, learning disability culture, and examining our own attitudes about disability, go a long way towards the development of disability cultural competence. But none of it will do any good if we are not fighting for disability access and disability inclusion, which are central issues for the disability community. Many people think that issues of access were solved by the passage of the Americans with Disabilities Act of 1990. But the implementation of that law is fraught and embattled, and there is lots of work to be done on the access front. Take a look at these simple guides below. They will go a long way in helping to engage the disability community and making us feel welcome! Above all, remember our movement’s rallying cry, “nothing about us, without us!”

    Website Accessibility

    Accessible Social Media Guide

    Meeting Accessibility

    Webinar Accessibility

    Public Event Accessibility

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