In April, Julee Lacey, 33, a Fort Worth, TX, mother of two, went to her local CVS drugstore for a last-minute Pill refill. She had been getting her prescription filled there for a year, so she was astonished when the pharmacist told her, "I personally don't believe in birth control and therefore I'm not going to fill your prescription." Lacey, an elementary school teacher, was shocked. "The pharmacist had no idea why I was even taking the Pill. I might have needed it for a medical condition."

Melissa Kelley, 35, was just as stunned when her gynecologist told her she would not renew her prescription for birth control pills last fall.

"She told me she couldn't in good faith prescribe the Pill anymore," says Kelley, who lives with her husband and son in Allentown, PA. Then the gynecologist told Kelley she wouldn't be able to get a new prescription from her family doctor, either. "She said my primary care physician was the one who helped her make the decision." Lacey's pharmacist and Kelley's doctors are among hundreds, perhaps thousands, of physicians and pharmacists who now adhere to a controversial belief that birth control pills and other forms of hormonal contraception—including the skin patch, the vaginal ring, and progesterone injections—cause tens of thousands of "silent" abortions every year. Consequently, they are refusing to prescribe or dispense them.

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Scenarios like these—virtually unheard of 10 years ago—are happening with increasing frequency. However, until this spring, the issue received little attention outside the antiabortion community. It wasn't high on the agendas of reproductive rights advocates, who have been preoccupied with defending abortion rights and emergency contraception. But when Lacey's story was picked up by a Texas TV station and later made the national news, Planned Parenthood Federation of America and others took notice.Limiting access to the Pill, these groups now say, threatens a basic aspect of women's health care. An estimated 12 million American women use hormonal contraceptives, the most popular form of birth control in the United States after sterilization. The Pill is also widely prescribed by gynecologists and family doctors for other uses, such as clearing up acne, shrinking fibroids, reducing ovarian cancer risk, and controlling endometriosis.

"Where will this all stop?" asks Lacey. "And what if these pharmacists decide they suddenly don't believe in a new lifesaving medicine? I don't think pharmacists should be in a position to decide these things."[pagebreak]

A Matter of Belief

The members of the antiabortion group Pharmacists for Life International say they have every right to make that kind of decision. "Our job is to enhance life," explains the organization's president, pharmacist Karen Brauer, RPh, who first refused to fill prescriptions for some types of birth control pills in 1989. "We shouldn't have to dispense a medication that we think takes lives."

Anti-Pill doctors and pharmacists base their stand on the fact that the Pill isn't perfect: Although it is designed to suppress ovulation and prevent fertilization, both can—and do—occur in rare cases. About 1 woman in every 1,000 who takes the Pill exactly as directed becomes pregnant in a given year. But while mainstream experts say ovulation happens only 2 to 3 percent of the time and fertilization is rare, anti-Pill groups claim both happen frequently. They say most of these fertilized eggs—in their view, nascent human lives—are unable to attach to the hormonally altered uterine lining. Instead of implanting and growing, they slough off. This theoretical action, which scientists can't confirm, is called the post-fertilization effect.

At the heart of the debate between anti-Pill forces and mainstream medicine lies a profound difference of opinion about when pregnancy and life begin. The long-standing medical definition of pregnancy, held by the American College of Obstetricians and Gynecologists, is that it starts not when an egg is fertilized, but when the fertilized egg implants in the uterine lining.This distinction is practical: A pregnancy test won't show a positive result before implantation. "It can't be an abortion before there is a pregnancy," points out David Grimes, MD, a clinical professor in obstetrics and gynecology at the University of North Carolina School of Medicine and one of the leading contraception experts in the US.

But anti-Pill doctors and pharmacists say life begins sooner, at fertilization. Sloughing off a fertilized egg, in their view, is a "chemical abortion."

"How many women know that if they become pregnant after breakthrough ovulation, these 'contraceptives' will almost always kill any son or daughter they've conceived?" asks the anti-Pill organization Pro-Life America on the group's website, ProLife.com.

Surprisingly, there's no science to back the theory that birth control pills really do discourage implantation. This claim, made by contraceptive manufacturers for decades, has never been proven, Grimes says. Even the American Association of Pro-Life Obstetricians and Gynecologists agrees that it's just speculation.[pagebreak]

Under the Radar

In the past decade or so, the "hormonal birth control equals abortion" view has quietly grown roots in the antiabortion underground. It's spread from doctor to doctor, through local newsletters, in books with titles such as Does the Birth Control Pill Cause Abortions?(written by Randy Alcorn, an Oregon-based antiabortion pastor and author), and through lobbying groups that have encouraged lawmakers in Arkansas, South Dakota, and most recently Mississippi to enact "conscience clauses." These legislative provisions protect health care professionals—in this case, pharmacists—who refuse to provide services they oppose on moral, ethical, or legal grounds. At press time, similar legislation had been introduced in 11 more states.

An Internet search turns up thousands of Web sites containing articles with titles such as "The Pill Kills Babies," "Are Contraception and Abortion Siamese Twins?" and "The Dirty Little Secrets about the Birth Control Pill." Hundreds of physicians and pharmacists have pledged not to provide hormonal birth control. Among them: 450 doctors affiliated with the Dayton, OH-based natural family planning group One More Soul; some members of the 2,500 doctors in the Holland, MI-based American Association of Pro-Life Obstetricians and Gynecologists; and a growing number of the 1,500-member Web-based Pharmacists for Life International, says Brauer. Not even anti-Pill groups know how many doctors and druggists are involved. And while the total is still a small percentage of the 117,500 family physicians and OB/GYNs and 173,000 pharmacists in the US, they are making their presence felt in women's lives and among law and policy makers on both the state and national levels. Their influence is far-reaching and disproportionate to their size—a quiet version of the public shock waves produced by the nation's relatively small number of antiabortion activists.

"Refusing women access to the Pill is a very disturbing trend," says Gloria Feldt, president of Planned Parenthood Federation of America. "The war on choice is not just about abortion anymore. It's about our right to birth control."[pagebreak]

Morality Versus Public Health

Anti-Pill doctors and pharmacists say the issue isn't about a woman's right to hormonal contraceptives, but about the right to act according to their beliefs. "I feel chemical contraceptives have the potential to harm an embryo," says Mary Martin, MD, an OB/GYN in private practice in Midwest City, OK. "And I decided, based on moral and ethical grounds, that I simply could no longer prescribe them." She stopped writing prescriptions for hormonal birth control in 1999. OB/GYN Arthur Stehly, of Escondido, CA, who hasn't prescribed contraceptives since 1989, says he feels the same way: "I function better and I sleep better at night knowing I'm not giving the Pill."

But at what point does personal belief undermine public health? If more women lose access to hormonal contraceptives, rates of unintended pregnancy and abortions will rise in the US, predicts Beth Jordan, MD, medical director of the Washington, DC-based Feminist Majority Foundation, an advocacy and research group.

What's more, oral contraceptives aren't only used to prevent pregnancy. The Pill may cut the risk of ovarian cancer by up to 80 percent and is used by women at high genetic risk for this hard-to-detect and usually fatal cancer. "There are easily more than 20 noncontraceptive uses for the Pill in common practice," says Giovannina Anthony, MD, an attending physician of obstetrics and gynecology at Beth Israel Medical Center in New York City. "This drug saves women from surgery for gynecological conditions like endometriosis, fibroids, and severe bleeding and pain." Most women's doctors agree that contraceptives are an important tool of good medical care. "I have a hard time with people who market themselves as women's health care physicians but who won't prescribe such a basic part of women's health care," says Anne Drapkin Lyerly, MD, a reproductive rights ethicist and an assistant professor of obstetrics and gynecology at Duke University Medical Center. "We're seeing a growing trend among pharmacists and medical practitioners who consider it acceptable to impose their morality on women's bodies. I don't think moral aspects should be a concern. Imagine a pharmacist asking a customer whether his Viagra prescription is to enhance sexual performance in his marriage or in an extramarital affair. Never!"[pagebreak]

Katie Williams' Story

Last winter, 24-year-old Katie Williams encountered a doctor who refused to give her a prescription for the Pill, even though she'd already been taking it for 5 years—originally to relieve extremely painful menstrual cramps. Williams, who had just moved to Milwaukee for a job with an insurance company, realized she was nearly out of Pills. Her roommate recommended the physician who had written a Pill prescription for her a year before: Cynthia Jones-Nosacek, MD, a board-certified family doctor with St. Mary's Medical Clinic, a Catholic medical center in Milwaukee. Williams made the appointment, explaining she needed a routine annual exam and a new prescription.

But when she arrived at the office, recalls Williams, "the doctor's assistant told me 'the doctor doesn't write prescriptions for the Pill.' I was totally floored. I just stared at her."

Williams opted to take her chances and see the doctor anyway, thinking the assistant must have been confused. After the doctor finished her exam, Williams asked for her script, explaining she'd been taking the Pill for several years. "The doctor told me she doesn't believe in oral contraceptives and does believe in natural family planning," Williams claims. "I told her that's ridiculous." Angry, Williams stormed out of the doctor's office.

In an interview, Jones-Nosacek, who has been in practice for 21 years, says she stopped prescribing the Pill after discovering a paper written by Salt Lake City family doctor Joseph B. Stanford, MD, an assistant professor of family and preventive medicine at the University of Utah and a recent appointee to the FDA's Reproductive Health Drugs Advisory Committee. "The paper talked about the Pill's post-fertilization effect," says Jones-Nosacek. "After reading it and several other books and papers, I realized I could no longer justify prescribing the Pill." Although Jones-Nosacek says she may have lost patients over her stand, she thinks most are happy to hear her opinion. "I think most women feel life begins at fertilization," she says. "When they find out the Pill has a potential post-fertilization effect, they're surprised, and some rethink their decision."

As for Williams, she got her prescription that day. Desperate—new to her job, she couldn't afford to take off another day without pay—she asked for help from an employee in Jones-Nosacek's office, who told her there was an OB/GYN in the same building. Williams went there directly and asked one of the doctor's assistants to relay her story to the gynecologist. This new doctor wrote her a prescription, no questions asked. "The doctor's assistant was shocked," says Williams. "She couldn't believe any doctor would refuse to give the Pill to somebody who had already been taking it successfully."[pagebreak]

Friends in High Places

Planned Parenthood's Feldt believes anti-Pill groups, like the larger anti-abortion movement that spawned them, have been emboldened by the Bush administration's antiabortion policies and appointees. "Pro-life groups know they have friends in high places," she says. In his first budget to Congress, President Bush stripped out a provision that required insurance companies participating in the Federal Employees Health Benefits Program to cover contraceptives. He has also withheld funding for international family planning; signed the Partial-Birth Abortion Ban Act of 2003, which critics say could result in making even second-trimester abortions illegal; and signed the Unborn Victims of Violence Act, which gives a fertilized egg, embryo, or fetus separate legal status if harmed during a violent crime. (Abortion rights groups say that giving a fetus separate legal rights from the pregnant woman opens the door to prosecuting anyone involved in an abortion.)

Bush also appointed three antiabortion doctors to the FDA Reproductive Health Drugs Advisory Committee: W. David Hager, MD, Susan Crockett, MD, and Stanford. When their committee and the FDA's Nonprescription Drugs Advisory Committee met jointly last December, the group voted 23 to 4 in favor of giving over-the-counter status to emergency contraceptives. Dissenters included Hager, Crockett, and Stanford. In May, the FDA decided not to grant the drug OTC status.While Hager and Crockett have gone on record saying they do not believe standard birth control pills cause abortions, their colleague Stanford says he has never prescribed them. "I found out in medical school that they may prevent fertilized eggs from implanting, and I decided then that I wasn't ever going to prescribe them," he says. A paper of Stanford's, published in the February 2000 issue of Archives of Family Medicine,in which he discusses the post-fertilization effect of the Pill, is often cited by anti-Pill groups.

Federal and state legislators are quietly adopting similar views. US Senator Rick Santorum (R-PA), for example, does not support use of the Pill to prevent pregnancy, his staffers told Prevention. In March 2003, during a debate on the Senate floor that touched on emergency contraception, Santorum said, "I will not be supportive of covering medications that would lead to a fertilized egg not [being] implanted in the uterus. I believe life begins at conception. I would not support drugs that would prevent a conceived embryo [from being] implanted."[pagebreak]

Problems at the Drugstore & Public Opinion

Though three states have conscience clauses for pharmacists, there is no such legal provision in Texas, where the CVS druggist refused to fill Julee Lacey's prescription.

The night it happened, Lacey says, she was shocked and responded, "Are you sure? I've had this filled here many times before." But the pharmacist was emphatic. "I just couldn't believe what I was hearing," recalls Lacey. "It was a school night, and I knew I had to put my kids to bed and get organized for work the next morning. I didn't want to run all over town for my Pills." Lacey and her husband complained to the assistant store manager that night and the district manager the next day. Finally, the pharmacy supervisor called and said he would have Lacey's prescription delivered that day. "He apologized and said he was unaware of the pharmacist's moral objections to the Pill. Apparently it was a new belief," says Lacey. (A CVS corporate spokesperson contacted by Preventionconfirmed Lacey's story. None of the employees has ever been named.)

Pharmacists in other states have refused as well. In 2002, a Kmart pharmacist in Stout, WI, allegedly denied Pills to a student from the local campus of the University of Wisconsin. The state department of regulation and licensing filed a complaint against the pharmacist; at press time a hearing on the matter had not yet taken place.

In 1996, Brauer says, she was fired from a Kmart pharmacy in Delhi, OH, after she refused to sign an agreement to dispense all lawfully prescribed medications regardless of her feelings or beliefs. (She filed suit against Kmart, but since the discount chain is in bankruptcy proceedings, it has never been settled.) "We've known for a long time that birth control pills are abortifacients," she says. "Now it's finally catching on."

Public Opinion

While abortion continues to be a divisive public issue, contraception is not. In fact, 95% of American women use some form of birth control during their childbearing years.

This is no silent majority. When a woman is denied the Pill and the incident becomes public, it triggers a loud response. Case in point: After Lacey's story appeared in the Dallas Morning News,there was an enormous outpouring of letters from readers appalled by the pharmacist's actions. "This was a huge issue in our area, and we're a conservative community," says Emily Snooks, director of media relations and communications at Planned Parenthood of North Texas. "People here are still talking about it, simply because the vast majority of people in this country believe access to birth control is a basic right."

But what will you do if, like Kelley, Williams, and Lacey, you encounter a doctor who tells you no or a pharmacist who won't honor your prescription? "If your gynecologist won't prescribe the Pill, find a new doctor—and tell all your friends what has occurred," says Vanessa Cullins, vice president for medical affairs at Planned Parenthood Federation of America in New York City. The same goes for pharmacists who refuse to fill your prescription. The best defense against this grassroots movement, Cullins notes, is another one—in opposition.