Emergency Contraception

Neufeld, Brenda G (TUC) \[Brenda.Neufeld@MAIL.IHS.GOV\]

Mon 12/15/2003 2:58 PM

I would be interested to hear about service units, which have \"Plan B\"
emergency contraception on their formularies. I am used to giving
patients emergency contraception with the requisite number of Ovral or
LoOvral pills with the addition of phenergan. However, as \"Plan B\" is
much better tolerated and may also be more effective, it would seem that
it would be the preferable alternative.

**Majus, George (PIMC) \[george.majus@MAIL.IHS.GOV\]**

**Mon 12/15/2003 5:35 PM**

The problem with emergency contraception is that it is considered by
many to be a form of abortion and since abortions or anything to do with
them is against federal law for federal clinics or hospitals, our
hospital ER does not prescribe it at all.

**Murphy, Neil**

# Mon 12/15/2003 5:53 PM

Emergency contraception is not an abortifacient.

 

It is the stated position of the Indian Health system, in Chapter 13 of
the IHS Manual, that we will be provide FDA approved contraception.

 

Emergency contraception is FDA approved and widely available throughout
the nationwide Indian Health system.

 

All the facilities in the Alaska Area have it available throughout my
now nearly 20-year tenure here.  I have heard similar obstacles where
misinformed providers or pharmacists refuse to provide EC on rare
occasions from around the country.

 

Care must be taken so that misinformed staff does not allow the Indian
Health system to abandon care to Indian Health patients.

 

There was one non-provider staff member at ANMC that took a similar
stand and we all just worked around it. Those arguments are spurious,
because EC is not an abortifacient.

 

Yes, Plan B makes emergency contraception much easier to prescribe and
obviates the need for anti-nausea agents.  

 

Here are some EC discussions on the MCH website:

 

Frequently asked question: Family Planning

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#F>

 

October OB/GYN CCC Corner (scroll down to MCH Alert posting)

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner101803.doc>

 

Dr. Bill Haffner's Annual contraception update

<http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/contraception2002.ppt>

 

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Mon 12/15/2003 8:02 PM**

I would like to echo what Dr. Murphy has said. Emergency contraception,
or the \"morning-after pill,\" is NOT an abortifacient. There is a good
study by Hatcher on this, and many confuse emergency contraception with
RU-486. George, although the docs in the ER will not prescribe it, the
Pharmacy does package it, so that it can be dispensed directly by the
physician or the nurse-midwife, without going through the ER staff.
There have been several \"battles\" fought over this specific issue. The
patient should not be required to have the provider\'s belief,
especially if the provider is wrong! Emergency contraception is NOT
abortion! This is the way to prevent abortions.

**Hinman, Clint \[Clint.Hinman@CHINLE.IHS.GOV\]**

**Tue 12/16/2003 6:08 AM**

I will also echo this stance as all of our clinics prescribe and provide
Plan B as emergency contraception. Although I feel this should not be
relied upon as the primary source of contraception (i.e. refusal of
foam, condoms, or oral contraceptives), appropriate education can
overcome this concern. I agree it is NOT abortion and provides another
tool in the battle to decrease the teen pregnancy epidemic in Indian
Country.

**Neufeld, Brenda G (TUC) \[Brenda.Neufeld@MAIL.IHS.GOV\]**

**Tue 12/16/2003 6:21 AM**

Are you aware of any IHS sites that allow patients to obtain emergency
contraception from pharmacies without seeing providers? I think that
requiring a clinic visit is a barrier to its use. As I\'m sure you know,
the FDA is debating this issue today.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Tue 12/16/2003 6:57 AM**

There are several states that allow pharmacists to prescribe emergency
contraception directly without a provider. Alaska, Washington, and New
Mexico. Eve Espey and Tony Ogburn published a paper in last month\'s
Obstetrics and Gynecology in which they visited every pharmacy in
Albuquerque and found only 20 % carried emergency contraceptives and

only 11% had the specific EC that was prescribed. The most common reason
cited for not stocking EC was that there was no demand. So, our biggest
task as providers is to make sure patients are aware it exists.

As for prescribing it in IHS, when I was at Gallup (3 yrs ago) we also
had one or two pharmacists who objected to it, so we kept it and
dispensed it in the clinic (then it was 4 Ovrals plus an antiemetic).
Gyn clinic is arguably not the best place to have EC available. It
should be in all walk-in clinics, ERs, Family medicine clinics etc. and
should be made available for women who might need it to have at home for
use as needed without having to make a trip to the clinic.

**Perry, Donna \[Donna.Perry@CHINLE.IHS.GOV\]**

**Tue 12/16/2003 11:55 AM**

As a provider in the high school based clinics, with good education our
patients are using this EMERGENCY CONTRACEPTION, both wisely and
appropriately. Our challenge is to educate teens and young women about
the availability and safety of this medication. It has been very well

tolerated.

The New England Journal, in the last year, had a great review with all
the references to support the safety, efficacy and mechanism of action.
There is no evidence that EC can cause an abortion.

**Birnbaum, Bernard \[Bernard.Birnbaum@CHINLE.IHS.GOV\]**

**Tue 12/16/2003 12:11 PM**

Another thought about EC\... I think it is reasonable to prescribe ahead
of time for select patient - that would address both the issue of
availability (b/c it would give pharmacies that didn\'t have it time to
order it) and would give women the choice to use it like an OTC med..
Clearly this requires adequate family planning counseling. EC should be
discussed at every contraceptive visit for appropriate patients\...

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Tue 12/16/2003 1:32 PM**

Maybe we can try some non-controversial subjects?

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Tue 12/16/2003 1:14 PM**

Emergency \"Contraception\" and Early Abortion

The recent approval by the Food and Drug Administration (FDA) of a new
drug (Preven), specifically for use as \"Emergency Contraception\" (EC),
is raising questions as to whether the drug\'s mechanism is
contraceptive or abortifacient in nature.

A major problem in this debate is the manipulation of terms. The FDA,
American College of Obstetricians and Gynecologists (ACOG) and abortion
advocacy groups long ago endorsed a change in the definitions of
\"conception\" and \"pregnancy\" to confuse the issue. Instead of
equating conception with fertilization, and seeing a woman as pregnant
if her body contains a living, developing embryo, they equate
\"conception\" and \"pregnancy\" with the implantation of the embryo in
the uterus 6 to 10 days later. Thus a drug or device that destroys the
early embryo or disrupts its development is redefined as
\"contra-ceptive,\" even though it is abortifacient in nature.

What is EC?

The new Preven regimen and similar so-called \"morning-after\" pills,
which can actually be taken several days after intercourse, are high
doses of ordinary birth control pills containing estrogen and progestin,
which have long been known to inhibit pregnancy. In response to years of
pressure from some medical and advocacy groups, the FDA recommended six
brands of oral contraceptive pills in high doses (Ovral, Lo/Ovral,
Nordette, Levlen, Triphasil, and Tri-Levlen) as \"safe\" and
\"effective\" for use as \"postcoital EC\" in February 1997.

EC pills are intended for use no later than 72 hours after
\"unprotected\" intercourse. One dose of pills is taken within 72 hours
and a second dose 12 hours later. Proponents claim that the pills are
75% effective in preventing pregnancy. Planned Parenthood, which offers
the regimen at many of its sites, says that the method is for \"special
circumstances\" such as after \"contraceptive failure\" or sexual
assault. (This raises the question: How can it be contraception, if
contraception has already \"failed\" so that conception has occurred?)
The method offers no protection against sexually transmitted diseases.
It also poses greatly increased health risks for smokers, although there
are virtually no warnings about this, according to Hanna Klaus, MD,
FACOG. About half the women taking ECPs experience nausea and 20% may
vomit for up to two weeks. Potentially fatal ectopic pregnancy (after a
high dose of estrogen) is also among the possible side effects.

How does EC work?

While Preven and other EC pills are FDA-approved as \"contraception,\"
medical and advocacy groups admit that the pills work in a variety of
ways. While these pills may sometimes have a contraceptive mode of
action because they prevent or delay ovulation or fertilization, they
are designed to prevent implantation as well.

According to the FDA, \"EC pills \... act by delaying or inhibiting
ovulation, and/or altering tubal transport of sperm and/or ova (thereby
inhibiting fertilization), and/or altering the endometrium (thereby
inhibiting implantation)\" (FDA Notice, 62 Fed. Reg. 861 \[Feb. 25,
1997\]).

The Alan Guttmacher Institute\'s Family Planning Perspectives made the
same observation in 1995: \"Emergency contraceptive pills, also known as
morning-after pills, are a postcoital hormonal treatment that appears to
inhibit implantation of the fertilized ovum\" (C. Harper and C.
Ellertson, \"Knowledge and Perceptions of Emergency Contraceptive Pills
Among a College-Age Population: A Qualitative Approach,\" 27 Family
Planning Perspectives 149 \[July-August 1995\]). It is this
abortifacient mode of action that EC proponents often downplay.

A recent editorial favoring EC in a major medical journal made a
fascinating connection in commenting on the drug\'s mode of action:
\"From a medical point of view, the use of emergency contraception
should not be considered abortion, since, as demonstrated daily in
programs for in vitro fertilization, pregnancy in a woman cannot begin
until the fertilized ovum is implanted in her uterus\" (P. Stubblefield,
\"Self-Administered Emergency Contraception \-- A Second Chance,\" 339
New England Journal of Medicine 41 \[July 2, 1998\]).

To most people, what IVF has underscored is the fact that a life begins
with fertilization (hence the popular name \"test-tube baby.\") The
editorial\'s analogy only proves that, if we want to call EC

\"contraception,\" we must also call it merely \"contraception\" to
deliberately discard and destroy developing human embryos in the
laboratory. Congress has never taken this view.

Abortion or Contraception?

A woman who uses EC after unprotected sex clearly intends to prevent
pregnancy. However, she may be quite unaware of \"where\" she is in her
cycle (i.e., whether or not she has ovulated). Although she may not
intend to abort, the drug\'s action of altering the endometrium to
interfere with implantation may in fact abort the developing embryo.

This point cannot be overemphasized. \"Taking a high level of estrogen
via ECPs within 72 hours of intercourse once the fertile phase has begun
will, in fact, precipitate ovulation. This will make it more likely,
rather than less, that fertilization will occur,\" according to Dr.
Klaus. Once an ovum

is in the Fallopian tube, the process of fertilization may begin within
15 to 30 minutes after intercourse. Thus some researchers conclude that
interfering with the endometrium \"could explain the majority of cases
where pregnancies are prevented by the morning-after pill\" (J. Wilks, A
Consumer\'s Guide to the Pill and Other Drugs at 154 \[1997\], citing F.
Grou and I.

Rodrigues, \"The morning-after pill: How long after?\", 171 Am. J.
Obstet. Gynecol. 1529-34 \[1994\].) Without implantation, which occurs
about a week after fertilization, the embryo cannot develop and will
die.

Brown University associate professor of medicine, Ralph Miech, M.D.,
Ph.D., agrees. \"This type of pill causes an abortion,\" he wrote in the
Providence Journal on August 3, 1998. \"From a pharmacologic
perspective, this type of pill should be called an \'abortion-after
pill\'.\"

The question must be asked: \"How is this contraception?\" Women are
being falsely led to believe that these pills are contraceptive in
nature. But one of their common and intended modes of action is to
prevent the development of the embryo, resulting in his or her death.

October 1998

**Burke, Thomas \[tburke@ANMC.ORG\]**

**Tue 12/16/2003 2:08 PM**

I think there are two very separate issues regarding Plan B or other
post coital contraceptives.

1 Once an institution has decided to offer this service then all members
of the staff including pharmacy and nursing need to work within the
decision or excuse themselves from the patients care. It\'s very
difficult when the patient gets conflicting messages and as
professionals we need to leave our personal politics outside the exam
room.

2-If a patient thinks of these methods as abortion then it is an
abortion. It is not our job to try to change patients' beliefs. The
question of what is an abortion is only a medical fact to us, for a
patient it is a moral or religious belief. If you persuade a patient to
accept treatment that is against their beliefs the may regret it later.

Leaving our politics outside the exam room works both ways.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Tue 12/16/2003 3:12 PM**

Thanks to Erik Johnson for so nicely illustrating the controversy over
emergency contraception. It\'s a question of semantics. If pregnancy
begins with fertilization, then EC, by preventing implantation, may
abort a pregnancy. If pregnancy begins with implantation, then EC is not
an abortifacient. Clearly those who oppose abortion and believe that
pregnancy begins with fertilization should not use emergency
contraception. The accepted medical definition of pregnancy is that it
begins with implantation and those who oppose abortion but agree with
that definition can use EC. The central ethical question, however, is
whether those opponents to abortion who believe that EC does abort a
pregnancy should impose their definition and their values on patients
who may not share those definitions and values. They would do so if they
prevent those patients from having easy access to EC. The ethical
approach for such providers would be to refer the patient to another
provider and leave it up to the moral values of the patient, herself as
to whether she wants to use EC.

PS. Smokers may safely use EC. There is no data showing any increased
risk in short-term users. The risk for combined contraceptives is based
on women who used OCs as ongoing contraception, not short burst users.
In addition, Plan B, the levonorgestrel EC has no estrogen.

N. Burton Attico, MD \[nbattico@POL.NET\]

Tue 12/16/2003 9:00 PM

Alan, Thanks for introducing those comments. Semantics is a part of
\"the game.\" ACOG defines pregnancy as beginning at implantation. We
also know from the sensitive pregnancy tests, and IVF work, that a large
percentage of fertilizations do not implant, that they dissolve, and/or
spontaneously abort - either way, they terminate spontaneously. That is
why 3-5 embryos

are routinely inserted (it was 4-8 at one time previously), so that at
least 1 embryo might potentially implant (and often doesn\'t). With Plan
B, which is only progestin, part of its action is changing cervical
permeability, as well as influencing tubal motility, and potentially
changing the endometrium. We really don\'t know how it works, except for
Hatcher\'s theories on EC. This is a very controversial subject, with
latest word being that the expert committee voted today to approve OTC
sale of Plan B.

California also has EC sale by pharmacists, although its a \"behind the
counter\" sale - she has to ask the pharmacist. In IHS, Pharmacist
Practitioners can dispense EC as a direct provider.

**Vasser, Donald \[donald.vasser@SHIPROCK.IHS.GOV\]**

**Wed 12/17/2003 7:57 AM**

This has been a good discussion. Clearly, a lot of things can be
justified simply by changing the terminology.

Obviously, those of us who believe, with good reason, that a new human
being is formed at conception cannot participate in this kind of
treatment and must be allowed by our patients and fellow-staff to excuse
ourselves from doing this, just like we would be excused from
participating in an \"official\" abortion.

It also clearly raises an issue of informed consent: Those of you who do
prescribe \"emergency contraception\" are obligated to explain to
patients the possible mechanisms by which the treatment works and the
ethical issues surrounding it. If you simply tell the woman \"Take these
pills and they will keep you from becoming pregnant,\" you may be
leading her down a path that she herself has ethical objections to and
will regret later.

**Majus, George (PIMC) \[george.majus@MAIL.IHS.GOV\]**

**Sun 12/21/2003 10:47 AM**

I understand what you are saying.  I spoke with providers on both sides
of the issues.  The one thing I came away with, was, that we have to
respect those providers who do use it and those who choose not to use
it.  Pregnancy is a state of health. It is not an illness, so the ethics
are different.  Since it is a state of health, it is the provider's
choice to use the morning after pill.  Emergency contraception is a poor
term.  There is nothing emergent about it and it is not contraception. 
It does not prevent pregnancy, it prevents implantation of the
fertilized egg.

For those who believe life begins at fertilization, this probably is not
an option for the provider or the patient, if the patient believes
this.  For those who choose to believe life begins at implantation or
those who believe life begins when you first can hear the heart beat,
this might be their choice.  But as one doctor described his belief to
me.  \"the morning after pill causes the patient to shed the lining in
the uterus, which causes the fertilized egg to have no possibility of
implantation, thus aborting the pregnancy\" to him it is an early
abortion and he chooses not to do it.  I see both sides of the ethical
issue.  The best treatment in my mind, is if a provider does not believe
in it, then do not see the patient. Let some one else see them or refer
them to OB/GYN clinic after explaining to the patient how the morning
after pill works, so the patient really is making an informed decision.

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Sun 12/21/2003 11:03 AM**

\"The best treatment in my mind, is if a provider does not believe in
it, then do not see the patient, let some one else see them or refer
them to OB/GYN clinic after explaining to the patient how the morning
after pill works, so the patient really is making an informed
decision.\"

The description of preventing implantation is also not a fully informed
mechanism, but also an opinion. ACOG defines pregnancy as beginning with
implantation, and the experiences with IVF further serve to further
strengthen this as the definition. Providers have come up with all sorts

of independent definitions of when pregnancy begins, ranging all the way
from the instant of fertilization to quickening, and each having some
basis as to why they chose that personal definition.

Therein lies a problem, as no one is sure at present exactly how EC
works, and the explanation will therefore be biased with the provider\'s
opinions. The major question is whether the patient is bound by the
provider\'s beliefs, or by the patient\'s own beliefs. If all give the
patient a

different background, it will not be an \"informed decision,\" but a
decision muddied by whichever provider the patient saw. DHHS rules do
specifically allow medications or procedures which block implantation.

Should the patient be \"blocked\" from being able to obtain something
that is defined in DHHS rules as being legal?

**Brunk, Donald \[donald.brunk@SHIPROCK.IHS.GOV\]**

**Mon 12/22/2003 10:35 AM**

I find it interesting that in spite of definitions of pregnancy by ACOG
we all date the pregnancy from the first date of the LMP, before
fertilization.

Why do we all date something that is undefined? Does this practice argue
against \"The Definition\"?

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Mon 12/22/2003 2:38 PM**

If you can\'t argue with the facts, then you change the definition. If
you can\'t play by the rules, change the rules. There\'s this thing from
Lewis Carroll I\'ll have to look up, where Humpty Dumpty says something
like the true meanings of words are too tyrannical to him, so he makes
the words mean what HE wants them to mean.

**Calder, William \[William.Calder@MAIL.IHS.GOV\]**

**Mon 12/22/2003 3:11 PM**

Since we have strayed so far from clinical medicine, which I have also
greatly appreciated, and into the equally fascinating realms of religion
and philosophy, I\'ll chime in, too. I agree, its really a matter of
personal beliefs for both patients and provider, with none of us having
a

mandate to change another\'s beliefs, excepting where boundaries are
imposed by regulations of the HHS institution as reflected by our larger
social culture.

If we could for a moment be somewhat more intellectual about it, then
consider stem cells and the life that clearly springs from even just one
cell. If we look even briefly in a microscope, in vivo sperm and egg
cells are each, on their own, clearly alive, sperm obviously moving and
each

physiologically active with purpose and potential. Life doesn\'t start
with any particular stage of development, however we might artificially
define it for social convenience or taxonomic classification; it is
ongoing at every single stage we are clever enough to identify, to think
we understand, or even to think we can regulate. For those of us blessed
to work in IHS, we have an opportunity to learn from a tradition in
which life is viewed as an unending and unbroken continuum, with value
and meaning at each and every point. Both this perspective and our
microscope render the question of \"when does life start\" as a
superficial and meaningless question; one usually posed from a dogmatic
agenda that already comes equipped with a comfortable answer.

Really for us to be consistent as a society, and if all life is to be
held sacred, then our compassion in avoiding abortifacients must also
extend to death row, to the lives of unwanted children born into being
unwanted, and indeed to all of our \"collateral damage\" innocents we
allow to die in other countries from stray bombs that fall from our own
warplanes.

I would suggest, especially in this holiday season, all life should be
held as worthy of our profound respect, and so should be the personal
beliefs of the both the patients we care for, and the providers who
care.

[**jsears01@citlink.net**](mailto:jsears01@citlink.net)

**Mon 12/22/2003 8:36 PM**

Well folks,

I hear what you\'re saying. However, there are too many unwanted
pregnancies and too many abortions in this world. If Plan B can decrease
those numbers, I am for it!

Ethics and morals have their place; don\'t get me wrong. In a perfect
world every baby would be planned and wanted. Unwanted babies are a
burden on the parents and society. The world is overpopulated, if you
haven\'t noticed. Abortion is mean and nasty. What do you call having a
baby that you don\'t want and/or can\'t afford? Plan B can decrease the
numbers of abortions, and it should be available OTC!

What that means in IHS is still up for debate.

**Ed Fields \[Edward.Fields@CHINLE.IHS.GOV\]**

**Tue 1/6/2004 9:08 AM**

Unfortunately, with all to many subjects, irrationality rules the
intellect.

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Tue 1/6/2004 12:34 PM**

To add to the controversy, here is an Op Ed piece from the N.Y. Times.
The history of \"the pill\" is important, and there were some unwritten
IHS rules about its use early on. Are we repeating the past? I remember
in my own infertility clinic, when there were questions and also
restrictions about unmarried women seeking infertility services . . . .
Many pregnancy surrogates are not married women, but are making an
important contribution to others.

The Big Lie About the Little Pill

By JOSHUA M. ZEITZ

The recent recommendation by two advisory committees that the Food and
Drug Administration should legalize over-the-counter access to the
morning-after pill seems likely to intensify the culture wars that have
dominated public and political discourse over the years.

Opponents of the emergency contraceptive, known as Plan B, say they are
concerned that among other things, widening access to the morning-after
pill will encourage sexual promiscuity, particularly among young people.
It was this apprehension that led Dr. W. David Hager of the University
of Kentucky to join three other committee members in voting against the

recommendation. Dr. Hager said he worried that Plan B was no less
revolutionary than the birth control pill, which he claims ushered in
\"a new day and age for the expression of sexuality among young
people.\"

Dr. Hager\'s argument is a common one. Legalized by the F.D.A. in 1960,
\"the pill\" has been widely described as starting a revolution in
sexuality and morals. But that is based on a misunderstanding of the
history of America\'s sexual revolution and the pill\'s role in it.

Before 1960, the story goes, the natural constraints of human biology
held Americans to strict standards of sexual discipline; after 1960, and
after the pill, Americans threw off the shackles (or, depending on
one\'s political perspective, the civilizing influence) of sexual
propriety. Ever since, we\'ve been either slouching toward Gomorrah or,
as Clare Boothe Luce once famously announced, living in an age when the
\"modern woman is at last free as a man is free, to dispose of her own
body, to earn her living, to pursue the improvement of her mind, to try
a successful career.\"

That\'s a lot of power for one little pill. In truth, this narrative is
flawed. Though the pill surely made contraception easier, and while it
gave women more power and responsibility in family planning, it hardly
created a sexual revolution. American sexual habits had been changing
long before the pill found its way onto the market. Early sex surveys
revealed that about half of all women who came of age in the 1920\'s
admitted to engaging in premarital sex (defined as coitus), a figure
that held steady for women in later decades.

Americans were also practicing birth control long before the pill. As
early as 1938 a poll commissioned by The Ladies\' Home Journal found
that roughly four of every five women approved of using birth control.
Just over two decades later, on the eve of the pill\'s legalization, 80
percent of white women and 60 percent of nonwhite women reported
practicing some form of family planning.

Even the heightened sexual permissiveness of the 1960\'s can\'t be
attributed to the pill. Throughout the better part of the decade doctors
generally prescribed the first oral contraceptive, Enovid, only for
married women, who made up the drug\'s largest market share in its early
years. As late as 1971 only 15 percent of unmarried women age 15 to 19
used the pill. Even in recent times, only about 23 percent of women age
15 to 24 report using it.

The pill, then, did not create America\'s sexual revolution as much as
it accelerated it. And that revolution had been a long time in the
making.

Over the course of the 19th century the average number of children born
to married couples dropped to about four from about seven. Americans
probably weren\'t having less sex. Instead, couples - particularly those
in the growing middle class, whose families no longer required legions
of children to work on the farm - were practicing birth control. They
were coming to view sex as an activity that wasn\'t merely procreative,
but also central to pleasurable and loving marriages.

In the early 20th century many Americans began experimenting with sex
outside of matrimony - partly because they could. By the 1920\'s a
majority of Americans lived in urban areas where they enjoyed greater
anonymity and social freedom. Meanwhile, a growing leisure culture
provided a host of places - from dance halls to movie theaters - where
men and women could meet.

At the same time, as an educated work force became increasingly
important to the vitality of America\'s advanced economy, more young
people (75 percent by the 1920\'s) attended high school, creating a new
heterosocial peer culture.

In the early 20th century more young women also entered the work force,
where they came into increased contact with men and enjoyed a limited
amount of financial and social freedom that could translate into a
loosening of sexual mores. This was particularly the case in the early
1940\'s, when millions of women (and exempted men) mobilized for war
production, and 16 million of their husbands and boyfriends enlisted in
the armed services. The resulting demographic and social upheaval
created an explosion of sexual freedom.

Finally, the ever-rising influence of consumerism and advertising after
1900 chipped away at the Victorian-era culture of asceticism and
self-denial, in effect legitimating the pursuit of pleasure. In a world
where Americans were encouraged to \"find a road of happiness the day
you buy a Buick,\" other activities that made people happy - like sex --
seemed less taboo than in prior years.

Though many young women from the 1920\'s onward engaged in premarital
sex, they probably did so with the intention of marrying their partners.
The revolution in morals was tame by later standards. Nevertheless,
women and men were steadily redefining the boundaries of romance and sex
long before the pill appeared.

The history of America\'s encounter with the pill helps inform today\'s
debate over Plan B. Oral contraception was a vital development in
women\'s reproductive rights and health, but it didn\'t cause a
revolution in morals and behavior any more than Plan B is likely to
sexualize a nation of young people who are already sexually active.
Surveys suggest that more than 75 percent of young people have sex
before they turn 20, yet only about one-fifth of sexually active high
school girls use the pill.

None of this minimizes the importance of either the birth control pill
or Plan B. Technology has always been an important catalyst of
historical change. But America\'s sexual revolution was a long,
complicated phenomenon. No pharmacist can stuff it into a bottle.
Cultural critics shouldn\'t try to do so, either.