Discipline Farmaceutic Disiplina Sex

L. L.
Wynn
Office of Population Research
Princeton University
James Trussell
Office of Population Research
Princeton University
The Social Life of Emergency Contraception

in the United States:
Disciplining Pharmaceutical Use, Disciplining Sexuality, and Constructing
Zygotic Bodies
This article is an examination of the FDA hearing on a proposal to permit nonpre-

scription access to the emergency contraceptive pill Plan B. Participants debated the
drugs impact on female and young adult sexuality, illustrating how the rhetoric over
disciplining pharmaceutical use in the American public is a displaced language for
talking about disciplining womens and girls sexuality. Debate over Plan B also fo-
cused on its mechanism of action and whether or not it was abortifacient, revealing
a medical technology characterized not only by moral but also by marked scien-
tific ambiguity. The scientific framing of the politics of emergency contraception is
testament to the powerful authority of biomedicine to narrate and thus produce ide-
ologies of bodies (individual, embryonic, social, and political), sexuality, and selves.
The discourse on access to Plan B in the United States demonstrates how womens
bodies are sites of control where the politics of sexuality, discourses on public health,
and medical constructions of biological processes intersect.
Keywords: [contraception, abortion, new medical technology, sexuality,
biomedicine]
New medical technologies are good to think with. Their very novelty makes them
prime subjects for debate over the meaning of medicine and science in a social and po-
litical order. Examining these debates can reveal cultural categories, social conflicts,
and the relationship between individual bodies and the body politic (Scheper-Hughes
and Lock 1987).
Emergency contraception (EC) is one such new medical technology for Ameri-
cans. EC refers to methods of contraception that are taken after sexual intercourse
to reduce (but not eliminate) the risk of pregnancy. Emergency contraceptive pills
Medical Anthropology Quarterly, Vol. 20, Number 3, pp. 297320, ISSN 0745-5194, online
ISSN 1548-1387. C 2006 by the American Anthropological Association. All rights reserved.
Permission to photocopy or reproduce article content via University of California Press Rights
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297
298 Medical Anthropology Quarterly
(ECPs) were thrown into the political spotlight in 2003, when Womens Capital Cor-
poration applied to the U.S. Food and Drug Administration (FDA) to make their
brand of ECPs, Plan B (later acquired by Barr Laboratories), available without a
prescription. The FDA scheduled a hearing for December 2003, and a large number
of medical groups and activists representing a wide spectrum of political positions
promptly mobilized to try to sway public opinion and to influence the outcome of
the hearing.
This article tells the story of the FDA hearing and the public arguments offered
for and against allowing nonprescription access to ECPs. This includes the argu-
ments and questions voiced by members of the FDA advisory committee who were
considering the Plan B application as well as statements by citizens and national
organizations in the FDAs open public hearing. We supplement an analysis of the
hearing with materials published in print or online by opponents and proponents
of EC to reveal the complex fashion in which medical authority and expert opinion
are strategically wielded and deconstructed. Opponents in the debate over nonpre-
scription ECP access invoke both health and morality as sometimes overlapping,
sometimes competing interests that the state has an interest in safeguarding.
The debate over nonprescription access to ECPs in the United States revolves
around medical descriptions of biological processes yet simultaneously seeks to
reinterpret these abstract, theoretical biological processes and give them new social
meaning. The FDA hearing revealed a medical technology characterized by marked
cultural ambiguity about the meaning of pregnancy, conception, and contraception.
The discourse on ECP access in the United States demonstrates how womens bod-
ies are sites of control where the politics of sexuality, discourses on public health,
and medical constructions of biological processes intersect (Ong 1988:35). Analy-
sis of the public statements and political strategies of pro- and anti-EC advocates
reveals competing ideologies of bodies, sexuality, and fetal personhood. The FDA
hearing illustrates how the rhetoric over disciplining pharmaceutical use in United
States is a displaced language for talking about disciplining sexualityparticularly
the sexuality of young people and women.
Emergency Contraception in the United States

The FDA approved the first hormonal contraceptive pill in 1960. In that same decade,
the postcoital administration of high doses of estrogen was first used as a treatment
for rape survivors (Van Look and von Hertzen 1993). In 1974, Canadian gynecolo-
gist Albert Yuzpe introduced guidelines for using a combined estrogenprogestin pill
for postcoital contraception (Yuzpe et al. 1974). The Yuzpe regimen prescribed
the use of high doses of certain regular birth control pills, taken up to 72 hours af-
ter sex, to reduce substantially the risk of pregnancy.1 Researchers later found that
progestin-only pills could be used with greater efficacy and fewer side effects than
combined estrogen-progestin pills. However, because the only progestin-only pills
available for hormonal contraception in the United States were low-dose formula-
tions (often termed the minipill and prescribed for breastfeeding women), the number
of pills required to attain the dose needed for emergency contraception is 40.2
It was not until 1998 that a dedicated ECP (i.e., pills packaged and labeled
for EC use) was approved by the FDA for prescription use in the United States.
Emergency Contraception in the United States 299
Preven, a combined estrogenprogestin ECP, was estimated to be about 75 percent

effective in reducing pregnancy risk when taken up to 72 hours after intercourse.3
A year later, a progestin-only ECP called Plan B was approved by the FDA. After
the pharmaceutical company Barr Laboratories acquired both Preven and Plan B
from their original manufacturers, they discontinued production of Preven, because
Plan B was both more effective (estimated to be 89 percent effective at reducing
pregnancy risk when taken up to three days after intercourse) and caused fewer side
effects.
In April 2003, the company later acquired by Barr Laboratories applied to the
FDA to switch Plan B from prescription to over-the-counter (OTC) status. A public
hearing was scheduled for December 16, 2003, convening both the FDAs Nonpre-
scription Drugs Advisory Committee and the Advisory Committee for Reproductive
Health Drugs. In addition to the standing FDA committees, the FDA hearing on Plan
B also included four voting consultants who were not regular committee mem-
bers, as well as one nonvoting acting industry representative and six nonvoting
FDA participants.4 The latter included Steven Galson, the acting director for the
FDAs Center for Drug Evaluation and Research, who was eventually to make the
final FDA decision regarding Plan B.
The FDA Hearing

The FDA hearing ran from 8:00 a.m. to 5:00 p.m. and was simultaneously broadcast
live over the Internet.5 FDA representatives opened the meeting and introduced
the issues to be debated. There were six questions, essentially revolving around
safety of the drug and whether the label developed for nonprescription use would
lead to consumers using it properly. The first five led up to the final question that
the committee would vote on at the end of the day: should Plan B be switched to
nonprescription status?
After introductions, Carole Ben-Maimon, the president and chief operating of-
ficer of Barr Research, presented Barrs case for taking Plan B OTC. Ben-Maimon
also introduced other medical authorities outside of the pharmaceutical industry in
support of the Plan B application. Vivian Dickerson, M.D., representing the Amer-
ican College of Obstetricians and Gynecologists (ACOG), testified that ACOG was
taking what she described as the rare step of publicly supporting a pharmaceuti-
cal product because it felt strongly as an organization that ECPs should be made
available without prescription to American women. More than 60 major medical
professional associations expressed public support for Barrs application, including
the American Medical Association (AMA), the Society for Adolescent Medicine, and
the American Association of Pediatrics.
The arguments of Barr Laboratories and its supporters for making Plan B avail-
able OTC were largely framed in terms of its safety and ability to reduce unintended
pregnancy and abortion. They presented evidence that Plan B was safe for women
to use without medical supervision, and they emphasized that its effectiveness in
preventing unintended pregnancy declined as the delay between unprotected in-
tercourse and taking the pills increased.6 Notably, both Ben-Maimon of Barr and
Dickerson of ACOG also spent much of their testimony emphasizing that Plan B
was a contraceptive, not an abortifacient.
The other expert testimony that Ben-Maimon marshaled in support of Barrs

application was that of David Grimes, vice president of Biomedical Affairs at Family
Health International, who also cited public health reasons for making ECPs more
readily available. He pointed out the high morbidity rates associated with pregnancy
and argued that expanding access to ECPs could eliminate such morbidity as well
as reduce abortion rates. Reducing the need for abortion was presented as a goal
in itself, justified on neither moral nor health grounds. But Grimes also suggested
a third reason for making ECPs available: peace of mind for the women taking
them. Amid all the previous talk about public health, morbidity statistics, and the
vague notion of abortion as bad (but for unspecified reasons), suddenly the audience
was introduced to an individual womans subjective experience of unprotected sex
and the fear of unintended pregnancy.
The Open Public Hearing

Barrs sponsor presentation was followed by a briefing in which several FDA rep-
resentatives reported on the agencys internal review of the product and proposed
labeling. They reviewed all of the available scientific research on progestin-only
ECPs and concluded that the overwhelming scientific consensus was that the drug
was both safe and effective for OTC use.
After the FDA briefing, an hour and a half was allotted for an open public hearing.
Individuals had applied in advance to speak and submitted materials in support of or
in opposition to Plan Bs going OTC. Speakers were allotted three minutes to make
their case orally; after three minutes, their microphones were cut off. The consider-
able number of speakers scheduled for the public hearing reflected the widespread
politicization of EC in the United States, with the FDA hearing serving as the new
focal point for activism.
This public hearing blended a curious mixture of dry, public health arguments
invoking expert authority and scientific research with vivid and personal arguments
by political activists on both sides of the debate. Among the first speakers were rep-
resentatives from two major national organizations that combine political activism
with health care provision. Both the representatives from Planned Parenthood Fed-
eration of America and the National Family Planning and Reproductive Health
Association were medical doctors whose arguments in support of OTC access were
supported by a body of impeccably authoritative medical and social science research
published in well-known, peer-reviewed medical journals. Neither of these activist
organizations framed the issue in terms of choice or womens rights, arguments
for which they are well known. Rather, they argued that the OTC switch would
address important public health goals (p. 162).
Large national organizations opposing increased access to ECPs were also rep-
resented, including Concerned Women for America (CWA), the Catholic Medical
Association, the American Life League, and Human Life International. Some of
these also were represented by experts who prefaced their remarks by announcing
their academic credentials (two of the CWA representatives were registered nurses,
whereas the Catholic Medical Association representative was a medical doctor). Sev-
eral private citizens with medical degrees also spoke against the Plan B switch. Most
made safety the main theme of their arguments, but the conclusions they drew from
the medical literature were completely at odds with those of the pro-EC advocates.
Three representatives from CWA claimed that no studies had established the safety
of the drug, particularly its long-term potential health consequences (p. 174). The
Catholic Medical Association representative invoked the public health disaster that
would ensue if teens used Plan B without medical advice from a health professional
(p. 197), including the rampant spread of sexually transmitted infections (STIs) and
pregnancy among teens who, he argued, would no longer have an incentive to use
condoms. Daniel Hussar, a pharmacist and professor at the Philadelphia College
of Pharmacy, also raised the specter of the risk it posed to a fetus conceived while
(or despite) taking the drug.7 The American Life League representative dramatically
charged that Plan B was potentially deadly (p. 213).8
In addition, many of these EC opponents claimed, in opposition to the testi-
mony of the Barr and ACOG representatives, that ECPs were abortifacient. Chris
Kahlenborn, a Pennsylvania medical doctor, Daniel Hussar, the pharmacist, and
Judie Brown, the president of the American Life League, all asserted that ECPs
acted as an abortifacient, not a contraceptive, because they had the potential to pre-
vent a fertilized egg from implanting in the uterus. Beth Jordan, the medical director
of the Feminist Majority Foundation, retorted that anti-EC advocates willfully or
naively conflated contraception and abortion, thus increasingly infringing upon
a womans right to choose even contraception (p. 186).
Aside from the medical practitioners who spoke, many activists from various
national and grassroots organizations as well as a number of private individuals
had signed up to speak at the public hearing. From these came the most colorful
arguments in support of and against expanded ECP access. Robert Marshall, a state
legislator from Virginia, said, As I look around the room today, one name that
should be on this NDA [new drug application] is Hugh Hefner. Playboys, adolescent
adult males, are going to be the primary beneficiaries of this. In fact, I will suggest to
you they may be the major purchasers of this, who in turn will sell it to high school
kids (pp. 162163).9 The Pennsylvania doctor claimed that in Jamaica, once ECPs
went OTC, women were using it as sweets (p. 199). The representative from the
American Life League implied that a conspiracy of sorts lay behind the creation of
ECPs:
Pills such as Plan B are designed with one purpose in mind: to destroy
the evidence that a sexual encounter has occurred that could result in the
conception of a child. The emergency in this case is a baby. If these pills
are made available over the counter, adolescents who might have given
such a result a second thought will not be inclined to take pregnancy into
consideration before engaging in risky sex. [pp. 213214]
One private physician conjured a vision of a nationwide epidemic of sexually
transmitted diseases (p. 188) if ECPs were to go OTC, particularly among the
nations teens. A representative from CWA echoed the legislator from Virginia by
invoking the specter of incestuous, adult sexual predators using ECPs to rape chil-
dren and adolescents without fear of being caught by pregnancy: Making ECs
available would be a welcome tool for adult sexual predators who molest family
members, children of friends or students. They could keep a stash in their bedroom
drawer or their pocket to give their victims after committing each rape (p. 227).
Expert Opinion and Political Activism

In support of the Plan B application, the National Organization of Women (NOW)
had devised what was clearly a unified strategy. Six members from three local chap-
ters of NOW described their personal experiences when trying to get ECPs. Instead
of framing the need for ECPs in terms of an abstract public health issue, scientific
studies on medical safety and use patterns, or concerns over hypothetical rapists and
teen playboys, these women all described their concrete experiences when seeking
ECPs: difficulties in finding doctors to prescribe; delays in getting appointments after
hours and on weekends; the high costs of doctor appointments; and doctors intru-
sive queries about their sexual relationships. One spoke of being in a new town and
having to call dozens of medical providers before she could find someone who would
prescribe ECPs; another said that when she had needed EC and did not have health
insurance, she had risked pregnancy because she could not afford the $150 for the
doctors appointment. Several also pointedly observed that their health insurance
plans covered Viagra, but not ECPs.
The NOW representatives deconstructed the notion of expert opinion that had
guided the hearing up to that point, in which each speaker prefaced her or his remarks
by listing medical and organizational credentials. For the NOW speakers (none of
whom were medical health professionals), being a woman, not a medical expert,
was what constituted credentials: We have a lot of experts in the room today, but I
have taken the morning after pill, and I know what could have happened if I hadnt
had it on hand, and I know what could happen to me if it isnt over the counter. I
think that makes me an expert (p. 178).
It was during the public hearing that arguments about medical safety made way
for more explicitly moral arguments in support of or against expanded ECP access.
Many of these revolved around the theme of control over ones own body. One NOW
representative argued that women had the right to make their own reproductive
health decisions: I must have the right to control my body and my life (p. 193), a
statement that earned the speaker a round of applause from the audience. However, a
proponent of natural family planning who was opposed to EC said that people
need to learn when to say yes and when to say no to sex (p. 182). Another EC
opponent reacted to the testimony of the NOW representatives, saying, Another
common thread that runs through these stories is the inability to control themselves
in sexual situations. As a young woman, how sad it is to know that these women are
slaves to their bodies and that the organizations they represent lead them to believe
that they themselves cannot control themselves (p. 239).
What the public hearing reflected, more broadly speaking, was not only the fact
that EC had become widely politicized in the United States but also the way that
grassroots activism, both in support of and opposing increased ECP access, came to
focus on this one FDA decision. To be considered as a speaker in the public hearing
required significant advance notice and preparation, and 41 different speakers were
scheduled and their remarks included in the official FDA transcripts of the hearing.10
The FDA hearing represents a key moment in the social life of this new medical
technology because it encapsulates the long-term activism by different groups and
showed who were (or who sought to be) the main players in the arena of public
opinion making around womens reproductive health.11 Many of these players have
also been vocal participants in debates over other new reproductive technologies
in the United States, including medication abortion, embryonic stem cell research,
assisted reproductive therapies, and therapeutic and reproductive cloning.
The FDA Decision

At the end of the day, the voting committee members were asked by the chair to
vote on the six questions concerning the OTC application. Twenty-three committee
members voted in favor of switching Plan B to nonprescription status. The four who
voted against taking Plan B OTC were Louis Cantilena, the chair of the Nonpre-
scription Drugs Advisory Committee, and the three Bush appointees to the FDAs
11-member Advisory Committee for Reproductive Health Drugs, Susan Crockett,
Joseph Stanford, and David Hager, all physicians. Susan Crockett sits on the board
of the American Association of Pro-Life Obstetricians and Gynecologists, and is the
coauthor of a chapter entitled Using Hormone Contraceptives Is a Decision Involv-
ing Science, Scripture, and Conscience, published in The Reproduction Revolution
(Horizons in Bioethics Series): A Christian Appraisal of Sexuality, Reproductive
Technologies, and the Family.12 Joseph Stanford, a vocal proponent of natural
family planning from the University of Utah, does not prescribe any hormonal
contraceptives to his patients, whether married or not, because of the possibility
that they might prevent implantation of what he calls newly formed human life.13
And finally, W. David Hager is probably the most well known of Bushs FDA ap-
pointees: when he was appointed, it was widely reported in the media that in his
private practice, Hager refused to prescribe contraceptives to unmarried women,
and he had published several books linking his approach to reproductive health
with evangelical Christianity, including recommendations about specific scriptures
and prayers for women seeking relief from premenstrual syndrome.14
Numerous observers have commented on the peculiarity of the Bush administra-
tions appointing to the Advisory Committee on Reproductive Health Drugs three
physicians who have published objections to womens using drugs for their reproduc-
tive health, ranging from analgesics for treating premenstrual syndrome to hormonal
contraceptives to mifepristone for early abortion. Thus, it took no one by surprise
when these three voted against making Plan B available OTC. But because 23 out
of 27 committee members voted in favor of the switch, it was widely expected that
the FDA would approve the Plan B application.
But on May 6, 2004, the FDA issued a not approvable letter, signed by Steven
Galson, acting director of the FDAs Center for Drug Evaluation and Research.15
The letter cited a lack of sufficient data on young adolescents use of Plan B.16 In July
2004, Barr resubmitted its application, asking for Plan B to remain a prescription-
only medicine for women aged 15 and younger but to otherwise be available without
prescription (an option suggested in Galstons letter rejecting the first application).
The FDA had until January 21, 2005, to respond. As had happened with the original
application, the deadline came and went without the FDAs making a decision. On
July 15, 2005, Health and Human Services Secretary Leavitt promised that FDA
would act on Barrs application by September 1 to ensure a vote on Senate confir-
mation of Lester Crawford as FDA commissioner. On August 26, 2005, Crawford
announced an indefinite delay in reaching a decision on the new Barr application, cit-
ing concerns over drug packaging and enforcement of the age restriction. Three days
later, Susan Wood resigned her position as the assistant commissioner for Womens
Health and director of the FDA Office of Womens Health, citing her disgust over
the FDAs handling of the Plan B application (Wood 2005).17
The FDA came under intense public scrutiny after its unusual rejection of the first
Barr application in May 2003, and again when it indefinitely postponed ruling on
the second application in August 2005. The independent Government Accountabil-
ity Office (GAO) concluded that the decision process for the first Plan B application
was highly unusual and that the decision was made with atypical involvement from
top agency officials and may well have been made months before it was formally
announced.18 Several medical authorities publicly condemned the FDA using un-
usually strong language; Dickerson, the president of ACOG, called the decision
morally repugnant, and the prestigious New England Journal of Medicine pub-
lished a scathing editorial entitled, A Sad Day for Science at the FDA (Wood
et al. 2005).19 The Union of Concerned Scientists called the handling of the Plan
B applications a key instance of the Bush administrations political interference in
science to serve conservative political agendas.20 Newspaper editorialists around the
country weighed in, with a considerable majority likewise condemning the FDA for
sacrificing science to politics under pressure from the religious right and the Bush
administration.21 CWA and other groups that had opposed the Plan B application
had the opposite reaction, praising the FDAs rejection of the first Plan B application
for choosing health over politics: The FDA is right to be cautious about making
a potent drug that can harm women available next to candy bars and toothpaste.
. . . We are grateful that the FDA put concern for womens health over political
pressure.22
The Individual Female Body: Competing Models of Female Sexuality and Decision
Making
Opponents of Barrs Plan B application argued that if women could buy the drug
without having to get a doctors prescription, doctors would lose key opportunities
to talk with their patients about contraception, sexual decision making, and the
risk of sexually transmitted infections. Susan Crockett made this argument the main
point of her objections to ECPs going over the counter: As an OB-GYN Im going to
go down kicking and screaming before I allow somebody to break that relationship
between myself and my patients, because I value the education component so much
in that relationship I have with my patients (p. 406). But Leslie Clapp, a pediatrician
sitting on the FDA committee, disagreed with Crockett: As a physician, I dont want
to have an inflated sense of self-importance, and I dont think that I should act as
the gate keeper or barrier to women, teenagers or whatever age accessing medical
care for themselves(p. 391).
Models of institutional politics often assume that a group (in this case, health
care providers) will always seek to expand the domain of their (medical) authority.
Indeed, some doctors who spoke at the public hearing in opposition to the OTC
application suggested that nonprescription status would put medical decisions in
the hands of irresponsible and uneducated patients who, they suggested, would be
prone to abusing the drug, and they insisted on the importance of keeping drug access
in the hands of physicians. Yet these appear to represent the minority of health care
providers. Most major medical organizations, including ACOG (which represents 95
percent of all U.S. board-certified obstetrician-gynecologists), the AMA, the Society
for Adolescent Medicine, and the American Association of Pediatrics, as well as the
majority of the physicians on the FDA committee supported the OTC switch, which
would have reduced the number of women needing to see a doctor and put more
responsibility for sexual health decision making in patients hands.23
Those who objected to expanded ECP access insisted that a nonprescription status
for Plan B would interfere with the beneficial doctorpatient relationship and in
particular argued that it would prevent doctors from being able to educate women.
This position reflected a particular representation of the doctorpatient relationship
that, their opponents argued, did not fit the reality of the way many women access
health care in the United States. Those who insisted that nonprescription access
would harm women by cutting them off from the expert advice and medical care
of their doctors neatly elided the fact that prescription status puts women into a
particular relationship of power with their doctor, one in which the patient comes
as supplicant requesting a prescription or drug that the doctor has the ultimate
right to grant, like a boon, or refuse. Further, they ignored the fact that this doctor
patient relationship entails an economic exchange where the patient (or the patients
insurance company or the state) pays for this expert advice. Thus, prescription
status for ECPs reinforces medical authority in several ways: by making the health
care provider the ultimate arbiter of a womans access to the drug; by mandating
the doctor as a principal beneficiary in the economy of the health care transaction
(because a woman does not pay just for the drug but also for the prescription, which
usually costs more than the drug itself); and by requiring the woman to submit to any
additional procedures (ranging from a pregnancy test to a pelvic exam to a pap smear
to STI testing) and expert advice (from a discussion about ongoing contraceptive
use to a discussion about sexual risk taking to one about mechanism of action of
ECPs and their potential effect on a fertilized egg) the doctor decides to impose.24
Although optimistically characterized as a dialogue with a caring and interested
health care provider, this ideal of doctorpatient dialogue is rapidly becoming less
and less possible as managed care has reduced the time doctors spend with patients
(Singer and Baer 1995:342). Further, several speakers at the public hearing argued
that many poor and minority women are intimidated by health care providers and
have trouble negotiating the U.S. health care system, another barrier to an idealized
model of doctorpatient dialogue. This doctorpatient dialogue inevitably occurs
within an unequal power relationship, as it is one in which the woman is forced to
participate if she wants to get the prescription she is requesting. It is a relationship
that many speakers at the hearing contested as not being in the womans best in-
terest for both economic and public health reasons. But other testimony offered at
the public hearing contested the doctorpatient relationships on more immediate,
experiential grounds that dismissed the abstractions of public health or economics.
The language of many women offering public testimony showed their frustration
with the way a doctor subjected them to a scrutinizing medical gaze that they in-
ferred to be a moralizing gaze, one that evaluated not their health but their moral
decisionsnamely, to have sex and to use contraception.
The assumption that doctors were a key point of compassionate health educa-
tion, rather than potentially intimidating authority figures who impose an economic
burden and subject women to their moralizing gaze, was one striking difference in
the arguments of EC opponents and supporters. Tied to those opposing models of
doctorpatient relationships were particular images of female sexuality and sexual
decision making. Arguments leveled against nonprescription ECP access repeatedly
invoked an exploitative male bogeyman who preys on a young, witless female victim
and claimed the need for medical intervention to protect women from sexual abuse.25
Susan Crockett, who voted against the OTC switch, brought up sexual abuse,
rape, and incest in arguing for her role as a doctor in dispensing the drug: If you
remove the ability or the necessity for that patient to come in and talk to me . . . youre
removing my ability to support them, to be an advocate for them, especially in cases
of rape or incest (pp. 377378). Other EC opponents argued that OTC availability
would lead to mens pushing the drug on their female sex partners and using it to
pressure them into sex without condoms, hence exposing them not only to greater
pregnancy risk but also STI risk. CWA representatives in particular portrayed the
drug as facilitating sexual abuse and incest. In contrast, the NOW representatives
spoke of their experiences of consensual sex with their boyfriends, fiances, and
husbands, of contraceptive decision making in the hands of equal partners, and of
the anxiety that both women and their male partners experienced trying to get ECPs
after a condom failure.
Viagra versus Plan B: Designating Sexual Predators and Victims

The comparison that several NOW representatives drew between insurance coverage
for Viagra and Plan B is useful for thinking through the different ways that mens
and womens sexuality are painted in this debate. A 2005 New York State audit
found that 200 convicted sex offenders had had Viagra prescriptions covered by
Medicare, and the announcement launched an outcry that resulted in legislation to
bar convicted sex offenders from receiving subsidized erectile dysfunction drugs.26
Yet the same organizations that have lobbied against expanded ECP access have
been strikingly silent on the issue, and there was no activism against the FDAs
approval of Viagra or other erectile dysfunction-treating drugs.27 Indeed, not one
of those groups has offered an equivalent rhetorical scenario that posits Viagra use
as enabling older predatory men using the drug to facilitate their sexual conquest
of unwitting female victims. Why do these groups portray Plan B but not Viagra as
facilitating the sexual exploitation of women?
In part, the double standard reflects a logic in which women, but not men, are
portrayed as victims of drugs that facilitate sexual activity, rather than beneficiaries.
Not a single speaker in the public hearing suggested that women might use Plan B to
facilitate their seduction of men, only that men would use Plan B to facilitate their
seduction of women. Arguments against easier access to Plan B implied that it would
make women less able to say no to sex. In portraying themselves or doctors as
educating and advocates for women, EC opponents use the notion that women
are the gatekeepers of sexuality and take that notion a step further: women must
be protected from the sexual predations of men, therefore, these groups propose
medical doctors and state power as the gatekeepers of female sexuality, because
women are manifestly too weak to guard the gates themselves. Men are portrayed
as predators on female sexuality in arguments surrounding Plan B but not Viagra by
organizations such as CWA and Human Life International (whose representative ar-
gued that women who use ECPs display an inability to control themselves in sexual
situations, p. 239) because these groups interest lies in regulating, protecting, and
indeed controlling female sexuality, and regulating a drug taken by women achieves
that goal more directly than regulating a drug taken by men.
Contesting Contraception and Constructing Zygotic Personhood

Another key to understanding the opposition of these groups toward Plan B and
not Viagra revolves around the status of ECPs as a drug that not only affects female
sexuality but also has a potential effect on an egg, and especially a fertilized egg. The
medical literature on ECPs has consistently posited three ways (or mechanisms of
action) by which they might work to prevent pregnancy. First, they can prevent
or delay ovulation. Second, they might inhibit tubal transport of the egg or sperm,
thus preventing fertilization of a released egg. Third, they might work after fertiliza-
tion by altering the endometrium (the lining of the uterus) or shortening the luteal
phase, thereby inhibiting implantation of a fertilized egg.28 Only the first of these
mechanisms has been empirically verified. All of these mechanisms of action are
considered contraceptive because biomedicine defines pregnancy as beginning when
a fertilized egg implants in the uterus; implantation triggers the hormonal changes
that allow the body to recognize that it is pregnant (and causes a pregnancy test to
turn positive).29 If a fertilized egg has already implanted, emergency contraception
has no effect.
It is the last possible mechanism of action, the prevention of a fertilized egg from
implanting in the uterus, that was the subject of considerable debate throughout the
FDA hearing. In their FDA testimony, both Ben-Maimon of Barr and Dickerson of
ACOG were at pains not only to remind listeners that Plan B was not an abortifa-
cient but also to assert that Plan B did not work by preventing the implantation of
an already-fertilized egg. Ben-Maimon dismissed the possibility of postfertilization
mechanisms of action as being unsupported by data. Plan B works like other
progestin-only oral contraceptives and prevents ovulation. . . . Again, I would re-
iterate: Plan B works by preventing ovulation. It is an oral contraceptive, not an
abortion pill (pp. 3031). She thus implied that Plan B was a contraceptive and not
an abortifacient because it worked by preventing ovulation and not by preventing
the implantation of a fertilized egg. Dickerson described in detail how pregnancy
occurs, and affirmed that medical science defined pregnancy as beginning when
the blastocyst (the fertilized egg that has begun to divide) implants into the lining
of the uterus. And yet, having defined pregnancy as beginning after implantation of
an already fertilized egg, she too emphasized a prefertilization effect in explaining
how ECPs work while dismissing the substantial literature speculating on a possible
postfertilization effect: Plan B primarily prevents pregnancy by inhibiting or pre-
venting ovulation and secondarily perhaps by impairing the migration and function
of sperm. In other words, it prevents pregnancy prior to fertilization (p. 37).
The pointed emphasis on the mechanism of action of ECPs was a key theme to
which later debate during the hearing frequently returned. Throughout the public
hearing, EC opponents contested its definition as a contraceptive, repeatedly calling

it an abortifacient because of its possible effect in preventing the implantation of a
fertilized egg. The president of the American Life League, Judie Brown, asserted that
preventing implantation of a fertilized egg represented the destruction of human life:
If a human zygote cannot implant, he or she will die. This means that the pills act
to prevent pregnancy by aborting a child (p. 213). With Browns deliberate use of
human and gendered pronouns, she modified the abstract, scientific term zygote to
attribute life and personhood to the microscopic ball of cells making its way through
a womans fallopian tube. The strategy is an old one in the antiabortion movement,
which uses such language to assert fetal and even embryonic personhood, but the
assertion of zygotic personhood pushes this strategy into new terrain.
The mechanism of action debate was not only a concern for members of the
public speaking at the open public hearing. The possibility that ECPs might have
a postfertilization effect played a key role in the final votes of at least two of the
committee members who voted against nonprescription ECP access. Joseph Stanford
and Susan Crockett argued that the Plan B label was flawed because it did not state
the possibility that the drug could work to prevent pregnancy by preventing the
implantation of a fertilized egg.
ECPs represent a state of fascinating cultural ambiguity as regards pregnancy,
conception, and contraception. EC is defined by medical authorities as contracep-
tion and understood by biomedical definitions to work in the same way as many
other nonbarrier contraceptive methods. Yet the laws in a number of states define
pregnancy as beginning with fertilization or conception, not implantation.30 The
discrepancy between popular, legal, and medical definitions of when pregnancy be-
gins (and, by implication, what constitutes contraception or abortion) reveals a social
and political debate over giving cultural meaning to abstract, theoretical biological
processes. It is a debate that revolves around medical descriptions of biological pro-
cesses, yet simultaneously contests medical definitions of these processes.
But the ambiguous status of ECPs in U.S. politics and popular culture cannot
be explained purely by their theoretical mechanism of action.31 The public debate
surrounding ECPs, which intensified at the time of the FDA hearing on Plan B,
reveals that a number of groups contest these medical interpretations and define
ECPs as an abortifacient to an extent that is not matched by political debates over
regular oral contraceptive pills, other hormonal contraceptive methods such as the
injectable, the patch, or the ring, or the intrauterine device (IUD). Why are ECPs
given such moral import as opposed to oral contraceptive pills? Why do not other
methods of hormonal contraception and IUDs receive the same degree of public
debate as ECPs? What is it about EC that gives it different ontological status from
other contraceptive methods?
Among the lay public, ECPs undoubtedly attain distinction as an ontologically
distinct form of contraception because they are used postcoitally, regardless of the
fact that biologically ECPs may work in exactly the same way as many precoital
methods of contraceptionand, indeed, in the same way as breastfeeding (Kennedy
and Trussell 2004). ECP advocates have often tried to use the comparison with oral
contraceptive pills and breastfeeding as part of their strategy for depoliticizing ECP
use, with little success. Because ECPs are taken postcoitally, there is considerable
confusion among the public between ECPs and medication abortion, confusion that
may be furthered by the popular term for ECPs, the morning-after pill. The strate-
gies of ECP opponents exploit the ambiguous status that the contraceptive method
has among much of the American public to blur the line between contraception and
abortion (Russo and Denious 2005; Sherman 2005). So, although CWA portrays
ECPs as a gateway drug that Planned Parenthood clinics use to try to lure young
women into complacency about abortion,32 the reverse is also true: CWA strate-
gically uses ECPs as a gateway drug in their own project to blur the line between
abortion and contraception, by redefining ECPs as an early form of abortion.
EC is thus a poignant example of how the moral status of a medical technology
has dimensions that extend well beyond any scientific characterization of that tech-
nology. And it is a reminder that political debates over new medical technologies,
especially new reproductive technologies, are not so much debates about science
and technology as they are centrally concerned with interpreting these technologies
within a web of (sub)culturally defined moral valuations and social interpretations
(Tone 2001). The FDA hearing on Plan B illustrates how giving social definitions to
these new medical technologies is a highly charged political enterprise in the United
States involving a whole host of actors with expert credentials and well-organized
strategies for promoting one particular social narrative of the technology in question.
Visual Imagery of Medical Technologies

Analyses of abortion debates have shown the powerful effect of visual imagery,
especially of fetuses, to influence public opinion about abortion technologies. A
considerable amount of literature has focused on how ultrasound allows patients
to visualize the fetus and the effect that this visualization has had in transforming
popular attitudes toward pregnancy, abortion, and fetal personhood.33 Elaine Gale
Gerber (2002) has expanded this insight by showing how medication abortion,
in which women take a drug that causes their uteruses to expel the products of
conception or the fetus at home, is another more tactile, less technologically mediated
form of visualizing the fetus.34 Gerber argues that this new medical technology
provides a new imaging technique that is changing French womens notions of fetal
development by giving them a direct image of a very small, amorphous bit of fleshy
matter, rather than the more developed fetuses that are typical of fetal imagery in
the popular media and antiabortion campaigns. Medication abortion is thus one
key example of how a new medical technology can unsettle and transform cultural
definitions of biological processes.
In contrast, ECPs are a medical technology that represents a virtual absence of
imaging. ECPs produce no fetal imagery, or even embryo imagery. Antiabortion ac-
tivists have made widespread use of images of aborted fetuses in their campaigns.
Yet none of the opponents of ECP use have produced visual aids depicting a zygote
making its way down toward the uterus, then being cruelly rejected from implant-
ing there and expelled with a womans menstrual blood. ECPs are a technology,
the action and effectiveness of which cannot be visualized except by using charts
with figures and perhaps diagrams of swimming sperm, fertilized eggs, or, at best,
microphotography of dividing eggs (which, activists realize, do not have quite the
same visual impact as a far more developed and therefore more human-looking
fetus).
Disembodied States and Medical Uncertainty

The lack of visual imagery in popular culture also reflects the debate within the
medical community over how ECPs work. Medical science cannot say with any
certainty what happens to any individual woman when she takes ECPs, and con-
clusions about mechanism of action are based partly on comparison with studies
in rats and monkeys. ECPs are a medical technology that embodies uncertainty for
medical practitioners as well as users, who often ask: Will it work for me? Is it
working? How can I know if it has worked? And finally, How does it work? (Wynn
and Trussell 2005). There is uncertainty about how often and even whether ECPs
can work after an egg has been fertilized, because there is no test for fertilization.
Therefore, the best scientific knowledge about the mechanism of action of ECPs
produces only contested probabilities, rather than authoritative medical narratives
about biological processes. Thus, the debate that casts ECPs as morally ambiguous
(Is a fertilized but unimplanted egg life? Is EC abortion or is it contraception?) re-
volves around a medical technology that is also characterized by scientific ambiguity
(Do ECPs ever work after fertilization?).
In this debate over expanded ECP access, both sides focused on mechanism of
action in crafting their arguments. Such an essentialist view of life and personhood
is portrayed as a neutral, scientific, medical construction, a portrayal that denies the
fact that both life and personhood are fundamentally cultural constructs (Heriot
1996). The debate over mechanism of action reproduces a view of the female body
and sexual experience that is disembodied and fragmented and revolves around
an abstract biological process that is actually speculative and cannot be pinned
down by medical science (in the absence of vivisection of womens reproductive
organs), rather than focusing on womens total experience of sex and contraception.
Many women simply do not care about the mechanism of action of ECPs. This is
the ground that the NOW representatives tried to recapture by speaking of their
own personal experiences with ECPs. When proponents of expanded ECP access
engage in this debate over mechanism of action, as did the pharmaceutical company
representative Ben and the ACOG president in deemphasizing the possibility of Plan
Bs postfertilization effect, they tacitly advance their opponents attempts to redefine
medical definitions of pregnancy and to construct a cultural notion of not merely
fetal personhood but indeed of zygotic personhood.35
Female Body as Symbol of the Social Order and the Body Politic
One way to understand the difference between the pro- and anti-EC arguments is to
examine differences in each groups views of the relationship between the individual
female body and the body politic. For each side in the debate over expanded ECP
access, the individual female body symbolizes the state of the nation: the right to
choose versus a culture of life.
Several anthropologists have observed that ideologies of bodily self-control are
often manifestations of a fear that the social order is threatened or under attack (e.g.,
Scheper-Hughes and Lock 1987:24). The discourse of EC opponents that links ECP
availability to the sexual revolution, rampant STI rates, and teen pregnancy reveals
anxieties about social change that map out the body politic on the female body.
Opponents of nonprescription ECP access portray a chaotic, uninformed or igno-

rant, undisciplined female sexuality that is vulnerable to exploitation by predatory
forces, from older men (who seek to avoid paternal responsibility as well as obtain
the pleasure of sex with women, unmediated by worries about either contraception
or consequences) to immoral reproductive health advocates who promote a hedo-
nistic vision of sex, divorced from moral or ethical concerns and characterized by a
lack of bodily (self-) discipline. The alternative they seek, then, is a more rigorously
disciplined female body, disciplined in terms of sexual activity, contraceptive use,
and reproductive health decisions. Rhetoric about disciplining pharmaceutical use
is a displaced language for talking about disciplining sexuality.
One disciplinary technique that these groups propose to effect this social order of
idealized female sexuality is self-discipline. In this ideal, female (and male) sexuality
is self-disciplined into resisting extramarital sexual activity and women (but not
men) take responsibility for the consequences of sexual activity. For these groups,
taking responsibility for sex does not mean preventing pregnancy with ECPs or
terminating an unwanted pregnancy with induced abortion, but rather avoiding any
intervention that would prevent a sexual act from resulting in a pregnancy carried
to term. Carrying a pregnancy to term is a further act of self-discipline in which
the female body sacrifices for the sake of the abstract entity life, be it a zygote,
embryo, or fetus, or even the potential for life represented by sperm making their
way toward an egg.
The other (and predominant) method of discipline proposed by EC opponents
at the FDA hearing is the combined discipline of state and medical authority over
the female bodythe medical management of not only the uterus but also the sex-
ual life of women. This is exemplified by Crocketts and others insistence that the
government regulate access to ECPs to facilitate doctors access to a captive audi-
ence of female patients to educate them about sex and contraceptive use. Arguments
against expanded ECP access assume a general lack of self-discipline when it comes
to responsible (read moral) sexual and contraceptive behavior, and they propose
that the state should continue to regulate access to ECPs via licensed medical profes-
sionals control over prescriptions to effect the moral self-discipline that women are
assumed to lack. Arguments that expanded ECP access would lead to irresponsible
repeat use, particularly by teens, reflect this assumption that women, and particularly
young women, are not capable of making informed and responsible decisions about
sex, contraception, and pregnancy without the intervention of a medical authority.
Arguments in favor of expanding ECP access reveal rather different underlying
assumptions about sexual decision making, what constitutes responsible contracep-
tive behavior, and the role of the state and medical authorities in enabling responsible
sexual and contraceptive behavior, so defined. In certain respects, EC advocates are
more pessimistic about responsible decision making in sex. They assume that men
and women tend to get caught up in the sexual heat of the moment and engage
in sex without contraceptive protection, and they do not advocate self-disciplinary
techniques for changing this social fact. Unlike their anti-EC opponents, they do not
believe that any state, religious, or medical intervention is likely to affect decision
making in the sexually charged moment. As Abby Berenson, chief of the Division
of Pediatric and Adolescent Gynecology at the University of Texas Medical Branch,
argued, It is the rare adolescent that ever comes to see me before she has sex the first
time. Thats because she never planned to have it in the first place. It just happens,
usually on a Saturday night when Im not available (pp. 395396). In contrast,
proponents of expanded ECP access consider obtaining ECPs as a responsible act
(rather than an indicator of failed responsibility) that redeems a previous act of
irresponsible sexual or contraceptive decision making. They also emphasize con-
dom failure to highlight responsible sexual behavior. They see the state, prescribing
medical authorities, and pharmacists as impeding, rather than enabling, responsible
decision making.36
Although both sides raised the specter of sexual assault in their arguments for or
against expanding ECP access, advocates of expanded ECP access invoked rape as a
situation in which contraception is not always in the womans hands at the moment
of sex but can be subsequently. Giving women direct access to ECPs after sexual
assault was portrayed as redemptive because it puts control back in the hands of
women. Again, the ideal view of female sexuality and reproductive decision mak-
ing revealed in these arguments is one that is liberated from state discipline and the
controlling authority of medical practitioners.37 In contrast, opponents of expanded
ECP access posit different sexual abuse scenarios: one in which contraceptive deci-
sion making is wrested from the woman by the seductive male sexual partner who
convinces the woman she does not need contraception because she can get ECPs
later, for example, and another in which maintaining ECPs as prescription-only is
the one sure way to force women to report crimes of sexual assault to state authority.
These scenarios argue for the necessity of the state in monitoring, regulating, and
disciplining both consensual and nonconsensual sex.
In the arguments of both opponents and proponents of expanded ECP availabil-
ity, we see how competing ideologies of disciplines of self and disciplines of the state
underlie their narratives of female sexual and contraceptive decision making. Fou-
cault has provided critical insights into the politics of the body, and, in particular,
the way Western medical authority developed into a force allied with the state to
scrutinize, study, and thus administer not only health but indeed, human sexuality
(Foucault 1978:24). At first glance, the eventual FDA decision, which kept control
over ECPs firmly in the hands of medical authorities, appears to be one such al-
liance between medical authority and the state to administer sexuality. But closer
examination reveals intriguing fragmentation in the supposed monolith of med-
ical authority. In the FDA hearing, the majority of the representatives from the
most authoritative medical bodies in the United States were in favor of lessening
the invasive power of both medical authority and the state to regulate womens
sexuality. The FDA rejection of Barrs application led to vocal outcry from some
of the countrys most powerful medical bodies and medical journals over the U.S.
governments alleged disregard for science,38 an outcry that coded anger over the
states (not womens) disregard for medical authority.
Conclusions
The FDA hearing over making the Plan B available without prescription sparked
heated debate over the public health implications of expanding access to this new
medical technology, the effect it would have on individual Americans sexual deci-
sion making, and the drugs status as a contraceptive. Arguments against the switch
to OTC status favored keeping doctors as gatekeepers to ECP access and implied that
disciplining pharmaceutical use would simultaneously discipline sexuality (and pro-
tect the health of adolescents). They framed womens and especially young womens
sexuality as being threatened by male sexual predators and prone to irresponsible de-
cisions regarding contraceptive use. They also posited a doctorpatient relationship
characterized by kindly concern for womens well-being and saw visits to a doctor as
a key opportunity for intervention in womens sexual decision making. Arguments
in favor of OTC access constructed an alternative version of female bodies in which
women are the ones in control of their own sexuality and deserve the right to make
their own reproductive health decisions. They highlighted the power differential in
the doctorpatient relationship, problems with access to health care, and the poten-
tially moralizing gaze of doctors. The debate over ECPs is thus a key example of the
framing and defining of not only female sexuality but also the relationship between
health professionals and patients.
The focus on the mechanism of action of ECPs in this debate and the attempt
by opponents of the OTC switch to characterize ECPs as an abortifacient rather
than a contraceptive revealed a challenge to the established biomedical definition of
when pregnancy begins. In focusing on the status of a fertilized but unimplanted egg,
they advanced a construction of zygotic personhood that pushes at the limits of the
arguments defending fetal and embryonic personhood that have become familiar
territory in the U.S. abortion debate as well as in debates over stem cell research
and the status of unused embryos created during in vitro fertilization processes. It
is interesting that neither side explored the implications of granting personhood to
a fertilized egg: Because the contraceptive effect of breastfeeding may operate by
preventing the implantation of a fertilized egg, should the merits of breastfeeding
be rethought in the name of human (zygotic) life, or should female sexual activity
be avoided during lactation? Because half of fertilized eggs never implant, should
more respect be given to the menstrual blood of sexually active women that most
Americans dispose of unceremoniously in tampons and other sanitary protection
products?
Giving special status to ECPs and not other contraceptive methods with similar
mechanisms of action reflected the drugs ambivalent ontological status as a con-
traceptive that, unlike other contraceptives, is used postcoitally. Yet the debate also
reveals unanswered questions about how ECPs actually work, despite the confidence
voiced by some of their proponents that ECPs prevent pregnancy prior to fertiliza-
tion. ECPs thus lie in a strange gray zone because of both the complex moral and
social meanings of a fertilized but unimplanted egg and scientific uncertainty over
how they work to prevent pregnancy.
The FDA debate is a key example of the framing and defining of female sexual-
ity. It is linked to broader national debates over abortion, reproductive rights, and
public health that reveal conflicting attempts at constructing womens bodies and
the zygotic bodies within them. For both opponents and proponents, expanded
ECP access symbolizes the social order, mapping out the female body on the body
politic.
It has become commonplace for scientists and reproductive rights activists to
accuse the administration of President George W. Bush of catering to an evangeli-
cal constituency and letting politics and religion trump science, in everything from
teaching evolution and abstinence-only education in schools to information on abor-

tion and condoms on government agency websites to federal funding for embryonic
stem cell research to the FDA decision (and later nondecision) on making Plan B
emergency contraceptive pills available to women without a prescription. Yet, in
both the official testimony and the open public hearing on the Plan B application,
both sides in the debate, including evangelical Christians and Bushs political ap-
pointees to the FDA, couched their arguments in terms that overtly revolved around
(differing interpretations of) biomedical definitions of reproductive processes as well
as individual and public health. At the same time, each side portrayed the science-
based arguments of the other as deviously masking an underlying moral stance as
regards bodies (womens bodies as well as zygotic bodies).
The fact that most of the medical and advocacy organizations represented at
the hearing couched their arguments overtly in terms of biology, medical science,
and public health, and only secondarily in terms of moral or ethical issues, perhaps
merely reflected the nature of the arena: an FDA hearing on whether a drug was
safe enough to be sold without a prescription. Yet even outside of the framework
of the FDA debateon websites and in publications both before and after the FDA
hearingreligious groups who oppose expanded (or even any) ECP access on moral
grounds continue to defend their positions in terms of science and public health.
Their adoption of the language of biomedicine is reminiscent of Loring Danforths
research into New Age movements in which he found that a wariness toward the
conclusions and ultimate goals of science was paradoxically paired with a fascination
with science and an attempt to appropriate scientific language for alternative agendas
(Danforth 1989:254).
The scientific framing of the politics of reproductive health in debates over EC
is testament to the powerful authority of biomedicine to narrate and thus produce
bodies (individual, embryonic, social, and political) and selves (Haraway 1993:365).
Nevertheless, the fact that most speakers at the FDA hearing (both for and against
expanded ECP access) slipped from scientific arguments into overtly moralizing
onesspeaking of ethics, responsibility, self-control, respect, rightsconfirms an
anthropological truism: namely, that a pure science or health argument cannot be
neatly dissected from the larger political process of assigning cultural meaning. Sci-
entific discourses and cultural meaning are inextricably intertwined and complexly
interdependent, and medicine is always a political process.
Notes
Acknowledgments. The authors wish to thank Angel Foster, Beth Jordan, and the three
anonymous reviewers from MAQ for their excellent suggestions for improving earlier drafts
of this article.
1. See http://ec.princeton.edu/questions/dose.html (electronic document accessed Jan-
uary 20, 2006) for a list of the pills that can be used in the United States for EC. Later
research (Ellertson et al. 2003; Rodrigues et al. 2001; von Hertzen et al. 2002) showed that
ECPs could be taken up to 120 hours (five days) after intercourse and still provide some
protection against pregnancy.
2. Combined and progestin-only pills are not the only methods of emergency contra-
ception. The postcoital insertion of a copper-T IUD can also be used as EC with far greater
effectiveness than ECPs (99 percent effective) up to five days after intercourse. Addition-
ally, recent research has shown that small (ten milligram) doses of mifepristone, the same
drug used in much higher quantities (200 milligrams) for medication abortion, can be very
effective for emergency contraception, but to date mifepristone is used for emergency con-
traception only in China. Mifepristone is not available in the United States in doses of less
than 200 milligrams and has not been approved by the FDA for EC use. Despite its high
effectiveness, many activists, doctors, and researchers prefer not to explore mifepristones
use for EC because of fear that this will blur the line between contraception and abortion.
Although there are multiple methods of EC, this article focuses exclusively on ECPs, because
it was an ECP that was being debated in the FDA hearing.
3. On average, if 100 women engage in sexual intercourse without using contraception
in the second or third week of their cycle, eight will become pregnant. If all women take
combined ECPs within 72 hours of intercourse, only two will become pregnant, a 75 per-
cent reduction in the pregnancy rate, whereas if the 100 women take progestin-only ECPs
(discussed below), only one will become pregnant, reflecting an 89 percent reduction in the
pregnancy rate.
4. The voting consultants were Abby B. Berenson, M.D., Michael F. Greene, M.D., Geri
D. Hewitt, M.D., and James Trussell, Ph.D., one of the authors of this article. Informa-
tion on the affiliations of consultants and names and job titles of the FDA participants
can be found at http://www.fda.gov/ohrms/dockets/ac/03/roster/4015R1 03 Consultants-
Guests.htm (electronic document, accessed January 20, 2006).
5. Transcripts of the hearing were later made available online at the FDA website. See
http://www.fda.gov/ohrms/dockets/ac/cder03.html#ReproductiveHealth (electronic docu-
ment, accessed January 20, 2006). These transcripts contain numerous typographical and
transcription errors and only a very incomplete errata page. The authors corrected obvious
errors in the quotes included in this article. Unauthored page references throughout this
article refer to these FDA transcripts.
6. Ben-Maimon cited studies showing that when ECPs are taken within 24 hours of in-
tercourse, the pregnancy rate is just 0.4 percent; if ECPs are taken between 48 and 72 hours
after sex the pregnancy rate rises to 2.7 percent. Thus, she argued, the drugs effectiveness
was dependent on how easy it was for women to access it. Having a prescription require-
ment, which would entail getting a doctors appointment, creates a delay in treatment.
7. He observed that oral contraceptive pills are classified by the FDA in pregnancy
Category X, and claimed that this [signified] the highest level of risk for a fetus (p. 201).
It is true that hormonal contraceptives are included in Category X drugs, but the FDA itself
has stated that this is not because of the risk they pose to the fetus; they are contraindicated
for pregnancy simply because they have no benefit during pregnancy (see Meadows 2001).
8. In fact, the FDA hearings established that no deaths have ever been associated with
the drug.
9. Delegate Marshall also insisted that ECPs are abortifacient, and, as though to em-
phasize that point, he wore a camera and used it to snap pictures of the pro-EC delegates
in what some felt was a threatening and menacing fashion. The picture taking evoked the
practice of some antiabortion activists who have posted photographs of abortion providers
on their websites (sometimes in wanted-type posters), which has led to violent attacks
on doctors and workers in abortion clinics.
10. The 25 organizations represented by speakers at the public hearing were: The Alan
Guttmacher Institute, the ACOG, the American Life League, the Association of Reproduc-
tive Health Professionals, the Catholic Medical Association, the Clara Bell Duvall Project,
Concerned Women for America, Family Health International, the Feminist Majority Foun-
dation, Gainesville Womens Liberation, HRA Pharma, Human Life International, Ibis Re-
productive Health, the National Family Planning and Reproductive Health Association, the
National Latina Institute for Reproductive Health, the National Organization of Women,
the National Partnership for Women and Families, the National Womens Health Net-
work, the National Womens Law Center, Physicians for Reproductive Choice in Health,
Planned Parenthood Federation of America, the Public Health Institute, Red Stockings Al-
lies and Veterans, the Religious Coalition for Reproductive Choice, and the Reproductive
Health Technology Project. Several organizations had more than one speaker (esp. CWA
and NOW), and several private individuals (not representing any organization) also spoke.
11. See Reynolds Whyte et al. (2002) for a provocative application of Appadurais (1986)
concept of the Social Life of Things to modern pharmaceuticals.
12. See http://www.fdaadvisorycommittee.com/FDC/AdvisoryCommittee/Stories/Rep-
roChair.htm, accessed January 20, 2006.
13. See Stanford 1999.
14. See, for example, Tumulty (2002). Hagers reappointment to the committee now
appears unlikely since the publication of an article in The Nation in which Hagers former
wife accused him of repeatedly raping and sodomizing her during their marriage.
15. The FDA letter can be read at http://ec.princeton.edu/news/FDA-Letter.pdf (elec-
tronic document, accessed January 20, 2006).
16. Notably, the FDA has never previously required specific adolescent research when
approving a drug either as a prescription product or in a prescription to OTC switch, high-
lighting the fact that this drug provoked unique social and political anxieties surrounding
adolescent sexuality.
17. A series of foibles and shakeups at the FDA followed Woods resignation. First, the
FDA sent out an e-mail on Friday, September 16, 2005, to womens groups announcing that
Lester Crawford, the recently confirmed head of the FDA, had appointed Norris Alderson,
who holds a Ph.D. in veterinary medicine, as acting director of the FDAs Office of Womens
Health. Crawford was roundly criticized for appointing a male veterinarian to head the
Office of Womens Health. Three days later, the FDA announced that Teresa Toigo had been
appointed to the position, and FDA spokesperson Suzanne Trevino denied that Alderson
had ever been selected for the job. Less than a week later, Crawford mysteriously resigned
his position at the FDA.
18. Decision process to deny initial application for over-the-counter marketing of the
emergency contraceptive drug Plan B was unusual. Washington DC: GAO, 2004.
19. See http://www.acog.org/from home/publications/press releases/nr05-07-04.cfm
(electronic document, accessed January 20, 2006) for the ACOG statement.
20. See Science overruled on emergency contraception, electronic document, at
http://www.ucsusa.org/scientific integrity/interference/emergency-contraception.html, ac-
cessed January 20, 2006.
21. Kaiser Network provides a summary of editorials and opinion pieces on the first FDA
decision at http://www.kaisernetwork.org/daily reports/rep index.cfm?DR ID=23635,
http://www.kaisernetwork.org/daily reports/rep index.cfm?DR ID=23713, http://www.
kaisernetwork.org/daily reports/rep index.cfm?DR ID=23763, and http://www.kaiser-
network.org/daily reports/rep index.cfm?DR ID=23884, and on the FDAs indef-
inite postponement of a decision on the revised Barr application at http://www.
kaisernetwork.org/daily reports/rep index.cfm?DR ID=29283 (all electronic documents
accessed January 20, 2006).
22. See Wong 2004.
23. About 40 countries make ECPs available without prescription. See
http://ec.princeton.edu/questions/dedicated.html (electronic document, accessed Jan-
uary, 20, 2006) for a complete list. Note that the most statistically effective methods of
contraception (the various methods of hormonal contraception as well as the IUD) are
also the most difficult to access, requiring a visit to a medical provider; the available OTC
methods have significantly higher failure rates. Yet the safeguarding mechanism more likely
to be needed with the OTC methods remains gated and, therefore, largely out of reach.
24. Michael Oldani (2004) elaborates on pharmaceutical companies strategies for at-
taining a captive audience with doctors to force them to listen to their product pitch. An
analogy can be made with doctors aims at attaining a captive audience of sexually active
women for their product pitch, whether regarding contraception, STIs, sexual ethics,
cancer testing, etc. Both pharmaceutical companies and doctors optimistically refer to this
provision of information as empowering the consumer, a characterization that deflects
attention away from the clear power relationship entailed in the term captive audience.
However, Oldani also discusses the tactics used by patients to get the drug they want (shop-
ping around for doctors, finding an online pharmacy provider, borrowing drugs from friends
with prescriptions, etc). Similar tactics are used by women to get around the prescription
requirement for ECPs.
25. See Kimala Prices (2005) discussion of the archetypes or characters with recurring
roles in arguments for and against EC and mifepristone.
26. For details on the investigation and its outcomes, see http://www.kaisernetwork.
org/daily reports/rep index.cfm?hint=3&DR ID=30276 (electronic document, accessed
January 20, 2006).
27. The fact that there is no attempt to make Viagra available OTC does not lessen the
comparison, because many anti-EC groups have lobbied not just against OTC access but
have also actively campaigned to bar state university health centers and U.S. military clinics
from dispensing ECPs, even with a prescription.
28. The literature on the possible mechanisms of action of emergency contraceptives is
considerable and often contradictory. A summary of the major studies with complete ref-
erences can be found at the following website: http://ec.princeton.edu/questions/MOA.pdf
(electronic document, accessed January 20, 2006).
29. This definition is endorsed by major medical associations. See ACOG (July 1998),
Statement on Contraceptive Methods.
30. Twenty-two states have enacted laws that define pregnancy; the definitions in 18 of
these laws are based on the idea that pregnancy begins with fertilization or conception, a
term that itself has no precise medical definition. See Gold 2005.
31. See Pruitt and Mullen 2005 for an analysis of the extent to which ECPs and medi-
cation abortion are confused in the U.S. media.
32. See Bossom n.d., which argues, Abortion promoters realize that if they can attract
a young woman [by offering an ECP prescription], they may have a client for life. See also
the discussion in Wynn et al. 2005.
33. See, for example, Duden 1993; Franklin 1991; Georges 1996; Petchesky 1987; and
Sandelowski 1994. The literature is reviewed in Gerber 2002:98.
34. Gerber focuses on RU-486, or mifepristone, as it was used in France. In this regimen,
women are first administered mifepristone to halt embryonic development, then several days
later they take misoprostol, a prostaglandin that initiates uterine contractions that expel the
fetus from the uterus. Other regimens of medication abortion include methotrexate with
misoprostol and misoprostol alone.
35. This process of defining EC cannot be understood independently of the current
U.S. political debate over other embryos, namely those used for stem cell research and
therapeutic cloning. It is the laboratory manipulation of embryonic cells in these other
new medical technologies that drives the social magnification of embryonic meaning in
the politics of emergency contraception. There are rich possibilities here for comparing the
way that scientific constructions of biological processes in one new reproductive technology
shape the cultural construction of meaning in another but insufficient space to fully explore
the matter in this article.
36. One of the subtexts of the argument for expanded ECP access is that nonprocre-
ative sexual activity is, in fact, not immoral but rather healthy and natural, even among
adolescents. Yet this position is underemphasized in the testimony for political reasonsan
important issue, in and of itself.
37. Studies have repeatedly shown that even in hospital emergency rooms, rape survivors
have difficulty accessing ECPs as part of their treatment. See Harrison 2005.
38. See, for example, New England Journal of Medicine (Steinbrook 2004).
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L. L.

The Social Life of Emergency Contraception

This article is an examination of the FDA hearing on a proposal to permit nonpre-

Emergency Contraception in the United States

Preven, a combined estrogenprogestin ECP, was estimated to be about 75 percent

The FDA Hearing

The other expert testimony that Ben-Maimon marshaled in support of Barrs

The Open Public Hearing

Expert Opinion and Political Activism

The FDA Decision

Viagra versus Plan B: Designating Sexual Predators and Victims

Contesting Contraception and Constructing Zygotic Personhood

hearing, EC opponents contested its definition as a contraceptive, repeatedly calling

Visual Imagery of Medical Technologies

Disembodied States and Medical Uncertainty

Opponents of nonprescription ECP access portray a chaotic, uninformed or igno-

teaching evolution and abstinence-only education in schools to information on abor-

Singer, Merrill, and Hans Baer

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