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On Friday, the Trump administration released long-anticipated rules that relax the Obama-era birth control mandate, which required employers to offer insurance that covered contraception for women.
Effective immediately, some companies can now more easily refuse to cover the cost of birth control by seeking religious or moral exemptions.
To justify this rollback, the administration wrote pages into the new regulations that challenge well-established research on the health impact of birth control — from whether contraceptives reduce unwanted pregnancies to the harms and benefits of the Pill.
Altogether, the case presented against birth control is a stunning distortion of the research on contraception. And it’s anything but novel.
There is a long history of false information shaping women’s health law and policy — part of a broader push to curtail women’s reproductive rights in America. “[These birth control regulations] seem to be part of this larger effort to roll back women’s health care, roll back access to reproductive options,” said Diane Horvath-Cosper, a fellow with Physicians for Reproductive Health. “It certainly looks like [the administration is] misusing science to that end.”
Here’s a quick rundown of the various abuses of science that surfaced in the government’s new birth control regulations. Many will be familiar — they echo claims the religious right has been making about the effects of contraception for years.
Yes, birth control does decrease the number of unplanned pregnancies
According to the White House, there isn’t good evidence linking access to birth control to lower rates of unintended pregnancies. More specifically, we don’t actually know that giving more women birth control reduces the risk of unwanted pregnancies at the population level, the new regulations say: “In particular, association and causality can be hard to disentangle.”
What the White House doesn’t mention is that you cannot do a causation-proving experiment on birth control. We know birth control works to reduce the risk of pregnancy, so it would not be ethical to randomly assign some women to use contraception while withholding it from others and waiting to see what happens.
The research we have on the population-level impact of contraceptives is indeed observational, and observational studies can only describe correlations between phenomena, not causation. But even given the limitations, it’s extremely informative.
Just take a look at the research from the CHOICE Project, out of Washington University in St. Louis. For this work, researchers gave out free contraceptives to local teenagers, and followed them for up to three years to see what happened to their rates of pregnancy and abortion.
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They published the results in a study in the New England Journal of Medicine: CHOICE participants were significantly less likely to get pregnant and have abortions compared to their American counterparts. As you can see in the chart above, women enrolled in CHOICE had birth rates, abortion rates, and pregnancy rates that were less than half that of the average American. (You can read all about the project here and here.)
“What this shows is that when you take away costs, when you take away barriers, you see increases in the use of more effective methods of birth control and a substantial decline among adolescent pregnancies,” said Megan L. Kavanaugh, principal research scientist at the Guttmacher Institute, adding that the CHOICE research is some of the best data out there on the effect of birth control on unwanted pregnancies.
The White House’s claim about correlation and causation also ignores one very basic thing about birth control: It works!
On the individual level, birth control is extremely effective at stopping women from getting pregnant. “If there wasn’t any use of methods of birth control, 85 percent of reproductive-age women would get pregnant every year, and we’re not near that,” said Leslie Kantor, vice president of education at Planned Parenthood and a professor at Columbia University’s Mailman School of Public Health. “So [this administration] is ignoring a lot of evidence to suggest we don’t know really well what birth control does.”
As to why the White House is ignoring the evidence, we have some clues. One of the architects behind the new birth control rules is reportedly Matthew Bowman, a lawyer at the Department of Health and Human Services who worked for Alliance Defending Freedom, a Christian legal advocacy (and anti-choice) group. Another top Trump adviser on health care is Katy Talento, an anti-abortionist who has claimed that side effects of hormonal birth include cancer and miscarriages. Trump put Teresa Manning, another anti-abortion lawyer who once said giving people easy access to the morning-after pill was "medically irresponsible" and "anti-family,” in charge of Title X, HHS’s federal family planning program. Trump’s positions on abortion have been wishy-washy, but it’s well known that Vice President Mike Pence has been crusading against reproductive rights for years.
Expanding birth control access hasn’t encouraged risky sex
Another argument the Trump administration cites in limiting access to contraceptives is that a birth control coverage mandate could “affect risky sexual behavior in a negative way.” In other words, give more women birth control and they’ll be more promiscuous.
No matter where you stand on the sexual freedom spectrum, this is another well-studied issue, and the best available evidence suggests birth control does not increase risky sexual behaviors.
Studies have looked at whether giving people access to contraception encourages people to have more sex. It doesn’t. Most women in the CHOICE study reported no change in their number of sexual partners after gaining access to free birth control. They were also no more likely to be diagnosed with sexually transmitted infections.
What’s more, the introduction of the Obamacare birth control mandate in 2012, which expanded access to contraception, has actually coincided with a period of less risky sexual behavior among Americans.
Consider the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance Survey, which has been tracking teen’s sex lives since the early 1990s. That study finds kids these days are actually less sexually active. Here’s Christopher Ingraham at the Washington Post explaining the findings before and after the Obamacare mandate:
The proportion of high school students who ever had sex dropped from 47.4 percent in 2011 to 41.2 percent in 2015. The share who were currently sexually active fell from 33.7 to 30.1 percent. Similar declines were apparent among the rate of teens having sex before age 13, and the share of teens having four or more sexual partners.
The latest federal data also shows that the teen birth rate has plummeted in recent years, from 41.5 births per 1,000 teenage girls in 2007 to 20.3 births per 1,000 teenage girls in 2017. And what contributed to the change? Birth control.
As Vox’s Sarah Kliff reported in September, “The percentage of sexually active teens who used at least one type of birth control the last time they had sex rose from 78 percent in 2007 to 86 percent in 2012.” More youngsters are also using more effective types of birth control, such as pills, IUDs, or implants.
The benefits of birth control outweigh its negative effects
Another reason the White House doesn’t want to require companies cover contraception for women? “[The] positive health effects might also be partially offset by an association with negative health effects,” according to the new regulations.
They go on to cite research suggesting oral contraceptives increases the risk of deep vein thrombosis in women, and question the Pill’s effects on cancer risk.
Every medical intervention has harms and benefits. But in this case, the Trump administration exaggerates the harms and undermines the benefits. With oral contraceptives, Alina Salganicoff, vice president and director of women’s health policy at the Kaiser Family Foundation, told me that both the Institute of Medicine and the Women's Preventive Services Initiative have reviewed the totality of the evidence for the contraceptive products on the market and determined that their benefits vastly outweigh their harms, so much so that they recommended birth control be a required preventive health service for women.
Let’s consider the White House claim about hormonal contraceptives increasing the risk of deep vein thrombosis, or blood clotting. There is indeed a small risk increase that comes with using hormonal birth control, but in the vast majority of women, this side effect never materializes.
“To put the risk in context," as NHS Choices, a fantastic medical information service from the UK government, pointed out, "you are far more likely to develop a blood clot in pregnancy than by using a combined contraceptive." For example, the NHS says, there are about five to 12 cases of blood clotting per 10,000 women who use oral contraceptives for a year — a small boost compared with women who are not on the Pill and who generally have two blood clot cases per 10,000.
On cancer, according to a World Health Organization review of the evidence, taking birth control pills “slightly” modifies the risk of various cancers — but this effect goes in both directions: There’s an association with an increased risk for some cancers, and a decrease for others. Through the Food and Drug Administration, however, “The federal government has found that every approved method of birth control has net positive health benefits for most women, or else they wouldn’t be approved for use in this country,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, in an email.
“We have an incredible amount of research that shows that contraception is safe,” said Horvath-Cosper, from Physicians for Reproductive Health. “The risks for the vast majority of people are much smaller than the benefits, and the benefit is they work to prevent pregnancy and they’re really good at doing that.”
For Kantor, Friday’s move by the administration is just another way to attack women’s advancement by limiting their reproductive rights in ways that’ll harm their health. And in a country that already has extremely poor health outcomes for women on many measures, that should be worrying.
“I think everybody who cares about science is concerned there’s a lot of non-science making its way into regulations,” said Kantor, “not just on [reproductive health] but other topics as well.”
