“A unique mix of barriers”: What stands in the way of students getting birth control?
“I came from a family where we were raised with the wait until marriage, none of that stuff, don’t even think about it,” LSA senior Emma Cheff began, responding to the question of why she sought out prescribed birth control.
“And so, I didn’t really know how to get birth control. I didn’t know how it works — honestly, I didn’t know anything until I had to go through Relationship Remix, which was really sad.”
Her junior year, Cheff began the process of figuring out how to access birth control. If she relied on her parents’ insurance, the bills would immediately disclose the prescription, but paying for the contraception out of pocket was not an option.
“I’m first gen,” Cheff said. “My family doesn’t make a lot of money. I’m working to pay through school. I don’t have money to pay for birth control every month.”
Luckily, through much research, Cheff learned she could access birth control and stay on her parents’ insurance by having the billing information sent to her instead of her parents. She then consulted with University Health Service medical professionals to find the birth control that worked best for her.
Contraception is widely used on the University of Michigan-Ann Arbor campus. According to the 2018 National College Health Assessment administered by UHS, 87 percent of students used some sort of contraception during their most recent vaginal intercourse. The usage of long-acting reversible contraception such as the intrauterine device and the implant, which are considered most effective due to their long-lasting and user-independent nature, are increasing steadily. In 2014, 10 percent of students used LARC during their last intercourse. This rose to 23 percent in 2018.
UHS is constantly striving to make contraception available to students, as well as to help students find what’s right for them. They recently implemented video visits as an option for contraception consultations. For students who have questions about health insurance, they have a Managed Care/Student Insurance Office.
And yet, the barriers remain. Students face financial, educational and cultural obstacles, stigmas about their sexualities and gender identities and concerns about birth control impacting their mental health. Each student has their own story — their own “unique mix of barriers,” as UHS health educator Laura McAndrew put it. How can UHS maximize support for all these students?
“I don’t have money to pay for birth control every month”
Student 1, a Kinesiology junior who requested anonymity as she did not wish to publicly come out as queer, found herself in a bind last summer when her health insurance suddenly stopped covering her.
As a person from a low-income background, Student 1 was covered by Medicaid. But due to a glitch in the system, her insurance wasn’t working. She had a birth control prescription from UHS, but without health insurance, she would have to pay out of pocket.
“I was trying to find places that were the cheapest that I could buy for because $20 to me is a lot of money,” Student 1 said. “Whereas I know to some of my friends and family members, it’s just a drop in the bucket. But for me, the first prescription that I was on was $70 out of pocket per month, which is absurd.”
Ultimately, she managed to scrape together enough money to purchase the student health insurance plan. The first thing she did was switch to an IUD, so she would not have to pay for birth control consistently.
“I switched to an IUD because I don’t have to pay for it month after month after month,” Student 1 said. “So now I’m baby-free for the next five years, hopefully.”
McAndrew said UHS tries to tackle the financial barrier in a few ways. The costs of different contraceptive methods are on the UHS website, and McAndrew said students are welcome to visit her or other Wolverine Wellness staff to think through their options. If students have concerns about using their family’s insurance plan, UHS can put information about that in their after-visit summary. McAndrew further encouraged students without health insurance to visit the Managed Care Office.
Susan Ernst, chief of gynecological services at UHS, said one option they point patients toward is accessing birth control pills from local pharmacies, many of which have steep discounts.
Another challenge is figuring out loopholes to get insurance companies to pay for contraception, Ernst said. She said sometimes insurance companies will pay for IUDs if they’re billed through the UHS pharmacy rather than their medical office.
If none of these options work, Ernst said they will refer students to Planned Parenthood, which offers contraception on a sliding price scale based on income. This is best for students who want an IUD or implant, she said.
“So, some of our students who have absolutely no income, they can get the IUD for pretty cheap,” Ernst said.
McAndrew emphasized UHS is always looking for ways to improve their system.
“We know that this doesn’t account for all circumstances,” McAndrew said. “I would really welcome ideas about how to better support students with the cost barrier, because I think it’s really important.”
“It’s very much taboo to talk about any sort of sexual, reproductive birth control”
Rackham student Jess Hernandez first went on birth control as an undergraduate at Michigan State University. She said as a Mexican American, birth control was a taboo topic in her household.
“I identify as Mexican American, and so, in our culture, it’s very much taboo to talk about any sort of sexual, reproductive birth control,” Hernandez said. “I knew that birth control was a thing, but I thought it was kind of frowned upon. It wasn’t something my mom encouraged.”
After some research and consultation with her stepmom, she went to the Planned Parenthood on campus. She’s gone there ever since.
“The only person who knows is my stepmom,” Hernandez said. “I would assume my mom knows that, obviously, I’m sexually active. It’s just not talked about, like, ‘Oh, what are you using for protection?’ And my stepmom is white.”
Students will approach getting contraception prescriptions differently based on how openly talked about it is in their community, McAndrew said.
“Our identities can shape the norms we experience related to health, sexuality and how open or taboo a topic sexual health is in your community,” McAndrew said. “So, navigating those nuances can be challenging.”
Student 1, too, came from a background where sex was considered taboo. She is from a small-town community where she said her sex education was “crap to begin with.” Her experience involved graphic images of STIs and being told that teenagers are incapable of love.
“They concluded it with teenagers aren’t capable of knowing what love is,” Student 1 said. “You’re only allowed to have sex with people you love therefore you just can’t have sex. That’s what they ended it with. And I was like, ‘What do you mean I can't feel love?’”
She managed to get a birth control prescription to treat hormonal acne, but her doctor would not have prescribed it to her if it was for contraceptive purposes. Friends who were sexually active were unable to get birth control pills, she said.
Her lack of knowledge in this area, Student 1 said, shows how crucial it is for University programs like Relationship Remix.
“Having the University have the basic beginning steps to get everyone caught up so everyone is accountable at the same level of, you did learn this because you had to go,” Student 1 said.
Relationship Remix includes information the effectiveness and availability of IUDs and implants at UHS, McAndrew said. But the mention of birth control is brief in order to make it relevant for the most students.
“I was worried as a queer woman who wasn’t fully out to myself”
Student 1 was initially hesitant to approach UHS for birth control because of her queer identity.
“I was worried as a queer woman who wasn't fully out to myself even when I came here as a freshman, and I didn’t want to accept that part of me,” Student 1 said. “I was afraid that people at this University also wouldn’t be accepting, because I had never been in a good relationship with health care providers that were very out there with supporting the LGBTQ+ community.”
Fortunately, she had a positive experience with UHS, who she said have a background in treating members of the LGBTQ community.
“Thankfully, the people at UHS had a good education on interacting with folks who don't fit in the straight, (cisgender) narrative that a lot of new students here have,” Student 1 said.
Student 1’s concerns are common in a healthcare system excluding LGBTQ patients, according to OB/GYN clinical lecturer Daphna Stroumsa, who specializes in reproductive justice and queer health.
“The health care system is not structured appropriately even when there isn’t inherent transphobia,” Stroumsa said. “The health care system is not structured to address the needs of trans people because it’s structured a priori around cisgender heterosexual people.”
Stroumsa said LGBTQ people face barriers of stigma and assumption in trying to access birth control, which can have harmful consequences.
“There’s often assumptions on everybody’s part about like, ‘Oh, if you’re gay, you’re never going to have sex with anyone who might get pregnant. We don’t even need to talk about this,’” Stroumsa said.
In the New England Journal of Medicine, Stroumsa led a study examining the case of a transgender man who came into the emergency room of a hospital with lower abdominal pain. The hospital attributed the pain to him not taking blood pressure medication. Several hours later, they learned he was pregnant, but no fetal heartbeat was detected.
Ernst mentioned this study as a catalyst that led UHS to improve care offered to trans and non-binary students. UHS has a Trans Care Team specifically devoted to these students with clinicians who have undergone extensive training.
Ernst also said UHS focuses on making language during consultations as inclusive as possible. One way of doing this is asking students to describe the ways in which they have sex rather than assuming penetrative, vaginal sex.
“It’s really like what parts go where when people are having sexual activity,” Ernst said. “We don’t judge who’s doing what but just what activities are happening, so that we can make sure that they’re safe and protected in any way that they’re having sex.”
Stroumsa said their experience with the intersection of gender identity and health care was completely different as a student.
“I came of age in a world in which talking about gender identity and sexuality with health care providers in an open way was unthinkable,” Stroumsa said. “I’m glad to see the world slowly moving to a different place, and I want to keep the momentum of that change going.”
“If this were a different medical condition, if it didn’t have to do with my reproductive system, would they believe me more?”
Student 2, an LSA sophomore who requested anonymity for medical privacy, decided to go to UHS for birth control her freshman year. For the next year, she suffered mental health issues she felt that UHS did not take into account.
When she went in for her consultation, she mentioned her history of severe menstrual symptoms. Since she’d had these issues throughout high school, she had normalized them, she said.
The UHS nurse practitioner told her birth control would likely help with her symptoms, lessening her cramps and flow. The practitioner gave Student 2 Tri Sprintec, a widely prescribed birth control pill. Immediately, Student 2 started feeling worse.
“I didn’t sleep for weeks, like I was getting two or three hours of sleep a night,” Student 2 said. “I was doing really poorly in a class that I shouldn’t have been just because my brain didn’t seem to work. And I was picking fights with my roommate and with my boyfriend. Something was wrong physically.”
She called UHS and was told to give herself some more time to adjust. When symptoms hadn’t improved after a month, she called again and was given a different pill. But there was no change. When she approached UHS again, the clinician she spoke to told her she should see a psychiatrist.
“She was like, ‘I don’t know what your home life is like, maybe you should see a psychiatrist,’” Student 2 said. “They were like, ‘It’s probably in your head, and we don’t believe you that this is something wrong with your body. We don't believe that it’s our fault for prescribing you this birth control’ … and that was so dismissive.”
So, she kept taking it. She said her relationship with alcohol spiraled, and her anxiety worsened. She cried easily, even randomly, at things that would not normally trigger tears. She tried going off the birth control, but her cramps that month were so bad she was forced to miss work.
Student 2 went back to UHS and saw a doctor affiliated with Michigan Medicine. They had a long, extensive conversation about her symptoms and her family’s medical history. The doctor ultimately diagnosed her with premenstrual dysphoric disorder, which the birth control was exacerbating.
“She was like, ‘You don’t have a mental health disorder. You have PMDD, a very severe case of it,’” Student 2 said. “During the luteal phase of your periods, the second two weeks after you ovulate … I have a genetically inherited protein abnormality in my brain that triggers an abnormal response to hormones. It’s very easy to treat with medication.”
After a journey of a little over a year, Student 2 is finally feeling better. The doctor she met with prescribed her medication to treat her PMDD, and she’s on birth control that’s specific to her condition. Studies have not established a consensus on whether people with PMDD and premenstrual syndrome are harmed or helped by birth control.
Student 2 said while she appreciated how willing UHS was to prescribe her birth control and how progressive the women’s clinic is in general, she didn’t feel like she was taken seriously in this instance.
“All it took was the (the Michigan Medicine doctor) listening and saying these experiences are not normal and you shouldn’t feel that way,” Student 2 said. “Having a girl tell a nurse or a doctor, ‘Oh, my birth control is making me cry a lot.’ That’s not normal. And then being like, ‘Oh, it’s probably just you. You don’t know what you’re talking about?’”
Ernst said UHS practitioners always note the side effects birth control may cause during contraception consultations. Sometimes patients will experience mood changes, but usually these symptoms resolve over time. If patients have follow-up concerns, they’re encouraged to call or reach out through the patient portal.
“We explain that there are many different formulations of hormonal contraception and if they don't tolerate the one we started, we can always change them to another method that works better for them,” Ernst said.
Student 2 has been thinking a lot more about the intersection of reproductive health and mental health, especially after learning of the high suicide rates linked to PMDD. Student 2 said she’s thankful she figured it out, but still wonders why she didn't get the right medical advice the first time around. She said the lack of conversation and understanding about mental health and contraception was a big barrier for her.
“If this were a different medical condition, if it didn't have to do with my reproductive system, would they believe me more?” Student 2 said.
“I wish that nobody had to worry about the cost of contraception”
Ernst said in a better world, no one would have to worry about the cost of contraception. Many insurance companies have arbitrary requirements regarding contraception, she said.
“You're just putting up barriers so that people can’t get the care that they need. I would say that drives me insane,” Ernst said. “I really wish there was universal health care, because everyone deserves the same care. Everyone deserves to have the best care that they need.”
McAndrew said UHS builds their systems to address issues most students are facing, while also trying to address individual student needs. This is something they continue to work on, she said.
“Unfortunately, there are some times when we can’t do everything that we want to do for somebody, and that is challenging, and that’s difficult, and it’s frustrating,” McAndrew said. “So, we just try to put our heads together about what is the best possible scenario we can make possible for this person.”
Jennifer Villavicencio, clinical lecturer in obstetrics and gynecology, said the best practice is to make clear what services are offered in a compassionate, nonjudgmental way. She emphasized that contraception is extraordinarily safe, but that it’s not a one-size-fits-all model. UHS has the power to make their services accessible to students, she said, and they can keep using that power.
“Those who have power always have the ability to use that power for good, and for equalizing and moving towards equity,” Villavicencio said.
Cheff is already using her power for good. She’s helping a friend with similar circumstances — strict parents, inability to pay for birth control on her own — navigate her contraception options.
“She’s scared because she wants the birth control,” Cheff said. “She’s really scared because she's not in a state to have a child, obviously. So, I’m helping her saying, ‘This is what I did, this is how it worked out for me. Whatever I can do to make it easier for you so that you can be safe and still enjoy what you’re doing.’”