IJFAB: International Journal of Feminist Approaches to Bioethics

In Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care, Jill B. Delston uses a feminist lens to examine the overwhelmingly common [End Page 200] gynecological practice of declining to write prescriptions for oral contraceptives (OCs) unless a woman agrees to an annual Pap smear (Grindlay 2016, 251), which is used to detect precancerous changes, as well as cancer of the cervix. Employing a comprehensive evaluation of the medical literature, Delston methodically builds a strong argument that these measures not only do not follow evidence-based medical guidelines, but they also carry a significant potential of harm to the patient. Furthermore, cervical cancer prevention has absolutely nothing to do with hormonal contraception provision. Since this practice of holding contraceptive refills hostage to annual Pap smears has no parallel in medical care provided to men, the charge of paternalism or even authoritarianism is insufficient: this practice is sexist. While they may not recognize this practice as sexist, “doctors know that withholding birth control harms patients; otherwise, it would not be an effective means to ensure compliance with otherwise unrelated tests” (39).

Chapter one is the empirical foundation upon which Delston’s normative argument rests. She establishes that the overwhelming majority of physicians withhold contraceptive prescription refills unless the patient keeps appointments for an annual exam. Furthermore, a large percentage also perform medically unnecessary annual Pap smears on teenaged girls, who are not sexually active, and on low-risk women.

In chapter two, Delston makes the case that withholding prescriptions for oral contraception to, essentially, force compliance with an unrelated annual exam injures patients. On the physical and psychological levels, withholding OCs puts women at risk of unintended pregnancy and recurrence of health conditions, such as irregular bleeding or pelvic pain, that are treated with OCs. A further moral injury occurs because, when the physician fails to discuss the appropriate medical standards and the risks inherent in unnecessary exams, women are denied an autonomous choice.

A major point that Delston makes in this chapter is that physicians should have been aware that annual exams violated medical guidelines as far back as 1995, referencing, in part, the American College of Obstetricians and Gynecologists (ACOG) committee opinion of that year. We want to gently push back on this claim, not to absolve physicians from responsibility, but rather to further buttress Delston’s claim that medical sexism shapes medical practice, including professional guidelines. Despite evidence from peer-reviewed medical literature and recommendations from other professional medical organizations, the ACOG guidelines did not explicitly condemn the coupling of contraception and Pap smears. Instead, they allowed for a loosening, recommending that women aged eighteen and above must have “three or more consecutive, satisfactory annual examinations with normal findings” before “the Pap test may be performed less frequently in a low-risk woman at the discretion of her physician” (ACOG 1995, 210; emphasis added). It was not until 2018 that ACOG (2018) issued guidelines to individualize recommendations for Pap smears with shared decision-making between provider and patient. Many obstetricians/gynecologists [End Page 201] may have been unaware that other groups, like the FDA, had changed their recommendations decades earlier because they mainly or exclusively read the OB/GYN literature.

In chapter three, Delston contends that when physicians engage in the practice of withholding prescription refills, they meet the legal bar of negligence and perhaps even malpractice, regardless of their intention or lack of knowledge. This is because physicians are expected to meet the standard of care at all times; that is, they are required to keep current on the medical literature and practice accordingly. In chapter four, Delston argues that withholding a birth control prescription refill in order to coerce a woman into having a pelvic exam is immoral because it is paternalistic. An opportunity for informed consent is not offered, and the woman is denied her right to autonomy. She argues that to deny a competent person’s autonomy is never acceptable and that autonomy cannot be...