Providing Access to Emergency Contraception for Survivors of Sexual Assault

[摘要]

Each year, an estimated 600,000 or more American women are raped,¹ with approximately 25,000 of those rapes resulting in pregnancy. As many as 22,000 of these pregnancies could be prevented by timely administration of emergency contraception.²

Hospital emergency departments do not consistently offer emergency contraception pills to sexual assault survivors, according to a study published in the June 2002 issue of the Annals of Emergency Medicine. The study, which analyzed seven years of data from the National Hospital Ambulatory Medical Care Survey, found that between 1992 and 1998, only 20 percent of sexual assault survivors received emergency contraception at the time of treatment at a hospital emergency department.³ This percentage represents less than half of the 45 percent of patients who would have been eligible to use emergency contraception because they were not infertile, using contraception or already pregnant.

The failure of many hospitals to routinely counsel sexual assault survivors about pregnancy prevention and offer emergency contraception has also been documented in studies conducted in several states and in national studies focusing on policies at subgroups of hospitals.⁴ 

Emergency contraception is a safe and extremely effective Food and Drug Administration-approved method of preventing pregnancy following unprotected intercourse when administered in a timely manner.⁵ The FDA has approved two products to be prescribed solely for emergency contraceptive purposes as well as approving the use of ordinary birth control pills, which are taken in high concentrations.⁶

Emergency contraception is most effective when taken within 12 hours of unprotected intercourse, with effectiveness decreasing as time passes⁷ and an outside limit of effectiveness now calculated at five days following intercourse.⁸ The sooner the medication is administered to a sexual assault survivor, the greater the odds that pregnancy can be prevented. Timely provision of emergency contraception to sexual assault survivors by emergency departments and urgent care centers is especially important because rape victims sometimes do not reach a hospital or urgent care center until hours or even days after an assault.

Instead of needing to take emergency contraception in two separate doses 12 hours apart, new research has demonstrated that both doses of one type of emergency contraception (levonorgestrel) can be provided at once.⁹ As a result, hospital emergency room personnel can accomplish the complete administration of emergency contraception while treating a rape survivor.

Emergency contraception has no effect on an established pregnancy and cannot dislodge an implanted embryo.¹⁰ When the use of emergency contraception was approved by the FDA, the agency stated, “The scientific and medical definition of abortion is after implantation. These birth control pills are used to prevent pregnancy, not stop it. This is not abortion.”¹¹ 

Timely access to emergency contraception would decrease the number of pregnancies experienced by survivors of sexual assault and the need for these patients to confront decisions about abortion. A study conducted by the Alan Guttmacher Institute concluded that increased access to emergency contraception prevented an estimated 51,000 pregnancies that would have ended in abortion in 2000.¹² 

Offering emergency contraception to sexual assault survivors at risk of pregnancy is the accepted standard of care.^13,14 Many, but not all, medical organizations have policies that explicitly recognize this standard of care. An editorial in the June 2002 Annals of Emergency Medicine concluded that emergency contraception options should be offered to all female patients following sexual assault as a routine standard of care.¹⁵ 

Efforts to ensure the offering of emergency contraception to at-risk rape victims by hospital emergency departments are separate and distinct from national efforts (including that supported by APHA) to make emergency contraception available over the counter¹⁶ and from the initiatives in several states to make the medication more available “behind the counter,” through direct pharmacist dispensing under an arrangement with a physician.¹⁷ While some rape victims who do not go to emergency departments will benefit from improved access to emergency contraception at neighborhood pharmacies, those victims who are receiving hospital treatment should not be expected to leave the hospital and, in an injured and traumatized state, fill a prescription at a pharmacy.¹⁸ Many communities do not have 24-hour pharmacies, and some pharmacies do not stock the medication.¹⁹ 

Despite emergency contraception’s proven effectiveness in preventing pregnancy after unprotected intercourse, few states have taken action to adopt laws or administrative policies that ensure sexual assault survivors are offered emergency contraception at the time of treatment in a hospital emergency department. As of June 2003, only three states (Washington, California and New Mexico) had enacted laws that require all emergency departments to offer EC to survivors of sexual assault. In Illinois, state law requires hospitals to tell sexual assault survivors about emergency contraception, but there is no requirement that it be provided.²⁰ 

In New York, the state department of health issued protocols in June 2002 requiring hospitals to counsel sexual assault survivors about pregnancy prophylaxis, but stopping short of absolutely mandating on-site provision of emergency contraception.²¹ 

Although the New York protocols have improved care for sexual assault survivors, the failure to require the immediate provision of emergency contraception has meant that 24 hospitals in 16 counties across the state still do not have policies of providing emergency contraception on site, according to a survey conducted by the New York State Coalition Against Sexual Assault and Family Planning Advocates of New York State. Some of these hospitals send patients to other hospitals or to family planning clinics and doctors offices that are not open 24 hours a day. Other emergency departments give patients a prescription that must be filled at an outside pharmacy, even though such pharmacies are not located nearby the hospital and may not be open 24 hours a day. These hospitals treat a combined total of up to 1,000 sexual assault survivors annually, sending vulnerable crime victims away without offering them the immediate means to prevent pregnancy.²² 

On the federal level, legislation was introduced in Congress in 2002 to require hospitals, as a condition of receiving federal funds, to offer emergency contraception to sexual assault survivors.²³ The legislation’s sponsor was not re-elected, and the bill has not been re-introduced in 2003.

The American Public Health Association reaffirms its longstanding position that access to the full range of reproductive health services is a fundamental right,²⁴ and its policy favoring the protection of consumer choice in health care and patients’ right to give informed consent;²⁵ and therefore recommends that:

1. Congress and state legislatures should pass legislation requiring all hospitals that have emergency departments, without exception, to provide all sexual assault survivors who are at risk of pregnancy with accurate, unbiased information about emergency contraception and immediately dispense the medication to those who request it.
2. Professional medical associations and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) should strengthen or adopt policies that will uphold as the standard of care the provision of information about emergency contraception and on-site emergency department or urgent care center dispensing of such medication to all sexual assault survivors who are at risk of pregnancy and desire emergency contraception.
3. Hospitals and hospital associations should adopt policies to ensure that all sexual assault survivors treated in hospital emergency departments receive accurate, unbiased information about emergency contraception and are offered it on-site.
4. State hospital regulatory agencies should adopt standards requiring hospitals with emergency departments, without exception, to provide sexual assault survivors with accurate, unbiased information on emergency contraception and immediately provide the medication to those who are at risk of pregnancy and request emergency contraception.

References

1. Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America: A report to the nation. National Victim Center, 1992. 
2. Stewart FH, Trussell J. Prevention of pregnancy resulting from rape: A neglected health measure. Am J Prev Med. 2000;19(4). 
3. Amey AL, Bishai D. Measuring the quality of medical care for women who experience sexual assault with data from the National Hospital Ambulatory Medical Care Survey. Ann Emerg Med. June 2002:39:631-638.
4. Patel A, Garg R, Simons R, Petraitis C, Shulman L. Shouldn’t all victims of sexual assault be offered emergency contraception? Obstetrics & Gynecology. 2002:99(4);29S. 
5. American College of Obstetricians ad Gynecologists, ACOG NY, “Medical Questions & Answers About Emergency Contraception.” 2003.
6. See ACOG Practice Bulletin No 25, March 2001, “Emergency Oral Contraception.”
7. Piaggio G, von hertzen H, Grimes DA, Van Look PFA. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen: Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353(9154):721.
8. Seeking Ways to Improve Emergency Contraception: An expanded time limit and a one-dose regimen are among options under study. Network. 2001;21(1).
9. von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet. 2002;360:1803-1810.
10. Grimes D, Raymond E. Emergency Contraception. Ann Intern Med. 2002:137:180-189.
11. FDA spokeswoman Mary Pendergast, quoted in “FDA Panel endorses ‘morning after’ pill,” CNN website, posted June 29, 1996. 
12. Jones R, Darroch J, Henshaw S. Contraceptive Use Among US Women Having Abortions in 2000-2001,” Perspectives on Sexual and Reproductive Health. 2002, 34(6):294-303.
13. See, American Medical Association, “Strategies for the Treatment and Prevention of Sexual Assault,” 1995, 18.3. 
14. ACOG Practice Bulletin No 25, March 2001, “Emergency Oral Contraception.”
15. Feldhaus, K. Editorial: A 21st-Century Challenge: Improving the Care of the Sexual Assault Victim. Ann Emerg Med. 2002;39.6:653-655.
16. Center for Reproductive Rights. Two Years Later: Over the Counter Emergency Contraception Still Stalled Before Bush Administration FDA. (February 12, 2003), downloaded 6/12/03 from: http://www.crlp.org/pr_03_0212.ec.html.
17. Alan Guttmacher Institute, “Emergency Contraception: Improving Access,” Issues in Brief (2002), downloaded 6/10/03 at: http://www.agi-usa.org/pubs/ib)_3-03.html.
18. Testimony presented to New York State Assembly Health Committee by Jacqui C. Williams, Director of Policy and Education, New York State Coalition Against Sexual Assault, January 14, 2003. 
19. Alan Guttmacher Institute, “Emergency Contraception: Improving Access,” Issues in Brief (2002), downloaded 6/10/03 at: http://www.agi-usa.org/pubs/ib)_3-03.html.
20. MergerWatch. “Emergency Contraception in the Emergency Room: State-by-State.” (2003), downloaded 6/12/03 at: http://www.mergerwatch.org/people/ECER2.html.
21. “Protocol for the Acute Care of the Adult Patient Reporting Sexual Assault,” State of New York Department of Health, May 2002.
22. Results of statewide survey downloaded 6/10/03 from: www.fpaofnys.org/education/ecsurvey2003.html.
23. HR 4113, “The Compassionate Care for Female Sexual Assault Survivors Act,” introduced by Representative Morella. 
24. APHA Policy Number 7704: “Access to Comprehensive Fertility-Related Services.”
25. APHA Policy Number 20003, “Preserving Consumer Choice in an Era of Religious/Secular Health Industry Mergers.”

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[发布日期] 2003-11-18

[学科分类] 医学（综合）