It is 2016 and we still don’t have fool-proof, non-permanent contraception. Regular birth control methods such as condoms and oral contraception are not 100 percent effective. However, if a condom breaks during intercourse and a woman does not want to become pregnant, there are options available. Emergency contraceptive pills (ECPs), often called “morning-after pills”, come to the rescue when regular methods fail or in cases where a couple had unprotected sex or a woman is a victim of rape.
There are three to four different varieties of the pill available, depending on the hormone it contains. The pill is also highly time-sensitive and, depending on the variety, should be taken within three to five days after unprotected sex or contraceptive failure. Since its effectiveness decreases with time, easy and immediate access to the morning-after pill is essential to preventing unwanted pregnancy.
There are also certain medical risks associated with the abuse and overuse of morning-after pills, and thus some medical practitioners advocate the requirement of a doctor’s prescription to procure the pill rather than have it available freely over the counter at pharmacies.
After weighing up the costs and benefits, a number of countries have decided to make the morning-after pill available over the counter without prescription, knowing that unwanted pregnancy may carry greater risks for a woman than the pill does. A 2012 University of Hong Kong study notes that “most developed countries” make the pill available over the counter to “eliminate the barrier to access.”
However, the morning-after pill cannot be bought over the counter in Hong Kong. Though illegal sales persist, it remains a prescription-only drug.
Behind the counter… and times
The policy in Hong Kong is in stark contrast to other parts of the developed world. In the United Kingdom, the morning-after pill is sold over the counter to anyone above the age of 16 and is provided free of charge from health professionals.
In a landmark decision in the US, the Food and Drug Administration (FDA) struck down the age limit on morning-after pills in 2013 after more than a decade of debate, and it is now available to people of any age without a prescription. While conservatives and anti-abortion groups opposed the FDA’s decision, scientists and medical organisations such as the American Medical Association and the American Congress of Obstetricians and Gynecologists argued that restrictions on access to the pill “keep many adolescents and younger teenagers from being able to use a safe drug in a timely way to prevent pregnancy, which carries greater safety risks than the morning-after pill.”
In Hong Kong, one can obtain the morning-after pill from the clinics and youth health care centres of the Family Planning Association Hong Kong (FPAHK), family doctors and government clinics – but not from pharmacies without a doctor’s prescription.
FPAHK advocates for the advanced provision of morning-after pills, meaning that customers can purchase the pills from FPAHK’s clinics and store them at home as a backup safety measure instead of visiting the clinic every time. However, it draws a line and does not support over-the-counter access.
FPAHK spokesperson Michelle Chak told HKFP the reason behind this policy. “…although OTC [over the counter] provision can make the drug more easily accessible, care has to be taken that it is not misused. For example users may not be aware of the limitations of the drug or may use it habitually instead of a reliable and regular form of contraception,” she said. “Hence at present we are not advocating for OTC provision of ECPs but urge for greater public education on the proper use of ECPs.”
Furthermore, in a 2002 study, FPAHK stated that the proposal for over-the-counter access “has invited the criticism that it might promote promiscuity and encourage people to neglect regular contraception.”
A large number of drugs sold at pharmacies also have limitations and medical risks associated with their overuse – however they continue to be sold freely and information on their usage is often conveyed through warnings on labels or by pharmacists themselves instead of regulating access. Why, then, are morning-after pills treated differently? The importance of the lack of easy access to the pill is further heightened by the fact that its effectiveness decreases with time.
It is debatable whether the fear of encouraging promiscuity, the lack of general knowledge among users, or concerns over misuse are legitimate reasons for the Hong Kong government to play the role of moral police and deny over-the-counter access to the pill.
Puja Kapai, associate professor of law and equal opportunity adviser at HKU, has concerns about the policy.
“For reasons of culture, age or other factors, those who find themselves in this position [in need of the morning-after pill] may be unable to or reluctant to seek the necessary and timely assistance and these barriers exacerbate the health implications, particularly for teenage girls and others who find themselves in this situation.”
Dr. Raymond Li, clinical associate professor at the University of Hong Kong told HKFP in an email, “Indeed research studies, both locally and overseas, have been conducted which showed clearly that improving easy access to EC [emergency contraception] by over-the-counter provision or advanced provision do not promote promiscuity nor encourage people to neglect regular contraception.”
While there is no denying the importance of reproductive health and relevant counselling, this is not mutually exclusive to over the counter provisions to the morning after pill. According to Linda Wong, executive director of NGO the Association Concerning Sexual Violence Against Women (ACSVAW), “There is no need to ban access to the morning-after pills as women have the right to access it. Instead, we should give more health education to women so that they get more information and knowledge about how to use the pills.”
Moreover, according to international standards, customers can indeed be trusted to educate themselves on sexual and reproductive health through other sources – such as proper sex education, warnings on labels, advice from pharmacists, or even the internet.
For customers who are already aware of the potential risks associated with the pill, there may be no option of opting out of unnecessary counselling services. Moreover, the bundling of counselling and drug provision services can increase the price of access to the pill.
At the FPAHK, visitors may pay as much as HK$360 for a consultation and a single dose of the morning-after pill.
The debate raises pertinent questions on whether the FPAHK has the right to decide whether women have sufficient “general knowledge about emergency contraception” at the cost of immediate access. It may be problems to allow the FPAHK to decide whether or not Hong Kong is ready for over-the-counter, around-the-clock access, especially when it already advocates for advanced provision of the pill.
‘Dignity and privacy’
Kapai is of the opinion that the availability of morning-after pills should be deregulated in Hong Kong and that the health needs of women need to be prioritised. “The restrictions imposed on the availability of emergency contraception not only violate fundamental human rights of women but are also an affront to the right to equality, non-discrimination, dignity and privacy,” she said.
“Regulation of access to such healthcare products which could potentially impact the decision-making freedom of women by leading to forced or unwanted pregnancies is a violation of women’s reproductive rights. Closely tied in with this are a woman’s rights to dignity and privacy in making decisions about her own body and her reproductive goals. It is also a breach of the right to gender equality and non-discrimination on the basis that women are the only group likely to be impacted by the restricted access to emergency contraceptive pills. As such, the present restrictions are not grounded in legitimate aims and are excessive.”