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Body Politic
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Does It Matter Whether Plan B Is Contraception or an Abortifacient?
In the U.S., all matters relating to reproductive health, no matter how straightforward the science, become unnecessarily complicated by so-called morality. Perhaps the wrong questions are being asked.
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This month marks the 26th anniversary of the FDA’s approval of Plan B, a progestin-based form of emergency contraception, and the first emergency contraception brand made available in the United States. On its surface, Plan B and its subsequent knockoffs offer a simple proposition: When taken within 72 hours of unprotected sex, these pills can reduce the chances of pregnancy, sparing people the stress of an unplanned and potentially unwanted pregnancy.
Yet, as with all things reproductive health, the American discussion of this straightforward contraceptive option has never been all that simple. And one question in particular has dogged progestin-based emergency contraception since its earliest days: Is it an abortifacient?
There are two possible reasons to want an answer to this question. The first one is extremely practical: If someone wants to terminate a pregnancy, it’s important to know whether Plan B will actually get the job done. On this point, the scientific consensus has been incredibly clear from the very beginning. Once a pregnancy has begun developing, progestin has no effect on it. Indeed, it would be odd if it did, as progestin is a synthetic version of progesterone, a hormone that is crucial for maintaining a healthy pregnancy. Indeed, the abortion pill mifepristone works in part by blocking progesterone within the body — the exact opposite of what Plan B does.
And yet in spite of this clear scientific consensus, which the FDA reasserted in 2022, questions about Plan B’s connection to abortion persist, often in the form of questions as to whether Plan B’s mode of action, which some have suggested includes preventing a fertilized egg from implanting, is itself a form of abortion. This line of inquiry isn’t about science, it’s about morality. More specifically, it’s about whether Plan B should be considered birth control and thus relatively in the clear morality-wise, or abortion, and thus morally suspect.
For years, reproductive-rights activists have played right into this moral debate, seemingly convinced that if they proved emergency contraception wasn’t abortion they could protect it from anti-abortion extremists. Unfortunately, that line of reasoning proved faulty. Not only has a willingness to cede ground on the morality of abortion enabled punitive restrictions, and even outright bans, on a life-saving medical procedure; it’s also failed to protect birth control from conservative ire.
But perhaps most offensively of all, it’s helped to reinforce the belief that abortion somehow sits outside the bounds of “normal” contraceptive methods, that there’s a bright red line between products that prevent pregnancy and those that end it. And that, to me, isn’t just promoting a cruel moral binary that shames and stigmatizes abortion patients. It’s also just bad science.
To be clear, Plan B and its progestin-based competitors — as well the many popular estrogen and progestin-based contraceptives on the market — cannot terminate a pregnancy, and are not abortifacients in any meaningful sense. But these estrogen and progestin-based methods are not the only contraceptives that exist. And for other methods, including the prescription-only emergency contraceptive sold as Ella in the United States, things are much, much fuzzier.
Because unlike Plan B and other over-the-counter emergency contraceptives, Ella isn’t progestin-based. Instead, its active ingredient is ulipristal acetate, a progesterone receptor modulator that works by blocking progesterone. Or, to put it more simply, from a chemical perspective, ulipristal acetate has much more in common with mifepristone than with Plan B.
For several years, there have been whispers that this similarity might be more than superficial; that in addition to working as a very effective emergency contraceptive, ulipristal acetate might also be able to terminate pregnancies. Earlier this year, an initial answer appeared. In a proof-of-concept study of 66 participants, ulipristal acetate was found to be an effective abortifacient when taken in conjunction with misoprostol (the medication that is paired with mifepristone during an abortion with pills). Plan B might not be an abortifacient, but Ella very likely is.
And it’s not just ulipristal acetate that seems to bridge the supposedly uncrossable birth control-abortion divide. Dr. Rebecca Gomperts, the founder of the abortion-pill provider Aid Access, has long suspected that mifepristone might have more reproductive health uses than just abortion. Last December, she announced promising early results from a study of low doses of mifepristone — 50 mg as opposed to the 200 mg used for abortion — as a weekly contraceptive pill.
Gomperts envisions a future where mifepristone can be used as a flexible, all-purpose contraceptive. In the market for a regular birth control pill? Take it weekly at one dose. Having sex too infrequently to commit to a weekly pill? Take a different dose for emergency contraception. Pregnant and don’t want to be? The 200 mg abortion dose is still here for you. (Notably, unlike the vast majority of available contraceptive options, mifepristone does not contain estrogen or progestin, and can be safely used by people for whom hormonal contraception is uncomfortable or unsafe.)
Whether Gomperts’s fantasy is scientifically (let alone politically) possible, her research, and the related findings about ulipristal acetate, should still give us pause. No one wants an abortion seeker to waste time or money taking Plan B instead of an effective abortifacient. But the line between “contraception” and “abortion” is far fuzzier than many of us think; more a spectrum of possibilities than two discrete and separate buckets.
If we’ve learned anything since the fall of Dobbs, it should be that treating abortion as some uncomfortable yet necessary fact of reproductive health — a procedure that should be “safe, legal, and rare,” as many used to say — serves mostly to preserve the stigma and shame around abortion while failing to protect access to essential reproductive healthcare. In a similar fashion, leaning in to the supposed hard and fast distinction between “birth control” and “abortifacients” does little beyond further stigmatizing people who need abortion care, and blinding us to the scientific reality of how expansive substances like ulipristal acetate and mifepristone truly can be.
Plan B may not be an abortifacient. But other forms of emergency contraception can be. That’s not something to shy away from or apologize for. That’s a liberatory revelation that we should be shouting from the rooftops.
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