More than ten years ago, when the implementation of the morning-after pill began to be discussed in Chile, the debate was marked by a warning that was repeated over and over again. Its detractors argued that facilitating access to emergency contraception would encourage early initiation of sexual activity, increase promiscuity among young people, and promote risky sexual behaviors.
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More than a decade later, the evidence shows a completely different scenario. The study More pills, safer sex? Emergency contraception and sexual and reproductive behavior among young people in Chile, published in June of this year, analyzed the impact of the availability of emergency contraception in our country between 2003 and 2015, and concluded that those fears not only did not materialize, but the opposite happened: access to the pill was associated with more responsible sexual behavior among young people.
The work carried out by an international team of researchers and published in the journal Archives of Sexual Behavior focused its analysis on determining how the availability of the pill at the community level influenced the sexual and reproductive behavior of young people between 15 and 29 years old.
The research involved Pablo Villalobos, director of the School of Public Health at Universidad Mayor, along with co-authors Ana Nuevo-Chiquero, economist from the University of Edinburgh, and Francisco J. Pino, academic from the School of Economics at the University of Chile.
The authors examined data from five waves of the National Youth Survey (ENJUV), corresponding to the years 2003, 2006, 2009, 2012, and 2015, cross-referencing this information with records of individual controls and the identification of municipalities that distributed or did not distribute the drug.
The research took advantage of a particularity of the implementation of public policy in Chile. Since access to emergency contraception initially depended on the decisions of each municipality, the researchers were able to compare communes where the pill was available with others where it was not, evaluating how the sexual and reproductive behaviors of adolescents and young adults changed.
The history of the morning-after pill in Chile was marked by one of the most intense discussions on sexual and reproductive rights since the return to democracy. In the early 2000s, emergency contraception began to be gradually incorporated into the public debate as a tool to prevent unplanned pregnancies, especially in cases of unprotected sex, contraceptive method failures, or sexual violence. However, its implementation was accompanied by strong political, religious, and judicial opposition.
The main focus of the controversy revolved around two arguments. On one hand, opposing sectors argued that emergency contraception would have an abortive effect, despite scientific evidence indicating that it acts by inhibiting or delaying ovulation and does not interrupt an already established pregnancy. On the other hand, it was warned that facilitating its access would promote promiscuity, advance the initiation of sexual life among adolescents, and discourage the use of regular contraceptive methods.
Carmen Andrade held the position of minister of the National Women’s Service (SERNAM) in 2009, when the project to allow the distribution of the pill in public health services was approved for the first time. Andrade recalls the political atmosphere of the time: “The arguments against it were terrifying. The discussions in parliament were also strong, that we were encouraging abortion, that we were encouraging sexual behaviors.”
Although at the time scientific evidence was limited, today there is consensus that the pill has no abortive effects. “It is a pill that is anovulatory and changes the consistency of the mucus, therefore, if I take it once ovulation has already occurred, the pill has no effect, and it would also have no repercussions in the case that a pregnancy was already underway, so it has no abortive effect, which was the great fear that existed back then,” explains Fernanda Cabrera, midwife nurse from the organization APROFA.
Due to the heated debate around the issue, for several years the distribution of emergency contraception faced a succession of legal challenges and regulatory changes. The pressure from groups against the measure was such that they managed to have the Constitutional Court prohibit its free delivery in the public health system, which caused women who needed access to the pill to only be able to obtain it commercially and with a medical prescription. “That made access to the pill basically for women from upper-middle sectors who had access to a gynecologist, access to the prescription, and could buy it at the pharmacy. So, what was intended was that the pill could also be distributed as a right in the public system,” recalls Carmen Andrade.
Fernanda Cabrera highlights the importance of access to the pill in public health centers: “This pill is being used, especially by young people from low-income backgrounds, which can undoubtedly change the course of those people’s lives.”
However, after the approval of Law No. 20.418 in 2010, which set standards on information, guidance, and services regarding fertility regulation, emergency contraception was again incorporated as a guaranteed service in the public health network.
Over the years, the discussion began to shift from projections and fears to evidence. Various studies allowed evaluating the real impact of the public policy, showing that many of the warnings made during the debate did not materialize. “These kinds of discussions about sexual and reproductive rights are very ideological and very irrational. There is little room for a scientific, rational conversation,” says Carmen Andrade.
From APROFA, Fernanda Cabrera points out that “many times many limitations and regulations are imposed, to ensure that the person is effectively making the best decision about their life, denying or distrusting the decision-making capacity that all people have when we have all the available and updated information.”
Regarding the various arguments against the morning-after pill, Pablo Villalobos, one of the study’s authors, states: “What we found is exactly the opposite. We started from the hypothesis of hypersexualization or promiscuity, which was usually used to prohibit or put some barriers to these policies.”
From her expertise, Fernanda Cabrera agrees with this and adds that “none of the myths and fears that were spread and defended by those opposed to access to the emergency contraceptive pill materialized, because again the debate focused on beliefs and myths and not on updated evidence.”
The study’s results were clear. Young people living in municipalities where emergency contraception was available had a lower probability of having initiated their sexual life than those residing in communes where it was not available.
“Our hypothesis is that in that contact with the health system something more than the delivery of the pill occurred, probably information was provided and that permeated both those young people and their groups, generating some changes in the behaviors of young people in those communes,” explains Villalobos.
At the same time, far from replacing prevention, the availability of the morning-after pill was associated with greater use of regular contraceptive methods. The research detected a significant increase in the use of hormonal contraception such as contraceptive pills or injectables before sexual relations, especially among adolescents under 20 years old and people not living with a partner. “What happened is that in those communes where the pill was available, the behavior change was towards more protective and preventive behaviors,” notes the study’s co-author.
According to the study, this change was closely related to young people’s contact with the health system. When attending a health center to request emergency contraception, many received counseling, sexual education, and information about regular contraceptive methods, which favored more consistent preventive decisions.
“We would have liked to have this information 30 or 20 years ago, when these things were discussed more broadly, but the conclusion remains the same: having a sexual and reproductive health policy is important and also having a policy that is comprehensive,” concludes Villalobos.
For years, the discussion about emergency contraception was crossed by moral arguments and predictions about its possible social consequences. “This idea they have of controlling us, watching us, and making decisions for us, I think is behind many of these fears,” reflects Carmen Andrade.
However, more than a decade of follow-up shows that those forecasts did not come true. The availability of the morning-after pill did not increase promiscuity, did not advance the initiation of sexual life, nor increase other risky behaviors. Instead, it was associated with greater use of effective contraceptive methods, a closer link between young people and the health system, and a reduction in unplanned pregnancies.
Over time, the evidence ended up resolving one of the most intense controversies in sexual and reproductive health in Chile, and demonstrated that the main fear accompanying its implementation never occurred.
