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Why is emergency contraception so hard to get in Japan?

Norlevo, a contraceptive approved in Japan, left, is seen next to an imported foreign contraceptive which is not approved in Japan, and said to be effective for longer. (Mainichi/Toshiyasu Kawachi)

TOKYO -- Views on emergency contraceptive measures used when conventional contraception has failed, or an individual has been subject to sexual violence, are a divisive issue between Japan's young and its medical community.

    While an increasing number of women are calling for the contraceptives to be made available over the counter, among other measures to make them easier to obtain, groups of medical professionals including obstetricians and gynecologists are unrelenting in their cautious approach to the issue.

    But why do opinions differ so much, and what are the issues precluding easy access to these medications? The Mainichi Shimbun spoke with people on both sides of the divide to find out more.

    Emergency contraceptive medication is a kind of hormone treatment; generally, they suppress ovulation to prevent pregnancy. If taken within 72 hours of sexual activity, they have an around 80% chance of averting pregnancy, and it is thought that the sooner they are taken the greater effect they have. They are seen as a last resort not just for people whose contraceptives have malfunctioned or broken, but also for women trying to avoid pregnancy after sexual assault.

    In Japan, two companies offer approved emergency contraception, but to obtain it individuals have to be seen at medical institutions. Because the medications are not subject to national health insurance subsidies, they are seen as medical care paid for at one's own expense, and cost anywhere between 6,000 and 20,000 yen (about $55-184). During times when clinics are closed for days, such as during the end-of-year and New Year holidays, even higher prices can be demanded for the drugs.

    Asuka Someya, left, is seen heading a press conference in relation to the nonprofit organization Pilcon's submission of a petition for emergency contraceptives to be made available at drugstores, in this image provided by Pilcon.

    Groups such as the Tokyo-based nonprofit organization Pilcon are primarily made up of women in their 20s and 30s tackling sex education issues. Among their activities are attempts to improve access to emergency contraceptive measures, by making them available to buy over the counter, among other methods.

    Pilcon's director Asuka Someya, 35, said, "At night and on weekends, when medical institutions aren't open, even if you hurry you can't get it. They're expensive, too. Among young people in their teens and at other ages, there are already many people who feel reluctant to being seen by obstetricians and gynecologists."

    Some people even import contraceptives from abroad for their personal use. Although cheaper than Japan-approved medication, it's difficult to confirm whether the drugs are safe or genuine, and they bring with them a risk of damaging health.

    But in Europe, the U.S. and elsewhere, the contraceptives sell in pharmacies for low prices equivalent to thousands of yen, and some countries reportedly even provide them free to people aged 18 and under.

    In October 2020, a citizens' group jointly chaired by Someya submitted to Minister of Health, Labor and Welfare Norihisa Tamura an online petition signed by around 100,000 people for emergency contraception to be available at pharmacies.

    The fifth basic plan for a gender equal society, which was approved by the Cabinet at the end of 2020, includes investigations into making the contraceptives available without a prescription. Although it includes conditions such as the individual having to take the medication in front of a pharmacist, Someya hailed the move, saying, "The people's voices have shifted politics."

    In 2017, an expert panel at the ministry of health decided not to go ahead with sales of emergency contraception at pharmacies. While online consultations with doctors for the medication were recognized in 2019, it includes controls such as that patients must be seen by obstetricians and gynecologists after being given the medicine. Both moves came after doctors serving as members of related panels voiced cautious views that making the contraception easy to obtain could lead to its abuse.

    An emergency contraceptive sold abroad is seen in this image taken in Tokyo. The medication can be imported individually for person use, but there are no guarantees regarding the material contained. (Mainichi/Kaori Gomi)

    Why are doctors refusing proposals to make emergency contraception easier to access?

    Tsugio Maeda, deputy chairperson of the Japan Association of Obstetricians and Gynecologists, says it is "natural" that many people want to see emergency contraception available over the counter, but he added, "There are concerns that if it's made easy to obtain, there will be more people who think if they take emergency contraception they can avoid pregnancy." He said there are concerns particularly around a situation in which men no longer take contraceptive measures.

    There are also doubts about the medication's efficacy. Maeda runs his own obstetrics and gynecology clinic, and has prescribed emergency contraception before. But he said, "It's said it has about an 80% contraceptive effect, and there are countless cases of people taking them appropriately and still becoming pregnant. I feel their actual effect is much lower."

    He continued, "It is ultimately a kind of drug for use in emergencies, so we need people to understand fully that this cannot be seen as an everyday contraceptive method." Although it does not have strong side effects, they do cause irregularities in the menstrual cycle, meaning that if used frequently they can compromise physical health.

    Some take the view that the continued negative stance by doctors and others as potentially linked to a possible fall in the number of patients being examined by doctors or undergoing abortion procedures if emergency contraceptives become easily available. In response to this, Maeda said decisively, "Even if we no longer prescribe emergency contraception, it won't have a huge effect."

    Regarding abortions, he said, "Recently the number of doctors handling those operations has fallen. Particularly during the second trimester, you may, depending on the area, have to go searching for a doctor." Reportedly there are some obstetricians and gynecologists who think doing abortions gives them a bad image.

    Tsugio Maeda, deputy chairperson of the Japan Association of Obstetricians and Gynecologists, is seen in this image taken in Tokyo. (Mainichi/Kaori Gomi)

    "For a doctor running a business, operations are one revenue stream, but having a system which can use anesthetic and other procedures also comes with costs. It's not that medical professionals want to avoid falling numbers of abortions," he said.

    According to figures from the ministry of health, in 2018 there were 161,741 abortion procedures carried out, with a fall of around 25,000 cases in the five years leading up to that year. Births have also fallen, so it appears the downward trend is attributable to an overall fall in pregnancies themselves.

    Although Someya and Dr. Maeda differ when it comes to easing access to emergency contraception, they do agree when it comes to improving sex education. Japan's junior high and high schools do not have clear structures for teaching about sexual intercourse or contraception, and attempts to engage in sex education are met with controversy, such as accusations that they are "encouraging children to have sex." As a result, many children grow up being exposed to hearsay and uncertain information online and elsewhere.

    But, the two do differ on how to proceed out of the present situation. Dr. Maeda sees difficulties in education at schools as an opportunity for medical areas to become places where young people can learn about sex. "When prescribing emergency contraception, we have an opportunity to provide people with sex education so they will be properly able to use contraception next time," he said.

    "If it's sold at pharmacies, many of them don't have private compartments or other setups like that, so there are questions over how personal they can make the instruction provided. If in the future this became a product available for sale at convenience stores and other places like them, there won't even be a way to communicate what kind of medication it is."

    Asuka Someya, director of the nonprofit organization Pilcon, is seen in this image taken in Tokyo. (Mainichi/Kaori Gomi)

    Conversely, Someya explained her thinking, saying, "Sex education is essential. Even more so now, improvements in access to emergency contraception for people in distress are also an essential part of the same issue." She continued, "Even if you do receive guidance or other help on contraception methods when seeing a doctor, there are cases when people have been sexually abused or who have a kind of relationship with their partner where they can't appropriately seek out contraception.

    "Japan's contraception options are limited, and women's sexual reproductive rights are behind the times," she stressed. When she sat in on ministry of health expert meetings and other events, she said she came away feeling that "they are trying to put out guidance without understanding the feelings and circumstances of women, the concerned party in this case." Almost all the meeting attendees were men.

    Someya said, "Isn't one of the causes of this that only a few women are involved in the decision-making process? But, women have a right to decide themselves what happens to their bodies. I don't want us to live as mindless beings, but as people who together create our future, and change society for the better."

    (Japanese original by Kaori Gomi, Integrated Digital News Center)

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