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Why Does No One Seem to Care that Plan B May Not Work for Fat People?

Plan b one step

Something that not nearly enough people talk about is the fact that Plan B may very well not work for women with a BMI over 25. This is not exactly breaking news — in fact it was written about quite a lot in 2013, after a European drug company called HRA Pharma released their version of the emergency contraceptive, Norvelo, with a warning label stating that the drug is completely ineffective for those who weigh more than 176 pounds and begins to lose effectiveness for people over 165 pounds.

norvelo warning copy
Source: Mother Jones

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A few great articles were written about the issue — including this one and this one, but then discussion of the topic ceased. The fact that Plan B-One Step may not work for fat people (and I'll be using the term "Fat" because there is no reason to dance around a word that fat people have heard time and again, most often in negative contexts — in fact, it's a very important word to reclaim) has largely gone unnoticed by the public discourse. When I brought it up with my friends, none of them were aware that Plan B begins to lose effectiveness for those with a BMI over 25. This is a problem that may affect a huge segment of the population who relies on Plan B for their reproductive health.

Ultimately, this is an issue of both health and rights: the right of everyone with a vagina to have access to functioning contraceptives, as well as the rights of fat people to adequate health care and medical research into needs specific to them.

We have a lot to get into here, but let’s start with the basics:

Plan B One-Step is a type of emergency contraceptive — meaning that it is a pill that can be taken after the moment of possible conception. Emergency contraceptives differ from preventative contraceptives — such as the pill, the implant, an IUD, and the various barrier methods (condoms, diaphragms, etc.) And Plan B One-Step, specifically, is only one of a few kinds of the emergency contraceptive pill, but it's by far the most ubiquitous and easily accessible to the general population.

Plan B, and it’s generics, uses the synthetic hormone levorgestrel — a kind of synthetic progesterone, the hormone that signals pregnancy — to halt ovulation, as well as close off the cervix with mucosa to prevent the passage of sperm. This inhibits fertilization and implantation in the uterus and makes Plan B a remarkably useful contraceptive.

The fact that it can be effective up to 120 hours after intercourse, its price ($50), and its availability over-the-counter (following a mandate by the FDA in 2013), are all reasons why Plan B has become the most widely available and affordable method of emergency contraception available in the United States.

Plan B also has notably minimal side effects for an emergency contraceptive — ones which tend to be manageable for most people (nausea, fatigue, cramping). Given the expense and difficulty in accessing other methods of birth control, Plan B One-Step has become a contraceptive that a sizeable portion of the population relies upon — particularly those that are low-income (who are statistically likely to have higher BMIs in the first place) and the young.

Plan B is particularly popular amongst teens; “among females ages 15 to 19 who have had sexual intercourse, 22 percent said they had used emergency contraception at least once in their lives.”

Plan B, for many, is a sexual and reproductive health necessity. That's why studies that report that Plan B ceases to be effective for individuals with higher BMIs are alarming. Research shows that levonorgestrel does not effectively prevent pregnancy in people with a BMI over 25 — “contraceptive efficacy was reduced in women weighing 75 kg [165 pounds] or more, and levonorgestrel was not effective in women who weighed more than 80 kg [176 pounds]." In fact, clinical trials at Edinburgh University reveal that the rate of pregnancy in people taking Plan B was three times higher for people with a BMI over 30 than it was for those with a “normal” BMI.

This means that as the BMI approaches 30, Plan B shows no reliable contraceptive effect.

This presents a serious problem because according to the Centers for Disease Control and Prevention has reported that, from 2007 to 2010, the average weight of women age 20 and over was 166.2 pounds, and for non—Hispanic black women, that average weight was 187.9 pounds. "There's a whole swath,” says James Trusself of a professor of public affairs at Princeton and a senior fellow at the Guttmacher Institute, a think tank for reproductive health issues, "of American women for whom [these pills] are not effective.” I myself am 5’6 and weigh 185 pounds — putting my BMI at 29. I know that for myself, not being able to rely on Plan B is a big fucking deal.

One particularly concerning aspect of all Plan B’s lack of efficacy is that the research is unclear as to why it doesn't work for those with BMIs over 25. Some biochemists believe that the higher weight affects how the drug is metabolized, while others say that the greater body mass simply dilutes the drug, reducing its efficacy.

BMI in and of itself is a poor indicator to overall health and body mass, so the root of the correlation is unclear to begin with. Some agencies even claim that Plan B does work for people with BMIs over 25 — such as the European Medicines Agency. The EMA concluded that there was not enough data to prove whether Plan B was ineffective for those with a BMI of over 25. But the fact that the results of their investigation were inconclusive is hardly a comforting thought, and should at least warrant more investigation into the subject.

In a Refinery 29 interview, Alison Edelman MD,  at Oregon Health & Science University, stated that the initial investigation done was "just a small pilot study and didn't measure the drug's effects on ovulation, which is what really matters in terms of preventing pregnancy. But... it definitely suggests that, for women with higher BMIs, one dose of Plan B may not be enough to actually affect ovulation."

The fact of the matter is that not nearly enough research is being done on this issue. For a contraceptive that millions rely on, there has been remarkably little investigation and discussion of the question. There is a clear correlation between weight and efficacy, and yet the cause is unknown. Following the groundswell of attention being paid to the issue following the 2013 release of the European Plan B, there has been little clinical research done in why Plan B is less effective for heavy people. This is concerning, because there is a significant portion of the population who are relying on a contraceptive method that is, at best, unreliable for them.

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What the lack of research — and lack of media attention in general — indicates, in a larger sense, is that the medical industry does not care about fat people.

The stigma against heavy people in the medical community is already well documented. First of all, the experience as a fat person at the doctor terrible, with “Primary care guidelines recommend[ing] that higher—weight individuals with a BMI above 30 should be provided with weight loss interventions and nutritional advice automatically even if their presenting concerns are unrelated to body weight.” If you have every been a fat person at the doctor, I’m betting that you’ve had an experience wherein you tell your doctor about a health issue, and they shrug their shoulders and tell you to lose weight. This is fundamentally unacceptable — but it is also unsurprising.

To quote the magnificent Amy Farrel in her work Fat Shame: Stigma and the Fat Body in American Culture, “our national ‘war on fat’ has created a colossal health and diet industry closely enmeshed with government agencies."

9780814727690 FullSource: NYU Press

Profit motives for our sixty-billion-dollar diet industries and fat stigma have become so entangled that it's difficult...to even entertain the possibility that we are fighting the "wrong war" — that war being the general fight against obesity.

Simply put: it is not in the economic interest of the medical industry to investigate many of the problems that fat people face — it is, rather, often much more profitable to sell them something that will make them lose weight. To rely upon the stigma of fatness to invalidate their health concerns; to tell them that their medical issues are their fault because they have “allowed” themselves to be overweight. 

For now, it is unclear whether it is possible to manufacture an effective Plan B-One Step pill for individuals with a BMI over 25 of 30. Simply upping the strength would not help, as "a dose increase of levonorgestrel is not proven to be a solution for this problem," as noted by an HRA Pharma spokesperson in an interview with Mother Jones. "However, women with higher weight are advised to discuss alternative emergency contraceptive options with their physician: IUD or alternative oral emergency contraceptive."

For many, however, these are not feasible options. The other emergency contraceptive pill of note is “ulipristal acetate — most commonly known as Ella”, and which “has been shown to be more successful for heavy people than just the levonorgestrel alone, but it still does not work as a reliable form of contraception for them.“

Medical experts recommend that people with a BMI over 25 get the IUD — the most effective contraceptive device on the market, at over 99% efficacy. The IUD, however, is not only sometimes painful, and can aggravate certain medical conditions, but it also has to be inserted by a doctor, and can cost between $500 to $900 in the US — making it a significantly less accessible option. Hormone-based birth control methods are not workable for everyone, for both medical and financial reasons, and condoms and diaphragms are also a weighty expense for many.

The fact that Plan B may not work for a significant portion of the population is deeply worrisome and represents a real public health issue.

For me, Plan B was always just what its name indicated: a fallback. It was always that option in the back of my mind; it was that option if the condom broke, if I missed too many birth control pills, if my partner and I just were sloppy and stupid — because I'm often a sloppy and a stupid person. Plan B was always that security net. Just the possibility fact that Plan B may not work for me is both frightening and infuriating. And what is more infuriating still, is the fact that no one really seems to care.

This is an issue, fundamentally, about two sets of rights: the rights for people with vaginas to receive adequate reproductive health care and the rights of fat people to receive healthcare, as well. The lack of funding and interest for why Plan B One-Step does not work for those with a BMI over 25 lies at the intersection of those two groups — two groups that historically have been and continue to be silenced, particularly in regards to issues of their bodily autonomy. The fact that Plan B may not work for fat people is troubling; the fact that no one seems to care is a manifestation of stigma and systemic discrimination.

Top photo from Wikipedia

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I'm a recent Bard grad livin large and in charge! I write and perform comedy (articles, standup, all that jazz). I'm writing a tv pilot right now about a cardiologist who is unlucky in affairs of the heart it's called "How to Get Away with Murmur."

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