Monday, November 14, 2011

Birth Control and Freedom in Taiwan

A letter of mine has been published in the Taipei Times again, this time on the topic of National Health Insurance's lack of coverage for birth control.

It's copied below as well. Enjoy.

Birth control and freedom
In my five years in Taiwan, I’ve been consistently impressed with the healthcare system here.
That’s why I was surprised to learn, after using the system for so long, that birth control is not covered by the National Health Insurance (NHI) and the birth control options available to women in Taiwan are limited at best. The cheapest options are similar in price to one person’s NHI monthly premium after employer subsidization. This is an insult to women’s rights and choice. It needs to change immediately.
I realize there are two factors at play in the decision not to cover contraceptives: The first is that the Taiwanese government is preoccupied with raising the birthrate and covering birth control appears to contradict that goal. The second is that it’s “elective” and not a necessity for a healthy life (although I could argue that for many women, it is a necessity for a fulfilling life).
I accept neither of these excuses. As for increasing the birthrate, making birth control needlessly expensive is not the way to do it. Middle-class and wealthy women in Taiwan can afford the NT$450 to NT$650 a month that birth control costs, as well as the initial OB/GYN consultation fees, but poorer women cannot. Does the government really want to raise the birthrate only among women who are pregnant only because they can’t afford birth control? How about among women whose husbands force them to have sex and who won’t wear a condom? Are these the households in which we want children to be born?
Shouldn’t the government instead pursue a policy in which babies are born into stable families who planned for them, want them and will love them?
Birth control is more than an “elective” — access to it is a necessary component of women’s freedom and rights. For some women, it’s the only thing standing between them and poverty, as they — married or not — can’t afford to raise a child.
It’s not a complete solution to say: “Make him wear a condom.” Unfortunately, many men in Taiwan refuse to do this, including married men. For many women, especially those in abusive or controlling marriages, taking control of their own form of contraception is the only option — and it’s a pricey one. It is one of the most expensive long-term medications to take, because it is not covered as most long-term medications are.
For some women, birth control is a medical necessity brought on by various health issues, either to maintain chronic conditions or because pregnancy would be dangerous or life-threatening.
This creates an unacceptably sexist bent to Taiwan’s national health policy. With Democratic Progressive Party Chairperson Tsai Ing-wen (蔡英文) in the running to be Taiwan’s first female president, Taiwanese women can only hope that she, in fighting for greater women’s rights and equality, will take a hard look at the issue and decide that things need to change. Now.
Jenna Cody


KasiaHo said...

I think the problem is more complex than that. The birth control pill you can get as cheap as 100NT per box. You dont need doctor's prescription, you just go and buy it as any candy bar. What do you want to subsidize?
It's not about the contraceptive price. It's about poor sex education at schools and that not many women know that the pill is so easily available. It's also fear that someone (who is next to us and disapproves this Western Devil Pill) will find out that a woman is taking it.

Jenna Lynn Cody said...

I don't know anywhere in Taiwan where one can get OTC birth control for NT$100 (and I'm no stranger to gray market drugs - I buy my Imigran OTC because I can't be bothered to go up to the hospital that will give it to you under health insurance as it's across town). And honestly, I'm not sure I would trust that source. I pay full price for OTC Imigran (about NT $1200), so super cheap birth control? Yeah, not striking me as terribly safe.

Yes, there is poor sex education in the schools - although honestly, I'll say this: it's better than the USA. I see more sex ed advertising here than back home, but that doesn't negate the fact that the Pill is so expensive.

My impression of Taiwan is not that it is filled with people who disapprove of birth control - I am sure they exist, but coming from the USA where you have the extreme religious right, Taiwan is downright tolerant. From my experience, most Taiwanese don't care what someone else is doing (unless they're an old lady inquiring about when you're going to have babies), and what would scare Taiwanese women wouldn't be what other people think - although they might fear what their parents think - but poor sex education leading to a fear of talking to the OB/GYN (or an OB/GYN who assumes you want to have a child in the near future - as mine did. Ugh).

KasiaHo said...

I mean legal market. You can go to the pharmacy and ask for Mercilon, this is the pill for 100 NT. I am sure there are more pills that are around that price. You can buy some up to 500NT (e.g. Yasmin), but this price I believe may be already too high for the poorest one.
The problem I found that women who do have money do not use the pill...and this is the education problem, sex education. Maybe in the US the education is poor as you say in this regard, but still women in the US know and are not afraid of using contraceptive, whereas here it is a different story.

Jenna Lynn Cody said...

I have not seen Mercilon for sale OTC in Taiwan, but it's worth looking again.

That said, Mercilon is an older contraceptive, and there's a reason why it's not as popular as other, newer medications. It has similar side effects, but as far as I know, they tend to be worse with Mercilon *and* efficacy is more limited than with, say, Yasmin.

(But then I've taken Yasmin and it made me absolutely sick - I had to switch pills. I couldn't take it anymore).

I have also heard that the fatal side effects - blood clots, thrombosis, heart attack, stroke - for Mercilon is higher than other medications including Yasmin (and these side effects are a huge issue with Yasmin now). Pretty much all oral contraceptives carry these risks but Mercilon, so I have read, is especially problematic in this case.

Which goes back to "choices are limited in Taiwan" - you can't get a shot (like Depo), implant (like Implanon) or other options. If you don't want to take pills or use condoms, your choices are an IUD or something like the NuvaRing (which can cause severe nausea especially in the beginning as the dosage of medication in it is fairly high).

Jenna Lynn Cody said...

And that's really the problem - birth control pills that are more expensive (ie Yasmin) and other contraceptives really ought to be covered under NHI. Not everyone can take or should take Mercilon. There need to be choices, but for poor Taiwanese women, there aren't any.

KasiaHo said...

I do agree that some of contraceptive should be subsidized(in any country), but I won't agree that lack of such subsidy is the reason why women in Taiwan choose abortion as a contraceptive method more often than the pill.
I do believe that the source of this problem is in education and culture.
As I said in Taiwan it is not the money that influence the decision whether to take or not to take the pill. Women who have abortion pay for it much more than for a pill.

Jenna Lynn Cody said...

I still disagree - because if a woman doesn't care what others think regarding her sexual activity (if she is sexually active), and if she'll go to the lengths of an abortion and doesn't care enough about what people think about that - and it is much easier to hide pill-taking than having an abortion from people like relatives - then it makes no sense that she wouldn't take the pill out of fear of being judged.

Now there is a lot of truth to the fact that some women don't take it because they weren't taught that they could/should. This probably makes up a large percentage of women in Taiwan.

But that doesn't negate the fact that plenty of OTHER women a.) can't take Mercilon and can't afford something different; b.) can't even afford the NT$100 a month for Mercilon (yes, that kind of poverty exists in Taiwan; there are stories occasionally that come out about things like a grandmother and child who only have enough money to share one bento box a day) and c.) deserve choices even if they are poor.

Because THOSE women very often end up either having the baby and becoming charity cases (if they weren't already), abandoning the baby (child abandonment, from what I hear, is actually on the rise in Taiwan), or if they can't pay for an abortion on their own (and many of them can't) borrowing money from unsavory characters to get it done and then being in debt to gangsters.

Which is worse.

So yes, I agree that sex ed could improve - although I do want to point out that it is true that plenty of American women are not properly educated about contraceptives either; many schools teach them "abstinence only", and many are taught by family that anything else is evil (of course they do it anyway, which is why this system doesn't work).

But on top of that, birth control needs to be covered, and poor women deserve options too.

John Chang said...

You can get Bayer or Marvelon contraception pills for 120 NT$ at any pharmacy in Taipei City or Xinbei City. Bayer is good German brand - no cheap and unsafe back alley lab stuff.

So P L E A S E stop spreading rumors that contraceptives are too expensive in Taiwan.

With Taiwan's birth rate, contraception doesn't seem to be an issue anyways - at least not for the local woman who do not complain in blogs or on TV.

It seems this is rather a personal issue for a certain Jenna Cody who is not a local woman and expects to freeload on Taiwan's socialized medical system so that she personally can enjoy life (hint: this is a euphemism) without needing to pay for her contraceptives.

Jenna Lynn Cody said...

John -

$120 NT *is* too expensive for some women, and if you think that the birthrate is the reason why this is not the issue, then you don't understand the issue: it is very much a problem for poor women, and very much a problem for women in violent/abusive relationships, especially ones that involve marital rape. The birthrate has nothing to do with that problem. It is highly personal for ALL women, including those who can't afford contraceptives.

Also, considering the issues Taiwan has with child abandonment *and* the fact that late summer/early fall is referred to by many in the medical field as the "Abortion Season", how can you say it's not an issue? Only ignorance would beget that conclusion.

By the way, Bayer is not all that great in some areas - Bayer also makes Yasmin and Yaz, and both of them also have side effects that include blood clots, thrombosis, heart attack and stroke. Yasmin is taking quite a beating for it.

And keep in mind that not all women can take whatever might be available over the counter - I personally have not seen OTC birth control, but I am willing to believe it exists (I'll check on that). The combinations of drugs in different pills mean that some pills give women terrible side effects while others do not (I had that problem with Yasmin - the side effects were so awful that I had to switch pills). Why should poor women be restricted to only the cheapest pills - which they may not even be able to afford?

Which brings me to the next point - what about poor women who have trouble affording birth control, but need it for other health reasons (ie menstruation problems)? Sometimes a doctor wants those women to take a specific pill that helps, and they can't just take any old pill. What if those women can't afford the pill they need? If you don't realize that, then you are truly ignorant.

Which is also beside the point, because contraceptives should be covered under national health insurance REGARDLESS. Other drugs are, even ones you can get OTC. Panadol is available OTC but you can get NHI-covered Scanol (which is basically the same thing) - so why not birth control?

I also don't appreciate your insinuation that sexual activity in women - ie something I do feel is necessary for a fulfilling life - is somehow wrong or bad or up for being mocked? It's not. It's normal and natural. We're beyond the misogynist age when women were just expected to be chaste and unsatisfied (while men suffered under no such strictures). I can't help but think you have a sexist streak if you're going to go down THAT road, John.

And if you are going to go down that road, I may as well add that I'm married, so what's it to you?

Finally, no, this isn't about me freeloading. First, I'm not "freeloading" off of Taiwan's healthcare system. I pay a healthcare premium like every Taiwanese person and I pay taxes in Taiwan on the income I earn here. That's not freeloading. I pay into the system so I deserve to be allowed to use it. Frankly, you're an asshole for implying otherwise.

Along those lines, this isn't about me at all. I earn good money. I can afford the contraceptives. It has nothing to do with me wanting to go out and have random sex across Taiwan (again, dude, I'm married). I can and do pay out of pocket.

My concern is with the women in Taiwan who aren't so lucky.

Jenna Lynn Cody said...

And this is why discussions about birth control are such an issue - the ignorance is staggering, from people who think they know what they're talking about. The sexism is staggering. The idiocy and downright lack of information and wrong beliefs are staggering, and the fact that it is still seen as somehow OK to attack someone personally over speaking up on an Just wow.

Kasia has some great points. I agree with much of what she says. John, you're just wrong.

Brendan said...

John's precisely the sort of commenter about whom the phrase 'Do not feed the trolls' was invented.

Mind you, I don't agree that you should never feed the trolls - they often set you up to make pretty good points that you wouldn't have made otherwise. Jenna's response was pretty spot-on, for example.

Also, I am in love with John's concluding paragraph, and if I posted regularly on Forumosa I would make it my sig (with attribution and a brief note that Jenna's my wife, of course).

Jenna Lynn Cody said...

Exactly, sweetie!

Normally I don't publish comments like John's - because I won't publish personal attacks (on me or anyone else who is not a public figure, ie a politician) that offer nothing constructive, and I especially don't publish anything that reeks of misogyny, because this blog is supposed to be a good resource for expat women in Asia and place to discuss women's issues in Asia.

But his idiotic comment gave me the chance to make some points that I deem quite worthy, that I could not make in the original editorial due to space it got through for that reason alone.

Not because his actual comment had any intrinsic merit.

KasiaHo said...

Hi Jenna, I am sorry you got such a comment, but as you said it shows quite a few issues we have been talking here about. It provides partly the answer why women (who can afford) do not take the pill.

What I have been trying to say here is that subsidy by NHI won't solve the problem. Why?
You said you want to help the women who can't afford the pill. My question is: Would they take the pill if they could afford? Then I look at all these women who earn enough money to buy any contraceptive pill and they choose not to do it.
That's why I say that the solution to this problem is somewhere else.
Anyway, nice talking to you and looking forward to the next step you are going to take in this topic :)

Jenna Lynn Cody said...

It's OK - I'm used to it! I just don't publish them if they're ridiculous and provide no platform for me to make any other points. It's a hazard of blogging. Especially for women. Which is sad.

I do think that women who can't afford the pill - at least some of them - would take it. I can't imagine that few (poor) women in Taiwan who, say, endure marital rape or men who refuse to wear condoms* would say no to the pill. You are probably right that SOME would, or wouldn't know to get it, but that's where education comes in - not just that there's nothing wrong with the pill, but that they need to get out of those relationships (with assistance to do so - another thing the government could amp up). But some surely would take it if they could.

As for women who can afford it...well, being one of them, I am not quite so concerned for them BUT its' still the principle of the thing: it should be covered because it is often a necessary long term medication.

*Yes, I agree that those women should refuse to sleep with a man who won't wear a condom, which is where sex ed comes in, but once again that education needs to be for men, too, because it's not Womankind's job to uphold all good moral and considerate practice. Men have to do it too. And yes, women who have abusive marriages and relationships that involve rape should leave, but it's not always that simple to actually do.

Anonymous said...

Mercilon is indeed readily available OTC in Taipei, I bought it with my girlfriend in several pharmacies in Nangang. I don't recall it was so cheap, though - I thought more like 300-400NT.

Interesting blog by the way. I agree, sex education can be somewhat lacking in Taiwan :(

Jenna Lynn Cody said...

That's the thing - in the US the equivalent of NT$400 is reasonable within American purchasing power parity. I feel it's a bit much for Taiwan where other medications are covered. Even $100, while more reasonable, is a lot more than other long-term drugs, which are often *free*.

But really, my issue there is that not all birth control pills are created equal. The pills themselves might be fine but women's bodies react to different formulas in different ways. Mercilon might be fine for one woman and make another unrelentingly nauseous. Yasmin might be fine for some women but it made me dizzy and irritable all day, every day. Sometimes what's prescribed is more for health factors (hormone regulation, menstrual issues) than to prevent pregnancy and a specific pill is needed.

So even if one or two types are available OTC, that's *just not good enough*.

Unknown said...

Hello,Jenna! I am happy to hear you to like my country, and maybe one day it will become our country. However, I feel sorry that I have to tell you that you are wrong on this "NHI doesn't cover birth control" issue, because it does cover!
Here's the page for what it cover:
I hope you can read that, or you can ask your Taiwanese friends translate for you.
The birth control pill for a month only takes you NT $35. So you don't need to pay NT $ 1200 for it.
(Maybe there are some wrong English usage, forgive me, thanks!)

Jenna Lynn Cody said...

Thanks for the comment, Olivia. That is indeed interesting!

Perhaps things have changed, however, I wrote this a few years ago when I was seeking out birth control options in Taiwan, and I can assure you that no pill my OB-GYN offered me was covered by National Health Insurance. The only choices I was given were NT600 or 650 per month out of my own pocket. I can afford that, but plenty of poorer women cannot.

I'll have to really look into it to see if things have changed, but as of when I wrote this, the information was accurate.

Jenna Lynn Cody said...

I should add that it doesn't really matter for me - this is usually Too Much Information to pass out on the Internet, but as this post is about women's health in Taiwan I feel okay about it.

I actually can't take hormonal birth control - the side effects are terrible. If I don't get nausea or dizziness, I lose my entire sex drive. That means we employ non-hormonal methods. The point? A lot of comments above seem to ignore the fact that different women's bodies react differently to hormones and what pill to take - or whether you can even take a pill - will be highly individual, and so all options need to be covered. Not every woman can handle every hormone/dose/combination. It's important not to lose sight of that when talking about this issue.

Maya O'Hara said...

hay I agree. But besides the pill, is the I injections available in Taiwan as well?

Jenna Lynn Cody said...

Not that I know of, no.