You're Gonna Have to Unload it Yourself

Happy Endings Are Not Covered by Insurance

Kelly Rippa, the lovably impish star of long-running talk show Live with Regis and Kelly and Michael and Ryan, is coming out with a memoir soon, and one of the stories she shares is about passing out during sex with her husband, actor Mark Consuelos. No, it was not because Mark is too hot, too well hung, or too boring to keep her awake. Nor was the daytime darling engaging in drinking, drugging, or other debauchery. Rippa had an ovarian cyst that ruptured during sex, and she passed out from the pain.

I can relate. I’ve mentioned the time I ended up in the ER with an ovarian cyst here before. While I didn’t pass out, I—a lifelong sufferer of emetophobia—could not stop vomiting. When the urgent care doctor who was about to send me home for the night with instructions to call my OB/GYN in the morning offered something for the nausea, I said honestly, “I’m not nauseated, it just hurt this much.” At that point, according to my husband, the doctor looked panicked and demanded I go straight to the ER. My cyst, which was the size of a golf ball, did not rupture, but it did twist the ovary back and forth, and the pain was definitely worse than childbirth (possibly an unfair metric given that I had an epidural at the first sign of contractions, but you get the idea).

Rippa explained that her cysts were caused by Polycystic Ovary Syndrome (PCOS), a common condition in which those with ovaries/uteri don’t ovulate (which leads to irregular or missed periods), have high levels of androgens (male sex hormones), and often get cysts on one or both ovaries. People with PCOS are also at greater risk of obstructive sleep apnea, insulin resistance, type 2 diabetes, gestational diabetes, obesity, heart disease, high blood pressure, and mood disorders. The high level of androgens can cause other issues like excess facial hair as well.  

There are treatments for PCOS including oral contraceptives and insulin blockers, but many people don’t know they have it until they end up in the emergency room writhing in pain.

In Rippa’s case, the physical pain was exacerbated by embarrassment when she woke up in the ER and saw the outfit her husband had put on her—a 1980s-style leotard, a pair of Mark’s sweatpants with snaps down the side, and red Manola Blahniks (because a workout outfit demands stilettos?). Rippa writes:

“Also, here is my husband, who is, dare I say, stylish, well-dressed at all times, and yet he dressed me like a dime store prostitute in my time of need. It's still baffling to me to this day that this is the best costume for the day that he could find for me, to the point where, when I was on the stretcher, I thought I was dreaming; I was having a nightmare. I didn't realize I had come to.”

This could be the one time when a hospital gown—with its tushy-revealing opening in the back—is preferable to your street clothes.

Contraception: A Long Way from Fish Bladder Condoms, but Access is Still Lacking

Monday was World Contraception Day, an annual event designed to improve awareness of all contraceptive methods. In honor of the day, MSI—an organization that provides contraception in 37 countries around the world—looked back at how far we’ve come from the days of using fish bladders to make condoms, acacia leaves as cervical caps, fermented dough as spermicides, and mercury, lead, and copper salt as long-term methods.

Since Charles Goodyear vulcanized rubber, which was used for the modern condom and ironically would later be used to make Spock’s ears on Star Trek (check me on that one, they might be foam), we’ve had the discovery of IUDs, the pill, and numerous other ways to get pregnancy-preventing hormones.

While it’s true that we still don’t have the perfect method of contraception that is both foolproof and side-effect-free for everyone (maybe the sonic testicle bath will be the one), we have a lot of options. Today’s issue is not science but rather access, and that’s been made extra clear in the U.S. since Alito decided our uteruses are not actually ours to control.

The Associated Press ran an article this week about teenagers desperately trying to access contraception in the months following the overturning of Roe v. Wade. While we don’t have any hard data yet, doctors across the country are seeing increased demand for appointments. A doctor at a pediatric practice in Cleveland, OH explained that appointments for Nexplanon (the contraceptive implant) have been consistently full, and requests for birth control refills are up 30-40%. A pediatric-adolescent gynecologist in Miami, FL said, she’s had patients in her office saying “please, I need some birth control in case I get raped” because that state’s law does not have an exception for rape or incest. A contraceptive clinic in Columbus, OH used to book first appointments within two weeks but now it’s taking more than a month, and they’re considering adding an extra provider. Planned Parenthood saw a 375% surge in online appointments for IUDs the day of the SCOTUS decision, and while that’s leveled off it’s still about 20% higher than it had been.

It's clear that some young people who want birth control can’t get it. Advocates for Youth and the #Freethepill Youth Council released the results of a survey conducted this summer which found lack of access to the pill was common and had utterly expected consequences. The survey included 243 participants from 43 states. The majority of participants (88%) had encountered at least one barrier to getting the pill under the current you-need-a-prescription rules. (Remember, the FDA is currently considering approving over-the-counter access to the progestin-only pill.) In fact, 75% of respondents encountered more than one barrier such as difficulty finding time to go to the doctor (67%) or transportation issues getting there (43%).

For just over half of participants (55%), these barriers meant that they did not end up on the pill at all, which had further consequences. Among this group, 58% experienced a pregnancy scare, 20% experienced an unintended pregnancy, and 16% sought an abortion. A report on the survey includes personal stories of how lack of access impacted participants’ lives.  

This is a small study and not necessarily a representative sample of all young people (participants were recruited through social media and listservs), but access to modern contraceptive methods has been difficult for years and is likely getting worse.

The University of Idaho’s General Counsel issued new guidance on Friday suggesting that in light of the state’s new strict abortion law—which criminalizes the procedure and threatens providers with up onto five years in prison—the University should stop offering contraception to students. Moreover, staff should not speak of abortion at work so as not to be seen as promoting the practice.

It’s hard to know what his logic is behind not providing contraception unless he wrongly believes that some methods cause abortion. (He did say the university could give out condoms for STD prevention only.)

It’s even harder to figure out his suggestion that employees on a college campus scratch abortion from their vocabulary. Though I wouldn’t be surprised if Idaho or other states start passing “Don’t Say A” laws, this law does not say anything about promoting abortion.

If faculty go through with this, it could have implications for courses in almost every department from biology to history. (I certainly would be fired from teaching Sociology of Sexuality about five minutes into my first class.) Oh, and did I mention, the university has a medical school?

Providing Contraceptive Access and STD Screening

This week, I got to Zoom with Sophia Yen, the CEO/Co-Founder of Pandia Health, a physician-led company that provides inexpensive birth control through the magic of mail and telemedicine. Users who have insurance can usually get the pill delivered to their door for free with automatic refills. For people without insurance, Pandia can provide the pill for $7 or $15 a month depending on the brand. Pandia will fill the prescription given by a doctor, or users can see one of their physicians via telemedicine. This costs $25 for the year and the doctors will answer any birth control questions you have during that time.

Dr. Yen—who is Board Certified in Adolescent Medicine—told me that their prescription process (choosing the best brand/formulation for each patient) is very personalized:

“We are not one size fits all we're customized care. We have an algorithm that results in 82% of women staying on the birth control pill after a year versus 55%, which is the standard. It’s because we know that there are differences by race (which we use as a proxy for genetics), age, and BMI. We’re not just pushing the cheapest pill or the ones with the best margins for us, but whatever is in your best interest.”

Yen also explained that Pandia’s doctors always write prescriptions for 12 months at a time, though whether they can be filled all at once is up to state regulations. Still, she thinks this is a practice that all contraception providers should adopt:

“If I write, dispense one, refill 12 times, I have chained you to the pharmacy and you’re screwed. So, it’s really about educating doctors to write the prescription for the full 12 months and then let the pharmacy and insurances figure it out.” 

Pandia’s doctors are also writing prescriptions for Emergency Contraception that users can have on hand in case they need it:

“Our doctors are saying, do you want some emergency contraception with that? I think every provider should have a discussion like this. I guess, I’m just a pessimist because I assume you’re going to miss three pills at some point in your life, and you’re gonna want some back up.”

Yen also wants to make sure that all discussions of emergency contraception pills remind people about the issue of BMI. While BMI (Body Mass Index) is not the end-all-be-all predictor of overall health that some physicians make it out to be, research has shown that it does impact how well ECPs work:

“Plan B and its generics don’t work as well if your BMI is 26 or greater. If it’s 30 or greater, this type of emergency contraception does not work. Ella [a different type of ECP that uses progestin] works up to a BMI of 35. If your BMI is greater than that, your only options are either the copper IUD or the hormonal IUD.”

Of course, the whole reason Yen and I were talking wasn’t about birth control at all. Pandia recently partnered with Simple Healthkits to offer STI screening. The kits, which use urine to check for chlamydia, gonorrhea, and trichomoniasis, are available for $89.99 and include a telemedicine visit with a provider if you test positive.

Annual STI screening is recommended for anyone with a vagina under the age of 25 who is having heterosexual sex. This is different than STI testing which anyone who is sexually active and has any kind of genital or pelvic symptoms should do:

“If you have symptoms, in-person is more important because the doctor wants to check if there's any uterine pain or any ovarian pain. Okay, it's just in the vagina, then we're good, but if it goes up to the uterus and the tubes, then it needs more testing and much more serious drugs.”  

Possibly because she was a doctor and a public health expert before she was a CEO, Yen wants people to know that if they have insurance and can get to a doctor, this may not be the cheapest option for screening:

“We try to save people money wherever we can. If your doctor were to order this test and you were to do it in their office or go to the lab and do it, it would be free. But if you need confidentiality, you don't have time, or your copay for any office visit is going to be $50 or $75, then this can work. Screening is really important because 75% of people with vaginas and 80% of people with penises have no symptoms with chlamydia. Similarly, 80% of those with a vagina have no symptoms with gonorrhea though people with penises are far more likely to have symptoms like discharge with this one.”

After that, we digressed because she said she was taught in residency to “milk the penis” when testing for gonorrhea and neither of us could get that phrase or the accompanying visual out of our minds. Maybe I should have asked her to enter our cow mucus product naming session—oddly, no one suggested Penis Milk.

Happy Endings Are Not Covered by Insurance

A woman in California is being indicted for insurance fraud after she hired dancers from a local strip club to provide services that were billed as acupuncture and chiropractic care to longshoremen.  

I don’t know why this story tickled me so much. The details are kind of dull (it is insurance after all). Maybe it’s because I have dreamt of ways to get insurance to cover my (completely non-sexual) massage habit. Possibly it’s because my least favorite part of adulting is getting reimbursed for out-of-network services (as evidenced by the stack of receipts on my desk waiting to be submitted). Maybe it’s just because I never get to write about longshoremen.

According to the indictment, Sara Victoria ran three wellness centers in Los Angeles that accepted insurance, including the plan offered to members of the International Longshore and Warehouse Union – Pacific Maritime Association (ILWU-PMA). While the details in the indictment are scarce, it looks like Victoria made a deal with some union members under which she provided either sexual services or cash kickbacks in exchange for allowing her to fraudulently bill their insurer.

The scam seems to have included both sexual services that were billed as legitimate health appointments (acupuncture with a happy ending sounds pointy at best) and claims filed for phantom appointments in the name of the men, their wives, and their children. Between 2017 and 2021, Victoria submitted approximately $2,110,920 in claims to the ILWU-PMA plan, for which she was paid approximately $551,810.

A longshoreman who allowed Victoria to bill his insurance for sexual services and services never rendered was also indicted with one count of conspiracy to commit health care fraud, two counts of health care fraud, and one count of making false statements to federal investigators.

If convicted the two could face up to 12 years in jail. No word yet on charges for the other people involved in the scheme.

Needless to say, the union was not happy with the employees who took advantage of their benefits plan. “Our union is proud to have negotiated health benefits with our employer that we believe all Americans should have. We will not tolerate fraudulent use of the benefits in our contract that longshore workers have fought for, and sometimes died for, over the past 90 years," a union spokesperson said in a statement.

Longshoreman usually have a lot a power in their negotiations with employers since these workers—who load and unload cargo ships at port—have the ability to choke off the global supply chain. Twenty years ago, the union negotiated an average salary in the low six figures and a benefits package worth more than $40K, but clearly happy endings were not included. Workers could try again as there are new negations going on right now, but I’m pretty sure the union would just come back with, “Sorry, guys, you’re gonna have to unload it yourself, just like you do at work.”