Where Disproportionate Need Meets Unequal Access: Plan B in Native American Communities

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When President Obama signed the Tribal Law and Order Act into law two years ago, it was a long overdue step to improve public safety in Native American communities — in particular among Native American women. Department of Justice data show that Native American women are more than two-and-a-half times as likely as other women in the United States to be sexually assaulted or raped. Another statistic that sets Native American women apart from other women in the United States is the likelihood that their victimizers will be non-Native men. While other women are usually attacked by men of the same race, 86 percent of reported sexual assaults against Native American women are perpetrated by non-Native men.

Most Native Americans depend on the Indian Health Service for health care; most IHS pharmacies don’t provide emergency contraception.

The feeling that this violence is inevitable is common to many Native American women, a feeling that some have attributed to the history of military outposts on Native American lands and sexual abuse in boarding schools. Historical factors aside, a contemporary jurisdictional dead zone has enabled the problem to persist. Tribal police on Native American reservations don’t have the authority to arrest or detain non-Native suspects. Those suspects fall under federal jurisdiction, but federal marshals are too small in number and too committed to other responsibilities to provide community policing on reservations. The situation of virtual amnesty for non-Native perpetrators has created a scourge that some have dubbed “rape tourism.”

The Tribal Law and Order Act was enacted to prevent victims of sexual violence from falling through the cracks by improving investigation and prosecution of sex crimes. A New York Times article from earlier this year reported that only 13 percent of the sexual assaults reported by Native American women lead to arrests, compared to 35 percent of those reported by black women and 32 percent of those reported by white women. The improvements that the Tribal Law and Order Act promises cannot come soon enough.

The recent attention to sexual violence against Native American women underscores the need for access to emergency contraception in Native American communities. Unfortunately, while improvements in prosecution are underway, access to emergency contraception seems to be another story.

The Tribal Law and Order Act mandated that the Indian Health Service (IHS) establish sexual assault policies modeled after those that the Department of Justice uses. In response, the national agency created a set of rules, but implementation on the ground at IHS clinics, hospitals, and mobile units has been inconsistent. Charon Asetoyer, executive director of the Native American Women’s Health Education Resource Center, told the news site Colorlines.com that IHS “sent word out to local service units that they could adopt their own standards, that they only had to use IHS standards as a base,” and to her knowledge “the IHS hasn’t given these service units a timeline.”

The Native American Women’s Health Education Resource Center (NAWHERC) released a roundtable report in February of this year that detailed many of the challenges Native American women face when they try to get emergency contraception (EC). It followed a similar report released in 2009 that found that only 37.5 percent of the IHS pharmacies they surveyed provided EC, and only a fraction of those offered Plan B contraception over the counter. By contrast, a recent study published in the journal Pediatrics found that 80 percent of the 943 commercial pharmacies surveyed were able to provide EC; an earlier study published in the journal Contraception surveyed 1,085 pharmacies and produced similar findings. The new report “found evidence of a worsened situation for Native American women” compared to their 2009 findings. One roundtable participant, Lisa Thompson-Heth, reported, “We have had rape victims given prescriptions to get EC, but at IHS they wouldn’t administer it, because the pharmacy director and her staff didn’t believe in it, so she wouldn’t administer EC.”

This theme was repeated by other roundtable participants, who cited religious objections to EC among IHS staff and a failure among many of them to refer patients to another health care provider so that they could still get EC. The report also attributed the “minimal availability of Plan B” to administrative problems, such as failure to add EC to approved drug lists at pharmacies.

The recourse when IHS patients are denied EC is to travel to the nearest commercial pharmacy, which for many patients can be hundreds of miles away, compounding what for many is already a cost-prohibitive drug with the time and expense of travel. Most Native Americans depend on IHS for their health care, but most IHS pharmacies, according to NAWHERC, don’t provide emergency contraception.

The situation is as persistent as it is untenable. The same journalist at Colorlines.com who spoke with Charon Asetoyer wrote a follow-up piece in June, in which she wrote about her experience contacting three IHS locations to find out if she could get Plan B. Each attempt was a strike.

The last attempt, though, offered a glimpse of hope. A nurse told her “she’d just received a policy draft from regional headquarters in Aberdeen [South Dakota] instructing providers to distribute [Plan B] without a prescription.”

More improvements should be on the horizon with the recent reauthorization of the Indian Health Care Improvement Act (IHCIA), a part of the Affordable Care Act of 2010 that was recently upheld by the Supreme Court. Although the IHCIA says little about reproductive health specifically, it authorizes many administrative improvements, including “[e]nhancement of the authorities of the IHS Director”; “comprehensive behavioral health, prevention, and treatment programs for Indians”; and “establishment of a Community Health Representative program for urban Indian organizations to train and employ Indians to provide health care services,” according to a White House press release.

With more than 800 locations around the country, Planned Parenthood health centers serve millions of people annually and can provide information about emergency contraception and other birth control choices, as well as other health care services. More than three-fourths of Planned Parenthood clients “have incomes at or below 150 percent of the federal poverty level,” and one of the many issues Planned Parenthood works on is increasing access to emergency contraception.