Deanna Hartog. NHeLP LegaI Intern, Summer 2023; J.D. Candidate, George Washington University Law School
Sexism shapes the U.S. health care system in many ways, such as providers’ failure to seriously consider women and gender-expansive peoples’ pain. For example, research shows that they are much more likely to prescribe women in pain sedatives rather than pain medication relative to their prescriptions for men in pain. Because providers are half as likely to prescribe Black patients pain medication than their white counterparts, Black women experience compounded discrimination. This discrimination shapes the standard of care for many conditions and procedures, particularly in a reproductive health care context. This blog post addresses the lack of adequate pain management in intrauterine device (IUD) insertion and removal and offers legal and policy solutions, including in the nondiscrimination legal realm.
The IUD is a highly effective and increasingly popular form of contraception. According to data from 2015–2017, 14 percent of women ages 15 to 44 who used contraception used an IUD. Many people choose IUDs for contraception because they are reversible, remain effective for a duration between three and ten years, and require less user maintenance than other forms of contraception, such as oral contraceptives. However, unlike other methods of contraception, IUD insertion is an (albeit minimally) invasive procedure during which a provider places an IUD in their patient’s uterus through the cervix. IUD removal essentially involves the reverse process, in which a provider pulls the IUD out. Each of these procedures can cause cramps and bleeding, which often goes away in a few days.
Pain associated with IUD insertion and removal varies person to person, but the procedure can be extremely painful. In a 2013 study, 17 percent of women who have never had children and 11 percent of mothers shared that they experienced substantial pain, requiring pain management, during the insertion process. In 2021, The Lily asked readers to share their experiences with pain management during IUD insertion. A vast majority of respondents described that they experienced some pain either during the insertion or after. One respondent described the IUD as “shards of glass” in her vagina, while another described the experience as “hell on earth.” Many individuals have reported that their providers fail to provide adequate pain management before, during, or after the procedure and even invalidate or minimize their pain. Perhaps this is because providers tend to underestimate the pain associated with IUD insertion. According to a 2013 study, patients rated their maximum level of pain from IUD insertion as 64.8 mm on a 100-mm visual analogue scale, while providers perceived their patients’ pain to be 35.3 mm out of 100 mm.
With so many individuals reporting moderate to severe pain and discomfort during and after IUD insertion, one would expect there to be a standard of care for pain management during and after this procedure. However, according to a 2013 study, “no comprehensive strategy has been developed for managing pain associated with the insertion of [IUDs] and no standard has been established.” Because there is no consensus, “non-steroidal anti-inflammatory drugs (NSAIDs) like Aspirin or Aleve remain the only widely recommended pain relief option for IUD insertion.”
However, research suggests over-the-counter pain relievers, particularly ibuprofen, are often ineffective in treating pain for IUD insertion. Furthermore, researchers in a 2013 study to assess the most effective pain management method concluded that “no prophylactic pharmacological intervention has been adequately evaluated to support its routine use for reduction of pain during or after [IUD] insertion.” This is because, according to the study, “most regimens have been adapted from other gynecological procedures.” Instead of appropriating these regimens, researchers should investigate and establish pain management strategies that specifically address experiences during IUD insertion and removal, including after the procedures. For example, some providers offer sedation when requested by patients, but many patients are not informed about this option, making access rare. A 2023 Connecticut bill aimed to mandate insurance coverage for anesthesia during contraceptive procedures, expanding access.
The standard of care for pain management during IUD insertion and removal and other gynecological procedures may be underdeveloped because the populations who utilize this care–namely women and gender-expansive people–and particularly Hispanic (including Latine) women and gender-expansive people, who are most likely to use IUDs as their contraceptive method of choice–are systematically underserved by our health care system. This can have severe consequences. In addition to preventable pain experiences, pain invalidation can hurt mental health outcomes, contributing to depression and lower well-being. Legal and policy action is needed to address the discriminatory treatment of women and gender-expansive people, and especially Latine and other people of color, in a sexual and reproductive health care context.
Legal and Policy Solutions
It is imperative that providers establish a meaningful standard of care for IUD insertion and removal—one that recognizes, validates, and adequately treats pain in women and gender-expansive people. We can achieve this through a combination of legal and policy strategies. For example:
- Enforce Section 1557. Section 1557 of the Patient Protection and Affordable Care Act prohibits discrimination on the basis of sex, race, color, disability, national origin, age, or any combination thereof in certain health care programs and activities. Section 1557 prohibits intersectional discrimination, such as a provider ignoring a Black pregnant woman’s pain due to combined racism and sexism. When health care providers refuse to discuss the pain that IUD insertion and removal may cause a patient, do not provide counseling on pain management options, or dismiss the pain that their patient experiences, this may constitute prohibited sex discrimination (g., related to sex stereotypes) or intersectional discrimination (e.g., if providers offer information or care options to white patients but not patients of color). Individuals who experience this discrimination can file their Section 1557 civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights using their Complaint Portal.
- Establish quality measures. Quality measures help the U.S. Centers for Medicare and Medicaid Services (CMS) “measure or quality [health care] processes, outcomes, patient perceptions, and organization structure and/or systems.” To promote care quality in Medicaid and the Children’s Health Insurance Program (CHIP), the Secretary of the U.S. Department of Health and Human Services (HHS) is required to identify and publish a core set of voluntary health care quality measures. CMS should consider establishing new quality measures to track whether Medicaid and CHIP providers provide pain management options counseling for IUD-related care and assess enrollees’ related experiences.
- Invest in further research. Congress should appropriate funds for research to evaluate the efficacy of pain management options during IUD installment and removal.
- The American College of Obstetricians and Gynecologists should consider updating its Practice Bulletin on “Long-Acting Reversible Contraception: Implants and Intrauterine Devices” to include options counseling for pain management. Health care providers should educate individuals who select IUDs as their contraceptive method of choice about the various levels of pain they may experience, the range of pain management options, and current (albeit limited) evidence on their efficacy.
- HHS should add training requirements to federal grant programs. One way to ensure that providers are being educated and trained more effectively is to require training on pain management associated with IUD insertion and removal in grants for health care providers, such as the Health Resources and Services Administration’s Rural Maternity and Obstetrics Management Strategies Program.
- Train Title X providers. The Reproductive Health National Training Center (RHNTC) and Clinical Training Center for Sexual and Reproductive Health (CTC-SRH) should train Title X providers to offer information and options counseling on pain management for IUD removal and insertion.