Senator Olympia Snowe of Maine, an abortion rights Republican who has sponsored legislation that would require insurance companies to cover contraception, has seen a major change. "Two decades or more ago, I don't think there was much of a divide on contraception and family planning," she says. "It was one area both sides could agree on as a way to reduce unwanted pregnancies. Now it becomes embroiled in philosophical disputes."

The Guttmacher Institute, which like Siecus has been an advocate for birth control and sex education for decades, has also felt the shift. "Ten years ago the fight was all about abortion," says Cynthia Dailard, a senior public-policy associate at Guttmacher. "Increasingly, they have moved to attack and denigrate contraception. For those of us who work in the public health field, and respect longstanding public health principles — that condoms reduce S.T.D.'s, that contraception is the most effective way to help people avoid unintended pregnancy — it's extremely disheartening to think we may be set back decades."





It was a Friday afternoon at the end of August last year, with most of official Washington on vacation, when a press conference was called at F.D.A. headquarters in Rockville, Md. The occasion was a major drug announcement, but no one from the agency's Center for Drug Evaluation and Research was in the room to hear Commissioner Lester M. Crawford declare that "the agency is unable at this time to reach a decision on the approvability of the application." It was for Plan B.

Plan B, the brand name for the most common form of emergency contraception, has been on the market since 1999 (another form, Preven, came on the market in 1998). The pill, which contains concentrated amounts of progestin, a hormone found in ordinary birth control pills, can prevent a pregnancy most effectively if taken within 72 hours of having sex. (The abortion pill, by contrast, can be taken up to 49 days after the beginning of the last menstrual period and causes the chemical abortion of a fetus.) Plan B's manufacturer applied in April 2003 for permission to sell Plan B over the counter. Reproductive and women's health professionals expected clear sailing for the drug (morning-after contraception has been available in some European countries for more than 20 years). Experts overwhelmingly considered it safe: in December 2003 the F.D.A.'s own joint advisory panel voted 28-0 that it was "safe for use in the nonprescription setting" and then voted 23 to 4 in favor of granting Plan B over-the-counter status.

The hope many people had for the drug was tied to an ugly number: 21. That is the number of abortions in the U.S. per year per 1,000 women of reproductive age, which puts the country at or near the top among developed nations. Put another way, according to a study released this past week by the Guttmacher Institute, there are 6.4 million pregnancies a year in the U.S., 3.1 million of which are unintended and 1.3 million of which end in abortion. In the seven years since the last such study, the overall unintended-pregnancy rate has remained unchanged; for women below the poverty level it increased 29 percent. If women had quick, easy access to a backup contraceptive, the thinking of Plan B proponents went, those rates — and thus the abortion rate — would drop. "I saw it as a win-win situation, something that everyone on both sides of the abortion issue could support," says Dr. Susan F. Wood, who was at the time director of the Office of Women's Health at the F.D.A. "I still don't get what happened."

One thing that happened, which Dr. Wood and many others may have failed to notice, was the change in conservative circles on the subject of contraception. At a White House press briefing in May of last year, three months before the F.D.A.'s nonruling on Plan B, Press Secretary Scott McClellan was asked four times by a WorldNetDaily correspondent, Les Kinsolving, if the president supported contraception. "I think the president's views are very clear when it comes to building a culture of life," McClellan replied. Kinsolving said, "If they were clear, I wouldn't have asked." McClellan replied: "And if you want to ask those questions, that's fine. I'm just not going to dignify them with a response." This exchange caught the attention of bloggers and others. In July, a group of Democrats in Congress, led by Representative Carolyn Maloney of New York, sent the first of four letters to the president asking outright: "Mr. President, do you support the right to use contraception?" According to Representative Maloney's office, the White House has still not responded.

Image The Pill: The birth-control method that, beginning in the 1960's, changed the cultural landscape. Credit... Tom Schierlitz

For those who were listening, that silence may have given an indication of what had been going on inside the F.D.A. After the agency's advisory committees voted in favor of over-the-counter status for Plan B at the end of 2003, and after it was further approved at every level of the agency's professional staff, standard procedure would have been for the Center for Drug Evaluation and Research arm of the F.D.A. to approve the application. But one member of the F.D.A.'s Reproductive Health Drugs Advisory Committee had reservations: Dr. W. David Hager, a Christian conservative whom President Bush appointed to lead the panel in 2002. (After an outcry from women's groups, who were upset at Dr. Hager's writing that he used Jesus as a model for how he treated women in his gynecology practice, he was shifted from chairman of the panel to ordinary member.) Dr. Hager said he feared that if Plan B were freely available, it would increase sexual promiscuity among teenagers. F.D.A. staff members presented research showing that these fears were ungrounded: large-scale studies showed no increase in sexual activity when Plan B was available to them, and both the American Academy of Pediatrics and the Society for Adolescent Medicine endorsed the switch to over-the-counter status. Others argued that the concern was outside the agency's purview: that the F.D.A.'s mandate was specifically limited to safety and did not extend to matters like whether a product might lead to people having more sex. Meanwhile a government report later found that Dr. Janet Woodcock, deputy commissioner for operations at the F.D.A., had also expressed a fear that making the drug available over the counter could lead to "extreme promiscuous behaviors such as the medication taking on an 'urban legend' status that would lead adolescents to form sex-based cults centered around the use of Plan B." In May 2004, the F.D.A. rejected the finding of its scientific committees and denied the application, citing some of the reasons that Dr. Hager had expressed.