"We've got to stop thinking we can pat young people on the head and say, 'We can take care of you, and this is how we'll do it -- with Depo-Provera.' "
A shot in the dark?
Some doctors readily prescribe Depo-Provera as birth control for native women. Experts worry the drug might reduce bone density and help foster other ailments.
Darleen Watts had heard enough about Depo-Provera, a contraceptive for women that doctors inject just once every three months. She was worried. A known, possibly irreversible side effect is significant bone loss, and reported complications include drastic weight gain, depression and hemorrhage. So Watts, who belongs to the Tseshaht First Nation on Vancouver Island, conducted an informal survey of 25 Aboriginal women among her family and friends. "Fifty per cent were on Depo-Provera -- that's an awful lot," says Watts, a former member of the First Nations Chiefs' Health Committee in B.C. Some of the women were only in their teens, still growing, and yet here they were, taking a drug that could permanently weaken their bones. And many didn't know it, says Watts, because their doctor hadn't taken the time to explain the risks. "It makes me sick that this is allowed to carry on within our communities."
The pharmacological sterilization of First Nations and Metis women with Depo-Provera, while temporary, is nonetheless raising serious health -- not to mention ethical -- concerns among community leaders, physicians and academics. Doctors suggest Depo-Provera's use among Canadian Aboriginal women is between 10 and 20 per cent of those who practise contraception. (Last year in Canada, 625,000 prescriptions for Depo-Provera were filled, worth $25 million, according to IMS Health, a market-trend watcher.) Caroline Tait, who teaches women's and gender studies at the University of Saskatchewan, worries Depo-Provera is being prescribed to Aboriginals without proper monitoring. "This is what's so frightening -- it seems to be common practice, but no one's keeping track of it."
Use among natives is as high as it is partly because the drug is easy to obtain, even though, because of its serious side effects, it should be prescribed only after other birth control methods have been tried. But doctors contend young native women seem incapable of remembering to take a birth control pill daily. In fact, Depo-Provera is sometimes the first thing a physician turns to, says Dr. Janet Smylie, director of the Indigenous Peoples Health Research Centre in Regina. "As a clinician working in a variety of settings, I've encountered colleagues who are using it as their first-line contraceptive for young Aboriginal women," Smylie says. "To solve the problem by temporarily sterilizing young women is ethically problematic."
Tait says she first became aware of Depo-Provera while researching fetal alcohol syndrome among natives. She noticed how judges, lawyers, social workers and teachers would readily label Aboriginals as suffering from the difficult-to-diagnose syndrome without benefit of a proper medical assessment. "In a hurry, and in an effort to address family planning and high fertility rates," says Tait, "the dominant society turns to something like Depo-Provera." The women are vulnerable because they have been marginalized, adds Tait, "and because there's a feeling of, 'Well, jeez, we've got to stop these people from having all these babies.' " (According to the most recent census, the Aboriginal population grew 22 per cent between 1996 and 2001, compared with a non-native rate of just 4.7 per cent.)
Pfizer Canada Inc., the drug's manufacturer, declined to be interviewed for this article, but issued a statement saying Depo-Provera, which contains the synthetic hormone medroxy-progesterone acetate, "has been used safely by millions of women around the world for decades." The World Health Organization says, "any lifetime increase in fracture risk is likely to be small," but acknowledges "key evidence gaps." Health Canada's view is that the drug carries all the appropriate written warnings, including: "The use of Depo-Provera has been associated with loss of bone mineral density which may not be completely reversible. Loss of bone mineral density is greater with increasing duration of use. It is unknown if use of Depo-Provera during adolescence or early adulthood, a critical period of bone [growth], will reduce peak bone mass and increase the risk for osteoporotic fracture in later life. Depo-Provera should be used as a birth control method . . . only if other treatments have been considered to be unsuitable or unacceptable and should be used for the shortest period of time possible."
Washington-based Public Citizen, known for warning consumers away from unsafe prescription medications, says women should avoid taking Depo-Provera. "I can't see any therapeutic value in this injectable drug over contraceptives that we already have," says Larry Sasich, a Public Citizen consultant. "The loss of bone density could potentially be a lifelong problem for a young woman."
Through a website, Maclean's talked to two-dozen non-Aboriginal women -- comparatively more affluent, and plugged into the networking capabilities of the Internet -- about their Depo-Provera experiences. They were concerned by reports of bone loss, but they also told stories of catastrophic weight gain (anywhere from 30 to 100 lb.), depression and wild mood swings.
Health Canada has collected 581 reports of adverse drug reactions since it approved the drug as a contraceptive in 1997. (The system is voluntary, and Health Canada acknowledges "there is considerable under-reporting.") Both Health Canada and Pfizer Canada caution that just because someone reports an adverse reaction doesn't prove the medication is responsible. But when Maclean's randomly picked 30 women from the Health Canada drug database, their claims included such side effects as cervical cancer, vaginal hemorrhage, suicidal tendencies, depression, panic, weight gain, lethargy and nausea. Out of these 30 women, nine got pregnant.
Health Canada spokeswoman Jirina Vlk notes that "no drug is without side effects." That comes as little comfort to Chantel Nagel, a customer service representative in a Regina call centre. Nagel started on Depo-Provera when she was 18 and continued for about a year, gaining 30 lb. Her boyfriend at the time had suggested the drug. Nagel's doctor told her she might bleed vaginally after the first shot. She was not, however, prepared for the "black sludge" that streamed from her body daily for the next three months. "With other women I've talked to, we call it the 'black death,' because it's black, not like blood. It's terrifying."
Nagel also suffered from crippling abdominal pains. "If I moved, it was like someone ripping my insides out with a steak knife." Her period stopped entirely, another possible side effect -- one favourably marketed on the drug's website. Her bones ached; she got migraines. She became severely depressed and "an extremely violent, angry person. It destroyed my relationship." Nagel stopped the injections in May, but she's still not fully recovered. "My periods are whenever they feel like coming. Sometimes I get them three times a month, sometimes I don't get them at all." She often has panic attacks. "I went from being a healthy 18-year-old," Nagel says, "to a sick 20-year-old medical wonder." But how does she know it's the Depo-Provera? "It all correlated around the shots. I would start to feel better, and then it would be time for another."
Because Depo-Provera allows for greater privacy, it's the preferred contraceptive for many young native women. In a devoutly Christian Cree community in the James Bay area, birth control pills are frowned upon, says a nurse-practitioner who worked in the region in 2001. A 15-year-old girl hoping to avoid pregnancy and finish high school, for example, would have trouble hiding her pills. "You have very little opportunity for keeping a secret in a two-bedroom house with 15 people living in it," said the nurse. The nurse also notes that in that Cree community, men's self-esteem is poor, and they worry about their women leaving them. So they throw out the birth-control pills and keep their partners pregnant.
Dr. Sally Mahood wishes there was another solution. A professor of family medicine at the University of Saskatchewan in Regina, she's put young Aboriginal women on Depo-Provera and seen them gain 20 to 30 lb. Given the native propensity for developing diabetes and the fact that being overweight increases the risk, says Mahood, "we're not doing them many favours." It's an ethical problem she faces all the time. "As a physician, you're always trying to minimize the risk, given no ideal option," explains Mahood. "My inclination is to stay away from this stuff because of the side effects, but you have to weigh those side effects against the immediate disaster that a pregnancy would be for a young woman."
The alternatives? "Education is prevention," says Watts. "We need to start funnelling health care funding to young women, men and families." We need to re-educate caregivers as well. "It's really hard to find a doctor who doesn't love Depo-Provera," says Nagel, who has consulted seven physicians. There is also an ugly paternalism on the part of health professionals, says Watts. "We've got to stop thinking we can pat young people on the head and say, 'We can take care of you, and this is how we'll do it -- with Depo-Provera.' "
November 24, 2005