Japan left behind in sexual and reproductive health and rights---medical abortion pills mailed from abroad (Part 1)*

By: Yoko Akachi**

Covid-19 Pandemic and SRHR

In April last year, multiple organizations around the world warned that the Covid-19   pandemic could have a devastating impact on women’s bodies and health.  The United Nations Population Fund (UNFPA)´s analysis predicted that in 114 low- and middle-income countries, 47 million women would no longer be able to use modern contraceptive methods and that "unwanted pregnancies" would increase by 7 million if six months of severe lockdown that affects access to health services and contraceptives should continue.   The lockdown measures, coupled with economic blows, have made the rise of sexual violence a global phenomenon.

It was not only in low- and middle-income countries where the women's bodies and health were affected by the pandemic. In Japan, following the nationwide closure of schools due to Covid-19 in the spring, newspapers and other media reported that pregnancy consultations from women, especially those in their teens and 20s, drastically increased at medical institutions and support organizations across the country.  The number of consultations related to sexual violence had also increased at the one-stop support centers nationwide.  There is ceaseless reporting of sexual violence, sexual abuse, underage pregnancy, and abandonment of newborn babies in Japan.

The calamity of Covid-19 exposed the various problems that the society had secretly held.  Sexual Reproductive Health & Rights (SRHR) is one of them. We hereby review the current state of SRHR in Japan through the topics of sexual violence, contraceptives, and abortion.  

Sexual violence: one in 13 women in Japan experienced rape

It is challenging to obtain accurate data on sexual violence. This is because most of the cases remain untold and unreported.  Women often do not tell others about it even if they are seriously harmed, and they also do not report it to the police or other places that should be reported.  Even though the #MeToo trend is starting to change the culture, victim shaming remains common and deeply entrenched in all countries.  

Therefore, comprehensive and reliable data on sexual violence are surprisingly scarce.  One of the few valuable sources of data is a survey of violence against women conducted by the EU through face-to-face interviews with 42,000 women in 28 member countries published in 2014[i].

Their findings were that after age 15, 1 in 3 women experienced violence, half of the women experienced sexual harassment, 1 in 5 women experienced stalking, and 1 in 20 women experienced rape at least once. Most of the violence was inflicted by current or past partners. About 12% of women said they experienced sexual abuse or some sexual event by an adult before the age of 15. 30% of women sexually violated by current or former partners experienced sexual violence as children.

What is the situation in Japan?

The Gender Equality Bureau of the Cabinet Office surveys violence on men and women every three years by postal mail.  According to the 2017 results, 164 out of 3,376 people (4.9%) answered that they have experienced rape. By gender, 7.8% of women and 1.5% of men had experienced rape.   

Most frequently, the perpetrators were current or past partners.  Next, it was someone related to work, someone related to school/university, and then siblings. Regarding rape before age 18, the assailant was a guardian (e.g., parents) for 19.4% of the respondents.

58.9% of women and 39.1% of men did not consult anyone about the rape. When asked why they did not consult anyone, more than half of the rape victims answered, "Because I was too embarrassed to tell anyone."

About 1 in 13 women have experienced rape.  And 20% of those raped by age 18 were raped by their guardian. This tells us that the sexual violence occurs much more frequently and closer to us than we think.

Contraceptives: low usage and dominantly sole use of male condoms

According to UN 2019 data[ii], Japan's contraceptive prevalence rate is 46.5%, which is lower than the averages of high-income countries (56.6%) and upper middle-income countries (61.0%).

In Japan, sole use of male condoms is the dominant method of contraceptives. This is not a contraceptive method that women can take their initiative in.

According to the 2016 survey by the Japan Family Planning Association on the use of contraceptive methods (multiple responses allowed), 82% used condoms, 19.5% extra-vaginal ejaculation, 7.3% Ogino method, 4.2% pills (oral contraceptives), and 0.4% IUDs (intrauterine devices). The extra-vaginal ejaculation and the Ogino method are not modern contraceptive methods, and the former in particular has a high failure rate and is often not recognized as a contraceptive method.  Male condoms should be used to prevent STIs, however, compared to other modern contraceptive methods such as IUDs, the failure rate of male condoms is higher in their actual use.  

The safe and effective contraceptive methods used in other countries around the world: IUS (intrauterine system.  approved in Japan in 2007), implants, patches, vaginal rings, injections, etc. are all difficult to access or even unapproved in Japan. The access barrier reflects high prices, complex procedure to obtain them, concerns about confidentiality, and negative experiences.  This leads to women not using safe modern contraceptive methods.

What is noteworthy about the contraceptives is that the approval of low-dose contraceptive pills in Japan took place in 1999 after 35 years of debate. North Korea and Japan were the only countries that had not approved the pill by then. Japan is known for taking time for overseas medicines to be approved. Prior to approval of the low-dose pill, however, Viagra, a treatment for erectile dysfunction, was approved only six months after its application.

Emergency contraceptives: unlike other 95 countries, doctor´s prescription required

In the case of rape or contraceptives failure, an emergency contraception (morning after pill) is taken to prevent unwanted pregnancy.  Currently in Japan, one needs to visit the hospital to obtain the emergency contraceptive it requires a doctor's prescription in principle. The pill needs to be taken as soon as possible after the sexual intercourse with the possibility of the pregnancy, and NorLebo which is approved in Japan, is ineffective after 72 hours. Since there are allergies to NorLebo and drug interactions (contraindications, contraindications, cautions, etc.), it is generally recommended to check with a doctor, nurse, or a pharmacist.

On July 21, 2020, an NPO that includes obstetricians and gynecologists submitted a request to the Ministry of Health, Labor and Welfare requesting that emergency contraceptives be made available for purchase as general medicines in pharmacies.    In NHK (Japan's public broadcaster) "Good morning Japan" broadcast on July 29, and at the press conference held on October 21, the representatives of the Japanese Society of Obstetricians and Gynecologists expressed their clear objections to the sales of emergency contraceptives without doctor prescriptions at pharmacies, stating that "it's too early."  They expressed their concern that the young women “do not have the knowledge” and that they may “abuse and misuse” these pills.

Emergency contraceptives are currently available for purchase from pharmacists without a doctor's prescription in 76 countries and are sold as over-the-counter medicines in pharmacies in 19 countries. These 95 countries include European countries such as Sweden, the Netherlands and France, Latin American countries such as Venezuela, African countries such as Madagascar and Mali, Asian countries such as Vietnam and Laos, Canada, the United States, Australia and New Zealand.

In addition, prices are generally cheaper in these countries than in Japan. Currently, it costs around 10,000 yen (about 95 USD) per use in Japan, and this amount alone is a barrier, especially for young women such as high school students.  

Abortion: medical abortion unapproved while “obsolete” method prevails

Unwanted pregnancies can occur due to rape, lack of / failure of contraceptives, and lack of access to emergency contraceptives. And the women have the right to access safe and legal abortion.   

WHO recommends vacuum aspiration or medical abortion for first trimester pregnancy termination. Mifepristone and Misoprostol are listed on the Core Model List of Essential Medicines of the WHO. The medicines on the list are those that should be made widely accessible by keeping costs low. It has been shown that this abortion method, which includes the use of oral pills rather than invasive surgical instruments, is safe and has an effective rate of more than 95 percent on early termination of pregnancy. Mortality of medical abortion is less than 1 per 100,000 cases[iii]. This is lower than the mortality rate of continuing pregnancy and giving birth. It is also lower than the mortality rate of many of the commonly taken drugs. For example, deaths from erectile dysfunction drugs, including Viagra, are estimated to be four per 100,000 users[iv].

Telemedicine for medical abortion does not require a doctor to conduct it. Telemedicine is also a remote care, meaning medicines are taken without direct supervision of a health care provider, in their home and without attending a clinic. It can safely be provided by other trained healthcare providers, such as physician assistants, nurses, and certified nurse midwives[v] . If the service is comprehensive with medical examinations, reliable information and medication guidance, counseling, aftercare, etc., the medical abortion by telemedicine is safe and effective for women. It is also an appealing option for women in terms of privacy, autonomy, cost reduction and scheduling.

The medical abortion pill Mifepristone widely became available since 2000 and is approved in more than 65 countries such as the United States, the UK, Sweden, Australia, Thailand, Taiwan, and India. Japan has yet to approve Mifepristone, a situation shared with some Muslim and Catholic countries, and a few countries where women's rights are highly violated.    

In contrast, instead of the WHO's recommended "Manual Vacuum Aspiration MVA", cervical dilation and endometrial curettage (D&C) is still commonly used in Japan. D&C is a method that is 'obsolete' internationally[vi].

The WHO's 2012 " Safe abortion: technical and policy guidance for health systems 2nd Edition"[vii] clearly states that "cervical dilation and endometrial curettage (D&C) are outdated surgical abortion methods and should be switched to vacuum suction and/or drug abortion methods."  D&C is said to be "inferior in safety" and causes "considerably stronger pain for women" than the vacuum suction method (WHO 2012 English version 41 pages).  The abortion at the early pregnancy is about 80,000 to 200,000 yen (75-190 USD), although there is some price range. The health insurance does not apply for the procedure.  

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We now saw a snapshot of the current state of SRHR in Japan. About one in 13 women have been raped, modern contraceptive options are limited, the sole use of male condoms remain to be the dominant contraceptive method, and emergency contraceptives are expensive and require a doctor's prescription.  Under such circumstance, when terminating an unwanted pregnancy, a globally obsolete method that is less safe and causes great pain to women is still used.

Under such circumstances, there is a non-profit organization that provides medical abortion pills which are not yet approved in Japan to women living in Japan.

Reference:

[i] FRA (European Union Agency for Fundamental Rights) 2014. Violence against women: an EU-wide survey. Main results report.

http://fra.europa.eu/en/publication/2014/violence-against-women-eu-wide-survey-main-results-report　

[ii] United Nations, Department of Economic and Social Affairs, Population Division (2019). Contraceptive

Use by Method 2019: Data Booklet (ST/ESA/SER.A/435). https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf　

[iii] Zane S, Creanga AA, Berg CJ, et al. Abortion-Related Mortality in the United States: 1998-2010. Obstet Gynecol. 2015;126(2):258-265. doi:10.1097/AOG.0000000000000945

[iv] Lowe G, Costabile RA. 10-Year analysis of adverse event reports to the Food and Drug Administration for phosphodiesterase type-5 inhibitors. J Sex Med. 2012 Jan;9(1):265-70. doi: 10.1111/j.1743-6109.2011.02537.x. Epub 2011 Oct 24. PMID: 22023666.

[v] Guttmacher Institute, 2019. Evidence you can use: Medication Abortion. November 2019. https://www.guttmacher.org/evidence-you-can-use/medication-abortion#　

[vi] 塚原久美　中絶技術とリプロダクティヴ・ライツ　フェミニスト倫理の視点から　2014

勁草書房　ISBN 978-4-326-60265-0

[vii] WHO. 2012. Safe abortion: technical and policy guidance for health systems. Second edition. Authors: World Health Organization, Department of Reproductive Health and Research. Number of pages: 132 Publication date: 2012 Languages: English, French, Japenese, Portuguese, Russian, Spanish, Ukrainian ISBN: 978 92 4 154843 4 https://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/　

* Original article in HuffPost Japan:

避妊と妊娠中絶で取り残される日本。海の向こうから送られる経口妊娠中絶薬〈前編〉https://www.huffingtonpost.jp/entry/story_jp_60220124c5b689330e322bbb

** Yoko is an independent consultant who works in the areas of global health, development, and gender. She has previously worked for international organizations such as WHO and the Global Fund to Fight AIDS, Malaria, and Tuberculosis. She has a doctoral degree from Harvard T.H. Chan School of Public Health and a bachelor´s degree from the University of Tokyo.