“By Choice, Not By Chance”

Canada is the only country with universal healthcare that does not provide universal contraceptive coverage. The result is inequitable access for marginalized communities.

Nicole Magnuson was 22 when she had to decide between her ADHD medication and birth control prescription. Her ADHD medication was $600 a month, but she needed it to function, especially since she couldn’t remember to take a birth control pill without it. “I went off birth control to try and save money,” she explains. And because she had to give up her birth control pill due to cost, she and her partner at the time had to resort to using condoms — which are notoriously ineffective. But since the birth control options for men are so few, they didn’t have another choice. Using condoms was far from ideal since not getting pregnant was deeply important to Magnuson. “I just knew that I was not meant to be a mother,” she says. Magnuson is a sociology major at Mount Royal University in Calgary. 

Canada’s Pharmacare Act, introduces the possibility of universal contraceptive coverage, which would address the main barrier to contraception, cost. It would save Canadians an estimated $4 to $7 billion per year. While the cost barrier is the biggest issue for most people trying to access reliable contraception, including Magnuson, critics say Canada needs to address the systemic and systematic practices and policies that enforce inequities in reproductive healthcare systems across Canada — standards historically linked to Canada’s infamous sterilization policies and even the Puerto Rico birth control trials in the late 1950s. Right now, in Canada, women rely heavily on methods like condoms and withdrawal, which have high failure rates. “Understanding what Canada looks like in comparison to other countries also lays out how unbelievable in some ways it is that this is the case here,” says Kat Owens. She is LEAF’s project director for their Reproductive Justice Project. LEAF is a national non-profit working to ensure Canada’s law protects equality for women, girls, and trans and non-binary people by challenging laws and policies that discriminate against the equality guaranteed in sections 15 and 28 of the Canadian Charter of Rights and Freedoms. Belgium, France and the United Kingdom are at the forefront of contraceptive access in Europe — providing contraceptive supplies and access, family planning counseling and online information for contraception. In Belgium, all female contraception is 100 per cent reimbursed up to the age of 25. The result? Only about 30 per cent of pregnancies are unintended. 

Contraceptive access in Canada

In Canada, effective, long-acting reversible contraceptives (LARCs) are highly underutilized due to the cost. “People might be choosing the pill because it’s $30 [per month], but what’s not as affordable is that lump sum for an IUD or that lump sum for depo,” says Magnuson. Depo-Provera is a brand-name progestin injection administered every three months to prevent pregnancy or manage menstrual conditions like endometriosis. “You’re not really getting to choose what’s best for you, and it might not be what’s best for your body.” This is why about half of pregnancies in Canada are unintended. And of those unintended pregnancies, more than a third end in abortion. “I don’t want to have an abortion if [I get pregnant],” says Magnuson. “I don’t ever want to be a mother and I would access as many abortions as I had to in order to ensure that, but I wouldn’t want to have to.” She has a husband and a dog and is more interested in connecting with her Métis culture than raising children. “The older I get, the more important it becomes to me,” says Magnuson. She enjoys beading and has recently gotten into food sovereignty. Magnuson started gardening as she lives in Calgary but plans to learn how to hunt. “To really reassert my rights as an Indigenous person to be on the land and to do what the federal government has put into our treaties,” she says. 

Nicole Magnuson lives in Calgary with her husband and dog. PHOTO: COURTESY OF NICOLE MAGNUSON

Because cost is the main barrier to accessing contraception in Canada, Quebec provides subsidies to youths and has the highest contraceptive use in Canada. To the west, British Columbia was the first province to provide free prescription contraception starting April 1, 2023. But in Alberta, Premier Danielle Smith pushed private insurance in response to the Alberta NDP’s contraception proposal on International Women’s Day. If you hope insurance will cover your birth control, that coverage may be extremely limited or even nonexistent. Contraceptive coverage is especially problematic for students who travel out of the province for college or university, where they might not have access to contraceptives as they do in their home provinces. And if you’re a young person relying on your parent’s insurance coverage you might not want your parents to know your personal decision — especially in families with strict religious values or expectations. But if contraceptives are free and covered by the government, the decision can be about personal needs. “Universal contraceptive coverage is an important step for choice… it allows people to choose the method of contraception that works best for them and not the one that they can just afford or that someone says they have to choose,” says Owens. 

“The shadow cast by the practice of forced sterilization creates the spectre of mistrust within the health care system at large, and it creates more barriers to access” 

Insiya Mankani
A dark history

Reproductive justice in Canada is a complex issue, but it starts with understanding our history. “We’ve certainly seen evidence in Indigenous communities of forced sterilization and within Black and disabled communities,” says Insiya Mankani, the public affairs officer with Action Canada. They are a non-profit, pro-choice organization advocating for sexual health and rights in Canada and abroad. Its website says, “Action Canada is Planned Parenthood Canada,” an organization very familiar to people involved in reproductive justice. In the past, Canadian eugenics laws required the forced, coerced sterilization of people considered “mentally defective,” but also targeted Eastern Europeans, Inuit, First Nations and Métis people. Sexual sterilization acts were passed in Alberta and British Columbia in 1928 and 1933, respectively. Repealing the acts in the 1970s didn’t stop the practice since Indigenous women are still being forced and coerced into sterilization, according to a 2022 report by a Senate committee on human rights. “Even if you need that form of contraception, there’s this deep unease of having to go to the doctor or having to go to a hospital, especially with marginalized communities and women,” says Mankani. In a 2021 report, again from a Senate committee on human rights, 16 women shared their experiences of sterilization. The report committee told Fakiha Baig with the Canadian Press that they are aware of a forced sterilization case in 2019. For 10 years before the acts were repealed, more than a thousand Indigenous women were sterilized. But the extent of these atrocities is underreported and underestimated. “The shadow cast by the practice of forced sterilization creates the spectre of mistrust within the health care system at large, and it creates more barriers to access,” says Mankani. 

It’s not only Indigenous women who distrust healthcare providers. Back in 1938, a synthetic hormone called DES used to prevent miscarriages was discovered to have harmful effects on their daughters 30 years later. Another drug, Thalidomide, was used for morning sickness in pregnant women and was found to cause malformations in newborns. Because of these medical failures, in the late 1970s, women from puberty to menopause were banned from pharmaceutical trials. This led to excluding all women as research subjects for almost two decades. But physicians still prescribed women medications that had not been tested on them, causing hostility between physicians and female patients. Beyond Canada and its sterilization and exclusion policies is a different story about reproductive injustice. The first birth control pills were unethically tested on Puerto Rican women in the 1950s. Researchers Gregory Pincus and John Rock needed to do human trials to get their oral contraceptive drug on the market. But they couldn’t get participants from the United States because of religious beliefs, limiting laws, and cultural opposition. Because Puerto Rico had no laws prohibiting birth control, they began their tests there in 1956. But, the women did not consent to a clinical trial. Pincus and Rock told the women they would be taking a drug that prevented pregnancy. Three women died in their inhumane experiments, with many more women experiencing severe side effects that Pincus and Rock disregarded as psychosomatic. Convinced they had succeeded, Pincus and Rock didn’t perform any investigation of the deaths or evaluation of the side effects. And as recently as 2013 in Canada, Yaz and Yasmin birth control pills were linked to 23 deaths related to blood clots. 

In 1997, to address the exclusion of women from pharmaceutical research, the Canadian Minister of Health introduced the “Inclusion of Women in Clinical Trials” guide to encourage the inclusion of women but ultimately did not require it. In Abby Lippman’s study of the Inclusion of Women in Clinical Trials, she notes that any encouragement for inclusion exclusively referred to women as subjects. And these calls failed to address the role of women with disabilities, racialized, Indigenous or any marginalized women who, when they were subjects in research studies, were included without informed consent. “There was no serious mention of the need for inclusion of women in the community of researchers or in the decision-making groups that set research agendas,” Lippman writes. Women are excluded from conversations about their health, while authorities omit their voices from decisions about their bodies, and it shows. Owens says, “we know that medical systems and research have consistently paid less attention to the health needs of women, trans and non-binary people.” Not only that, she adds, “we know this is particularly the case for those who are racialized and Indigenous, for folks who are disabled, who don’t fit that sort of standard medical model of a straight white male who’s been studied and prioritized within health care.” Each unethical case study, preventable death, or normalization of pain is a manifestation of patriarchal, colonial practices.

Nina Lamberti used her master’s thesis to spotlight intersectionality 
concerning reproductive injustice and the lack of research accounting for different experiences.

In Puerto Rico, as in Canada, racialized and Indigenous women have borne the brunt of reproductive injustice. “Canada has this very toxic attitude of being colourblind, and that we’re the most diverse country in the world,” says Nina Lamberti. She completed the first and only study in Canada to research contraceptive access from a lens of intersectionality — a term coined by US scholar Kimberle Crenshaw, describing it as “a lens through which you can see where power comes and collides, where it interlocks and intersects.” Intersectionality takes into account oppression, not just based on gender, but also other lines of difference such as race, sexual orientation and disability. Lamberti completed the paper as the thesis for her master of science in public health and health systems at the University of Waterloo. She works in research and social services and starts her Ph.D. in public health sciences at the University of Toronto in the fall of 2023. Throughout her research, she realized that Canada has no race-based data mandate, further hiding the racism that exists. “I realized, holy crap, there’s literally no information on racialized women and how they use reproductive health care, specifically contraception,” she says. This is a stark contrast to the United States; Lamberti grew up in Rochester, N.Y.. She doesn’t deny the US has issues when it comes to race, but it gets vocalized thanks to the commitment to research. She says Canada’s false front of diversity and attitude of being post-racial — being free from racial discrimination and prejudice — perpetuates white supremacy because we don’t collect the data. “Colonization and reproductive oppression are so salient in Canada,” she says. 

The resulting barriers

Research and statistics are one thing, and pain management and bodily autonomy are another. “Our bodies aren’t always treated with the respect that they should be,” says Magnuson. “At the very least, we are not warned or told this might be painful.” When Magnuson wanted to switch from the birth control pill to an IUD, she went to a clinic in Brooks, Alta., for her appointment. The doctor wasn’t well practiced with IUD insertions, a common concern in rural areas, and placed the IUD incorrectly. Despite feeling debilitating pain, Magnuson says, “I was told that that pain was a normal part of the process… It was painful as fuck.” Not only that, but incorrect IUD placement also puts you at risk of pregnancy. It wasn’t till months later that she finally got it removed. But the trauma of that experience meant she went back on the pill, which she later had to stop due to cost, rather than trying to get another IUD. Years later, she went to a clinic specializing in IUD insertions to try her second one. Magnuson’s experience is a familiar one, as this underestimation of pain is magnified for Black and Indigenous women. “We’ve seen health care providers who won’t believe, for example, that Black or Indigenous women are in pain when they say that they’re in pain or wrongly assume that they’re using drugs,” says Owens. She points out that this reality of discrimination deters racialized folks from seeking care. “This can compound all sorts of existing inequities because folks who need services won’t access them because it’s not safe and it’s not safe for them to go to hospitals and work with healthcare providers,” says Owens. Discrimination also negatively impacts trans and non-binary folks. Owens attributes the ongoing transphobia within the healthcare system to a lack of training and education regarding care for trans and non-binary people. This institutional ignorance means they don’t receive adequate reproductive healthcare. And Canada’s healthcare policies particularly harm folks with disabilities. Because physicians bill on what’s called a ‘fee for service’ model, they are incentivized to see as many people as possible even if that’s not the best practice for their clients. “What we see is people who have more complex health needs, which include some [people with disabilities], don’t get the care they need, again, reinforcing those reproductive inequities,” Owens says. 

Universal contraceptive access and reproductive equity go hand in hand. “All forms of contraception need to be free and available to all people,” says Mankani. It’s not uncommon for healthcare providers or partners to coerce patients into making decisions they’re not comfortable with. It can even come in the form of physical or verbal threats. Patients can find themselves in situations where they don’t feel safe disclosing their contraceptive choices to those closest to them. So access to all forms of contraception opens the door for folks to choose one that is consistent, safe and potentially hidden. Lamberti says, “I have a lot of girlfriends that had a really hard time justifying to their family doctor why they wanted an IUD. Family doctors said, ‘oh, well, it’s invasive… why don’t you just get the pill? Why don’t you just do something else?’ So they really had to self-advocate. And for a lot of people, that’s difficult.” From Mankani’s perspective, she says, “at the end of the day, it’s not up to a doctor to make your contraceptive decisions for you, and nor should they even try to.” This is where sex education can play a pivotal role. “It’s really important that everyone has the right information about all forms of contraception. Part of that is the federal government taking control and creating an effective portal where a lot of people can get their information from,” says Mankani. Lamberti and Owens also recognize the need for standardized sex education alongside universal contraceptive coverage. “It’s important that we accompany universal coverage with education about what the different options are so that individuals are able to make informed choices,” Owens describes. And Lamberti says, “if Canada really took that step to universally subsidize contraception, it does create an environment of being more sex-positive, taking sexual health seriously.” Education is also needed to help alleviate the stigma around contraception that still exists across Canada. “A lot of those historically held beliefs still exist. Like contraception is bad for you, contraception is impure — contraception is a sin. Those beliefs still exist, so you need a source to say, ‘hey, here’s the facts,’” says Mankani. 

“We understand reproductive justice to mean that everyone gets to make their own choices about having or not having children,” says Owens. She says rights to self-determination, sexual and reproductive health services, information and education, rights to equality and non-discrimination, and the ability to raise children in safe and healthy environments with the resources and the support they need to parent with dignity are all aspects of reproductive justice. Introducing the Pharmacare Act will hopefully create better contraceptive access across Canada, better serving Canadian’s reproductive rights. Still, the sordid history of sterilization, eugenics and the unethical development of the pill taint reproductive health care for marginalized women in Canada. “When you’re including [contraceptive coverage] in the Pharmacare strategy, it has to ensure that it avoids discriminatory practices as we’ve certainly seen evidence of it,” says Mankani. And while universal contraception would benefit women, non–binary folks, and Canada as a whole, to ensure equitable access for all, Canada needs to address its history of sterilization and birth control testing to provide reproductive healthcare free of discrimination. Universal contraceptive coverage is the first change of many to ensure equitable access for all. Magnuson says, “it would help Indigenous women have a better chance at the [privilege] that white women experience every day. Especially for Indigenous communities who have already suffered so much reproductive injustice, it would be a true step towards real reconciliation if that even exists,” she says. 

Taking control over her reproductive autonomy, Magnuson had her fallopian tubes removed in May 2022 after many years, and some pushback, of asking for sterilization surgery — which is covered by the government in Canada. She was back to work within five days and now has reduced the risk of cervical and ovarian cancer by 80 per cent. She hopes doctors will provide it to people who want it. “So few people that I know who don’t want children have been unable to receive the surgery,” she says. Magnuson is Indigenous, but white-passing. “My whiteness benefitted me, there is no doubt about that,” she says, “I wish other people had the same support that I have… universal contraceptive access would make all women have a better shot, a better chance at the [privilege] men experience every day.”