Almost every one of Shaylan’s friends has a child. She’s 25 and lives in rural Eastern Kentucky, where 47 percent of all pregnancies are described as unplanned, according to Power to Decide. Her county is a “contraceptive desert,” meaning it lacks the full spectrum of contraceptive methods and doesn’t meet the needs of women eligible for publicly funded care.
“Growing up in Harlan, I lived 45 minutes from the nearest OB-GYN and the nearest hospital. So if I didn’t get a ride from my mom, I wouldn’t have been able to get on birth control. I would say the biggest challenge for me was distance,” she told VICE News. Shaylan wanted to go on the patch, but the doctor on staff refused to prescribe this method for her, so despite her preference, she was forced to travel another 45 minutes to be seen elsewhere.
Shaylan says that if a clinic existed in her community, many young women in her county would have more options. Instead, they have kids.
The Supreme Court’s decision to overturn Roe v. Wade may have dangerous implications for Americans seeking access to birth control and contraceptives beyond what anyone imagined. More than 19 million women in the United States live in contraceptive deserts, and while it’s too early to tell because preliminary data hasn’t been released, many experts fear that access to contraceptives is likely to worsen. In addition, some state legislatures have already sought to ban access to intrauterine devices (IUDs) and the morning-after pill, arguing that these drugs are abortifacients—substances that can stop the implantation of a fertilized egg in the uterus.
As a result, vulnerable communities are increasingly turning to the approximately 35,000 online pharmacies, of which about 96 percent operate illegally, according to the Alliance for Safe Online Pharmacies. At these pharmacies, no matter where you live, counterfeit drugs, including birth control and contraceptives, are always in stock.
When people talk about counterfeit birth control and contraceptives sold on rogue websites, they’re talking about medications or devices that do not work. Deliberately intended to look like other medications, these drugs (both branded and generic formulations) are often intentionally packaged to pass as the real thing but may contain completely different active ingredients or simply don’t contain enough active ingredients to work. In other instances, they could have contaminants or be repackaged expired products, says Dr. Michael C. White, of the University of Connecticut School of Pharmacy.
The primary function of birth control pills is to prevent ovulation, the biological process in which the ovary releases a mature egg. The most common tablets contain a combination of estrogen and progesterone, to mimic what the body already does with these hormones when it stops ovulation. These pills also thicken the cervix’s mucus, preventing sperm from joining with an egg. IUDs, on the other hand, are “a form of continuous birth control,” explains Dr. Jessica Shepherd, a board-certified OB-GYN and Verywell Health’s chief medical officer. The copper form of the IUD prevents fertilization by making the endometrial cavity uninhabitable for sperm. Once implanted, IUDs have the greatest efficacy of any contraception method since the possibility of user error is all but eliminated.
Emergency contraception works entirely differently from the Pill: The hormones in Plan B prevent or delay ovulation from occurring, so there’s no egg to meet the sperm, explains Shepherd. To work, the pills must be taken within 72 hours of unprotected sex. None of these methods of contraception is an abortifacient, but they’ve still become targets for anti-abortion advocates, who believe these medications can destroy a fertilized egg, despite what the science says.
Because access to birth control is already at risk, illicit drug manufacturers from all corners of the globe will fill the gap by creating counterfeit versions of these medications.
Online pharmacies have become a cornerstone of the modern age; since 1998, they’ve seen explosive growth as consumers shift to buying their medications via the internet. Keeping pace with their legal counterparts, illicit drug manufacturers have grown more emboldened over the years, advertising their services on social media and websites outside the jurisdictions of the United States, making it difficult if not impossible for government agencies like the Food and Drug Administration (FDA) and Drug Enforcement Agency (DEA) to keep up. Between 2016 and 2021, 64.6 percent of the unique actions (including cease-and-desist letters, written agreements, removal, and prohibitive orders) the FDA took involved counterfeit medications sold online, and 84.6 percent of those enforcement activities revealed that counterfeit medicines could be obtained without a prescription, according to a study published this year in Annals of Pharmacotherapy.
Dr. White, who authored the study, says the problem is the FDA’s lack of funding and resources, which he describes as “wholly insufficient for being able to protect… consumers from counterfeit medications.” White says he initially believed the FDA wasn’t doing enough, but once he dug deeper, he found that the federal agency was simply overwhelmed by the sheer volume of fake websites, covert advertisements on social media, and even ads embedded into photos online (a representative for the FDA declined a request for an interview). In addition, White points out that the FDA’s other responsibilities include monitoring all food, medical devices, dietary drugs, and over-the-counter medications, implying it’s too much for one government agency. “With the FDA, one of its big issues is resources. So they’re supposed to be keeping all medical devices, all food, all prescription drugs, dietary supplements, and over-the-counter products safe, you know,” he says.
The combined impact of U.S. policy and lack of access to reproductive health has many people worried about their ability to get birth control and emergency contraceptives. Preliminary data collected following the overturn of Roe v. Wade in late June found twice the number of questions about birth control on the organization’s sexual health advice chatbot, according to Diana N. Contreras, M.D., MPH, chief healthcare officer at Planned Parenthood Federation of America.
Those unable to access family planning services may be pushed toward purchasing birth control and emergency contraception online. However, since only about 5 percent of all online pharmacies comply with U.S. pharmacy laws and practice standards, the vast majority are operating illegally, according to the FDA. While it’s difficult to determine exactly how many consumers have purchased drugs from illicit sources online, a 2016 poll conducted by the Kaiser Family Foundation (KFF) found that 8 percent of respondents in the U.S. had purchased medications outside of the country. Based on the Census population estimates for that year, the KFF estimated that this data translated to 19 million adults in the U.S. The COVID-19 pandemic accelerated demand for online pharmacy use further, with a 17 percent increase reported in 2021 over the previous year, according to Clarivate, so it’s safe to say supply and demand for these drugs on the black market are booming.
These illegal pharmacies sell deeply discounted drugs, an appealing alternative for uninsured customers who may be priced out of purchasing the medication or may not have access to a healthcare provider who can write them a prescription. According to Planned Parenthood, emergency contraception can cost anywhere from $10 to $50, while the annual out-of-pocket cost for birth control pills is $240 to $600, and up to $1,000 for intrauterine devices, according to the National Women’s Health Network. In addition to convenience, buying medications online ensures consumers maintain their privacy since many illegal pharmacies accept cryptocurrency as a form of payment, and savvier internet users can use their VPNs (although, while online purchase methods made with crypto may provide the ability to perform these actions under a false name, they’re not genuinely anonymous, according to a new study).
Getting found out, however, will depend on the state and federal response to purchasing a non-controlled substance without a prescription. Controlled substances are divided into five classifications and are organized by the likelihood of developing a “physical and mental dependence,” according to the United States Drug Enforcement Agency. While purchasing a controlled substance online without a valid prescription “may be punishable with imprisonment under Federal Law,” the purchase of non-controlled substances is less scrutinized. For example, a 2015 report issued by the National Criminal Justice Reference Service listed only Connecticut, Massachusetts, and Washington as states where the dispense of non-controlled substances is tracked as part of Prescription Drug Abuse Prevention Plans mandated by state-specific rules.
Supreme Court Justice Clarence Thomas’ concurring opinion that the 1965 decision in Griswold v. Connecticut, which established the right to contraceptives for married couples (and paved the way for Eistenstadt v. Baird, which extended the right to use contraceptives by unmarried people), should be “reconsidered” now that Roe v. Wade has been struck down has many people fearful of what’s next. Given the precarious legal status of contraceptives and birth control, consumers worried about states criminalizing their purchases in the not-so-distant future will inevitably turn to rogue pharmacies. But those pharmacies are “often run by criminal networks that knowingly and unlawfully sell potentially unsafe, ineffective, or counterfeit drugs to consumers in the United States,” according to BeSafeRX, the FDA’s national campaign to educate consumers and healthcare professionals about the dangers of buying medications from online pharmacies.
Rachel*, a 40-year-old resident of Seattle, who prefers not to use her real name for fear of legal repercussions, turned to an illegal online pharmacy in the Republic of Vanuatu to purchase her birth control after losing her insurance and discovering how convenient the entire process was online.
“I didn’t have to worry about finding a doctor, [or] paying for the doctor, getting childcare for my kid while I’m at the doctor, finding a pharmacy, or any of the hassle of all that. It was just so much easier not to have to deal with that,” she says. Rachel says she can’t be sure what she’s receiving is reputable but that she was referred to the website by a midwife she trusts. Rachel says she’s shared the website with friends and isn’t opposed to letting others know how well the process has worked for her, despite the potential risks involved.
Rachel says she enjoys the newfound sense of freedom she’s gained since shopping for her birth control this way, explaining that she used to get her medications with a prescription from her doctor. Online, she says she pays a fraction of what the medication costs her for the same generic medication she’s received before, but the brand name differs.
She acknowledged that she’s never had any of the medications she’s received tested or inspected by a medical professional to determine how safe they are, leaving that up to her own intuition. “I think it’s just trust,” she said. Rachel says she draws the line at purchasing medications to treat serious medical conditions like cancer or a seizure disorder from illegal internet pharmacies, but she believes purchasing other prescription medications this way is acceptable.
“I think if people have a way to try it, they certainly could. And should. I think it depends on what people can access. If you have insurance and a great doctor, well, no problem there. You wouldn’t need it,” she says.
“But for someone without insurance or who doesn’t have access to a doctor or pharmacy, it’s super easy. So I think that would be a very easy way for people to get the medication they need.”
Could the U.S. be headed down the same path as some Latin American countries, like Brazil and Peru? In a 2014 study, researchers from the Georgia Institute of Technology discovered nearly a quarter of contraceptive pills in Peru were substandard. In that case, cultural factors in the predominantly Catholic country were cited as one of the reasons the government was slow to adopt birth control, coupled with less-than-stringent protocols to monitor the drug supply chain, which allowed counterfeit medications onto pharmacy shelves throughout the country. Today, lack of access is one of many factors contributing to women not receiving adequate sexual healthcare in Latin America.
According to Dr. Elizabeth Sully, senior research scientist at the Guttmacher Institute, 18 million women in low and middle-income Latin American countries have an unmet need for modern contraception (i.e., birth control and emergency contraceptives). This isn’t only a question of access; it’s also a result of concerns about side effects. Researchers suggest diversifying the available contraceptive methods to improve the likelihood of contraceptive use.
While the circumstances are different, changing U.S. public policy and the surrounding social stigma around contraception could create similar opportunities for drug counterfeiters here. Moreover, having access to limited contraceptive options may not be enough. The data from Latin America reveals that many consumers may forgo contraceptives altogether due to factual or anecdotal evidence about possible side effects of one particular method. These same concerns could also drive some people to purchase drugs or devices they are comfortable with from other illicit online sources with dubious manufacturing and safety protocols.
“Some people are going to get a lot more side effects…and other people will get hardly any benefit at all,” says Dr. White.
A representative from the FDA told VICE News that “ensuring the quality of prescription drugs and safeguarding the integrity of pharmaceutical distribution are crucial roles the FDA plays in protecting the health of the American public. The FDA continues its ongoing review, surveillance, and compliance efforts across every product area and will continue to work with members of the drug supply chain… Illegitimate and unsafe products must be kept out of the U.S. drug supply chain.”
The sobering reality is that millions of Americans currently buy counterfeit medications from fake online pharmacies, including counterfeit birth control and emergency contraceptives. Current state abortion legislation, in addition to reduced inventory for emergency contraception due to recent surging sales, could push illicit drug manufacturers to create a new supply of fake birth control and contraceptives to meet demand, White says. Therefore, more considerable efforts must be made to find and prosecute counterfeiters in cooperation with international governments in places like China, India, and Russia (where many fake drugs are produced). In addition, more extensive outreach efforts are needed to educate U.S. consumers on the dangers of taking counterfeit drugs.
Purchasing birth control and contraceptives online from legitimate pharmacies is generally safe and convenient for consumers. However, until access to these medications increases in every state and federal protection for access to contraceptives is ensured, consumers like Rachel and many others will continue to find what they’re looking for elsewhere. As a result, some consumers may purchase legitimate products, but many more will face the consequences of ingesting counterfeit medications.
Despite the risks, Rachel says if faced with the same predicament, she would continue buying her birth control from the illegal online pharmacy she used in the past—even if she received health insurance coverage again.
“I probably still would just because it’s so easy. It’s one click at this point. It’s way too easy to change course and try to get a doctor and childcare,” she says. But she doesn’t anticipate buying birth control anymore–-because her husband is getting a vasectomy.