World Population Awareness

Birth Control Choices

A Brief History of Contraception

   February 18, 2015, Atlantic Monthly   By: Jackie Lay

The use of contraceptives dates all the way back to 1850 B.C., when women in ancient Egypt used honey, acacia leaves, and lint to block sperm. This two-minute animation traces the history of contraception through the centuries, from sea sponges (500 B.C.), linen sheath condoms (1564), lemon cervical caps (1700), and the "rhythm method" (1920) to modern advancements such as vaginal rings, hormone injections, IUDs, and patches. doclink

Birth Control Choices

Struggling Colorado Birth Control Program Worked Even Better Than Thought, Says Health Department

   October 22, 2015, Gazette, The   By: Jakob Rodgers

A program offering birth control to low-income teens and young women is more efficient than previously thought, Colorado's health department announced last Wednesday.

The initiative, which provided long-acting reversible contraceptives at little or no cost, dropped the state's teen birth and abortion rates by 48 percent from 2009 to 2014, the Colorado Department of Public Health and Environment found.

The intrauterine devices can prevent more than 99 percent of pregnancies within the first year of implantation. They should not affect fertility once removed, according to WebMD.

Previous data from the program's first four years found teen births had dropped 40 percent from 2009 through 2013, while abortions declined 35 percent, the department said.

The new data comes as the program faces several challenges.

A five-year, $25 million grant from the Susan Thompson Buffett Foundation ended in June, and legislation to continue funding failed in the Republican-held Senate.

Several Colorado foundations have since offered $2.2 million in bridge funding through June 30, 2016. The health department said Wednesday it is seeking more sustainable funding.

Unintended pregnancies are more likely to result in children lives and health being at risk, according to the health department.

The initiative also has been credited with saving Medicaid an estimated $79 million from 2010 through 2012, the health department said. doclink

How a Billionaire-Backed IUD is Fighting the GOP War on Women's Bodies

Republicans should love Liletta, but instead they're fighting it every step of the way
   October 27, 2015, AlterNet   By: Kali Holloway

Liletta is a new intrauterine device which became available in April. It is affordable, safe, 99% effective, and widely accessible. Studies prove the IUD reduces rates of unplanned pregnancies, and it's been shown to decrease the number of teen abortions. Once Liletta is inserted by a healthcare professional, it can remain in place for up to three years without any patient intervention, effectively eliminating the kinds of user errors that lead to pregnancy.

In multiple studies, Liletta has been proven safe, placing it far outside the troubled history of IUDs.

Unfortunately the conservative response has been to obstruct the use and availability of Liletta and similar contraceptive methods at every opportunity. Their mission seems like one less focused on protecting the sanctity of human life than it is penalizing and stigmatizing women for having non-reproductive sex.

Most IUDs cost anywhere from $800 to $1,200 -- prohibitively priced for most family planning clinics, many of which are already severely underfunded. But with Liletta, its developer Medicines360 has capped out-of-pocket expenditures for insured women at $75, and in cases where patients qualify financially, even that cost can be subsidized. Medicines360 has made it a priority that public health care centers can purchase the IUD at just $50 a pop, allowing them to keep plenty in stock. Batches of Liletta have been recently shipped to 49 states, with more than half of the devices going to clinics that serve low-income patients.

The Susan Thompson Buffett Foundation, the philanthropic organization co-founded by Warren Buffett and his late wife, has recently focused on funding family planning work, spending an estimated $200 million to determine the best and most effective contraceptive methods, underwriting costs for product development, conducting clinical trials, and creating distribution channels that ensure affordability.

Judith DeSarno of the Buffett Foundation, said that Warren "thinks that unless women can control their fertility -- and that it's basically their right to control their fertility-that you are sort of wasting more than half of the brainpower in the United States."

In 2007, the Buffett Foundation gave approximately $20 million to fund the Contraceptive Choice Project, a three-year study involving more than 9,000 women of childbearing age in St. Louis, Missouri. Participants were given information about various types of birth control, with particular insights on IUDs, and offered the method of their choice for free. 56% ultimately opted for an IUD, proving women would be interested in the devices when armed with the right information.

Between 2008 and 2013, the Buffett Foundation spent over $50 million in Colorado on a project that offered free and reduced-cost IUDs to some 30,000 women through 68 family planning clinics statewide. Subsequently the teen birth rate in the state fell by 40% from 2009 to 2013, while their rate of abortions fell by 42%, according to the Colorado Department of Public Health and Environment. There was a similar decline in births for unmarried women under 25 who have not finished high school.

Colorado governor John Hickenlooper said that "Colorado moved from the 29th lowest teenage birth rate in the nation before the initiative began in 2008 to 19th lowest in 2012." The project saved the state "$42.5 million in public funds in 2010 alone."

In the 1970s and '80s, IUDs were synonymous with the Dalkon Shield, a brand that was recalled for causing septic abortions, infertility, and in rare cases, death. In 2000, the FDA-approved Mirena hit the market, followed in 2013 by pharmaceutical giant Bayer's Skyla, both of which helped revive interest in the IUD for a generation of women less familiar with its history.

To remedy the dark name of the IUD, the Buffett Foundation spent $74 million to launch Medicines360, which immediately set about creating a generic IUD. Liletta was the result.

There are nearly 3.4 million unintended pregnancies each year in America; many likely to end in abortion. Poor and low-income women, more specifically, are five times more likely than wealthier women to experience both unplanned pregnancies and unintended births, according to a Brookings Institute study.

Although conservatives often discuss the birth rate among women in underserved communities as if it points to some innate, class-based moral failing, Brookings notes that rates of premarital sex are not socioeconomically determined. "There is no 'sex gap' by income," researchers write.

A study by the Guttmacher Institute of women aged 18-34 with household incomes below $75,000 found that cost led many women to cut corners with their birth control, skipping pills, delaying prescriptions, or adopting a one-month-on, one-month-off approach to taking the pill. One in four women who struggle financially are forced to take such measures, compared to among women with financial stability, whose rate is roughly one in seventeen.

Because of the upfront cost of IUDs and hormonal implants, low-income women are less likely to access these most effective forms of birth control, which are 99% successful in preventing pregnancy.

Another Guttmacher survey finds that a "majority of respondents reported that birth control use had allowed them to take better care of themselves or their families (63%), support themselves financially (56%), complete their education (51%), or keep or get a job (50%). Young women, unmarried women, and those without children reported more reasons for using contraception than others: not being able to afford a baby, not being ready for children, feeling that having a baby would interrupt their goals, and wanting to maintain control in their lives were the most commonly reported reasons for using birth control.

Many conservatives might not be interested in the self-determination birth control provides for women. But as a measure that helps reduce abortions and unwanted births -- they should be all for it. In 2010, nearly 70% of unintended births were paid for by public insurance programs, especially Medicaid. The GOP, which supposedly values dollars and cents above all else, should appreciate any solution likely to send those numbers downward.

Early this summer, House Republicans voted to eliminate funding for Title X, the only federal program which specifically funds family planning and reproductive-health services, including birth control, for low-income women. Now they are currently trying to defund Planned Parenthood, which provides a long list of family planning services to millions of women. Abortions represent just 3% of the services Planned Parenthood offers, a figure Republicans might care about if any of this was actually about abortion.

Conservatives in Texas, Kansas, Utah, Arkansas, Louisiana and Alabama are trying to defund Planned Parenthood at the local level. Louisiana Planned Parenthood clinics don't even provide abortion services, "so defunding it would only keep low-income patients...from accessing cancer screenings and other preventative health-care." Across the country, health care clinics have been rapidly disappearing, thanks to Republican efforts.

In 2014 the Supreme Court's Hobby Lobby decision ruled in favor of a companies with closely held religious beliefs to opt out of providing women insurance that covers the cost of IUDs and some morning-after pills. (Hobby Lobby says IUDs are abortifacients; doctors and elementary school-level reproductive science say that's not true.)

Ann Friedman wrote of the decision: "The Supreme Court's decision -- and most reproductive-health restrictions passed by lawmakers across America over the past several decades -- expresses the view that women make their choice when they choose sex, and it's up to them to figure it out after that. That there is no social or moral or governmental obligation to make it easier for them to make choices that follow from a perfectly human impulse to want sex but not babies. For women, sex is an option, an inessential luxury like LASIK eye surgery."

In Colorado, after money ran out on a family planning project that resulted in a massive drop in teen pregnancies and abortions across the board, conservatives in the legislature turned down a bill to fund the program. One local anti-choice group said giving teens access to contraception "does not help them understand the risks that come with sexual activities."

These anti-choicers want no part of a program that teaches young women how to be sexually responsible, or that doesn't scare them into believing the only way sex can end is badly. These same conservatives refuse to fund anything that benefits children once they leave the uterus, who vilify single mothers, who bemoan "entitlement programs" for the most vulnerable families and children. In voting against those measures, conservatives are voting for teen pregnancy, unplanned births and abortion.

As more clinics introduce Liletta to their clients, and more health care plans offer it as a choice (mine does!), the 10% of women who rely on IUDs for birth control will only continue to grow. Republicans will keep pushing for policies that attempt to stop women from having sex, instead of plans that actually benefit women's reproductive health and offer real choice. doclink

Female Condoms Are Power, Protection, Pleasure

   Pathfinder International

To these young women, the female condom is a game changer

In some parts of the world, a woman asking a man to wear a condom is counter to cultural practices. A condom for women puts the power and protection in her hands. Pathfinder International is on the ground around the world working to tear down these barriers and we need your help.

September 16 was Global Female Condom Day. Join us in spreading the word about condoms for women! doclink

First Self-injectable Contraceptive Unveiled in UK

Pfizer launches Sayana Press long-acting reversible contraceptive which can be administered at home instead of a GP surgery or clinic
   September 24, 2015, Mail and Guardian

The Sayana Press long-acting reversible contraceptive has received a license, which means women can inject themselves at home instead of having to go to their GP surgery or clinic.

Each jab of the UK's first self-injectable contraceptive for women provides contraception for at least 13 weeks. Around 5 million women in the UK use hormonal contraceptives. doclink

Karen Gaia says: Chances of getting pregnant with the Sayana Press: less than one percent. If women wait too long between shots, the failure rate increases to 6%.

Fertility does return once the injections are stopped, but the time varies from one woman to the next. Some women may not be able to conceive for up to a year, sometimes longer, after having their last injection. Read here for more if you are interested in using Sayana Press:

These Amazing New Contraceptives Could Be the Future of Birth Control

   February 6, 2015, VOX Media   By: Megan Thielking

Due in part to high failure rates (18%), only 20% of couples choose condoms. Scientists continue working to develop better options. The pill is still the most commonly used contraceptive in the US, but since women must remember to take the pill every day, it has a 9% failure rate. Potential side effects include nausea, mood swings, and possible stroke. For these reasons, there's a push to develop new, long-acting reversible contraceptives, says Dr. Michael Thomas, OB/GYN at the University of Cincinnati's Center for Reproductive Health.

Longer acting options include a hormonal patch called Ortho Evra that must be changed every week, and the NuvaRing hormone-releasing uterine ring that must be changed every three weeks. Contraceptive implants are thin plastic devices inserted under the skin on the upper arm. Current versions release hormones for up to three years. Still, removing them requires a trip to the doctor. A T-shaped intrauterine device (IUD) under study may work for up to 12 years, but removing an IUD still requires a trip to the doctor.

Working with the Gates Foundation, MicroCHIPS Biotech is developing an implant that will last up to 16 years, which women can to turn it off by remote control. Human trails should start next year. The same microchip technology has been tested successfully in women with osteoporosis, so MicroCHIPS Biotech believes the implant could be on the market by 2018.

Over the longer term (at least 10 years), the NIH is partnering with researchers to develop a lower-dose version of emergency contraception Ella, which would work like "the pill" if taken daily. The estrogen-free pill would reduce side effects and be more effective for certain women, particularly obese women who have higher failure rates using estrogen-based contraception.

Northwestern University says that, like condoms, new vaginal rings could prevent sexually-transmitted infections. Two-in-one options under study include a contraceptive similar to the current Nuvaring, which is placed in the vagina. It uses hormones to prevent pregnancy and also releases an antiretroviral drug to inhibit HIV and herpes.

Men use about one-third of all contraception. Aside from condoms, some men rely on vasectomies that can only be reversed via surgery. In coming years men will have more reversible birth control options. In the 1950s, scientists tested on prisoners a form of male birth control that weakened the sperm. It worked until it was tested outside of the prisons, where interactions with alcohol caused vomiting, profuse sweating, and headaches. Over 60 years later, scientists are still trying. Dr. John Amory of the University of Washington is now testing molecules to gum up an enzyme that facilitates sperm maturation. If this works, they will approach the FDA within the next few years to start clinical trials.

RISUG stands for reversible inhibition of sperm under guidance. Trials in India showed the procedure to be 100% effective. A doctor injects the vas deferens with a gel that makes the sperm unable to travel. The procedure lasts for years and can be reversed at any point with another injection. A U.S. company used the same concept to create Vasalgel. It is now in animal testing, still years from approval.

The NIH, in partnerships with the University of Washington and UCLA, is researching gels currently used for hormone-replacement therapy in men with low testosterone. The gels stop sperm production with hormones - much like "the pill" works for women. The challenge is to manage sperm production without reducing testosterone levels for the rest of the body. Each day men apply a progestin hormone gel on the abdomen and a testosterone gel on the arm. The progestin gel halts sperm production by blocking the supply of testosterone in the testes. Then, a testosterone gel applied to the arm reintroduces the hormone to the blood, which allows it to stimulate libido and enable ejaculation. Diana Blithe, Program Director at the NIH's Contraceptive Discovery and Development Branch said that in human trials, "It works if they use it every day, and even pretty well if they miss a day," The gels will be combined into a single, easier-to-use formula. Blithe anticipates at least a 10 year wait before the product is available. doclink

How Likely is it That Birth Control Could Let You Down?

   September 13, 2014, New York Times   By: Gregor Aisch and Bill Marsh

Note: click on the link in the headline to see these wonderful interactive charts that show the effectiveness (or ineffectiveness) of most major kinds of birth control

Misuse and failure of birth control are major contributors to the millions of unplanned pregnancies in the United States each year. Failure rates of contraceptives usually refer to a given year of use. Over time the risk of failure is compounded over time. The longer any method of contraception is used, the greater the probability of unplanned pregnancy.

These charts show probabilities of pregnancy for each method by two standards: typical use, which is usually incorrect or inconsistent use, and perfect use - when used exactly as specified and consistently followed. Over long time periods, few couples, if any, achieve flawless contraceptive use.

Only the 10 year probability is shown here. Jump to the link to see the charts.

* Spermicides 96% chance of pregnancy

* Fertility awareness-based (ovulation method) 94%

* Sponge (after giving birth) 94%

* Withdrawal 92%

* Condom (female) 91%

* Condom (male) 86%

* Diaphragm 72%

* Sponge (prior to any births) 72%

* Pill, Evra patch, NuvaRing 61%

* Depo-Provera 46%

* Copper IUD 8%

* Female sterilization 5%

* Levonorgestrel IUD 2%

* Male sterilization 2%

* Hormonal implant 1%

Sources: James Trussell, Office of Population Research, Princeton University; Brookings Institution doclink

Karen Gaia says:

a) The average American woman spends 30 years trying to avoid pregnancy. 11% of women at risk of unintended pregnancy are not currently using any contraceptive method. 18% of these are teens.

b) 16% of women using birth control use the pill, while 15.5% use female sterilization, 9.4% use male condoms, and only 7.2% use IUDs or implants, although this number is growing.

Male Birth Control, Without Condoms, Will Be Here by 2017

   September 9, 2015, Daily Beast   By: Samantha Allen

Vasalgel, a reversible, non-hormonal polymer that blocks the vas deferens, is about to enter human trials. How will rhetoric change when male bodies become responsible for birth control?

Vasalgel is proving effective in a baboon study. Three lucky male baboons were injected with Vasalgel and given unrestricted sexual access to 10 to 15 female baboons each. Despite the fact that they have been monkeying around for six months now, no female baboons have been impregnated.

It is essentially a reimagining of a medical technology called RISUG (reversible inhibition of sperm under guidance) that was developed by a doctor named Sujoy Guha over 15 years ago in India, where it has been in clinical trials ever since. Unlike most forms of female birth control, Vasalgel is non-hormonal and only requires a single treatment in order to be effective for an extended period of time.

Elaine Lissner of the Parsemus Foundation is worried about the effectiveness of the pill, given how many women forget to take pills during any given cycle. The Parsemus Foundation has to rely on donations and crowdfunding in order to bring male birth control to the market. Potential funders in the pharmaceutical industry would much rather "sell pills to men's partners every month." doclink

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The Abortion Pill

The First 12 Seconds of This Video Should End the Anti-Birth-Control Argument

   September 5, 2012, Upworthy   By: Rollie Williams

It couldn't be a more clear-cut issue. Women need to be able to control their own futures, and the way to make that possible is through readily available contraception (which would consequently save 700,000 lives per year). Seriously, how could we possibly have gender equality without it?

Giving women and girls access to family planning tools and information is the easiest way to empower them to determine their own futures.

Raise your voice and pledge to support family planning for the millions who need and want it: doclink

Karen Gaia says: Contraceptives prevent the sperm from fertilizing the egg. Saying that contraceptive is killing unborn children is like saying every time a woman menstruates or a man ejaculates outside of vaginal intercourse -- they are killing babies.

Study: Home-Administered Misoprostol Safe Abortion Option for Women Up to 63 Days Pregnant

   March 15, 2010, IPPF

Swedish researchers conclude that taking misoprostol at home as part of a medical abortion regimen is a safe option for women who are 50 to 63 days pregnant. In the U.S., women have been permitted to take physician- prescribed misoprostol at home since 2000.

Mifepristone -- the first drug in the medical abortion regimen, which is taken three to four days prior to misoprostol -- is administered at a clinic, physician's office or hospital. Most European countries require that women take both drugs in a clinic, doctor's office or hospital.

Among women who were fewer than 50 days pregnant, 199 experienced complete abortions, while 186 of the women who were between 50 and 63 days pregnant experienced complete abortions. Ten women required surgery. About six in 10 women needed extra pain medication. doclink

U.S.: HHS Moves to Define Contraception as Abortion

   July 15, 2008, RH Reality Check website

The Department of Health and Human Services released a proposal that allows any federal grant recipient to obstruct a woman's access to contraception. It is attempting to redefine the birth control, which 40% of Americans use, as abortion. This would protect extremists. The proposed laws prohibit federal grant recipients from requiring employees to help provide or refer for abortion services.

Abortion is the termination of a pregnancy and there are two views on when a pregnancy begins. Some consider it begins at the fertilization of the egg by the sperm, while others consider it to begin when the embryo implants in the lining of the uterus. About 49% of Americans believe that human life begins at conception and think that any action that destroys human life after conception is abortion. Those who believe pregnancy begins at implantation believe abortion only includes the destruction of a human being after it has implanted.

Some medical authorities have defined the term "established pregnancy" as occurring after implantation. Others present different definitions. For example, pregnancy is "the state of a female after conception and until the termination of the gestation." or "the condition of having a developing embryo or fetus in the body, after union of an oocyte and spermatozoon".

Up until now, the federal government followed the definition of pregnancy as: pregnancy begins at implantation. It now claims that pregnancy begins at some biologically unknowable moment and there would be no way for a woman to prove she's not pregnant. Thus, any woman could be denied contraception.

There is no scientific evidence that hormonal methods of birth control can prevent a fertilized egg from implanting in the womb. This argument is the basis upon which the religious right hopes to include the 40% of the birth control methods Americans use, under "abortion." In 1999, the physicians released an open letter stating: "Some special interest groups have claimed that some methods of contraception may have an abortifacient effect. It is speculation, and if a family, decides to use this modality, we are confident that they are not using an abortifacient."

The absence of evidence does not slow anti-abortion attempts to classify hormonal contraception as abortion. Because the statutes seek, in part, to protect the conscience of the individual or institution within the bounds of reason. Both definitions of pregnancy are reasonable. The Department proposes to allow individuals and institutions to adhere to their own views. So HHS proposes that anyone can enforce his or her own definition of abortion "within the bounds of reason." This new rule establishes a legal precedent that may be used as a basis for banning the most popular forms of birth control with abortion. doclink

U.S.: After 2 More Deaths, Planned Parenthood Alters Method for Abortion Pill

   March 18, 2006, New York Times*

Planned Parenthood announced that it would change the way it gives RU-486, or Mifeprex. The F.D.A. has received reports that six women in the US died after taking the pills, and a seventh died in Canada. The previous four resulted from infections with Clostridium sordellii. One of the two recent deaths occurred within days of the victim's undergoing a pill-based abortion, while the other woman died within five weeks. Mifeprex has been used in more than 560,000 medical abortions in the US and more than 1.5 million in Europe. The risks of death after using the pill are similar to the risks after surgical abortions or childbirth. When Mifeprex was approved in 2000, the standard regimen was to give the drug in a doctor's office followed two days later by an oral dose of a different drug, misoprostol, also in a doctor's office. Women expelled the fetus over the following days or weeks in a process that mimicked a miscarriage. The procedure must begin within 49 days of conception. Soon after Mifeprex's approval, most doctors instructed women to insert misoprostol vaginally at home two to three days after taking Mifeprex. But this regimen was not approved by the drug agency. As reports of deaths trickled into the F.D.A., officials issued warnings that doctors should stick to the approved regimen but until Friday, Planned Parenthood had rejected those warnings. Patients would still be asked to take the second drug orally at home. The drug agency said it was "investigating all the circumstances associated with these cases." The agency repeated that women who undergo pill-based abortions should be vigilant for signs of nausea, vomiting or diarrhea and weakness with or without abdominal pain and they should be given antibiotics. Doctors may not associate a death with a pill-based abortion, especially if the death occurs weeks later. The risk of infections could be eliminated if abortion patients were given antibiotics as a preventative. But officials say that the risk of infection from Clostridium sordellii is so slight that it does not merit such a precaution. doclink

Australia: Evidence Shows RU486 May Be Safer Than Surgical Abortion

   November 21, 2005, AAP (Australia)

The Royal Australian College of Obstetricians and Gynaecologists is backing an effective ban on the pill RU486 to be lifted. The drug should be made available to Australian women. The evidence suggests it may be safer than surgical termination of pregnancy. John Howard signalled he would offer Liberal MPs a conscience vote on the issue. In Australia, women wanting to use RU486 have to apply through their doctor for government approval. The Australian Democrats plan to move an amendment which would remove Mr Abbott's powers to grant approval for the drug's use. Mr Abbott has cited health department advice which warned it could be dangerous for women in rural and remote areas because its use requires medical supervision and access to emergency care. But that advice has been discredited by experts. The first decision a woman makes is whether or not she wishes to have a termination of pregnancy and why she would prefer a surgical or a medical termination. Practitioners would have good evidence so they could discuss that with the woman so she can make an informed decision. doclink

U.S.: More Health Professionals Balk at Giving Birth Control

   August 8, 2004, Copley News Service

The overwhelming number of Americans support birth control and use it. However, A small percentage of physicians, nurses and pharmacists have steered clear of supplying contraceptives because of religious convictions. A pharmacist in Cincinnati refuses to fill birth-control prescriptions because she considers abortion a sin and a termination of human life. Some doctors contend that millions of American women are wrongly prescribed birth-control drugs when alternatives such as natural family planning are cheaper and carry fewer health risks. More than 400 health care providers attended the American Academy of Fertility Care Professionals conference, triple the number the previous year. Organizers say the increase is fueled by religious doctrines and advances in drug-free contraception and fertility practices. The issue centers on when human life begins and for many this is when a sperm penetrates an egg, for others once the fertilized egg is implanted in the woman's uterus. Others believe it is when a baby draws its first breath. With such wide-ranging interpretations, the forms of contraception can present difficult moral choices for health care practitioners and some experts wrestle over whether measures of contraception are ethical. The Catholic Church and other religious institutions have long preached against most forms of birth control beyond abstinence or the rhythm method. Twelve million women rely on hormonal contraceptives, which require a prescription, to keep from getting pregnant, but the number of physicians and medical professionals who believe that using birth control and morning-after pills is abortion appears to be increasing. The war on choice is not just about abortion anymore, it's about the right to birth control. In rural communities, patients may have to drive miles to obtain or fill a prescription. Wal-Mart, dispenses birth-control pills but refuses to sell emergency contraception. The San Diego office of Planned Parenthood allows patients to sign up over the Internet for the morning-after pill, which has to be taken within hours of intercourse to be fully effective. Trying to force your beliefs on others is not only arrogant, it breaks the American covenant, which is tolerance of other people's beliefs. Most of the regulatory boards allow health care professionals to opt out of treatments for moral reasons as long as they arrange alternatives for their patients. At least 20 states have bills pending that would recognize the rights of physicians and pharmacists to deny prescribing birth control, but such legislation has only become law South Dakota. Some companies allow workers to refuse service to customers, and others do not. doclink

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Male Responsibility

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