“I don’t know how else to put it, except that people lied all the time.”
That’s how a medical provider described the culture in a Catholic-run health-care system, where religious rules ban most contraceptive methods.
“You would say birth control pills were [prescribed] because [a patient] had irregular periods, when her periods were fine,” the provider told the authors of an article published December 4 in Perspectives on Sexual and Reproductive Health. “She’d be using it for contraception, but you couldn’t prescribe [the pill] for that reason.”
Catholic health systems, which have expanded to control at least one in six acute-care beds and many outpatient offices nationwide, generally follow rules that also ban abortion, sterilization and some gender-affirming procedures. The report focused on the issue of contraception, and found that while Protestant-affiliated health systems did not restrict access to the service, Catholic systems did.
Providers in Catholic facilities have long found creative ways to get around the rules and provide needed care, often by documenting a medical diagnosis of heavy periods, severe cramps or acne. “The providers wanted to be able to offer their patients the contraception that patients wanted, and I understand why they felt that making up a false diagnosis was better than not providing contraception at all,” said Debra Stulberg, associate professor of family medicine at the University of Chicago, who worked on the study with lead author Yuan Liu. The authors said their report appears to be the first to document how administrators at some of these institutions directly told clinicians to falsify medical charts. Being forced into such deception by the Catholic restrictions deepens the stigma surrounding contraception at a time when access to birth control is under threat by the federal government, the authors said.
“It’s especially frightening to hear from the providers interviewed for this study that they were explicitly instructed by their supervisors at Catholic hospitals to lie and fabricate diagnoses that patients did not have,” Stulberg said. “I’m extremely concerned about systems that hold themselves out to the public as providing full-scope health care and then instruct doctors in how to lie in order to provide that care.”
Providers told the researchers they sometimes walked patients through leading questions about possible medical conditions in order to document a diagnosis that would merit a contraceptive prescription. Sometimes they felt uncomfortable with the deception involved in this process, and sometimes they risked their jobs; several told researchers that hospitals used “the threat of audits and censure” as a way to “ensure that medical records showed that contraceptives were used only for noncontraceptive medical indications.”
Under the rules, certain methods, like IUDs and tubal ligations, were often off limits altogether. Many providers had to refer patients elsewhere for contraception, adding barriers that impacted low-income patients the most. And while the workarounds removed these barriers, the authors voiced concern that documenting a false diagnosis could lead to patients being denied insurance coverage if an insurer finds they failed to disclose a medical condition listed in their chart. The practice could also confuse and alarm patients who discover a condition in their records that they don’t have. And withholding birth control unless a patient can cite a separate medical justification can send the message that birth control is wrong, the authors said.
“Even if the provider themselves is very sympathetic, it still sends a message [that] this is something we don’t approve of, this is something that’s wrong, you have to go somewhere else to get this care, and I think that reinforces this idea that contraception is stigmatized,” Lee Hasselbacher, a senior policy researcher at the University of Chicago and co-author of the report, said.
The report comes at a time when access to contraception is under threat by the Trump administration, which this year cut off Title X family planning funding to hundreds of clinics that refused to comply with its ban on abortion referrals. Hasselbacher noted an “irony” in how the Trump administration and the Supreme Court have sought to grant religious institutions like Catholic hospitals wide latitude to deny contraception and abortion on religious grounds, even as the institutions themselves appear to be undermining their own religious rules. “The current administration is talking about all these protections for religious liberty and religious provision of care,” Hasselbacher said. “It feels just a little dishonest.”
The revelations reflect a long-standing tension between secular administrators of Catholic health systems and the Catholic bishops who oversee whether these systems are complying with Catholic doctrine. Hospital administrators and providers — perhaps recognizing that denying contraception is an unsustainable business decision — have long found ways to subvert the rules, sometimes carving out designated areas where services like sterilizations and IUD insertions are permitted. In one example cited in the report, an OB-GYN practice that was bought out by a Catholic system “formed its own subcorporation with separate malpractice insurance, nursing and billing, so that it could continue to provide contraceptive care in its clinic.” But Catholic bishops have in some cases intervened to shut down these kinds of arrangements. Last year, the U.S. Conference of Catholic Bishops sought to crack down on workarounds, issuing stricter rules for mergers and affiliations between Catholic and non-Catholic entities.
Beyond the tactics deployed by providers seeking to get around the Catholic rules, the report illuminates the wider issue of how these restrictions hinder access to contraception. As Catholic health care systems have increased their reach, many patients nationwide may find that these facilities are their only option for care. And prior research has shown many of these patients don’t realize their health care system is religious. More than a third of women who named a Catholic hospital as their go-to place for reproductive health care were unaware the facility was Catholic. Another study found that less than a third of Catholic hospital websites noted how religion impacted care in the institution. The rules may be further obscured by the fact that they can extend to non-Catholic institutions; the latest report documents how these rules were applied through lease agreements to secular clinics on Catholic-owned land. In at least one scenario described in the report, a Catholic hospital sold property to a non-Catholic institution and imposed a ban on abortions taking place on the property after the sale.
Providers also acknowledged to researchers that they didn’t always disclose the restrictions until patients came in for appointments. “I only talk about [restrictions on care] if it comes up,” one provider said. “I don’t stand there waving a poster at them saying, ‘Don’t come here for birth control.’”