SALT LAKE CITY — To go on birth control pills, a 13-year-old in North Carolina or California doesn't have to go to a doctor. All she has to do is connect to a website or app where she can get a prescription for oral contraceptives to be delivered to her home.

She can also order day-after pills, sometimes called emergency contraception, and a drug that cuts the risk of contracting HIV.

The service is offered in 17 states by a company called Nurx, which hopes to begin operating in Utah and the rest of the nation before the end of the year. Based in San Francisco, Nurx is part of a sea change in how women and teens obtain birth control: contraception via telemedicine.

Websites and apps enabling women to order birth control pills and other forms of contraception for home delivery are ending the need for regular visits to a doctor's office or clinic to get prescriptions renewed. But they also allow adolescents to take hormone-altering drugs without the oversight of a parent or physician. Some people see it as a sensible way to protect teens from pregnancy, but others see it as a risky practice that enables teen sex in a culture that has disconnected sexual intimacy from healthy relationships.

Even as Nurx works to line up providers in Utah, online birth control prescribing is already available in the state. A company called Project Ruby was the first to offer online prescribing to Utah women, and Planned Parenthood of Utah recently launched a telemedicine option to its menu of services. They are part of a broader movement aiming to make birth control easier to obtain, particularly in rural areas with fewer health care providers, and ultimately, to make birth control pills available without a prescription.

In 2017, Utah Republican Congresswoman Mia Love introduced legislation that would allow manufacturers of birth control pills to petition the Food and Drug Administration for permission to sell their products over the counter.

In the current legislative session, a Utah state representative has sponsored a bill that would enable the state to provide free contraception for poor women.

And specially trained pharmacists in five states — California, Oregon, Washington, New Mexico and Colorado — can now give birth control pills to women who don't have a prescription after conducting a brief health assessment.

For now, however, it's telemedicine that's making the biggest changes in how women and teens obtain birth control. But it's not without controversy as proponents and opponents disagree on the risks that this access poses for youths.

How it works

Until recently, Project Ruby was the only way Utah women could order birth control pills online. The company, which is based in Colorado, fulfills orders out of a nationwide distribution center in Sandy, Utah, and charges $20, which includes an online consultation, a month's supply of pills and shipping.

But Planned Parenthood of Utah has introduced a similar service where women can see a doctor and get a birth control prescription online through a pilot program that the organization has not yet advertised. Communications and marketing coordinator Katrina Barker said Planned Parenthood is still assessing the demand and its capacity to expand online services.

Project Ruby's CEO Peter Ax said his company plays an important role in women's health, not only in the U.S., but throughout the world as well, since it donates a portion of its profit to a Washington, D.C.-based nonprofit that provides health care to women in developing countries.

"A woman’s economic status is largely defined in the world based on when she decides to have children," Ax said.

Unlike Nurx, which accepts most insurance and can provide birth control for some women at no cost, Project Ruby doesn't take insurance. The company charges a flat $20 fee.

Ax, managing partner of Phoenix Capital Management, based in Scottsdale, Arizona, got the idea for the company after his daughters returned from traveling in Africa and he had a conversation with them about gender issues in developing countries. (The "Ruby" in Project Ruby comes from one of Ax's daughter's middle name.)

More than 40 percent of pregnancies worldwide are unintended, according to the Guttmacher Institute, a U.S. nonprofit that conducts research on reproductive health.

There has been little opposition to the service since Project Ruby began 15 years ago, Ax said.

“I’ve actually been surprised that it’s not been an issue, but the world has come to realize that women taking control of their bodies is a positive thing,” he said. “If we’re trying to stop abortions in this country, the best way to do it is to allow women to plan.”

Guttmacher researchers have said that better access and improved reliability of birth control are major factors in abortions in the U.S. dipping to their lowest level since Roe v. Wade became law in 1973.

Ax said that Project Ruby adheres to state laws regarding when minors can obtain birth control. A person using the website cannot continue the order if she types in an age that is under the age of consent for her state. In Utah, that age is 18, and a state statute says that written parental consent is required for unmarried teens under 18 to obtain prescription birth control.

The opposition

The American College of Obstetricians and Gynecologists advocates the distribution of oral contraceptives without a prescription, calling unintentional pregnancies "a major public health problem in the United States."

The American Academy of Family Physicians agrees, noting in a statement that birth control pills are available over the counter in more than 100 countries.

But not everyone agrees with that position, or that distributing them via the internet is a good thing.

"Screening for potential contraindications to using hormones, as well as screening for sexually transmitted diseases, like HPV and chlamydia, is an important part of health care, especially for teens who could be in high-risk situations, and who are most in need of counseling and screening for abuse," said Dr. Donna J. Harrison, executive director of the American Association of Pro-Life Obstetricians and Gynecologists.

Mary Taylor, president of Pro-Life Utah, said her organization doesn't typically take a stand on birth control issues, but added, "We would hope that a teenager would not have access to birth control without parental consent and close supervision of a doctor."

And Eric J. Scheidler, executive director of the Pro-Life Action League, said making contraceptives easier for teens to get makes them more likely to have sex and it gives the appearance of society condoning it.

“It sends a message: We don’t expect you to exercise good judgment; we expect your judgment to be flawed and weak,” Scheidler said.

According to the U.S. Department of Health & Human Services, about 41 percent of high school students in the U.S. report having had sex. Although there are no recent studies that show an association between teen sex and availability of contraception, a 2017 report on teen sexual behavior and contraceptive use, issued by the federal Division of Vital Statistics, noted that about 1 in 5 teens who have not had sex said their primary reason for abstinence was fear of pregnancy.

Teens and birth control: These are the methods of contraception used by girls aged 15-19 between 2011 and 2015.

"Whether and to what degree teenagers want to avoid pregnancy influences their sexual and contraceptive behavior," the report said.

The American College of Obstetricians and Gynecologists recommends that girls should see a gynecologist (a physician who specializes in women's reproductive health) for the first time between the ages of 13 and 15.

But the college and Dr. Cora C. Breuner, a pediatrician in Seattle, who spoke to the Deseret News on behalf of the American Academy of Pediatrics, said there is no reason for a teenager to have a pelvic exam (an internal examination of reproductive parts) before beginning birth control — the recommended age for that is 21 — and that the online providers are asking the right questions to ensure women and teens get the right medication.

Breuner called online providers like Project Ruby an “excellent resource,” particularly for those who have difficulties accessing health care.

“I’m not trying to put myself out of business here, but I feel strongly that we need to make sure reproductive health is available to everybody,” Breuner said.

She noted that providers like Nurx and Project Ruby have to comply with prescribing and consent laws specific to each state, and she believes that the companies do a good job ensuring that the right medication is prescribed for each person and verifying the patient's identity and age.

Nurx, for example, requires women to upload photo identification that includes a name and birth date. The company also requires a recent blood-pressure reading before shipping.

“And their questions are excellent,” Breuner added. “Honestly, I don't think many doctors ask in detail that many questions about past medical history."

Nurx and Project Ruby ask prospective clients to answer questions about their past and current medical conditions, and what drugs and supplements they are taking.

In Utah, prescribers must follow the rules established in the 2010 Online Prescribing, Dispensing and Facilitation Licensing Act, which requires, among other things, that the health care provider "conduct an assessment and diagnosis based upon a comprehensive health history" and that the patient be informed electronically of the benefits and risks of the recommended treatment.

Moreover, the act specifies that online prescribers be "held to the same standards of appropriate practice as those applicable in traditional settings."

Drugs without doctors?

Birth control pills carry health risks, which may include a slightly elevated risk of breast cancer, as one recent study concluded. (Women who take oral contraceptives have a slightly lower risk of some other types of cancers, however.) Other research has linked birth control pills to depression.

Certain types of birth control pills should not be used by women over the age of 35 who smoke, as well as women who have had blood clots, breast cancer, uncontrolled high blood pressure, diabetes or liver disease or heart problems. (Planned Parenthood also advises women not to take certain types of birth control pills in the first three weeks after giving birth if they are breastfeeding because the hormones can affect the quality and output of milk.)

Side effects of the pill, as Project Ruby discloses, can include nausea, mood changes, weight gain and changes in menstruation.

Because of birth control's potential impact on women's health, some people object to the distribution of these drugs over the counter, and they are equally concerned about the potential for abuse or misuse when the only interaction between doctor and patient is via computer. (Some women take a double dose of birth control pills — or even more — if they believe they need emergency contraception.)

But Nurx spokeswoman Maryam Fikri said the company views a face-to-face consultation with a physician as a barrier that keeps sexually active teens from getting necessary protection.

“Either there isn’t one in their area — no access to a provider or clinic — or they don’t have the time,” she said. “They can just log on to our website or order through their phone.”

Dr. David Talcott, who teaches philosophy at The King's College in New York City and specializes in Christian sexual ethics, said he's not sure how many teens would order birth control over the internet, especially if they're trying to keep their sexual activity a secret.

“This may not give them the anonymity they might want, having a package show up on your doorstep," he said. "It might be easier to go somewhere on your own time, like a clinic."

'Not a perfect world'

In Utah, state Rep. Raymond Ward, R-Bountiful, has sponsored legislation that would provide free birth control pills and other forms of contraception to women below the federal poverty line. HB12 has passed the House and is awaiting action in the Senate.

Ward, who is a family physician, said he doesn't understand why online providers offer so-called emergency contraception since women have to wait for the product to come in the mail, and they can buy them over the counter. But he has no issue with businesses that offer birth control without women seeing a doctor in person.

“In a perfect world, you would be able to have a conversation with a physician about the side effects, but this is not a perfect world, and I’m open to that,” he said.

Talcott, of The King's College, said that most Christian denominations, outside of the Roman Catholic Church, are accepting of birth control within marriage. But, he said, "I do think it would raise questions in evangelical churches if unmarried teenage girls were ordering (birth control pills) over the internet without their parents knowing." The fact that there hasn't been more outcry about the services, he said, may be that many parents don't know they exist.

The birth control debate, however, is just one part of a larger issue, which is the hypersexualization of the culture, both Scheidler and Talcott said.

“One of the big problems we have in the broader culture is that we’ve separated sexual activity from the whole context of what it was meant for, a committed marriage relationship, a loving relationship between a husband and a wife," Talcott said.

"The bigger problem is, we need to teach better about sex — not just the health mechanics of it, but its meaning. What is it for? What is its significance? We need to help young people understand its meaning, and then what we do with birth control is a secondary question," he said.