Caracas, Venezuela - Yorlenis Gutierrez, a 28-year-old mother, spent months vainly scouring pharmacies for a drug whose scarcity is complicating her sex life and that of countless Venezuelans. In a country beset by shortages, this is one of the hardest: the disappearance of contraceptives.
When she couldn't renew her supply of birth control pills, Gutierrez and her husband made a choice. Long-term abstinence was not an option, they agreed.
They tried to be careful, but soon she was pregnant with her second child.
"We barely eat three times a day now," said a distraught Gutierrez, a former hair washer in a beauty salon who lost her job because of the economic crisis. "I don't know how we're going to feed another mouth."
In Venezuela, a collapse in oil prices coupled with nearly two decades of socialist policies has sparked a severe recession and one of the world's highest inflation rates. People often wait hours in line to buy bread. Prices for staples jump almost by the day. Medical shortages range from antibiotics to cancer drugs.
But the shortage of contraceptives has put Venezuelans in a particularly bleak quandary: Have sex - or don't ?
For the most part they are, sometimes with dire consequences.
There are no recent official statistics. But Venezuelan doctors are reporting spikes in the numbers of unwanted pregnancies and sexually transmitted diseases that are adding to the country's deepening misery.
Mainstream media outlets have published articles about the "counting method" of contraception that women can use to calculate when they are ovulating and likely to get pregnant. An article on the Venezuelan website Cactus24 offered "15 home remedies to avoid pregnancy," including eating papaya twice a day and drinking two cups of tea with ginger.
Many Venezuelan women have found a solution on social media, where Facebook, Instagram and Twitter have become informal exchanges for the purchase or trading of birth control pills, intrauterine devices and implants - albeit at black-market prices.
Other women beg friends and relations to bring them contraceptives from outside Venezuela.
"Last time, I got them from my sister-in-law, who brought them from Colombia," said Alejandra Moran, a 27-year-old Caracas publicist. "And I'll be traveling to Spain in December, so I'll stock up for myself and my friends."
For years, oral contraceptives, IUDs and condoms were available free at many public hospitals or through government programs. But the cash-strapped government has largely suspended those handouts, leaving some forms of contraceptives impossible to find and others prohibitively expensive.
"It's hard for young people especially to access them," said Vanessa Diaz, a gynecologist at Caracas University Hospital. "Contraceptives like condoms used to be given out and there were many brands available, some of them cheap. But that's just not the case anymore."
The shortage, medical experts say, has also fueled an increase in dangerous attempts to terminate pregnancies at home - not a surprising development given that abortion is illegal in Venezuela except when the mother's life is at stake.
Marissa Loretto, an OB/GYN at Caracas's Concepción Palacios Maternity Hospital, said she recently treated a woman who had tried to induce an abortion by forcing parsley and laundry detergent into her uterus.
The young woman had arrived at the hospital bleeding, and with contractions that ultimately caused a miscarriage. As often happens in such situations, Loretto said, she subsequently suffered an infection.
"We ended up having to remove her uterus," Loretto said.
Officials at Venezuela's Health Ministry did not respond to emails and phone calls seeking comment.
For years, most pharmacies here acquired medications through a system in which the government set beneficial dollar-exchange rates for the import of foreign-made drugs. But that system has at least partly broken down, meaning pharmacies have few contraceptives to sell and often charge hundreds of times the normal price for them. Overall, stocks of oral contraceptives have fallen by as much as 90 percent since 2015, according to the Venezuelan Pharmaceutical Federation.
On a recent afternoon in central Caracas, one pharmacy said it hadn't received birth control pills in more than a year.
Two blocks away at another pharmacy, a female customer in her 20s looking for pills was told, "We only have the imported ones" - implying they would be sold at a black-market rate. The manager offered her a single pack of 21 pills for 120,000 bolívares. That's about $3, equal to one-third of Venezuela's monthly minimum wage.
"They're expensive, but I need them," the young client said, purchasing them anyway. She declined to give her name before scurrying away.
Many name-brand condoms, meanwhile, have disappeared from store shelves. But the cheaper brands taking their place are still imported, and therefore still unaffordable for many. A three-pack can now cost several days' minimum-wage pay.
"I inherited my best friend's condoms when he left the country to move to the United States," said Juan Noguera, 28, an unemployed economic researcher. "Sometimes we just share them between friends. This is the sharing economy."
In Venezuela's macho society, many men refuse to wear condoms anyway. But now that they cost more, experts say, the indexes of unprotected sex are getting even worse.
The cheaper brands can also be unreliable. A few months ago, Andres Rodriguez, 28, said he was en route to his girlfriend's house when he stopped to buy a pack of condoms. All he could find was a brand he had never heard of.
"I bought them anyway. I was in a hurry," he said. During sex, he said, the condom broke - although his girlfriend did not get pregnant.
"Can you imagine? In this economy?" he said of the prospect of a pregnancy. "What a disaster."
Doctors blame the situation for a worrying increase in HIV cases and sexually transmitted diseases such as gonorrhea, syphilis and herpes.
María Eugenia Landaeta, head of infectious diseases at Caracas University Hospital, said the number of HIV patients being treated there has surged to 5,600 this year, up from 3,000 in 2014.
"One of the causes is the lack of prevention methods," she said.
Diaz, the gynecologist from Caracas University Hospital, said the number of patients with STDs she is seeing has soared.
"In my private practice, out of every 10 patients, five or six now have an STD," she said. "Two years ago it was just two or three."
Making matters worse, drug shortages are so severe that doctors often lack what they need to treat patients with STDs.
"Something as simple as penicillin - the cheapest antibiotic in the world - can't be found in the country," said Moraima Hernández, an epidemiologist at Concepcion Palacios Maternity Hospital.
In Venezuela, birth control usually is left up to the woman - and nowadays, for many, that means the black market or nothing. After going months with sporadic access to birth control pills, Lorena Mendez, a 24-year-old economist, decided she could no longer run the risk of pregnancy. She used Instagram to track down a black-market dealer of etonogestrel implants, rods inserted into the arm that release a contraceptive hormone.
The device can function for as long as three years. Mendez paid 600,000 bolívares for one - 300 times the official subsidized rate.
"It was extremely expensive. Not many people have access to it," she said. "But it was worth it. Now I have peace of mind."
The Washington Post