App-ropriate Contraception?

Just under 60 years ago, the contraceptive pill was made widely available to women in the Western world. And, for many, this was one of the greatest steps forward in the history of women’s rights—a medication centered around women’s needs that provided women with greater control over when, and with whom, they had children. Though it was not made legal for unmarried women to use until the late 1960s, millions of women began to use the pill. Today, the pill still tops the charts as one of the most commonly used methods of contraception for women in the United States and the UK.

So it may come as a surprise to some that, after over half a century of use, some women are now turning against the pill. Over the past few years, younger women have started to turn away from more commonly trusted methods of contraception—the pill, implants, condoms or surgery—and are instead using high-tech versions of traditional fertility awareness-based methods (FABMs) . What women over the age of 50 would perhaps recognize as the “counting method” has been rebranded by apps like “Natural Cycles.” These (often expensive) apps ask women to use bio markers (like monitoring their basal body temperature and menstrual cycles) in order to map fertility and suggest times in which it would be most safe to have unprotected sex without causing a pregnancy. However, after an initial boom in interest, it quickly became transparent that a significant number of women using such methods had ended up with unwanted pregnancies. Natural Cycles was penalized by the UK Advertising Standards Agency for advertising itself wrongly as a “highly accurate contraceptive.”

The demand for these apps seem driven by younger women’s concerns about the side effects of the pill—not just the usual complaints about weight gain or acne, but a more worrying claim that the pill induces anxiety or depression.

In 2016, a group of researchers at the University of Copenhagen in Denmark surveyed one million Danish women and came to the conclusion that users of hormonal contraception were 1.23 times more likely to suffer from depression. Although there was no evidence to prove that these women were suffering from depression as a direct result of taking the pill, much of the international press ran with the story, claiming tha0t taking the pill was negatively affecting women’s mental health.

Despite the lack of scientific evidence, personal, experience-based criticism of the pill has been around for a while. Three years before the Danish research was published, in her book Sweetening the Pill: Or How We Got Hooked on Hormonal Birth Control, Holly Grigg-Spall wrote that: “It wasn’t until I stopped taking the pill that I developed the needed energy, motivation and clarity of thought to express why I had to stop.” Grigg-Spall links the controlling of women’s hormones to a feminist argument against women’s oppression. “The pill is as intrinsic to Western patriarchal capitalist culture as it is to the lives of millions of women,” she writes. “What would our society be without the pill?” Vicky Spratt, a feminist journalist based in the UK, has followed in Grigg-Spall’s footsteps, releasing her own investigation, Mad About The Pill, which details her personal journey. Spratt explains how she believes the pill caused her significant mental distress, despite doctors telling her it had nothing to do with hormonal contraceptives. So, is it true? Does the pill make women depressed? Not quite. But, as Ann Furedi, head of the British Pregnancy Advisory Service, tells me: “when it comes to contraception we know an awful lot, but we don’t know a lot about depression and mental illness.” Furedi says there has been a shift in our relationship with mental health, and so women today are rightly or wrongly more aware of changes in their moods. “In the past, doctors would talk about side effects of contraception in a way which was perhaps less sensitive—if you stick it out for a few months it’ll settle down. That meant mood swings and changes in libido were seen as par for the course of preventing a pregnancy.” This doesn’t mean that the pill has always caused problems with mental health, but that women’s awareness of—and sensitivity to—changes in their mental well-being has made some look differently at hormonal contraception.

The technology might be slightly more advanced, but FABMs have been around for donkey’s years. The Billings method, developed in the 1950s by monitoring cervical mucous, was almost as radical as the pill. Brid Hehir, a retired midwife, told me that she remembered her time in training at the Coombe Women and Infants University Hospital in Dublin. One day, a nurse was appointed to teach women the Billings method, as at that time women would be kept in for a few days after they had given birth. For women living in Catholic Ireland—where birth control was not just stigmatized, but forbidden—this was revolutionary. Not only did it give women a chance to learn more about their cycles and how their bodies functioned, but it gave them a tool that would go some way towards helping them control their pregnancies. “It was amazing to see women being empowered in this way,” Hehir says.

Presumably becoming aware of the fact that women were looking for ways to control their fertility, the Catholic church has developed its own versions of contraceptive methods. Natural Family Planning methods (NFPs) encourage women to count and predict their fertility windows, but abstain from sex during the time at which fertility is highest rather than relying on condoms. Back in 2010, Linda Pinto—who works with corpus, the National Association for an Inclusive Priesthood—wrote an article for this very magazine about CycleBeads, the rosary-bead-like counting aid that had been produced by Georgetown University. Pinto questioned whether or not the resistance to “artificial” contraception (like the pill) was healthy: “If we were to use the same analogy, why would we endorse the artificial use of electricity? Cutting down trees, treating them with preservative chemicals, stringing wire that transports dangerous levels of electricity through backyards and fields certainly seems artificial. Why not stick with beeswax candles and wood stoves?”

Indeed, much of the reaction to the pill seems to be linked with a back-to-nature trend among a younger generation of women. Similar desires have given rise to a rejection of synthetic sanitary products like tampons and pads, as well as traditional beauty products (I know some women who preach against the evils of shampoo). Women my age often talk about feeling unsafe or unsure about the influence of synthetic hormones on their bodies. The idea of intervening in the natural process of women’s bodily functions doesn’t sit right with them.

It’s easy to draw parallels between this modern anti-meddling approach to women’s bodies expressed by some young sceptics and the Catholic hierarchy’s hostility to contraception, which believes that a woman’s body is too sacred to be meddled with—preventing a pregnancy by artificial methods is inherently wrong. Perhaps feminist pill critics like Grigg-Spall and supporters of Humanae Vitae like Pope Paul VI have more in common than either might like to admit.

This is not to say that non-hormonal methods should be totally dismissed. In fact, Chelsea Polis, associate at the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, tells me that part of the reason some women are turning away from trusted medical advice is because of hostility towards traditional methods. “In some communities—including the medical community and the scientific community—there is not always a breadth of knowledge about these methods,” she says. “And so people interested in them have sometimes felt dismissed or brushed off when they inquire about them.” Polis says the problem with FABMs is not that they’re ineffective, but that we don’t know how effective they are. Polis took part in a systematic analysis of peer-reviewed journals relating to FABMs, and none—yes, none—of them were deemed of “high quality,” and only 21 were deemed of “moderate” quality. Put simply, this means that there isn’t enough research going into FABMs to determine whether they are effective-enough contraceptive methods.

This hasn’t stopped the US Food and Drug Administration from clearing the app Natural Cycles “as a medical device” suitable for use as contraception. Neither has it stopped the president, Donald Trump, from proposing changes to the supply of Title X funding meaning that, alongside restricting access to information about abortion, doctors would be encouraged to prioritize “natural family planning methods” over other methods of contraception like IUDs or the pill. This would effectively mean that the poorest women in the United States— those reliant on Title X funding—would receive the least useful or accurate information about their contraceptive options.

This injustice is often repeated in the context of access to information about contraception in developing countries. USAID-backed projects like the Fertility Awareness for Community Transformation (FACT) Project use government funding to teach women in Nepal, India, Rwanda and Uganda the “Standard Days Method” (another counting method) as well as information on fertility. Rather than provide women in poorer parts of the world with the most-effective tools to control their fertility (i.e., with medicine and hormonal contraception), these state-sanctioned outreach programs judge old-school methods to be sufficient.

So what do women need? For Polis, it’s simple—more information. “We need to center what people’s preferences are when they’re talking about the use of a contraceptive method, and ensure that they have reliable information about the advantages and the disadvantages of all of their contraceptive options,” she says.

And, despite the new skepticism around the pill and its side effects, when it was first introduced it inspired women to look for more information about their bodies and their fertility. At the time it was first introduced, the pill was given to women in doses exceeding 10 times the necessary quantities for preventing a pregnancy. As such, many women suffered extreme side effects; some even died. But rather than provoke a backlash against the pill itself, gender and sexuality historian Dr. Lesley Hall tells me that it inspired a revolution in feminist theory. The influential book Our Bodies, Ourselves, published initially as a stapled booklet in 1970, was an invitation to women to “take full ownership of their bodies” and to stop relying on the information given to them by male doctors and male-dominated society. “This was about women making an informed choice, and talking about it with other women,” Hall tells me.

Personally, I’ve had a hard time with hormonal contraception— I’ve ballooned in weight, dealt with irregular and inconvenient periods and even severe hair loss as a result. But I still think the concept of a magic pill that allows me to take control of one of the most important parts of my life as a woman—when and if I get pregnant—is nothing short of brilliant. It worries me that, rather than demanding better and more advanced solutions to preventing pregnancy, some women are turning against tried and trusted methods in favor of those that are less-researched and potentially less-effective. Women’s reproductive rights and access to information about their fertility is still shrouded in mystery. Just look at the discussion around abortion in the West, where women aren’t treated with enough respect or trust to decide for themselves when they start a family. It’s no wonder that our approach to contraception is just as poor. As with most aspects of life—knowledge is power. We need to empower women with the knowledge and the tools to take control of their bodies, and thus make healthy decisions about their lives.