burdenofcontraception

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Overview

Recently, topics surrounding birth control and contraception methods have surrounded some discussions between my friend groups and within my classes. A friend of mine told me about her birth control experience and how scared she was to undergo the removal process. It prompted me to think about my position and why certain roles are taken (surrounding pregnancy prevention) while others aren’t. Within the conversations I had and research I had done in another class of mine, it seemed that the most commonly talked about and effective modes of contraception were for pregnancy-capable individuals. 

For my final project, I aim to explore how contraception can be seen as a woman’s responsibility in the United States. The cultural and societal messages place the burden of responsible reproductive planning on them, creating an unequal divide. I would like to explore current contraceptive methods and possible side effects that may intensify stigmas surrounding the experience and the toll of the (emotional, physical, and mental) effects it may have on those taking birth control or practicing other forms of contraceptives.

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Glossary

Androcentrically: a dominant male/masculine point of view

Gender-Equitable Attitudes (GEM): attitudes toward gender norms in intimate relationships or differing social expectations for men and women, boys and girls

IUDs: a t-shaped piece of plastic inserted into the uterus to provide birth control; over 99% effective and lasts a few years

LARCs: Long-Acting Reversible Contraceptives which provide effective contraception for a long time

Novel Male Contraceptives/Male Body-Based Methods: hormonal/non-hormonal modes of contraception (e.g., condoms, spermicide, withdrawal, vasectomy, etc.)

Tubal Ligation: female sterilization, involving the tying or severing of the fallopian tubes

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CR 1: More Than a Physical Burden: A Women's Emotional and Mental Work in Preventing Pregnancy

This article discusses how a gendered social structure within the healthcare system can create additional mental and emotional troubles for women (in addition to the physical aspects of contraception). The author opens up a conversation by explicitly stating that “in the United States, responsibility for preventing pregnancy in heterosexual relationships disproportionately falls on women… the mental and emotional responsibilities of preventing pregnancy is both a product of and contributor to gender inequality” (Kimport 2018). The author notes how prominent the gendered social structure is in the reproductive health care system.

They analyzed contraceptive counseling visits of women (or pregnancy-capable individuals) who did not want children in the future. Looking at these visits was useful “to investigate the contours of the time, stress, and attention components of fertility work as well as to examine whether and how those responsibilities are discursively marked as belonging to women”. Data was collected through audio recordings of the visit - felt that if they were present in the visit, it would have altered the way in which the counseling visit unfolded.

A portion of the patients brought up fears they faced surrounding physical pain during any contraceptive method but mostly regarding the placement of IUDs. In response to the patient’s fears, clinicians simply recommended the consumption of pain-killers (over-the-counter medication), one clinician stated, [discussing types of painkillers] “It makes you a little bit high though. Like if you took it, you’d have to have someone waiting for you” (2018). During the consultation, only one clinician brought up male contraception. The authors found that clinicians tend to normalize women undergoing the crowding of emotional and mental tasks surrounding contraception. Clinicians frequently treated patients with surprise and doubt if stated that they did not want children in the future. During instances in which a patient wanted something permanent, like tubal ligation, they left the visit with birth control pills, which forced her to continue to be involved with fertility work even though it was not desired.

Gender inequality is discursively and structurally reproduced through clinical encounters. Results demonstrate that the clinical visit constructs the mental and emotional responsibilities of contraception for women through both discursive processes and structural practices.

The assignment of these responsibilities [to women] is a product and contributor to gender inequality. These findings show how the production of reproductive health care is related to being a gendered social structure.

Aspects of contraception described by patients to attribute to the emotional and mental burden

Attention

Time

Stress: Not feeling ‘natural’ & the emotional stress of commencing contraception

Fear of the side effects of (hormonal/non-hormonal) methods

Emotional/mental fears regarding physical pain for contraceptive methods, mostly concerning the placement of IUDS (which is one of the more effective methods). “fears about the physical experience of contraception illustrate some of the emotional and mental stress that using contraception entails for women. They further suggest that such stress can arise precisely because women assume the physical burden...”

Clinician responded that they could just consume painkillers for any troubles, as stated

[discussing types of painkillers] “It makes you a little bit high though... like if you took it, you’d have to have someone waiting for you”

Fertility work as normative:

“Clinicians not only normalized women undertaking the immediate mental and emotional tasks of using contraception. They also discursively legitimized women assuming responsibility for nonphysical fertility work in perpetuity"

This study consisted of patients who did not want future children, yet clinicians treated them with surprise and doubt… “some patients had to articulate this preference more than once”

When stating that they don’t want children in the future, clinicians prompted a conversation entailing the future of their fertility… when the patient had already stated that their fertility future is ending…

Many young patients (as well as older ones), told their clinician that they wanted a tubal ligation, but the clinician would typically deviate the conversation to contraceptive methods that didn’t end their fertility (even if they wished to do so)

“Ultimately, the patient leaves the appointment planning to use the contraceptive pill, a method that requires her to engage in ongoing fertility work”

“The disbelief in the permanence of desiring to remain child-free was widespread”

Heteronormative expectations that (most) women will want to become mothers… yet women with children were not exempt from the normative expectation (meaning if a woman had kids and went to a consultation to discuss a tubal ligation, she was still met with uncertainty)

They were told what they wanted and were not listened to

Believed that their desire is temporary and possibly false

Providers can perpetuate normative expectations around pregnancy and motherhood because of structural forces (the social structure of heterosexuality).

Kimport K. 2018. More Than a Physical Burden: Women's Mental and Emotional Work in Preventing Pregnancy. Journal of Sex Research, 55(9), 1096–1105.

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CR1: "Clinicians regularly expressed doubt about or dismissed women’s desire not to have future children, thereby reifying ongoing fertility, and the attendant mental and emotional burdens of contraception as normative"

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CR 2: Women's Contraception Perceptions, Beliefs, and Attitudes: An Integrative Review of Qualitative Research

This article discusses the relationship women have with contraceptives and its connection to possible power relations and gender norms in the United States. They used a “feminist poststructuralist framework” to understand the possible power relations (whether it be the power of the patriarchal society imposing limits of contraception or the power of knowledge that a woman has in regard to modes of contraception). Researchers examined studies and journals in the United States that “qualitatively examined women’s perceptions, beliefs, and attitudes regarding contraception”. They focused their studies to address adult women, not focusing on younger or adolescent women because they felt that there is sufficient literature that addresses those age cohorts. The researchers believe that it is imperative to understand “the lived experience of women’s relationships with contraception” to combat rates of unintended pregnancies and possible power dynamics. They aimed to explore women’s perspectives of contraception to understand how and why they hold the beliefs that they do.

Gender norms largely impacted the contraceptive choices held by women and in some cases, the decision-making “defaulted” to men. Patients (women) who sought out contraceptive methods constructed their action (or inaction) on what seemed appropriate through cultural or social norms. This is the root of power dynamics when it comes to making decisions about contraceptive methods. They found that the way in which “women internalize power structures and interpret them in relation to their own sense of self plays a role in their contraceptive perceptions and behavior”.

Gender Norms:

A constructed connection between fertility and femininity

“Women were also unlikely to choose contraception options that they felt might harm their fertility in the future”

Women retained the desire for fertility if, in the future, they connected with a partner who wanted children. All based on what their future partner would want, fearing that they would not work out if she did not retain her fertility. Her value and femininity are reliant on fertility – independent from herself.

Power of Husband and Sexual Partners:

For casual encounters: “power manifested in contraceptive negotiations that often included that partner taking a stance against contraception and condom usage”

Formal relationships: “male power represented a more encompassing control over metho choice, usage, pregnancies, and healthcare-seeking behavior in general”

Power of Health Care Providers:

Often perceived as coercive in the discussion of contraceptive options

Impact of language: [patient} untrustworthy of contraception

Power of Subjectivity (the individual’s sense of self, created by the individual’s internalization of social power relations):

Women’s sense of their own fertility is shaped by their views on contraception

Perception of motherhood: “The ways in which women viewed their role as mothers sometimes meant their contraceptive action did not line up with their stated desires or plans” (LARCs, side effects, hormonal/non-hormonal, reversible vs permenant)

Control (lack of): moments where women are unable to make their preferred contraceptive decisions (because of outside influences)

Alspaugh, A., Barroso, J., Reibel, M., & Phillips, S. 2020. Women's Contraceptive Perceptions, Beliefs, and Attitudes: An Integrative Review of Qualitative Research. Journal of Midwifery & Women's Health, 65(1), 64-84.

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CR2: "Women internalize power structures and interpret them in relation to their own sense of self plays a role in their contraceptive perceptions and behavior"

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CR 3: Men's Willingness to Use Novel Male Contraception is Linked to Gender-Equitable Attitudes: Results

This article explores cisgender men’s willingness to adopt preventative modes of action when it comes to reproduction responsibility. Specifically, they seek to find how open men are when it comes to using male contraceptives and how traditional gender roles in the United States may be a factor that affects their willingness to take responsibility. How gendered attitudes regarding the responsibility of contraception affected the willingness of men to take up those roles.

Their sample size was relatively large – 2066 respondents. Over half of the respondents reported that they were willing to use hormonal male contraceptives and 65% were willing to take part in non-hormonal methods. Three-quarters surveyed said that they would use either novel hormonal or nonhormonal male contraceptives. Disinterest regarding hormonal male contraceptives existed because of “concerns about hormonal side effects, particularly those that might affect their masculine presentation and sexual function”. Researchers note that there is a relationship between a cis-male willingness to incorporate male contraceptives and the total GEMS score. Those who responded that they were willing to use any novel male contraceptive scored higher on the gendered equity score. One-third of respondents “strongly agreed that men should be tough… notions about masculinity may be barriers to male contraceptive uptake among some men”. This does not include men who even ‘slightly agreed’ with that mindset.

I liked this article because it examines cis-men’s reproductive characteristics and why they hold the opinions that they due (opinions that concern preventative health behaviros). To understand why there may be a socialized/gendered burden of contracpetion (if any), getting insight on what men have to say (what what theta re willing to do/not to do) is imperative.

Disinterest of hormonal male contraceptives existed because of “concerns about hormonal side effects, particularly those that might affect their masculine presentation and sexual function”

Men are more willing/open to hormonal/non-hormonal modes of contraception, but “male contraceptive remains a critically absent component of gender-equitable family planning programs”

Male contraceptives remain “a critically absent component of gender-equitable family planning programs… support for male contraceptive research and development continues to be limited by doubts from investors and industry about cisgender men’s willingness to use novel male contraceptives and tolerate their potential side effects”

Firms have been faced with numerous studies that show how more and more men are willing and are interested in having reproductive responsibility… yet it is not heavily or thoroughly discussed in situations when it should be.

“The persistence of doubt in the face of such evidence is suggestive of deeply entrenched biases about cis-men’s reproductive responsibility and gender roles with respect to contraception”

“The social framing of pregnancy prevention as “feminine” or a “women’s issue” makes some cis-men even reluctant to discuss contracption with their female partners”

But the american public may be changing - for example, more cis-men are taking on traditional caretaking roles

Survey included questions/domains covering:

Gender roles (traditions)

Relationships (how couples ,ake decisions)

Masculinity (how men should behave)

Sexuality (how sexually active men should be)

Violence (if women should tolerate violence to keep her family from falling apart)

¾ of men reported willingness to use either novel hormonal or nonhormonal male contraception

Those who were more willing to incorporate any form of male contracpetion (hormonal or non), their score on the gender equity scale increased

⅓ of respondents “strongly agreed that men should be tough… notions about masculinity may be barriers to male contraceptive uptake among some men”

Nguyen, B. T., & Jacobsohn, T. L. 2023. Men’s Willingness to Use Novel Male Contraception is Linked to Gender-Equitable Attitudes: Results from an Exploratory Online Survey. Contraception, 110001.

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CR 3:"Even if more unique... methods are developed, the mental and emotional burdens of having to obtain contraception to prevent pregnancy will remain on cisgender women and pregnancy-capable individuals."

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Review 4: "We're a Little Biased": Medicine and the Management of Bias through the Case of Contraception

There are divisions surrounding the responsibility of pregnancy prevention across gender, but there is also immense divisions within gender (of women and/or pregnancy-capable individuals). Through contraceptive counseling visits, patients are informed and coerced to pursue particular methods through the bias of the clinician. This article explores the functions of biases in contraceptive medical encounters, which creates highly racialized, classed, and gendered contexts.

Birth control and access to contraception have been used as a mechanism to "limit the births of socially marginalized women in the United States through intentional involuntary sterilization and eugenics programs..." which causes providers to inadvertently hold onto these traditions (revolving around intentions). Through this, physicians may unconsciously pressure marginalized women to take upon their preferred method; this preference/coercion is not typical in the counseling visits of privileged patients (e.g., white and/or higher SES women).

Essentially, clinicians make assumptions based on the patient's demographics. They then orchestrate the way in which they perform their counseling visit; their actions are rooted in biases and stereotypes.

demographics relating to: gender, race, ethnicity, age, and class

ex: for teens, a practitioner may influence or motivate the teenager's mode of action. they may influence them to take upon methods that are highly effective, not taking the side effects into account.

Data surrounding demographic traits become seen as institutionalized knowledge or a "commonsense" way of evaluating the patient's background. Essentially, data normalizes this behavior.

A white male nurse practitioner made loose references to data on pregnancy risk and contraceptive compliance to explain (and excuse...) why he feels inclined to steer young patients of low SES toward LARCs. He felt that he was doing others a favor. He is well aware of the impact of his personal bias. He knew that it would differ from the patient's initial preference. He outwardly made preemptive conclusions about possible risks to the patient based on stereotypes/demographic traits.

"data-driven decision-making about who is 'statistically" more at risk for unintended pregnancy as rationale to "steer" some patients to sue LARC methods rather than prioritizing his patients' preferences".

There is an implicit racial undertone: "interpersonal interactions with the clinician encounter can reflect and produce system, gendered racism around reproductive equity and contraceptive access".

Lack of cultural competence [with the practitioners] reinforces stigmas that add to structural inequality, specifically, widening the gaps in social, economic, and health outcomes for marginalized populations. Reinforcing rather than aiding the systemic issue.

Making assumptions for the sake of scientific rationale... patients would be targeted in these interventions. "promotion of the most effective method by providers on the presumption that the patient is at higher risk for an unintended pregnancy... not taking the preference or personal risk of patients into account...". Rooted in disparate stereotypes which perpetuate such images and inequalities.

Providers continuously came up with reasons to support and justify their biased communication and persuasive advice.

Although they may feel as if they are helping, there are many negative connotations of race and class throughout their contraceptive discourse. Clinicians/practitioners may not recognize the root of their recommendations, but it still does an immense amount of harm to that community.

“Stephanie [a clinician] is still more likely to prescribe an IUD to a poor woman because shifting her language simply obscures the bias rather than confronts it. Using safe biases allows for this more explicit bias to be managed, justified, and discreet in her assertions that IUDs are ideal for women of low SES”

Providers do not confront (or seek to confront...) how their beliefs in turn take away contraceptive choice, even if they seek to advocate for marginalized communities.

Essentially... colorblind racism. Verbal strategies to conceal explicit racist statements. Implicitly, racialized language.

Drew, a white physician, explained their approach by demeaning the patients' education levels and trying it to SES & similarly, culture to race.

"I mean the “less-educated” person… one… they’re not exposed to the information as much… I find that the less educated people… don’t understand well when I try to explain [contraception]... whereas somebody who’s a higher-educated person… they obviously get [it].”

This is not an issue of which contraception method a patient chooses, more, there is an institutional root of disadvantage. Marginalized patients are implicitly told that they are uneducated in this regard, therefore the physician makes a decision for them – not fixing the issue, it is getting exacerbated.

Manzer, J. L., & Bell, A. V. 2021. “We’re a Little Biased”: Medicine and the Management of Bias through the Case of Contraception. Journal of Health and Social Behavior, 62(2), 120-135.

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R4: "Recommending LARCs to help put women in the "easiest position possible" neglects the structural factors that put these women in such difficult, marginalized positions in the first place."

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Review 5: Talking About Male Body-Based Contraceptives: The Counseling Visit and the Feminization of Contraception

The unequal burden (of women bearing responsibility of preventing pregnancy in heterosexual relationships) is the consequence of broad social narratives and interpersonal negotiations. Discussions and actions within counseling visits are orchestrated around the feminization of contraception – women are typically bear the responsibility, continuously imposing that role through these visits. Through the gendered division, clinicians typically reproduce normative gendered expectations about fertility work. Since contraception is feminized, it devalues male body-based methods, which reinforces control.

“The contraceptive counseling visit is increasingly recognized as a site of the discursive production of normative ideas about reproduction, suggesting that clinicians themselves may contribute to the assignment of responsibility for contraceptive labor to women”.

Perhaps, the reason why male body-based contraceptive methods aren’t thoroughly looked into or discussed to a larger extent is that they may “disrupt the feminization of responsibility for contraception”.

In the typical counseltation visit, clinicians normalize the devaluzation of male body-based methods.

In situations where it is discussed, clinicians had a tendency to emphasize aspects of male methods that were presumed to be “negative (e.g., the lower efficacy of withdrawal and condoms) but not features that the patients might view positively (e.g., the high efficacy of vasectomy or the lack of side effects with condoms and withdrawal”.

This marginalizes male body-based methods as a probable method to even consider. This discursively places the responsibility on women (or pregnancy-capable individuals), creating an unequal gendered division of fertility work.

Access to contraception initally a feminist issue that gave women autonomous control over their bodies and choices, but “the placement of the contraceptive burden exclusively on women’s bodies is not entirely consistent with the idea of women having bodily autonomy and control”.

"There is no best option [method of contraception] from a medical perspective".

The best option is the one that the patient prefers, it is subjective.

“Clinicians discursively suggested that patients’ first consideration in selecting condoms as a contraceptive method should be men’s willingness to use them rather than their own preferences”. They would pose a question regarding men's willingness to adhere to condoms and take responsibility regarding pregnancy prevention (but they would assume their answer to be uncertain...):

Clinician: and how do you think he would be with using condoms?

Patient: I think there should be no problem

Clinician: and how do you feel about him using condoms?

Patient: I don’t know

Regarding withdrawal, clinicians characterized men's behavior as something unchangeable (whether it be physical or mental (i.e, ulterior motives) reasons).

“Some guys are good at it and some aren’t–they can’t concentrate, can’t predict, have ulterior motives.”

“... its unreliable lay in men’s lack of psychological commitment to preventing pregnancy”

Most research regarding contraceptives relies on female bodies (of course there are methods and research done that has created modes for male bodies). “This low allocation of research resources is enabled, in part by social beliefs that contraceptive responsibility is inconsistent with masculinity. Fewer male-based methods that can be chosen”.

Gendered biomedical process

Kimport, K. 2018. Talking About Male Body-Based Contraceptives: The Counseling Visit and the Feminization of Contraception. Social Science & Medicine, 201, 44-50.

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R5: "Women should engage in ongoing fertility work and therefore choose contraception that preserves their fertility"