Engender blog

Guest Post: Why contraception needs a Me Too moment

As discussions around schemes which offer women support on the condition they utilise long-acting reversible contraceptives (LARC) continue, we'll be hosting a series of blogs by Elspeth Wilson discussing her research into how LARC has historically been - and continues to be - used to control the fertility of marginalised people.

In this first blog, Elspeth discusses ideas around contraception and consent.

I am being told for the third time in a row that there is no possibility that the coil I have fitted could be causing any of the repeated vaginal discomfort and infections that I have been experiencing for months. I explain, again, that I previously had a coil before and that this was the only other time in my life where I had consistent infections but that, because it was my first time using a coil, I had been more easily placated when told there was no possible link. Now, faced with the same difficulties (which ironically made the point of the contraception moot in the first place due to the severe irritation) my literal lived experience of my body caused me to suspect that the coil was the cause of my woes.

This doctor has a kinder manner than the others and tells me that she will remove it if I really insist but that she advises against it. Cowed and already feeling vulnerable I doubt myself and leave with my resolve in pieces, coil still in place. Not for the first time I cry after leaving the doctor’s surgery. It is not until several weeks later that I finally get the coil removed. The infections stop days after and do not recur.

Later, I will find out that on the NHS website having an IUD (another term for a coil) is listed as a factor that makes bacterial vaginosis more likely. I know my own body but, at the time, do not know this fact which may or may not have been helpful given some doctors’ lack of knowledge on contraception. At a conference the next week I meet a woman who does research on global health and tell her that I experienced difficulties getting my IUD removed. She looks unsurprised and tells me she experienced similar difficulties herself. As I started to conduct qualitative research on the topic of long-acting reversible contraception (LARC) I found that stories like this are common. Some, like mine, are more subtle with people being discouraged from changing contraception despite unpleasant side-effects. Some participants in the research experienced much more explicit incidents such as point-blank refusal to remove long-acting contraception until the patient ‘gives it a few more months’ or a doctor re-inserting a new implant without checking properly first. The underlying theme which ties these experiences together is consent; this wasn’t initially obvious to me as a patient but thinking as a researcher made me realise that women’s consent is still often violated in contraceptive care.

Consent is ostensibly extremely important in medicine with ‘informed consent’ being central to medical ethics. However, just as discussions burgeon about the fact that sexual consent is so much more than ‘no means no’, it is equally important to have nuanced conversations about other forms of bodily autonomy, including contraceptive care. Given the contrasting power dynamics at play in medical consultations, the unequal burden of contraceptive labour which means birth control usually falls to people with wombs, and the history of sexism, racism and ableism in discussions of fertility, a Me Too movement for contraception is long overdue. As recently as 1975 medical guidance was published which describes woman as ‘feckless’;

‘Feckless females’ is a generic term used to cover the type of women all GPs know very well. Of inadequate personality, low intelligence and prone to anxiety, they are bound to miss Pills, or stop taking them without seeking medical advice. Side effects can be guaranteed to be severe and multitudinous. Recurrent unwanted pregnancies and pitiful pleas for abortion will result.'

Oldershaw, the GP and author, suggests that women who have had abortions need to use LARC because “the patient often needs protection, not only against pregnancy, but also against herself… If a patient of mine would not agree to use a method, I would question my estimate of her need for abortion”. Depressingly, such paternalistic medical attitudes still occur today, with one senior sexual health specialist I spoke to noting that many doctors feel they know what is best for patients, including but not limited to contraception. As National Institute for Health and Care Excellence (NICE) policy guidelines encourage increased uptake of long-acting reversible contraception (which includes the coil, the implant and the contraceptive injection) discussions of consent are particularly important given that these are not all types of contraception that patients can choose to stop using without medical intervention. One participant’s doctor told them that they had to wait to have their implant removed despite it interacting negatively with their psychiatric medication, thus causing her to miss time off work and negatively impact her career.

This is not to say that there isn't also excellent contraceptive care out there; several participants made a point of mentioning doctors and nurses who had provided them with excellent information and made otherwise distressing insertions bearable or even positive experiences. But what is a common theme amongst the 19 participants I spoke to is that their wishes and concerns were not always taken seriously and, in the worst cases, were actively ignored, indicating the importance of continuous, active consent in healthcare. Of course, there may be times when a clinician has to go against a patient’s initial wishes for medical reasons but in these situations the reasons should be properly communicated; consent and communication are two sides of the same coin.

The fight for reproductive rights and bodily autonomy does not only encompass access to contraception but also the right to change and end use of different methods. In amongst the reluctance to remove contraception is the assumption that pregnancy prevention matters above all else but as a society we have to ask ourselves who does this control serve? Research shows that effectiveness is not always the number one concern of users, who are also concerned about aspects like side-effects and insertion, and there has to be recognition that patients are a heterogeneous group.

Promoting long-acting contraception must never be at the expense of the individual patient, particularly for those whose fertility is otherwise devalued by society, like young women, women of colour, disabled women and trans people. It is important to question whose needs are being put first and who are the potential losers in a situation where persistence is sometimes key in accessing the desired contraceptive care. Inevitably, societal valuations of fertility enter into whose pregnancy is considered acceptable and whose is not, as seen in the Pause programme which requires vulnerable women to use a form of LARC to be eligible to access much-needed help.

In social science the concept of biopower describes the way in which ‘healthcare’ can be used to control a population; as Nadesan (2008) argues some groups of people are more likely to be deemed lacking in self-government and thus in need of bodily discipline. If people can only access support if they choose a certain contraception or if they have to stick with an option that doesn’t work for them because they cannot access the appropriate healthcare then that is no real choice at all.

References

Bharadwaj, Preeti, Akintomide, Hannay, Brima, Nataliya and D’Souza, Rachel. 2012. ‘Determinants of long-acting reversible contraceptive (LARC) use by adolescent girls and young women.’ The European Journal of Contraception and Reproductive Health Care 17(4): 298-306.

Foucault, Michel, 1998. The Will To Knowledge: The History of Sexuality Volume I. London: Penguin.

Nadesan, Majia Holmer. 2008. Governmentality, Biopower and Everyday Life. New York: Routledge.

National Institute for Health and Care Excellence (NICE). 2005. Long-acting reversible contraception [online]. Available at: https://www.nice.org.uk/guidance/cg30/chapter/Introduction [Accessed 30 April 2018].

NHS. 2018a. Bacterial vaginosis [online]. Available at: https://www.nhs.uk/conditions/bacterial-vaginosis/ [Accessed 13 June 2019].

Pause. How we work with women [online]. Available at: https://www.pause.org.uk/what-we-do/the-pause-model/ [Accessed 14 June 2019].

Oldershaw, K Leslie. 1975.

Contraception, Abortion and Sterilization in General Practice. London: Henry Kimpton Publishers.

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