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Chapter 7: Contraception Learning Objectives Contraception: History and Cultural Variations • Identify methods of contraception that were commonly used in ancient times. • Describe the political and social controversies surrounding birth control in U.S. history. • Develop a clear understanding of contraceptive history and development in the United States. Methods of Contraception • Explain the things to consider when choosing a contraceptive method. • Identify, describe, and understand the function and effectiveness of contraceptive methods that protect against pregnancy and STIs. • Identify, describe, and understand the function and effectiveness of contraceptive methods that protect against pregnancy but not STIs. • Describe the connection between sexual health, positive decision-making, and communication skills. Contraception and Sexual Well-Being • Identify new forms of contraception that might be available in the future. Chapter Outline Chapter 7: Contraception Learning Objectives 7.1 Discussion Topic 7.1 Discussion Topic 7.2 Discussion Topic 7.3 Discussion Topic 7.4 Learning Objectives 7.2 Discussion Topic 7.5 Discussion Topic 7.6 Discussion Topic 7.7 Discussion Topic 7.8 Learning Objectives 7.3 I. Contraception: History and Cultural Values • Contraception is any method that we use to prevent conception and unintended pregnancy. Additionally, many contraceptive methods prevent the transmission of STIs. • Because contraception is used to prevent pregnancy, abortion does not fit the definition of contraception. A. Cross-Cultural Variations in Contraception • Some methods of contraception used in different cultures are: o Coitus interruptus, or withdrawal of the penis from the vagina before ejaculation, is a technique practiced in many cultures around the world. o Coitus obstructus is the general category of putting pressure on the testicles, a method from Ancient India, which was thought to cause sperm to be ejaculated into the bladder. o Coitus reservatus is a method from Hindu medicine in which the male totally avoids ejaculation. o Douching, a method of washing out the vagina or washing the penis, has been used since the ancient Greeks. o A suppository, object, or elixir placed in the vagina is known as a pessary. It either kills or blocks the passage of sperm into the cervix. o Sea sponges were used by ancient Jews and other people to block the sperm from entering the cervix. o Condoms have been produced in the United States since 1840 and have been second in popularity of contraceptive methods only to the fairly ineffective withdrawal method. o Breastfeeding in many cultures is used as a form of contraception. • Most of these methods are not effective. • When we look closely at cultural beliefs and practices, we find many variations in contraception. These variations depend greatly on the cultural context in which contraception occurs, as well as on how people of the culture perceive pregnancy and birth. B. History of Contraception in the United States • In the 19th and early 20th centuries, those who opposed the use of contraceptives passed federal laws making it illegal even to distribute information about it. Some people were brave enough to oppose this law despite the threat of being imprisoned, but, that law was not repealed until 1965. • Anthony Comstock (1844-1915), a Connecticut social reformer, was instrumental in the passage of the Comstock Act (1873), officially titled “Act for the Suppression of Trade in, and Circulation of, Obscene Literature and Articles for Immoral Use.” Part of this law made it illegal to distribute information about contraception and devices because they were considered immoral and obscene. • In contrast to Comstock, Margaret Sanger (1879-1966) believed in free love and sexual rights. A mother of three, an active feminist, and the person generally credited with coining the term birth control, Sanger was motivated not only by her compassion for people struggling with issues of contraception, but also by personal experience. o Sanger actively campaigned to decriminalize contraception. She decided to fight the contraceptive part of the Comstock Act and advance the sexual literacy of women through contraceptive education, counseling, and clinical services. • Some of the milestones in the history of contraception are: o 1938—In a case involving Margaret Sanger, a judge lifted the part of the Comstock Act that banned distributing birth control information and devices. Diaphragms became a popular method of birth control. o 1960—The first oral contraceptive, Enovid, was approved by the FDA as a form of birth control. o 1960s—The first intrauterine devices (IUDs) were manufactured and marketed in the United States. o 1965—The Supreme Court (in Griswold v. Connecticut) established the right of married couples to use birth control as protected in the Constitution as a “right to privacy.” o 1972— The Supreme Court (in Baird v. Eisenstadt) legalized birth control for all citizens of this country, irrespective of marital status. o 1980s and 1990s—Hormonal birth control methods expanded to include the female condom, implants, and injectables. o 1992—Emergency contraception became more widely available as a result of public awareness campaign. • Today we continue to see a rapid expansion in available methods as well as in improvements in safety and effectiveness of contraceptives. Some newer methods include the hormonal patch, the vaginal ring, injectable hormones, single rod implants, and trans-cervical female sterilization. II. Methods of Contraception • Most people engage in sexual activities not to conceive offspring, but to experience sexual pleasure. Many heterosexual couples of childbearing age want to enjoy sex and to prevent unplanned pregnancy. • The prevention of STIs is critical for people in intimate relationships who engage in sexual activity regardless of sexual orientation and age. Thus, contraception is an important concern for most people. • Equipping oneself with contraceptive knowledge can help one understand which methods are reliable. It can also help one understand why using it consistently helps to prevent both unintended pregnancies and STIs and helps to increase your ability to find pleasure in your sexual encounters. A. Choosing a Method of Contraception: What to Consider • Do you one day want to have a child or children?—If you know that you will never want to conceive a pregnancy, a tubal ligation (for women) or a vasectomy (for men) might be a reasonable option to consider. • What is the effectiveness of different birth control methods?—The effectiveness of any given contraceptive method is best evaluated by examining the failure rate, which is the number of women out of 100 who will become pregnant within the first year of using a particular method. In fact, most contraceptives have two known failure rates: typical failure rate and perfect-use failure rate. o Typical failure rate is the typical number of people who become pregnant accidentally with a particular method, while the perfect use failure rate is the failure rate of a contraceptive method that is used regularly and correctly. o Hormonal injections are highly effective methods because fewer than 3 of 100 women using these methods become pregnant in a year. Barrier methods are only moderately successful in preventing pregnancy. o Human error is the most important variable when evaluating effectiveness. Issues that influence the effectiveness of available contraception include the user’s motivation, lack of partner involvement, forgetfulness, accessibility, and the inability to follow directions. • The prevention of STI transmission—If you are at risk, protecting yourself from an STI means using a condom in addition to any method of contraception every time you have sex. You can choose between a male or female condom to reduce your risk for STIs. • Your own health—If you smoke more than 15 cigarettes a day and are 35 or older or if you have a history of high blood-pressure, stroke, blood clots, liver disease or heart disease, you may not want to consider combined hormonal methods. If you have latex allergies, latex condoms or other latex barrier methods may not be an option. • Your comfort level—There are many contraceptive methods that require women to insert and remove them from their vagina. Women who are uncomfortable touching their bodies in this way need to gauge whether these methods would work for them. • Your own sexual behavior—In a committed heterosexual relationship, you may want to use a method that prevents pregnancy but does not prevent STIs. In a same-sex committed relationship, you may not need to consider any method. • There are many things to consider in choosing a contraception method. Table 7.1 summarizes the different types according to their ability to prevent STIs and pregnancy, the method’s effectiveness, cost, and the pros and cons of each. B. Methods That Protect Against Pregnancy and STIs • Abstinence and Fluid-Free Sexual Behaviors—Completely refraining from sexual intercourse in order to prevent pregnancy is called continuous abstinence. Religious groups, among others, endorse this method, particularly for unmarried individuals. o Selective abstinence means engaging in sexual behaviors that will not cause pregnancy or transmission of STIs and that do not involve vaginal, anal, or oral intercourse. These kinds of behaviors can include deep kissing, touching, and mutual masturbation with a partner. o One type of selective abstinence, fluid-free sexual behavior, means engaging in sexual behaviors that avoid the sharing or mixing of bodily fluids. Fluid-free sexual behavior excludes unprotected vaginal, anal, or oral intercourse. • Barrier Methods—Barrier methods generally work by preventing sperm from reaching an egg in the female reproductive tract. Condoms are the only barrier method that protects against STIs, including HIV. o Male condom—The male condom is a thin sheath made of latex, natural animal membrane, polyurethane, silicone, or other material that fits over the erect penis. During ejaculation, the condom catches semen and prevents it from entering the vagina, cervix, anus, or mouth. Figure 7.3 illustrates how to use a condom. o Female condom—The female condom, like the male condom, is made of latex or polyurethane. It resembles the male condom in appearance, but a woman wears it internally (Figure 7.3). C. Methods That Protect Against Pregnancy But Not Against STIs • Cervical barrier methods—Cervical barrier contraception methods use an object in combination with a vaginal spermicide to cover the opening to the cervix to prevent sperm from joining an egg. In the United States, four types of cervical barriers are available: diaphragm, cervical cap, Lea’s Shield, and FemCap. • Vaginal spermicides—Spermicides are creams, foams, gels, suppositories, and films that contain a chemical that is lethal to sperm. While spermicides can be used alone, they are most effective when used with barrier methods. Spermicides do not protect against STIs. • Hormonal Methods—Female hormonal methods of contraception alter specific characteristics of a woman’s ovulation cycle or reproductive tract. Hormonal methods prevent ovulation, thicken cervical mucus to prevent sperm from joining the egg, or alter the lining of the uterus to prevent implantation of a fertilized egg. o Currently, all available methods of hormonal contraception are designed for women, but there are some new research projects targeting male populations. o Oral contraceptives—The first oral contraceptive, or birth control pill, was introduced in 1960. There are two basic types of birth control pills: combination pills, named this because they combine estrogen and progestin, and the minipill, which contains progestin only. Birth control pills work in three ways: They prevent ovulation from occurring by changing a woman’s hormone levels. They thicken the cervical mucus to prevent sperm from joining the egg. They change the uterine lining to prevent implantation of a fertilized egg. There are three basic types of pills; they differ because of the levels of hormones in each type: Monophasic pill—contains 21 active pills that all contain the same level of hormones. Biphasic pill—contains 21 active pills with two different levels of estrogen and progestin. Triphasic pill—contain 21 active pills with three different hormone dosages. The progestin-only minipill contains no estrogen and is designed specifically for women who are breastfeeding, because the estrogen in combination birth control pills can reduce milk production. The minipills are also designed for women who have health conditions that prevent them from taking estrogen, including women who have a history of blood clots. Women need to be vigilant about taking their oral contraceptives at the same time every day. When pills are not taken consistently, the effectiveness of this contraceptive method declines. o Hormonal implants—The hormonal implant is a small tube of progestin that is inserted under the skin of a woman’s upper arm. Implanon is a single-rod hormonal implant that is inserted in about 1 minute and prevents pregnancy for 3 years. o Injectable contraceptives—Another method of administering contraceptives is through an injection of Depo-Provera to the hip or upper arm. The liquid contains a form of progestin called DPMA (medroxyprogesterone acetate), which prevents pregnancy in a manner similar to hormonal implants. o The patch—A patch is worn on the skin of the arm, buttocks, or abdomen that releases estrogen and progestin directly into the skin (brand name of Ortho Evra). Each patch contains a 1-week supply of hormones and releases a daily dose of hormones equivalent to a low-dose oral contraceptive. o The vaginal ring—The contraceptive or vaginal ring (brand name of Nuva Ring) is a flexible, transparent ring that is placed in the vagina. It delivers hormones similar to a combination oral contraceptive every day over a 3-week period. o Emergency contraception—Emergency contraception (EC) can prevent pregnancy after an instance of unprotected intercourse or when a condom or other barrier fails. Plan B is the most common form of EC and contains levonorgestrel. • Intrauterine Methods—An intrauterine device (IUD) is a small, T-shaped plastic device that a medical professional places in the uterus to prevent pregnancy. Figure 7.5 shows the correct placement of an IUD. o With a copper IUD, a small amount of copper is released into the uterus. Copper IUDs prevent sperm from reaching the egg by immobilizing the sperm on the way to the fallopian tubes. o With hormonal IUDs, a small amount of progestin or a similar hormone is released into the uterus. These hormones thicken cervical mucus to make it difficult for sperm to enter the cervix. o A woman using an IUD is always protected against pregnancy. IUDs begin working right away and can be removed at any time. o IUDs do not protect against STIs and women are at an increased risk for an STI during the first 4 months after insertion. IUDs are recommended mainly for women in monogamous relationships. • Surgical methods—Sterilization: One of the most widely chosen methods of contraception in the United States is sterilization, also referred to as voluntary surgical contraception (VSC). There are three methods of sterilization available for women and men today. For women, tubal ligation and a small metallic implant (called Essure) are two VSC methods. For men, it’s the vasectomy. While VSC is considered a permanent method of birth control, reversal (particularly vasectomies) is becoming increasingly common and successful. o In women, surgical sterilization is typically done by laparoscopy (Figure 7.6). Two small incisions are made in the abdomen in which a viewing scope and surgical instruments are inserted. o For a tubal ligation, the fallopian tubes are cut, tied, or blocked using a variety of techniques. This prevents fertilization by interrupting the passage of sperm or egg through the fallopian tubes. o Another VSC method is a metallic implant called Essure (Figure 7.7). This device works by causing scar tissue to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by sperm. o For men, a vasectomy involves making a small incision in the scrotal sac to reach the vas deferens, which are cut and then blocked at both ends (Figure 7.8). The blocked vas deferens prevents the passage of sperm into seminal fluid by blocking the vas deferens. • Fertility Awareness Methods—Of all the contraceptive methods available, fertility awareness methods, or natural methods, are the least successful ways to prevent pregnancy. These methods are based on abstaining from intercourse when a woman is fertile. One reason for their higher failure rate is that trying to determine when a woman is fertile depends on many factors. Usually, a woman is only fertile for about 1 day every month after an egg is released during ovulation. Sperm, however, can survive for 3 to 7 days in a woman’s reproductive tract. o The idea of fertility awareness methods is to learn when a woman ovulates and then to agree to abstain from intercourse for 7 days prior to and 1 day after ovulation to reduce the risk of pregnancy. Logically, this makes sense. The problem, however, is that knowing when a woman will ovulate is a complicated learning process that involves self-discipline, time, organization, and a willingness to become intimately familiar with one’s body and bodily fluids. In addition, these methods provide no protection from STIs. The names of three common fertility awareness methods are the Standard Days Method (SDM), the TwoDay Method, and the Basal Body Temperature Method. o The Standard Days Method is based on reproductive physiology. A woman’s fertile “window,” which are the days in the menstrual cycle when she can get pregnant, begins approximately 5 days prior to ovulation and lasts up to 24 hours after ovulation. Researchers at the Institute for Reproductive Health at Georgetown University have identified the fertile window in the woman’s menstrual cycle, using a computer simulation that takes into account the probability of pregnancy, probability of ovulation occurring on different cycle days, and variability in cycle length from woman to woman and from cycle to cycle. Their analysis found that avoiding unprotected sex on days 8 through 19 of the cycle provided maximum protection from pregnancy while minimizing the number of days to avoid intercourse. o The TwoDay Method, illustrated in Figure 7.9, is a fertility awareness–based method that uses cervical secretions as the indicator of fertility. This method instructs women to monitor daily the presence of secretions to know when pregnancy is most likely. o To use the Basal Body Temperature Method, a woman must take her basal body temperature (BBT) each morning before getting out of bed using a BBT temperature that measures to tenths of a degree and record it on a temperature graph (Figure 7.10). Basal body temperature is the lowest temperature attained by the body during rest (usually during sleep). After 3 to 4 months a woman should be able to predict when she is ovulating based on the fact that the temperature drops just prior to ovulation and rises and remains elevated for several days after. The temperature rises in response to increased progesterone levels that occur in the second half of the menstrual cycle. Couples must avoid intercourse on the day that the temperature rises and for 3 days after. III. Contraception and Sexual Well-Being • In 2010, the United States marked the 50th anniversary of the birth control pill. In this period of time the United States has seen an incredible increase in the varieties and effectiveness of contraceptive methods. • Contraception has been controversial in the United States since the 19th century, as politics blocked people’s access to sound pregnancy planning and sexual well-being. Politics has also strongly impacted how people participate in and receive sound reproductive decision-making information. • But research has shown that better sexual literacy and access to preventive health care for family planning is associated with a reduction in abortion. Advocates for contraception as a tool for public health and sexual well-being have two clear goals: greater access and more choice. • Due to the fact that so many of the available contraceptive methods are utilized by women (e.g., the pill, the patch, diaphragms), many wonder what is on the horizon for men. Currently, scientists are researching hormones like testosterone, progestin, and androgen to inhibit sperm production. • Whatever the approach, providing greater access to contraception and increasing effectiveness of existing methods requires continued research and development. Contraceptive decisions have a powerful impact on our sexual well-being because they help to ensure that we can protect our sexual health and maximize the pleasure we get from sex. Key Terms Contraception—any process or method used to prevent conception or pregnancy. Some contraceptive methods may also prevent the transmission of STIs Douching—a method of washing out the vagina or washing the penis Condom—popular barrier contraceptive device worn by either the male or the female Tubal ligation—a form of permanent, surgical contraception in which the fallopian tubes are tied, cut, or blocked to prevent egg and sperm uniting Vasectomy—a form of permanent, surgical contraception where sperm are prevented from mixing with semen in ejaculate by cutting or tying off the vas deferens Failure rate—the number of women out of 100 who will become pregnant within the first year of using a particular method Typical failure rate—the typical number of people who become pregnant accidentally utilizing a particular method Perfect-use failure rate—the failure rate of a contraceptive method used by people who utilize it regularly and correctly Withdrawal method—an unreliable method of contraception involving removing the penis from the vagina just prior to ejaculation Continuous abstinence—a form of contraception that involves completely refraining from sexual intercourse Selective abstinence—a form of contraception in which individuals avoid certain sexual behaviors that could lead to pregnancy or the transmission of STIs, such as vaginal, anal, or oral intercourse Fluid-free sexual behavior—sexual behaviors that avoid the sharing or mixing of bodily fluids, including unprotected vaginal, anal, or oral intercourse Male condom—a thin sheath made of latex, natural animal membrane, polyurethane, silicone, or other synthetic material that fits over the erect penis prior to intercourse Female condom—a thin sheath made of latex or polyurethane that is worn internally by a woman during intercourse Spermicides—substances that kill sperm cells. They can be used alone or together with a barrier method of contraception. Oral contraceptives—pills containing female hormones that are taken every day by women to prevent pregnancy; also known as birth control pills Hormonal implants—small tubes of progestin that are inserted under the skin of a woman’s upper arm. These implants can provide continuous protection against pregnancy. Emergency contraception (EC)—concentrated hormonal pills that can interrupt a woman’s normal hormonal patterns to protect against an unplanned pregnancy in the event of unprotected intercourse Intrauterine device (IUD)—a small T-shaped plastic device containing hormones or copper that is placed in the uterus to prevent pregnancy Sterilization, or voluntary surgical contraception (VSC)—a surgical alteration of the internal reproductive system of either male or female that permanently blocks sperm cells from fertilizing an ovum Laparoscopy—a surgical procedure whereby small incisions are made in the abdomen in which a viewing scope and surgical instruments are inserted to perform surgery Fertility awareness methods, or natural methods—contraceptive methods based on ovulation prediction and the viability of sperm; intercourse is timed to avoid fertile days in a woman’s reproductive cycle Basal body temperature (BBT)—the lowest temperature attained by the body during rest (usually during sleep) Instructor Manual for Human Sexuality: Self, Society, and Culture Gilbert Herdt, Nicole Polen-Petit 9780073532165, 9780077817527
