Adolescents, ACOG, and LARCs: Coercion or Choice?

via re: Cycling, where Laura Wershler expresses her disgust with “drug and device based birth control and its zealots.” According to Wershler, “birth control in the U.S. has become synonymous with drugs and devices. The pill, patch, or ring; Depo-Provera or hormonal implant; copper IUD or Mirena IUD; traditional hormonal birth control or long-acting reversible contraceptives. All impact the function of the menstrual cycle; some suppress it completely. As a pro-choice menstrual cycle advocate I take issue with the fact that keeping your cycle and contracepting effectively are now considered mutually exclusive.”

Wershler is especially concerned that  the American College of Obstetricians and Gynecologists now recommends Long-Acting Reversible Contraceptives (LARCS) such as hormonal implants and IUDs as the best birth control methods for teenagers. Wershler observes that “The research this recommendation is based on did not even study pregnancy outcomes for women using condoms, barriers, or fertility awareness methods. These methods were not among the free contraceptives offered to study participants. Another story reported that ‘the new guidelines say that physicians should talk about (implants and IUDs) with sexually active teens at every doctor visit. This sounds like a hardcore sales pitch to me.” According to Werschler, ACOG’s recommendation on LARCs as the best birth control methods for teens “is just a step away from coercive, patriarchal decision-making by doctors for teenage girls, and a threat to the sexual agency of many young women.”

Since we at Nursing Clio have been posting enthusiastically about giving adolescent girls more access to every available contraceptive method, Wershler’s words probably come across as something of a downer.  What’s not to like about LARCS?  After all, many women love this form of  birth control. IUDand nun New York Magazine published a glowing article on “IUD Evangelism” (illustration at right) in which current users spread the “good news” about how awesome this contraceptive method is:

““I sound like a ParaGard commercial sometimes,” begins a comment in one of the more than 4,700 IUD-related threads on Web searches reveal that getting an IUD is an occasion worth tweeting about. Jezebel writer and “part-time IUD evangelist” Jenna Sauers blogged her IUD insertion two years ago and recently proclaimed her enduring love for the device at a potluck brunch. ”

Now, these “IUD evangelists” came of age in the era after the Dalkon Shield debacle.  The Dalkon shield was an IUD manufactured by A.H. Robbins Company and introduced in the U.S. in 1971.  Tens of thousands of women suffered serious injury or death. In the U.S. alone, the device killed 17 and caused 200,000 women physical injury, infections, miscarriages and hysterectomies.

Rossssc2364Reproductive health activist Loretta Ross (left) drew on her own experience with the Dalkon shield to stress both her commitment to reproductive choice and her concerns about rushing new technologies to market. At age twenty-three, Ross decided to use the IUD while a student at Howard University because “I was not what they call a good contraceptor, because I’d just forget the things.” After becoming pregnant and miscarrying, Ross decided she was a good candidate for the Dalkon Shield. At first, Ross did not suffer any of the usual menstrual difficulties associated with Dalkon Shield use. She recalled, “I thought I’d been blessed. I thought it was the greatest birth control, effortless, thoughtless, birth control.” Unfortunately, the Dalkon Shield had a design flaw that made it easy for bacteria to enter the uterus. Three years after the device was implanted, Ross acquired a severe case of peritonitis and doctors performed a total hysterectomy to save her life. Ross’ experiences led her to become an activist for reproductive rights and anti-violence. She was one of the first women to win a suit against A.H. Robins, manufacturer of the device. In 1979 she became director of the D.C. Rape Crisis Center, the only center at the time run primarily by and for women of color.

During the late 1980s, while serving as Director of Women of Color Programs for the National rhtplogoIPOrganization for Women, Ross was part of a group of reproductive health activists who came together to form the Reproductive Health Technologies Project (RHTP). Their earliest efforts were aimed at bringing the medical abortion drug RU-486 (mifepristone) to the United States. Ross observed that many supporters of RU-486, “in their panic and desperation for more birth control options, have compromised their once-vigilant concern for women’s health.” Ross warned that this “atmosphere of excitement about a new option” had led some to trivialize or dismiss outright possible drug risks. “Women should have learned from our experiences with noninvasive treatments such as DES and the birth control pill,” Ross noted, “but in this struggle we have sometimes overlooked our history of being victimized by medical ‘solutions.’” Nevertheless, Ross agreed with RHTP that they needed to do something to combat anti-choice groups’ aggressive campaign against RU 486 by providing accurate, evidence-based information about this contraceptive method.

In the project I’m working on for my upcoming sabbatical, I argue that understanding this historical background is important because  there is a tendency  to focus solely on the enduring culture wars over abortion and reproductive rights. Consequently, the policy on this issue ends up being deadlocked by the rhetoric of the pro-choice and pro-life movements. For example, an article by members of the Reproductive Health Technologies Project have attributed the rise and fall of various new contraceptive technologies to conservative media portrayals that “interfere with the public’s ability to gain a nuanced and realistic understanding of the benefits and limitations of particular contraceptive methods.”

This interpretation ignores the ways in which the public shapes what “counts” as scientific knowledge. It also overlooks the specific historical circumstances that lead to the production of new knowledge, especially when this involves a politically controversial health topic. Most importantly, the article quoted above treats “the public” as though it were a homogenous entity, ignoring the multiple constituencies who have contributed to reproductive health policy and the ways in which their positions have changed over time.

obos73(1)Much has changed since the 1970s, when feminist health organizations such as the Boston Women’s Health Book Collective and the National Women’s Health Network protested against the dangers of contraceptive drugs and devices and the abuse of women by a nearly all-male medical profession.  Sandra Morgen shows that over the past thirty years, the concerns of feminists and other progressive health care activists “trickled up” to federal agencies responsible for public health and medical research.

Wershler ignores these recent developments as well as scientific advances that have made the latest contraceptive drugs and devices far safer than those of the past.  Wershler comes down particularly hard on the Contraceptive CHOICE Project, a study by researchers at Washington University School of Medicine in St. Louis. This study followed more  than 7500 participants who were free to choose, with all costs covered, from a range of contraceptives. The researchers then examined the contraceptive failure rates of various methods.  The key findings were that  “Women who used birth-control pills, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device (IUD) or implant.” The difference in effectiveness was even more marked for women under 21 who used  the pill, patch or ring. Their risk for unintended pregnancy with these methods, as compared with long-acting reversible contraceptives (LARCs), was almost twice as high as for older women.

So, my question is, what’s wrong with making the latest scientific information available to all women and then letting them choose for themselves? In her latest re:Cycling post, Wershler complains about the hype of LARC Awareness Week, billed by the California Family Health Council as “a chance to increase awareness about LARCs as a safe, effective, and long-acting birth control method.” Women were invited to contribute video messages on the theme Why I Love My LARC.LoveMyLARC__FINAL

Wershler encourages women to speak out about their negative experiences with LARCs and perhaps post Why I Hate My LARC videos on Youtube.  Fair enough.  But isn’t just as bad to criticize women who find these methods work best for them?  It’s all about choice, right?

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Laura Wershler

Heather, This is a provocative piece that adds to the discussion I’m trying to have about contraceptive choice-making. I totally agree with the idea that there is a “tendency to focus solely on the enduring culture wars over abortion and reproductive rights. Consequently, the policy on this issue ends up being deadlocked by the rhetoric of the pro-choice and pro-life movements.” What I find discouraging is exactly what you note – that the public is having trouble gaining “a nuanced and realistic understanding of the benefits and limitations of particular contraceptive methods.” Why? Because in the U.S. especially, there is such a fight to protect access and affordability of birth control, that the pro-choice community seems hesitant to formulate a critical analysis of the downsides of so many contraceptives, and the reasons women reject it. If you’ve read some of my other posts, you’ll see I’m adamant that pro-choice sexual health-care providers do a better job of serving women who don’t want drugs and devices. It’s time to commit to creating a new approach to helping women use barriers and fertility awareness methods effectively and confidently. That’s choice! It’s not enough anymore to say women want “easy” birth control. Maybe what we need, at least as one option, is slow, mindful birth control.

I hope you appreciate that in many respects I am trying to play the devil’s advocate with my push back on the hype about LARCs. I am not criticizing women who like them. Lucky them, though I don’t doubt for one minute that some who love their LARCs will also experience health issues related to them. I don’t believe that women, and especially teens, are getting full disclosure on the potential downsides of these methods. Nor are they getting accurate, comprehensive information on the health benefits of ovulatory menstruation. (ie. What you give up when you choose Mirena or Implanon.) Many women experience side effects they do not even realize are related to their birth control methods.

I am particularly concerned that women of all ages, and especially teens, may find it difficult to persuade their care providers to remove LARCs if they have problems. You can find lots of stories about this on blogs and forums. Women’s concerns about side effects are too often dismissed, and doctors are dissuading, or trying to dissuade, women from having them removed. Is this choice? Self-determination? This is a subtle abuse of authority. (You might be interested in Power in the Helping Professions by Adolph Guggenbuhl-Craig.)

Your research sounds fascinating. I hope to learn more about it.

Laura Wershler (no “c”)

Heather Munro Prescott

Thanks for your comments Laura and sorry for misspelling your last name! I’ve updated the post to correct that. Yes I do appreciate your perspective (that might not be clear in my post). It’s hard to have a nuanced conversation in this political climate.

Laura Wershler

Yes, it is difficult to have a nuanced conversation. Perhaps you and I can have some of those conversations. It’s always great to find someone willing to do so.

I meant to comment on the question you ask in your title: Coercion or Choice? I think the answer is some of both. BUT, when adolescents are concerned, I have to say that I don’t believe informed choice is happening in the way that I – as a veteran sexual and reproductive health advocate who has talked to scores of young women about this very thing – understand informed choice. I also think there is some kind of decision-making going on that exists between choice and coercion that we don’t fully understand. More nuance!

Heather Munro Prescott

Thanks for your comment. My first book was on the history of adolescent medicine so I’m sympathetic towards professionals in this field. During the 1960s and 1970s they put their jobs on the line (and in some cases risked arrest and jail time) to give teenagers access to contraception. Things are pretty tough for them now in today’s political climate. So, the suggestion that they are coercing teens doesn’t sit right with me.

Laura Wershler

Fair comment. I don’t think professionals do it either consciously or with malice, but I do think teens tend to do what their doctors/practitioners suggest they do. I’ve heard too many women in their 20s berate themselves for making uninformed choices about birth control in their teens. The bottom line is that many wish they’d known more about how their bodies work and more about the downsides of hormonal contraception. At the very least, they wish they had received more support from their doctors when they were searching for non-hormonal alternatives.

You mentioned the 60s and 70s. I often say that in the 60s and 70s women had to fight to get hormonal contraception. Today, women seem to have to fight NOT to take it.


I think it’s important to remember that young women, like most women, will never find a form of contraception that is without risk and without side effects. Pregnancy is not a benign complication of birth control failure. It carries significant risks, including hemorrhage, infection, seizure, stroke, loss of fertility, deep vein thrombosis, ectopic pregnancy, renal damage, immunocompromise, intractable vomiting, and death, all at higher risk than those related to any form of contraception.

I also take issue with the idea that teens are less-informed in their consent than are middle-class adult women. As said middle-class adult woman, I have never once had a clinician discuss risks of any form of contraception. As a clinician, I discuss risks thoroughly with my patients, who for the most part are younger than 25. The assumption that young women are less informed about the relative risks of contraception and pregnancy does them a disservice. They often come in armed with a great deal of information and excellent questions and concerns.

Laura Wershler

Then the young women who have you as their clinician are fortunate.

I’m speaking out for the ones who do not feel that they were adequately informed, and whose concerns about side effects are too often dismissed by their clinicians. Many women are actively discouraged from discontinuing drug- and devise-based methods. Yet it is their right to choose to do so, and I believe it is reasonable for them to expect support, information and services to use barrier and fertility awareness methods effectively and confidently. It is my belief, based on 25+ years experience as a member of the pro-choice sexual and reproductive health community, that women who do not want to use hormonal methods and those who self-select to use alternatives are not being adequately served.

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