Cultural assumptions create unbalanced risk assessment when the medical community weighs the risks and benefits of common contraceptive methods, the authors of a recent study concluded.1

Researchers studied contraception risks and assessed how these risks were prioritized in reproductive health providers’ understanding of contraceptives and their potential side effects.

“We were interested in how contraceptive counseling prioritizes effectiveness over side effects and reproductive autonomy,” says Andrea Bertotti, PhD, professor of sociology at Gonzaga University in Spokane, WA. “Why is effectiveness the most important thing, over side effects or women having autonomy? By autonomy, I mean that if you end up with LARC [long-acting reversible contraceptive] or sterilization, you don’t get to decide, daily, if you’re going to do that or not.”

Risk Assumptions

Bertotti breaks down risks into three categories:

  • Embodied risk. This is the risk that is contained in the patient’s body, including ovulation, menstruation, and pregnancy.
  • Medical risk. These are the risks of side effects from various contraceptive methods.
  • Lifestyle risk. This risk pertains to the choices people make, such as women not engaging in contraceptive self-management.

“We ultimately found that the reason contraceptive effectiveness ended up being more important is the underlying assumption about women’s bodies being risky,” Bertotti says.

This assumption included the idea, whether conscious or not, that it is better for individual women to put their bodies at risk from contraceptives than to experience the scourge of pregnancy. “Both are based on assumptions, and risk becomes illogical,” she adds.

For instance, the assumption that women’s bodies are risky does not consider the health benefits of pregnancy and breastfeeding. “Some of the benefits associated with hormonal contraception are also benefits of pregnancy and breastfeeding, and they don’t bring that into the risk-benefit analysis,” Bertotti says. “Some women would consider pregnancy is better than headaches, and some women are really concerned about side effects from contraception.”

Clinicians who have not considered this way of looking at contraception and risk-benefit analysis might have been influenced by gynecology textbooks, which are based on a particular set of paradigms. Women’s concerns about adverse contraceptive effects were often interpreted by providers as myths because what the women reported was inconsistent with their formal medical knowledge and their trust in the value of pharmacontraceptives.2

“The language in the medical textbooks undermines the side effects,” Bertotti says. “They’d say, ‘Here are the side effects, but it’s not that important.’”

Also, the language in medical textbooks creates a certainty for benefits of contraceptives and suggests doubt of side effects, she adds.

Investigators assessed the disparities in medical textbook language and how risks and benefits were described. “I don’t know what’s going on in the exam room; I don’t have that data, but the textbooks are framing it this particular way,” Bertotti explains.

Another illogical risk-benefit comparison is the assumption that any side effects of contraceptives are better than pregnancy. “What they’re doing is not distinguishing the risks, not doing a clear job of distinguishing the risks of mechanism of action,” Bertotti explains. “One mechanism of action could cause blood clots, while another mechanism of action — condoms — does not have any side effects, unless there’s a latex allergy.”

Data show that about two out of three women using reversible contraception rely on either short-acting hormonal methods or LARCs, such as hormonal intrauterine devices.2

Since a woman is more likely to become pregnant with condom use than from LARC or birth control pills, the condom is considered riskier because of the risk associated with pregnancy, although that does not take into consideration the risk of side effects, she adds.

“The current model of contraceptive counseling is very much about long-acting, as much as possible, because the goal is to avoid unintended pregnancy,” Bertotti says.

But the model does not take into account the historic — and even current — reproductive abuses that vulnerable women have experienced. As a sociologist, Bertotti has taught medical students about the historical context of reproductive coercive behavior.

“Assumptions embedded in our current situation that are rooted into behaviors of the past have placed us at risk of replicating that kind of coercive position as experts in medicine,” she explains. “This happens if you’re looking at someone as a statistic and not looking at them as individual people.”

One common assumption is that women’s reproductive choices have a huge impact on their lives. “There’s a little too much weight on what the rest of your life would be like if you get pregnant,” she says.

When people begin to consider the possibility that contraceptive side effects might be a worse outcome to some women than is pregnancy, they can assess, without bias, the risks and benefits of nonhormonal contraceptive methods, including those with less efficacy in preventing pregnancy, such as condoms, the withdrawal method, and natural family planning.

To improve patient care, providers need to look at people as individuals and gear counseling to their individual needs rather than viewing them as potential threats to society if they do not use contraception wisely, she adds.

Historical Abuses

The historical context is especially important to know. For instance, American history and its eugenics movement has many examples of federally funded programs that coerced sterilization of immigrants, people of color, poor people, unmarried mothers, the disabled, and the mentally ill.3

California performed about 20,000 sterilizations at state institutions in the 20th century, without the full knowledge and consent of the men and women involved. A report from The Center for Investigative Reporting found that California paid doctors $147,460, between 2006 and 2010, to perform tubal ligations on female inmates. More than one-quarter of the former inmates reported being coerced into the sterilization. Most of the women were Latino and Black Americans.3,4

“It’s not ancient history, and it’s not just the eugenics movement,” Bertotti says.

REFERENCES

  1. Bertotti AM, Mann ES, Miner SA. Efficacy as safety: Dominant cultural assumptions and the assessment of contraceptive risk. Soc Sci Med 2020;113547. doi: 10.1016/j.socscimed.2020.113547. [Online ahead of print].
  2. Bertotti AM, Miner SA. Constructing contentious and noncontentious facts: How gynecology textbooks create certainty around pharma-contraceptive safety. Soc Stud Sci 2019;49:245-263.
  3. Ko L. Unwanted sterilization and eugenics programs in the United States. Independent Lens. Jan. 29, 2016. https://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states/
  4. Johnson CG. Female prison inmates sterilized illegally, California audit confirms. Reveal. June 19, 2014. https://revealnews.org/article/female-prison-inmates-sterilized-illegally-california-audit-confirms/