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278 CHAPTER 10
Historical and Social Perspectives
In what ways can contraception contribute to personal and societal
well-being in the United States and in developing countries?
Sharing Responsibility and Choosing a Birth Control
Method
What do both men and women have to gain by sharing
responsibility for birth control?
What should an individual or a couple consider in choosing a
method of birth control?
Hormone-Based Contraceptives
How do hormone-based contraceptives work? What are some risks
associated with their use?
Barrier and Spermicide Methods
What is the only method that provides protection from transmission
of sexually transmitted infections (STIs)?
What are some of the advantages of male and female condoms,
vaginal spermicides, and cervical barrier methods compared with
hormone-based contraceptives?
Intrauterine Devices
Why might a woman choose to use an intrauterine device (IUD)?
Emergency Contraception
What are the types of emergency contraception?
Fertility Awareness Methods
What are the four fertility awareness methods?
How do they work, and which one is most reliable?
Sterilization
What are the benets of vasectomy compared to female
sterilization?
Unreliable Methods
How reliable are breast-feeding, withdrawal, and douching as
methods of contraception?
New Directions in Contraception
What new contraceptive methods are being developed for men and
women?
278
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10
Contraception
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Contraception279 279
It’s a good thing that there are lots of birth control options, because I’ve used
different ones at one time or another. I did have the good sense to use the
sponge the first time I had intercourse, and I insist on condoms when I’m with
a new partner. I tried the combination pill and the minipill, then used an IUD
when I had a long-term boyfriend. I haven’t had any particular problems with
any of the methods, and I’m very grateful not to have had an unwanted preg-
nancy. But I do wonder if there will ever be a method I dont have to remem-
ber every day or use at the last minute and is 100% effective and reversible.
(Authors’ files)
Historical and Social Perspectives
People’s concern with controlling conception goes back at least to the beginning of
recorded history. In ancient Egypt women placed dried crocodile dung next to the
cervix to prevent conception. In 6th-century Greece, eating the uterus, testis, or hoof
paring of a mule was recommended. In more recent historical times, the 18th-century
Italian adventurer Giovanni Casanova was noted for his animal-membrane condoms
tied with a ribbon at the base of the penis. In 17th-century western Europe, vaginal
sponges soaked in a variety of solutions were used for contraception (McLaren, 1990).
Contraception in the United States
Although we may take for granted the variety of contraceptive, or birth control, meth-
ods available in the United States today, this situation is quite recent. Throughout
American history both the methods available for contraception and the laws concern-
ing their use have been restrictive. In the 1870s, Anthony Comstock, then secretary
of the New York Society for the Suppression of Vice, succeeded in enacting national
laws that prohibited the dissemination of contraceptive information through the U.S.
mail on the grounds that such information was obscene; these laws were known as the
Comstock Laws. At that time, the only legitimate form of birth control was abstinence,
and reproduction was viewed as the only acceptable reason for sexual intercourse.
Margaret Sanger was the person most instrumental in promoting changes in birth
control legislation and availability in the United States. Sanger was horried at the mis-
ery of women who had virtually no control over their fertility and bore child after child
in desperate poverty. In 1915 she opened an illegal clinic where women could obtain
and learn to use the diaphragms she had shipped from Europe. She also published
birth control information in her newspaper, e Woman Rebel. As a result, Sanger was
arraigned for violating the Comstock Laws. She ed to Europe to avoid prosecution but
later returned to promote research on birth control hormones, a project nanced by her
wealthy friend Katherine Dexter McCormack.
Sanger and McCormack wanted to develop a reliable method by which women
could control their own fertility (Tone, 2002). However, it was not until 1960 that the
rst birth control pills came on the U.S. market, after limited testing and research in
Puerto Rico. Fertility control through contraception rather than abstinence was a pro-
found shift that implied an acceptance of female sexual expression and broadened the
roles that women might choose (D’Emilio & Freedman, 1988; Rubin, 2010).
Prior to the 1965 U.S. Supreme Court ruling in Griswold v. Connecticut, states could
prohibit the use of contraceptives by married people (381 U.S. 479). e Court based
Critical Thinking Question
How does the belief that abstinence is the
only moral form of birth control play out
today?
Contraception
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280 CHAPTER 10
its decision to overrule states’ prohibitions on the right to privacy of married couples.
In 1972 the Supreme Court case Eisenstadt v. Baird extended the right to privacy to
unmarried individuals by decriminalizing the use of contraception by single people (405
U.S. 438). A 9% overall drop in the birth rate of 15- to 20-year-old women occurred
after access to the birth control pill became legal (omas, 2009).
In the ensuing years other laws governing contraceptive availability have continued
to change. In most states, laws now allow the dispensing of contraceptives to adolescents
without parental consent and permit pharmacies to display condoms, spermicidal foam,
and contraceptive sponges on shelves in the main store rather than behind the counter.
However, anti-contraception forces continue to engage in political battles on various
fronts to reduce access to contraception, as discussed in the Sex and Politics box, “e
Power of Pro-Life Anti-Contraception Politics.
Contraception as a Contemporary Issue
In the United States, 99% of the approximately 62 million women of reproductive
age have used contraception at one time or another (Jones & Dreweke, 2011). Fur-
thermore, the typical heterosexual woman may need some form of contraception for
30 or more years because she is only trying to become pregnant, or is pregnant, for a
small percentage of her reproductive life (Gold & Sonfield, 2011). The increase in
teenagers’ contraceptive use in the United States is very positive news. A significantly
larger proportion of teens are using contraceptives than did 20 years ago, even the first
time they have sexual intercourse. Of sexually experienced teens ages 15 to 19, 78% of
females and 85% of males used contraception the first time they had sexual intercourse
(Martinez et al., 2011). However, the United States continues to have among the high-
est rates of teen pregnancy, birth, and abortion in the developed world (Kaiser Family
Foundation, 2011). In Europe where teen pregnancy rates are much lower, govern-
ments support mass media public health messages to encourage the use of contracep-
tion, emphasizing both safety and pleasure (Alford & Hauser, 2011).
e availability and use of reliable birth control is desirable for a variety of reasons.
First and foremost, with contraception heterosexual couples can enjoy sexual intimacy
with minimal risk of unwanted pregnancies (May, 2010). Children are more likely to be
born to parents who are prepared for the responsibility of rearing them, and the ability
to space children at least 18 months apart increases newborn health (Conde-Agudelo et
al., 2006). Far fewer women than ever before have to decide to have an abortion. Eec-
tive birth control methods have also allowed women in the United States to become
equal partners with men in modern society. As a result of the increased earning power
of women, men have had opportunities unknown to their own fathers to expand their
involvement with their children.
Insurance coverage for contraceptive costs is an important variable in accessibility in
the United States. As of 2011, 28 states required insurers that cover prescription drugs
to provide coverage for contraceptive drugs and devices (Guttmacher Institute, 2011b). In
addition, following recommendations from the National Academy of Sciences, the Obama
administration required private health insurance plans written after August 1, 2012, to
cover all FDA-approved contraceptives for women without co-payments. Despite the fact
that 71% of U.S. voters support having health plans cover prescription birth control at no
cost, conservative Republican politicians and leaders of the Catholic Church quickly advo-
cated the elimination of the required coverage (Condon, 2012; Jervis, 2012; Pear, 2012).
Objections to contraception often stem from religious beliefs, and a few individuals
and couples do not use a birth control device because of their religion. Fully 88% of
voters in the United States support womens access to contraception, and most contem-
porary religious groups approve of and even favor the use of birth control (National
Margaret Sanger dedicated herself
to helping women and families have
every child be a wanted child.
© Bettmann/CORBIS
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Contraception281 281
Campaign to Prevent Teen and Unplanned Pregnancy, 2011). Despite the fact that
98% of Catholic women in the United States have used a contraceptive method, the
ocial doctrine of the Church continues to maintain that all birth control methods
other than abstinence and methods based on the menstrual cycle are immoral (Jones
& Dreweke, 2011). Many far-right Christians, self-described as pro-life, also oppose
contraceptive use, explained further in the Sex and Politics box, “e Power of Pro-
Life Anti-Contraception Politics.
Contraception as a Global Issue
Worldwide contraceptive use has increased dramatically in the last several decades:
An estimated 63% of partnered women of reproductive age practice contraception.
Unfortunately, the use of modern contraceptives by the poorest of the worlds poor in
developing countries remains low. For example, only 6% of married women in Nigeria,
compared to more than 70% in the United States and China, use birth control. About
215 million women across the globe are not using effective contraception (Reading,
2012). Tragically, millions of women and couples around the world are unable to exer-
cise their right to decide freely and responsibly whether and when to have children.
Each year in sub-Saharan Africa, South Central Asia, and Southeast Asia, 49 million
married and unmarried women have unintended pregnancies (Darroch et al., 2011).
Further, in these countries, a womans chance of dying from complications of preg-
nancy, childbirth, and abortion averages 1 in 65. Africas poorest nation, Sierra Leone,
has the worst rate: 1 in 8 mothers there dies in childbirth. In contrast, women in the
United States have a 1 in 4,800 chance of suffering the same fate (Anghelescu, 2008b).
For many years, the United States has contributed less of its gross national income
than European countries to help fund international contraceptive and reproductive
health services (Barot, 2009). However, following President Obama’s election in 2008,
his administration expanded funding and the scope of services supported by the United
States by 40% from the level a year earlier at the end of the Bush administration (Cohen,
2010). Services expanded to include comprehensive contraceptive and sex education
instead of abstinence-only programs, including a crucial shift to a broader view encom-
passing the impact of poverty, the rights of individuals, and gender equality, with an
emphasis on the interaction between these issues (Fritz & Spero, 2010).
Making contraceptives available to the men and women
throughout the world who desire to use them will enhance
the quality of their lives and help alleviate overpopulation. At
the end of the 20th century, worldwide population stood at
6.5 billion, compared with less than half that number—2.3
billion—in 1950. e United Nations projects an increase
to 8.9 billion by 2050. Of that growth, 95% is expected to
occur in poorer, developing countries whose populations
already exceed the availability of bare necessities: housing,
food, and fuel. When impoverished families have many
children, they cannot secure adequate food, health care, and
education for each child. Moreover, overpopulation (and
overconsumption of the world’s resources by developed
countries) poses a dire threat to the earths environment.
An essential factor in controlling population levels is to
expand womens access to education and economic opportu-
nity (Douglas, 2006). roughout the world, women with
higher levels of education have fewer children and are more
likely to use contraception (Saleem & Pasha, 2008).
Critical Thinking Question
What role, if any, did religion play in your
parents’ contraceptive use? In your birth
control decisions?
Critical Thinking Question
How are the limits to contraception access
gained by pro-life religious groups compatible
or incompatible with freedom of religion?
Nirmala Palsamy was named Heroine of the Planet in honor of her
work to educate women about family planning and birth control.
© Kapoor Baldev/Sygma/Corbis
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
282 CHAPTER 10
The Power of Pro-Life Anti-Contraception Politics
SEX &
POLITICS
Although the vast majority of U.S. citizens have a favorable
view of modern birth control methods, much of the pro-life
religious right opposes all contraceptive methods. Anti-
contraception religious groups do not see contraceptives
as a means of preventing abortion. Rather, they believe
that birth control itself is abortion or a gateway to abortion.
Abortion will never end as long as society accepts the
use of contraception” (
American Life League, 2011a, p. 1).
Far-right politicians and groups have attempted to estab-
lish “personhood” amendments
in the state constitutions of
Colorado and Mississippi. These
amendments dene a “person”
as every human being from the
moment of fertilization. Under
such amendments it could be
possible to make some con-
traceptives illegal (Khan, 2011;
Sheppard, 2011).
False claims about how
methods work appear to be a
thin veneer on pro-lifers’ over-
all opposition to birth control.
Even methods like condoms,
spermicides, and diaphragms
that prevent the egg and sperm
from reaching one another are
believed to offend God because
they prevent the conception of a
human being: “[A]ny act of sex-
ual intercourse must occur within
marriage and be open to . . .
procreative purposes” (
Ameri-
can Life League, 2004, p. 3). In
spite of the enormous personal
and public health benets of condoms, anti-contraception
abstinence-only groups—including Pro-Life America,
United for Life,
Physicians for Life, American Life League,
and the Vatican—have been engaged in a well-nanced
anti-contraception campaign. Many individuals and groups
who oppose contraceptive use embrace the traditional
role of women staying at home and raising children as an
ideal.
Therefore, they view access to contraception, with its
potential to help women expand their roles beyond obliga-
tory reproduction into traditional male realms of work and
politics, as a threat that they must combat (Quindlen, 2005;
Scheidler, 2006).
The political inuence of anti-contraception groups
increased during the administration of George W. Bush. Bush
appointed anti-birth control individuals to key reproductive
health, judicial, and scientic positions in the government,
and in attempting to achieve the goals of his far-right sup-
porters, his administration implemented many restrictive
policies and laws concerning reproductive health (Tummino,
2006). For example, anti-contraception forces succeeded in
reducing federal and state funding for contraceptive services
(Stevens, 2008). By 2006, funding for community clinics
that provide free or affordable birth control had declined
signicantly, leaving several million
low-income women without access
to contraception, in spite of the fact
that 73% of Americans believe that
access to birth control should not be
limited by inability to pay for it (Har-
ris
Poll, 2006).
During the recent economic
downturn, federally funded family
planning and
Planned Parent-
hood clinics have experienced an
increased demand for services due
to the increase in uninsured clients
and a decrease in clients who are
able to pay the full fee (National
Campaign, 2011). Beginning in
2009, funding for public family
planning services increased under
the Obama administration as part
of its “abortion reduction” strat-
egy (Gold et al., 2009). Increased
federal funding for contracep-
tive services did decrease rates
of unplanned pregnancies (Kost
et al., 2012).
However, since then
antichoice activists and politicians
have attempted to block federal funding for contraceptive
services.
This effort failed on the federal level, but several
state legislatures passed laws that severely limited or com-
pletely eliminated funding for family planning and Planned
Parenthood clinics, which has resulted in increased rates of
unintended pregnancies (
Ertelt, 2011; Gibbons, 2011; Kost et
al., 2012; Simon, 2012).
The sex-negative motivation behind
these kinds of activism was expressed by
Rick Santorum
during his bid to become the 2012
Republican presidential
candidate (Bettelheim, 2012; Volsky, 2011).
He pledged to
repeal all federal funding for contraception, claiming that
birth control devalues sexual union: “It’s a license to do
things in a sexual realm that is counter to how things are
supposed to be” (Begala, 2012).
UCLAs Fowler Museum exhibit, “Dress Up
Against AIDS, hoped to destigmatize condoms
and inspire their use to prevent AIDS. It fea-
tured 14 garments designed by Brazilian artist
Adriana Bertini, made entirely of condoms
rejected by industry quality tests.
J.P. Moczulski/Reuters/CORBIS
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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Contraception283 283
Sharing Responsibility and Choosing
a Birth Control Method
Each birth control method has its advantages and disadvantages. An individual or a
couple might find that one method suits a certain situation best (Gordon & Pitts,
2012). Sharing the responsibility enhances a particular method’s use.
It Takes Two
Research shows that more couples share contraceptive decision making now than in the
past (Grady et al., 2000). Sharing the responsibility of contraception can enhance a rela-
tionship and can be a good way to initiate discussing personal and sexual topics. Couples
who do talk openly about sex and birth control are more likely to use contraception
(Durex, 2008; Manlove et al., 2007). Failing to talk about birth control can cause women
to resent men for putting the entire responsibility on them. Furthermore, it is foolish for
a man to assume that a woman has “taken care of herself. As one male student asked,
If you have sex with a girl and she tells you she’s on the pill, how do you know
if she’s telling the truth? (Authors’ files)
Many women do not regularly practice birth control, and some use methods
inconsistently or incorrectly (Wilson & Koo, 2008). Not using contraception can
negatively aect both partners sexual experience and general feelings of well-being,
and dealing with an unwanted pregnancy is dicult. It is in the best interests of both
partners to be actively involved in choosing and using contraception (Montgomery et
al., 2008).
e rst step in sharing contraceptive responsibility may be for one partner to
ask the other about birth control before having intercourse for the rst time. Both
male and female college students need to develop skills to discuss contraception.
Women need to become eective in obtaining contraceptives, and men need to
learn to be assertive about refusing to engage in intercourse without eective con-
traception. Openness to using condoms or to engaging in noncoital sexual activi-
ties, whether as the contraceptive method of choice or as a backup or temporary
method, is another way for partners to share responsibility for birth control.
Choosing a Birth Control Method
Many forms of birth control are available to couples. However, an ideal
method—one that is 100% effective, completely safe, with no side effects,
reversible, separate from sexual activity, inexpensive, easy to obtain, usable by
either sex, and not dependent on the user’s memory—is unavailable now and in
the foreseeable future. Each current method has advantages and disadvantages
with regard to effectiveness, side effects, cost, and convenience (as summarized
in
Tables 10.1 and 10.2). It is a good idea to be familiar with the various meth-
ods available because most people will use several of them during their active
sex lives. In addition, a woman who is satisfied with her contraceptive method
is more likely to use it consistently and, hence, improve its effectiveness (Frost
& Darroch, 2008).
Copyright Pharmacists Planning Service Inc. (PPSI); e-mail: ppsi@aol.com
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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284 CHAPTER 10
At a Glance
TABLE 10.1 Factors to Consider When Choosing a Birth Control Method
Method Cost per Year for
100 Occurrences
of Intercourse
Advantages Disadvantages
Outercourse 0 No medical side effects; helps develop non-
intercourse sexual intimacy.
Risk of unplanned intercourse; no protection
from S
TIs.
Hormone-based methods
Estrogen-pro-
gestin pills,
including
Seasonale
$384–$516 ($32–
$43 per cycle)
Very effective. No interruption of sexual
experience. Reduces PMS and premen-
strual dysphoric disorder, menstrual
cramps, and ow. Improves acne. May
reduce migraine headaches associated with
menstrual cycle uctuations. Reduced risk
of ovarian, endometrial, and colon cancer.
No increased risk of stroke in healthy, non-
smoking women under age 35.
No protection from STIs. Slightly increased
risk of blood clot, especially in rst 2 years
of use. Increased risk of cervical cancer. May
increase migraine headaches. May suppress
some degree of normal bone mineral devel-
opment when used during adolescence.
Possible side effects of nausea, uid reten-
tion, irregular bleeding, decreased sexual
interest.
Progestin-
only pills
$384–$456 ($32–
$38 per cycle)
Very effective. No interruption of sexual
experience. No estrogen-related side
effects. Can be used during breast-feeding.
No protection from S
TIs. Breakthrough
bleeding. May worsen acne. Must be taken
same time each day to be effective.
Vaginal ring
(NuvaRing)
$580 Do not have to remember to take daily pill.
Consistent, low-dose release of hormone.
No interruption of sexual experience.
No protection from S
TIs. Increased vaginal
discharge.
Expulsion of ring. Not effective
for women over 198 pounds.
Skin patch
(Ortho Evra)
$580 Same as vaginal ring.
Higher incidence of blood clots than with
pill or ring. Slightly higher breakthrough
bleeding than with oral contraceptives. Skin
irritation. No protection from S
TIs.
Depo-Provera
injection
$132–$300 for 4
injections each
year
Very effective. No interruption of sexual
experience. Do not have to remember to
take on daily basis. No estrogen-related side
effects. Good choice during breast-feeding.
No protection from STIs. Breakthrough
bleeding. Weight gain.
Headaches. Mood
change. Clinic visit and injection every 3
months.
Lunelle $420 for 12 injec-
tions per year
Same as for Depo-Provera. May have
estrogen-related side effects. No break-
through bleeding.
Same as for Depo-
Provera, but clinic visit
and injection required monthly.
Implanon $130–$270 (initial
cost $400–$800,
but lasts for 3
years)
Offers longer protection than any other hor-
monal contraceptive.
Highly effective. No
need to remember to use daily or monthly
method. No estrogen-related side effects.
No increased cardiovascular risks.
No protection from S
TIs. May cause amen-
orrhea, irregular bleeding, spotting, and
headaches. Risks of progestin-related side
effects.
Progestin IUD
Mirena $35–$100 per
each of 5 years
(initial cost
$175–$500)
Very effective. No interruption of sexual
activity. Don’t have to remember to use.
Can be used during breast-feeding.
No protection from S
TIs. Increased risk of
pelvic inammatory disease for women with
multiple partners. Cramps. May be expelled.
Rare incidence of perforating the uterine wall.
Barrier and spermicide methods
Male
condoms
$100 ($1.00 each) Some protection from STIs. Available with-
out a prescription.
Interruption of sexual experience. Reduces
sensation.
Female
condoms
$400 ($4.00
each); 2nd
generation $200
($2.00 each)
Same as male condoms. Same as male condoms. Higher cost than
male condoms. Difculty inserting.
Vaginal
spermicides
$85 (85¢ per
application)
No prescription necessary. Interruption of sexual experience. Skin irrita-
tion. No protection from S
TIs. Not effective
enough to be used without a condom.
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Contraception285 285
Method Cost per Year for
100 Occurrences
of Intercourse
Advantages Disadvantages
Cervical barrier methods with spermicide
Diaphragm $15–$75 ($7.50–
$38.00 if used for
2 years); $85 for
spermicide
Some protection from bacterial S
TIs. Can
be put in before sexual experience. No side
effects. Decreased incidence of cervical
cancer.
Limited protection from S
TIs. Increased
urinary tract infections.
Requires practice to
use correctly. Can cause vaginal or cervical
irritation.
Cervical cap Same as
diaphragm
Same as diaphragm. No increase in urinary
tract infections.
Same as diaphragm.
Sponge $400 ($4 each) Same as diaphragm. No increase in urinary
tract infections.
Same as diaphragm.
FemCap $65 ($32.50
if used for 2
years); $85 for
spermicide
Same as diaphragm. Does not need to be
tted by health-care practitioner.
Has a loop
to assist removal.
Same as diaphragm.
Lea’s Shield $145 ($60 each,
replaced every
year); $85 for
spermicide
Same as diaphragm. Does not need to be
tted by health-care practitioner.
Has a loop
to assist removal.
Same as diaphragm.
Nonhormonal IUD
Copper-T
(ParaGard)
$15–$42 per
each of 12 years;
initial cost
$175–$500
Can be kept for 12 years. Don’t have to
remember to use.
Also used for emer-
gency contraception. Can be used during
breast-feeding.
No protection from STIs. Increased men-
strual ow and cramps. May be expelled.
Increased risk of pelvic inammatory dis-
ease for women with multiple partners.
Rare
incidence of perforating the uterine wall.
Sterilization
Tubal
sterilization
$1,500 – $6,000
Highly effective and permanent. Reduces
risk of ovarian cancer.
Transcervical ster-
ilization is safest and least expensive of
female sterilization procedures.
No protection from STIs. Not easy to
reverse for fertility. Discomfort after
procedure.
Vasectomy $350–$1,000 Easier procedure, less expensive, and lower
failure rate than female sterilization.
No protection from STIs. Not easy to
reverse for fertility. Discomfort after
procedure.
Fertility awareness
Standard
days method
0 Most effective of fertility awareness meth-
ods.
Acceptable to Catholic Church.
No protection from S
TIs. Uncertainty of safe
times.
Periods of abstinence from inter-
course or use of other methods.
Requires
careful observation and tracking.
Rhythm,
calendar, basal
temperature,
and cervi-
cal mucus
methods
0
Acceptable to Catholic Church. No medical
side effects.
No protection from STIs. Uncertainty of safe
times.
Periods of abstinence from inter-
course or use of other methods.
Withdrawal 0 No medical side effects. No protection from STIs. Interruption of
intercourse.
No method 0
Acceptable only if pregnancy desired. No protection from STIs.
SOURCES: Berenson et al. (2008), Berenson & Rahman (2009), Blumenthal et al. (2008), Halbreich et al. (2012), Hannaford et al. (2007), International
Collaboration of Epidemiological Studies of Cervical Cancer (2007), Jensen et al. (2008), Lurie et al. (2008), Mansour (2008), Merki-Feld et al. (2008), Nanda et
al. (2011), Panzer et al. (2006), Pikkarainen et al. (2008), Pitts & Emans (2008), Planned Parenthood Federation of America (2008), and Speroff & Fritz (2005).
At a Glance
TABLE 10.1 Factors to Consider When Choosing a Birth Control Method (continued)
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286 CHAPTER 10
TABLE 10.2 Effectiveness of Various Birth Control Methods
Method Failure Rate
a
if Used Correctly
and Consistently
Typical Number
a
Who Become
Pregnant Accidentally
Outercourse 0 0
Hormone-based methods
Estrogen-progestin pills, including Seasonale 0.3 8
Progestin-only pills 0.5 3
Vaginal ring (NuvaRing) 0.3 8
Skin patch (Ortho Evra) 0.3 8
Depo-Provera injection 0.3 0.7
Lunelle 0.05 0.2
Implanon 0.05 0.1
Progestin IUD 0.1 0.1
Mirena 0.5 0.1
Barrier and spermicide methods
Male condoms 2 1 7. 4
Female condoms 5 27
Vaginal spermicides 18 29
Cervical barrier methods with spermicide
Diaphragm with spermicide 6 16
Cervical cap
Woman has been pregnant 20 40
Woman has never been pregnant 9 20
Sponge
Woman has been pregnant 26 32
Woman has never been pregnant 9 16
FemCap 4 15
Lea’s Shield 6 18
Nonhormonal IUD
ParaGard 0.5 0.8
Sterilization
Tubal sterilization 0.5 0.7
Vasectomy 0.1 0.2
Fertility awareness
Standard days method 5 12
Rhythm, calendar, basal temperature, and cervical
mucus methods
9 20
Withdrawal 4 27
No method 85 85
a
Number of women out of 100 who become pregnant by the end of the rst year of using a particular method.
SOURCES: Graesslin & Korver (2008), Guttmacher Institute (2008a), Hutti (2003), Planned Parenthood Federation of America (2008), and Speroff & Fritz (2005).
Effectiveness
Contraceptive effectiveness is best evaluated by looking at the failure rate (the number
of women out of 100 who become pregnant by the end of the first year of using a par-
ticular method). Table 10.2 shows the failure rate when contraceptive methods are used
correctly and consistently; it also shows the rate of accidental pregnancies resulting from
improper or inconsistent use. The most important variable of method effectiveness is
failure rate
The number of women out of 100 who
become pregnant by the end of 1 year
of using a particular contraceptive.
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Contraception287 287
backup methods
Contraceptive methods used simul-
taneously with another method to
support it.
human error. Ignorance of the correct use of a method, negative beliefs about using a
method, lack of partner involvement, forgetfulness, or deciding that this one time wont
matter all greatly reduce effectiveness and increase the chances of pregnancy. Some
individuals eroticize or romanticize the risk of pregnancy (Higgins et al., 2008). In
addition, people who feel guilty about sex may be less likely to use contraception effec-
tively. Men and women who are uncomfortable with their sexuality are likely to take a
passive role in contraceptive decision making, leaving themselves vulnerable to whatever
their partners do, or do not do, about birth control. A woman may also be concerned
about whether her partner sees her as a nice girl” or as easy. A simple way to appear as
a nice girl” is to be unprepared with birth control (Angier, 1999). Unfortunately, that’s
also a simple way to have an unwanted pregnancy or contract an unwanted STI.
Using Backup Methods to Increase Contraceptive Effectiveness
About half of all unintended pregnancies occur among women using contraceptives
(Frost & Darroch, 2008). Unmarried women younger than 30 years old are most likely
to have a contraceptive failure, and married women older than 30 are least likely to do
so. In addition, low-income women experience greater failure rates than more-affluent
women, possibly because of limited availability of health care (Fu et al., 1999).
Under various circumstances, a couple may need or want to use backup methods
that is, more than one method of contraception used simultaneously. Condoms, contra-
ceptive foam, and the diaphragm are possible backup methods that can be combined in
many ways with other birth control methods for extra contraceptive protection (Peipert
et al., 2011). Circumstances in which a couple might use a backup method include the
following:
During the first cycle of the pill.
For the remainder of the cycle, after forgetting to take two or more birth con-
trol pills or after several days of diarrhea or vomiting while on the pill.
The first month after changing to a new brand of pills.
When taking medications, such as antibiotics, that reduce the effectiveness of
the pill.
During the initial 1 to 3 months after IUD insertion.
When first learning to use a new method of birth control.
When the couple wants to increase the effectiveness of contraception (for
instance, using foam and a condom together offers effective protection).
Which Contraceptive Method Is Right for You?
Effectiveness is not the only important factor in choosing a method of birth control. Many
additional factors—including cost, ease of use, and potential side effects—influence indi-
viduals and couples’ decisions about whether to use or to continue a particular birth control
method (Westhoff et al., 2007). Table 10.1 summarizes some of the most important fac-
tors: comparative expenses, advantages versus disadvantages, and possible side effects of
the most commonly used methods. The costs in the table are estimates because the price of
contraceptives can vary greatly; prices at Planned Parenthood and campus and government
health clinics can be considerably lower than standard pharmacy prices. The IUD is the
lowest-cost reversible method if a woman continues to use it for the allowed time period
(Trussell et al., 2009). Coverage of contraception by health insurance companies also helps
reduce costs, and some states have required that prescription benefits include birth control.
Further prescription benefits became available nationwide in August 2012. Regulations
established by the Obama administration required private health insurance plans written
after that date to cover all FDA-approved contraceptives for women without co-payments.
Another means of contraceptive
backup is to be prepared and have
emergency contraception on hand—
pills taken after unprotected sex.
National Institute for Reproductive Health
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288 CHAPTER 10
Answer yes or no to each statement as it applies to you
and, if appropriate, your partner.
1. You have high blood pressure or cardiovascular disease.
2. You smoke cigarettes.
3. You have a new sexual partner.
4. An unwanted pregnancy would be devastating to you.
5. You have a good memory.
6. You or your partner has multiple sexual partners.
7. You prefer a method with little or no bother.
8. You have heavy, crampy periods.
9. You need protection against sexually transmitted
infections.
10. You are concerned about endometrial and ovarian cancer.
11.
You are forgetful.
12.
You need a method right away.
13.
You are comfortable touching your genitals and your
partner’s.
14.
You have a cooperative partner.
15.
You like a little extra vaginal lubrication.
16.
You have sex at unpredictable times and places.
17.
You are in a monogamous relationship and have at
least one child.
Scoring
Recommendations are based on yes answers to the follow-
ing numbered statements:
• Combination pill and Lunelle: 4, 5, 6, 8, 16
• Progestin-only pill: 1, 2, 5, 7, 16
• Condoms: 1, 2, 3, 6, 9, 12, 13, 14
• Depo-Provera: 1, 2, 4, 7, 11, 16
• Cervical barrier methods: 1, 2, 13, 14
• IUD: 1, 2, 7, 11, 13, 16, 17
• Spermicides and the sponge: 1, 2, 12, 13, 14, 15
Which Contraceptive Method Is Best for You?
YOUR SEXUAL
HEALTH
Beyond the variables listed in Table 10.1, the decision about which birth control
method to use must take into account one more important factor: the individuals who
will be using it (Ranjit et al., 2001). e statements presented in the Your Sexual Health
box titled Which Contraceptive Method Is Best for You?” are designed to help you take
into account your own concerns, circumstances, physical condition, and personal quali-
ties as you make this very individual decision. We discuss a number of commonly used
contraceptive methods in the paragraphs that follow, and this more specic information
may help you make your choice.
“Outercourse”
This important method deserves special mention because it involves the decision to be
sexual without engaging in penile–vaginal intercourse. Noncoital forms of sexual intimacy,
which have been called outercourse, can be a viable form of birth control. Outercourse
includes all avenues of sexual intimacy other than penile–vaginal intercourse, including kiss-
ing, touching, mutual masturbation, and oral and anal sex. The voluntary avoidance of coitus
offers effective protection from pregnancy, provided that the male does not ejaculate near
the vaginal opening. Outercourse can be used as a primary or temporary means of prevent-
ing pregnancy, and it can also be used when it is advisable not to have intercourse for other
reasons—for example, following childbirth or abortion or during a herpes outbreak. This
method has no undesirable contraceptive side effects. However, it does not eliminate the
chances of spreading sexually transmitted infections, especially if it involves oral or anal sex.
Hormone-Based Contraceptives
In this section, we look at the most popular hormone-based birth control methods:
oral contraceptives, the vaginal ring, the transdermal patch, injected contraception, and
contraceptive implant.
outercourse
Noncoital forms of sexual intimacy.
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Contraception289 289
Oral Contraceptives
Oral contraceptives have evolved during 40 years of developing variations in the chemi-
cal structure and dosage of hormones, resulting in a wide range of choices. Oral con-
traceptives are the most commonly used reversible method of birth control by women
younger than 35 in the United States, and 80 % of women have used the pill during
their lifetime (Dempsey et al., 2011; Guttmacher Institute, 2008a). More than 100
million women worldwide use the pill (Blackburn et al., 2000). Four basic types of oral
contraceptives are currently on the market: the constant-dose combination pill, the
triphasic pill, the extended-cycle pill, and the progestin-only pill.
Placebo-controlled studies of oral contraceptives have found no signicant dif-
ference in side eects such as headache, nausea, breast pain, or weight gain. Bleed-
ing irregularity was correlated with the low-estrogen dose pills (Grimes & Schultz,
2011). Taking the pill does not interfere with subsequent ability to become pregnant
(Mansour et al., 2011). For most women who use them, oral contraceptives improve
overall health (Spero & Fritz, 2005). However, for about 16% of women, oral con-
traceptive use is not advisable (Shortridge & Miller, 2007): is percentage includes
women with a history of blood clots, strokes, circulation problems, heart problems,
jaundice, cancer of the breast or uterus, and undiagnosed genital bleeding. In addi-
tion, a woman who has a liver disease or who suspects or knows that she is pregnant
should not take the pill.
Women who smoke cigarettes or have migraine headaches,
depression, high blood pressure, epilepsy, diabetes or prediabetes symptoms, asthma,
or varicose veins should weigh the potential risks most carefully and use the pill only
under close medical supervision.
Table 10.3 describes rare but serious side eects of
the birth control pill.
The Pill: Four Basic Types
The constant-dose combination pill has been available since the early 1960s and
is the most commonly used oral contraceptive in the United States. It contains two
hormones, synthetic estrogen and progestin (a progesterone-like substance). The dos-
age of these hormones remains constant throughout the menstrual cycle. There are
more than 32 different varieties of combination pills, and each variety contains vari-
ous amounts and ratios of the two hormones. The amount of estrogen in pills has
decreased from as much as 175 micrograms in 1960 to an average of 25 micrograms
(Ritter, 2003).
SEXUALHEALTH
At a Glance
TABLE 10.3 Remember ACHES” for the Pill: Symptoms of Possible Serious Problems With the Birth Control Pill
Initial Symptoms Possible Problem
A Abdominal pain (severe) Gallbladder disease, liver tumor, or blood clot*
C Chest pain (severe) or shortness of breath Blood clot in lungs or heart attack
H Headaches (severe) Stroke, high blood pressure, or migraine headache
E Eye problems: blurred vision, ashing lights, or blindness Stroke, high blood pressure, or temporary vascular
problems at many possible sites
S Severe leg pain (calf or thigh) Blood clot in legs
*The risk of nonfatal blood clots among users of birth control pills containing drospireone is greater than that of pills containing levonorgestrel (FDA, 2011).
SOURCE: Adapted from Hatcher & Guillebaud (1998).
constant-dose combination pill
Birth control pill that contains a con-
stant daily dose of estrogen.
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290 CHAPTER 10
e triphasic pill, which has been on the market since 1984, is another type of
oral contraceptive. Unlike the constant-dose combination pill, the triphasic pill provides
uctuations of estrogen and progestin levels during the menstrual cycle. e triphasic
pill is designed to reduce the total hormone dosage and any side eects while maintain-
ing contraceptive eectiveness.
Another constant-dose pill on the market is called an extended-cycle contraceptive
because it is taken continuously for 3 months without placebo pills. e only brand on
the market, Seasonale, has a lower dose of estrogen and progestin than most other con-
stant-dose or triphasic pills. Seasonale reduces the number of menstrual periods to 4
instead of 13 per year, which signicantly benets women who have uncomfortable men-
strual symptoms during the placebo phase of using the combination pill (Kripke, 2006).
e progestin-only pill, which has been on the market since 1973, contains only
0.35 milligrams of progestin—about one third the amount in an average-strength com-
bination pill. Like the combination pill, the progestin-only pill has a constant-dose for-
mula. e progestin-only pill contains no estrogen and is a good option for women who
prefer or require a non-estrogen pill (Burkett & Hewitt, 2005).
How Oral Contraceptives Work
The estrogen in the combination, triphasic, and extended-release pills prevents con-
ception primarily by inhibiting ovulation. The progestin in these pills provides second-
ary contraceptive protection by thickening and chemically altering the cervical mucus
so that the passage of sperm into the uterus is hampered. Progestin also causes changes
in the lining of the uterus, making it less receptive to implantation by a fertilized egg
(Larimore & Stanford, 2000). In addition, progestin can inhibit ovulation. The pro-
gestin-only pill works somewhat differently. Most women who take the progestin-only
pill probably continue to ovulate at least occasionally. The primary effect of this pill
is to alter the cervical mucus to a thick and tacky consistency that effectively blocks
sperm from entering the uterus. As with the combination pill, secondary contracep-
tive effects are provided by alterations in the uterine lining that make it unreceptive to
implantation.
How to Use Oral Contraceptives
Several ways exist to begin taking oral contraceptives; a woman who does so should
carefully follow the instructions of her health-care practitioner. Unlike other oral
contraceptives that are taken in 28-day cycles, Seasonale is taken daily for 3 months,
followed by 7 days of inactive tablets before taking it for another 3 months. Some med-
ications reduce the effectiveness of oral contraceptives; these are listed in
Table 10.4.
Forgetting to take one or more pills sharply reduces the eectiveness of oral contra-
ceptives, as does taking the pill at a dierent time each day. Missing one or more pills can
lower hormone levels and allow ovulation to occur. A signicant number of women do
forget to take the pill each day. However, women underestimate how often they forget
their pills. A study that relied on electronic tracking of the time and date women took pills
from the container, rather than on user self-report, found that up to 50% of users missed
three or more pills per cycle, greatly reducing the contraceptive eectiveness of the method
(Potter et al., 1996). To help prevent missing pills, a woman can use a pill case with a built-
in clock and alarm to alert her at the same time each day if she has not taken her pill.
If you are using oral contraceptives and you miss a pill, you should take the missed
pill as soon as you remember and then take your next pill at the regular time. If you
forget more than one pill, it is best to consult your health-care practitioner. You should
also use a backup method, such as contraceptive foam or condoms, for the remainder
of your cycle.
SEXUALHEALTH
triphasic pill
Birth control pill that varies the dos-
ages of estrogen and progestin during
the menstrual cycle.
Seasonale
Birth control pill that reduces men-
strual periods to four times a year.
progestin-only pill
Contraceptive pill that contains
a small dose of progestin and no
estrogen.
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Contraception291 291
Deciding to discontinue using the pill requires thoughtful planning to prevent preg-
nancy. About 61% of unintended pregnancies are attributable to women discontinuing
the pill and adopting a less eective method or using no method (Dempsey et al., 2011).
The Vaginal Ring and the Transdermal Patch
NuvaRing and Ortho Evra are two hormone-based contraceptive methods that do not
require taking a pill each day. Both synthetic estrogen and progestin are embedded
in either a 2-inch-diameter soft and transparent vaginal ring (NuvaRing) or a beige
matchbook-size transdermal patch (Ortho Evra), as shown in
Figure 10.1.
How the Ring and Patch Work
Both NuvaRing and Ortho Evra release the hormones embedded in them through the
vaginal lining or skin into the bloodstream. The hormones then work in the same way
as the pill to prevent pregnancy. Women using the ring report fewer side effects than
do oral contraceptive users (Kerns & Darney, 2011).
How to Use the Ring and Patch
The ring is inserted into the vagina between day 1 and day 5 of a menstrual period. It
is worn inside the vagina for 3 weeks, then removed for 1 week and replaced with a new
ring. The ring can remain in place during intercourse, or it can be removed for up to 3
hours at a time without reducing its contraceptive effectiveness (Long, 2002).
In using the patch, a woman chooses a specic day of the week after a menstrual
period starts and identies that day as patch change day. She replaces the old patch
with a new patch on that same day each week for 3 weeks, followed by a patch-free
7-day interval. e patch can be placed on the buttock, abdomen, upper outer arm, or
upper torso.
TABLE 10.4 Medications That Reduce Oral Contraceptive Effectiveness
Some medications can reduce the effectiveness of birth control pills. Tell every
physician who gives you medication that you are taking oral contraceptives. Use
a backup method, such as foam or condoms, when you use any of the following
medications or herbal remedies.
Barbiturates Dilantin
Ampicillin Rifampin (for tuberculosis)
Tetracycline Phenylbutazone (for arthritis)
Tegretol St. John’s Wort
SOURCES: Markowitz et al. (2003) and Zlidar (2000).
Figure 10.1 The ring, left, and patch,
right, eliminate the need to remember
a birth control pill each day.
© J. Darin Derstine
© REUTERS /Landov
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292 CHAPTER 10
Injected Contraceptives
Depo-Provera is an injectable hormone-based contraceptive. It was approved by the
U.S. Food and Drug Administration (FDA) in 1992. Lunelle, another injected contra-
ceptive, was approved in 2000.
How Injected Contraceptives Work
The active ingredient in Depo-Provera is progestin, which inhibits the secretion of
gonadotropins and prevents follicular maturation and ovulation. These actions also
cause the endometrial lining of the uterus to thin, preventing implantation of a fer-
tilized egg. Progestin also alters the cervical mucus. Lunelle combines progestin and
estrogen, as do combination pills.
How to Use Injected Contraceptives
A health-care provider gives the Depo-Provera shot once every 12 weeks, ideally
within 5 days of the beginning of menstruation. It usually takes 10 months after stop-
ping Depo-Provera for a woman to get pregnant (Galewitz, 2000). Lunelle requires a
monthly injection, and fertility returns immediately after stopping injections.
Contraceptive Implant
Implanon is a matchstick-size slender rod 1⁄ inches long. It is inserted under the skin of
the upper arm and releases contraceptive hormones. Implanon had been sold in more than
30 countries since 1998 before it was approved by the FDA in 2006 for
use in the United States (Bridges, 2006). In developing countries, long-
acting methods play a critical role in providing effective contraception, and
efforts to reduce its cost and expand awareness of the method are essential
for more widespread use (Neukom et al., 2011; Tumlinson et al., 2011).
How the Implant Works
Implanon releases a slow, steady dose of progestin, and it prevents
pregnancy in the same ways as the progestin-only minipill. It may not
be effective for women more than 30% heavier than their medically
ideal weight.
How to Use the Implant
A medical practitioner inserts the rod in a quick surgical procedure
that requires only a local anesthetic. It is effective for up to 3 years, and
fertility usually returns quickly after removal of the device (Graesslin
& Korver, 2008).
Barrier and Spermicide Methods
Hormone-based methods cause changes in a womans body that inhibit
ovulation and implantation. Another group of contraceptive devices
works in a different way—by preventing sperm from reaching an ovum.
In this section, we look at condoms and four cervical barrier devices. In
addition, we include vaginal spermicides in this section because their
effect is also to prevent sperm from reaching an egg. Other than the con-
dom, barrier methods do not protect against STIs, including AIDS and
genital warts (Winer et al., 2006).
Couples can include the use of barrier contraceptives
in their sex play.
3660 Group Inc./CMSP
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Contraception293 293
Couples who use barrier methods can incorporate their
use into sex play instead of viewing them as an “interruption.
Either partner—or both—can put a condom on or insert a
female condom, cervical barrier device, or spermicide. Using a
barrier method can be an extension of erotic touching.
Condoms
A condom is a sheath that fits over the erect penis. It has a
long history. An illustration of a man wearing a condom was
painted on a wall in a cave in France 12,000 to 15,000 years
ago (Planned Parenthood Federation of America, 2002).
In 1564 an Italian anatomist, Fallopius, described a penile
sheath made of linen. Mass production of inexpensive mod-
ern condoms began after the development of vulcanized rub-
ber in the 1840s.
Condoms, also called prophylactics and rubbers, are the
only temporary method of birth control available for men and
the only form of contraception that eectively reduces trans-
mission of sexually transmitted infections, including AIDS
(Reece et al., 2010b). A study of 15-year-old students from
24 countries found that condoms were the most frequently
used method of contraception (Godeau et al., 2008). In the
United States, 80% of male and 69% of female sexually active
adolescents reported using a condom at last penile–vaginal
sex (Fortenberry et al., 2010). Signicantly, teens who use
condoms at their rst sexual intercourse are more likely to
continue their use and consequently have fewer sexually
transmitted infections than are teens who do not use condoms at their sexual debut
(Shai et al., 2007). Condoms are used twice as often with casual sexual partners as
with partners in established relationships (Reece et al., 2010b).
Condoms are made of thin surgical latex, polyurethane, or natural membrane (from
sheep intestines). However, natural-membrane condoms contain small pores that can
permit the passage of viruses associated with several STIs, including AIDS, genital her-
pes, and hepatitis. Some condoms have special features, such as being colored or avored,
having ribs to supposedly increase sensation, or incorporating a desensitizing agent on
the inside to help delay ejaculation. Some condoms have a small nipple at the end, called
a reservoir tip, and others have a contoured shape or textured surface. Most condoms
come rolled up and wrapped in foil or plastic, and they are lubricated or nonlubricated
(
Figure 10.2). Lubricated condoms are less likely to break than nonlubricated ones.
Condoms are available without prescription at pharmacies and grocery stores, from
family planning clinics, by mail order, in vending machines, and in school-based con-
dom programs. ey have an average shelf life of about 5 years (not all packages are
dated). Condoms should not be stored in hot places, such as the glove compartment of
a car or a back pocket, because heat can cause the condom to deteriorate.
How the Condom Works
When a man uses a condom properly, both the ejaculate and the fluid from Cowper’s
gland secretions (sometimes called precum or prejack in slang) are contained in the
tip. The condom thus serves as a mechanical barrier, effectively preventing any sperm
from entering the vagina.
condom
A sheath that ts over the penis and is
used for protection against unwanted
pregnancy and sexually transmitted
infections.
Figure 10.2 Condoms come in many varieties.
© Joel Gordon
A new condom called Sensis has two pull tabs that make putting
on a condom quicker and easier.
Europics/Newscom
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294 CHAPTER 10
How to Use the Condom
Correct and consistent use of the condom is essential for its effectiveness, but studies
of college students have found that user error is common. Putting a condom on after
vaginal penetration but before ejaculation is a common error that increases the risk
of pregnancy and STI transmission (Barclay, 2010). The Let’s Talk About It box dis-
cusses the importance of condom use and provides some suggestions for communicat-
ing more effectively about their use.
Condoms are available in dierent sizes. A man may benet from trying dierent
sizes to nd what ts him best, because poor t increases the likelihood of the con-
doms breaking or slipping o (Hollander, 2008b). Most condoms are packaged rolled
up. Correct use includes unrolling the condom over the erect penis before any contact
between the penis and the vulva occurs. Sperm in the Cowpers gland secretions (the
prejack) or in the ejaculate can travel from the labia into the vagina. For maximum com-
fort and sensation, an uncircumcised man can retract the foreskin before unrolling the
condom over the penis (Bolus, 1994). When using a plain-end condom (without the
reservoir tip), the end needs to be twisted before unrolling the condom over the penis,
as shown in
Figure 10.3. Doing this leaves some room at the end for the ejaculate and
reduces the chances of the condom breaking. In the unusual case that a condom breaks
or slips o during intercourse, contraceptive foam, cream,
or jelly should be inserted into the vagina immediately
(Walsh et al., 2004).
A condom breaks more easily without lubrication than
with it, so if the condom is nonlubricated, put some saliva
or water-based lubricant on the vulva and on the outside
of the condom before inserting the penis into the vagina.
Do not use oil-based lubricants, because they reduce the
condoms integrity and increase the chances of breakage
(Spruyt et al., 1998). See
Table 10.5 for a detailed list of
safe and unsafe lubricants to use with condoms.
Because the penis begins to decrease in size and hard-
ness soon after ejaculation, it is important to hold the
condom at the base of the penis before withdrawing from
the vagina. Otherwise the condom can slip o and spill
semen inside the vagina. Condoms are best disposed of in
the garbage rather than the toilet, because they can clog
plumbing.
The Female Condom
The female condom ( Figure 10.4) is made of polyurethane or latex and was approved
by the U.S. Food and Drug Administration in 1993 (Beksinska et al., 2011). It resem-
bles a male condom but is worn internally by the woman. In 2009 the FDA approved
the FC2 female condom, which is made of softer material for quieter use and is about
one-third less expensive than the original female condom, and since then other female
condoms have become available or are in development (Beksinska et al., 2011; Heavy,
2009). A flexible plastic ring at the closed end of the sheath fits loosely against the cer-
vix, rather like a diaphragm (discussed in the following section). Another ring encircles
the labial area. Although the female condom fits the contours of the vagina, the penis
moves freely inside the sheath, which is coated with a silicone-based lubricant. Used
correctly, female condoms can substantially reduce the risk of transmission of some
STIs and are of particular benefit for women in countries with high HIV rates (Center
for Health and Gender Equity, 2011).
SEXUALHEALTH
Figure 10.3 (a) The end of a plain-end condom needs to be twisted,
leaving space at the tip, before it is unrolled over the penis. (b)
A
condom with a reservoir tip does not need to be twisted.
Courtesy of San Francisco AIDS Foundation
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Contraception295 295
TABLE 10.5 Which Lubricants Are Safe and Unsafe to Use With Condoms?
Safe Unsafe
Water-based or silicone lubricants Aldara cream
Aqualube Baby oil or cold creams
Astroglide Bag Balm
Cornhuskers Lotion Edible oils (e.g., vegetable, olive, peanut, corn, sunower)
Water and saliva Body lotions
Glycerin Massage oils
All ID lubricants (except ID Cream) Mineral oil
Aloe-9 Petroleum jelly
H-R Lubricating Jelly Rubbing alcohol
K-Y Lubricating Jelly Shortening
Prepair Suntan oils and lotions
Probe Whipped cream
ForPlay Vaginal yeast infection creams and suppositories
Gynol II
Wet (except Wet Oil)
Silicone lubricant
DeLube
Vaginal spermicides
SOURCE: Adapted from Hatcher (2003).
Don’t Go Inside Without Your Rubbers On
LET’S TALK
ABOUT IT
The writers of a sex education book expressed their
strong distaste for anyone who still whines about using
a condom:
If we hear any more whining about how condoms are
annoying, uncomfortable deal breakers, we are going
to puke. Could it be you’ve been using nonlubricated,
inch-thick, ve-cent prophylactics from a vending
machine all your life? So condoms dont gure in
your full-on, esh-to-esh fantasy world—we get it.
Were also sure that oozing genital ulcers and child
support payments don’t pop up in that utopia either.
(
Taylor & Sharkey, 2003, pp. 182–183)
Women purchase 50% of condoms sold today. One
study found that refusing to have sex unless a partner
used a condom was the most common approach used by
college women to encourage condom use (De Bro et al.,
1994).
These facts represent good condom sense because,
along with unwanted pregnancy, women have much more
to lose than men when a couple does not use a condom.
A woman is much more likely to get an STI (including HIV/
AIDS) from one act of intercourse than is a man, and bacte-
rial S
TIs do much more damage to a woman’s reproductive
tract than to a man’s and can eliminate her subsequent
ability to have a baby.
The book Before You Hit the Pillow, Talk (Foley &
Nechas, 1995) offers suggestions for communicating about
condoms. Basically, be clear and assertive and do not get
drawn into an argument. Deciding beforehand that you
will not have intercourse without using a condom will give
your position the strength it needs. Some examples of
specic conversations follow.
Partner’s Statement Your Response
“I’m on the pill. You don’t
need to use a rubber.
“I’d like to use one any-
way, then we’ll be doubly
protected.
“It doesn’t feel as good
with a condom.
“It will still feel better than
nothing.
“It’s not very romantic. “Neither is pregnancy or
disease.
“I wouldn’t do anything to
hurt you.
“Great. Let me help you
put it on.
“I’d rather not have sex if
we have to use a condom.
Okay. What would you like
to do instead?”
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296 CHAPTER 10
Vaginal Spermicides
Several types of vaginal spermicides are available without a prescription: foam, sup-
positories, the sponge, creams and jellies, and contraceptive film (
Figure 10.5). Foam
is a white substance that resembles shaving cream. It comes in a pressurized can and
has a plastic applicator. Vaginal suppositories have an oval shape, and the sponge is a
Figure 10.4 (a) The female condom. (b) A female condom consists of two flexible polyurethane
rings and a soft, loose-fitting polyurethane sheath.
J. Darin Derstine
(a)
Applicator
Flexible
rings
Wrapper
(b)
Figure 10.5 Vaginal spermicides are available in pharmacies without a prescription.
Vagina
Uterus
Applicator
Spermicidal
foam
(a) Vaginal contra-
ceptive foam
J. Darin Derstine
(b) An applicator filled with foam is inserted into the vagina,
and the foam is deposited in the back of the vaginal canal
(c)
Vaginal contraceptive film (d) The contraceptive sponge
vaginal spermicides
Foam, cream, jelly, suppositories, and
lm that contain a chemical that kills
sperm.
J. Darin Derstine
J. Darin Derstine
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Contraception297 297
doughnut-shaped spermicide-containing device that absorbs and subsequently kills
sperm. VCF, a vaginal contraceptive film, is a paper-thin, 2-by-2-inch sheet that is laced
with spermicide. It is packaged in a matchbook-like container holding 10 to 12 sheets.
How Spermicidal Methods Work
Foam, suppositories, the sponge, creams and jellies, and VCF all contain a spermicide, a
chemical that kills sperm. When foam is inserted with the applicator, it rapidly covers
the vaginal walls and the cervical os, or opening to the uterus (see Figure 10.5). Con-
traceptive vaginal suppositories take about 20 minutes to dissolve and cover the walls.
One brand of suppository, Encare, effervesces and creates foam inside the vagina; other
brands melt. Once VCF is inserted into the vagina, next to the cervix, it dissolves into
a stay-in-place gel.
How to Use Vaginal Spermicides
Spermicides are less effective in preventing pregnancy than are most other methods,
so they need to be used with condoms. Complete instructions for use come with each
package of vaginal spermicide. For maximum protection, it is important to use the
product as directed. Another application of spermicide is necessary before each addi-
tional act of intercourse. In contrast, the sponge is effective for repeated acts of inter-
course and can be inserted up to 24 hours before intercourse. It is probably better to
shower rather than take a bath after sex when using a spermicide, to prevent the sper-
micide from being rinsed out of the vagina.
Cervical Barrier Devices
The practice of covering the cervix to provide protection from pregnancy has existed for
centuries. In 18th-century Europe, Casanova promoted the idea of using a squeezed-
out lemon half to cover the cervix, and European women shaped beeswax to cover the
cervix. In 1838 a German gynecologist took wax impressions of each patient’s cervix to
make custom caps out of rubber (Seaman & Seaman, 1978).
As shown in
Figure 10.6, the diaphragm, cervical cap, FemCap, and Leas Shield
are four methods combining a physical barrier that covers the cervix with vaginal sper-
micide to protect the cervix from contact with viable sperm. ese devices are dome
shaped, with a rim around the open side. e diaphragm covers the upper vaginal wall
from behind the cervix to underneath the pubic bone. e cervical cap ts over the
cervix only. e FemCap and the Leas Shield have rims that rest on the vaginal wall sur-
rounding the cervix and have removal straps. Unlike the other devices, the Leas Shield
allows a one-way ow of uid from the cervix to the vagina but prevents semen from
contact with the cervix.
How to Use Cervical Barrier Devices
The diaphragm and cervical cap are individually fitted by a skilled health-care prac-
titioner. The practitioner should also teach women how to insert it properly so that
they are confident about using it on their own (Hollander, 2006). In contrast, the
FemCap and Leas Shield do not have to be fitted. However, unlike the case in several
other countries, where they are available over the counter, they require a prescrip-
tion in the United States. All barrier devices are used with spermicidal cream or jelly
placed inside the dome of the cup and on the rim. Do not use oil-based lubricants
with a diaphragm or cervical cap because these devices are made of latex and will
deteriorate when used with oil-based lubricants. (The FemCap and Leas Shield are
made from silicone.)
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298 CHAPTER 10
To insert any of these barrier devices, squeeze the sides of the rim together with one
hand, and use your other hand to open the lips of the vulva, as shown in Figure 10.6e.
With the spermicide side up, push the device into the vagina. After you have inserted
it, you or your partner need to feel inside the vagina to make sure the dome covers the
cervix. Some women prefer to insert the dome ahead of time, in privacy, whereas others
share the insertion with their partners.
All cervical barrier devices should remain in the vagina for at least 8 hours to provide
time for the spermicide to kill sperm in the folds of the vagina. If intercourse occurs
again before 8 hours elapse, leave the device in place and apply additional spermicide
inside the vagina. Recommendations vary by method for the length of time before inter-
course for insertion and after intercourse for removal:
Hours Before Intercourse Hours After Intercourse
Diaphragm Up to 6 At least 8, no more than 24
Cervical cap Up to 6 At least 8, no more than 24
FemCap Up to 8 At least 8, no more than 48
Lea’s Shield Up to 8 At least 8, no more than 48
Figure 10.6 Cervical barrier devices.
Cream or jelly
Diaphragm
Squeeze spermicide into
dome of diaphragm and
around the rim.
Squeeze rim together;
insert jelly-side up.
Check placement to make
certain cervix is covered.
(a) Diaphragm (b) Cervical cap
(c) FemCap
(d)
Lea’s Shield
(e) Insertion and checking of a diaphragm
J. Darin Derstine
J. Darin Derstine
J. Darin Derstine
J. Darin Derstine
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Contraception299 299
To remove the diaphragm or cervical cap, put a finger under the front rim to break
the air seal, then pull the device out of the vagina. The FemCap and Leas Shield have
flexible loops for removal. After removal, wash the device with a mild soap and warm
water and then dry it. The diaphragm and cervical cap can last for several years, but
the FemCap and Leas Shield are usable for only one year. Take the device with you to
your annual exam and Pap smear so that your health-care practitioner can evaluate its
fit and condition. A pregnancy (including a miscarriage or an abortion) or a weight
change of more than 10 pounds may require a different diaphragm.
Intrauterine Devices
Intrauterine devices, commonly referred to as IUDs, are small, plastic objects that
are inserted into the uterus. The two IUDs are the ParaGard and Mirena (
Figure
10.7). The ParaGard is a plastic T with a copper wire wrapped around its stem and
copper sleeves on the side arms. Mirena is a polyethylene T with a cylinder containing
progestin (Akert, 2003). The IUDs have fine plastic threads attached; the threads are
designed to hang slightly out of the cervix into the vagina.
e IUD is the most common reversible contraceptive used by women in the develop-
ing world (Salem, 2006). About 6% of women in the United States use the IUD, and those
who do use this method are usually very pleased with it, as indicated by its 80% continu-
ation rate (how many women who start using a method are still using it one year later;
Nordqvist, 2011). is is a higher continuation rate than for pills, patches, rings, condoms,
or Depo-Provera (Hatcher, 2006). e IUD and implant are the only long-acting revers-
ible contraceptives (ompson et al., 2011). In addition, serious complications are rare
with the modern IUD (Campbell et al., 2007) and are described in
Table 10.6.
How the IUD Works
Both the copper and the progestin in IUDs are effective in preventing fertilization.
The ParaGard with copper seems to alter the tubal and uterine fluids, which affects
the sperm and egg so fertilization does not occur. Mirena has effects similar to those of
hormonal contraceptive methods such as the pill and Depo-Provera. It disrupts ovu-
latory patterns, thickens cervical mucus, alters endometrial lining, and impairs tubal
motility (G. Stewart, 1998).
IUD
Uterus
Vagina
Cervix
Applicator
(a)
(b)
Figure 10.7
(a) The Mirena IUD.
(b)
Position of the
IUD after insertion
by a health-care
practitioner.
© Julian Claxton/Phototake
intrauterine device (IUD)
A small, plastic device that is inserted
into the uterus for contraception.
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300 CHAPTER 10
How to Use the IUD
The IUD is inserted by a health-care professional using sterile instruments. The inserter
and IUD are introduced through the cervical os into the uterus; the inserter is then with-
drawn, leaving the IUD in place. The ParaGard can be in place for 12 years, and the
progestin IUD Mirena for 5 years (Planned Parenthood Federation of America, 2008).
A woman should be screened for gonorrhea and chlamydia before IUD insertion because
the procedure can carry bacteria associated with these STIs into the uterus. The use of
the IUD is best limited to women who are in monogamous relationships and do not have
other risk factors for sexually transmitted infections (Speroff & Fritz, 2005).
While a woman is using an IUD, she or her partner needs to check each month after
her menstrual period to see that the thread is the same length as when the device was
inserted. To do this, one reaches into the vagina with a nger and nds the cervix. e
thread should be felt in the middle of the cervix, protruding out of the small indentation
in the center. Occasionally it curls up in the os and cannot be felt, but any time a woman
or her partner cannot nd it, she needs to check with her health-care specialist. She
should also seek attention if the thread seems longer or if the plastic protrudes from the
os; this probably means that her body is expelling the IUD.
Emergency Contraception
What if a condom slips off, or a divorced couple is unexpectedly intimate (for old time’s
sake”) without birth control, or a couple runs out of condoms and uses only foam, or
a woman is raped while trying to walk to her car after a night class, or a woman is two
days late starting a new pack of pills, or a woman drinks too much at a party and has
unprotected sex, or a woman leaves her NuvaRing in longer than 5 weeks, or a couple
with a new baby have intercourse before they restart birth control? What if a woman is
one of the 54% of single, nonmonogamous women who do not use birth control every
time (Beil, 2009)? Studies indicate that each night more than one million women in the
United States who do not want to get pregnant have unprotected sex (G. Harris, 2010).
Fortunately, in these and numerous other situations, a possible pregnancy can be
prevented by using emergency contraception (EC). After unprotected intercourse,
a hormone pill, packaged as Plan B or Next Choice (
Figure 10.8); a nonhormonal
pill, Ella; or insertion of a ParaGard IUD are options for emergency contraception.
e IUD is the most eective in preventing pregnancy and can be inserted up to 7
days after unprotected intercourse. If the ParaGard IUD is inserted up to 5 days after
unprotected intercourse, it is over 99% eective in preventing pregnancy (Golden et al.,
2001). It is appropriate for women who plan to use the IUD as an ongoing method of
SEXUALHEALTH
At a Glance
TABLE 10.6 Remember “PAINS” for the IUD: Symptoms of Possible
Serious Problems With the IUD
Initial Symptoms
P Period late, no period
A Abdominal pain
I Increased temperature, fever, chills
N Nasty discharge, foul discharge
S Spotting, bleeding, heavy periods, clots
SOURCE: Adapted from G. Stewart (1998).
emergency contraception
Hormone pills or an IUD that can be
used after unprotected intercourse to
prevent pregnancy.
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Contraception301 301
contraception, but its use is limited to women who are at low risk of sexually transmit-
ted infections and pelvic inammatory disease (Long, 2002).
Plan B or Next Choice is the most commonly used method and is most eective
taken within the rst 24 hours after intercourse, typically 95% eective in preventing
pregnancy. Within 72 hours both are 75% eective, and even within 120 hours, they can
provide a small degree of protection from pregnancy (G. Harris, 2010; Piaggio et al.,
2011). Any woman or man, 17 years of age or older, can get Plan B or Next Choice by
asking a pharmacist (Wood et al., 2012). However, a pharmacist is not required by law
to dispense emergency contraception, and one study found that one in ve pharmacists
may refuse to give emergency contraception to young women (Szalavitz, 2012). Search
the website http://ec.princeton.edu for a pharmacy in your area that dispenses EC, or
call the telephone hotline at 1-888-668-2528.
In 2010 the FDA approved another emergency contraceptive, Ella, that works up to
5 days after unprotected sex. Ella, available only by prescription, is a nonhormonal pill and
contains ulipristal, a drug that blocks the eects of key hormones necessary for conception.
As shown in
Table 10.7, two or more oral contraceptives can be substituted if the
emergency contraceptive treatment is not available. ese hormone treatments work
primarily by inhibiting ovulation (Population Council, 2005). ey may also provide
secondary protection by altering cervical mucus and the lining of the uterus. When a
woman uses EC, she should also be aware of and watch for side eects similar to those
related to birth control pills.
Increased knowledge and use of EC could prevent an estimated 2.3 million unin-
tended pregnancies each year in the United States. A study of college students found
that only 16% knew EC was available at their college health center (Miller, 2011). Most
women are not aware that an IUD is a possibility for emergency contraception (Wright
et al., 2012). Studies at abortion clinics indicate that 50 to 60% of the patients would
have been treatable with and would have wanted to use emergency contraception rather
than have an abortion if they had known about it and had had access to it (Spero &
Fritz, 2005). Women in London, England, can order emergency contraception over the
Internet, and a courier will deliver it within two hours (Hope, 2012).
Fertility Awareness Methods
The birth control methods that we have discussed so far require the use of pills or
devices. Some of these methods have side effects in some users, and there can be health
risks associated with using oral contraceptives and the IUD. The barrier methods we
have looked at—condoms, vaginal spermicides, and the diaphragm—have fewer side
SEXUALHEALTH
Figure 10.8 Emergency contraception pills.
UPI Photo/Landov
© 2012 Watson Pharma, Inc. All rights reserved.
© Phanie/SuperStock
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302 CHAPTER 10
At a Glance
effects, but they require that the couple use them each time they have intercourse. In
the next paragraphs, we look at methods of birth control based on changes during the
menstrual cycle. These methods, which may answer some couples’ needs, are some-
times referred to as natural family planning or fertility awareness methods. They are
based on the fact that a fertile womans body reveals subtle and overt signs of cyclic
fertility that can be used both to help prevent and to plan conception.
ere are four dierent fertility awareness methods: the standard days method, the
mucus method, the calendar method, and the basal body temperature method. Any
of these can be used in combination to increase eectiveness (Frank-Hermann et al.,
2007). About 3% of Catholic women in the United States use natural family planning
(Jones & Dreweke, 2011). During the fertile period, couples using fertility awareness
methods can abstain from intercourse and engage in other forms of sexual intimacy
or can continue having intercourse and use other methods of birth control during the
fertile time (Gribble et al., 2008). Unfortunately, present research indicates that, other
than the standard days method, fertility awareness methods are considerably less eec-
tive than most other birth control methods (Jennings et al., 1998).
Standard Days Method
The standard days method is the newest approach to natural family planning. It is
appropriate for women who have menstrual cycles between 26 and 32 days long. Cou-
ples avoid unprotected intercourse on days 8 through 19 of each menstrual cycle. This
“fertile window” is 12 days long to take into account both the days around ovulation
and the possible variations in timing of ovulation from one cycle to another. The stan-
dard days method has been clinically tested and shows the highest rate of effectiveness
for natural family planning methods (Arevalo et al., 2002). A woman can keep track on
a calendar or use the CycleBeads shown in
Figure 10.9 to help track the days.
TABLE 10.7 Oral Contraceptive Pills for Emergency Contraception
Instead of Progestin-Only Plan B
Ovrette: 20 pills as soon as possible within 120 hours and 20 pills 12 hours later after unprotected intercourse
Estrogen-Progestin Alternatives
a
2 pills as soon as possible within 120 hours after unprotected intercourse and 2 more 12 hours later:
Ogestrel Ovral
4 pills as soon as possible within 120 hours after unprotected intercourse and 4 more 12 hours later:
Cryselle Levlen
Levora Lo/Ovral
Low-Ogestrel Nordette
Portia Seasonale
Seasonique
5 pills as soon as possible within 120 hours after unprotected intercourse and 5 more 12 hours later:
Alesse Aviane
Lessina Levlite
Lutera
a
In 28-day packs, only the rst 21 pills can be used. The last 7 contain no hormones.
SOURCE: Adapted from Princeton University, Ofce of Population Research & Association of Reproductive Health Professionals (2006),
Answers to Frequently Asked Questions About Emergency Contraception in the United States of America. Retrieved 2006 from the Emergency
Contraception website: http://ec.princeton.edu/.
fertility awareness methods
Birth control methods that use the
signs of cyclic fertility to prevent or
plan conception.
standard days method
A birth control method that requires
couples to avoid unprotected inter-
course for a 12-day period in the
middle of the menstrual cycle.
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Contraception303 303
Mucus Method
The mucus method, also called the ovulation method, is based on the cyclic changes of
cervical mucus that reveal periods of fertility in a womans cycle. To use this method, a
woman learns to read” the amounts and textures of vaginal secretions and to maintain
a daily chart of the changes. A woman reads her mucus by putting her fingers inside
her vagina and noting the consistency of the secretions:
After menstruation some dry days pass when no vaginal discharge appears
on the vulva.
When a yellow or white sticky discharge appears, unprotected coitus should
be avoided.
Several days later, the ovulatory mucus appears. It is clear, stringy, and
stretchy in consistency, similar to egg white. A drop of this mucus will stretch
between an open thumb and forefinger for at least 1/ inches before break-
ing. A vaginal feeling of wetness and lubrication accompanies this discharge,
which has a chemical balance and texture that help sperm enter the uterus.
Approximately 4 days after the ovulatory mucus begins and 24 hours after
a cloudy discharge resumes, it is considered safe to resume unprotected
intercourse.
e fertile period usually totals 9 to 15 days out of each cycle. In many cities classes
in the mucus method are oered at a hospital or clinic. Each womans mucus patterns
vary, and taking a class is the best way to learn how to interpret the changes.
Calendar Method
Using the calendar method, also called the rhythm method, a woman estimates the
calendar time during her cycle when she is ovulating and fertile. To use this method, a
woman keeps a chart, preferably for 1 year, of the length of her cycles. (She cannot be
using oral contraceptives during this time because they impose a cycle that may not be
the same as her own.)
The first day of menstruation is counted as day 1. The woman counts the
number of days of her cycle, the last day being the one before the onset of
menstruation.
To determine high-risk days, on which she should avoid unprotected
coitus, the woman subtracts 18 from the number of days of her shortest
cycle. For example, if her shortest cycle was 26 days, day 8 would be the first
high-risk day.
To estimate when unprotected coitus can resume, the woman subtracts 10
from the number of days in her longest cycle. For example, if her longest cycle
is 32 days, she would be able to resume intercourse on day 22.
Figure 10.9 CycleBeads, based on the standard days method, help
a woman track her menstrual cycle and know when she can and
cannot get pregnant. To use the CycleBeads, a woman moves a black
ring each day onto the next of 32 color-coded beads, which represent
fertile and low-fertility days.
J. Darin Derstine
mucus method
A birth control method based on
determining the time of ovulation by
means of the cyclical changes of the
cervical mucus.
calendar method
A birth control method based on
abstinence from intercourse during
calendar-estimated fertile days.
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304 CHAPTER 10
Basal Body Temperature Method
Another way of estimating high-fertility days is through temperature, using the basal
body temperature method. Immediately before ovulation the basal body tempera-
ture (BBT, the body temperature in the resting state on waking in the morning) drops
slightly. After ovulation the corpus luteum releases more progesterone, which causes
the body temperature to rise slightly (0.2°F). Because these temperature changes are
slight, a thermometer with easy-to-read gradations must be used. Special electronic
thermometers have been developed for measuring BBT and are effective in indicating
fertile times in the cycle.
Sterilization
Sterilization is the most effective method of birth control except abstinence from sexual
intercourse, and its safety and permanence appeal to many who want no more children
or who prefer to remain childless. Sterilization is the leading method of birth control
in the United States and around the world (Peterson, 2008). Although medical proce-
dures to reverse sterilization in both men and women can be performed, current rever-
sal procedures involve complicated surgery, and a subsequent pregnancy is uncertain
(Hsiao et al., 2012). Therefore, sterilization is recommended only to those who desire
a permanent method of birth control (Lawrence et al., 2011b).
Needless to say, sterilization should always be the decision of each individual or cou-
ple. Unfortunately, that has not always been the policy in the United States. In 1924 a
Supreme Court decision, Buck v. Bell, legalized forced sterilization as part of the eugen-
ics (good breeding) program in the United States. Continuing into the 1970s, more
than 30 states participated in the forced or coerced sterilization of 70,000 U.S. citizens.
Most victims were women, and more than 60% were African Americans. Some women
were sterilized without their knowledge after giving birth. Others were forced to choose
sterilization or termination of family welfare benets. e state ordered some steriliza-
tions for women it dened as lazy or promiscuous. To date, North Carolina is the only
state to issue a formal apology and to establish a commission to make amends to the
victims (Schoen, 2006; Sinderbrand, 2005). Since 2003 a North Carolina task force has
identied 48 of the estimated 2,000 victims still living and is working toward providing
monetary compensation for them and establishing a museum exhibit about the states
eugenics program (Goldschmidt, 2012; Kessel & Hopper, 2011).
Female Sterilization
Female sterilization has become a relatively safe, simple, and inexpensive procedure.
Approximately 25% of married women of childbearing age in the United States rely
on female sterilization as their method of contraception (Mosher & Jones, 2010).
Tubal sterilization can be accomplished by a variety of techniques that use small inci-
sions and either local or general anesthesia. A laparoscopy is shown in
Figure 10.10.
One or two small incisions are made in the abdomen, usually at the navel and slightly
below the pubic hairline. A narrow, lighted viewing instrument called a laparoscope
is inserted into the abdomen to locate the fallopian tubes. The tubes are then tied off,
cut, clipped, or cauterized to block passage of sperm and eggs. The incisions are gener-
ally so small that adhesive tape rather than stitches is used to close them after surgery.
Sometimes, in a procedure called a culpotomy, the incision is made through the back of
the vaginal wall.
basal body temperature method
A birth control method based on body
temperature changes before and after
ovulation.
tubal sterilization
Female sterilization accomplished by
severing or tying the fallopian tubes.
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Contraception305 305
Newer techniques do not require an operating room, general anesthesia, or much
recovery time (Lee-St. John & Gallatin, 2008). e procedure takes half an hour and is
performed using local anesthesia. During a transcervical sterilization, a physician inserts
a tiny coil, called Essure (shown in
Figure 10.11), made of polyester bers and nickel-
titanium alloy (the same material that is used to make articial heart valves), or a silicone
implant, called Adiana, into the vagina, through the cervix, and into the opening of each
fallopian tube in the uterus. Essure and Adiana promote tissue growth that, after 3 months,
blocks the fallopian tubes and prevents the ovum and sperm from meeting. Women and/or
their partners should use another form of birth control during those 3 months (Hollander,
2008c). e most common side eect is cramping; in rare cases the device is expelled or
perforates the fallopian tube.
Sterilization does not aect a womans repro-
ductive and sexual systems. Until menopause
her ovaries continue to release their eggs. e
released eggs simply degenerate, as do millions
of other cells daily. e womans hormone levels
and the timing of menopause remain unchanged.
Her sexuality is not physiologically changed,
but she may nd that her interest and arousal
increase because she is no longer concerned
about pregnancy or birth control methods.
Male Sterilization
Male sterilization is as effective as female ster-
ilization and has the advantages of being safer
and less expensive and having fewer complica-
tions following surgery. However, of people who
(a) Cross section (b) Front view
Small
intestine
Fallopian tube
Laparoscope
Cauterized
Tied and cut
Fallopian tube
Ovary
Uterus
Figure 10.10 Female sterilization by laparoscopic ligation. Front view shows tubes after ligation.
Figure 10.11 Essure, a tiny coil that
is used in female sterilization.
Courtesy of Conceptus Incorporated
transcervical sterilization
A method of female sterilization using
a tiny coil that is inserted through the
vagina, cervix, and uterus into the fal-
lopian tubes.
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306 CHAPTER 10
have sterilizations, less than half are men (Shih et al., 2011). Worldwide, 3% of women of
reproductive age rely on their partner’s vasectomy for contraception (Kols & Lande, 2008).
Vasectomy is a 20-minute minor surgical procedure, usually done in a physicians
oce, that involves cutting and closing each vas deferens, the sperm-carrying duct, so
that sperm are blocked from passing out the penis during sexual arousal and ejaculation
(
Figure 10.12). Under a local anesthetic, a small incision or puncture is made in the
scrotal sac, well above the testis. e vas is lifted out, and a small segment is removed.
e free ends are tied o, clipped, or cauterized to prevent rejoining. A man can expect
swelling, inammation, or bruising in the region of the surgery—an eect that lasts
from 1 day to 2 weeks. In one study, about 25% of men reported some brief pain follow-
ing vasectomy; a few from that group continued to experience discomfort for more than
3 months and required analgesics or medical attention (Rasheed et al., 1997).
A signicant number of sperm are stored beyond the site of the incision, and a man
remains fertile for some time after the operation. erefore, eective alternative meth-
ods of birth control should be used until semen analysis reveals no sperm in the seminal
uid. Many physicians recommend that a vasectomized man have a test for sperm 3
months after the vasectomy (Shah & Fisch, 2006). In 2008 the FDA approved Sperm-
Check, a test that can be used at home to determine infertility following vasectomy
(Kates, 2008). In rare cases the two free ends of the severed vas grow back together (this
is called recanalization; Stewart & Carignan, 1998).
Vasectomy does not alter production of male sex hormones. In addition, a vasecto-
mized man continues to produce sperm, which are absorbed and eliminated by his body.
e consistency and odor of his semen remain the same, and his ejaculations contain
almost as much volume as before, because sperm constitute less than 1% of the total
ejaculate. Some men avoid vasectomy because they fear that it will negatively aect their
sexual functioning (Kols & Lande, 2008), but many experience greater spontaneity and
pleasure when they are free from concern about impregnating their partners.
Unreliable Methods
Besides the contraceptive methods we have been discussing, others exist that are far
less effective and less commonly used. We mention some of them here because people
may have misconceptions about their effectiveness. We discuss nursing, withdrawal,
and douching as methods of birth control.
Nursing
Nursing a baby delays a womans return to fertility after childbirth when the baby is
only breast-fed. However, breast-feeding is not a fully reliable method of birth control
because there is no way of knowing when ovulation will resume. Amenorrhea (lack
of menstruation) usually occurs during nursing, but it is not a reliable indication of
inability to conceive. Nearly 80% of breast-feeding women ovulate before their first
menstrual period. The longer a woman breast-feeds, the more likely it is that ovulation
will occur (Kennedy & Trussell, 1998).
Withdrawal
The practice of the man removing his penis from the vagina just before he ejaculates is
known as withdrawal. It is ineffective because the preejaculatory Cowper’s gland secre-
tions can carry sperm that can fertilize an egg. Also, it may be difficult for the man to
(1) The vas deferens
is located.
(2) A small incision in the
scrotum exposes the vas.
(3) A small section of the vas
is removed, and the ends
are cut and/or cauterized.
(4) The incision is closed.
(5) Steps 1–4 are repeated
on the other side.
Figure 10.12 Male steriliza-
tion by vasectomy.
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Contraception307 307
judge exactly when he must withdraw, and his tendency is to remain inside the vagina
as long as possible, which may be too long. Any sperm deposited on the labia while
the man withdraws his penis can swim into the vagina. Both partners may experience
pleasure-reducing anxiety about whether he will withdraw in time (Whittaker et al.,
2010). One study found that almost 12% of sexually active 15-year-olds from 24 coun-
tries used withdrawal as their primary means of contraception (Godeau et al., 2008).
Douching
Although some women use douching after intercourse as a method of birth control, it is
ineffective. After ejaculation some sperm reach the inside of the uterus in a matter of 1
or 2 minutes. In addition, the movement of the water from douching may actually help
sperm reach the opening of the cervix. Furthermore, frequent douching is not recom-
mended because it can irritate vaginal tissues.
New Directions in Contraception
As we have seen in this chapter, potential health hazards and inconveniences are associ-
ated with available contraceptive methods. Unwanted pregnancies occur each year because
of contraceptive and user failure. We look at future possibilities for both men and women.
New Directions for Men
Current research has focused on methods designed to inhibit sperm production,
motility, or maturation or the sperms ability to join with the ovum—without causing
significant side effects or impairing sexual interest and function. The most promising
possibility is using various formulations of testosterone or a combination of progestin
and testosterone, which appears to work in 95% of men. Researchers are also attempt-
ing to develop nonhormonal contraception for men, including the use of medications
for other purposes that result in infertility (Belluck, 2011).
Research has shown that most men would use a male contraceptive pill if it were
available. Most women say they would trust their partners to use such a pill; only 2%
said they would not trust their partners to do so. In addition, men and women think
that a male pill is a good idea because the responsibility for contraception tends to fall
too much to women (Nieschlag & Henke, 2005). e “male pill will most likely, how-
ever, be administered by injection or implant, patches, or cream (Belluck, 2011).
Additional sterilization methods in clinical trials with human subjects in India, China,
and the United States may be more easily reversible than vasectomy. One involves injecting
a blocking gel into the vas deferens; to reverse the procedure, the gel can be dissolved. e
second method uses the Intra Vas Device, which consists of two plugs inserted into each
vas deferens; the plugs can be removed later. Implantation and removal of these devices
can be done in 20 minutes each (International Male Contraception Coalition, 2011).
New Directions for Women
Other new directions for women consist of variations on methods of delivery and for-
mulations of hormones in existing methods. A spray-on contraceptive may be added
to the choices of transdermal contraceptives, and a vaginal contraceptive ring used
continuously for one year is under development (Harrison-Hohner, 2010). Some of
the research on new contraceptive methods for women is focusing on nonhormonal
SEXUALHEALTH
vasectomy
Male sterilization accomplished by
cutting and closing each vas deferens.
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308 CHAPTER 10
means of birth control, including a contraceptive vaccine, a vaginal ring, and vaginal
spermicide with nonhormonal substances that block sperm motility (Brown, 2008; Z.
Williams et al., 2006). Possible new designs for IUDs include a reversible plug in the
oviduct that has been shown to be effective in preventing pregnancy in rabbits and has
a high rate of pregnancy subsequent to removal (Wang et al., 2011).
Hoping to provide women with STI and HIV protection that is under their own
control, researchers are studying spermicides that contain microbicides (substances that
stop STI transmission; Kerns & Darney, 2011). Research with these gels also includes
feedback from women about the consistency of gel that best enhances sexual pleasure
(Littleeld, 2011). (See Chapter 15 for a discussion of microbicides.)
Since the advent of the pill, contraceptive options have greatly increased. However,
the ideal of 100% eective, reversible contraceptives for men and women—methods
that also have no side eects and protect against sexually transmitted infections—will,
unfortunately, not be available anytime in the foreseeable future.
Summary
Historical and Social Perspectives
From the beginning of recorded history, humankind has
been concerned about birth control.
Margaret Sanger opened the rst birth control clinics in the
United States at a time when it was illegal to provide birth
control information and devices.
Objections to contraception stem from Roman Catholic
doctrine and far-right anti-contraception beliefs. However,
most church members in the United States approve of and
use some kind of articial contraception.
Sharing Responsibility and Choosing a
Birth Control Method
A man can share contraceptive responsibility with his female
partner by getting informed, asking a new partner about
birth control, accompanying his partner to her exam, using
condoms and/or coital abstinence if the couple chooses, and
sharing the expense of the exam and contraceptive method.
Comparison of convenience, safety, cost, and eectiveness
may inuence the choice of contraception.
People who feel guilty, have negative attitudes about sexual-
ity, and do not talk with their partners about contraception
are less likely to use contraception eectively than are people
who have positive attitudes about sexuality.
Hormone-Based Contraceptives
Four types of oral contraceptives are available. e constant-
dose combination pill contains steady doses of estrogen and
progestin. e triphasic pill provides uctuations of estro-
gen and progestin levels throughout the menstrual cycle.
e extended-cycle pill reduces menstrual cycles to four per
year. e progestin-only pill consists of low-dose progestin.
Advantages of oral contraceptives include high eectiveness
and lack of interference with sexual activity. Birth control
pills are also associated with lower incidences of uterine,
ovarian, and colon cancer. An additional advantage is reduc-
tion of menstrual ow and cramps. e advantage of the
progestin-only pill is the reduced chance of side eects from
estrogen. e vaginal ring (NuvaRing), the transdermal
patch (Ortho Evra), and the injectable Depo-Provera are
hormone-based contraceptives that do not require remem-
bering to take a pill each day.
Disadvantages of hormone-based contraceptives include
possible side eects such as a slight increase in the likeli-
hood of blood clots, an increase in migraine headaches,
nausea, uid retention, irregular bleeding, and reduced
sexual interest. Disadvantages of the progestin-only pill
include irregular bleeding and the possibility of additional
side eects. In general, the health risks of oral contraceptives
are far lower than those from pregnancy and birth.
Depo-Provera is an injectable contraceptive that lasts for 3
months.
Barrier and Spermicide Methods
Condoms are available in a variety of styles. Advantages
include protection from sexually transmitted infections
and availability as a backup method. Disadvantages include
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Contraception309 309
interruption of sexual activity if the couple do not incor-
porate its use into their sex play. A female condom has also
been developed.
Vaginal spermicides (including contraceptive foam, the
sponge, vaginal suppositories, creams and jellies, and contra-
ceptive lm) are available without a prescription. Advantages
of vaginal spermicides include lack of serious side eects
and added lubrication. Disadvantages include low level of
eectiveness unless used with a condom, possible irritation
of genital tissues, and interruption of sexual activity.
Advantages of cervical barrier methods include lack of side
eects, high eectiveness with knowledgeable and consis-
tent use, and possible promotion of vaginal health. Disad-
vantages include interruption of sexual activity, potential
irritation from the spermicidal cream or jelly, and possible
misplacement during insertion or intercourse.
Intrauterine Devices
ParaGard and Mirena are the only intrauterine devices
(IUDs) on the U.S. market. Advantages of the IUD include
uninterrupted sexual interaction and simplicity of use.
Disadvantages include the possibilities of increased cramp-
ing and spontaneous expulsion. Uterine perforation is rare.
e IUD increases risk of pelvic inammatory disease for
women with multiple partners.
Emergency Contraception
Plan B, oral contraceptives, and the ParaGard IUD can be
used for emergency contraception when a woman has had
unprotected intercourse.
e FDA denied over-the-counter status to emergency
contraception, against its committees recommendation.
Fertility Awareness Methods
Contraceptive methods based on the menstrual cycle—
including the standard days, mucus, calendar, and basal
body temperature methods—help in planning coital activity
to avoid a womans fertile period.
Sterilization
At this time sterilization should be considered permanent.
A decision to be sterilized should be carefully evaluated.
Tubal ligation is the sterilization procedure most commonly
performed for women. It does not alter a womans hormone
levels or menstrual cycle or the timing of menopause.
Vasectomy, the sterilization procedure for men, is not eec-
tive for birth control immediately after surgery because
sperm remain in the vas deferens above the incision.
Unreliable Methods
Breast-feeding, douching, and the withdrawal method are
not reliable methods of contraception.
New Directions in Contraception
Possible contraceptive methods for men in the future include
the use of hormones and nonhormonal methods to reduce the
production and motility of sperm or to create a dry orgasm.
Possible future contraceptive methods for women include
nonhormonal contraception, variations of the IUD, and new
methods for delivering hormones.
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Also access links to chapter-related websites, including
Margaret Sanger Papers Project, Successful Contraception,
International Planned Parenthood Federation, Birth Control:
How Hormones Work to Prevent Pregnancy, e National
Womans Health Information Center, New Male Contracep-
tives, When Timing Is Everything, and Condomania.
Media Resources
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