January 13, 2016 (C-Fam) — When it comes to family planning and international policy, there is no shortage of myths.
According to the most recent figures from UNFPA and the Guttmacher Institute, 225 million women in the world have an “unmet need” for family planning. Upon closer inspection, it isn’t really a need and isn’t really unmet at all, but for family planning advocates, the essential problem is this: there are women they (the advocates) think would benefit from contraceptive use, but they (the women) are not using them.
International standards – including agreed UN language – have long emphasized that family planning must be voluntary and not coerced. The 1994 International Conference on Population and Development held in Cairo agreed that:
“All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so.”
In other UN language, Millennium Development Goal 5B (stealthily tacked on a few years after the rest of the goals were formulated) aimed to “Achieve, by 2015, universal access to reproductive health.”
Bear in mind, that’s “access,” not “use.”
The concept of “unmet need” for family planning, as defined in the indicator from MDG 5B, is as follows:
“Women with unmet need are those who are [fertile] and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child.
The concept of unmet need points to the gap between women’s reproductive intentions and their contraceptive behaviour.”
Of importance here is the fact that “unmet need” does not imply any attempt to measure demand, access, or intent to use contraceptives. But that hasn’t stopped groups like the International Planned Parenthood Federation from wildly mischaracterizing the “unmet need” figure as a lack of access. Take, for example, this billboard they put up in New York City’s Times Square in 2014:
In the literature of family planning groups, voluntary non-use of modern contraceptives is never taken at face value. Instead, we hear about “barriers to use,” “lack of access,” and of course, “misinformation.” Perhaps the best illustration of how these groups think of women can be seen in this delightful graphic from the Population Council:
Notice that there’s no escape from the family planning machine here: women are drips that have to be piped back into the bucket from which they’ve escaped. They “need” to be in that bucket, whether they like it or not.
A new paper published by the Guttmacher Institute’s International Perspectives on Sexual and Reproductive Health examines some of the “negative myths and misconceptions” that the authors describe as “a barrier to modern contraceptive use.”
The study focused on several “myths” within the context of three African countries:
1. Use of a contraceptive injection can make a woman permanently infertile
2. People who use contraceptives end up with health problems
3. Contraceptives can harm your womb
4. Contraceptives reduce women’s sexual urge
5. Contraceptives can cause cancer
6. Contraceptives can give you deformed babies
7. Contraceptives are dangerous to women’s health
8. Women who use family planning/birth spacing may become promiscuous
9. Family planning/birth spacing is women’s business and a man should not have to worry about it
Apart from dismissively labeling those statements as myths, the authors did not attempt to fact-check them individually – which is unfortunate given that many of them are in fact true, with some caveats. Here’s a brief, and certainly not exhaustive, rundown:
- While injectable contraceptives are certainly not permanent in general, the United States Food and Drug Administration (FDA) does include “lack of return to fertility” among the adverse effects of the Depo Provera shot experienced by fewer than 1% of users. That’s not frequent, but the “myth” only claimed that the injection CAN make a woman permanently infertile, not that it often does.
- At the risk of being pedantic, people in general end up with health problems – as a side effect of being mortal. But the fact that modern contraceptives are linked to specific adverse health effects is hardly a myth (see some examples below.)
- Once again, this “myth” is written very broadly, but long-term use of oral contraceptives or IUDs have been found to make achieving a later pregnancy more difficult. Additionally, the FDA states that emergency contraceptives, like other oral contraceptives, “may prevent a fertilized egg from attaching to the womb.” Contraceptives that render the womb inhospitable to implantation could have an abortifacient effect – a matter which raises burdensome ethical questions and would undoubtedly be regarded as a “harm” by many women who are otherwise unopposed to using contraceptives.
- The fact that some contraceptives can reduce a woman’s libido is hardly the stuff of mythology, but this blog from Psychology Today lists among the Pill’s “potentially sex-impairing effects” the following item: “Loss of libido. Pill-induced androgen suppression can diminish or destroy erotic feelings.” This review gives a more measured view: not all women suffer this side effect, but some definitely do, and should be counseled accordingly.
- While causation is always harder to prove, it can certainly be said that some contraceptives are correlated with increased risk of certain forms of cancer, according to this summary from the US’s National Cancer Institute.
- I’m tempted to give them this one – a recent paper received a lot of news coverage for finding no link between oral contraceptives and birth defects, and reports saying otherwise are far from conclusive. But for a woman to have concerns about this issue is hardly unreasonable – for instance, the manufacturer of Depo Provera states, “It is not known whether medroxyprogesterone acetate can cause fetal harm when administered to a pregnant woman” in the latest revision of its US label. The bottom line is that it’s a lot easier to dismiss this concern as a mere “myth” when you’re not the drug’s manufacturer, and therefore less likely to be sued if new evidence of harm emerges.
- Once again, an extremely broad statement. As with any drug or medical device, there are risks involved, and those have to be explained to the patient for informed consent to be possible.
- The word “may” makes it very difficult to prove or disprove that particular “myth” – certainly not every user of contraceptives will become promiscuous, and not all promiscuous people use contraceptives. But as the author of the previously-noted Psychology Today blog says: “The Pill gives women total control over their reproduction, virtually eliminating anxieties about unintended pregnancy. This can feel freeing and boost sexual interest and energy.” Furthermore, the link between modern contraception and the movement for “sexual liberation” is not a matter of much dispute. As author and historian Nancy L. Cohen writes, “The Pill made possible the sexual revolution of the 1960s.”
- Fun fact about the “family planning is women’s business” notion: in 2011, the Guttmacher Institute published a paper on contraceptive technologies paying particular attention to the possibility of concealing the method from one’s partner. From the summary:” Investment in longer-term work is needed to discover and develop new modes of contraceptive action that do not cause systemic side effects, can be used on demand, and do not require partner participation or knowledge.” So much for collaboration between the sexes.
The bottom line: most of the statements the paper regards as “myths” are at least arguably true, some quite demonstrably so. But for the family planning lobby, some facts need to be withheld from women, because:
“Latent demand for family planning may be translated into actual use if programs can dispel false perceptions about contraceptives.”
That’s right: a voluntary, informed decision not to use contraceptives can be dismissed as concealing a “latent demand” for the same. And do family planning programs – which claim to be all about women’s empowerment – really want to use the argument that a woman’s “no” is meaningless because, really, deep down, she was asking for it?
So, are there false perceptions regarding family planning? Sure – the article helpfully quotes one woman who thinks the Pill “can accumulate into a life-threatening mass in the stomach, can cause blood to flow out of the nose and mouth, and can cause delivery of children with two heads and no skin.” Oddly enough, that was not included among the widely-believed “myths”…but you can probably find at least one person who believes just about anything.
But concerns about the health risks of contraceptives are widespread in regions with both low and high levels of contraceptive use, and as one 2014 article about “unmet need” points out:
“In high-use countries these concerns are more likely to be based on personal experience than on perceptions.”
Another point to consider: Demographic and Health Surveys (DHS) from 1986-1990 – prior to ICPD – found that among women with a purported “unmet need” for family planning, 4% cited lack of access to contraceptives, while 25% claimed a lack of awareness of methods. In more recent surveys ranging from 2006-2013, lack of access remains at similar levels (4-8%), while lack of knowledge has dropped to only 1-6%. This suggests that women today are better informed about family planning methods, and those refusing to use them are more likely to have made a conscious choice in that regard.
There is a lot of misinformation about contraceptives – but it’s the family planning groups who are perpetuating most of it. Furthermore, their ability to convince governments and other donors of a huge “latent demand” for their products translates into millions (if not billions) of dollars directed right into their coffers.
Some mythologies are just too lucrative to allow for any competing narratives.
Reprinted with permission from Turtle Bay and Beyond.