A few weeks back I did an interview with Leslie Botha regarding the distribution of Depo Provera to women in developing countries. Recently Leslie shared with me an email she received from someone working in a family planning clinic in Karnataka, India. He described how he was providing the Depo Provera injection to women and finding that, after they stopped using it, they were not experiencing menstruation for up to nine months. He asked for advice – “what is the procedure to give them normal monthly menses….is there any medicine?”
I have written previously about one potential problem of providing women with Depo Provera – the possibility of continuous spotting and bleeding that would not only be distressing with no warning that this might happen and no medical support, but could also be difficult to navigate in a place with poor sanitation or with strong menstrual taboos. As women in developed countries are so very rarely counseled on side effects of hormonal methods of contraception, it seems unlikely women in developing countries receive such information. As we know, some women will instead experience their periods stopping entirely during use of the shot and, as we see from this email and from the comments on other posts written for this blog, long after use.
In this context I find it interesting that the Gates Foundation’s programs for contraception access have a very public focus on Depo Provera. The method was mentioned again by Melinda Gates in a recent TED interview and when she was interviewed as ‘Glamor magazine Woman of the Year’ the shot was front-and-center of the discussion of her work. Yet the Foundation also funds programs that provide support for menstrual management and sanitation. Continuous bleeding from the shot, or cessation of bleeding altogether, would seem to be an important connecting factor between these two campaigns.
Much has been written on the menstrual taboo in India and how this holds women back. In the US we have come to embrace menstrual suppression as great for our health and our progress as women. We see menstruation as holding women back in a variety of ways. However, in India could lack of menstruation also be seen as a positive outcome? Instead of dealing with the menstrual taboo with expensive programs that provide sanitary products and education, might suppressing menstruation entirely be seen as a far more cost-effective solution? It may seem like a stretch, but I am surprised this has not been brought up during debates about the need for contraceptive access in developing countries. Yet of course, the menstrual taboo may well extend to absence of menstruation – a woman who does not experience her period might also be treated suspiciously or poorly.
When Melinda Gates says women “prefer” and “request” Depo Provera I always wonder whether that’s after they’ve been told how it works (perhaps described as a six-month invisible contraception) or after they’ve had their first shot or after they’ve been on it for two years and then, via FDA guidelines, must find an alternative? How much follow up is there? As the self-injectable version is released widely how will women be counseled? Gates argues that the invisibility of the method is part of the draw as women do not have to tell their partners they are using contraception, but what happens when they bleed continuously or stop entirely?
It seems to me like there might be a real lack of communication – both between medical practitioners and their patients, drug providers and the practitioners, and those who fund these programs with everyone involved. It is often argued that the risks of pregnancy and childbirth in developing countries justify almost any means to prevent pregnancy – including the use of birth control methods that cause health issues. How much feedback are groups like the Gates Foundation getting on women’s preferences if they seem to be so unaware of the potential problems, even those that would greatly impact their wider work?
Guest Post by Lisa Leger
Posing while pregnant in my pro-choice T-shirt in 1993 was a political statement, one I made with a huge sassy grin on my face. When I recreated the pose recently on my daughter’s 21st birthday, I found it easy to reprise the grin. First take, in fact. My choice tee is well worn; it’s a house/jammy shirt that my daughter has seen me in her whole life. Little does she know that she’s had her nose wiped by a piece of Canadian history.
I bought the choice tee at a fundraiser in Toronto when the Ontario Coalition for Abortion Clinics was helping Canadian abortion rights crusader Dr. Henry Morgentaler with legal expenses when he was forced to defend in court his practice of providing safe abortions in a free-standing clinic. At the time, abortion was legal in Canada, but only if approved by a Therapeutic Abortion Committee and performed in a hospital. I was 27 years old, fresh from university, and a legal abortion had allowed me to finish my degree unburdened by an unplanned pregnancy, but I supported fewer restrictions to access.
Like most twenty-somethings, I had a long history of contraceptive use. I’d tried the pill, an IUD, and even the rhythm method, a fuzzy grasp of which I probably had picked up in a public school health class. I had a rotten attitude about my fertility, saw it as a huge hassle, and had no interest whatsoever in becoming a mother. My social and political opinions about the right to reproductive choice were fully formed when I bought this T-shirt for the cause I so ardently supported.
I was 32 years old when I posed in it while pregnant. By then I’d been charting my menstrual cycles for enough years to have improved my attitude about fertility dramatically. I’d met Geraldine Matus in the late 80s and learned to use the Justisse Method for Fertility Awareness that she developed. It changed my life forever; not only did I gain body literacy, develop a healthy relationship with my cycling body, and break free from contraceptive drugs and devices forever, I also gained a cherished mentor in Geraldine, and a career path as a Justisse fertility awareness educator that has sustained and gratified me for the past 25 years.
I took that picture in my choice T-shirt in 1993 because, for me, it says “I’m choosing to be pregnant.” I grinned because it was my choice to have Clair; I wasn’t scared or forced or coerced into that pregnancy. It was entirely my free will to lend my body to the great task of having a child and I made that choice because of the healing that had gone on over the years of charting, coming into relationship with my body, and learning to appreciate the awesomeness of my pro-creative power. Now that my daughter is 21 years old, I think about the freedom and choices she has as a Canadian woman in 2014, and feel sadness for those who don’t have that choice. I reflect on what a shame it is that these battles over reproductive choice, human rights, access to birth control, stigma, and power seem never to be put to rest. On Clair’s birthday, I posed in my choice T-shirt for my family archives and for those who still do not have choice.
Lisa Leger is a Holistic Reproductive Health Practitioner (HRHP) and women’s health activist on Vancouver Island. She serves on the board of the Society for Menstrual Cycle Research.
I’d given up reading the comments on online articles for the good of my mental health when a small slip last week steeled my resolve. In response to an article exploring the arguments made by “birth control truthers” a concerned father decided to have his say, taking the defensive arguments put forward by those in opposition to these “truthers” to their only logical conclusion:
“Perhaps we should market contraceptive pills as hormonal supplements to reduce cancer risk instead of as “contraception”? After all, it is only in modern times that women have hundreds of menstrual cycles throughout their lives. Even up until 1800 it was common for women to be either pregnant or lactating throughout much of their short lives.
The body simply wasn’t built to handle so many menstrual cycles, which raises the risk for cancer.
Who could argue with taking supplements to prevent cancer?
This may sound strange, but I am seriously considering putting my 11 year-old daughter on the pill (with no placebo) just for the health benefits. I just have to convince my wife first who is a little shocked by the idea…”
I cannot count how many times I have heard that the birth control pill “prevents cancer” – specifically “preventing” ovarian and endometrial cancer. In the last few months I have seen references to this benefit explained less and less so as a “lowered risk” and more and more so as a “preventative” action. I think this is significant as the word “prevent” suggests that the pill guarantees you will not get these forms of cancer. And yet, to remark that the pill is counted as a carcinogenic substance by WHO – due on the increased the risk of breast and cervical cancers – will get you tagged as a “truther.”
What is interesting, of course, is that despite the “cancer protecting” benefits of pregnancy, and early pregnancy at that, we do not see women encouraged to get pregnant in order to lower their risk of ovarian cancer. Criticism of child-free women does not generally include comments about their lax attitude towards their own health. The risk goes down further with every pregnancy and further still with breast feeding, especially breast feeding for a long period of time after birth. Women who have children young, and multiple children, have a lower risk of breast cancer than women who have no children or children after 30. Yet we see more talk of women having “too many” children at an age that is “too young” – in fact I was contacted via Twitter by someone who read this piece and who saw, in the comments, that one woman who uses natural family planning admitted to both liking the method and having 14 children. This admission disgusted the person who contacted me, even when I pointed out that it seemed the woman had very much chosen to have those 14 children.
It seems the people who are advocating prescription of the pill for cancer prevention purposes are not advocating women have children earlier, more children, or consider breast feeding for the good of their own health – in fact two of the loudest critics of my “birth control truther” book are vehemently against pregnancy and breast feeding being part of women’s lives (Amanda Marcotte and Lindsay Beyerstein). The risks of the pill are frequently compared to the health risks associated with pregnancy and child birth, but we don’t often hear women say they are choosing to not have children to avoid putting their health at risk for nine or so months.
Which leads me to this article in the LA Times that suggested nuns should also be on the birth control pill for its cancer-protecting abilities:
“And are the pills really unnatural? Our hunter-gatherer ancestors had their babies four or five years apart, because of long intervals of breastfeeding. As a result of that and their shorter life spans, they had as few as 40 menstrual cycles in a lifetime, while a modern woman can have 400. Though we can’t claim that today’s pills are perfect, their use is certainly less unnatural than enduring the hormone turmoil of hundreds of menstrual cycles.
I was curious. If Cameron Diaz’s purpose in writing The Body Book: The Law of Hunger, the Science of Strength, and Other Ways to Love Your Amazing Body was empowerment, helping women to understand how their bodies work, would she include information about the menstrual cycle?
There was no way of knowing from her Jan. 22, 2014 radio interview with Jian Ghomeshi on CBC’s Q. I listened to Diaz explain that conversations she’d had and overheard in the last few years made it clear to her that women are completely confused about their bodies. She said this had her thinking, “Wow, that’s such a crazy thing that after so many years of living in your body that you actually don’t have an understanding of it.”
Then she revealed her intention in writing the book – to empower women to make “informed decisions about their nutrition and their physical activity.” Judging from this comment, the book’s subtitle, and the fact she did not mention menstruation during the interview, I wondered if the menstrual cycle would even be mentioned.
I sought out The Body Book at my local bookstore and quickly scanned the table of contents and index. I found myself smiling, thinking about Betty Dodson, author of Sex for One: The Joy of Selfloving, and how she revealed in Chapter 1 that whenever she gets a new sex book she “immediately” looks up “‘masturbation’ to see where the author really stands on sex.” Whenever I see a new book about women’s health I look up “menstruation” to see what the author really knows about the menstrual cycle. Turns out Diaz, and/or her co-author Sandra Bark, know both a lot and not so much.
In Chapter 21, Your Lady Body (the book’s introduction starts with the salutation Hello, Lady!), she presents a fairly accurate endocrinological description of the three phases of the menstrual cycle: follicular, ovulatory, luteal. So far so good. But then, in the last paragraph of the luteal phase section, comes the big, fat menstrual untruth, the implication that whether you use hormonal birth control or not, this is how your menstrual cycle unfolds. It’s an absolute falsehood, and one that many women in this age of burgeoning body literacy are sure to see through.
The last paragraph of this luteal phase description (page 182) is ridiculously misleading. If a woman’s birth control method is the pill, patch, ring, implant or (Depo-) Provera shot, the synthetic hormones each contains will shut down her normal menstrual cycle function. She most definitely will not experience a cycle with follicular, ovulatory and luteal phases. Hormonal contraception does not “protect” her eggs. She will not ovulate, therefore the egg will not die. She may have a “withdrawal bleed” but it is not a true period. This is the truth.
I can understand, possibly, why Diaz made this egregious implication. What were her choices? Open a can of worms? State categorically, as every description of menstrual cycle function should, that you don’t ovulate or experience a normal menstrural cycle while taking hormonal contraception? Maybe something like this?
Hey Lady! If you use hormonal birth control none of this fascinating menstrual information applies to you. Wish I could tell you what this means for your health and fitness but, sorry, that’s beyond my area of expertise.
If Diaz’s intention for this book is to empower women to better understand their bodies, then she failed when it comes to the menstrual cycle. I hope she’ll correct this big mistake in any future editions.
A month ago I was musing about what it might be like to blog about fun stuff like food, fashion or travel – you know, topics not quite so “fraught” as the menstrual cycle. Sometimes it feels like just so much work sharing facts and opinions about why body literacy matters, why knowing how our cycles work and how ovulation impacts our health can lead us into meaningful, self-determined relationship with our bodies and ourselves.
But in the days leading up to Christmas, I was reminded by two young women, both of whom I’ve known since they were babies, daughters of friends, one in her late 20s, the other in her early 30s, why I do what I do.
The younger had contacted me last September, at the suggestion of her mother, with questions about switching birth control methods. She was fed up with the Pill, wanted to quit, was considering the Mirena IUD, told me about her history with ovarian cysts, irregular cycles. In a stable relationship, she hadn’t thought much about children. We talked about options. I assured her there were effective non-hormonal methods she could use, that by doing so she could assess her fertility, get her cycle functioning normally before making a decision about the Mirena. I sent her information about treatment – not involving hormonal contraceptives – for ovarian cysts; I asked a medical colleague questions on her behalf. She was thankful, emailing me that she had “some heavy thinking to do, including my actual timeline for children.”
I hoped to see her at her family’s annual Christmas party. We greeted each other briefly when I arrived, but not until the house was teeming with guests did we have the chance to talk privately amidst the holiday din. She told me she’d stopped the Pill three months before, could hardly believe how much better she felt, even though she’d yet to have a period. She thanked me, again, for validating her desire to quit the Pill. It so happened she had an appointment the next day with her family doctor; she knew what treatment she would request to help get her cycle started.
It did not go well. Her doctor, like so many I’ve heard about, was not interested in the menstrual cycle research she had done or the choices she wanted to make about her reproductive health. Quite the contrary: her doctor was hostile. It was disheartening for her, maddening to me, but not surprising.
A day later, at another holiday gathering, the other young woman stopped me in the hall to ask what I thought of the Mirena. She’d made the switch from the combined Pill (estrogen/progestin) to a progestin-only version to help with migraines. She offered that she and her partner had not yet decided about children, but she was concerned about leaving it too late. I told her the Mirena was intended as a five-year method, and if she was thinking she might want a child, it was a good time to stop hormonal contraception and assess her fertility before making a decision, either way.
I forwarded both women links to a naturopath skilled in menstrual cycle and fertility issues, and to a fertility awareness instructor who’d just announced her 2014 Eco-Contraception Program. The decision about what to do next, of course, will be theirs.
I sense both young women are searching for new, mindful connections to their bodies. Even if all I ever do is help a few such women find the support they need to make this connection, then to hell with food and fashion, I’ll keep writing about the menstrual cycle.
Questioning and quitting the pill are current hot topics, fueled in no small part by Holly Grigg-Spall’s recently released Sweetening the Pill Or How We Got Hooked on Hormonal Birth Control. Her book has drawn ample backlash, brilliantly addressed by re:Cycling blogger Elizabeth Kissling.
Adding to the media clamour was Ann Friedman’s New York Magazine online piece No Pill? No Prob. Meet the Pullout Generation which explores how and why women she knows are ditching hormones and depending on withdrawal and period tracking apps for birth control.
Both writers, along with Toronto freelancer Kate Carraway, recently discussed the topic Rebelling against the pill: ‘Pulling-Out’ of conventional birth control on CBC Radio-Canada’s The Current.
Listening to Grigg-Spall, Friedman, and Carraway discuss the pill rebellion affirms that while many young women are through with hormonal birth control, their transition off the pill, etc., is not without risk-taking and pushback.
Grigg-Spall nailed the pivotal point when she said “It’s a provider issue.”
The rise of the “pullout generation” is proof that sexual health-care providers and educators, among whom I count myself, have failed on two counts:
1) We’ve failed to address a key aspect of contraceptive use: how to transition successfully between method groups, in this case from hormonal to non-hormonal methods. We’d rather present the so-called “latest and greatest” hormonal methods and say – earnestly, pleadingly – try this! The CBC panelists provided strong anecdotal evidence that more and more women are having none of it.
2) We’ve failed to adequately acknowledge and serve women who can’t, won’t or don’t want to use hormonal methods. We are NOT providing across-the-board support and programs that include easy access to diaphragms or certified training in fertility awareness based methods (FABM), either onsite or through collaborative referral strategies.
For over 25 years I’ve advocated for increased access to information, support and services for women who want to use non-hormonal methods of birth control. It’s self-evident such services must include access to qualified instruction to learn FABM that have effectiveness rates over 99%. This is not to say there isn’t a place for withdrawal as an effective back-up. Check out this confessional how-to post by fertility awareness instructor Amy Sedgewick.
As Friedman said on The Current, women are intimidated by the idea of learning fertility awareness. I believe this is mostly because mainstream sexual health-care providers have never fully educated themselves about FABM or fully committed to presenting these methods as viable options to drugs and devises. Do they think that most women can’t or don’t want to learn fertility awareness skills? That would be like thinking most girls can’t or don’t want to learn to read.
As I’ve written elsewhere: “Fertility awareness, like riding a bicycle, is a life skill.”
If you can learn to swim, ski or snowboard, knit a sweater, read a balance sheet or master Adobe InDesign, you can learn to observe, chart and interpret your menstrual cycle events. We can all acquire body literacy.
Until sexual health educators and care providers develop programs to fully serve women who won’t use or want to stop using drugs and devises for birth control, we will continue failing to meet the growing “unmet need” for effective non-hormonal contraceptive methods.
The reign of hormonal birth control as the top-of-the-contraceptive-hierarchy gold standard appears to be coming to an end. The pullout generation represents just one thread in this transition. The questions is: Are sexual health educators and care providers paying attention and, if so, what are they going to do about it?
I had the privilege of writing the foreword for Holly Grigg-Spall’s recently published book Sweetening the Pill: Or How We Got Hooked on Hormonal Birth Control. It’s astounding to me that more than 30 years ago, before Holly was born, I was asking some of the same questions she explores in her book. I thought we’d have more answers by now, but one thing is certain: Holly’s book has prompted long-overdue discussion and debate about issues related to hormonal birth control. Below is my foreword to Sweetening the Pill.
In a letter dated March 22, 1980, I proposed to the editor of an American woman’s magazine that they consider my enclosed article: The Contraceptive Dilemma – A Subjective Appraisal of the Status of Birth Control.
“Recent articles (about birth control) deal almost exclusively with the basic pros, cons, and how-tos of the various contraceptives available – matter-of-fact discussions that reduce birth control to a mere pragmatic decision. If only that were the case.
Contraception, like the sexual interaction that necessitates it, involves our emotions as much as it does the facts. Yet the subjective, personal aspect of contraception is so often ignored. In this age of scientific research we are expected to (subjugate) our emotional reactions to significant probabilities, our anger to logic. Very real fears and earnest questions are dismissed as irrelevant….”
Although today I wouldn’t use the phrase “emotional reactions,” it’s hard to believe that three decades later, the status of birth control and women’s relationship to it has not much changed. Websites, not magazines, now host information about the basic pros, cons and how-tos of available birth control methods. And it is writers like Holly, half my age, who honour women’s real fears and ask earnest questions that are still being dismissed as mostly irrelevant.
Just as my personal story with the pill – including over a year of distressing post-pill amenorrhea – set me on a course of research and advocacy, so too has Holly’s personal experience. Sweetening the Pill explores and challenges the ways in which the pill and other drug-based contraceptives damage women’s health, threaten our autonomy and thwart body literacy. What we don’t know about our bodies helps pharmaceutical companies “sell” their contraceptive drugs, and keeps us “addicted” to them.
At some point between my first attempt at non-hormonal contraceptive advocacy and Holly’s exploration of how we’ve become hooked on hormonal birth control, something disturbing transpired. Prescribing the pill, or other forms of hormonal contraception, has become, in the minds of most health-care providers, the “standard of care” for being a girl. It is all too common to subjugate a girl’s menstrual cycle to synthetic hormones that superficially “regulate,” but actually suspend the maturation of her reproductive system. And for many girls, the use of hormonal contraception continues well into their 20s, without awareness of what might be or has been sacrificed.
There are many women like Holly who are fed up with hormonal birth control. I’ve met scores of them during my 30 years involvement within the mainstream pro-choice sexual and reproductive health community, the one that prides itself on inclusion and diversity. Yet I’ve been unsuccessful in my constant advocacy for this community to accommodate a more inclusive, diverse approach to contraception, to provide acknowledgement, support and services to women who cannot or do not want to use drug- or devised-based methods. We pay lip service to the idea, but the message we convey is: “You’re on your own.”
I’ve found enthusiasm in other realms for my menstrual cycle advocacy and my belief that many women want to, and can, learn to use non-hormonal methods effectively and confidently. I’ve found scientific evidence of the value of ovulation to women’s health and well-being.
I’ve read, met or worked with several of the sources included in this book. Many have devoted their careers to understanding women’s bodies and our relationships with our bodies in ways the medical mainstream typically ignores and barely comprehends. They have made contributions that help us imagine a different way of thinking about fertility, contraception and our menstrual cycles in relation to our sexual, reproductive and overall health.
It’s been more than 20 years since Susan Faludi first published Backlash (with the provocative subtitle, The Undeclared War Against American Women), her thorough documentation of the ways women and feminism were under attack in the U.S. The War Against Women has been now been openly declared in American politics, and there is a backlash among women in online feminism.
I’m referring to discussions of hormonal birth control; specifically, how and with whom we can criticize the birth control pill. Before she joined the re:Cycling team, Holly Grigg-Spall wrote a guest post for us titled, Why Can’t We Criticize the Pill? At the time, the title may have seemed a little overwrought, but now that her book criticizing the pill has reached the market and been reviewed in several online publications (including by some reviewers who refused to even read it), the question is more than apt. Lindsay Beyerstein’s review for Slate prompted some readers to start a petition asking the publisher to cease publication. Amanda Marcotte has written two posts on her blog slamming the book without reading it, and refused offers of a free copy so that she could respond accurately. Dr. Jen Gunter is also uninterested in reading it, labeling the book “that atrocious pill book” on Twitter and suspecting “a pro-life agenda”.
The criticisms of the book are many and inconsistent: (1) an assertion that Grigg-Spall claims the pill is bad because it is not ‘natural’, (2) since the pill was bad for Grgg-Spall, no one should take it; (3) the pill is sexist and therefore dangerous; (4) the pill is anti-feminist; and furthermore, (5) Holly advances all of these claims in service of a anti-feminist, anti-woman, anti-choice, pro-life, Christian right-wing agenda. That last one is particularly galling, as every time she speaks or writes about these issues, Holly prefaces her talk or mentions in her writing that she is atheist, feminist, and pro-choice. (She often also mentions that she’s British, and was raised with a very different health care system than those of us in the U.S., and thus held different assumptions about access.)
All of these criticisms are either factually incorrect, or exaggerated or deliberate misinterpretations of Holly’s actual arguments. For instance, while she does question what ‘natural’ cycles would be like if women didn’t take the pill, she does not assert that pill = unnatural = bad. Nor does she advocate banning or restricting the pill. She does locate the pill in a complex matrix of capitalist and patriarchal social structures that do not benefit women, which is not exactly the same as saying “the pill is sexist”.
As a feminist, a scholar, and as a reader of books, I’m both fascinated and frustrated by the criticism Sweetening the Pill has received. I’m appalled that reviewers would write and publish reviews completely panning a book they haven’t read, and then refuse to read it. As a feminist, I’m frustrated by apparent efforts to shut down dissent. The pill has never been more politicized in American life, and as I’ve asserted elsewhere, we cannot be so focused on preserving access that we’re willing to ignore questions of safety. Furthermore, it is not anti-feminist to disagree with one another. Feminism has a long history of proliferating and becoming more powerful by listening to dissent from within. Anyone remember the “Lavender Menace“? The emergence of intersectionality? As a commenter on one of the hack pieces eloquently put it,
The feminist critique of reproductive technology (including the pill’s discontents) are well established going back before the existence of the pill itself as debates with Sanger and colleagues. I’m sure this is widely taught in the Women’s Studies programmes you mention, it was to us even in A-level sociology.
I just don’t understand why you are pretending this is a new thing or that anyone taking these positions is a non-feminist. Are genuinely unaware of the history of your own movement or is this a crude rhetorical move against people you don’t agree with? Feminists (Seaman and Wolfson) provided critical testimony in the 1970 Senate Hearings, this is not some sort of obscure or secret fact, Wolfson’s outburst as to the constitution of the hearings and why drug companies were better represented than women is surely famous?
It seems to be the case you want to retro-actively kick Barbara Seaman out of feminism. You know, the woman that Gloria Steinem said was the prophet of the women’s health movement… with respect I don’t think you have the power and you don’t have an argument.
Feminism has always supported counter-intuitive critiques given that problems are multi-valenced. While Sanger held that reproductive control was an essential pre-condition of liberation, “who controls the control”, why and how are far more provocative questions.
Agree or disagree with Sweetening the Pill, or any other book, but read it for yourself, and form an opinion based on what the book actually says — not what a reviewer says or a 140-character criticism on Twitter suspects it might say. And think very carefully, and perhaps read it again, before you decide that it’s not feminism just because it doesn’t match exactly your feminism.
Why are media-based discussions about menstrual cycle advocacy vs. menstrual suppression, or hormonal birth control (HBC) vs. non-hormonal birth control (NHBC), so often fraught with conflict, suspicion and untested assumptions?
Because the opposing frames of reference are often considered to be an either/or dilemma, with “right” and “wrong” solutions according to our preferred position, rather than two ends of a polarity between which a dynamic range of positions fluctuate. We live with many common sense polarities, like rain and sunshine, knowing the right combination of both is in our best interests.
Please Don’t Judge Me for Skipping My Period, a recent post by Sarah Fazeli at Xojane illustrates the challenges in managing polarities. The title suggests the writer expects to be or has already been judged for her “wrong” decision, yet many of the 427 comments demonstrate the range of positions held on the issue.
At one end of the menstrual cycle polarity is my preferred position – based on experience, research and evidence-based medicine - that consistent ovulatory menstruation supports women’s bone, breast, heart, reproductive, sexual, psychological and overall health. HBC disrupts endocrine function and stops ovulation, impacting many physiological systems. Many women are choosing NHBC because they are HBC-intolerant and/or want to experience healthy menstrual cycles. I advocate for improved access to information, support and services to help them use NHBC effectively and confidently.
I understand how my position might be construed as an either/or dilemma, but in no way am I demanding HBC be banned, bullying women to stop taking their pills or alluding to anti-abortion views. Yet others make and act on untested assumptions that I and others who hold this position are doing some or all of these things.
So how might we all – advocates, health professionals, educators, journalists, bloggers and the public – talk about the menstrual cycle polarity in ways that create opportunities and commitment to work together to meet all women’s needs?
For answers I revisited my training manual in Contemplative Dialogue. In 2009, I took a four-day intensive workshop to learn about this process of engaging collective awareness to create “a deep experience of community where division or separation may have been the felt starting point.”
Contemplative means taking a long, compassionate look at the real; dialogue is the practice of creating shared meaning. Compassion is a key element because “it helps us get past the kind of guarded and defended reactions that undercut us doing things together.”
I refreshed my memory on how to avoid acting on untested assumptions. I thought about how I might become skilled enough to back not just myself but other people down Chris Argyris’s “ladder of inference” in a non-threatening way to resolve misunderstandings and create shared meaning.
Contemplative Dialogue also incorporates into its process Barry Johnson’s work in managing polarities. In emotional debates it helps if we can learn to speak across polar values.
This process calls for me to identify both my preferred value and the opposite value. In dialogue I first acknowledge the upside of the opposite value followed by the potential downside of my preferred value. Keeping my language fair and non-pejorative, I then speak of the downside of the opposite value that I fear. Finally, I get to talk about the upside outcomes to my preferred value that I’m striving for.
I want to keep talking about these issues, but I’m not up for a range war, a spilling of metaphorical menstrual blood to determine who holds the higher ground or owns the greater truth. I’m committed to practicing contemplative dialogue to bridge the divisions between the two ends of the menstrual cycle polarity.
Recently, in a piece for the Ms. Magazine blog, re:Cycling’s Elizabeth Kissling remarked on the lack of media coverage of serious safety issues with the popular birth control pill brands Yaz and Yasmin. Of the coverage there has been, little has looked beyond the significant number of injuries and deaths caused by blood clots to the potential dangers held in the negative psychological impact of these drugs, an impact that it appears a large number of women may have experienced.
As I read the stories of women who had suffered strokes or gone blind, I wondered how many women using Yaz or Yasmin had also been driven close to death, or perhaps even died, due to the depression the pills can provoke.
I decided to interview Dr Jayashri Kulkarni at Australia’s Monash University, one of the few people researching into this area, to find out more. As a practicing psychiatrist Dr Kulkarni treats women with mental health issues as well as leading research studies into this possible root cause of psychological problems.
Of the potential for these pills to create suicidal tendencies in users Dr Kulkarni says, “We have seen amongst women using these oral contraceptives a profound lowered self-esteem which causes them to lose perspective, misinterpret comments, and feel like no one would notice, or the world would be better off, if they weren’t around anymore. We’ve seen suicide attempts.
Dr Kulkarni is undertaking both a large-scale national and international survey of women’s subjective experiences with Yaz, Yasmin, as well as the Mirena IUD, Depo Provera shot, and Implanon implant and a smaller scale in-clinic study of the impact of oral contraceptives like Yaz and Yasmin on women over a three month period. The psychological impact is not what she calls “major depression” but instead a “sub-clinical depression” wherein women experience a mood change that impacts their relationships, work, and overall happiness.
“This depressive syndrome has a spectrum of symptoms. We tend to think depression just means sadness, but it can present as fuzzy headedness, inability to multitask, guilt, irritability, anxiety, and in behavioral changes like the development of obsessive compulsive disorders. Women experience a change in perspective that makes them magnify issues that occur in their lives, be that a slight weight gain or an argument with a partner, into feelings of worthlessness. It can also cause impulsivity, making the woman suicidal.”
At her clinic Dr Kulkarni describes treating a mother who found it difficult to let her children go to school for fear something would happen to them and another who became transfixed with the idea that her partner was cheating, and so called his phone repetitively to check on him. She believes that the provoked anxiety can display itself clearly as panic attacks, but it can also appear as paranoia and agoraphobia. When taken off Yasmin and Yaz these women returned to their previous state with a healthy perspective.
The Depo Provera shot and Implanon implant have shown in the research to also cause particularly profound depression. For women who have a history of mental health issues or have environmental factors that make them more vulnerable to mental health issues, these methods have been seen to provoke serious negative changes in mood.
Dr Kulkarni’s hypothesis is this: “Low estrogen pills and progesterone-only methods seem to cause depression at the highest rate. In our research we’ve seen women respond better to higher dose estrogen and natural progesterones. Clinical studies on animals have shown progesterone in a low dose causes increased anxiety, but conversely in a high dose it alleviates anxiety.” Her findings will be published later this year in full.
At present Dr Kulkarni treats her patients by changing their hormonal birth control method with her research in mind, a practice she believes to be generally successful. She prescribes new pill Zoely to patients who have responded badly to other brands. Zoely (which contains 2.5 mg of nomegestrol acetate and 1.5 mg of 17-beta-estradiol) was refused approval by the FDA for the US in 2011.
Don’t feel bad if you missed last week’s headline news about the deaths of 23 young women from their birth control. It was a top story for CBC news and a few other Canadian sources, but it was barely a blip on the radar of most U.S. news outlets. Yaz and Yasmin, two similar new-generation birth control pills from Bayer, are suspected in the recent deaths of these young Canadian women.
These are among the best selling oral contraceptives in the world, but this is not the first time Yaz and Yasmin have been suspected of causing death or adverse effects. Earlier this year, Bayer agreed to pay up to $24 million to settle claims from plaintiffs with gall bladder injuries caused by the drugs, and the company set aside $1 billion to settle claims from approximately 4,800 women who have suffered blood clots due to Yaz or Yasmin. As of February, 2013, approximately 10,000 lawsuits against Bayer are still pending in the U.S., and an additional 1,200 unfiled claims are pending. The company anticipates additional lawsuits—and additional settlements—regarding blood clot injuries, such as pulmonary embolisms or deep-vein thrombosis.
The history of the birth control pill and its social impact is well documented. First approved by the U.S. Food and Drug Administration in 1960, it quickly became the world’s first “lifestyle drug,” and it has become the one of the most studied drugs in history. It is considered to be so safe that the American Congress of Obstetricians and Gynecologists (ACOG) recently recommended that oral contraceptives be sold without a prescription.
But all hormonal contraceptives–the pill, the patch, the shot and the vaginal ring–carry a risk of blood clots. For most users, this is a minor concern, affecting approximately six of every 10,000 pill users. For users of new-generation pills—that is, pills containing drospirenone, the fourth-generation synthetic progesterone found in Yaz, Yasmin, Ocella and several other brands—the risk jumps to ten of every 10,000 users, although Bayer maintains that their own clinical studies find the risk comparable to older pills. Note, however, that the risk in most of these studies is compared either to other hormonal contraceptives or to pregnancy, not to using effective non-hormonal contraception. As if women’s only choices were to be pregnant or be on the pill.
And it is this matter of women’s choices that brings me to my main point: Why we have we seen so little media attention to the safety profile of Yaz/Yasmin (and hormonal contraceptives more generally)? This isn’t about just a few unlucky Canadian women: Four women in Finland have died, more than 50 U.S. users of Yaz and Yasmin died in just a few years and France reports 20 deaths per year due to birth control pills between 2001 and 2011, with 14 attributed to the new-generation contraceptives. This is a major consumer safety concern, and a women’s health issue.
In an earlier time, this might have led to Congressional investigations, such as the Nelson Pill Hearings, which resulted in FDA-mandated Patient Package Inserts (PPIs)—the printed information about risks, ingredients and side effects included in pill packets, first required for oral contraceptives and then for all prescription drugs. It is hard to imagine today’s Congress calling for such an investigation. Among many other social changes since 1970, drug manufacturers in the U.S. hold more influence over both legislators and consumers, now spending nearly twice as much on promotion as they do on research and development.
A parallel can be found in the health crisis triggered by an outbreak of Toxic Shock Syndrome (TSS) linked to tampon use in 1980. TSS is a potentially fatal infection caused by bacterial toxin Staphylococcus Aureus. A new brand of superabsorbent tampon was linked with 813 cases of TSS, including 38 deaths, that year. By 1983, the number of menstrual-related cases reported to the CDC climbed past 2,200, and manufacturer Proctor & Gamble had “voluntarily” pulled the product from the market before the FDA forced them to do so. The intense media coverage, public concern and outcry from feminist activists pushed the FDA to reclassify tampons as a Class II medical device, an upgrade which meant tampons would require more specific regulation and possibly after-market surveillance. They were much slower to mandate absorbency standards, but eventually did so under court order. These actions resulted in a documented decrease in menstrual-related TSS, although it is important to note that it has not disappeared.
Today, more than 30 years later, young women are again dying from something purported to help them, something that affects mostly women. Thousands more are experiencing life-threatening, health-destroying side-effects, such as blindness, depression and pulmonary embolism. Canada’s professional association of OB-GYNs defended the drug, suggesting that perhaps the recent deaths could be attributed to non-contraceptive reasons for which it was prescribed, such as PCOS or diabetes, both of which are associated with higher risks of blood clots. But there is little evidence of public concern, outside of Yaz/Yasmin user message boards. Even feminist outlets aren’t always covering these issues as vigorously as we might hope.
Yet the birth control pill in general has never been more politicized in the U.S.: In the last year or so, we’ve seen headlines and public debates about insurance coverage of the pill, access to emergency contraception and so-called personhood bills which have been introduced in legislatures in at least eight states. Feminist activists and health care advocates have been working tirelessly to protect access to the pill along with other forms of birth control, as well as the right to end an unintended pregnancy—and feminist journalists have been writing about these activities.
In the urgency of responding defensively to these political attacks—and we must respond—feminists cannot ignore corporate threats. Just as preserving contraceptive and abortion access is critical to women’s health and well-being, so is protecting contraceptive safety.
Cross-posted from Ms. magazine blog.