The invention of the pill was heralded as a triumph of modern medicine. It was also a crucial moment in the ongoing fight for people who can become pregnant to retain autonomy over their bodies and their lives. Birth control, like abortion and all reproductive health services, should be available for everyone, free of cost, stigma, or delay—but it's not.
But for patients who do have access, and are trying to find the right method for them, there is more to the story.
Struggling to find a balance between possible benefits and side effects of birth control is a well-documented phenomenon; the Washington Post and the New York Times have published powerful accounts of patients’ attempts to find an option they can tolerate.
“Currently available hormonal contraceptives have been improved greatly since they were first developed, but there is always room for innovation,” Diane Horvath, an OB/GYN and medical director at the Whole Woman’s Health of Baltimore told VICE. “In the past, research didn't always center the needs of the people being studied or the populations who would be using the method after development. We're doing better in that regard, but we have a long way to go.”
These can be incredibly difficult, and delicate conversations to have in the current political climate. The Trump administration is doing everything in its power to gut access to all family planning services including birth control, by attacking a federal birth control program known as Title X and loosening rules that employer health insurance must cover birth control; not to mention appointing judges, both to the Supreme Court and lower courts poised to uphold these restrictions.
It feels counterproductive—even potentially harmful—to ask more from these methods when the few that we have are being threatened, when access to contraception is a fundamentally good and necessary thing. Then there’s a concern that voicing our frustrations with birth control itself could provide ammunition to those who want to restrict it; to anti-abortion propagandists and crisis pregnancy centers who spread lies about completely unfounded risks of using contraception.
Writer and designer Megan Magray recently shared on Twitter that she's been hesitant to talk about how, after trying many kinds of birth control, she now uses fertility-awareness based methods. Her hesitation stems in part from the association of FABMs with anti-abortion activism and other people who fight against access to contraceptives.
I currently have a Mirena IUD; it’s helpful, but not ideal. In 2016, I was diagnosed with endometriosis, a chronic reproductive health condition which can cause severe pain and infertility. The gold standard in care for endometriosis is excision surgery—but it’s cost-prohibitive and the majority of providers are not skilled enough to perform it so they rely on cauterizing the lesions and suppressing hormones with drugs like birth control. Before I found the specialist who manages my care, doctors put me on everything from your run of the mill combination estrogen and progestin pill to a 5mg dose of progestin daily (by comparison, one common combination pill contains 0.15mg of progestin component)—none of which worked, all of which only made me feel worse.
It’s a tough balance; I have worsened anxiety on the Mirena and I still have some debilitating pain days. But the times in my life when I have been off birth control were nerve wracking constantly worrying about unintended pregnancy; and, despite the side effects, I sleep easier at night knowing I have a less than 1 percent chance of becoming pregnant when I have sex.
Becca Thimmesch is a campaign manager at Free the Pill, an organization working to bring a birth control option over the counter, covered by insurance, and accessible to people of all ages. Thimmesch acknowledged that her birth control journey has been “extremely long and painful.” She said she tried a half dozen pills, then the Nuvaring, which she liked. Then, in a long-term relationship, she decided to get a Mirena IUD.
“For the first few months, I thought the debilitating cramps were just my body adjusting. But they lasted for two years before I finally got my Mirena removed.” Next she tried the shot, which her body didn’t agree with; now she’s back using the Nuvaring, and while she’s more anxious about getting pregnant, she’s glad to not be managing the side effects of the other methods.
Reina Sultan, a writer living with endometriosis, said that after struggling to find a birth control pill that agreed with her, she had a Mirena IUD inserted a few years ago.
“I think it is so important for us to be able to talk about the limitations of birth control options that exist now,” she said. “Reproductive healthcare IS regular healthcare and should be treated as such. If I have strep throat or bronchitis, I tell my doctor that my body doesn't tolerate amoxicillin very well and they prescribe me something else. It should be the same with birth control.”
Hayley Farless, a reproductive justice advocate, uses the pill both to prevent pregnancy and to control her periods—without the pill, her cycle makes the symptoms from her autoimmune disorder much more severe. But she still has criticisms.
“I have an anxiety disorder that is worsened by my current birth control pill,” she said. “But I have chosen to continue taking the pill because I decided that the benefits of pregnancy prevention and menstrual pain relief were worth the worsened anxiety.” She said the most important thing for her is autonomy.
“That's a decision I made, knowingly and willingly, for my own body.”
But this isn’t a zero-sum game, Farless points out.
“We need to acknowledge that two things are true at once. Birth control is becoming harder and harder to access; it's already been pushed out of reach for many low-income folks,” she said. “At the same time, we can admit that the current state of birth control options is honestly just not that great.”
And Thimmesch notes that this isn’t just about the current administration; the fight for better access has been ongoing, especially for marginalized people.
“Obviously the Trump administration is making things worse,” she said. “But frankly many of the young people I work for have always had a hard time accessing the care they need, irrespective of who sits in the White House. So, to me it’s less about fighting a particular presidential administration and more about building a better future for all young people.”
There have also been warnings from providers and reproductive justice advocates about the way long-acting methods like IUDs are disproportionately recommended for women of color. There’s not only the pain associated with IUD insertion, but programs intended to make the long-acting devices free for low-income people that make their increased use even more complicated when you consider our country's history of forced sterilization.
Then there’s the patient-provider dynamic; Twitter was set ablaze recently with heated discussions about science vs. anecdote in reproductive healthcare and whether doctors are too eager to dismiss patients' concerns. But one line of discussion stood out as a voice of reason: listening to patients. Centering the lived experience of patients, especially those who have been historically marginalized and disbelieved by the medical community, like women—and especially women of color—will only benefit us and further our progress in the fight for better access to and quality of reproductive healthcare.
“Patients are the experts on their own lives,” Horvath said. “And understanding people's lived experiences is essential if we want to develop treatment plans that work.”
There is an inherent misogyny in telling patients to suck it up when it comes to pain and the side effects of birth control; this does not mitigate the violence of restricting access and scaremongering about the safety and efficacy of hormonal contraception from both by current administration and propagandists who seek attack reproductive healthcare.
Fighting to expand current birth control access while also advocating for better methods can sound contradictory on the surface, Farless said. “But both of these conversations are matters of justice and bodily autonomy that are inextricably linked.”
And Horvath rightly cautions that “avoiding nuance isn't going to stop the attacks on reproductive healthcare.”
"I believe it's not only possible but imperative that we continue to have difficult conversations that center the people who are most affected by restrictions on abortion, contraception, and pregnancy care," Horvath said. "It's OK to be uncomfortable, to reject binary choices, and to demand better options for ourselves and our communities.”
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