In Our Control (15 page)

Efficacy for the cervical cap is, unfortunately, lower than either a diaphragm or condom. For women who have never given birth, the ideal success rate is 91 percent, while the typical use success rate is 84 percent—similar to the diaphragm rates. But for women who have given birth, the usefulness of the method declines precipitously, failing somewhere between 26 and 32 percent of the time. This brings up a “chicken-and-egg” problem: a traditional cervical cap requires a precise fitting, and it is difficult to say whether more demand for the method would also create a demand for more skilled practitioners to provide and fit it, ultimately improving the device’s success rate. FemCap’s efficacy may be slightly higher, but good discrete data on the device is hard to find.

Barriers aren’t for everyone, but they are a sensible, welcome choice for many. So much of this discussion has to do with how our perceptions of what is burdensome are formed. For me, remembering to take a pill every day and dealing with the bleeding that resulted when I forgot was burdensome. I spoke to one woman in her early thirties who had three unwanted pregnancies (and abortions) while taking the Pill because she simply couldn’t remember to take it routinely. Coping with mood swings is burdensome. For some, dealing with the increased possibility of urinary tract or vaginal infections is burdensome. For others, the idea of having to touch intimate parts of their body is burdensome. Each woman is unique, but unfortunately our contraceptive world treats women as if they are the same. The conversation should not involve arguing that one option is better than another. In fact, that is exactly the problem. What
is
necessary is that women and health care providers become open to the idea that considering an array of options, and embracing the necessary experimentation to discover which works best for each individual, is the best approach to contraceptive health.

Condoms for Her and Him

Most people growing up in the era of AIDS have at least some awareness of male condoms. Today’s prophylactics have little in common with their thick, fragile forerunners. A trip into most American drugstores provides a contraceptive buyer with multiple condom options, each promising thinner, sleeker, more sensitive products. Much less attention is given to the female condom, which, considering the disappointing results of tests of diaphragms for HIV/AIDS prevention, remains the only female-controlled contraceptive that can also reliably stop the spread of STIs.

Introduced in the early 1990s, the female condom is a seven-inch-long polyurethane device with a flexible ring on either end. It is held in place by one ring that sits over the cervix while the other stays outside the vagina, providing partial coverage to the vaginal lips.

While it made excellent media fodder following its release and marketing, the female condom never caught on with most women and remains more of a curiosity than a health safety tool. People saw the device as cumbersome, a larger, less sensitive version of the male condom. It is said to make strange noises during sex, and to feel, as one male user frankly put it, “like making love in a garbage bag.” They can reduce sensitivity for some women and even curtail orgasm. A twenty-eight-year-old law student told me that she and her boyfriend tried a female condom on a whim because they were sitting alongside male ones in the student health service center. “I actually didn’t know he was inside me—that’s how little I could feel,” she explains. Some women disagree, arguing that the two rings actually enhance sex, providing clitoral and cervical stimulation.

Another factor in women’s reluctance to adopt the option is a lack of education. Susie Hoffman, an assistant professor of clinical epidemiology at Columbia University, notes, “In the United States there has been strong bias against it … but if presented the right way, many women do like it.”
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One serious drawback of the method is cost: female condoms are far more expensive than their male alternatives. On a recent trip to my closest pharmacy, I checked to see if the items were available. There was one brand of female condom, priced at a whopping $18 for three. The Web site
Drugstore.com
offers them for slightly less, at $14.99 for five. Since female condoms can’t be reused, this makes them cost prohibitive for many women.

The imperative of finding new ways of preventing the spread of STIs has led to a recent product remodeling that seeks to address some of the flaws of the original model.
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Polyurethane has been replaced with synthetic rubber to reduce costs, and the design has been altered slightly to reduce the embarrassing and irritating squishing noises. Educators stress that the new design feels more natural. Manufacturers estimate that the cost of each condom can be reduced to $0.60 a piece for international distribution, which is still high when compared with the male condom at $0.04.

Yet there are advantages to using the female condom. It has efficacy comparable with male condoms, between 79 and 95 percent. This female-controlled method has sparked international interest, particularly in Africa, where thirty thousand women in Zimbabwe signed a petition calling for access to the devices and ten thousand people have been trained in Ghana to teach women how to use them.
¹⁰

The male condom is the king of contraceptives. It dates to prehistory and functions on the simplest possible principle: put something between the vagina and the penis to prevent the transmission of sperm. Condoms are the only form of reversible birth control for men (other than pulling out), and they are easily available across the country at almost any drugstore.

Before sex, a condom is rolled onto the erect penis. If a man is uncircumcised, he may want to pull back the foreskin before doing so. With one hand, the top half inch of the condom is pinched to push out air and make room for semen. The other hand rolls the thin tube (usually made of latex, but occasionally another material like polyurethane or animal skin is used) down to the base of the penis. A tight band holds the device in place. After intercourse the male partner should withdraw before he loses his erection, being sure to hold the condom in place while doing so to prevent slippage. Condoms can’t be reused, so they should be thrown out after sex. Partners should be careful to avoid direct contact between male and female genitals after taking off the device because the penis might still have sperm on it. Contrary to some teenage beliefs, condoms should only be used one at a time—not doubled up—to prevent breaks and tears.

Condoms are a method with great efficacy variation. With perfect use they can be as much as 98 percent effective at preventing pregnancy, but with actual use failure is closer to 17 percent. This means that how you
use condoms makes a big difference in determining whether they will prevent pregnancy. Practice makes perfect, but using lubricant to prevent tearing and storing condoms in a temperate dry place also help. Avoiding heat not only maintains the structural integrity of the device, but it prevents spermicide (present on many condoms) from losing effectiveness. Most condoms will last from two to three years with proper storage, but you should always look at a condom when putting it on to make sure that it doesn’t have any obvious holes or tears. Avoid oil-based lubricants and other chemicals that can cause the material of the condom to break down.

Spermicidal Options: Films, Jellies, and Sponges

Contraceptive sponges have been used since ancient times. Modern versions were extremely popular in the nineteenth century. Famous free thinker and contraceptive advocate Annie Bessant recommended an early version in her self-published 1879 guidebook,
Law of Population.
¹¹
But the sponge, like the diaphragm, fell out of favor with the advent of the ubiquitous Pill.

The Today Sponge is a famous but infrequently used contraceptive that is most well known for being the method of choice of Elaine Benes, a fictional character on the wildly popular 1990s television show
Seinfeld
. When the sponge was pulled from the market in 1994, Elaine lamented the loss and hoarded her remaining supply for partners deemed “sponge worthy.” The first withdrawal of Today—America’s only contraceptive sponge—happened because of a problem with the FDA. The company that made the sponge, owned by the larger drugmaker Wyeth, was found to have problems with its manufacturing plant that the parent company deemed too expensive to fix. Instead, they opted to stop making the product.

Another company, Allendale Pharmaceutical, acquired the name and the rights to the product, and eleven years later reintroduced it to the market after rebranding the item and launching a massive advertising campaign. The Today Sponge was now marketed with imagery worthy of a “chick lit” bestseller, complete with pink packaging and a flirty cartoon spokeswoman. By December 2008, Synova, the company that eventually bought Allendale, had gone into bankruptcy, and the product was again
pulled from shelves. In the past year, the sponge has once again become available. Only time will tell if this reemergence is permanent or simply the next chapter in the tumultuous history of sponge availability.

The Today Sponge is a small plastic foam object about two inches in length with a loop on one side for removal from the vagina. To use it, a woman wets the sponge with at least two tablespoons of water, and, folding it away from the loop, inserts it as far into the vaginal cavity as it will go. Users should check to make sure that the cervix is covered. The device works by covering the cervix and also releasing nonoxynol 9, a spermicide that is activated when the device is wet. The sponge can remain in the body for up to thirty hours, during which time intercourse can happen repeatedly. It must remain in for six hours after the last intercourse.

Like cervical caps, the sponge works much less effectively if you have had a child. For those who haven’t given birth, the failure rate is somewhere between 9 and 16 percent. For those who have delivered a child, the failure rate climbs to between 20 and 32 percent. Those who are allergic to sulfa drugs (a preservative used in the product contains this chemical); women who have recently had a baby, an abortion, or miscarriage; and those prone to toxic shock syndrome shouldn’t use this method. The sponge shouldn’t be used while a woman is menstruating. If the device breaks apart, or if a woman is unable to remove it, she should see her doctor.

Other spermicidal options, such as contraceptive film, foam, cream, and jelly, should be used as partner contraceptives, in combination with another method (such as a condom or diaphragm). Used alone, their failure rate is very high. The most common spermicide (which works by immobilizing and, as the name suggests, killing sperm) is nonoxynol 9. Many women (and men) have allergies to this chemical, and if you find that you are one of them, you should seek other options. Nonoxynol 9 can be a vaginal irritant, causing micro-tears that make it easier for viruses and pathogens to enter the bloodstream. For this reason, health educators recommend that people at high risk for sexually transmitted infections avoid nonoxynol 9, making sure to use condoms without nonoxynol 9. Generally, spermicides are inserted into the vagina about ten minutes before intercourse and remain effective for about an hour.

Writing the Next Chapter: Today’s Intrauterine Devices (IUDs)

When I mention that I am writing a book on birth control, the Planned Parenthood health educator with whom I am speaking brightens. “Are you going to mention IUDs?” she asks. “You really should—they’re hot right now.” It’s a funny idea that this contraceptive, which has been around for decades and frequently received less attention than either hormones or barrier options, is suddenly back in the limelight. In fact, health organizations, including the Alan Guttmacher Institute and Planned Parenthood, have recently reemphasized the usefulness of intrauterine devices by raising their profile in educator and clinical training. Today’s IUDs—one of which is nonhormonal and one of which is a hybrid with a hormonal piece—still live under the shadow of disgrace and distrust cast by older, more dangerous devices. Whether today’s version is indeed better remains to be seen, but most women’s health experts are cautiously optimistic.

While modern IUDs are a relatively new invention, the idea that putting something in the uterus could block pregnancy is an old one. Renowned gynecologist William Parker writes that in ancient times, “nomadic people placed stones in the uteruses of their camels to prevent pregnancy during long journeys.”
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It is likely that the technology was employed in humans as well during this time.

Modern IUDs appeared on the scene in the nineteenth and early twentieth century. By the mid-nineteenth century, there were over 123 designs listed in the
Transaction of the National Medical Association
, and one doctor complained that other physicians were recklessly “filling … the vagina with such traps making a Chinese toy-shop out of it.”
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Early versions were pen-shaped items made from metal and rubber. The devices gained an early acceptance from doctors that other methods—namely diaphragms—lacked.

Some early models were a subcategory of other so-called pessaries, used to treat multiple gynecological problems. Usually, a pessary was a device that was inserted into the vagina for either bladder support or contraception, like a diaphragm. In the case of the stem pessary, a device was inserted partially into the uterus with a connecting stem holding it in place at the cervix. This early device wasn’t very effective, and worse, frequently
caused uterine infection and inflammation. Still, women used the option, and German case histories gathered during the First World War include the story of a thirty-year-old Bavarian woman who requested a uterine “splint” after the birth of her second child.
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Other designs used silkworm thread modeled in the shape of a ring.