In Our Control (18 page)

After surgery, a woman will need to rest for two to three days, but the procedure is immediately effective. It is still a good idea to wait at least a
week before trying to have sex to make sure that the body has had time to heal. Tubal ligation is 99.5 percent effective for pregnancy prevention, though there is a small chance of ectopic pregnancy. It is possible to reverse the surgery in some cases, but women undergoing sterilization should think of it as a permanent decision. In the cases where it is reversed, the risk of ectopic pregnancy increases.

Because it is a permanent decision, it is important for women to think more carefully and dynamically about this choice than they would about reversible methods. Possible life changes (a breakup with a partner, a spousal death, or the death of a child, among others) should be considered before opting for surgery.

Women who have tubal ligations have few side effects, but abnormal bleeding and bladder infections are two possible problems. Some women say that they experience a condition called “post-tubal sterilization syndrome.” While this is controversial, and some doctors deny that it exists, many women insist that they experience symptoms such as irregular and painful periods, midcycle bleeding, and even loss of periods. Hormone levels are generally minimally affected. The surgery is expensive, but it can be cost effective over time.

In 2002 the FDA approved a procedure called Essure, which works like tubal ligation but doesn’t involve surgery. With Essure, a doctor places tiny “microinserts” into the fallopian tubes by going through the vagina, cervix, and uterus rather than making surgical cuts. The procedure, like IUD insertion, requires only local anesthetic. During the three months following insertion, body tissue grows around the microinserts to eventually block the fallopian tubes. This process takes time, so Essure isn’t immediately effective and other birth control is necessary in the meantime. After three months, a doctor tests to make sure that the fallopian tubes are fully blocked. The procedure isn’t reversible, and because it is new, there is a lot we don’t know about potential problems and side effects. Still, it promises another option for women who want nonreversible birth control.

There are other less common forms of female sterilization, including hysterectomy (where either the uterus or both the uterus and ovaries are removed), but this much more invasive surgery with far-reaching health implications and dangers is usually performed because of other serious health problems.

Vasectomy, the most common form of male sterilization, is even less invasive than tubal ligation. In this procedure, which is generally performed under local anesthetic in about fifteen minutes, the doctor makes a small cut in the skin of the scrotum. The vasa deferentia (tubes that carry sperm) become visible and the doctor cuts them. Once these passageways are severed, sperm have no way to enter the ejaculate. A man will still produce semen; it simply won’t have sperm in it. The procedure is 99.9 percent effective, although in rare instances the tubes may repair themselves and unplanned pregnancy may result.

After a vasectomy, a man will typically rest at the doctor’s office before going home (faintness is a typical side effect of the surgery). Once home, he should rest from work for two days and avoid strenuous labor for at least a week. Sexual activity should also be delayed for about a week or two while the body is healing. Men don’t become sterile immediately after having the procedure. Sperm maturation is a slow process, and at first some sperm remain in the ejaculate and in various stages of viability. After about ten to thirty ejaculations, doctors will typically perform follow-up tests to make sure that ejaculate has negative sperm counts.

Vasectomy isn’t just less invasive than tubal ligation, it is also more reversible. In about 70 percent of cases, the severed sperm tubes can be repaired. This doesn’t mean that pregnancy will definitely be possible; in fact, it becomes much less likely. Because of this, people opting for vasectomy should consider that it may well be permanent and treat the decision as a final one.

Sterilization in America has a shocking and difficult history of being implemented through coercive and violent means. This history lays bare the ways that control over reproduction is used to reinforce power relationships and as a site for social engineering. Historian Dorothy Roberts traces the history of sterilization abuse in America back to the treatment of slaves, noting that castration was used as a punishment for African American men accused of various crimes, sexual and otherwise.
⁴³
Mandatory sterilization of criminals became a popular tool of social control in the late nineteenth and early twentieth century. Forced sterilization under eugenic laws resulted in thousands of people being stripped of reproductive and human rights during the first half of the twentieth century.

It is easy to distance ourselves from these bodily violations committed
so many years ago. Slavery and even the now-discredited pseudoscience of the early twentieth century can seem impossibly distant from our own lives, particularly for those of us who have spent almost as much of our lives in the new century as in the one that came before. And yet, when it comes to sterilization abuse, to paraphrase William Faulkner, the past isn’t over; it isn’t even past. Even in the 1960s, when “the last nail was barely in the coffin of eugenic theory,”
⁴⁴
a new type of coercive sterilization began to be institutionalized. Ironically, as desegregation allowed African Americans and other people of color new access to health care in public facilities, it created a novel way for doctors and lawmakers to impose racist social policy on the bodies of women. In the 1970s, sterilization was one of the fastest growing methods of contraception. Between 1970 and 1980, the number of women who were sterilized rose from 200,000 to over 700,000. Working through public health care, including the Medicaid program, many doctors worked to bully, threaten, and pressure women of color and poor women into giving up their fertility.

Sometimes authorities threatened to withhold welfare and other forms of economic relief until women agreed to be sterilized. Other times, doctors threatened to refuse services, such the delivery of babies, until mothers agreed to undergo ligation or hysterectomy. Some doctors simply performed the procedure without permission after a birth or other medical intervention. This was done for a number of reasons: sometimes the woman already had several children and her doctor decided she shouldn’t have any more; other doctors did it to give medical residents surgical practice; some felt that the women in their care weren’t intelligent enough to use reversible birth control; and, of course, some were driven by ideas about quelling social unrest by reducing the population of poor and nonwhite people.

Dorothy Roberts notes that in the South, hysterectomies were often called “Mississippi appendectomies,”
⁴⁵
and she tells the story of Minnie Lee and Mary Alice Relf, the children of illiterate farm workers in Montgomery, Alabama, who were sterilized in 1973 at the ages of fourteen and twelve. Mrs. Relf, who couldn’t sign her name, consented to her daughters’ participation in a trial of Depo-Provera by signing an
X
. She did this at the urging of nurses from a federally funded hospital in the area. After the Depo-Provera trials ended because of concerns about the drug’s potential to cause cancer, the two girls were sterilized instead.

Legal action to try to achieve some justice for the Relf sisters exposed how rampant and racially based sterilization abuses were: legal documents for the case, tried in the 1970s, estimate that between 100,000 and 150,000 poor women were sterilized each year under the auspices of federally funded health care programs. Of these women, almost half were black.
⁴⁶
African American women in the South were not the only victims of these sorts of abuses: American Indian women were also subjected to programs of coercive sterilization. During the 1970s as many as 25 percent of women on reservations underwent some sort of nonreversible procedure. And in Puerto Rico, the site of the Pill trials, a massive campaign to sterilize women led to as many as one third of women between fifteen and forty undergoing “la operación” by 1968. In the early 1970s, a group of Latina women brought a legal case in Los Angeles against a hospital that had sterilized them without giving informed consent: the women had been given information and consent forms they couldn’t understand. In addition, some were told that the surgery was reversible.
⁴⁷

Helen Rodriguez-Trias, the Puerto Rican doctor and heroine of the women’s health movement, was one of the women who led the battle to end these atrocities. The Committee to End Sterilization Abuse (CESA) organized in the mid-1970s for reform and for the establishment of guidelines to protect Medicaid patients and other women receiving reproductive health care through public funds. Among CESA’s recommendations were provisions to insist on a thirty-day waiting period before a procedure could be performed, extensive information and education in the patient’s native language, and a requirement of written consent on the part of the patient.

In the late 1970s, women’s groups led mostly by white activists fought to ensure that women who wanted sterilizations could get them. For white women the problem was different: very few doctors would agree to perform the procedure on a white middle-class patient unless “her age multiplied by the number of children she had equaled 120.”
⁴⁸
So a woman in this group who had no children wouldn’t be a candidate for the surgery regardless of her age, marital status, or desires.

The result of these two different sets of experiences led to a clash between white and nonwhite feminists that in many ways articulated the racial tensions underlying the second wave women’s movement.
Rodriguez-Trias later explained, “We were unprepared for the ferocity of the opposition to our guidelines.” She added that while the feminist movement was “very diverse … the more public positions articulated by the movement didn’t concern the experiences or concerns of women of color or poor women.”
⁴⁹
Mainstream groups led by white feminists such as Planned Parenthood and the National Abortion Rights Action League (NARAL) refused to support CESA’s objectives and even actively opposed them in some instances. Despite this, in 1978 CESA’s guidelines became government policy. Today, though health care policies have undergone massive reforms, African American women are much more likely to be sterilized than white women, even though they comprise a smaller part of the total population. While progress has been made to reduce race- and class-based reproductive abuses, much work remains.

Final Thoughts on Nonhormonal Methods

So, in the end, who killed the diaphragm and the other nonhormonal methods of birth control? Well, I suppose you could say it was the magic bullet. Or at least the idea of a magic bullet—the notion that hormonal options could be made to work for every woman. This happened despite extensive clinical and anecdotal experience to the contrary. In some ways it was an inside job: the same medical communities that used the diaphragm as a vehicle to professionalize contraception were quick to disown the method when persuasive, pharmaceutically funded information suggested that hormonal methods were the only way to go. Perhaps, though, reports of the diaphragm’s death have been greatly exaggerated. I, for one, hope that that is the case. In a world without enough contraceptive options it would be a tragedy to unnecessarily eliminate a unique and historically useful one.

It is significant that the IUD—the only nonhormonal method getting attention from large public health and medical groups—happens to be a long-term method whose use is totally dependent on medical practitioners. Methods that allow women more freedom to choose when and how they will be used should be encouraged and made accessible.

Women want to look to the future when it comes to birth control, but new technology isn’t always quick to arrive. When it
does
arrive we find
that newer isn’t always better, and from a medical safety perspective, sticking with older time-tested methods can be a smarter way to go. While we embrace new ideas and hope for better options, let us not forget the wellspring of knowledge that past technologies hold.

Chapter Four
By Any Other Name: Alternative Distribution Methods and Hormonal Contraception

With the Pill turning fifty, now is the perfect time to reflect on the birth control innovations this queen of contraception has inspired. Recently I interviewed college-age women at a small school in the northeastern United States about their experiences with birth control, starting with a seemingly simple question: how has contraception changed over the past fifty years? Many of the young respondents who shared their stories with me had similar answers, telling me that contraception has undergone substantial changes in recent decades. There are new methods coming out every day, they said—look at the vaginal ring, the contraceptive patch, injectable and implantable birth control, and even a chewable pill.

Thanks to successful drug company marketing, it can be easy to believe that the past twenty-five years have seen an enormous number of new contraceptive options hit the market, including Depo-Provera, Norplant, NuvaRing, Ortho Evra (the birth control patch), Mirena (the hormonal IUD), low-dose pills, and of course, menstrual suppression drugs.

It is important to realize that while these are all alternative distribution methods—meaning they help drugs reach your body in different ways—they are also all forms of hormonal contraception, using the same estrogen and progestin that have made up the Pill since its creation. So what are the unique advantages and disadvantages that might encourage a woman to choose one of these younger methods over the older daily Pill? How do issues of age, race, and class motivate these Pill alternatives, and in what ways must we understand them as “new” from a safety perspective?