In Our Control (14 page)

The issue of female control is still a complicated one. Indeed, being responsible for the procurement and proper use of birth control affords women a measure of power, even as it puts responsibility for the outcome more fully on female shoulders. Potential burdens of this kind of control
include financial issues of paying for sometimes-expensive methods, legal dangers in obtaining controversial methods, and physical and medical complaints that can result from using various options. These two sides of the same coin—control and burden—account for deeply divided opinions among women. While some insist, like Sanger, that female-controlled methods are the only way to go, others wonder why there is no pill for men and argue that such diverse responsibilities placed on women constitute another method of controlling female bodies.

In the late nineteenth and early twentieth century, though, any ability to prevent pregnancy represented an irresistible alternative for couples. Especially in a time before modern birthing science, the prospect of repeated childbirth and the ensuing health hazards quickly nullified other concerns.

By the dawn of the twentieth century, increasing numbers of women in the United States and abroad were opting for the diaphragm. Margaret Sanger’s long, vexed love affair with the device began at this time. She became intrigued by the Mensinga diaphragm in 1915, when Dutch doctor Aletta Jacobs championed the device. But when Sanger was ready to open her Brownsville clinic in 1916, no American manufacturer had started making anything like the reliable Mensinga product. Because birth control was still illegal in the United States, as was bringing the devices in to the country from Europe, Sanger opted instead to offer the Mizpah, an American-made cervical cap marketed primarily for treating prolapsed uteruses. It had the added advantage of being “one size fits all” and therefore not requiring a doctor’s fitting.

This changed a few short years later when Sanger and her second husband, James Slee, created the Holland-Rantos Company, the first corporation in America to make and sell birth control devices—mostly diaphragms—solely to doctors and the medical profession. Women who wanted the devices would have to have a fitting at the doctor’s office. Putting devices in the hands of doctors disassociated birth control from vice and made its distribution seem like a medical, not a moral, issue. Sanger realized that in order to change American perceptions about contraception, the practice would need to be married to medicine.

Andrea Tone notes, “By the 1930s, thanks largely to Sanger, the diaphragm and jelly had become the most frequently prescribed form of
birth control in America.”
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But although diaphragms were the most prescribed method of birth control in the mid-twentieth century, at no time did the majority of American women use them. Indeed, use was limited to a small number of women who were heavily middle class and white. This was probably due, at least in part, to the reliance of the method on access to medical professionals to properly fit them. The problem wasn’t that poor or uneducated women couldn’t use the method; it was that they lacked access to it.

By this point, Sanger was already starting to look for something better. Her feminist position on family planning was beginning to twist toward eugenics. Frustrated with the low rate of diaphragm use in low-income communities, she started to believe that the method was too sophisticated for poor women, especially women from parts of the world that, as population control advocates argued, posed a threat to the American way of life. The notion that the majority of women couldn’t handle the responsibility of inserting a barrier method began to set the stage for the advent of the Pill. From the beginning, the emphasis of the Pill was not on respecting female autonomy, but rather on offsetting women’s incompetence.

Within a decade of the legalization of hormonal contraception, women were forsaking barriers in dramatic numbers for both the Pill and the new IUDs. The diaphragm and the cervical cap experienced a renaissance in the 1970s and 1980s as information about the dangers of the Pill and IUDs began to proliferate, and after the 1970s Dalkon Shield scandal—when that IUD was found to cause severe internal injuries—use of diaphragms and cervical caps in America climbed to account for 6 percent of all American contraceptive use. But the damage had been done, and the barrier never regained its former place as a prominent player on the contraceptive playing field.

As the years passed and safety concerns about other forms of contraception decreased, the diaphragm began to slowly disappear. Between 1988 and 1995, use fell by two thirds, making up only 2 percent of total American birth control use. That number continued to decline, and today only .3 percent of Americans use a diaphragm, making it less popular than Natural Family Planning, the method of choice for .4 percent of birth control users.
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The percentage of women who choose cervical caps is too small to
count discretely. A blogger on the popular site
Feministing.com
describes a conversation with an older coworker: “She couldn’t believe that I didn’t know any woman my age who use a diaphragm. Most are on the Pill, I told her.”
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Indeed, the closest contact most women under forty have had with the diaphragm is watching the television show
Sex and the City
, in which the main character, Carrie Bradshaw, uses the device.

The reasons for this vanishing act are numerous. The safety of the Pill and the IUD have improved substantially, and in this age of HIV/AIDS, many couples opt for condom use. But not all of the reasons are practical. Birth control pills and other hormonal methods have made tremendous amounts of money for their manufacturers; a diaphragm, by comparison, only generates a small amount of income. Compare the Pill, which costs between $30 and $80 each month, with a diaphragm, which has a one-time cost of around $60 and lasts up to two years (although many doctors recommend being refit each year just to be on the safe side). There are additional costs for spermicidal jelly. Pharmaceutical giants pour enormous sums into advertising the Pill, using powerful television and print media images to promote oral contraceptive use. Ubiquitous commercials showing stylish, hip, ambitious, urban women continue to promote a certain idea of what makes an ideal contraceptive. At the same time, the use of older devices has been painted in unflattering cultural colors. The Pill is a Porsche, the diaphragm a Model T. It isn’t just about pregnancy prevention anymore, it’s about lifestyle choice. For the woman who has everything, taking the hot new brand of pills is akin to a designer bag, a killer job, or an elegant apartment.

In schools, sexual education programs inform students that while diaphragms are an option, it’s best not take risks. The Pill “works” better, although in this case, of course, the only marker of efficacy is a lack of pregnancy, and the other side effects of hormonal contraception are ignored. From a teenage perspective, this set of priorities makes sense. But misinformation about the diaphragm eliminates it as a potential option for those who want to explore nonhormonal contraceptive possibilities.

Education is not the only factor holding back barrier use: access is increasingly a serious problem. Traditional cervical caps are not currently available in the United States. Diaphragms are becoming more challenging to find by the day. I spoke to one young woman who had to visit three different
doctors before she found one that would fit her with a diaphragm, and she went to four pharmacies before she located one that would stock the item. Many practitioners aren’t trained to fit the devices properly or have limited experience doing so. Anyone can write a prescription for a pill, but it takes skill to choose the right size for a barrier. In addition, physician education—often funded by pharmaceutical companies—has stressed pill use to the point where (and I can speak from multiple firsthand experiences) health care providers are hostile to the idea of diaphragm use and encourage women to try many brands of oral contraceptives before exploring other options. I attended a reproductive health conference with graduate school–age women, where I listened to a presentation on contraceptive access. The young educator passed around samples of the various options so we could see them up close. As the diaphragm wound its way through the rows, I heard one woman giggle and say to her friend, “My God, it’s
huge.”
“I know,” the other said, “it’s so eighties.”

I believe it is worthwhile to work to overcome negative preconceptions and revive this old girl, this remnant of contraceptive past lives, as an active, available option for today’s women. In a country with record rates of uninsured people, and particularly many uninsured young women, it is worth asking why we would dismiss such a cost-effective, easily reversible birth control method. Barriers are the most effective woman-controlled, nonhormonal option besides a copper IUD and tubal ligation. As women age, the risks associated with hormonal contraception rise, particularly after age thirty-five. With so many vital pieces of knowledge about long-term hormone use remaining inconclusive, it would be a mistake to turn this easy, proficient option into a dinosaur before its time.

The Real Story behind Barriers

A major perception of young women about diaphragms is that they are messy and difficult to use. I believed this before I tried one, and I was shocked to find that the diaphragm is simple to prepare and insert.

A diaphragm is a rubber cup with a bendable ring that holds its shape. To use it, a woman fills the device with a tablespoon or two of spermicidal jelly, folds it in half, and inserts it into her vagina, checking to make
sure that the dome is covering her cervix (the small, firm, knobby protrusion located between the uterus and the vaginal cavity). After intercourse, a woman must wait six hours before removing the device. Repeated intercourse is possible without taking the diaphragm out; one need only insert more spermicide into the vagina.

I mastered the technique after about two weeks of practice; at first I struggled to find the right angle and to feel secure that it was in properly. After that warm-up period, use could not have been easier. It takes about the same amount of time to insert a diaphragm that it does to put on a male condom, but because it is inserted before intercourse—sometimes hours ahead of time—it doesn’t interrupt the mood or the moment in the same way that male barriers can. Inserting a diaphragm is slightly more complicated than popping a pill, but diaphragms free you of the need to think about birth control until you plan to have intercourse.

Diaphragms, like all birth control options, have drawbacks and contraindications. Women who have just given birth shouldn’t use them for a couple months and should be refitted after the birth of each child (although use while breastfeeding is fine after six weeks have passed). Women who have had recently had cervical surgery or undergone an abortion should likewise choose other methods. Those who have never had sex or are new to intercourse may have trouble inserting the device. People with an allergy to latex or spermicide, or people who are predisposed to urinary tract infections and toxic shock syndrome are not good candidates for this option. When women are menstruating they should use alternative contraception, probably a condom. Women should learn to recognize the movement of their diaphragm, so that in the rare instance it is dislodged or moved during sex, they will know quickly enough to act and prevent method failure or consider emergency contraception if necessary. Diaphragms are not a good choice for women who lack frequent access to sanitary facilities. They should be washed after removal with soap and water and inspected frequently for holes and tears.

When HIV/AIDS became an international health concern, researchers hoped that diaphragms could provide some level of protection against the infection. They reasoned that since the cervix is particularly vulnerable to infection, blocking it might provide a shield to disease. The MIRA (Methods for Improving Reproductive Health in Africa), a joint scientific study
involving the University of California, San Francisco, and the Medical Research Council of South Africa, set out to test the usefulness of offering patients a diaphragm along with condoms. The results, published in the
Lancet
, found that the device didn’t offer statistically significant protection above that provided by condoms alone.
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Condoms (male and female) are still the only barriers shown to provide HIV protection. The study was not designed to test whether diaphragms provided more protection against STIs than no barrier at all, and that remains an open question.

The cervical cap is a small, shot glass–sized silicone or latex plug that fits using suction over the cervix. It is significantly smaller than a diaphragm. The FemCap, the only available FDA-approved version of this device, resembles a tiny clear plastic sailor’s hat. FemCap isn’t fit like a diaphragm. Rather, it is available in three sizes: one for women who have given birth, one for women who have been pregnant but haven’t given birth, and one for women who have never been pregnant. As with a diaphragm, the cup is filled with spermicide before inserting. It is utilized by squeezing the cap’s rim, inserting the device into the vagina, and placing it directly over the cervix. Once inserted, the user should gently touch the cap to ensure that it is firmly suctioned in place. Eight hours after sex, the cap can be removed by pulling to release suction. The same side effects and cautions that apply to diaphragms apply to this method, with the additional disadvantage that the device is more frequently felt by—and thus a source of discomfort to—partners.

What is the reality of barrier efficacy? Is it simply less safe to rely on a diaphragm? That more pregnancies occur in barrier users than in women on the Pill cannot be denied. But when efficacy statistics are presented, particularly to young people, the ideal success rates for the Pill sometimes appear alongside the typical rates for barrier methods. Most women are well aware that ideally, the Pill works in the first year of use 99.7 percent of the time. Fewer women know that the typical use statistic for the Pill is much lower, with a success rate of only 91.3 percent.
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So for every hundred women who take the Pill for a year, between one and eight or nine of them will become pregnant. The diaphragm, when used correctly, works 94 percent of the time, with a typical use success rate of 84 percent. For every hundred women who use a diaphragm for a year, between six
and sixteen will become pregnant. Compare this with a male condom, which typically works about 82 percent of the time. What this means is that while not perfect, the diaphragm is an extremely effective contraceptive method.