In Our Control (34 page)

For now, women’s health advocates are gathering information and trying to think through the potential positives and pitfalls of changing the way that women get birth control. “It’s all so complicated,” Allina told me. “How this plays out in the reality of women’s lives is really the question.
Is it more of a barrier to access to sit in a clinic for two hours and pay for a doctor’s visit? Or is it more of a barrier to pay a higher price for the drug? It’s a tough question.”
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The issue of gaining insurance coverage for contraceptives has been a feminist battleground for decades. Women are no strangers to navigating political minefields on the way to picking up their birth control pills. Today it is estimated that only 15 percent of indemnity insurance plans and 39 percent of HMO plans cover all FDA-approved contraceptive methods. Only twenty-seven states require insurers who cover prescription drugs to pay for contraceptive drugs and devices,
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and many of these have conscience clauses and opt-out policies for employers and insurers. This means that women spend 68 percent more money out-of-pocket on health care than their male counterparts.
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Still, the proportion of insurers who cover contraceptives has skyrocketed in the past decade and is three times higher than just ten years ago.
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For low-income women, there is good news and bad news. The good news is that family planning coverage is mandatory in the Medicaid program. Title X programs, which provide services for women at varying income levels but largely focus on people below the poverty line, fill an important gap in coverage for women who don’t qualify for Medicaid. This program also provides family planning services, but (and here’s the bad news) the program is chronically underfunded. Since 1980, this resource, which provides contraception to 4.2 million women, has seen its funding slashed by 61 percent.
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Ironically, the contraceptive equity movement really gained steam when insurers who refused birth control coverage began paying for erectile dysfunction drugs. Women from both sides of the political spectrum saw the injustice of covering drugs that may lead to unplanned pregnancies while refusing to pay for prescriptions to prevent them. While this comparison has proved powerful, Gretchen Borchelt, senior counsel for health and reproductive rights at the National Women’s Law Center, notes, “Certainly we want to think more broadly than just Viagra.”
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When Margaret Sanger and the early mothers of modern contraception allied their movement with the medical profession, they made a bargain: contraception would be a health issue, not a sexual one. In exchange for legality and respectability, women would cede some level of
autonomy and authority. The unwillingness of insurers to cover sexual health products breaks this time-honored arrangement. Either contraception is medicine or it is not. If it is not, then women shouldn’t have to go through gatekeepers to get it. If it is, then it should be covered like any other prescription pill.

Chapter Eight
Running in Cycles: Fertility Awareness and Natural Birth Control

I’m dreaming now: of adolescents knowing how their reproductive systems work before they become sexually active and before they choose a birth control method; of women and men being as aware of our fertility as we are about our sexuality
.
—Katie Singer

Something was in the air as I took the podium to talk to a group of graduate students in Washington, DC, in February 2009. I hesitated as I began to speak, sharing the history of hormonal contraception and moving on to the current issues surrounding birth control today. When I opened up the conversation for questions, hands flew up. I expected some to be annoyed about my cautious attitude toward the Pill or perhaps curious about new drugs like menstrual suppressants. Instead, the women wanted to know about fertility awareness.

“Given the lack of innovation in pharmaceutical contraception and the dangers of existing methods,” asked a quiet, chicly dressed redhead, “what is the future of birth control? Is it fertility awareness?” Mumbles of agreement spread around the sunny conference room.

It wasn’t the first time I had faced this question. In the past year or so, friends had begun to inquire in hushed tones about the possibility of natural birth control. We had all been raised in the church of the Pill, and such talk was blasphemous. The reasons to fear natural methods were well known: they were unreliable, risky, and the near-exclusive practice of quite another church. And yet as my friends edged closer to thirty and problems with other types of birth control persisted, they began to chip away at the gospel of pharmaceutical infallibility. They came to me because I was a well-known heretic.

What are the facts and fictions surrounding natural birth control methods, particularly fertility awareness? Is it indeed a viable method of
managing fertility, simply a useful system for acquiring knowledge of one’s body that should have little to do with contraception, or an unreliable crackpot method suitable only for religious fanatics and pharmaceutical alarmists? How do religious and social relationships affect the acceptance and availability of knowledge about this type of fertility control, and are those historical alliances shifting?

History, Naturally

A surprising fact about the Fertility Awareness Method (FAM), either as a method of birth control or a tool for improved gynecological health, is that it is a modern method that stands alongside the Pill as a twentieth-century innovation. Although women have been manipulating their fertility for as long as they have been menstruating, good knowledge about the ovary and how it functions has emerged slowly over the past two thousand years. While interest in the uterus was more profound until the end of the nineteenth century, these olive-shaped and sized organs have attracted ample speculation and misinterpretation over the course of recorded human history, and only in recent years have we come to fully understand what they do and how they do it.

It is impossible to know who was the first individual, driven by curiosity, eccentricity, or perhaps something darker, to open the abdominal cavity of a female animal or human and notice these tiny matching organs sitting like ears on the sides of the uterus. Aristotle observed that castrating animals seemed to have an effect on their sex drives but didn’t extend the possible implications of this information to humans. His influential theory of human conception, which continued to inform doctors for well over a thousand years, was the “seed and soil” model: the female body provided rich “soil” in which the male “seed” could thrive. In this system, the ovary was essentially irrelevant. Other doctors and philosophers quickly began to consider that perhaps the ovary had a direct role in reproduction, and second-century Roman physician Galen believed that it made a kind of sperm. But interest in the ovary stalled—or at least slowed precipitously—for about a thousand years.

Then in the sixteenth century, Fallopious (1523–1562) explored the existence
and function of the tubes that bear his name and compared the ovaries with the male testicles. It was around this time that the two oval female glands acquired their name. Despite changes, many doctors continued to believe that follicles and ovulatory material were a product of, rather than a partner in, conception.

Regnier de Graaf (1641–1673), a Dutch physician and anatomist, believed that the ovary was important and had been misunderstood and underestimated by those who came before him. De Graaf rejected older notions that ovaries were appendages and dismissed false analogies between male and female reproductive systems. He wrote in 1672 that he believed the whole organ was a giant egg, just like the kind laid by birds. De Graaf based this conclusion, in part, on experiments conducted with the recovered ovaries of corpses, which he boiled and tasted.
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He insisted that the taste was similar in texture and flavor to avian products. In all of this questionable experimentation, de Graaf noticed something important: he became one of the first to accurately describe the corpora lutea (what ovarian follicles become after ovulation has occurred).

By the end of the seventeenth century, three distinct schools of thought had emerged concerning what ovaries actually did and their role in making babies: the first held firmly to the Aristotelian view that men were the active agents in conception and women were simply loyal farmers who nurtured their crops. The second believed that the ovary itself was the site of conception. A third, approaching something closer to (although still distant from) the truth, believed that the ovaries were female testes that produced some sort of reproductive product (although it would still be many years before the clear differences between these male and female organs would be spelled out).

In the eighteenth and the early nineteenth centuries, doctors continued to worry about the exact anatomy of the ovary. Many ideas, some ahead of their time, were in the air, including the notion that the actions of the organs controlled menstruation. These ideas were noted, although largely ignored, by a medical world that still believed that menstruation had a purgative quality and therefore functioned to relieve the body of toxins, not in response to hormonal fluctuations.

As with so many discoveries about women’s bodies (and bodies in general), more substantial knowledge about the ovary began to emerge in the
nineteenth century, in part in response to an increase in the desire of doctors to perform surgeries on them. In the 1840s Félix A. Pouchet, a French naturalist, debunked the belief that the ovary functioned in response to sexual intercourse. Pouchet was used to working with animals, and like so many before and after him, drew mistaken analogies between human and nonhuman bodily processes. He believed that menstruation was equivalent to heat in nonhumans and proposed therefore that ovulation must happen during menses.
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His belief that bleeding signaled the start, rather than the end, of the menstrual cycle would haunt the practice of natural birth control well in to the twentieth century. Other thinkers, such as Adam Raciborski, thought that Pouchet was wrong. In 1843 Raciborski published his observations about recently married women. He noticed that those married after the twelfth day of their menstrual cycle were less likely to become pregnant than those married in the first half of the month.
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Still, the damage was done, and the notion that midcycle sex was safest for pregnancy prevention was popularized.

These decades of uncertainty and the contraceptive systems that emerged based on faulty science created a deeply held distrust on the part of women and their partners of the use of bodily indicators alone to predict fertility. To this day, many educated people believe that natural methods rely exclusively on such outdated and mistaken ideas about the female body.

By the 1870s doctors had discovered ovulation, and this realization triggered a shift in focus away from the uterus as the center of female health. It also set scientists on a path that ended with the discovery and isolation of sex hormones and the eventual development of contraceptive methods based on them. By 1905, another Dutchman, Theodor Hendrik van de Velde, showed that women ovulated only once during an individual menstrual cycle. Then in the 1920s two doctors independently made a breakthrough:
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Hermann Knaus of Austria and Kyusaku Ogino of Japan both found that in women with normal menstrual cycles, ovulation occurs approximately fourteen days before the onset of menstrual bleeding.
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Before women knew how their ovaries worked in relation to their menstrual cycles, they couldn’t avoid or engage in sex strategically to control fertility. It just wasn’t possible. Once better information became available, exactly how best to use this information remained—and to some extent remains—an open question.

In this sense, methods of contraception based on fertility awareness are twentieth-century innovations. They are developments contemporary with the Pill, and historically postdate older methods like condoms, cervical caps, and IUDs.

Becoming Aware: Different Methods of Natural Fertility Control

One of the most confusing things about understanding natural contraception is realizing that there are several different methods and combinations of methods that have been used over the past seventy-five years.
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They are different in ideology, approach, terminology, and efficacy. Understanding these distinctions is the first step in evaluating whether and to what extent fertility awareness can play a role in your own contraceptive choices.

When I call these methods “natural,” I mean only that they involve no chemical, surgical, or device intervention to prevent pregnancy (although of course many people use them in combination with other methods, particularly barriers). I am specifically not making any sort of moral or ideological judgment about what people should or shouldn’t do to manage their fertility. As a person who has used pills, barriers, and occasionally fertility awareness, I believe that there will be a different answer to the question of how or whether to prevent pregnancy for every adult engaging in heterosexual sex. And as I hope my discussion of the mythical cavewoman in previous chapters has made clear, I have no interest in theorizing about what is natural or unnatural when it comes to sex.

There are four major types of natural contraception: calendar (which uses a woman’s menstrual cycle to guess when she will ovulate and therefore avoid sex for several days around that time), those based around fertility signs like cervical fluids and cervical position, those that analyze changes in basal body temperature, and approaches that use devices such as saliva tests or fertility monitors to estimate when ovulation has occurred. Other approaches combine various aspects of these different methodologies. Calendar-based methods (such as the rhythm method) and systems that use abridged monitoring of fertility signs don’t work nearly as well as comprehensive regimens that look at temperature, cervical fluid, and other
physical indicators that ovulation is going to happen. This latter system is usually called the fertility awareness method, or FAM. Experts who teach FAM lament the association of what they consider a reliable way to control fertility with much less predictable methods based largely on guesswork.