CONTRACEPTION, PLANNING A FAMILY AND INFERTILITY
Contraception literally means ‘against conception’ and any practice, device or substance which prevents conception is said to be contraceptive. So, clearly, abstaining from intercourse is a means of contraception, as is oral intercourse, anal intercourse, mutual masturbation and, for that matter, any sexual activity that does not involve intercourse between a fertile man and a fertile woman. The practice of sterilisation, in which the tubes delivering the eggs or sperms are interrupted, can be used to make either sex permanently infertile. Avoiding intercourse at and around ovulation, or the man withdrawing his penis from the vagina before he ejaculates, are both contraceptive practices. The use of devices which allow him to ejaculate in the vagina but which prevent the sperms reaching the cervix are contraceptive as are those such as the Pill which prevent ovulation occurring. Although abortion is sometimes spoken of as being a form of contraception, it clearly is not and, since it often allows conception to occur, the IUD is probably not really a method of contraception in the strict sense but is included here nevertheless. No one really knows how the IUD forces the lining of the uterus to eject the fertilised egg — it should in fact be considered as a kind of extremely early method of abortion rather than a type of contraception.
We have called this chapter contraception and planning a family because the two are rather different. Contraception, is by definition simply a way of preventing the conception of a baby, but family planning may well involve the planned spacing of children. Many women attending so-called ‘family planning’ clinics are not planning a family at all — they are looking for a ioo per cent successful way of not getting pregnant, often for the many fertile years after they’ve finished having their children.
If words mean anything, and contraception means ‘against conception’ then any method with a significant rate of failure is clearly not truly contraceptive. We feel this point is worth making because the topic is often discussed as if there were a wide choice of efficient methods. This is simply not so.
If a couple want to avoid conception but also want to have intercourse freely, the method they use should ideally be ioo per cent effective. To some extent the method they choose will depend on the woman’s age since most couples are increasingly less fertile after thirty or so. For the older woman a less efficient method can be used yet still be highly effective because her fertility is less high as a result of her having less intercourse as she and her partner age.
As well as being efficient, the ‘ideal’ contraceptive method needs to be acceptable and simple. A ioo per cent efficient method which is so complex that only 10 per cent of the population are able enough to use it properly is only 10 per cent effective. Similarly, a ioo per cent efficient method which is unacceptable to 90 per cent of the population because of, for example, religious reasons, medical fears, messiness, or interference with sexual pleasure, is again only 10 per cent effective.
However effective any given contraceptive method is in theory it is only as reliable as the person using it. A major and powerful influence affecting personal efficiency in the practice of contraception is motivation. The essential point to grasp here is that unconscious factors can so easily alter a person’s conscious intentions. Many so-called ‘method failures’ in which the individual woman claims to have used the method conscientiously but nevertheless has become pregnant, are probably caused by an unconscious deliberate mistake. The topic is a large but often ignored one and it is only possible to give a few examples here.
The young are particularly likely to be victims because, although they may consciously believe that they are free from guilt about intercourse, unconsciously they are still strongly influenced by the moral teaching of our culture instilled into them in their childhood. A sexually inexperienced girl may say to herself, out of guilt, after each time she has intercourse, that she is not going to do it again until she is married, so there is no need to go to a doctor or a clinic to get an effective method of contraception. Indeed, to take such a step, she may well think, will only encourage her to ‘sin’ again. This accounts for the apparent paradox of the girl who will not use contraception until she is ‘going steady’. The point is that she has been taught that sex is justified only if you love a man. So before that blessed state arrives she is constantly trying — and failing — to avoid sex by avoiding contraception. It is because of this that many girls reared with excessive and unreasonable moral restraints are among those most likely to have unwanted pregnancies. Such girls often deny to themselves, as much as to others, that they have sexual desires, and so they, unlike girls who can accept their sexuality, never prepare for sex. The all too obvious point that only those who thoroughly accept their sexuality have any hope of controlling it is largely overlooked, both in child rearing and sex education, especially as far as girls are concerned.
One of the first things that girls are told about their sexuality in our culture is that they will grow up and one day have babies like mummy. The strong unconscious notion is thus imparted — and later greatly reinforced — that sex is for babies. From this it is a short step to believe that sex other than for babies is sin and that pregnancy is the punishment. This view lurks behind much anti-abortion propaganda.
The consequences of all this for contraception and family planning are enormous. Some women cannot enjoy sex unless there is a chance of pregnancy. This leads to contraceptive fecklessness such as stopping the Pill on the most trivial of excuses. Often actions such as this are rationalised on the grounds of medical fears, or the fear of fatness, for example, but the real underlying fear is that of sin; the woman has not fully accepted her right to sexual pleasure although at a conscious level she may regard herself as completely uninhibited. Eventually her fear of pregnancy will drive her back to the Pill, but she will be vaguely unhappy and may even say her sex drive or her ability to achieve orgasm has gone. In this way she writes off the only 100 per cent effective method and her unconscious desires will have been fulfilled. Other consequences are that such a woman will unconsciously see a pregnancy as punishment, and accept it, even though it does not fit into her plan for her family; for the same unconscious reasons (needing a possibility of pregnancy) a woman may lose all pleasure in sex after she has been sterilised or reaches the menopause.
Other unconscious motives for frustrating contraception whilst consciously trying to ‘contracept’ are: to escape from a work situation; to punish parents; to provide a dependent baby who will really love her (she thinks that no one has ever really loved her); to give her partner something to worry about; to compete with a sister, a friend, or a colleague; to prove her fertility (many women fear that small breasts, scanty periods, a previous abortion, or using the Pill have impaired it); and so on.
All this leads us to the conclusion that effective contraception starts with sensible child rearing in respect of sex. Beyond that, and provided that the underlying attitudes are satisfactory, then it is true to say that the only true contraceptive we possess at the moment is the Pill (oral contraception). It is the only method which approaches totally efficiency. Unfortunately, recent evidence has found that there are real, if small, health hazards in women over thirty-five who use the Pill and are fat, have high blood pressure or smoke, so this makes it only suitable up until this age. After thirty-five it is probably best for women to use a progesterone-only Pill (the so-called ‘mini’ Pill; it is the oestrogens in the Pill that are mainly suspected of causing the problems in older women), or another method. Let us now look at the main types of contraception.
Currently, about 1.7 million UK women use family planning clinics and 2.7 million their GP. For 84 per cent of the latter the Pill is prescribed whereas only 55 per cent of clinic patients receive it. The implication of this is that probably clinics tend to see more patients with problems since the diaphragm, IUD and natural methods are more likely to be prescribed.
Due to costly litigation in the US, the pharmaceutical industry is slowly withdrawing from research into contraception and this, combined with the effects of concern about AIDS, is likely to affect the overall situation in the future. In fact, a world expert has said that things will continue to deteriorate so that at the close of the century we will end up with fewer contraceptive methods than we started the century with.
Girls under 16 require parental consent to their receiving contraceptive advice. Provided her parents are sensible and realistic this is wise. If the girl is really unwilling to approach her parents a doctor can still prescribe for her if it is in her best interests to do so, if she is mature enough to understand and is having, or intends to have, intercourse regardless and may suffer if help is withheld. This also is wise.
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