Are you feeling uncertain about what the future will bring?
Yeah, me too.
Are you a person with female reproductive capabilities?
Yeah, me too.
Feelings of uncertainty around health care—and particularly women’s health care—are at an all-time high. For how much longer will we have an Affordable Care Act? Will it be repealed, replaced, repaired? Maybe you won’t have health insurance next year; maybe your doctor will no longer serve your area; maybe women’s health won’t exist as a discipline. (Kidding! Probably kidding. Actually, I can’t tell anymore.)
In the months since the election, women have faced this reality and taken action, which for many has meant utilizing some of the newer birth-control methods known as Long Acting Reversible Contraceptives (LARCs). These devices include IUDs and contraceptive implants; together, they’re a collection of technologically advanced, long-lasting, and incredibly effective options for the prevention of pregnancy. In part, LARCs are so successful because they remove human error from contraceptive management: Set it and forget it, so to speak, for somewhere between three and 10 years, depending on the method. They allow women to stop having to remember a pill every day or use a condom with every act of intercourse (though, of course, many still should), and because of that, LARCs have efficacy that is close to that of permanent sterilization.
Because we have good data showing increased efficacy, many doctors (including me) have been strongly encouraging our patients to consider these methods, especially in light of the, ahem, current political situation. Anecdotal evidence suggests that more women have been asking for them since election night.
Some patients are thrilled to get a LARC. But here’s a surprise: Many are completely uninterested in the idea. Some are outright hostile to it. Some of that resistance is just the ick factor, or the weirdness of adding parts to your perfectly functioning body. (Though I do think the contraceptive implant, in particular, is less painful than many piercings, and far more functional. This analogy has not yet convinced anyone, but I try.)
But I think the real reason women aren’t accepting LARCs is trust. Much of the LARC discussion is predicated on the idea that patients might not have access to a doctor anytime soon. This, we are saying, might be their last chance. The major advantage of the LARC is that, in theory, if they can’t get to a doctor they still have excellent contraception. But, in point of fact, if my patients don’t have access to a doctor or coverage for birth control, then who is going to remove the damn thing?
The thing about reproductive health care is that it is complicated, and intimate, and individual. The goals of that care change with every person, and for any given person, they usually also change markedly over time. So yes: An undesired pregnancy can be a tragedy. But—and this can be hard to realize, particularly in the context of birth control—the absence of a desired pregnancy is also tragic. And creating one of those tragedies in the medical effort to prevent the other is not a great solution.
Furthermore, this opposition to LARCs may be particularly resonant for the very populations targeted for LARC use—poor women, women of color—who have historically been subjected to acts of sterilization abuse, itself a practice with roots in eugenics and much admired by the Nazis.
Some providers are attempting to address these concerns. Other providers are working to empower patients to remove their IUDs by themselves. Yes, this may sound extreme, but to give some context, IUDs get removed unintentionally all the time; some women don’t even realize it happened, and it’s not usually a traumatic experience, except for the part where they are suddenly without birth control.
I guess, then, that managing your LARC on your own could theoretically be possible. But in my opinion, the patient–self-removal of LARCs is an iffy business. For one, this requires a level of comfort with the relevant anatomy that many women are just not going to be interested in achieving. For two, although there are no studies looking at this method, there could be some complications if the IUD gets only partially removed, or gets broken in the process, making the residual removal a much larger and riskier procedure.
However, this idea is mostly terrible because of the assumptions entailed: In the richest country in the world, we’re presuming a future for these patients where they do not have access to the health care they need. We are assuming this patient might not have the ability to contact a qualified medical provider—not for LARC removal, not for LARC–related side effects, not for annual health care maintenance, not for HIV testing or chlamydia treatment or appendicitis. We are assuming she will have nothing.
That assumption is abandonment; we are presuming she is off to the wilderness. And that possibility of abandonment can poison the offer of the LARC, and of most everything else a doctor can offer. Because, really, is a prolonged undesired contraception device really that different from old-timey sterilization abuse? Those practices, in these very same populations, echo loudly, and women can hear them.
These days, when I offer my 29-year-old postpartum patient a 5-year contraceptive option, she may hear that I have something that meets her needs and helps her time her pregnancies to her desires. Or she may perceive that our medical establishment is placing a device but not making access to removal a priority—that we are willing to spend money on preventing her ability to have children now, but we soon may not be as invested in her ability to be healthy or grow her family when she wants. My patient will probably hear that she will lose any liberty to plan her future childbearing unless she can get together enough cash to come in for a LARC removal. She will probably stop listening shortly thereafter. I can’t blame her.
That’s the thing about reproductive health care: It’s complicated; it’s intimate; it changes over time. And in reproductive health, it only takes a moment of mistrust to make a LARC impossible for a woman, even if it might otherwise be a great option for her. We invented LARCs, and that was great. But we also need to maintain access to our health care. Or it turns out that none of it does any good.