This week, US pediatricians (in agreement with a previous report from US gynecologists) announced a set of recommendations on contraceptives for young women. The headline grabber: IUDs and implants should be first-line choices. After all, they’re safe, effective, and as “set it and forget it” methods, reliable.
IUDs, formerly obscure, have become a little more popular in recent years. But implants? I didn’t know they were even still on the market.
Both have bad reputations based on ancient history, although (as the AAP and ACOG say) modern versions beat out other forms of contraception on almost any cost/benefit analysis. To those who object to potential side effects of hormonal contraceptives, it’s important to remember that contraceptives are safer than pregnancy.
So what’s the deal with these devices and why are they so obscure? Let’s step back into the time machine. First stop: 1971.
IUDs: the past
The Dalkon Shield, an IUD introduced that year, ended up being sold to 2.5 million women, of whom 17 died and 200,000 experienced infection, miscarriages, and hysterectomies. Lawsuits followed, some with hefty settlements, and it was pulled from the market.
IUDs: the present
Discussing this history, Anna Bahr of Ms. Magazine quips that “the new and improved IUDs are like iPhones compared to the telegrams of old.”
As the AAP report discusses, today’s IUDs are safe even for women who have never had children (in spite of old warning labels that said otherwise). Another concern, that women who contract a sexually transmitted infection are at higher risk of getting pelvic inflammatory disease, is only a risk in the first few weeks after insertion, and so providers can test for STIs at insertion time.
Implants: the past
If you’ve heard of contraceptive implants, you’re probably thinking of Norplant, the 6 implantable rods that were offered to, and perhaps pushed on, poor women and especially poor women of color in the early 1990s. The mini-documentary Skin Deep talks to some of these women, who experienced side effects they say they weren’t warned about, and who found it easy and cheap to get the device inserted but are having trouble getting it out. A doctor explains how difficult the removal process will be; a woman on public assistance says that she knows women who paid to get it inserted and removed, but that her doctor refuses to remove it. (The same laws that provided free insertion didn’t cover removal.)
About 10 minutes in, the Dalkon Shield makes a cameo, as the women compare the two methods, saying they felt like they were experimented on.
Implants: the present
Like the Dalkon Shield, Norplant is no longer on the market. Single-rod implants (Implanon and Nexplanon) are now available, which have milder side effects and are easier to remove.
But still, old-fashioned attitudes are a major barrier, among both patients and providers. Take this op-ed from a doctor on Fox News. He says that while as an obstetrician he understands that IUDs are a great choice, as a father he would never recommend one to his teenage daughter. Why? He brings up issues from the bad old days, and neglects to consider that the risks of modern IUDs are far less than the risks that accompany pregnancy.
What does he recommend instead? Abstinence. In case the flaw in his logic isn’t clear, here is what the AAP’s report says about this method, which should be 100% effective with “perfect use” (compare to 99.95% for implants and 99.8% for IUDs, rates that are nearly identical for typical and perfect use in these methods):
…existing data suggest that the ["typical use"]
effectiveness of abstinence for preg-
nancy and STI prevention over ex-
tended periods of time is likely low. For
example, among adolescents reporting
virginity pledges in the National Longitu-
dinal Study of Adolescent Health, at 6-year
follow-up (wave 3), 88% had engaged in
sexual intercourse (most premarital), and
5% were infected with STIs.
They go on to recommend that providers check in with the patient at each visit to ask if they still intend to remain abstinent, and to make sure that they understand the other options available. (This includes gay and lesbian teens, because some will occasionally have opposite-sex partners.) It’s a smart attitude for doctors, and it would be a smart attitude for parents to adopt, too.
The AAP report devotes several pages to the minefield of confidentiality and consent, noting that girls are better about using contraceptives when they don’t have to explain it to their parents, but insurance billing, among other things, makes this difficult.
After all, the age when a person starts having sex, and the age when they are ready to be a parent, are typically many years apart—no matter what their old-fashioned father thinks.