‘Cervical mucus? I’m digging it!’ : contraceptive decision-making and natural family planning in times of the hormonal imperative

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Medical

Anthropology &

Sociology

Master Thesis: Francesca Patan Student-ID: 10501657

Supervisor: Dr. Bregje de Kok Second reader: Dr. Eileen Moyer 11 August 2018, Amsterdam

Source: mynfp.de

‘Cervical mucus? I’m digging it!’

Contraceptive decision-making and natural family planning in

times of the hormonal imperative

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Table of contents Chapter 1. Introduction 1

Acknowledgements

First of all, I would like to thank all my informants without whom, this project wouldn’t have been possible. I am so grateful that all of you have been so open and honest with me. Thank you for inviting me to your world and sharing your most intimate and vulnerable experiences with me. I appreciate your honesty which this project is based on.

Next, I would like to thank all the sensiplan-counsellors who have supported my project and shared their contacts with me. Above all I would thank Mrs. Dechow for inspiring me, thinking with me and introducing me at conferences and workshops. Thank you Ada, for being my main inspiration to do this project.

I owe special thanks to my supervisor Dr. Bregje de Kok for her dedication and attentiveness. Her detailed feedback and meetings guided me through my own decision-making process which was this thesis. Thank you for your time and for always doing your best to work towards a solution.

I would like to thank my family, my boyfriend and my friends – who’s names I have used as pseudonyms – for all the mental and emotional support, sending all this positive energy my way. Especially my parents have been a great help: I wouldn’t know what I would do without you! Last but not least, I would like to thank my small but mighty writing group. Every session was motivational in its own way; and there was always someone with a friendly ear for my questions and reasoning.

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List of abbreviations Chapter 1. Introduction

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List of abbreviations

AK Authoritative Knowledge BBT Basal Body Temperature CI Coitus Interruptus

ECOC Extended Cycle Oral Contraception

FAB Fertility Awareness-Based Methods (Umbrella Term)

FAM Fertility Awareness Method (Method promoted by Toni Weschler) IUD Intrauterine Device

MDH Malteser Hilfsdienst e.V. (German Aid Agency) NER Natürliche Empfängnis Regelung

NFP Natural Family Planning STM Symptothermal Method

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1.1. Contraception in Germany Chapter 1. Introduction

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1. Introduction

I have just started my research on natural family planning in Germany. It’s my first time being in a gynecologist’s office, after ten months of successful usage of the sensiplan method as a contraceptive method. The sensiplan method uses body observations of the female body to determine its fertile phase and enables users to either abstain from sexual activity or use a barrier method during that phase. I am a little nervous to see a new doctor today as I am in a new city. It’s warm outside. I go up the cold staircase to the first floor and wait at the receptionist’s table. The receptionist is a small lady in her late forties with dyed burgundy hair. She greets me with half a smile and asks for my insurance card. After receiving it, she sends me to the waiting room. I take a seat next to the open window. A couple of minutes later the receptionist enters the waiting room and hands me an iPad. Since you are new here, you need to fill this out, she says. I’m impressed with this technology in a gynecologist’s office in a rather small town in North Rhine-Westphalia. It saves a lot of paper work I guess. The iPad asks me where I live, when I had my first period, what types of illnesses run in my family and finally the question: What is your current method of contraception? I stumble. The iPad offers several options: the contraceptive pill, the contraceptive patch, the vaginal ring, the intrauterine device (IUD), injectable birth control, condoms, and none. Diaphragm is not on the list, I observe, and there is no sign of any natural family planning method. I get up and walk back to the receptionist’s desk. Assuming that I have finished filling in the patient form, she reaches for the iPad without even looking at me. Excuse me, I say, I am a little confused about the methods of contraception. I use sensiplan and it’s not on the list. Now the receptionist looks confused. Sensiplan, she asks, is this the new hormonal patch? No, I answer, it’s a method without hormones. Well, you have to communicate this with the doctor then, she answers before she disappears behind her computer again. At first, the gynecologist seems interested but has no clue what I’m talking about: Oh you count days then? No, I reply and try to include as many studies, famous doctors and fancy words in my explanation of the method. Nevertheless, she insists on recounting the advantages of the hormonal pill, before she puts me in the gynecological chair. I spread my legs while she asks if I’m not worried using such a risky method. In this context, where natural family planning is seemingly non-existing, situations like the one I encountered lead to the questioning of my ability to take a responsible and thought-through decision.

1.1. Contraception in Germany

My encounter at gynecologists office shows how contraceptive choices are dominated by hormonal options. This line of thinking seems to remain dominant even though pharmaceutical companies, got some bad publicity over the years. Especially the outrage around the pharmaceutical company Bayer contraceptive pill was prominent in the German media. Newspapers reported that Bayer was accused to produce a contraceptive pill which caused thrombosis and even heart failure in dozens of women (Weber, 2015). In 2012, 651 women all over world were compensated by the pharmaceutical company from Leverkusen, Germany (ibid.). According to the German ‘Initiative Thrombose-Geschädigter’ (initiative of thrombosis victims due to hormonal contraceptive pill

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1.2 Natural Family Planning in Germany Chapter 1. Introduction

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intake) the contraceptive pill claimed the lives of at least 28 women in Germany and 190 in the USA; and made others sick for lifetime1_{. As a result, even health insurance companies in Germany}

warn against particular contraceptive compounds according to the German ‘Pillenreport 2015’2

(Glaeske & Thürmann, 2015). This report as well as other European medical journals emphasize the increasing risk of thrombose as a the side-effects of oral hormonal contraceptives, especially the new – thus the third and the fourth – generations of contraceptive pills are considered as health-damaging (Birkhäuser et al., 2000; Glaeske & Thürmann, 2015; Hanbury & Eastham, 2016; Mallmann, 2013; Martinez et al., 2015; Möstl & Maier, 2012; Sheldon, 2002; Winkler, 2006). The ‘Pillenreport’ was much discussed in the German media (Apotheke Adhoc, 2015; N-tv Online, 2015).

For generations before that, the pill was considered as the tool for emancipation, putting women in charge of their fertility, enhancing their sexual freedom and through that increasing women’s agency all over the world (Weschler, 2015). Nevertheless, the negative side-effects are more often emphasized from different fronts within the Germany society and a rising number of women express that they do not want to use artificial hormones as method of contraception anymore (Gerstmeyer, 2018). However, it seems that there is no alternative method which can compete with the simplicity, spontaneity and efficacy of hormonal contraception (Tone, 2012). This might be some of the reasons why the majority of women up to today uses the contraceptive pill or some other hormonal methods (ibid.). According to the Federal Centre of Health Education in Germany (BZgA), 91% of women under the age of 25 have experiences with the contraceptive pill (Baier, 2017). The professional association of German gynecologists claims that over 65 % of adults who use contraception choose hormonal methods3_{. Albeit the most used hormonal method}

of contraception, the public image of the pill obtained a severe crack – and yet it is still the most chosen method in Germany, just like everywhere else. This points to one contradiction linked to contraceptive decision-making and it sparked my interest in 1) the contraceptive decision-making itself and 2) into women who use non-hormonal contraception.

1.2 Natural Family Planning in Germany

As the natural family planning (NFP) scene is very active due to the NFP working group, I choose to research in Germany. The NFP working group documented 43.000 cycles by 1.700 women, which is the largest database in Europe (Raith-Paula, Frank-Herrmann, Freundl, & Strowitzki, 2015). Non-hormonal methods of contraception include condoms, diaphragms, vasectomies and among others natural family planning (NFP). Natural family planning (NFP) includes fertility

1_{http://www.risiko-pille.de/}

2_{This report was facilitated by the University Bremen, Germany}

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awareness-based methods (FAB) and coitus interrupts (CI) often referred to as withdrawal (Freundl, Sivin, & Batár, 2010: 113). Under FAB several methods are pooled together, as for example the calendar/rhythm method in which the fertile days of the current cycle are estimated based on previous ones or the temperature method which is based on measuring temperature to ‘indicate that ovulation is likely to have occurred’ (ibid.: 114). Also, the symptothermal method (STM) with the patent name sensiplan, is one of these methods which combines the daily observation of the body basal temperature (BBT) and the monitoring of the cervical mucus. Other fertility signs such as the position of the cervix can be included as well. Sensiplan is the only NFP method based on the double check principle (ibid.: 117). The German NFP working group and other scholars argue based on the evidence collected, from their database, that sensiplan is effective in preventing pregnancy, it is more effective than other NFP methods and its Pearl-Index can be even compared to hormonal contraception (Frank-Herrmann et al., 1997; Freundl-Schütt, Wallwiener, & Freundl, 2016; Freundl, Herrmann, Brown, & Blackwell, 2014; Gnoth, Frank-Herrmann, & Freundl, 2002; Raith-Paula et al., 2015). Unfortunately, there are no exact numbers on how many women use sensiplan in Germany. According to the UN, 3,7% of the women living in Germany and using contraception decide to use FAB methods (Freundl et al., 2010: 116).

The pooling of all FAB methods leads to a problem: All of them are framed as inefficient, even though scholars try to emphasize the efficacy of sensiplan in comparison to other methods. The media contributes to this common mix up of sensiplan and methods that are based on counting days (Gerstmeyer, 2018; Uhlmann 2018). In the German media, contraception-apps which follow the counting pattern have been portrayed rather negatively lately (Gerstmeyer, 2018; Uhlmann, 2018). Especially the case of 37 Swedish women getting pregnant while using a fertility tracking app was highly discussed (Huffingtonpost, 2018; Uhlmann, 2018). As a result, all NFP methods are framed as ‘unsafe’ within the broader German society. This points to another controversy women are facing in their contraceptive decision-making, especially if a woman’s choice is to contracept with sensiplan. In this controversial context I will find out more about the contraceptive decision-making of women living in Germany. I choose to focus on women who have discontinued hormonal contraception and transitioned to sensiplan, because they are a minority group within the German context dealing with presumptions regarding efficacy, safety, simplicity and so forth of their chosen method. As shown above, the biomedical field has provided a lot of research on sensiplan. To my knowledge however, sensiplan as a method of contraception has not been researched much within the field of anthropology. Therefore, I can make a valuable contribution with my research to the field by focussing on the contraceptive decision-making process of this particular group.

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Within this controversial context of multiple information flows, different knowledges on hormonal contraceptives and contraception in general as well as on sensiplan, women are making their contraceptive decisions. I will research this process based on the following key question: How do women who discontinued using hormonal contraceptives take contraceptive decisions? I will answer this question in this thesis based on three months of fieldwork in North Rhein Westphalia (NRW). I chose this region because the NFP scene is very active there. This is related to the German Malteser Hilfsdienst e.V. (MHD) having their headquarters in Cologne, a catholic aid agency which finances the NFP working group. The MHD also owns the patented symptothermal method called sensiplan. Sensiplan is based on STM knowledge, but it holds a particular set of rules. The MHD offers seminars for women and couples wanting to learn more about the method and facilitating trainings for new sensiplan-counsellors creating this active engagement with STM in this region.

In my thesis, I argue that this decision-making process is embedded in meaning, (bodily) experience and their intersection. Within the contraceptive discourse dominated by medicalization and hormonal birth control, women make a decision on a method for contraception, influenced by society, knowledge, bodily experiences and their social environment as partners, friends, family, gynecologists and NFP-counselors. I will explore the experiences of women who discontinued hormonal contraception and switched to sensiplan, how they assign meaning to their experiences and their contraceptive methods and how those in turn influence their decision-making, in the German context. First, I will focus on how my informants constructs the meanings of hormonal contraception and how they assign these meanings based on their experiences. Secondly, I will dive into the importance of knowledge in contraceptive decision-making in times of the hormonal imperative. Thirdly, I will look at the meanings of sensiplan and the connection of bodily experiences and contraceptive decision-making. I will argue that those meanings are crucial to the women’s decision-making process and are arising from a combination of knowledge and bodily experiences which are reinforcing each other.

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1.3 A brief introduction to the sensiplan method Chapter 1. Introduction

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1.3 A brief introduction to the sensiplan method

Figure 1: Cycle Sheet sensiplan (Raith-Paula et al., 2015: 47)

In the following, I will describe the sensiplan method in a nutshell in order to explain important terms, to provide an inside into practical application of the method and to give a first indication why it might be framed as controversial or unreliable. One note ahead, it is very interesting that in the subject literature NFP includes so many different methods, while in the German field that I encountered NFP means STM means sensiplan. I could reflects on this even more, but due to space reason, I choose to leave it at that and follow the field by using sensiplan and NFP interchangeably. The sensiplan method attempts to detect the beginning and the end of the fertile phase by using body observation as a tool (Raith-Paula et al., 2015)

Therefore, the basal body temperature (BBT) needs to be observed. The BBT should be measure at as many days as possible, sensiplan requires at least six low temperature days to comply with its promised Pearl Index 0,44_{(Freundl-Schütt et al., 2016). A rise in the BBT indicates the}

ovulation, if the BBT stays high for three days – there might be exceptions – the cycle can be evaluated; but only if the control value – cervical mucus or position of cervix – is in place as well. All women I encountered use the mucus observation, so I will focus on how to evaluate the mucus: 1) the appearance of the cervical mucus and 2) the feeling (Empfinden/Fühlen) of the vagina are

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1.3 A brief introduction to the sensiplan method Chapter 1. Introduction

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observed. The appearance of the mucus can be for example white and cloudy or slippery and clear (see cover page), the latter is fertile mucus. Connected to the fertile mucus is a wet feeling in the vagina, while other feelings can be dry or moist. The mucus peak is shown by ‘H’ in the sheet (figure 1), after ‘H’ three days the infertile phase can be anticipated if there have been three high temperature values. A barrier method, e.g. condom, diaphragm has to be used during the fertile days.

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2.1 The contraceptive discourse Chapter 2. Empirical and theoretical inspirations

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2. Empirical and theoretical inspirations

In the following, I will review the anthropological literature on hormonal contraception and discuss important theories and concepts within this literature. I will focus on the medicalization of reproduction, the normalization of hormonal contraception and the feminization of contraception. All three point to the idea that within the contraception discourse there is one dominant way to contracept; that is hormonal contraception. It is in relation to that discourse that women assign meaning. In addition, I will focus on the conceptualization of decision-making in different disciplines, the agency of women and the role of knowledge in relation to contraceptive decision-making. I will use feminist phenomenology to work with the experiences of the women to be able to focus on individual experiences as a minority resisting the dominant discourse. Furthermore, I will discuss the notion of embodiment since I use it as a lens of to look at bodily experiences and how they intersect with decision-making.

Several qualitative studies from the field of anthropology focus on hormonal contraception (Gunson, 2010; Hanbury & Eastham, 2016; Hardon, 1997; Kimport, 2018; Purdy, 2001; Tone, 2012; Waller, Tholander, & Nilsson, 2017). Anita Hardon, reviewed social science studies on ‘the acceptability of the hormonal contraceptives used most extensively in family planning programs worldwide’ (Hardon, 1997). Hardon claims that we have little understanding of women’s views on and experiences with hormonal contraceptives, because many researches focus on the aspects which are important for biomedicine or policy-making. As a result, viewpoints and experiences of women as contraceptive users are not included. Based on her review Hardon comes to the conclusion that more qualitative research in the field of contraception is needed and proposes eight types of studies. With my research I can contribute to a number of Hardon’s proposed research foci: I will shed light on women’s ‘preferences, experiences and practices during their reproductive lives’, I will ‘determine in what way women’s […] views on, use of and experiences with fertility regulating methods are related to the quality of services that provides the method’ and I will ‘deepen understanding of women’s […] health concerns about existing hormonal contraceptives’ (ibid.: 74). Those are some gaps in the literature to which I will contribute with my research.

2.1 The contraceptive discourse

Other anthropological and sociological scholars have contributed to the body of literature on the medicalization of reproduction focusing on contraception (Gunson, 2010; Purdy, 2001; Tone, 2012; Waller et al., 2017). This literature is especially interesting in relation to the discourse on contraception, as I will show later on. Medicalization is the process where originally non-medical phenomena are treated, described or seen as a medical issue. The notion of medicalization was coined by Zola to highlight the role of medicine in the legal system, authority and practice (Zola,

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1972). Through that medicine was exerting higher impact on the daily life and increasingly relevant in broader areas of people’s lives (ibid.). Thus, Zola argued how medicine becomes a ‘major institution of social control’ and the ‘new repository of truth’ (ibid.). Another scholar involved in the concept of medicalization early on emphasizes in his article ‘The medicalization of life’ the suffering which may result from ‘too much medical interference’ (Illich, 1993: 73). Furthermore, he notes that this medical interference is ‘disguised as care’ (ibid.). I will discuss the medicalization critique in the following section. Looking further into medicalization is interesting in relation to the discourse on contraception, because they structure said discourse and thus also the decision-making and assigning meaning of my informants. Within the discourse on contraception as I will argue in the following that there is one dominant ideal and that is hormonal contraception, thus the medicalized form. Looking at my informants want to specify my key question focusing on the role of discourse: How are women able to take decisions which divert from the dominant discourse? Keeping that in mind, I will elaborate on the link of the dominant discourse on contraception and the medicalization of contraception in the following, before I will go further into the decision-making process.

The US-scholar Andrea Tone for example, shows how the contraceptive pill depicts one chapter within the medicalization of reproduction focusing on the US. She chooses an historical approach and follows the development of pill, when the pill was introduced 60 years ago. In most Western countries, the pill was approved in the 60s (Tone, 2012: 320). Before preferred methods for birth control where: condoms, the rhythm method and withdrawal or coitus interruptus (CI) (ibid.). Nevertheless, no method seems to be as simple as the contraceptive pill. When the pill entered the markets, it was perceived – by women and men equally – as ‘the savior of sex life’ and sexuality promising freedom and spontaneity in comparison to non-hormonal contraceptive methods as condoms or diaphragms (ibid.). Also Weschler a well-known scholar on FAM (Fertility Awareness Method), the US-American equivalent to sensiplan, illustrates how the pill has been presented as the tool for women to be in control of their sexuality and to have agency over their bodies (Weschler, 2015). Within this context, the pill is portrayed as the opportunity to achieve emancipation, agency and a free choice (ibid.). Since the pill was such a success pharmaceutical companies focused on developing more ‘hormone-based contraceptives: trans-dermal patch, implants, a vaginal ring, a progestin-releasing intrauterine device, injections and more’ (Tone, 2012: 322).

This ‘hormonal imperative’ – as Tone calls it – becomes part of the dominate cultural narrative on contraception and has several drawbacks (ibid.). Firstly, all of the hormonal methods are targeting the female body leading to the feminization of contraception (Dereuddre, Buffel, & Bracke, 2017; Kimport, 2018). This offers an addition to the ‘original’ medicalization critique by

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not only emphasizing social control, but the control of the female body. Secondly, alternative methods are less accessible, including male body-based methods (Dereuddre et al., 2017). And thirdly, it silences conversations around the possible negative impact of hormonal contraception which is particularly problematic in contraceptive counselling and contraceptive decision-making (Kimport, 2018; Tone, 2012). Thus, hormonal imperative disguises that the contraceptive pill remains a drug which interferes with the physiological and psychological processes of the female body (Guida et al., 2005: 1101). At the same time, women might choose willingly for medicalization and interference with physiological processes as it is anticipated that it leads to advantages (Gunson, 2010; Purdy, 2001). One example is menstrual suppression with the use of extended cycle oral contraception (ECOC). Some women experience their menstruation very negatively. Those women might make the conscious decision to medicalize their menstruation by supressing it with ECOC, in that way they exert agency over what they do with their bodies (Chrisler, Marván, Gorman, & Rossini, 2015; Gunson, 2010).

This reasoning is reflected in Lupton’s orthodox medicalization critique in which she problematizes the disposition of Foucauldian thinkers who disregard taking the agency of the individual into account and fail to examine ‘the ways that […] medical discourses and practices are variously taken up, negotiated or transformed by members of the lay population in their quest to maximise their health’ (Lupton, 1997: 94-5). With this Lupton points out that lay people are not docile bodies existing at the mercy of medical discourses, but they are active agents shaping those discourses (ibid.: 96). Foucault developed the notion of discourse to demonstrate for example how language and knowledge are organized to structure the social world (Foucault, 1969: 48-9). Foucault himself focuses on the historical context, institutions and power, I will research how the contraceptive discourse is experienced on the ground. Thus, I will research how women experience their contraceptive decision-making and investigate the factors influencing this process. I argue that the discourse of contraception points to one ideal, one ‘group of rules proper to discursive practice’ (ibid.). This represents the focus of my thesis pointing to the hormonal imperative, meaning the ideal method of contraception which is medicalized and feminized, thus hormonal contraception. Important to remember is – as also Foucault emphasizes – that the individual exists within the discourse and therefore, gives meaning always in relation to the discourse, even when the individual is resisting or adverse to the discourse. In his way of theorizing discourse Foucault has been critiqued for framing humans as docile bodies embedded in institutional and historical power structures. Even though I am acknowledging those structures, I will figure out how women exert agency in their contraceptive choice. Therefore, I will focus in my first empirical chapter on the following question: How do my informants construct the meaning of hormonal contraception?

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I argue that agency is connected to the knowledge on bodily processes and contraceptive methods. This will be tackled in the last empirical chapter. To find out more about the role of knowledge in the contraceptive discourse I will use the concept of authoritative knowledge (AK) by Brigitte Jordan (1997) and types of logic by Betty-Anne Daviss (1997). By working with the concept AK Jordan demonstrates how some knowledge systems are more valued or ‘carry more weight than others’ (Jordan, 1997: 56). Jordan points out that parallel knowledge system can exist which are ‘equally legitimate’ (ibid.). In the context of contraception in Germany – as in many other high income settings – however ‘one kind of knowledge gains ascendance and legitimacy’ (ibid.) and this is the knowledge on hormonal contraception. As a consequence other forms of knowledge are devaluated or rejected (ibid.). Daviss writes about those competing types of knowledge which are differently valued in different contexts and identifies eight types of logics (Daviss, 1997: 443-4).

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2.2 Contraceptive decision-making Chapter 2. Empirical and theoretical inspirations

15 Figure 3. Eight Logics (Daviss, 1997: 443-4)

Interesting for my thesis is that sensiplan is presented by scholars in favour of the method as scientifically proven knowledge. At the same time, sensiplan-knowledge is differently perceived within the society and the broader medical realm. Therefore, I will focus in my second empirical chapter on the influence of contraceptive knowledge on the decision-making process.

2.2 Contraceptive decision-making

Based on reviewing literature from the field of public health I tried to find out how the discipline conceptualizes patient decision-making within health care in general. Within this literature it becomes clear that the dominant ideal is that the patient is able to make an informed decision (Kurtzman & Greene, 2016; Straus, Tetroe, & Graham, 2011). To do so, the individual needs to gather enough information and knowledge to make an informed health care choice. All healthcare professionals are responsible for providing this knowledge and making it understandable to support their patients in the process of making an evidence based decision. Within this conceptualization of decision-making the individual has all the agency to make the decision to their preference. The doctor’s role is to help the patient in providing the knowledge, but only the patient makes the decision eventually. I will make three points based on this conceptualization. Firstly, decision-making from a public health perspective is framed as rather individualistic: the individuals choice is framed as solely based on individual agency. Secondly, health care professionals are framed as docile bodies doing what the health care system and textbooks are telling them to do.

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Thirdly, there appears to be an assumption that the health care professional can and do provide their patients with all existing knowledge. Yet, Health care providers might influence patients by emphasizing particular information while alternative information might perish. Other factors may matter as well, for example the social environment including friends and family, but also the partner. Thus, as I will show in my empirical chapters, a patients decision-making is not only based on individual agency.

A crucial moment for many women in Germany in their contraceptive decision-making process is the counseling session at the gynecologist. The contraceptive pill and other hormonal contraceptives, as well as the morning-after pill are only available by prescription after having a counselling session with the gynecologist. Both, Kimport and Waller and colleagues focus their research on these sessions and how women are making ‘their’ contraceptive decision. Kimport based her research on 101 recorded counselling sessions in the San Francisco Bay Area. She argues that the risk perception of hormonal contraceptives is influenced by clinicians during the counselling visit and through that the decision-making of the woman (Kimport, 2018). According to Kimport, clinicians on one hand ‘downplay the importance of consideration of side effects in women’s contraceptive decision-making’ (ibid.: 44). On the other hand, during those sessions contraceptive methods based on the male body (condoms, CI and vasectomy) are rarely mentioned (ibid.: 47). If those methods are mentioned their low efficacy (condoms, CI) compared to hormonal contraception or their high invasiveness (vasectomy) is emphasized (ibid.: 48). Those – maybe unconscious – strategies used by clinicians during contraceptive counselling, also lead to the feminization of contraception and shows how the contraceptive responsibility is ascribed to women and their bodies (ibid.: 49). Kimport’s article shows how clinicians impact women’s contraceptive decision-making.

Also, Waller and colleagues research women’s experiences with contraceptive counselling and how those encounters influence women’s choice regarding their contraceptive method. They base their study on six semi-structured interviews they conducted in Sweden. Their participants were between the age of 15 and 23, when they first started using the contraceptive pill. To analyze their findings they use interpretative phenomenological analysis. Based on their analysis they come up with three main themes for their results. First, they point out how hormonal contraception in particular is framed as a normal aspect of a woman’s life, they call this a the ‘normalization process’ (Waller, Tholander, & Nilsson, 2017: 1). Within this line of thinking they point out how the use of hormonal contraception is experienced by women and promoted by caregivers as a ‘natural part of womanhood’ (ibid.). Since those women felt using the hormonal pill belongs within the rite de passage into adulthood, which is ascribed to their gender and age, they perceived the pill as positive (ibid.: 5). Thus, the pill gave them a feeling of belonging (ibid.). At that age, they did not reflect on

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possible side effects of hormonal contraception themselves and the caregivers did neither inform them or offer other opportunities (ibid.). Only later in life they began to reflect on the influence of hormonal contraceptives on their body, and they started wondering ‘if the feeling of belonging and normality is really worth years of dampened happiness, decreased sex-drive, and the feeling of not being themselves without ever understanding why’ (ibid.). Waller and colleagues argue that the caregivers ‘strongly contribute to the normalization process of the pill’ since they offer neither non-hormonal contraceptive methods nor the opportunity to being ask about alternatives (ibid.). Furthermore, they emphasize how women experienced hormonal contraception as a female responsibility and duty as caregivers highlight the lower efficacy of other contraceptive methods (ibid.: 6).

Second, the authors focus on the experiences with insensitive caregivers. In those encounters, their participants expressed the feeling that they were ‘treated like a child’ because they were ‘not […] allowed to participate in the decision-making process’ (ibid.: 8). The women also reported that they felt ‘not being taken seriously’ by their caregivers (ibid.: 9). The women experienced that the caregivers would emphasize the advantages of the pill while dismissing the concerns of the women, therefore the women perceived their caregivers as patronizing (ibid.). At the same time, those women described their caregivers as ‘educated’ and ‘having greater knowledge’ which pushed them in an even more disadvantaged position to make their own choice (ibid.: 10). Third, Waller and colleagues describe the last theme as ‘feeling like a guinea pig’ (ibid.: 1). The Guinea-pig-metaphor represents the feeling of being ‘dismissed from the decision-making process’ (ibid.: 10). Their participants felt like their agency was taken away, they were denied information, especially in term of side effects, and not in control of their own decisions (ibid.: 11).

The article shows how the normalization of hormonal contraception can be enforced and reproduced through caregivers and that this negatively impacts the agency of women in their contraceptive choice. Both articles seem to focus more on the structural factors, while neglecting the women’s agency. To some extent, they frame the women as docile bodies who make their decision only depending on their health care professional. Thus, this literature shows how caregivers influence the women’s decision-making, but a focus on the experiences of women who make a different decision and are not following the dominate ideal are missing. Hence, I pay detailed attention to women’s experiences and how they construct meanings of their contraceptive methods. Nevertheless, the impact of caregivers remains important and will be discussed in chapters four and five.

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Chapter 2. Empirical and theoretical inspirations

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2.3 Feminist phenomenology and embodiment

Figure 4. Denise: Vulva key chain

I choose to draw my data from the experiences of women in regard to their contraceptive choices. Thus, I am using phenomenology to focus on how come things to exist and that is through experiences. Therefore, I am focusing on interviews. However, there is a difference between experiences and recalling experiences, I will reflect on that later on. All that data I collected are accounts of experiences and I take that as an approach to look at reality, so I use phenomenology as my epistemological approach. Thus, I am focussing on this particular phenomenon and its lived experience as it appears to this particular group of women. In other words, by ‘theorizing experience as such’ (Katz & Csordas, 2003: 277). I use a feminist phenomenological approach in my research. This approach is particularly useful for my research on the meaning of NFP as it facilitates to ‘reconfigure what it means to be human, to have a body, to suffer and to heal, and to live among others’ (Desjarlais & Throop, 2011: 88; emphasis mine). As the classical phenomenological thinkers (Husserl, Heidegger, Merleau-Ponty) neglect the female body, I am drawing on feminist phenomenology (Hekman, 2015; Kruks, 1992; Young, 1980, 2002). This tradition combines the ‘theory of the lived body’ as formulated by those classical thinkers with the emphasis on the ‘situation of women’ (Young, 1980: 141). This is useful for my research on women

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2.3 Feminist phenomenology and embodiment Chapter 2. Empirical and theoretical inspirations

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using sensiplan, as they experience the female reproductive age. Within the tradition of phenomenology the conceptualization of the body using the notion of embodiment is seen as one of the ‘most influential contributions’ to the field of phenomenological anthropology as it is today (Troop ibid.: 89). The traditions’ focus on embodiment deals with the lived experience and concentrates on questions around how ‘concrete bodily experiences’ form ‘knowledge and practice’ (Desjarlais and Throop, 2011: 90). Brining this together with feminist phenomenology, I will focus on the female body. After the transition from hormonal contraception to NFP, the method is based on observing the body (mucus, temperature) and using bodily experiences (dry, wet, moist) according to the sensiplan knowledge. An interesting addition to the phenomenology in general and classical feminist phenomenology especially, is the focus on the active role of women in deliberately shaping of their bodily experience in relation to this new knowledge and practice.

As shown above hormonal contraception does something to/influences the female body and also NFP is a new bodily experiences. Thus, in my sixth chapter I will focus on how the method is embodied, how the ‘new’ NFP-body is experienced and how women given meaning to. Therefore, I choose to focus on the experience of the body and following Csordas in his proposal on using a ‘paradigm of embodiment’ for my research (Csordas, 1995: 12). Embodiment can be described as the ‘bodily aspects of human beings and subjectivity’ (Desjarlais & Throop, 2011). This means that the body is not only a combination of flesh and bones, but it is a ‘living entity by which and through which, we actively experience the world’ (ibid.). Lock follows a similar line of thought and is able to phrase it in a – in my opinion – in a more comprehensible way. Lock points out that the ‘body mediates all reflection and action upon the world’ (Lock, 1993: 133). This is connected to the notion that we have a body and we are a body at the same time (ibid.: 136). By this she means that have a body as an object and we experience the world and express ourselves through the body we are. Being a body is linked to our subjectivity, meaning that we are an individual in a certain context, with a certain perception, with an individual consciousness and mind. Lock emphasizes that ‘subjectivity and its relation to biology and society cannot be ignored’ (ibid.). By saying this Lock shows that the body is a ‘product of specific social, cultural, and historical contexts’ (ibid.: 134). At the same time she emphasizes the active role of the individual in mediating with society and the physical processes of the body. I follow Lock in highlighting that women do have an active role in having and being a body. Therefore, to learn more about how women embody the method, shape and make sense of their bodies and their meaning, I will ask the following sub question: How do women assign meaning to their NFP-bodies, thus post-hormonal contraception using the new method?

From my perspective I regard the focus on experiencing the body as useful. However, I as a research cannot experience what my respondents experience, what I can research is how they

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2.3 Feminist phenomenology and embodiment Chapter 2. Empirical and theoretical inspirations

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made sense of it, because one can have a bodily experience and make sense of it one or the other way. I can research their accounts of how and what they communicate and focus on their perception of the society. This leads us back to the role of society and the notion of discourse, as women make sense of said experiences within a certain discourse. Feminist phenomenology is useful because it allows me to focus on the individual experience, the individual experience of the female body in particular and the lens of embodiment allows me to show the importance of the experience of the body in having and being a body. Using this lens, I will proceed to my research methods.

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3.1 Participants Chapter 3. Research methods and data analysis

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3. Research methods and data analysis

As mentioned, my research focusses on the German state North Rhine-Westphalia (NRW). NRW is in the Western part of Germany, next to the Dutch border, and includes four major cities – Cologne, Dortmund, Düsseldorf and Essen. I was born and raised in Germany and lived in and close to my research area for most of my life. German is my mother tongue, so there was no language barrier. The main source of data in this research are in-depth interviews with 12 current and former users of sensiplan. I focus on the experience of those women and how they assign meaning to contraceptive methods based on those experiences which influence their decision-making. In addition, I conducted participant observation at two conferences on natural family planning. Furthermore, I used photovoice to triangulate my interview data.

I choose to focus predominantly on interviews because participant observation with my focus group was not possible, as the sensiplan-users have no place to gather except for the internet and the international conference, which focused on doctors and sensiplan-counsellors instead of sensiplan-users themselves. The initially planned focus group discussions with women could not be implemented due to practical reasons. Since there is a current lack of counsellors, the network of my main sensiplan-counsellor was spread all over the entire federal state of NRW which made it impossible to gather enough women for a focus group discussion who are willing to participate in one city. The observations at the conferences gave me an insight into the work of sensiplan-counsellors, the position of gynecologists and the practical use of sensiplan. Those observations complimented my interview data revealed the practical relevance of my research.

3.1 Participants

I recruited my respondents based on three main criteria. The women had to be 1) of reproductive age, 2) use or have used sensiplan as a method of contraception for at least twelve months and 3) were, prior to NFP, using hormonal contraceptives. According to the NFP working group, twelve months is the time span in which the effects of hormonal contraceptives might be still visible but are supposed to have completely dissolved in the end (Raith-Paula et al., 2015). I found my interviewees through their NFP-counsellors. The following tables provide an overview of my respondents.

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3.1 Participants Chapter 3. Research methods and data analysis

22 Figure 5. Overview of my informants – Table 1

Figure 6. Overview of my informants – Table 2

As this table shows I was able to cover a broad age range, my youngest respondent being 20 years old and my oldest 35 years old. Except for two women, all women I interviewed are in a relationship. As sensiplan is often framed as a couples method for contraception, it is interesting and necessary to reflect on the single women using or not using sensiplan in particular in another

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3.2 Interviews Chapter 3. Research methods and data analysis

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study. As I am interested in the transition from hormonal contraception to natural family planning, that’s why I include attention for the hormonal contraception method used and the intake time. Most of my informants used the contraceptive pill, in several cases as long as ten or even fifteen years. As shown above one women is not using the method currently due to giving birth and not having a partner, another women stopped using the method a couple of months ago due to a busy lifestyle with the intention of picking it up when the busy period is done. In the introduction was shown that sensiplan has a religious connotation within the German society, therefore I was interested to find out more about that aspect. However, only two women have identified themselves as religious. Both women stated that their choice to transition to sensiplan was not rooted in their religious environment, rather in individual aspects. So, I did not follow up on the influence of religion on the method any further.

3.2 Interviews

In total, I conducted twelve semi-structured interviews. All interviews took between 45-85 minutes and were tape-recorded. I used a topic guide, making sure on one hand that I was flexible in asking my questions, on the other hand that I would cover every topic during the interview (Bryman, 2012: 471-2). This means that I went through the same topics, but in a different order which was navigated by my informants, thus I was able to ask my questions depending on their stories. This was especially useful as I interviewed women coming from different life and lifestyle backgrounds. When I interviewed singles, I asked them about how they deal with their fertile days and what changed using the method compared to the times they lived in a relationship using the method. When I talked to those women who identified as religious, I asked questions about that topic and would let them comment on to what extend this was rooted in their religious beliefs to find out about the links of sensiplan and religion. Thus, through semi-structured interviewing I could adjust to the particular situations of my informants.

Furthermore, I memorized my interview guide beforehand to focus on my informants during the interview keeping eye contact and being an engaged listener (Kvale, 1996). In most cases, I would not look on my printed version of my interview guide during the interviews, but I was rather trying to be responsive to what was said to make my respondents feel comfortable, instead of feeling like a research object. I used several other interviewing strategies. Following the example of Beardsworth and Keil I used the ‘lines of thought identified by earlier interviewees’ and ‘presented [them] to later interviewees’ (Beardsworth & Keil, 1992: 261-2). In addition, I gave my informants the opportunity to raise ‘additional or complementary issues’ (ibid.) This included an inductive element in my approach. Therefore, based on the first six interviews I revised my topic guide, removed some topics and included new questions.

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3.3 (Participant) observations Chapter 3. Research methods and data analysis

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I visited all my interviewees at home, except for one who is living with her family and did not feel comfortable being interviewed at her parents’ house. With this one respondent I met in the office of her NFP-counsellor while said counsellor was at a seminar. I made clear that it is the choice of the women where the interview would be held and who would be present. At most interviews I was alone in the room with my informants. Occasionally the partner would be sitting in a different room. On three occasions babies where present during the interview, in those cases I adapted the process of the interview to the needs of the babies if necessary. During one interview the partner was present as well, he did add some complementary aspects while his wife did the main talking. His presence seemed to support her in sharing very sensitive details.

One last aspect that influenced my interviews is my age. In Germany it is ‘good manner’ to address adults in honorific terms. Ideally, the older person offers the younger person to use the informal “Du” instead of the more formal “Sie”. Being 26 years old myself, I am right in the middle of the age range of my informants. According to German manners, it was tolerated that I would ask my interviewees if I could call them by their first names. If the informal “Du” was not offered by the informants, as in most cases, I asked them when we met for the interview. Eventually, all interviews were held on first name terms, which seemed to lower the barrier to talk about personal issues. My inductive and flexible approach in combination with the trust relationship the women have with their NFP-counsellors worked out great. I was positively surprised how open my informants would talk about these personal, sensitive and intimate topics, this delivered several detailed accounts of their experiences.

3.3 (Participant) observations

As mentioned above, it was impossible to conduct extensive observations. I managed to attend one workshop on natural family planning on a women’s health congress in Wuppertal. During the introduction round it appeared that among the four participants no one using NFP for contraception was present. Another two workshops on contraceptive methods in general were cancelled due to not enough registrations. The second part of observations I was able to gather at the International Natural Family Planning Conference in Cologne, which is held every five years. The conference was set up not only for doctors, however most of the lectures were specific medical presentations which were not easy to follow without a medical degree. I picked up some important information from the speakers, sensiplan-counsellors, teachers, doctors and midwives. At all times I presented myself as a researcher. I joined a workshop on the topic on ‘extraordinary’ cycles. This was a workshop addressed at NFP-counsellors to enhance their knowledge and offer them a space to discuss the practice of the method. During the workshop, the group would run solely through a list of possible medical explanations of disturbances of the cycle or body observations. At this conference I gained various useful insights such as the role of doctors within sensiplan, how

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NFP-3.4 Photovoice Chapter 3. Research methods and data analysis

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counsellors could profit from my findings and it gave me an impression of the field. Lastly, the whole conference revealed that indeed qualitative research is missing in the field of natural family planning. This confirmed that my research is very helpful and able to deliver new information for the field in which the female body is regarded from a medical perspective and the woman inside this body is easily forgotten.

3.4 Photovoice

The photovoice is a method in which participants take photos of things and moments of their everyday life that they regard as important in relation to a certain topic. The assignment was to make one picture for five days of something that the participant associates sensiplan with in everyday life. This method is particular useful for my research, as I am dealing with rather private and intimate topics. Photovoice enables people to express those topics in a more powerful way and it can give voice to a minority group (Sarti, Schalkers, Bunders, & Dedding, 2017; Schalkers, Dedding, & Bunders, 2015). The photos were taken after the interviews to give the participants the chance to include new topics and aspects in their photos that were not covered during the interview. One participant (Helen) of the photovoice activity was not interviewed due to reasons of time. Due to reason of space, I use the photos mostly to illustrate. Yet, in the last empirical chapter, I make a start to analyze one theme that the photovoice revealed, connected to the NFP-body.

3.5 Positionality & Limitations

I have been using the symptothermal method (STM) successfully as a contraceptive method myself for over one year. My partner and I learned sensiplan during a seminar given by a NFP-counselor in Düsseldorf, Germany. I position myself among the women I encountered and interviewed during my research. Therefore, I decided to describe the contraceptive decision-making and everything else connected to that process and the transition from hormonal contraception to STM through their eyes. My aim is not to ‘demolish’ hormonal contraceptives, I focus on honoring the experiences of a minority group of women making a different contraceptive choice within the German context. As I am a user of the method I might be biased by personal experiences. Therefore, I paid attention that I am not only confirming the experiences that I had, but being an engaged listener and responsive to all experiences. Furthermore, I focussed on being critical of sensiplan. On the other hand, being a user myself enabled me to relate to what my respondents said as I am just as knowledgeable on the topic as they are and aware of the NFP-vocabulary and practicalities of NFP. As I am a woman myself, they might feel freer to talk to me about intimate topics. On the other hand this leads to a limitation: Focussing on women results in missing out on men’s perceptions and experiences on the topic. Another potential bias is linked to my sample of

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3.6 Ethical Considerations Chapter 3. Research methods and data analysis

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NFP-users, because I found them through their sensiplan-counsellor. Other or no counselling sessions might lead to different experiences which I haven’t included in my research.

3.6 Ethical Considerations

I was mainly concerned about the fact that my respondents are opening up to me about very sensitive and intimate topics about their lives and in turn might expect something from me that legitimizes those kinds of questions. I want to give something back to the women, therefore my research is guided by the thought of how I can make my work understandable and useful for people who supported my research. Thus, I do not want to ‘abuse’ their data for an exclusively theoretical approach, but draw out practical knowledge which can be used for improving contraceptive decision-making.

Prior to every interview I sent my informants an informational sheet about my research and their participation. Before starting the interview we went through the sheet and cleared all questions. Afterwards I asked them for written consent. My respondents are over the age of 18 and have no kind of cognitive or mental disability that might deprive them from giving informed consent. I explained to them that they were free to withdraw at any moment and could refuse to answer any question. All names are changed to pseudonyms and other identifiable features were anonymized. My informants received no compensation (money or other) for their participation.

3.7 Analysis of data

I transcribed all interviews literally, while doing so I looked out for repeating topics and collected interesting quotes in a separate document. Thus, I already started to develop a preliminary coding system while transcribing the interviews (Green & Thorogood, 2004: 182). In a second step, I summarized all topics in codes which I split up in descriptive and theoretical codes (ibid.). The theoretical codes where more difficult to be put together, therefore I used literal quotes from different women. I wrote them on cards and put them together how they fitted together content wise. Afterwards I thought about fitting concepts to summarize the quotes using the following question: ‘What is the concept that this particular code relates to? What connects the different instances (extracts) that are coded in this way?’ (ibid.). This brought me from a descriptive level to the first steps of analyzing and focusing on relationship between codes and concepts (ibid.). Those steps led me to my final coding system that I entered in the qualitative data software Dedoose. I choose to work with a software to analyze as thoroughly and systematically as possible, since I have a rather large amount of data (ibid.).

All the collected data are in German and had to be translated to English, to prevent issues of translation I did two things: All the translations have been approved by three native German speakers who have been living in an English speaking country for at least a year, in addition, all the

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3.7 Analysis of data Chapter 3. Research methods and data analysis

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original German quotes can be found in the appendix. With the help of that data I revisited the empirical and theoretical literature on family planning and anthropology which I read in preparation for my research.

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4.1 The initial construction of the hormonal pill Chapter 4. The meaning of hormonal contraception

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4. The meaning of hormonal contraception

In this chapter I will focus on the phase within the transition from hormonal contraception to sensiplan in which women make and communicate the decision to discontinue their previous hormonal method. All women I encountered experienced unpleasant to severe side effects, such as headaches, vaginal dryness, cramps and wateriness in the legs or coagulum, both preliminary stages of thrombosis, that are commonly liked to hormonal contraception, as I have shown in a previous chapter. The women themselves linked those experiences partly to the usage of hormonal contraception, because the side effects are listed in the patient information leaflet which comes with every type of hormonal contraception. In two cases the gynecologists made the connections. Those negative experiences with their previous method encouraged them to make the transition from hormonal contraception to sensiplan.

4.1 The initial construction of the hormonal pill

In Germany gynecologists have their own doctor’s offices where women have to go for an annual reproductive health check-up and for counselling sessions if they want to get their prescription for hormonal contraception or place an intrauterine device (IUD). This makes gynecologists a crucial actor in the contraceptive decision-making process of women. Most of my informants started hormonal contraception when they were teenagers. During those counseling sessions they got the recommendation by their gynecologists to use hormonal contraception. At that time they constructed contraception in a different way compared to their current position; I will deal with their current position in the next section of this chapter. When thinking about to these counselling sessions three aspects were emphasized by my informants as being influencial for the initial construction of the pill. First, all gynecologists were experienced as advocates of hormonal contraception, the pill in particular was praised. For example, Jenny’s gynecologist said to her: ‘Next to the pill, there is nothing else which is as good, the pill is the very best’. This shows how the ideal way of contraception is communicated to teenagers: the pill is the only and the best option. The role of gynecologists is directly related to the second concern.

Secondly, my informants were critically about their age when starting hormonal contraception. Christin reflects on the influence of being a teenager on her contraceptive decision-making:

‘At some point I had the feeling that I used the contraceptive pill, because I didn’t know better, especially because I was quite young back then. Sure, you are busy with other stuff in your teens and then my gynecologist told me: it’s great and blemished skin won’t be a problem anymore. And I thought, awesome then you know when you get your period and

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so, and especially for when you’re on vacation. Back then I had those kind of thoughts is my head.’

Christin problematizes her being so young insofar as she was thinking about other things than the influence of a contraceptive on her body. Other informants confirmed that as well. She also hints to the missing knowledge she had at that point and that her gynecologist was doing the opposite of providing her with the knowledge needed to make an informed decision. In her account the hormonal imperative silencing all other options is reflected, meaning that the pill is perceived as the only option. This shows how a certain image of the contraceptive pill is reproduced through the influence of gynecologists on teenage girls. Christin’s account points to another interesting aspect of how the gynecologist constructed the contraceptive pill. Kimport (2017) has shown that clinicians downplay the side effects of hormonal contraception by not mentioning them during counselling. This occurrence was also confirmed by my informants as their gynecologists focused on how practical the contraceptive pill is and how the skin will become great.

Another way how the hormonal imperative influences counselling sessions is shown in this account in which the gynecologist only emphasizes the positive outcomes. By emphasizing that the pill provides great skin Christin’s gynecologist reproduces gender expectations and beauty norms linked to the female body. Thus, Christin’s decision to take the pill is based on her gynecologist’s normative view of the female body. According to Littlejohn, beauty norms that are often linked to hormonal contraception and particularly influencing younger women (Littlejohn 2013). Other gynecologists did this as well by emphasizing clear skin, weight loss, flexibility and the regulation of the period with the help of the pill. Especially their normative view on the ability to contracept effectively with other than hormonal methods was resulting in conversations as experienced by Katharina at her first counselling session:

‘My gynecologist told me: If you don’t want to get pregnant, you have to take the pill, this is the only possibility.’

This again shows the impact of the hormonal imperative and how the pill is framed as the only option by the gynecologist, it also reflects a normative view on responsibility. The gynecologist frames the pill as the only responsible decision for a young women.

Thus, gynecologists add to the construction hormonal contraception in a certain way. In this context, women see their age very critically because they link it to a different perception as shown above, in addition they point out their young age as a problematic factor because back then they felt they lacked not only the need but the ability to challenge this construct. Johanne explained:

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‘I had taken the pill quite a long time, 15 years. I had to take it because the intervals of my periods were always so long I think. And the doctor said then with the pill, we can do it [give you a regular cycle]. Sure, because then it is so controlled by the hormones in the pill and you don’t question that at the age of 15. So you're glad if you have a reason to take the pill and not have to talk with your parents about that. At that time I found it cool and did not question it for a long time.’

In this particular case her gynecologist fostered the construction of the pill as ‘healing’ the irregularity of Johanne’s periods. Furthermore, she mentions twice that she was not able to question the doctor’s position at that age. Thus, it suggests that her age makes her vulnerable to the normativity of the gynecologists; she was not in a position of power to make her own contraceptive decision. That the information provided by the gynecologists was not questioned initially due to young age and the resulting manipulation the initial decision-making was a repeating concern for all informants over the age of 20.

Johanne’s statement hints to the third point I would like to make about the initial construction of hormonal contraception. At first she perceived the pill as ‘cool’. This is linked to the argument by Waller and colleagues (2017) is that the hormonal contraception is framed as a natural part of womanhood, and being a women is something that young women at that age particularly aspire to. Denise highlights this by saying:

‘In the age of 16/17 everyone was on the pill, it just felt like an initiation rite.’

This experience of the pill as an rite de passage shows how Denise constructs the pill as something rather positive because she links it to a feeling of belonging. This initial construction was reflected in several other interviews as well. Thus, initially women construct hormonal contraception as something socially desirable, something to belong, something female to do, and – pushed by their gynecologists – something responsible to do. In this context it is important to point out the vulnerable position of a teenager and as a result the huge influence of the gynecologist. Both aspects have a huge impact on this particular construction and due to the lack of challenging this view, it becomes internalized. Yet, the women I spoke to switched to sensiplan. Hence, the question is how, when and why this construction is questioned. This I will try to answer in the following sections.

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4.2 Hormonal Contraception as Sick-Making Chapter 4. The meaning of hormonal contraception

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4.2 Hormonal Contraception as Sick-Making

In the following two sections, I will show how the initial construction of hormonal contraception changed at a later point in life, having made the decision to discontinue hormonal contraception. In this section I will focus on how my informants construct hormonal contraception as sick-making. These first two accounts exemplifying the most common side effects, I came across throughout my research:

Christin: ‘At some point I had a feeling that I don’t feel comfortable with it [contraceptive pill] anymore and I didn’t felt well either. I also experienced extreme negative mood swings. So, I wouldn’t label it as depressive, it was just very negative, and it didn’t feel good at all. And to me it [taking the pill] just didn’t feel right anymore. […] There was a point when I thought and said to myself: no, this [the pill] doesn’t suit you, you will look again for another method and you actually want something without hormones.’

Karolin: ‘When I got there and prescribed the pill for the first time, she never told me what kind of side effects this could have. When I arrived with a headache and nausea, she said it might come from the pill. And I also had a lot to do with negative moods, so I had a lot to fight with, so I stopped using the pill.’

Next to negative mood swings, headaches or nausea other women experienced especially severe side effects. Jasmin used an hormonal IUD for contraception:

‘Well, I'd had that (the IUD) for one year and four months before I had it taken out again. In those 1.33 years, that was hell. Well, it is said that it (the IUD) needs six months to set into the body. I was bleeding all the time, that would not have been so bad, but so I have relatively large breasts by nature as a woman and I've been in pain, I could not walk, I rode a bicycle and had endless pain, my breasts were huge and bulging and it just hurt. And that must be because the progesterone is not produced properly. I would need to research this again, but it is said so, yes, the Mirena does not prevent ovulation, but in the end that's it. So, all those hormonal stories that say we do not prevent ovulation, but in the end they do. And my body said okay, progesterone that luteal hormone that we do not need to form anymore, that now forms the Mirena and besides, it also always pretends to your body that you are somehow pregnant. This is not a permanent condition, especially if you have to work and I am also close to the patient. So I couldn’t even hug my daughter, so that was really a disaster. And that's why I had it taken out again.’