The re-feminization of contraception
Rejecting Hormonal Contraceptives, Trusting the Natural Cycle
A mixed methods study into the motivations and the practices of trust
within natural contraception usage among Dutch women
Laīla Wiersma 10111824 Research Master Social Sciences, Mixed methods track 2017-2019 Supervisor: Patrick Brown Second reader: Gerben Moerman August 2019 Department of Sociology, University of Amsterdam lailawiersma@gmail.comAbstract
The negative side effects of hormonal contraceptives on women's health, sexuality and sexual experience have led to their questioning in the last decades, as well as a noteworthy shift towards the use of natural contraceptive methods. However, these natural ways and means are deemed as less reliable than hormonal contraception by the mainstream medical domain. This thesis explored the motivations and the practices of trust of Dutch natural contraception users using a mixed methods approach. Results are based on the triangulation of a web survey with over 2148 respondents and 14 interviews with natural contraception users (NCUs). The study finds that the key NCUs personal characteristics that influence the choice for, ability to trust in and really use natural contraceptive methods (NCMs) are age; relationship or marital status; and perceived risk of pregnancy. Women above 26 years old, in a stable relationship and for whom getting pregnant does represent only a medium to low difficulty in their lives, tend to choose for NCMs and trust them as a reliable practice to not conceive children. The non-hormonal discourse, socially shared negative experiences with hormones and the desired ‘natural woman’ identity motivate women to use NCMs, and in relation to these personal characteristics, four type of users are identified; the Natural, Religious, Convenient and Non-user. This study also finds that trust is an effect of highly disciplined behavior in natural contraceptive practices, thereby depends mostly on user‘s control, which in turn is needed to make the method reliable. The thesis concludes that the shift towards NCMs is emancipatory as women can exert a reasoned control over their fertility; however, this has a re-feminization of contraception as a corollary.Acknowledgements
Special thanks to all my respondents, all 2148 of them, for taking the time and effort to fill out the survey, and my 15 interviewees for opening up their personal experiences and beliefs to me. I want to thank Patrick Brown for his commitment to this thesis, his ongoing positive support and help in all stages of the thesis. Especially, for creating structure and clarity in this process and in my mind. I want to thank Gijs Schumacher and Gerben Moerman for their advice on the survey, and Gijs in particular for his guidance through data, statistical and survey issues. I am grateful for Javier Koole, Emma Van Der Goot and Carla Brega Baytelmann for their advice, feedback and inspiring discussions. Then, my incredible Josien Arts, my academic sister, who is always there for me with her brilliant mind and positive support and critical feedback. Then, I want to thank my mother, Marion Irene Wiersma, amti diali Fatima Zora El Younssi, Mark Bais and Johanna Katharina Dirks-Wiersma, for their incredible support.T
ABLE OF
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ONTENTS
Chapter 1. Introduction ...6
1.1 Introduction ... 6
1.2 Contraception in the Netherlands ... 8
1.3 Natural contraception ... 9
Chapter 2. Theoretical frame ...11
2.1 The deployment of sexuality ... 11
2.2 Discursive & disciplinary power in contraceptive practices... 12
2.3 Contraceptive uncertainty in cultural, social and identity domains ... 13
2.4 Escaping structuralism; an understanding of ‘trust’ agency in contraceptive practices ... 15
2.5 Conclusion... 17
2.6 Research questions ... 19
2.7 Hypotheses ... 19
Chapter 3. Methodology ...20
3.1 Methods design ... 20
3.2 Quantitative & qualitative Data ... 21
3.3 data sampling and collection ... 21
3.3.1 Quantitative data sampling and collection ... 21
3.3.2 Qualitative data sampling and collection ... 22
3.3.3 Basic ethical considerations and reflections ... 22
3.4 Data analysis ... 23
3.4.1 quantitative Data analysis ... 23
3.4.1 Qualitative Data analysis ... 23
3.5 Quantitative Data & Measurement... 24
3.5.1 Quantitative sample description ... 24
3.5.2 Factor analyses ... 27
3.5.3 Regression models ... 27
3.5.4 Correspondence Analysis (CA)... 28
Chapter 4. The survey findings and analysis ...29
4.1 Descriptive Statistics ... 29
4.2 Exploratory factor analysis (FA) on motivations & trust ... 33
4.3 Regression Analyses ... 35
4.4 Correspondence Analyses ... 40
4.5 Summary survey findings ... 42
5.1 Contraceptive practices and discipline ... 46
5.2 The elements of trust ... 48
5.3 Motivations in detail ... 55
5.4 Summary qualitative findings ... 63
Chapter 6. Triangulation ...67
6.1 Quantitative and qualitative typologies triangulation ... 67
6.2 Discussion ... 72
6.3 Conclusion... 75
Bibliography ...79
Appendix ...84
Topic List ...92
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HAPTER
1.
I
NTRODUCTION
1.1
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NTRODUCTIONIn recent years a growing number of women have addressed the negative effects hormonal contraceptives have (had) on their health, sexuality and sexual experience in newspapers, blogs and vlogs. These women have described feeling more depressed tired, less sexual and address weight gain as a result of using the pill (NRC 2017; The green guide 2019). Consequently, some of these women have stopped using hormonal contraceptives and started using various forms of natural contraception. However, the current dominant medical and public discourses state that the latter methods are less reliable than artificial contraception. The Dutch government, the medical world and NGOs as Rutgers National Knowledge Centre of Sexuality, whom give contraceptive advice, advocate this (Brochmann & Dahl 2017; Rutgers 2019; WHO 2019). Therefore, it is of interest to understand how and why women trust or rely on natural contraception. Trust plays its part in all social interaction, however, it becomes even more interesting and tangible when the risk is high (Möllering 2006; Rodrigues 2016; Sundstrom et.al 2018). The risk within this study on contraception is the risk of falling pregnant, which is, or could be, a life changing event. Natural contraception consists of keeping track of your reproductive cycle to determine your (un)fertile days by, for example, recording your temperature, observing your cervical mucus, and/or counting your cycle days. Natural contraception also means that during your fertile period you practice abstinence, coitus interruptus (withdrawal) or use condoms, to protect you against a pregnancy (Attar et al. 2002; Frank-Herrmann et al. 2007). These natural contraception methods are increasingly digitalized and the field of fertility tracking applications has recently expended greatly, circa 100 applications are available to assist women in tracking their reproductive cycle (Duane et al. 2016:508). The wider social relevance of this research lies in the gender inequality of contraception responsibility, usage and who suffer the consequences; side-effects of contraception are normalized for women whereas they are non-acceptable for men (Behre et al. 2016; Oudshoorn 1999; 2002; 2003). Thereby, the impact hormonal contraception usage has on health is solely a women’s burden, examples of this impact are a decrease of sexual drive, higher chances on breast cancer and depression (Herzberg et al. 1971; Mørch et al. 2017; Skovlund et al. 2016). The natural contraception movement is a recent phenomenon which remains understudied, as most existing contraceptive decision-making research (e.g. Noone 2004; Wigginton 2016) is conducted on hormonal contraception, tends not to invoke a specific focus on trust (c.f. Sundstrom et al. 2018) and does not exist for natural contraceptive practices in the
Western world. This research aims to close these gaps in the literature and thereby contributes to academic discussion regarding whether natural contraception is an emancipating method; whether it enforces or dismantles the feminization of contraception (Dereuddre et al. 2017; Kimport 2018; Wigginton et al. 2015) and whether it increases or reduces disciplinary mechanisms for its users (Hayter 2005;2007). Furthermore, it sheds further light on the discussion on the (re)medicalization (using bio-medical knowledge to understand the body, thus, democratizing medicalization; less medical dominance) (Broom & Woodward 1996) and de-farmaceuticalisation of contraception by means of natural contraception (Abraham 2010). As women seek other, culturally deemed less effective or even illegitimate, contraceptive methods, I will investigate the grounds upon which they base this choice. Therefore, relevant questions might be; who are these women, do they share common indicators (i)? Why do they choose for natural methods of birth control (ii)? How do they practice trust within natural contraceptive practices (iii), and, what is the relation between trust in Natural contraception methods (NCMs), the perceived risk of pregnancy and these common indicators (iv-v)? For now, preliminary research has informed me that natural contraception has a considerable impact on everyday life. Hence, the research question: How do natural contraception users (NCUs) experience and practice every day natural contraceptive practices in the Netherlands? I propose a mixed methods approach to answer the research question due to the fact that NCUs are a relative new group that should be mapped quantitatively, in order to get a broad insight into who this group consists of, and investigated qualitatively to understand their choices, beliefs and natural contraception practices. The data collected for this study is rich; a dataset of N=2544 and 14 interviews. On top of that, the data is unique; the survey that composed this dataset was designed specifically for this study. Apart from deriving results from both findings separately, by means of triangulation of these findings I will provide a rich understanding of this recent phenomenon and of the lifeworlds of NCUs.
1.2
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ONTRACEPTION IN THEN
ETHERLANDS In order to understand the recent movement towards natural contraception, it is important to first sketch a short context of contraception in the Netherlands. Before the introduction of the contraceptive pill in the 1960s, women merely had a few methods of contraception; the diaphragm as medial method and condoms, the rhythm method and withdrawal (or coitus interruptus) as non-medical methods (Tone 2012). The contraceptive pill was presented as an emancipating tool that gave women agency over their bodies, reproduction and sexuality (Weschler 2015) and has been perceived by many as such (Tone 2012). After a few years the contraceptive pill was simply referred to as “the Pill”, which shows the normality of its usage (Tone 2012). The pill has a high level of efficacy, when taken correctly the pill is 99.7% effective in protecting a woman against pregnancy, however, in practice this drops to 92%, which is still high compared to methods that were available before the pill’s arrival. For instance, withdrawal has a protection level between 73-96%. All protection rates are available on the Pearl Index; an index of all contraception forms and pregnancy rates on the basis of perfect use and normal use (Brochmann & Dahl 2017; WHO 2019). This high level of efficacy of the pill set the new standard of what contraception could, and thereby, should be able to offer women and, consequently, gave a negative evaluation on methods with lower protection rates (Tone 2012). Furthermore, the pill was much less demanding is its usage compared to its precursors, as a diaphragm might protect for 88-93 %, it has to be anointed with spermicide, correctly inserted around the cervix before sexual intercourse, be left in place for 8 hours afterwards and taken out, cleansed and reinserted on the next sexual intercourse (Brochmann & Dahl 2017). Moreover, due to its high efficacy level and user convenience, the pill became the ‘most successful lifestyle drug in history’ (Tone 2012:320); it is used on a daily basis by millions of women of reproductive age, which lies between 15 and 49 years old (ibid.), and is the most generally used form of contraception in the Western world for several decades (Guttmacher Institute 2011). Due to its success, other forms of hormonal contraception have been developed by pharmaceutical companies, such as the vaginal ring, a contraceptive patch, an injection and intra-uterine device (IUD) (Tone 2012: 322). These methods proved diverse manners of drug transmission while taking advantage of the pill’s proven profitability (ibid.) In the Netherlands, the Rutgers National Knowledge Centre of Sexuality promotes hormonal contraception for women, driven by an emancipatory mission (Rutgers 2019; Weschler 2015). In 2003, 41% of Dutch women used the pill, whereas in 2013 this decreased to 37%, however, other forms of hormonal contraception increased from 4% in 2003, to 12% in 2013 (CBS 2014). Hence, hormonal contraception has become the norm. It is this contraceptivecontext what Tone coins as ‘hormonal imperative’ (2010:322); hormonal contraception is the dominant discourse on contraception. However, as stated above, this hormonal discourse started to crumble as recently pill safety is questioned more and more by (previous) consumers and physical, sexual and mental damage that hormone usage can ignite, becomes increasingly legitimized as a risk (Guillaume 2014: Herzberg et al. 1971; Mørch et al. 2017;Skovlund et al. 2016). Thus, a field of contraceptive uncertainty arises, on the one hand, the existence of a hormonal imperative on contraception, on the other hand, hormonal risks of contraception. In order to move away for these hormone-associated risks some women start to embrace a non-hormonal contraceptive idea of which natural contraception is one strategy. In the subsequent chapter a detailed explanation of natural contraception follows.
1.3
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ATURAL CONTRACEPTIONNatural contraception practices consist of (1) fertility awareness methods, (2) the medium which predicts fertility and through which users obtain a variety of information, and (3) the sexual strategies. All three together serve as natural contraception.
Fertility awareness methods The menstruation tracker method, this is comparable to the calendar method, in which women write down when their period is and count the days until their ovulation to determine their fertile period. The calendar method has gone digital and so has the prediction (Duane et al. 2016), with several apps such as Flo or Clue. The temperature method, this method is used by women that use Natural Cycles (NC) and the Lady-Comp (LC). Temperature is preferably taken each day before getting out of bed with a special thermometer. The temperature in signed into the app by the user, whereas the LC registers this on its own. Sometimes ovulation tests are required for the app to make fertility predictions. (See Natural Cycles (2018) or Lady-Comp (2018) for more details). The sympto-thermal method, this ‘double’ method is used by Sensiplan (SP) users. The temperature is measured as in the previous method, and, on top of that, the cervical mucus is observed. The substance of the mucus informs women if and when they are ovulating, this is done on specific times in the cycle when the ovulation is expected, although some users do it daily. SP is the only non-digital medium in this study, its users follow an intense course which expanse over 3 months and has 4 meetings to learn how to predict their fertility. (See Sensiplan (2018) for more details).
Media Multiple apps, the NC app, one cycle computer (LC) and the SP course are the media for NCMs in this study. The apps predict fertility and provide information on the cycle, feelings associated with certain phases of the cycle and information on how to best deal with these. The cycle computer predicts fertility and the LC company sends regular mails with cycle information, whereas SP users independently predict fertility and are informed by their course consultant and the SP book (Natuurlijk & zeker 2019) Interesting to add; Sensiplan has a religious background and so does Lady-comp, whereas Natural Cycles does not make such claims. Sexual strategies All the following strategies merely apply during the fertile period, which is defined by the fertility awareness practices and the information and predictions of the media. The main three strategies are: abstinence and/or sex without penetration, the use of condoms and withdrawal (coītus interruptus). Now that the context of contraception in the Netherlands has been described and natural contraception is explained, it is important to theorizes this context to gain a deeper understanding of why women opt for natural methods, what they trust on and how they make sense of their lifeworlds.
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HAPTER
2.
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HEORETICAL FRAME
In this theoretical framework power, truth and knowledge techniques within the domains of sexuality and contraception are discussed to place contraceptive practices in a historical, discursive and disciplinary context (Foucault 1990; Hayter 2005:2007). Brown’s understanding of the Habermasian concept of lifeworlds is introduced since it offers a more multidimensional consideration of discourse and relates to action and experience more than Foucault does (Brown 2015). This creates space to explore agency and various ways of overcoming uncertainty in contraceptives practices, for which notions of trust are pivotal (Gallivan & Depledge 2003; Möllering 2006; Rodrigues 2016; Sundstrom et.al 2018).2.1
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HE DEPLOYMENT OF SEXUALITY In the ‘History of Sexuality’ Michel Foucault (1990) unravels strategies of power and knowledge that are omnipresent in sexuality and its deployment and, thereby, he exposes sexuality as a historical construct as opposed to a furtive reality. He demonstrates that sexuality can be seen as “a great surface network in which the stimulation of bodies, the intensification of pleasures, the incitement to discourse, the formation of special knowledges, the strengthening of controls and resistances, are linked to one another, in accordance with a few major strategies of knowledge and power’ (Foucault 1990:105-106). This implies that the domain of sexuality is a field of power that enables and inhibits people to act in certain ways through various means. As I will outline below, this does not merely help us begin to explain how and why the medical domain predominantly represents hormonal contraceptives, although these can have severe (sexual) health consequences for its users (Behre et al. 2016; Hayter 2007; Herzberg et al. 1971; Mørch et al. 2017; Skovlund et al. 2016). It may also explain why contraception is (still) a female responsibility. Foucault introduces ‘the power over life’ which encompasses power based on norms, regulations, knowledge, meaning, discipline and life and has the optimization of the latter as its main objective (1990). Here Foucault connects the power over life to the rise of capitalism, since death or uncontrolled, perhaps disobedient subjects and populations have no place in productivity while optimized life, with obedient and productive subjects, does. He coins ‘biopower’ as the technologies of power and knowledge that manage life in an optimized and productive manner, for which sexuality and reproduction need to be secured. Hence, it became the family’s task to anchor sexuality and to foresee it with a permanent support. This is done through major strategies of knowledge and power that developed four specific deployments of sexuality; (1) the hysterization of women's bodies, (2) the pedagogization of children’s sex, (3) the socialization of procreative behaviour and (4) the psychiatrization of perverse pleasure(Foucault 1990:104-105). In short, women have to behave responsibly, children sexless, birth ensured, and in a lesser degree, perverts identified and diminished and the medicalisation of non-(re)productive sexualities as deviant species. These strategies are established by the technology of sex; a range of different tactics that join the objective of disciplining the body and that of regulating populations together in varying proportions, coined as anatomic politics and biopolitics, together coined as biopower. The former entails anatomical power over the human body; in a way treating it as a machine by disciplining it; the latter entails power to regulate the population through the reproductive capacity of the human body. Moreover, the deployment of sexuality in all its strategies is the coming together of these anatomical and biopolitics in the form of concrete links, with sex being the ‘pivot of the [these] two axes along which developed the entire political technology of life’ (Foucault 1990:145). In contraceptive practices sexuality is mostly deployed through the hysterization of women's bodies and the socialization of procreative behaviour, as for instance nurses discursively construct a body at risk; the external risk of falling pregnant (Hayter 2007). Biopower is ensured by regulating the population through this discursively created risk of the reproductive capacity of the body and capacitated through discipling this body to use hormonal contraception (ibid.). Although the risk of falling pregnant merely is a risk when one does not want to become pregnant, this risk is utilized to exert the power of life since biopower is not produced by unwanted pregnancies and children. In other words, pro-creation has to be stimulated, yet regulated, in order for biopower to be optimal, which entails a specific deployment of contraception; in this case a hormonal one (ibid.). In the next section I will outline how sexuality and contraception are deployed through discursive and disciplinary power in contraceptive practices.
2.2
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ISCURSIVE&
DISCIPLINARY POWER IN CONTRACEPTIVE PRACTICESAs mentioned in the introduction, the current dominant discourse entails that natural contraception methods are deemed less reliable than hormonal contraception (Brochmann & Dahl 2017; Rutgers 2019; WHO 2019). This is a discursive act which enables normalizing and disciplinary techniques that lead women to be responsible and to correctly manage their pro-creative behaviour in such a manner that birth is optimally ensured. I use the term responsible as opposed to hysterical, which refers to how women have been problematised within the deployment of sexuality. This discursive construction of unreliable natural contraception makes pregnancy a risk. In other words, the hormonal discourse seemingly places pregnancy opposite
to medical contraception, as two sides of the same coin, which leaves no ‘truth’ outside these domains for natural contraception (Hayter 2007). The latter is deemed false and unreliable, therefore, it is and can be pushed towards the pregnancy side of the duality of either choosing for pregnancy or for medical contraception (Brochmann & Dahl 2017; Hayter 2007; Rutgers 2019; WHO 2019). Further drawing on Hayter (2005), a Foucauldian study on data of audio-recorded consultations between nurses and women in sexual health clinics, reveals how nurses utilise a discourse of risk as a technique to strengthen and generate self-care practices. Especially, the discursively created risk of pregnancy enables various disciplinary techniques that make women view their bodies as objects of care (cura sui), which entails specific work (mia chora) and habitual surveillance (epilemeia) in order to avoid this risk (Hayter 2005). First, to view the body as an object of care women are incited to pay attention to the workings of their bodies and minds, which is conveyed through the tutorage of a medical expert. Second, once the cura sui is developed, nurses begin to construct the mia chora, which consist of learning specific bodily practices and techniques which joins bodily knowledge and bodily practice. Bodily techniques, such as correctly placing a cervical cap or feeling if the IUD is in place, relate to tensions between the fertile body and the non-pregnant body, for the latter might be at risk of becoming pregnant when these techniques are conducted incorrectly. Third, the epilemeia is constructed as medical experts incite women to undertake self-examination on a daily basis in the form of a regimen. Through instating self-care practices as part of their daily lives, constant embodied action accomplishes a fertile but non-pregnant body. These three disciplinary techniques regulate reproduction for a particular body and the population at large. Hence, we return to where we started, the power over life (Foucault 1990). Hayter demonstrates multiple mechanisms in addressing how Foucauldian discursive and disciplining powers are at play in contraceptive counselling within the medical domain (2005; 2007), I will use a similar lens to investigate how natural contraceptive practices are disciplining and analyse the behaviour of the natural contraception users in light of this wider discursive socio-political context. In the next section I turn to the possibility of natural contraception as a contraceptive option for women amidst this context.
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ONTRACEPTIVE UNCERTAINTY IN CULTURAL,
SOCIAL AND IDENTITY DOMAINSThe Foucauldian theoretical frame, as outlined above, has quite some deterministic tendencies and merely addresses discourse and subjects whereas it neglects a societal level of integration, therefore, I introduce the Habermasian concept of lifeworlds (Habermas 2015). The latter
consists of three dimensions; cultural interpretation which relates to discourse, societal integration which is pivotal in trust processes and socialisation which relates to subjectivity. I choose to use Brown’s understanding of these Habermasian concepts since he specifically refers to trust and hope as ways by which people can and do work on their lifeworlds, thereby providing theoretical space for agency, a concept the Foucauldian frame lacks (1990). Moreover, a more multidimensional consideration of discourse, the addition of integration processes and the ability to relate this to action and experience by providing theoretical space for the notion of trust are needed to understand the various contraceptive choices that are made. In the subsequent section I elaborate more on Brown’s work and, thereafter, connect this to various contraceptive choices, including a choice for natural contraception. Brown provides an Habermasian understanding of these processes of ‘truth’, legitimacy and authenticity, which are enabled by communicative action, and are the three main instruments through which processes of cultural interpretation, integration and socialisation take shape. Importantly, these processes discipline and ‘limit what is thinkable and therefore questionable as uncertain’ (Brown 2015:91), as is the case in the questioning of the pill and the recent move towards natural contraception. In other words, communicative action, or discursive action, (re)produces lifeworlds in three distinct dimensions of culture, society and identity and refers to “interpretations of an objective world, which can be considered true or not (in relation to a common cultural stock of knowledge); the ordering of a social world, which can be deemed legitimate or not (in relation to a membership of a particular community); and the expression of experiences of a subjective world, which can be deemed authentic or not (in relation to a particular narrative identity)” (Brown 2015: 83). These three layers will be used to understand the lifeworlds and choices of NCUs. As mentioned in the introduction, the norm of the contraceptive pill being a magic bullet has faded (NRC 2017; The green guide 2019). Pill and hormonal contraceptive usage was legitimate when culturally perceived as normal, however, when the cultural loses its taken-for-granted notion, an array of uncertainties is released in terms of legitimacy; ‘whereas before a more legitimate risk concern was about getting pregnant, concerns with pill safety and hormone-associated risk to one’s body became increasingly legitimized (Guillaume 2014)’ (ibid.). On top of that, the framing of pill usage as ‘everyday’ or as risky, and its (il)legitimacy in certain communities ‘can come to bear importantly on the experiences of selfhood’ and narrative identity (Guillaume 2014:38). Thus, the questioning of the pill and the loss of its perceived objectivity within the cultural domain has made it possible to not only question its usage but also enables women to make different contraceptive choices, in which trust to overcome these contraceptive uncertainties will be highlighted in the next section. All in all, in contraceptive practices these Habermasian processes entail on the one hand
understandings that the contraceptive pill is safe and appropriate are no longer universally true, increasingly related to this shift the pill may be seen legitimate in certain groups but not in others, and authentic merely for some women (Guillaume 2014). On the other hand, natural contraception which holds no normality within the wider cultural domain either, is legitimate in some groups as opposed to others and authentic for some. The aim of this research is to understand those women who choose for natural contraception and their identities, in their relation to authenticity, legitimacy and truth and the role of trust in these processes. In the next section I will explain how women overcome contraceptive uncertainty in divers manners and choose for various contraceptive methods by utilizing trust as a form of agency.
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SCAPING STRUCTURALISM;
AN UNDERSTANDING OF‘
TRUST’
AGENCY IN CONTRACEPTIVE PRACTICESFar from passively dwelling in lifeworlds or discourses which cannot be thought otherwise, contraception users ‘actively construct and bracket off their lifeworlds through processes of risk, trust and hope in relation to‘ contraception in order to make use of and trust upon it (Brown 2015:79). Attentiveness to this agency helps in elaborating Foucauldian notions of resistance to knowledge and power. Foucault refers to resistance as followed; ‘where there is power, there is resistance, and yet, or rather consequently, this resistance is never in a position of exteriority in relation to power’ (Foucault, 1990: 95). Yet the specific mechanisms by which such intrinsic resistance functions – not least in relation to knowledge of risk and uncertainty - remains unclear. In this sense I refer to processes where risk, trust and hope are consciously handled in reworking lifeworlds as examples of the agency of women to resist hegemonic discourses around their contraceptive choices. The way they use these tools to reshape an uncertain contraceptive domain does not mean they are free from power and disciplinary mechanisms however. In this study I will mostly focus on various notions of trust as outlined below. Trust occurs when an actor develops an ‘as-if attitude’ in which one ‘brackets out irreducible social vulnerability and uncertainty as if they were favourably resolved’ (Möllering 2006:115). This suspension of uncertainty enables trusting. In other words, ‘trust can be imagined as the mental process of leaping – enabled by suspension – across the gorge of the unknowable from the land of interpretation to the land of expectation’ (Möllering 2001:412). On the interpretation side we (still) questioned and were unsure, on the expecting side, we have bracketed out these uncertainties and defined these ‘as-if’ positive imagined possibilities as if they were ‘true’, hence, it is the latter that enables us to expect. Since trust builds gradually, in
time the as-if can become taken-for-granted. Nevertheless, it is quite simplistic to pretend that trust or uncertainty are absolute, as opposite sides of a gorge since “the leap of trust cannot be made from nowhere nor from anywhere” (Möllering 2001:414). This entails an interesting dialectical (or paradox) relationship where the creating of as-if realities and the faith in these fictions, serve as a basis from which the leap of trust can be made. Therefore, we need trust in underlying systems to enable trust (Luhmann 1988).
Thus, uncertainty in the contraceptive domain can be overcome by active trust and trust in underlying systems, the question remains; how do women actively trust in their contraceptive choices and these underlying systems? Therefore, to theorize this question, I will discuss the relation between trust and control, the notion of knowledge-based trust and the interrelation of system and interpersonal trust (Gallivan & Depledge 2003; Meyer et al. 2008). According to Gallivan & Depledge, trust and control form a dialectic, hence, each construct merely exist in relationship to the other (2003). Therefore, when trust is absent in a partnership, control has no meaning and vice versa. The start and the maintaining of a relationship are two different things, the start might require a bigger ‘leap of faith’ whereas the continuance of a relation can be built upon knowledge-based trust; ‘trust resulting from direct experience with the partner or the assurance of adequate controls’ (Gallivan & Depledge 2003:182). Thus, on the basis of prior performance, knowledge-based trust encompasses the ability to predict, or expect, the behaviour of the trustee (Husted 1998; Möllering 2006). In natural contraception practices trust is built in relation to trustees; contraceptive counsellors (Sensiplan 2019) or digital devices (Duane et al. 2016; Lady-comp 2019; Natural Cycles 2019). Hence, through interactions with the digital device or counsellor, trust could enhance. Furthermore, trust in digital devices on the one hand, and counsellors on the other hand, entails different forms of trust. Meyer et al. discuss theories of system (institutional) trust and interpersonal trust (2008). The digital natural contraception devices can be placed under system trust, in which trust is placed in the system behind an app or cycle computer, whereas the SP course falls under interpersonal trust, in which interaction between people can build trust (and system trust of which the healthcare provider/counsellor is a representative). Meyer concludes that both trust forms work together and should not be understood as divided domains which linearly influence each other, but as a complex ‘web of interaction’ (et al. 2008:182). In line with Luhmann (1998), trust in underlying systems is necessary for both the trust in digital devices as in counsellors, as both are embedded within an alternative, however, by some deemed legitimate, healthcare system.
Furthermore, according to Sundstrom (et al. 2018) a manner in which women actively trust in their contraceptive choices and these underlying systems is through embodied experiences and the locus of control they have over a specific contraceptive method, more than the medical assistance and knowledge of healthcare providers and the underlying systems (Sundstrom et al. 2018). This is in line with Rodrigues research on how everyday medical users take medical decisions for minor ailments in the (un)certain pluralistic medical landscape of Maputo (2016). Rodrigues’s theory on trust is quite comparable to trust within contraceptive practices (Sundstrom et al. 2018), since both are choices placed within the medical domain but not of severe medical importance. Rodrigues analyses this decision-making process through a theoretical frame of three modalities of trust; ‘trust in (1) the medical system which refers to a body of knowledge, (2) its health organisation and providers, (3) individuals and socially shared experiences’ (2016:401). These three layers of trust are heavily intertwined, but had uneven weight on individual medical decision-making, as Rodrigues finds that personal and socially shared experiences weight the heaviest (2016). Personal experiences are related to Brown’s concept of authenticity and identity, whereas socially shared experiences are similar to legitimacy and social integration (2015). As Sundstrom et al. (2018) conclude that women in contraceptive practices trust through and make decision based on their embodied experiences, Rodrigues states that ‘more pragmatic and embodied forms of trust prevail in decision-making. These latter features of trust were especially evident when uncertainty and multiple choices existed’ (2016:403). I will use these concepts of trust to analyse if, how and to what extent this is the case in my data.
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ONCLUSIONNatural contraception usage has become a possibility due to the negative hormonal experiences women bring up in public debate that created contraceptive uncertainty on cultural, societal and personal level (Brown 2015; Guillaume 2014). Furthermore, the notion of trust is relevant in bracketing out these contraceptive uncertainties (Möllering 2006). An array of divers types of trust are discussed; knowledge-based trust that is relevant in relation to the trustee (Gallivan & Depledge 2003), being a person or digital device, and system trust and interpersonal trust, which underlie these trustees (Meyer et al 2008). Furthermore, the locus of control in terms of agency and control over specific contraceptive methods and embodied, personal and socially shared experience that are important to overcome contraceptive uncertainty (Rodrigues 2016; Sundstrom et al. 2018). Truth, legitimacy and authenticity will be used as sensitizing concepts throughout this study (Brown 2015), as embodied and personal experiences that contribute to notions of authenticity and a specific narrative identity, and socially shared experiences that relate to legitimacy, will be highlighted in the following results section in order to grasp and
understand the lifeworlds and choices of NCUs. In discursive perspective, contraceptive practices reproduce the biopower of a population through two specific deployments of sexuality; the hysterization of women's bodies and the socialization of procreative behaviour (Foucault 1990). The risk of pregnancy is discursively reinforced by treating the natural contraception as outside of the medical discourse of which solely ‘reliable’ contraception are part. This discursive trick enables specific disciplinary techniques or, in other words, anatomic politics (Foucault 1990; Hayter 2005;2007). In the results sections I will focus on anatomic politics, whereas biopolitics will be addressed in the discussion, and relate to why contraception is (still) a female responsibility. Moreover, the aim of this research is to understand those women who choose for natural contraception and their identities, in their relation to trust, risk, authenticity, legitimacy and truth, therefore, the following research questions and hypotheses are developed.
2.6
R
ESEARCH QUESTIONS Following the line of the theories explained allows me to deduce the first three questions which are related to (i) identity; (ii) authenticity, legitimacy and truth (Brown 2015); and (iii) trust (Gallivan & Depledge 2003; Meyer et al. 2008: Rodrigues 2016; Sundstrom et al. 2018). (i) Do natural contraception users share typical key personal characteristics? In terms of age, type of relationship, level of education, religious values, certain lifestyles and certain experience with hormonal contraception. (ii) What are the main motivations for natural contraception usage? (iii) What types of trust are natural contraceptive practices founded on?2.7
H
YPOTHESES These hypotheses are based on the idea that risk and trust are interrelated and seek to determine the direction and strength of these relations (Brown 2015, Möllering 2006). Preliminary research and the first 12 interviews have provided me with an idea of these directions, therefore, I produced to following hypotheses: (iv) (H1.a) The perceived risk of pregnancy is lower the older NCUs become. (H1.b) The perceived risk of pregnancy is lower when NCUs are married or in a registered partnership. (H1.c) The perceived risk of pregnancy is lower when NCUs are religious. (H1.d) The perceived risk of pregnancy is lower when NCUs have a conscious lifestyle. (H1.e) The perceived risk of pregnancy is lower when NCUs have a child wish within two years. (v) (H2) Trust in the natural method is higher among natural contraception users when the perceived risk of pregnancy is considered as (quite) non-problematic, controlling for key personal characteristics.C
HAPTER
3.
M
ETHODOLOGY
This section presents the different aspects of the research design. First, the relevance of a mixed research design is discussed. Second, the data collection process is described, as well as the qualitative and quantitative sample, and their ethical considerations. Third, the general analysis strategies of both data type, followed by data and measurement of the main variables and the quantitative data, are presented.3.1
M
ETHODS DESIGN This study focuses in obtaining an in-depth understanding of natural contraception users, as well as developing a theoretically informed typology of NCUs (generalizable to the population). A mixed methods research design allows, on the one hand, to identify and define natural contraceptive users and their practices using a quantitative approach; and on the other hand, to ‘see through the eyes of the people being studied’ through a qualitative approach (Bryman 2008:384-390). The qualitative approach focuses on the why (ii) and how (iii) questions in order get access into lifeworlds of NCUs (Brown et al. 2019), for which a (solely) quantitative method would fall short (Bryman 2008:159). Quantitative techniques are, however, more adequate to define the group of Dutch natural contraceptive users and interested women (i), and to measure and generalize patterns concerning natural contraceptive practices to this population (iv), for which a quantitative survey approach is a suitable choice (ibid.:155-157). Another advantage of a mixed methods design is that qualitative methods assist in refining and constructing internal validity, whereas quantitative methods serve to discover patterns and enable inferences pertaining to the external validity of these patterns. Thus, both methods and subsequent validities bring about a robust methodological frame (Bryman 2008:415, 612-613), which is advantageous in a field that remains understudied, from both sociological and medical perspectives. This study has a sequential structure of three phases (Creswell & Clark 2011:82-100). In the first phase, 12 qualitative interviews were conducted. This follows an instrument-development or exploratory design (ibid.:90), as the first round of interviews informed the design of the web survey (quantitative) that was applied in the second phase of the study. This strategy overcomes the fact that, to date, there is no other survey that considers the relationship between (digital) natural contraception usage and notions of trust, identity and social legitimacy. Furthermore, an exploratory design fulfils the goal ‘to generalize exploratoryfindings’ from the interview by means of the survey (ibid.:9-10). In a third phase of the study, another two qualitative interviews were conducted with the purpose of completing the NCUs profiles. The quantitative results are interpreted independently, but also explained in the light of the qualitative findings. Therefore, this research design is explanatory and exploratory (ibid.).
3.2
Q
UANTITATIVE&
QUALITATIVED
ATAThe qualitative data consists of 14 semi-structured interviews of 45-60 minutes each, conducted on the basis of an interview guide (See Topic list in Appendix). The interviews covered (1) contraception narratives (type of contraception used throughout life course); (2) ethnicity, education level, religious values, children and marital status; (3) trust in relation to various forms of (natural) contraception practices and motivations for contraceptive choices. Moreover, the interviews focused on the meaning of natural contraception in the lives of the participants ; encompassing the possibility for participants to add and elaborate on anything they find relevant in their contraceptive narrative. The quantitative data are the result of a web survey I designed, distributed and applied. Similar to the qualitative interviews, the online survey included questions about (1) the contraception used throughout life courses; (2) general indicators such as age, ethnicity, education level, marital status, religious values, and wish of having children; (3) trust in various forms of (natural) contraception practices, and motivations for contraceptive choice (See Survey in Appendix).
3.3
DATA SAMPLING AND COLLECTIONThe data collection started out inductively with foreshadowed ideas about natural
contraception in the Netherlands, reading about the topic and going to meetings on natural contraception to gain access to this community (Hammersley & Atkinson 2007). The sampling strategy is two-sided; purposive sampling for the survey distribution and snowball sampling for the recruitment of participants as I demonstrate below (Bryman 2008:414-415).
3.3.1
Q
UANTITATIVE DATA SAMPLING AND COLLECTIONThe quantitative data were collected thanks to coordination and collaboration with different companies and organizations that provide natural contraception and/or engage in sexual education. The survey was placed on the websites of Rutgers National Knowledge Centre of Sexuality and The Green Guide blog (lifestyle blog). In addition, the survey was mailed to
costumers of the following contraceptive companies: Natural Cycles, Lady-comp, Sensiplan and PCOS-solutions (company that aims to help women who suffer from Polycystic Ovary Syndrome). Another way to reach people was through my private contacts (sharing survey on my personal Facebook account), and through small organizations such as WondaWomen (young feminist organization based in Amsterdam, The Netherlands). The survey reached 2,544 women, and the final sample consists of 1501 women due to data depuration procedures (see Table 0.).
3.3.2
Q
UALITATIVE DATA SAMPLING AND COLLECTIONAt the same time, a snowball sampling strategy started as key informants (Sensiplan counsellors & CEOs) proposed clients to me for an interview. On top of that, the survey provided participants as women could opt for an interview at the end of the survey and 2 women from my own network were interviewed. Finally, the snowball sampling strategy became theoretical as I specifically sampled a few participants that use the Lady-Comp, which until then were missing in my qualitative data sample. In grounded theory data analysis, which I will use, theoretical sampling is used with the aim to reach theoretical saturation; in which further data collection finds no more new information (Bryman 2008:415; Charmaz & Belgrave 2007). Furthermore, I deliberately choose a divers pool of women in terms of trust; some that very much trust the method and others that try to trust or distrust the natural method. The reason is that for the latter few trust is less deeply taken-for-granted, and therefore ‘the social processes intrinsic to trust become more explicit and are more reflected upon’ (Brown et al. 2019; 7), which can be beneficial to understand their lifeworlds.
3.3.3
B
ASIC ETHICAL CONSIDERATIONS AND REFLECTIONSEthical issues were addressed in both quantitative and qualitative data collection processes. All participants gave verbal informed consent on the recording and usage of their interviews for sociological research purposes. They were assured that all data was handled anonymously and not provided to third parties. All respondents were presented with the following ethical assurances in the survey: All research data will be processed anonymously and confidentially. Personal data are not made available to third parties. At the end of this survey you can indicate whether you want to participate in an interview and whether you want to receive the results of the research. Your answers in the survey will in no way be linked to your e-mail address or a possible interview. By continuing the survey they agreed to these conditions.
Furthermore, in reflection, the power dynamics within the interviews felt in balance since I as a young woman was talking to other (mostly) young women on sexual health choices. However, as a researcher asking question to participants this power disbalance did excited. All in all, I was aware of my role as researcher and tried to create an open and safe environment for my participants, of which the rich interviews are a corollary.
3.4
D
ATA ANALYSIS3.4.1
QUANTITATIVED
ATA ANALYSISThe quantitative analysis consists of descriptive statistics, factor analysis, regression analysis and correspondence analysis (Agresti & Finlay 2009; Clausen 1998; Devellis 2003). Factor analysis (FA) is a statistical analysis in which underlying structures of a specific set of interrelated variables, in this case variables on trust and motivations, are clustered on the basis of their shared variance. Or in other words, a FA provides the possibility to reduce the 16 variables on trust into a few latent variables of trust, which helps answer question (iii). A similar strategy is used for motivations, in order to answer question (ii). I choose for an exploratory FA, since I seeks for shared variance between variables without a priori assumptions about the number of factors (Devellis 2003:102-108). The regression analysis is ‘a mathematical function that describes how the mean of the response variable changes according to the value of an exploratory variable’ (Agresti & Finlay 2009;315). In this case, this function predicts variability in the values of the ‘perceived risk of pregnancy’ variable (model 1) and the ‘trust in the method’ variable (model 2) at each value of the independent variables: age, marital status, religious values, lifestyle and child wish within coming 2 years (and perceived risk of pregnancy in model 2) in order to test H1 and H2. The correspondence analysis is an exploratory correlation analysis that measures the proximity relationship between two variables (Child wish and Contraception method & Age and Perceived Risk of Pregnancy) and demonstrates this graphically (Clausen 1998;1-5). These analyses are made to answer question (i) and create quantitative typologies of NCUs which relate to risk (H1) and trust (H2) as well.
3.4.1
Q
UALITATIVED
ATA ANALYSISThe qualitative analysis is a grounded theory approach, a simultaneously performed data collection and analysis in which the collection is informed by preliminary findings of the analysis and the researcher constantly moves back and forth between the two (Charmaz &
Belgrave 2007), which is known for a high level of validity. Furthermore, I follow Brown et al. in their belief that ‘critical awareness and in depth analysis are the key to lifeworld excavation’ (2019;15), which is the main aim of this study. The mixed methods data provides the possibility to combine the quantitative and qualitative findings is a manner of analysis in which the level of convergence, corroboration and divergence between these results comes to light, a method also known as triangulation. Triangulation aims to overcome weaknesses of each method independently and to find mutually corroborating results to strengthen the validity of these findings (Bryman 2006), and thereby, provides the ability to answer the research questions more fully than one method could. However, divergence between sources can also be important for the development of nuanced understandings of lifeworlds of NCUs (Brown et al. 2019). All in all, in this study triangulation aims to verify, strengthen and provide the possibility to build typologies of NCUs that are both rich in detail as broad in scope.
3.5
Q
UANTITATIVED
ATA&
M
EASUREMENT3.5.1
Q
UANTITATIVE SAMPLE DESCRIPTIONThe dataset obtained through the web survey consists of Dutch women who use, have used or consider using natural contraception. This sample is large (N=2544) and covers users of different companies and/or methods of natural contraception. Although the representation of the sample for Dutch natural contraception users in 2018-2019 is not to be measured, no users have been excluded a priori. It might be plausible that a reliable image of Dutch natural contraception users who use Natural Cycles, Lady-Comp and Sensiplan in 2018-2019 is presented by the sample, however, this is not a certitude. The complete dataset consisted out of 2544 respondents (all women), narrowed down to 1501 by the following process (depicted in Table 0). The majority of the excluded cases (510) correspond to descriptive variables (age, marital status, religion and lifestyle). However, respondents with missing values in key variables such as perceived risk of pregnancy (35), 16 statements on motivations for contraception method (82) and 16 statements on trust in contraception method (173), where also ruled out. Respondents that do not use, ever used and will never use Natural Contraception Methods (40) are also excluded from the final sample, as well as those respondents under 18 years of age. See Table 0. Below for the sample selection process.
Table 0. Sample selection process Step ni (dropped) Starting sample 2544 1. Descriptive variables missing (Age; Marital status; Religion; Conscious lifestyle) 2034 (510) 2. Exclude those who do not use, ever used and will never use Natural Contraception Methods 1994 (40) 3. Perceived risk of pregnancy not missing 1959 (35) 4. Motivation for contraception method not missing 1877 (82) 5. Trust in contraception method not missing 1704 (173) Final sample 1501 Table 1. below contains summary statistics of the variables included in the analyses. I further highlight a few distributions of this sample: It is important to state that 68% of the NCUs are between 26,4 and 39 years old, whereas reproductive age lies between 15-49. In terms of marital status, 37% is single, 50% is married, 12% has a registered partnership and 2% is divorced. Whereas, in relationship terms, the NCUs define themselves to be single (8%), in a relationship without official status (30%) and married or registered partnership (62%). This is an insight into the ‘single’ option of marital status, as women with this status can have a stable unofficial relationship, and as the results show, most of these women are within such a relationship. The perceived risk of pregnancy is measured on a 0 (great to be pregnant) to 10 (terrible to be pregnant) scale and lies between 2 and 8.5 on for 68% of the sample. This wide distribution corresponds with the diversity in child wishes; 40% wants children within two years, 25% is uncertain and 35% does not want a child in this time period. The variable ‘conscious lifestyle’ is the result of the merging of three variables on food choices into one robust variable (Cronbach’s alpha 0.7). As a result, the variable is measured on a 10-point scale, for which 0 means no vegan, vegetarian and biological food preferences at all, whereas 10 means maximum vegan, vegetarian and biological food preferences. In this sample 68% of the respondents describe to have a conscious lifestyle between 2.2 and 6.7, and with a mean that lies below average (5.5 is average whereas the mean is 4.45), this sample appears to have medium conscious food preferences. Almost half of the sample defines as religious (45%), which can be due to the religious background of natural contraception; Sensiplan and Lady-Comp share such a background. The
other half defines as non-religious (45%) and 10% defines as spiritual. The current contraception methods are not all NCMs since some respondents used NCMs before or will use these in the future, but currently use other forms or are pregnant.
Table 1. Summary Statistics of Variables
Proportion Mean / SD Range
Age (in years) 32.69 6.30 19-79 Marital status Single 0.37 Married 0.50 Registered partnership 0.12 Divorced 0.02 Child wish within coming 2 years Child wish 0.40 No Child wish 0.35 Uncertain Child wish 0.25 Religion Non-religious 0.45 Religious 0.45 Spiritual 0.10 Conscious lifestyle 4.45 2.25 0-10 Perceived risk of pregnancy 5.25 3.25 0-10 Current contraception method Hormonal contraception (pill, IUD, vaginal ring) 0.04 Non-hormonal contraception (copper IUD, condoms) 0.08 Natural method: Abstinence in fertile period 0.21 Natural method: Abstinence & barrier methods in fertile period 0.55 Sterilization (women) 0.01 No contraception 0.11 Observations 1501 Note: Natural Contraception Survey 2019, own calculations.
Furthermore, education is the only main variable that is not presented in Table 1, due to the fact that it is neither significant nor substantively of influence in any of the analyses. The distribution is as followed: 3% of NCUs have a low education level, 21% of NCUs have a medium education level and 76% of NCUs have a high education level (Table 2. Education Descriptive Statistics in Appendix).
3.5.2
F
ACTOR ANALYSES FA measures if the 16 motivations variables have a (few) common latent variable(s), or factors. The motivation variables consists of 16 statements on possible motivations which are derived from the interviews. These are measured on a 5 point Likert scale ranging from ‘Totally not agree’ to ‘Totally agree’, with value 6 being the “Not applicable” option. For statistical purposes the latter are imputed to the mean value per statement. In Table 3. In the Appendix ‘Summary Statistics of Variables for exploratory orthogonal Factor analysis motivations’ all statements are displayed. This analysis provides one or more factors with factor loadings, the latter explain how much percentage of variation within the variable is explained by the factor (Devellis 2003:135), to which the results section is dedicated (See Chapter 4, section 4.2.). A similar strategy is chosen for the 16 categorical trust variables, 9 dummy variables on sexual strategies, 8 dummy variables on contraceptive methods and an interval variable on user time are part of this analysis. In Table 4 in the Appendix ‘Summary Statistics of Variables exploratory orthogonal Factor analysis trust’ all statements and displayed in detail. Note, the trust variables consist of 16 statements on possible trust items, which are derived from the interviews. These are measured on a 5 point Likert scale ranging from ‘Totally not agree’ to ‘Totally agree’ and the “Not applicable” option with value 6 is imputed to the mean value per statement.3.5.3
R
EGRESSION MODELS As stated above, linear regression models measure the influence the independent variables have on the mean of the dependent variable. This technique allows for a precise indication of the influence of variables such as age, marital status, religious values, conscious lifestyle and child wish within coming 2 years, on the dependent variable the perceived risk of pregnancy (model 1) (See Summary statistics Table 1.). As for model 2, a precise indication of the influence of the following independent variables; perceived risk of pregnancy and the control variables are age, marital status, religious values, lifestyle and child wish within coming 2 years as independent variables (See Table 1. Descriptive statistics), on the dependent variable ‘trust in the method’. The latter is derived from the factor analysis on trust, the first factor of trust had high factorloadings (>0.8) on three variables of trust that measure trust in the method. These three variables are transformed into one robust variable which is measured on a 5 point Likert scale ranging from ‘Totally not agree’ to ‘Totally agree’ (See Table 5. below).
TABLE 5. Operationalization of Dependent Variable regression model 2
Variable Mean SD Range
Trust in the method 2.82 0.50 1.33-5
Observations 1501
3.5.4
C
ORRESPONDENCEA
NALYSIS(CA)
The correspondence analyses was conducted with a bigger sampe than outlined above in the data section (N=2148), since the missing data on the following variables ‘conscious lifestyle’, ‘trust’ and ‘motivation’ questions, do not influence the correspondence analyses on the four specific variables, however, it does increase the generalization and clarity of the results immensely. See TABLE 6. Summary Statistics of Variables Correspondence Analysis (CA.1) & (CA.2) in the Appendix. CA model 1 is based on the variables ‘Contraception method’ and ‘Child wish’ and CA model 2 is based on the variables ‘Age’ and ‘Perceived risk of Pregnancy’ (See Table 6 in Appendix). Since correspondence analysis is an analysis most successful for categorical variables (Abdi & Valentin 2007; Claussen 1998), age is recoded into four categories, 18-26 years, 27-35 years, 36-44 years and 45+, and the 10-point-scale of perceived risk of pregnancy is recoded into three categories; 0/3=1 “Low risk”, 4/6=2 "Neutral" and 7/10=3 "High Risk”. Note, the Do-file is not attached and accessible on request, so are the imputation tables.
C
HAPTER
4.
T
HE SURVEY FINDINGS AND ANALYSIS
4.1
D
ESCRIPTIVES
TATISTICS Negative experiences with hormonal contraception I order to give a contraceptive background of the respondents in the dataset, the previous used forms of contraception, before switching to natural contraception are: the pill (47%), the hormonal IUD (12%), the Copper IUD (4%), the Vaginal ring (6%), condoms (9%), implant 1% and nothing (11%). Merely 9% has always used natural contraception (See Table 7 in Appendix). Furthermore, 74% of the respondents have had a negative experience with hormonal contraceptives (See Table 8 in Appendix) and 97% describe they do not want hormones in their body (Table 9 in Appendix). The latter two results will be addressed in the factor analysis results on motivations for NCMs (See section 3.6.2 ) Contraceptive methods, media and sexual strategies The NCUs use the following media, contraceptive methods & sexual strategies, see tables 10, 11 and 12 below for an overview. Table 10. Media (N = 1501)Media Freq. Percent.
Lady-Comp 736 49% Natural Cycles 225 15% Sensiplan 262 18% Menstruation- tracker apps 192 13% Other contr. apps 38 3% On paper 86 6% Table 11. Method (N = 1501)
Method Freq. Percent
Ovulation tests 104 7%
Symptho-thermal 375 25% Feelings 212 14% Calendar 375 25% Nothing 62 4% Temperature 882 59% Table 12. Sexual strategies (N = 1501)
Sexual strategies Freq. Percent
Abstinence 277 18% Condom 681 45% Pullback 186 12% Nothing 33 2% Sex without penetration 201 13% Always condom 339 23% Always pullback 99 7% The media, method and sexual strategy tables do not add up to a 100% due to the fact some NCUs use more than one medium, method and sexual strategy. Interestingly, the most common used method is the temperature method and the most common used medium is the Lady-comp which is based on temperature method. Furthermore, most widely used sexual strategy is condom use. The satisfaction of natural contraception user has a mean of 8.4 on a 10-point scale, with a SD of 1.89. Thus, 68% is satisfied between 7.5 and 9.9, which, on a 10-point scale, entails that these users are quite satisfied (See Table 13in Appendix). In line with these findings are the recommendation results; 83% would recommend NCMs to others, 5% would not and 11% do not know (See Table 14. In Appendix) However, in terms of the ‘Feeling of protection against pregnancy’, the scores are not that high, see Table 15. below. (I have reduced the sample to 1140 respondents whom currently use NCMs).
Table 15. Feeling of protection against pregnancy (N = 1140) Mean SD Range Feeling of protection against pregnancy 8.14 1.72 0-10 Respondents that currently use NCMs (N=1140), score a mean of 8.13 with a SD of 1.72 on how protected they feel against pregnancy, on a 10-point scale (0=Not protected at all, to 10=Fully protected). Thus, 68% of the women that currently use NCMs feel protected against pregnancy between the range of 6.42 and 9.86 on a 10-point scale. One would say that protection against a pregnancy is the main aim of contraception, and anything below a 10 is not sufficient. In the correspondence analysis results (See section 3.6.3.) this issue will be addressed in which the perceived risk of pregnancy plays an important part. Table. 16 Responsibility natural contraception
Responsibility natural contraception Freq. Percent
NCU is solely responsible 111 7.75 NCU is responsible for the most part 550 38.41 Equal sharing of responsibility 718 50.14 Partner is mostly responsible 9 0.63 Not using contraception 33 2.3 Other 11 0.77 Missing 69 4.6 Total 1501 100 Table 16 displays the attitudes NCUs have towards sharing of responsibility with their partner in natural contraceptive practices. Interestingly, 8% of NCUs feel that they bear responsibility of contraception on their own, these could be women that do not have a fixed partner, as 91% of the sample has a fixed sexual partner and 5% has changing partners whereas 4% has no sex partner (See Table 17. In Appendix). However, table 16 shows that 38% of NCUs has the feeling that she bear the responsibility for the most part on her own and 50% describe a shared responsibility, both are an immense difference in relation to hormonal contraception (Tone
2012). In the last chapter I address the shared responsibility in relation to the re-feminization and emancipation.
Table 18. Opinion on sex life (N = 1501)
Opinion on sex life Freq. Percent
Positive change 761 50.70 No change 443 29.51 Negative change 211 14.06 Table 18 shows that 51% of NCUs describe a positive change in their sexual life, this might relate to the idea that non-hormonal contraception does not influence libido. 14% experiences a negative change of their sexual life, which can coincide with the necessary sexual strategies NCMs consist of. In Chapter 5 this will be further addressed. Table 20. Trust sources (N=1501)
Advise Freq. Percent
Female family members 302 20.12 Female friend 592 39.44 GP 252 16.79 Gynaecologist 270 17.99 Partner 127 8.46 Scientific Article 719 47.90 Rutgers 76 5.06 GGD 97 6.46 Own experience 999 66.56 Online research 854 56.90 As the table 20 shows, NCUs reported using multiple sources they trust on which they base their contraceptive choices. The main sources are their own experience (67%), doing online research on their own (57%) and reading scientific articles (48%), which are quite individual manners of obtaining and trusting information. However, socially shared experiences and advise of female friends (39%) and mother and other female family members (20%) are important as well. The healthcare representatives are less influential GP (17%) and the gynaecologist (18%). These
findings correspond with Rodrigues’ theory on socially shared and personal and/or embodied experience being most important in coming to a medical decision (2016), and that healthcare providers are less important in these matters (Sundstrom et al. 2018). Table 21. Self-knowledge & the cycle (N=1501) Variable
Mean Std. Dev. Range
I am always aware of where I am in my cycle 7.82 2.07 0-10 I manage my cycle on a daily basis 6.88 2.81 0-10 Keeping track of my cycle gives me self-knowledge 8.47 1.77 0-10 Keeping track of my cycle only serves as a contraceptive method 4.43 2.86 0-10 Table 21 shows statements that indicate that the cycle is an important element for NCUs and that NCMs are more than just a contraceptive method. As the third statement demonstrates, with a mean of 8.47, most NCUs describe to obtain self-knowledge through NCMs usage, more specifically through getting to know their cycle. These findings will be further addressed in Chapter 5.
