pageok
pageok
pageok
The Contraceptive Failure Rate of Abstinence?

The Seattle & King County Public Health page called "HIV/AIDS Program: How effective are condoms?" reports:

No method of contraception or disease prevention is effective when practiced incorrectly or inconsistently. A 1988 National Survey of Family Growth found abstinence to have a contraceptive failure rate of 26% when not practiced consistently. So, in abstinence, as in condom use, consistency is key.

Mighty odd-sounding, as OpinionJournal reported: Is it really abstinence when you aren't consistently abstaining? Or is their claim that people who decide to be abstinent nonetheless in practice end up backsliding — and often enough that they get pregnant in 26% of the first year in which they chose to be abstinent? (That's how contraceptive failure rates are generally measured.) If that's so, then that would suggest that abstinence decisions, at least unless reinforced by some belief system that will deepen the commitment to the decision, are remarkably ineffective.

But here's what's really going on: (1) a confusing term being used by public health scholars, which (2) likely led to confusion on the part of the person writing the Web page, which (3) translates into false claims being passed along to the public. If you look at abstracts of the 1988 Survey, you find that 26% is the failure rate for "periodic abstinence", which means "rhythm and natural family planning."

That's right: 26% is the failure rate for the rhythm method, not for deliberate decisions to abstain. Public health scholars apparently refer to the rhythm method and similar practices as "periodic abstinence," which is literally accurate, but potentially confusing to nonexperts, since it's close to a term ("abstinence") that means something quite different in lay discussion. The Web page author seemed to have been confused, interpreting "periodic abstinence" simply as "inconsistently practiced abstinence," and thus labeling it simply as "abstinence." And readers will therefore be getting false information: "Abstinence" in lay discussion generally refers to a deliberate decision not to have sex at all — rather than just to a decision to have sex only on one's presumably less fertile days — so people will read the claim as pointing to the dangers of abstinence, rather than the dangers of the rhythm method.

So three tips: (1) If you're a scholar, especially in a discipline where laypeople or nonacademic public policy analysts might consume your output, try to avoid adopting terms that may confuse outsiders. (I realize that sometimes there may have to be trade-offs between clarity to outsiders and clarity or convenience to fellow scholars, hence my use of "try.") Lawyers and judges, by the way, are frequent offenders here, creating legal terms that sound like one thing in English (e.g., "actual malice" in libel) but mean something quite different in legalese. This is especially dangerous in law, where the lay public is especially likely to be interested in the information, though also especially hard to root out, since many of these terms evolve over decades, and are hard to clarify because of the weight of precedent and tradition.

(2) If you're consuming academic works, be on the lookout for terms that don't mean quite what they seem to mean at first, and for qualifiers that are sometimes overlooked but are tremendously important. There are false friends in translation from technical English into lay English just as there are in translation between languages.

(3) Don't believe everything you read.

Columbienne:
The Seattle Public Health page does appear to have been mistaken about the meaning of "abstinence" in the 1988 study, but the underlying point is still absolutely correct -- all methods have failure rates, condoms, abstinence, and rythym method included.
8.17.2005 3:23pm
Steve Dillard (mail) (www):
Eugene-

The "rhythm method" is not the same thing as "natural family planning." As the Couple to Couple League explains:


Calendar Rhythm basically assumed that women would have 28-day cycles with ovulation around Day 14. It was ineffective if cycles were either shorter or longer. Modern NFP acknowledges that a woman can routinely have cycles that are shorter or longer than the "average" of 28 days, and that her cycle can even vary from month to month. NFP users make their interpretation choices based on the fertility symptoms they are currently experiencing this month, which is why it is still highly effective for women with irregular cycles, unlike Rhythm.


Those who are interested can read more about NFP here.

Moreover, NFP is highly effective when it is done properly.
8.17.2005 3:23pm
Noah Snyder (mail):
Anyone know what the failure rate (measured by pregnancies per year) of abstinence users (measure by people who have taken a pledge that year, or self-reporting, or some more clever measure) actual is? Prof. Volokh is right to point out that this study is not reporting that number. But 10 minutes of googling hasn't turned up the actual number for me yet.
8.17.2005 3:26pm
Jonathan M (mail):
This all sounds like something you'd find on an LSAT...
8.17.2005 3:44pm
Columbienne:
Steve - I wouldn't call 87% (at best) "highly effective," not by a long shot.
8.17.2005 3:44pm
Richard Blaine (mail):
Or it could be that... Eugene doesn't get the joke!
8.17.2005 4:31pm
Simon Spero (mail):
I'm strongly in favour of Absinthe-only Sex Education.
8.17.2005 4:49pm
Steve:
While there is humor in pointing out this typo, it's a bit much to conclude that "readers are getting false information." Anyone who is intelligent enough to navigate to a webpage is unlikely to gather from that webpage that people who do not have sex get pregnant 26% of the time.

This is a good example, however, of how a law professor can develop a lecture even from a ham sandwich.
8.17.2005 4:50pm
Steve Dillard (mail) (www):
Columbienne-

The 87% effectiveness rate to which you refer is for one NFP method at "typical use," rather than "perfect use." If you're going to be critical of NFP and my comment at least have the courtesy to place things in their proper context.

So that this doesn't happen again, here's the relevant information:

Here's a look at the effectiveness rates of the different methods of natural family planning. Effectiveness rates are available for all methods except cervical position and dilation.


Effectiveness rates for preventing pregnancy after one year

Method Perfect use (%) Typical use (%)
Calendar 95 87
Temperature 98 80
Cervical mucus 97 78
Symptothermal 97-98 80-87
Standard days 95 88
TwoDay 96 86

These effectiveness rates represent how effective each method is at preventing pregnancy for couples who use natural family planning for one year. For example, with typical use of the symptothermal method, 10 to 13 women out of 100 become pregnant. With perfect use, only two to three women out of 100 become pregnant.
8.17.2005 4:53pm
stupid:

Eugene says:

"Is it really abstinence when you aren't consistently abstaining? Or is their claim that people who decide to be abstinent nonetheless in practice end up backsliding..."

Still, I hear that backsliding is less likely to get you pregnant than frontsliding...

;-)
8.17.2005 5:01pm
Columbienne:
Steve - right, perfect use, rather than typical use, which is only 80-87% effective. That's the proper context. I would wager that perfect compliance with NFP is much, much harder than perfect compliance with any other method.

Anyway, even the perfect rates (95-98%) are nontrivially worse than perfect use of hormonal contraceptives (99.5%) and about the same as typical use of hormonals. (Not to mention that perfect condom use is 97% anyway and has the added bonus of STD protection.)
8.17.2005 5:15pm
Steve Dillard (mail) (www):
Columbienne-

Yes, self-control is a tough sell these days. On that we agree.

But beyond the moral implications of "hormonal contraceptives," there are also serious health risks associated with the use of such birth control:


Hormonal contraceptives, besides being abortifacient, have horrific side effects for the women who use them. From high blood pressure to blood clots, to heart attacks, to migraine headaches, to menstrual problems after you quit taking the drug, hormonal contraceptives (the pill, Norplant, and Depo-Provera etc) can wreak havoc on a woman's body. It is no coincidence that the rise in breast cancer followed ten to fifteen years after hormonal contraceptives first became readily available. It is also no coincidence that many women who have been on the pill for years and now want children, find they are now infertile. Infertility has become a national epidemic, with couples spending hundreds of thousands of dollars trying desperately to conceive. Unethical doctors continue to become wealthy prescribing contraceptives and then treating the side effects.
8.17.2005 5:37pm
Amy Phillips (mail) (www):
Noah Snyder,
I don't have pregnancy data, but apparently, a study was done about STD rates among pledgers:

"Although not a controlled trial, one of the largest studies of the effect of abstinence pledges tracked the sex lives of 12,000 US teenagers aged between 12 and 18 (American Journal of Sociology, vol 106, p 859). A group led by Peter Bearman, a sociologist at Columbia University in New York, investigated whether taking a virginity pledge affected the age when people first had sex. It did, with an average delay of 18 months. The pledgers also got married earlier and had fewer partners overall.

But when Bearman went back six years later and looked at the STD rates in the same people, now aged between 18 and 24, he was in for a surprise. In research presented at the National STD conference in Philadelphia last year, he found that though pledgers had had fewer sexual partners than non-pledgers, they were just as likely to have had an STD. And the reason? 'Pledgers use condoms less,' says Bearman. 'It's difficult to simultaneously imagine not intending to have sex and being contraceptively prepared.'"

Seems less than 100 percent effective to me...
8.17.2005 5:46pm
Columbienne:
Steve - Good, so now it's clear you're someone against effective birth control in general, rather than someone in favor of broadening knowledge about of all kinds of birth control.

Anyway, thanks for providing an object lesson in real time of what the Seattle Health Department is dealing with when it tries to present accurate information about birth control. The reason they tried to make the comparison between the effectiveness of condoms and the effectiveness of abstinece in the first place is because of the anti-birth control crowd's misrepresentation of the data.
8.17.2005 6:04pm
Anonymous Coward:
Columbienne:

The site says that imperfect use of condoms is 86% effective-- ie very comparable to imperfect use of NFP. The "perfect" rates are also similar. While more effective, hormonal treatments also have more side effects.
8.17.2005 6:06pm
Amy Phillips (mail) (www):
More data: according to the Heritage Foundation (which endorses the effectiveness of virginity pledges), teenage girls who take virginity pledges are 33-50 percent (depending on in their words, the strength of the pledge) to get pregnant than teenage girls who make no such pledge. The pregnancy rate for under-18 non-pledgers was reported as 9.7 percent, while the rate for pledgers was 6.5 percent, and for "strong pledgers" it was 4.3 percent. That Heritage study also has data for out-of-wedlock births in women over age 18, unprotected sex, and other indicators.

Of course, it's entirely possible that there's a selection bias at work. Girls who would agree to take a virginity pledge may have already been inclined to delay or abstain from sex, even without the pledge. They may have had different behavior than non-pledgers with regard to birth control, STDs, etc. even if they had never been asked or agreed to take a pledge. But, taken for what they're worth, the numbers still support the conclusion that abstinence, as typically practiced, is not perfect protection.
8.17.2005 6:07pm
Steve Dillard (mail) (www):
Columbienne-

I do oppose hormonal contraceptives, but I hardly see why that means I am "someone against effective birth control in general, rather than someone in favor of broadening knowledge about of all kinds of birth control."

As I've already demonstrated, NFP is effective if used properly, and I am all in favor of women being informed of the dangers of the "effective birth control" you seem to embrace.

I would also be interested in you explaining to the readers of VC exactly what you mean by "the anti-birth control crowd's misrepresentation of the data." I assume you have data/references to back up this claim, right? Or are you just parroting Planned Parenthood talking points?
8.17.2005 6:13pm
Columbienne:
I hardly think I need to cite the anti-condom hysteria that's out there. Just google around for Focus on the Family or Concerned Women for America.

I really can't stand to debate people who are against effective birth control, yet are almost certainly anti-abortion too. Ugh.
8.17.2005 6:16pm
Steve Dillard (mail) (www):
Columbienne:

Oh yes, heaven forbid that you might actually have to defend the culture of death you promote/embrace (not that it's possible to do so).

And yes, I am pro-life. I believe in defending the most helpless/defenseless amongst us. I believe that if a woman chooses to have sex, then she ought to face up to the consequences of her actions (and so should the man as well). And in cases of rape and incest, I don't believe that an unborn baby should be put to death for the sins of the perpetrators of those actions.

And that makes me a monster, right?

Whatever. You are obviously incapable of defending your views, so I'll let you slink away.

Oh, and before you ask, yes I do oppose the death penalty.
8.17.2005 6:27pm
Columbienne:
I'm going to have unmarried sex and use birth control and not have a million babies, and you can't stop me, neener neener neener!
8.17.2005 6:33pm
Steve Dillard (mail) (www):
How sad. I'll pray for you.
8.17.2005 6:34pm
Amy Phillips (mail) (www):
Steve,
If you're going to accuse those who endorse the safety of hormonal contraceptives of "parroting Planned Parenthood talking points," I would appreciate seeing some data from you that aren't from Christian organizations explictly opposed to the use of medical methods of preventing pregnancy.

The data on hormonal contraceptives do indeed state that there are risks, as there are with any medication. For example, acetaminophen, the main ingredient in Tylenol, is associated with liver, renal, and gastrointestinal toxicity that leads to as many as 100 annual deaths and 56,000 annual emergency room visits. All drugs have risks, and so the question is how prevalent are those risks, and how do they measure up to the benefits or harms prevented. With modern hormonal contraceptives, the risks are negligible. The risk of death or serious injury from pregnancy is significantly more statistically significant than the risk of taking the pill, even over the course of many years.

From the Food and Drug Administration:
"Fears about blood clots, heart attack, and stroke, which spurred exhaustive research on oral contraceptives in the '60s and '70s, have largely been laid to rest by the safer, low-dose birth control pills on the market today. Current research suggests that healthy, non-smoking women have little if any greater risk of these serious health problems than do women who do not use the pill.

Questions about the pill's association with cancer, however, remain. Some widely reported recent studies support the hypothesis that in certain groups of women the risk of breast cancer increases with oral contraceptive use. A larger number of studies, however, found no significant increased risk. Nor is it definitely known yet whether or not the pill causes cervical cancer in some groups of women. So far, a cause-and-effect relationship has not been established.

But the pill has been found to help prevent two major types of cancer--cancer of the ovaries and cancer of the endometrium (the lining of the uterus)."

If you would like to dig up some peer-reviewed data from an unbiased source on the statistical incidence of the birth control risks you noted, I would be happy to read them. Until then, I think I'll continue to take the advice of the numerous medical organizations that have endorsed the use of hormonal contraceptives.
8.17.2005 6:41pm
Columbienne:
No, Steve, I'll pray for you that god may heal your misguided obsession with controlling other people's fertility.
8.17.2005 6:46pm
Steve Dillard (mail) (www):
Amy-

Sure. Here are some non-Christian and/or peer-reviewed sources that you might find of interest:

If you'd like some more, I can provide them.

And here's a question for you: Why is that so many people who eschew the artificial in favor of the all-natural in virtually every other area of their life—e.g., food, clothes, etc.—are unwilling to extend that mentality to birth control. I find that fascinating, don't you?
8.17.2005 7:09pm
Lady Jane (mail) (www):
Abstinence has a 100% rate of effectiveness. Otherwise, it isn't abstinence.
8.17.2005 7:10pm
Bruce Hayden (mail) (www):
James Taranto, in today's WSJ Best of the Web: "You've got to hand it to Volokh: With a problem scientific, he's colossal and terrific."
8.17.2005 8:36pm
Keith Hilzendeger (mail):
I'll elaborate on Lady Jane's point: As a rhetorical device, this piece might be blatant anti-abstinence editorializing. After all, "abstinence," as that term is bandied about by those who advocate its use as a birth-control method, means simply not having sex. The rhythm method and natural family planning are not "abstinence," because they rely upon knowing when conception is least likely during the woman's cycle to make a decision whether to have sex in the first place. By characterizing the rhythm method and natural family planning as "failures" of "abstinence," then, the piece points out the failure of the "abstinence" movement.

Brilliant, I say.
8.17.2005 8:50pm
Columbienne:
Steve, Gary Null, who you cite above, is a quack, and the rest of the studies simply repeat what Amy Phillips said.
8.17.2005 8:56pm
Steve Dillard (mail) (www):
Columbienne-

O.k., let's say that he is. So what? I notice that you fail to address the other links I reference. Care to take those on, or is this a one shot hit-and-run rejoinder?
8.17.2005 9:13pm
Columbienne:
As I said above, the rest of the links just repeat what Amy Phillips posted already -- that there are risks and benefits to hormonal contraceptive use. Anyway, there's not much point in debating this with you because your agenda is to end contraceptives, not to help women's health. If you really cared about women's health you'd be advocating for safer contraceptives or promoting condom use.
8.17.2005 9:20pm
Amy Phillips (mail) (www):
Steve,
I don't know, why is it that people are willing to use artificial means of removing dirt from their homes, or curing infection, or alleviating pain? Come to think of it, why are people willing to use artificial means of communication, like computers, instead of relying on all-natural methods like a town crier or two tin cans strung together?

I jest, yes, but honestly, I find the "all-natural" crowd sort of bizarre myself. I don't understand why a person wouldn't want to wear comfortable synthetic fabrics or eat tasty, healthful food grown with the aid of chemicals any more than I understand why people would eschew safe, effective, convenient birth control. I simply don't understand the mindset that altering my own behavior to fit the natural world is somehow superior to or safer than altering the natural world to fit the choices I want to make in my life.

On the sources you provided. The first gives no information about the likelihood of the risks occurring; the data I'm reading state that the risks are extremely low for healthy women under 40. Do you have any actual numbers on the incidence of such problems? The second cites studies of women who took the pill in 1986 or before. The pill women take today has much lower doses of hormones than the pill from 20+ years ago, and thus the risks are believed to be negligible. The third source, once again, states that the risks are extremely low for healthy younger women. The fourth source does call into question the risks for long term use of Depo-Provera, the birth control shot. I assume, however, that women can talk with their doctors about the risks that are, per the FDA's mandate, clearly listed on the packaging, and decide for themselves whether they believe their health is jeopardized. Finally, your last source is again a study of women who used the higher-dose pill that has largely been phased out in favor of lower hormone pills. It also states that "10 years or more after they stopped using OCs, their risk of developing breast cancer returned to the same level as if they had never used birth control pills," which is why many doctors do not recommend the pill for women over 35 or 40, as most breast cancers develop at least a decade after that age. So all in all, I find no really compelling evidence in the sources you've provided that hormonal contraceptives pose a high risk to most women who use them.

I hope that women are talking to their doctors about the relative risks and benefits of any medications they are taking. I hope that men, women, and couples are considering all of their options and making informed decisions about what is right for them in their lives. Not every option is right for every person, and I'm glad that you've given so much thought and research to what is right for you in your life. However, you quoted (and therefore, I assume, endorsed) a very strong claim that, "Unethical doctors continue to become wealthy prescribing contraceptives and then treating the side effects." You've provided no evidence that doctors are withholding information from their patients, or that profit motives are getting in the way of responsible medicine, or that hormonal contraceptives pose a significant risk to most healthy women. I would urge you to really be certain of your evidence before making such extreme accusations.
8.17.2005 9:24pm
Steve Dillard (mail) (www):
Here are some additional non-Gary Null links, courtesy of Brown University, University of Chicago, the FDA, and Cornell University.

And there's a lot more references if you're truly interested.
8.17.2005 9:24pm
Columbienne:
Steve, that FDA link is the same one Amy linked to above, and the rest yet again fail to add anything new. I think this means we win!
8.17.2005 9:35pm
Some guy from somewhere (mail):
It's not very appropriate to use the abstinance pledge in determining the "typical" failure rate of abstainance over a long time. At some point, the person makes a decision to be sexually active. Maybe you could chalk up the first few times to "inconsistant use", but at some point, you have to recognize that the person has made a decision not to abstain.

This would be like someone going on the pill for a couple months, then missing a couple days, having sex anyway, and never bothering to take it again. You'd hardly continue to count suck a person torwards the effectiveness of the pill.


Re: NFP, it is rather effective at preventing pregnancy, but it takes a bit of effort and self control (or a supply of alternate birth control for a portion of the cycle). Lots of women do end up with side effects on the pill (weight gain, loss of libido, etc), and NFP can be a good alternative. It isn't much for preventing STDs, of course, but neither is the pill.

Toni Weschler has a great book called Taking Charge of your Fertility which explains how to do it without a lot of the moralizing you get in other books on the topic.
8.17.2005 9:36pm
Some guy from somewhere (mail):
"count suck a person"

Of course, that was supposed to say "count such a person".

Why do we always catch those things in the millisecond afrer we hit send, before the page refreshes?
8.17.2005 9:39pm
Amy Phillips (mail) (www):
Steve,
The FDA link you provide in your second list of links is, amusingly enough, the same FDA link I provided in my original post to you. If you read past the title, you'll find this:
Oral contraceptives have been kept under surveillance for 30 years. In fact, over the years, more studies have been done on the pill to look for serious side effects than have been done on any other medicine in history, according to FDA.

Fears about blood clots, heart attack, and stroke, which spurred exhaustive research on oral contraceptives in the '60s and '70s, have largely been laid to rest by the safer, low-dose birth control pills on the market today. Current research suggests that healthy, non-smoking women have little if any greater risk of these serious health problems than do women who do not use the pill.

Questions about the pill's association with cancer, however, remain. Some widely reported recent studies support the hypothesis that in certain groups of women the risk of breast cancer increases with oral contraceptive use. A larger number of studies, however, found no significant increased risk. Nor is it definitely known yet whether or not the pill causes cervical cancer in some groups of women. So far, a cause-and-effect relationship has not been established.

But the pill has been found to help prevent two major types of cancer--cancer of the ovaries and cancer of the endometrium (the lining of the uterus).

Last December, an FDA advisory committee, reviewing the relative risks and benefits of today's birth control pills, recommended that the upper age limit of 40 then in use for the pill be lifted for healthy, non-smoking women, thereby making this popular, effective means of contraception available until menopause.

All of the University links in your second post note that the serious side effects are "very rare." Can you provide data showing that birth control is significantly more risky than Tylenol? More risky than driving a car every day? More risky than pregnancy and giving birth? If not, what you're arguing isn't that the pill is objectively seriously dangerous. Rather, you're arguing that, based on your own subjective valuation of risk and benefit, the slight risks of blood clots, compromised fertility, and certain cancers are not worth the convenience, protection from pregnancy, lower risk of certain other cancers, and other health benefits of taking the pill. Luckily, no one is forcing you to ignore your own valuation of those risks and benefits. All we're asking is that you not attempt to force those of us who disagree with you to ignore our judgement when it comes to our health.
8.17.2005 9:42pm
Steve Dillard (mail) (www):
Columbienne-

You once again presume that if one is against hormonal contraceptives then he is automatically "against women's health." That's sheer nonsense. As is this silly statement:


If you really cared about women's health you'd be advocating for safer contraceptives or promoting condom use.


I believe NFP is the best method for a woman's health. Am I not permitted to hold this position?

Amy-

Thank you for the thoughtful response. And we certainly agree that women should be "talking to their doctors about the relative risks and benefits of any medications they are taking, and that "men, women, and couples [should be] considering all of their options and making informed decisions about what is right for them in their lives."

I pray that more people will choose NFP, but I realize that many aren't willing to make that sacrifice.

As for this statement:


"Unethical doctors continue to become wealthy prescribing contraceptives and then treating the side effects."


I wasn't necessarily endorsing it. That having been said, the vast majority of woman that I (and my wife) have spoken to about birth control have no clue about the side effects (such as they are). Indeed, before I converted to Catholicism, neither I nor my wife had any idea about the moral implications and health risks associated with birth control. I realize this is just my life experience (and not a formal study), but I strongly suspect that my wife and I were not in the minority re: our lack of knowledge about birth control.
8.17.2005 9:42pm
Steve Dillard (mail) (www):
Amy-

Too funny. I thought that article looked familiar. :)

And yes, I am arguing that "based on [my] own subjective valuation of risk and benefit, the slight risks of blood clots, compromised fertility, and certain cancers are not worth the convenience, protection from pregnancy, lower risk of certain other cancers, and other health benefits of taking the pill."

I also strongly oppose hormonal contraceptives on moral grounds.

But I don't think I've said anything to suggest that I am "attempt[ing] to force those . . . who disagree with [me] to ignore [your] judgement when it comes to [your] health."

I am merely presenting an alternative view.
8.17.2005 9:47pm
Columbienne:
Steve - Faulty syllogism there, buddy. I said that your agenda is anti-birth control, not that you're anti-women's health (although hurting women's health is probably one outcome of your position).
8.17.2005 9:49pm
Columbienne:
Steve, forgive me for not believing that your ultimate agenda is not to force your morality on others through legislation.
8.17.2005 9:52pm
Amy Phillips (mail) (www):
I have been prescribed the pill by at least 4 different doctors over the past several years. Each one has asked me a detailed list of questions about my sex life, smoking, eating habits, family history of certain cancers, and other risk factors. I have never been prescribed the pill without a warning that certain side effects may occur (commonly headaches and breakthrough bleeding, but also the much smaller risks of blood clots and other serious problems), and advice to call the doctor's office if I have any problems or concerns. I am sorry that your wife and her friends have not been lucky enough to have doctors as conscientious as mine. I also make a point to actually read the information that comes with my prescriptions, ask my pharmacist about potential interactions between them, and call my doctor if I have concerns. I suspect you are right that not enough people do that, and I don't have an easy answer to that problem. However, do you really think that people who can't take 5 minutes to read their prescription information will take the time and care to chart their menstrual cycles properly? If reading paperwork is too much effort to expend on their health, I suspect that their use of natural family planning would not be as diligent and responsible as your family's.
8.17.2005 9:53pm
Steve Dillard (mail) (www):
Amy-

My wife was asked those questions as well, but her doctors (in the past) did not go over (verbally) the potential side effects of the pill or patch. As for the boilerplate prescription information, I think you and I are in a distinct minority (I read them as well). :)

I guess my overarching point is that many women take birth control without having really considered all of their options. It's become a right of passage of sorts, and I just think more woman ought to critically examine the issue rather than blindly pop that pill every day.
8.17.2005 10:00pm
Steve Dillard (mail) (www):
make that: "more women"
8.17.2005 10:01pm
ADT:
"If you really cared about women's health you'd be advocating for safer contraceptives or promoting condom use."

What about advocating safer practices, such as sex within a marriage, or total abstinence. Does that not fall under caring for women's health?

As a woman, who cares very much for women's health, I support abstinence education. I think we have failed our children by promoting "safe sex" just because of the "they're going to do it anyway" reasoning. Birth control is given out at adolescent clinics all the time, yet the girls keep coming back pregnant. Sometimes the daily pill is just "hard to remember." Perhaps the problem is children too young to be responsible enough to take a pill or use a condom are having sex. Maybe we should be encouraging them from a young age to respect themselves and abstain.

I am only a few months away from an MD. I, and many of my colleagues, have decided not to prescribe birth control. Many physicians don't feel comfortable with the possibility of post-fertilization effects of the pill. Also, I'm not sure I feel comfortable treating a healthy patient with hormones. Yes, other drugs have side effects as well, but they are used to treat real medical problems. Fertility is not a disease, so why treat it as one by prescribing something that has some significant risks. And as far as the protection against ovarian cancer, etc, pregnancy offers the same protection as the pill.

Anyway, I only wanted to say that it is possible to care significantly about women and not be pro-birth control or pro-abortion.
8.17.2005 10:02pm
Columbienne:
ADT - You are almost an MD and you haven't heard about the patch or the ring, which are exponentially easier to remember than the daily pill? That's interesting.

And then there's your statement about ovarian cancer: "pregnancy offers the same protection as the pill." This is a classic anti-birth controller nonsequitur. What, so should we all go get pregnant now to lower our ovarian cancer risk? We're chosing between methods of birth control, not between using birth control and getting pregnant. What that point of view really suggests is hostility towards effective birth control in general.

And your point about abstinence education is irrelevant -- we're talking about adult women here.

By the way, are you going to disclose to your patients up front that you refuse to prescribe the pill?
8.17.2005 10:19pm
wodamark (mail):
Paraphrasing Pope Paul VI:
Men are sex pigs and contraceptives have made us more piggish.

"Another effect that gives cause for alarm is that a man who grows accustomed to the use of contraceptive methods may forget the reverence due to a woman, and, disregarding her physical and emotional equilibrium, reduce her to being a mere instrument for the satisfaction of his own desires, no longer considering her as his partner whom he should surround with care and affection." #17 from Hunanae Vitae
8.17.2005 10:31pm
ADT:
Columbienne-
I understand that alternatives to the pill exist, but they still offer the same fundamental problem as OCPs. They are all treating the non-disease fertility.

And no, people should not get pregnant just to prevent ovarian cancer. I hope that you don't think that I believe that. Sometimes I feel that when OCPs are praised for their benefits such as reducing cancer risks, it is overlooked that pregnancy does the same thing. OCPs are not the only way to reduce risk. My point was only that I think it is important for people to know that if they choose to have children they also are getting that same benefit.

Yes, my patients will know my position. I am sure my future patients will be glad to know you were concerned. I will educate them as to their options, but they will know that I don't prescribe contraceptives and why. A patient is always free to choose to go elsewhere.
8.17.2005 11:07pm
cathyf:

...creating legal terms that sound like one thing in English (e.g., "actual malice" in libel) but mean something quite different in legalese. This is especially dangerous in law, where the lay public is especially likely to be interested in the information,...

Unless you are being deliberately coy, I think you are understating things a bit here, aren't you? The lay public don't just have an idle curiosity, they are obligated under pain of criminal or civil penalty to follow the law. Is the law what it means in English or some meaning known only to some high priesthood?

Oh, and BTW post-ovulatory NFP has lower theoretical and actual failure rates than either the pill or the IUD. Ya' can't get a baby out of a dead egg!

cathy :-)
8.17.2005 11:30pm
Columbienne:
You're still not getting the point -- the choice to take birth control pills is not the choice to never have children. The reduction of ovarian cancer risk is not presented as a reason to take birth control pills, but rather as one element of the costs and benefits. The effects of pregnancy (except its role as a risk when considering less effective means of birth control) does not factor in at all. You're comparing apples and oranges.

And characterizing fertility as "not a disease" does not add much to the conversation. Reproduction is a physical process humans have always been keenly interested in regulating, which is the essence of medicine.
8.17.2005 11:34pm
Columbienne:
"Is the law what it means in English or some meaning known only to some high priesthood?"

Fine, Cathy, when you get into legal trouble get your car mechanic to represent you, instead of a lawyer, a member of the dreaded "high priesthood."

I really disagree with Eugene here -- the job of lawyers is not to dumb down the law itself, but rather to explain what the law means to the lay person. That's a completely different exercise.
8.17.2005 11:38pm
Kimberly (mail) (www):
Notes on the original post: I do think it's amusing when reporters write that abstinence has a significant failure rate. If sex causes pregnancy, not having sex won't cause pregnancy. Even if they're confusing the terms "periodic abstinence" and "abstinence," you'd think someone would catch that on a read-through, no?

Also, "actual malice" still bothers me after three years of law school, including a First Amendment class and the bar -- it's hard not to read the words with their everyday meaning : )

A comment on a subsequent comment:

"If you really cared about women's health you'd be advocating for safer contraceptives or promoting condom use."

I'm an adult woman who's abstinent (and will be until marriage), and in addition to meaning there's a zero percent chance I'll get pregnant beforehand, I also figure that's pretty good for my health, since I have no risk of STD's (fairly well epidemic in this country) or any side effects or negative impacts on fertility from artificial birth control. Seems to me the nonnegative impact of abstinence on women's health is a good reason for people who care about women's health to advocate abstinence. (It's also good for men.) As for after marriage, I'm with Steve in that while I realize it's a common and legitimate choice for many women to use hormonal birth control, I would practice NFP and hope more couples will come to do the same.
8.18.2005 1:16am
Phil (mail):
This conversation does reveal one of the most interesting aspects of modern medicine, its treatemnt of normal bodily functions as medical problems. A goes to the doctor and says that his "problem" is that when he has intercourse with a fertile woman conception might occur, or when he consumes more than 3,000 calories a day his body stores the excess as fat, or after he runs an ultra-marathon his plantar foscii hurt. (I will not ene bring up simple cosmetic surgery.)
I do not mind this change. I do think, however, that it is a reason to not hang much in arguments on "medical" opinion. If A wants to avoid, eg, AIDS, there are things to avoid. If A wants to shooot drugs intravenously and be the recipient of anal sex with multiple anonymous partners, A is asking a different sort of medical question. Similarly if A wants to avoid obesity there are things to be avoided. If A wants to avoid obesity but eat a two monster burgers and a large fry for lunch everday, A is once again asking a very different sort of question.
Medicine has become about preference satisfaction and this has made it impossible to settle disputes by relying on medicine (assuming it ever was possible)
8.18.2005 3:33am
matt:
You americans with your creationists, women-are-only-for-getting-married-and-children and flat-earth-society-movements are quite funny. Hurray for the last stronghold against enlightenment.
8.18.2005 3:55am
Amy Phillips (mail) (www):
ADT,
I do believe that you are considering what you believe to be best for your patients, and I'm glad you're open to the possibility that they have a different opinion about what is best for them. I hope, however, that you will tell women before they make appointments with you that you do not prescribe hormonal birth control. Many people have health insurance that allots them only one checkup or gyn exam each year, and they cannot see a second doctor of the same kind unless they are diagnosed with a problem. Women without health insurance must pay the costs of each visit out of pocket, and may not be able to afford to see two doctors. If one of these women makes an appointment with you and then finds out only afterwards that she cannot get birth control from you, it may cost her hundreds of dollars to see another doctor.
I'm all in favor of doctors using their best medical judgements, and I respect your right to decline to provide certain treatments, but I hope you will instruct your receptionist to inform every female patient who calls you that you are refusing to provide certain types of standard medical care before she makes an appointment.
8.18.2005 10:27am
cathyf:

Fine, Cathy, when you get into legal trouble get your car mechanic to represent you, instead of a lawyer, a member of the dreaded "high priesthood."


I really disagree with Eugene here -- the job of lawyers is not to dumb down the law itself, but rather to explain what the law means to the lay person. That's a completely different exercise.


So you are telling me that it's perfectly fine to need to hire lawyers to accompany each member of my family 24x7 to continuously scrutinize our behavior and explain to us when we are about to violate some statute which we couldn't possibly understand? I figure that's 16 lawyers (4 members of my family, 168 hours in a 7-day week). No, better make that 17 or 18 because we need some floaters to cover sick days and vacation... Yikes! My minivan only has 7 seat belts. What happens if buried in that mass of incomprehensible-to-the-lay-person verbiage there is some law which requires every rider in a car to be in a seat belt?

Gee, don't you think that it would be easier to have competent writers write laws so that people would be able to know, without needing to hire a lawyer to explain it, that they are required to wear seatbelts, or required to file their tax returns on April 15th, or any of the myriad things which they are required to do or prohibited from doing?

cathy :-)
8.18.2005 11:13am
Columbienne:
Kimberly - Anyone honestly interested in promoting effective abstinence would want to formulate some definition of "failure" in order to design measures that prevent such failure. That might require expanding the definition of failure beyond the way it's used for other birth control methods, for instance, asking something like "how many people articulate an intention to be abstinent, don't prepare themselves with any other kind of birth control, and then in the heat of the moment have unprotected sex?" Or, "how many people call themselves abstinent but engage in other sexual activities that still pose a risk of STD transmission?"

Cathy - I do think that more explanations of the law should be available in plain language, and I think that all high schools should offer classes educating students on their basic legal rights and responsibilities. But I don't think that lawyers or legislators should be constrained by those considerations from the outset.
8.18.2005 11:47am
Ryder (mail) (www):
Amy,

I noticed a post from, like, hours ago when you were questioning why people would use "articificial" means to clean their homes, communicate, etc., but not to prevent pregnancy. You admitted being tongue-in-cheek, but I have an entirely serious and related question for you:

Why is it that people who use hormonal contraceptives fail to see the absurdity of going to a doctor to STOP a perfectly good system in their body from working properly? If any other system in your body stopped working as it should, you'd run -- not walk -- to the nearest doctor to get it working properly again. Respiratory system getting you down? Go to the doctor to check for pneumonia. Endocrine system on the blink? Better check for a tumor in that pituitary gland and do whatever surgery or therapy is necessary to fix it!

But when it comes to being responsible with sex, we go to the doctor and say "Doc, my reproductive system is working perfectly...can you break it?" And when someone who gives a damn points out all the risks of doing that (including recent findings about permanent loss of libido...not sure that has been brought up yet) you get angry and defensive? Huh?

At some point, hopefully before it is too late for them to have the children they've always planned to have...later...I hope that women who share your misconceptions (no pun) realize that the purpose of hormonal birth control isn't -- nor was it ever -- to benefit women. It was, and is, pushed on you to allow grown-up boys to continue getting all they want from their relationships with women without having to be men and accepting the responsibility that comes with sex. You are being used, whether you realize it or not, and whether your sex partner is willing to admit it or not. And while you keep injecting and/or swallowing chemicals to please those boys, threatening your health and libido, you risk one more thing: letting the window of your individual fertility slam shut without having the chance to have the child or children you'd planned for and hoped for. If this is not a concern, so be it. But if you're like a relative of mine and several of my friends, who contracepted through their 20s only to get to their 30s and find themselves unable to conceive, there will come a very bitter time in your life when you realize that what I've just said is completely true, and that you've been cheated out of motherhood by guys who think of you as nothing more than the human version of an electical outlet. Please think about it.
8.18.2005 2:47pm
Public_Defender:
Abstinence has a 100% rate of effectiveness. Otherwise, it isn't abstinence.
Thanks for the tip. The next time I'm at a sentencing hearing, I'll tell the judge my client will sign a pledge to abstain from crime. Since "abstinence has a 100% rate of effectiveness," I'm sure the judge will vacate the charges and release my guy.

Seriously, abstinence, like any other birth control "method," has a failure rate because sometimes people "fail" to abstain. As others have shown, there are risks to abstinence (less condom use/higher STD rates for abstainers).

To be more accurate, perhaps everyone should use the term "abstinence pledge" instead of mere "abstinence" when comparing the risks and benefits of birth control methods. By adding the word "pledge," it's clear that we're accounting for the fact that some people will fail to abstain.
8.18.2005 3:00pm
Amy Phillips (mail) (www):
Ryder,
I don't believe I was being angry or defensive; I was attempting, in what I believe was a calm and rational matter, to counter arguments that I found flawed with evidence that the facts do not support those arguments. If responding to a claim with a counterclaim constitutes "get[ting] angry and defensive," I'm not sure how anyone is ever supposed to have a rational debate.

I disagree with your assertion that I am being used, mostly because I believe I am intelligent enough to decide for myself what is in my best interest even if that happens to coincide with the interests of my sexual partners. I also believe that most women are similarly well-situated to determine for themselves what is in their best interests. Plenty of women are equally interested in "getting all they want from their relationships with [men] without having to be [women] and accept the responsibility that comes with sex" if by being a man/woman you mean being a parent. You may judge their choices as incorrect or bad, but it seems quite presumptuous for you to decide that you are better equipped than they are to make those choices for them.

There are, I agree, very few medical instances in which we treat healthy people to alter for their convenience the ways their bodies work. A few I can think of off the top of my head are medications that people take to prevent unwanted sweating ("breaking" the body's natural cooling mechanisms), gastric bypass surgery ("breaking" the digestive system), and inducing labor in healthy pregnant women ("breaking" the natural birth process). Those may be controversial, but the point is that we do accept medical intervention to raise quality of life for people who don't like the way their bodies naturally respond. Similarly, I don't have any problem with people who wish to temporarily or permanently "break" their body's natural tendency to conceive a child when they are unwilling or unable to care for a child.

I don't at all think it's absurd for us to use the technology available to us to get what we want from life, up to and including modifications of our own bodies. I believe that by choosing a method of birth control that assures we will not get pregnant unless and until we want to does constitute "being responsible with sex" as I define it. You are welcome, of course, to use a different definition of "responsible" in your own life, but please don't denigrate the careful choices that other women have made about theirs.

I agree that if there are fertility risks attendant to the use of hormonal birth control, doctors should discuss those with their patients. However, the medical evidence I have reviewed and presented here seems to show that those fertility risks mostly stem from high-hormone birth control pills that were prescribed 20-50 years ago, and which have now fallen out of favor. Your anecdotes, while very poignant, do not prove a correlation, much less causation, between hormonal birth control and the fertility problems your friends experienced. If you have evidence of a statistically significant fertility risk or risk to future libido that can be conclusively linked to the use of the low-dose hormonal birth control methods currently in use, I'd be happy to review it.

Finally, I'd like to note that you've made a lot of assumptions about what I and other women want from our lives. As it happens, I do not want children, and so I would welcome a pill that ruined my future fertility. I plan to get permanently sterilized as soon as the method I have chosen has been in wide use long enough that I am reassured of its safety. The idea that "there will come a very bitter time in your life when you realize that what I've just said is completely true, and that you've been cheated out of motherhood by guys who think of you as nothing more than the human version of an electical outlet" assumes that I desire motherhood, and that I desire a particular sort of relationship with the men in my life that not all women want. I assure you, I have thought about what I want from my life, and children aren't a part of my plan. I think it might be helpful in future discussions for us all to refrain from making assumptions that other people want what we want, and that we are therefore qualified to decide for them how best to pursue a happy life.

Thanks for your thoughtful response, but there's no need to worry about me. I know what I want, I've done my homework, and I've made the choices I think are best for me. It's admirable that you want to help other people make informed choices, but in order to do so, they need to get accurate information. I hope we can agree that women have the right to get the scientific facts about their reproductive health and make their own decisions based on that evidence and their own beliefs and desires.
8.18.2005 3:48pm
Amy Phillips (mail) (www):
Back on the original topic, I have a question that I haven't been able to find a conclusive answer to. When measuring the failure rate for condoms, what counts as a failure? Are they counting pregnancies among women who use condoms as their primary method of birth control, or are they somehow counting pregnancies that result from individual sex acts in which condoms were used? My suspicion is that it's the former, meaning that a certain number of those pregnancies probably resulted from a couple who normally use condoms not using one during one or more sexual encounters. It would be awfully difficult to determine which unplanned pregnancies occurred from a particular sexual encounter when a condom broke or failed, as distinct from unprotected sex by a person who considers condoms the primary method of birth control. But I don't know...

I know that the failure rate of hormonal birth control includes pregnancies by women who use the pill as their primary birth control method, but who forgot to take it one or more times and then got pregnant. That's where the discrepancy between "perfect" and "typical" use occurs.

Given those methods of counting, it seems only fair that pregnancies among women who use abstinence as their method of birth control should be counted in the "typical" use of abstinence. After all, if I usually use condoms as my birth control, and I run out of them one night and, against my better judgement, agree to have unprotected sex, that counts as a condom failure. Why then, if I use abstinence as my birth control and my willpower slips one night and I agree, against my better judgement, to have sex, should that not count as an abstinence failure?
8.18.2005 3:59pm
Columbienne:
I'll own up to being angry and defensive -- that's because you guys don't want to stop at overturning Roe; you want to go all the way back to Griswold and pass laws banning all contraceptives. If I'm wrong, please correct me, and I'll be much less angry. That said, Amy's lack of anger certainly makes her the better spokeswoman.
8.18.2005 4:31pm
Steve Dillard (mail) (www):
Columbienne-

I am all for overruling Roe and Griswold with impunity because neither decision is even remotely supported by the text, history, and/or structure of the federal Constitution.

I also happen to personally oppose abortion in all cases, as well as all forms of artificial birth control (especially those that act as an abortifacient). But given how widely accepted birth control is these days, I think it's silly of you to be concerned about state laws being passed--upon Griswold being overturned--"banning all contraceptives." And even if a state were to enact such a ban, them's the breaks in a dual sovereignty system, sister. Just because you cherish your access to birth control doesn't make it a protected constitutional right.
8.18.2005 4:56pm
Columbienne:
Steve - You still haven't answered directly. Are you personally in favor of state laws banning contraceptives?
8.18.2005 5:13pm
Steve Dillard (mail) (www):
Columbienne:

Well, I thought my response made it pretty clear that I would support state laws banning contraceptives that act as an abortifacient. But in case there remains any doubt about my position, the answer is yes. I would most certainly favor prohibiting those types of contraception.
8.18.2005 5:20pm
Columbienne:
No, that wasn't clear at all. I wanted to make sure I was clear on how extreme your postition was.
8.18.2005 5:32pm
Steve Dillard (mail) (www):
To paraphrase Barry Goldwater: Extremism in defense of innocent life is no vice, and moderation with regard to the culture of death is no virtue.
8.18.2005 5:41pm
Columbienne:
That statement, my friend, pretty much blows the integrity of your constitutional arguments out of the water. You're obviously so commited to controlling other people's fertility that all your analysis on Roe etc. will be results-oriented, rather than based on any honest theory of constitutional interpretation.
8.18.2005 5:55pm
Steve Dillard (mail) (www):
Columbienne:

Let me explain this to you as simply as I can. The fact that one is personally opposed to abortion does not mean that person is also unable to likewise argue that the holding of Roe v. Wade is not supported by the text, history, and structure of the Constitution. My personal feelings re: abortion have no bearing on the merits of any constitutional challenge I might make with regard to Roe. I realize that you are unable to separate your personal feelings from constitutional analysis, but that doesn't mean that others are unable to do so.

BTW, and FWIW, there are many proabortion folks who think Roe was wrong decided.
8.18.2005 6:01pm
Columbienne:
You're stating the obvious. My point is that you are so committed to being anti-birth control (being a new convert throwing around such intoxicating phrases like "culture of life," with so much self-righteous relish) tends to suggest that you don't have a principled constitutional view on this, but rather that you are, dare I say it, an...
A-C-T-I-V-I-S-T jurisprude.
8.18.2005 6:08pm
Steve Dillard (mail) (www):
Ah yes, the "deeply held" beliefs rejoinder. Thanks for revealing your true indentity, Senator Schumer.
8.18.2005 6:13pm
Columbienne:
You're the one who just implied that extremism was justified in the face of deeply held values (which is something I don't believe that Judge Roberts has ever said.) If God really mandates a "culture of life," then why should the constitution get in your way?
8.18.2005 6:28pm
Steve Dillard (mail) (www):
It's called the rule of law. Matters of policy must be dealt with in the legislative arena, and the judicial branch should/must limit itself to interpretating the law.

Of course, you're not a big fan of originalism or textualism, now are you? Because if the Supremes actually interpreted the Constitution, rather than creating new "rights" out of wholecloth, you'd actually have to persuade your fellow citizens in the legislative arena to sign on to your hedonistic agenda. And why do that when you can ram it down out throats by judicial fiat, right?
8.18.2005 6:40pm
Columbienne:
No, you're wrong. I do think it's better to legislate, and I don't have a well-formed view on constitutional interpretation -- except for that what I've see of originalist and textualist analysis employes an extremely thin, if not laughable, theory of language and meaning.

Anyway, so what I hear you agreeing to is that your mandate to promote the Culture of Life ends at the courthouse doors?
8.18.2005 7:15pm
MrSpkr (mail) (www):
What an interesting discussion. Columbienne, while I agree politically with Steve on many issues, we differ on this one. I would not support banning contraceptives (although abortifacients are a separate issue). I would, however, be in favor of repealing Roe and its progeny, back through to Griswold.

Roe v. Wade, is, aside from any political ramifications, one of the most atrociously reasoned Supreme Court decisions in our history. There is little argument among serious legal scholars that the majority decision, such as it was, is legally and logically unsound.

That being said, Griswold is a poor decision, too. It creates, of whole cloth, a right to privacy which simply does not exist in the Constitution. I believe that we should have a right to privacy under certain circumstances (and the 4th Amendment outlines those instances); I just disagree with the Supreme Court creating one out of thin air.

Frankly, if Roe were repealed, most states would still allow abortions under some circumstances (most likely restrictions on the term of the pregnancy). Some might ban abortions entirely while others would allow them under all circumstances -- that is part of the way federalism is supposed to work.

As to contraception, I doubt any state would ban contraception. I strongly suspect that some states would prohibit distribution to individuals under a certain age, but they would not ban them. Contraception is too widely accepted and used for an outright ban to have any political support whatsoever.

I am curious, though -- if you support Roe strongly, do you similarly support the outcome in Bush v. Gore? Or are you one of those folks that only supports Supreme Court decisions which agree with your personal political predilections?
8.18.2005 7:16pm
Columbienne:
I don't think Bush v Gore and Roe can be compared -- taking the evidence most favorable to their critics, they each commit very different kinds of interpretive sins. If you're probing my commitment to the interpretive method of Roe, it would be better to find a case where an unenumerated right that can be characterized as "socially conservative" was found in the constitution.
8.18.2005 7:37pm
Steve Dillard (mail) (www):
Col.-

What you're hearing is that as a judge I would not impose my personal beliefs by judicial fiat. The role of a judge is to interpret the law, and nothing more.

Now, if I were king (or even president) then you'd be quite unhappy, but sadly that's not likely to happen.
8.18.2005 7:49pm
TheCuriousKitten (mail) (www):
In my case fertility *is* a disease. If I were to get pregnant, I'd have to go off of *all* of my medication. Including pain medication and mental-health medication. This means nine months of *hell* while I deal with OCD, Depression, and chronic abdominal pain.

My doctors won't tie my tubes or take out my uterus. Why? Because they are using their "best medical judgment." They pat me on my head and tell me not to worry. I'll change my mind.

I am a married woman. I have gone to college and studied biochemistry. I've done my homework and I've accepted the risks.

And my doctors refuse to let me take responsibility for my actions.

I wish doctors were less paternalistic. What is better? Birth control or an abortion? Because the rhythm method won't work in my case. Without birth control, my cycle is completely erratic, and I often bleed for a month at a time.

Should I have never married? Should I punish my husband by taking his wife away from him for nine months at a time while I deal with mental illness? Or should I have an abortion?

I think that this is a problem of doctors assuming the job of common sense for their patients. Yes, some women don't think. They pop the pill and they don't even bother to ponder the consequences. It's a shame, but it's *Their* problem.

When you do their thinking for them you punish the women who *do* think, who study and do their homework. No, I am not a doctor, but I think I should have the right to take the risks and the consequences for my actions.

Shame on you for patronizing women and not allowing them that basic right!
8.19.2005 1:03pm