Discussions about consent have entered the mainstream in the last few years, from consent workshops at universities to the open secret of endemic sexual violence being exposed in the media. However, a focus on white, famous women has obscured the roots of the #MeToo movement which was founded by Tarana Burke, a black activist. Originally created to provide women, particularly women of colour, with solidarity in the face of violence, Burke was initially overlooked in media reports on #MeToo indicating the ways in which conversations around consent have been distilled for mainstream discourse. Furthermore, mainstream media has largely concentrated on personal and professional relationships, with some important aspects of consent, like consent in medicine, being ignored. Whilst informed consent is an important principle in medicine, power structures complicate the picture and make it clear that consent is a deeper issue. It was my own experience of a lack of consent during contraceptive care that led me to conduct qualitative research with 19 users of long-acting reversible contraception (LARC) for my MPhil in Gender Studies at Trinity College Dublin.
In the UK, LARC methods include both the hormonal and non-hormonal coil, the contraceptive implant, and the contraceptive injection (although the latter is not considered a long-acting method in many other countries). Policy guidelines issued by the National Institute for Health and Care Excellence (NICE) in 2005 encouraged uptake of LARC, with many initiatives particularly being targeted towards younger people. Whilst completing a Public Health placement with a focus on sexual health, it was apparent to me that many sexual health clinicians and clinics were primarily concerned with how to increase uptake of LARC without much room for reflection or nuance about the different things a patient might want to get out of contraception. The increased numbers of patients opting for LARC methods has been accompanied by positive newspaper storieson long-acting contraception, linking their use to notions such as ‘responsibility’.
Clearly, safe, free access to contraception is a key aspect of healthcare. Though there remains an inequality of care in rural areas, LARC methods are generally widely available in the UK. Yet some of my experiences as a patient using LARC felt more like increased coercion rather than an expansion of choice. As a young woman, I was strongly encouraged to consider LARC methods every time I spoke to a doctor about sexual and/or reproductive health despite explaining why they wouldn’t be suitable for me. On one occasion, I sought medical care for repeated thrush and bacterial vaginosis that had only started after having a coil fitted. I was told by multiple doctors that there was no way that this could be linked to my new form of contraception. When I did my own research, I found that the NHS Choices website lists having an IUD as a factor that makes bacterial vaginosis more likely. On seeing a fourth doctor in as many weeks, I finally felt able to insist on getting the coil removed; the infections immediately stopped and did not recur.
Speaking to friends and family about my personal experience and reading online discussions provided a more complex picture of LARC. Some people shared stories of being happy and/or relieved to have finally found a method of contraception that worked for them among relatively limited options. However, there was a significant amount of people who felt that they had not been given the correct information. I wanted to find out who is being offered LARC and why, and hear about people’s experience of using these methods. I spoke to 19 people aged between 18-35 who had accessed contraceptive care through the NHS. The majority of participants were white, and all were cisgendered or did not report their gender identity. Though my sample was limited, I uncovered some important themes which point to the need for discussions around contraception that go beyond the issue of access and speak directly to questions of consent.
Lack of informed consent
About a quarter of the participants I spoke to said they had received either misleading or incorrect medical advice on LARC. Undoubtedly, this was in part due to a healthcare system suffering from understaffing and a lack of resources as several participants reported feeling ‘rushed’ in consultations. However, in other instances, participants felt like they were dismissed or not taken seriously with one describing the doctors she had seen as ‘very dictatorial in their approach. They don’t explain things well and generally didn’t give me a range of options to consider. For example, no-one ever talked about the coil as an option.’
Another participant was not properly advised to regularly check the location of her implant and so was not unduly worried when she couldn’t feel it. When she eventually went to the doctor to have it replaced, she was told that it was ‘physically impossible’ for it to have moved even though she was certain it was no longer in her arm. She had to do her own research in order to convince doctors she needed a CT scan; the implant was eventually found in her lung. Surgery to remove it has thus far failed and the participant may have to remain on medication for the rest of her life. Although this complication is exceedingly rare, aspects of this case – a woman not being believed, concerns being dismissed by doctors, ignoring feminine pain – are unfortunately not. Informed consent and accurate, honest information are two sides of the same coin – the clue is in the name of the former. However, in a gendered medical establishment with an extremely patriarchal history, power relations can make this a difficult ideal to achieve. Promotion of LARC without addressing these power relations led many participants to make choices that were not informed and sometimes resulted in debilitating consequences.
Violations of consent
Several participants experienced more explicit violations of consent, often on top of a lack of information or misinformation. These experiences often occurred at the time of removal. One woman who had got an implant removed after suffering negative side-effects was immediately fitted with another one without being asked whether she wanted it or being given any explanation of what was happening.
Another participant struggled to get her doctor to agree to remove her implant despite it interacting negatively with her psychiatric medicine – a possibility she had briefed him about in advance.
I has [sic] THREE appointments practically begging him to remove my implant. Each time I saw him he said ‘just give it a bit longer’
Eventually, the doctor agreed to remove it but only after the participant’s career had suffered due to being forced to take time off work. Another participant had a similar experience of struggling to get the implant removed after having it inserted at the time of an abortion. At the time of interview, it was still in place and she was suffering with severe side-effects. These experiences suggest that, although LARC methods are promoted for their ease of use, it can be much more difficult to get them removed than inserted as patients rely on clinicians to stop use. Such experiences raise the question of who benefits from this apparent ease of use, and indicate that if a patient is unlucky with their allocated clinician, they may lose control over their reproductive choices.
Contraception as a tool of governmentality
Whilst participants spoke about explicit ways in which consent was violated and information miscommunicated or withheld, their experiences raised wider concerns about consent and structural violence. One of the key questions that needs to be asked of a system where LARC is promoted is: whose fertility is valued and why? The flipside of this is, of course, whose fertility is to be controlled. Amongst my participants, three women who were in their late teens or early twenties expressed that no-one had told them about the potential of delayed fertility after using the contraceptive injection Depo-Provera because of their youth and the presumed assumption that they wouldn’t want to get pregnant anytime soon. When I spoke to a senior sexual health consultant as part of the research, they suggested that some clinicians think that they know what is best for the patient – better than the individual themselves. This has the worrying potential to intersect with different societal valuations of fertility based on factors like age, race, class and (dis)ability.
In the same way that wider conversations about consent have to address the fact that women existing at the intersection of marginalised identities are more likely to suffer from sexual violence and less likely to see any form of justice, conversations around consent and contraception must recognise the violence certain groups are more likely to face. Whilst my participants were mainly white and cisgendered, my research identified several young women who believed they hadn’t been properly informed due to their age. Researchers in the United States conducted an experiment in which doctors were shown a video of several 27-year-old women from different socioeconomic groups and races and asked to recommend a form of contraception. The researchers found that doctors were more likely to recommend an IUD to low-income women of colour than low-income white women. This study suggests that there may be an element of racial profiling when it comes recommending LARC (Dehlendorf et al, 2010).
Furthermore, research on disabled women has indicated that their fertility is frequently devalued by clinicians leading to recommended – or sometimes coerced – use of LARC (Engender, 2018, McCarthy, 2009).Recently, the controversial Pause programme has been extended from England to Scotland. It offers holistic support to extremely vulnerable women who have had children taken into care. However, they can only access this support if they agree to using a LARC method, which provides a stark example of state involvement in reproductive choices. Like any kind of consent or violations thereof, consent in contraception should be examined at the structural level rather than at that of the individual. As Latour (1988:228) says, science is ‘politics by other means’. LARC policy is political as healthcare and politics are not discrete spheres; indeed, healthcare is one of the principal ways in which the state exercises control over and shapes the population.
Will contraception get its #MeToo moment?
This is not only about consent in contraception. As Criado-Perez (2019) discusses, in many aspects of society, including medicine, the idea of ‘male as default’ has meant women’s needs and safety are compromised. It might seem counterintuitive to think of contraception in this way, yet patient needs are not necessarily at the forefront of contraceptive policy. The conversation needs to be extended to wider discussions about medicine where evidence suggests that women’s pain is underrated and overlooked, as is that of people of colour. Black women therefore exist at the intersection of marginalised identities where they are far less likely to get adequate healthcare, which results in black women being five times more likely to die in childbirth than white women in the UK. Contraception needs a #MeToo moment along the lines of how Burke originally conceived the movement: an uncompromising look at power relations and the structures that enable routine violations of consent.
I believe that there is some apprehension within feminist and policy circles to have nuanced conversations about contraception because of the hard-won access to free and safe contraceptive methods and a desire to decrease pregnancy rates among young people. Yet if we only focus on access, we risk a hugely unbalanced picture that serves to maintain the status quo. We do not have to be quiet and grateful just because we have a (relatively narrow) range of contraception available. For disabled people, queer people and people of colour, the conversation around consent and contraception is sorely needed. These groups have historically been marginalised in healthcare, and what research exists on their experiences of LARC in Britain is largely dated. Thanks to the efforts of black (American) feminists in creating the #MeToo movement and providing the theoretical framework of intersectionality, now is a perfect time to look at the ways in which contraception controls as well as liberates individuals. It’s time to ask what the future of contraception looks like. Doing so isn’t a luxury but a necessity.
Elspeth Wilson is a Scottish writer and researcher. She has twice won the Write to End Violence Against Women awards for Best Blog and was recently longlisted for the FWSA student essay prize. She can usually be found in or near the sea and her nature writing was shortlisted for Canongate’s 2019 Nan Shepherd prize.
Further listening and reading
‘Birth Control – Choose Your Own Adventure’. Ladies, We Need to Talk podcast. Available online.
Dehlendorf, Christine, Ruskin, Rachel, Grumbach, Kevin, Vittinghoff, Eric, BibbinsDomingo, Kirsten, Schillinger, Dean, Steinauer, Jody E. 2010. ‘Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status.’ American Journal of Obstetrics and Gynaecology 203(4): 319.e1-319.e8.
Engender. Our Bodies Our Rights. 2018. Available online.
Fassler, Joe. 2015. ‘How Doctors Take Women’s Pain Less Seriously’ [Accessed 10 July 2018]. Available online.
Gomez, Anu Manchikanti, Fuentes, Liza, and Allina, Amy. 2013. ‘Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods’. Perspectives on Sexual and Reproductive Health. 46:3: 171-5.
Hoffmann, Diane E. and Tarzian, Anita, J. ‘The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain’. 2001. Journal of Law, Medicine and Ethics. 29: 13- 27.
McCarthy, Michelle. 2009. ‘‘I have the jab so I can’t be blamed for getting pregnant’: Contraception and women with learning disabilities’. Women’s Studies International Forum 32(3): 198-208.
McGregor, Jen. 2016. The Tale of a Defective Woman: Jen McGregor [Accessed 31 May 2018]. Available online.
Scott, Alison. 2019. ‘Why we must support women to make their own contraceptive choices’. Available online.