Why contraception use decreases in a relationship

I received sex education four times during the nine years I lived in Ohio. Sex education teaches adolescents how to build healthy relationships, practice safe sex, and address tough issues such as gender identity and body image. While the four instances in which I learned sex education were at three different school districts, they had one major aspect in common: the content stressed abstinence until marriage. I remember learning about pregnancy and the different types of sexually transmitted infections (STIs) and diseases (STDs) and their symptoms and consequences. The class was then warned that the only way to be 100% sure that we don’t get pregnant or an STI is to wait until after marrying someone—also a virgin—to guarantee that we only engage in sex within a monogamous relationship. Birth control methods, typically only the existence of condoms and oral pills, were just briefly mentioned, if at all, in the programs.

Planned Parenthood has identified these solely abstinence-based sex education programs to be ineffective. However, while a large portion of the American population engages in sex regardless, people apply various contraceptive methods to prevent STI transmission, pregnancy, or both. Heather Boonstra at the Guttmacher Institute, a sexual and reproductive health and rights research organization, commented specifically about adolescents: “Teens are using contraceptives more consistently and more effectively,” even though the quality of sex education in the United States is lacking and continuing to decrease.

While this may suggest that Americans are vigilant and fairly knowledgeable about safe sex practices, this is not completely true. In addition, there appears to be a misconception that consequences related to sex, especially unintended pregnancies, only occur in one-time or short-term sexual relationships. In fact, birth control usage decreases as a relationship is maintained for longer. This means that pregnancies are probably equally, if not more, likely to occur in long-term relationships. Although some reasons for this seem obvious, there are other factors that affect this change over time.

Seemingly-obvious reasons

A study found that, of the total pregnancies that occur in the United States, almost half are unintended. Furthermore, 70% of these pregnancies occur outside of a marriage. Disadvantaged women, whether it be socially or financially, are more likely than advantaged women to experience an unintended or unwanted pregnancy because of their more inconsistent use of contraceptives. This, however, is not due to disadvantaged women’s inability to financially afford contraception or their lack of access to them. The discontinuation of contraceptives for these women are higher than that of advantaged women because of their differences in the following two factors: efficacy and misinformation and lack of knowledge about pregnancy risks.

Efficacy

According to this same research study, efficacy refers to a woman’s ability to consistently use one or more contraceptive methods. While a part of this is being able to remember to take the oral pill or go receive the next dose of the hormonal shot if the woman is using a stable form of birth control, efficacy is also being able to be assertive with partner, especially if the woman needs to rely upon condoms as the only form of contraception. After engaging in a sexual relationship with the same person for a longer period of time, men may refuse to participate in using condoms because they are inconvenient, or they do not feel as much pleasure as sex without it. It is up to the woman in the sexual relationship to negotiate condom usage, or sex will occur without protection.

The stark contrast between assertive negotiation and the lack of efficacy can be clearly seen from the in-depth interviews conducted by the study. Bella, a 21-year-old Caucasian, and Yuko, a 27-year-old Asian, both set the ultimatum with their partners: no condom equals no sex. On the other hand, Heather is a 20-year-old white woman who started orals pills while in a relationship. However, she struggled to consistently take the pill even though condom use halted. Thus, the use of contraception became inconsistent in her relationship.

Lack of knowledge and misinformation about pregnancy risks.

Disadvantaged women also have higher rates of unintended pregnancy due to the lack of knowledge and misinformation about the reproductive system. The same study found that many women assume that either they or their partner are infertile if they do not get pregnant within the first few months of having unprotected sex. Maleyna, a 28-year-old African American who was interviewed, said, “You think like the first time you had sex without a condom, whatever, you were going to get pregnant…then you don’t get pregnant for so long, you stop thinking about it…I started thinking like maybe I’m one of those people that don’t get pregnant.” This, however, is incorrect; the Mayo Clinic reported that it takes longer than a few months for a normal fertile woman to get pregnant. Women who have not gotten pregnant from unprotected sex will most likely continue to not use birth control in the future until a pregnancy occurs due to this misunderstanding.

Men’s involvement in women’s contraception methods

When it comes to sex, there is the expectation for men to provide and use condoms, especially during one-time or short-term sexual relationships. However, as previously mentioned, condom usage decreases as a relationship progresses, whether it be because of the man’s refusal to wear the barrier or the couple’s desire for greater intimacy. However, not all women use hormonal contraception such as the oral pills, implant, or the shot. A study found that that the majority of men do not believe that they understand these alternative contraceptive methods well enough, and they are hesitant to address these options with their partner (given that they are concerned about continuing birth control usage in the first place). Of the thirty men that were interviewed, only four of them felt confident discussing contraception options within their long-term heterosexual romantic relationship. For example, only after Murray, one of the interviewees within this study, became aware of the existence and effects of the oral contraceptive pill did he feel comfortable enough to encourage his partner to start using it.

This hesitation and lack of confidence that men experience derive from the general American social norm that women should be in charge of contraception usage in the relationship. This gender division was also embraced and accepted by women as well; the same study found that a third of the women sampled preferred to be the sole person in charge of birth control within their relationship. Because of this separation, men are not always included in the conversation of contraceptive methods that are used by women in their own long-term romantic relationship. This encourages this environment in which women uphold the burden of safe sex by themselves, and, combined with the issues of efficacy and lack of knowledge among disadvantaged women especially, risks relating to inconsistent birth control usage increase.

Cultural influences in contraception use

While the American social norm may expect women to find and implement more stable contraceptive methods in long-term relationships in which condom usage discontinues, this is not universal. Culture and background also influence the presence of birth control within a relationship. A study stated that in countries and cultures in which the male-female power dynamic is lopsided and men have more control, women cannot always be involved in contraception decisions. For example, the traditional Hispanic culture creates a moral and safety problem for Hispanic women due to its encouragement of young men to have sex but young women to stay chaste. In order to appear to follow the cultural expectation of maintaining their virginity, women may not use contraceptives in order to hide their sexual activity. In addition, the men within the culture may become violent or angry with their female partner if she asks him to use condoms, as condom usage is associated with the accusation of infidelity or guilt of having cheated. These beliefs trap Hispanic women into a situation where they cannot find a form of contraception that can be used in lieu of condoms in long-term relationships.

Little usage of long-term contraceptive methods

Finally, in the United States there is an overall lack of long-term contraception usage. As previously mentioned, forms of stable, long-term contraception include the implant, hormonal shots, and the oral pill. Of these three, the oral pill is the most commonly known and implemented, but it is also the easiest to be used inconsistently due to the fact that women need to remember to take it daily at the same time. A study found that the implant and hormonal shots, which were both introduced in the United States in 1991, have never been extremely popular within the country. They were associated with a negative political connotation throughout history, and their side effects and implementation scared and worried many women, especially those who were disadvantaged.

Negative political connotation

The implant method is associated with a negative connotation, especially among disadvantaged communities. When this long-term form of contraception was initially introduced to the public, a small subset of politicians and judges wanted to push for its usage among poorer and underserved communities (which tend to be composed of racial minority groups). The belief was that it would lower pregnancy risks among “poor teenagers or neglectful mothers.” With women’s advocacy and civil liberties groups’ protests, the implants became rapidly associated with socioeconomic status and racial stratification. Its usage and demand dropped in the years afterward due to this negative connotation despite its high pregnancy prevention rate on a longer-term basis.

Lack of knowledge and fear

The same study also found from its 1995 survey that the main reasons why women prefer alternative forms of contraceptive measures, rather than the implant or the shot, is because of their lack of knowledge and fear of their side effects. Furthermore, the researchers found that women who are older (30 or more) or have a college degree and are single, have children, and use condoms are less afraid of the side effects than their counterparts. Thus, those who are more likely to be hesitant of these long-term birth control methods are those who are disadvantaged, younger, do not have children, and/or are in relationships. This is problematic in that those who may need reliable contraception the most are too afraid to use the most stable forms that currently exist. Combined with the aforementioned arguments of efficacy, lack of knowledge about pregnancy risks, and men’s exclusion from the issue, these women are more likely to use contraception inconsistently as their relationship progresses.

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In addition to these reasons, the study discovered another reason why many women do not want to use the implant or hormonal shot: they also said that they are satisfied with their current form of contraception. It may be that the shot and implant were introduced to Americans too late, and women were too familiar with the preexisting forms of birth control. Although the pregnancy prevention rate of oral contraception is lower than that of the implant and shot, it is still able to have the same effects if used correctly. Still, those who are not able to consistently take the oral pill or feel severe side effects then face the dilemma of either choosing another contraceptive method such as these two in question, of which they may be afraid or lack knowledge, or taking risks by foregoing protection.

Thus, it can be seen that there are many factors that negatively affect stable forms of contraceptives being used in long-term relationships. There are many different institutional ways to encourage safe sexual intimacy among couples, one of which is to change the sex education that is taught in schools. Rather than focusing on abstinence-based sex practices, if adolescents are taught the various contraceptive methods and ways to address cultural issues and men’s involvement on the topic, they would be able to practice safe and healthy sex throughout their adult life. While this is not the end-all-be-all solution, it is the first step in the right direction.