Post “Roe,” Advocates Fear for the Future of Contraceptive Self-Determination

Jacora Johnson, a 22-year-old Texas resident, is facing a difficult and potentially painful decision. They currently use the Depo-Provera shot, a type of birth control that’s administered by a medical provider every three months. In addition to being a highly effective form of contraception, it’s also gender-affirming for Johnson, who is nonbinary.

“I don’t get my menstrual cycle, which is great because that can be dysphoric for me,” they said. Johnson also enjoys having regular check-ins with a doctor. But in Texas, most abortions have been banned since September 2021, when SB 8, the law that encouraged private citizens to enforce it by suing those who “aid or abet” abortions, went into effect. And as of late August, abortion is banned in Texas entirely: Performing an abortion is a felony punishable by life in prison or a $100,000 fine. That — along with concerns that Texas Republicans may capitalize on their recent electoral victories to go further, perhaps banning certain forms of contraception — has Johnson looking into a contraceptive implant instead, because it lasts for up to five years. Though many people also stop menstruating while using the implant, there are no guarantees about how each individual person’s body might react to a new method of birth control.

“Thinking about having to see what that shift would do to my body, and feeling uncomfortable as a result, is hard,” said Johnson. They also feel their doctor hasn’t understood their sense of urgency around the decision. “My autonomy is at stake,” they said. Ultimately, Johnson thinks the implant might be a good choice for them — they just wish they had more breathing room around the decision. “This is my body. I have to live in it,” Johnson said. “I want to be comfortable and happy, but I also want the freedom to do what I want with my body.”

Even before the fall of Roe, there were many barriers to contraceptive access, particularly for young and low-income people. For example, 23 states place limits on the ability of people under 18 to consent to contraceptive services, many of them with exceptions only for minors who are married or already parents themselves. Eleven states — many of the same ones that now ban abortion — still have not expanded Medicaid, leaving large swaths of people uninsured. And according to the nonprofit Power to Decide, 19 million U.S. women live in “contraceptive deserts,” communities without reasonable access to a health center offering the full range of contraceptive options.

Now, the end of legal abortion in more than a dozen states has intensified right-wing efforts to spread misinformation about how birth control works and even to ban certain contraceptive methods, especially intrauterine devices (IUDs) and emergency contraception, which Republicans have long sought to lump in with abortion. Contraceptive misinformation ranges widely, from lawmakers claiming in Congress that Plan B terminates a pregnancy (it does not), to TikTok influencers spreading myths about the safety and efficacy of various birth control methods.

Simultaneously, many people capable of becoming pregnant are feeling the same pressure as Johnson. Facing the loss of abortion rights in their state, many people are switching to contraceptive methods they might not otherwise choose, whether that pressure comes from medical providers, friends, family, partners, or their own worries. In particular, many told Truthout that they felt pressure to switch to a long-acting reversible contraceptive (LARC) method, a category that includes IUDs and the implant. The fact that so many people feel they are making their choices about birth control under duress brings to mind the United States’s dark history of contraceptive coercion and eugenics, particularly among people of color, disabled people and those living in poverty — some of the same populations most likely to seek abortions.

The first human trials of the birth control pill, for example, took place in the mid-1950s in Puerto Rico. The 1,500 women who took the pill weren’t told that it was experimental or that there could be negative side effects (the early birth control pill contained much higher doses of hormones than its modern cousins). Three women died, and their deaths were never investigated. The trial was backed by Planned Parenthood founder Margaret Sanger, who was herself involved with the eugenics movement.

A few decades later, the first IUD to enter the U.S. market, the Dalkon Shield, caused at least 200,000 serious uterine infections and killed at least 18. It was already known that the device had significant safety issues before it came to market in 1971, yet it was introduced anyway. It sterilized many people, including one of the founders of the reproductive justice movement, Loretta Ross. After it had caused untold injuries here, the U.S. government “dumped” Dalkon Shield devices by sending them to 42 other countries as part of supposed aid programs. Forced sterilization policies in the U.S. long targeted people of color and disabled people, and continue among disabled people today.

Justina Licata is an assistant professor of history at Indiana University East and a historian of U.S., women’s and African American history. One of her subjects of study is Norplant, a contraceptive implant introduced in the 1990s. In her research, Licata found that Norplant was pushed on many women by the Indian Health Service (IHS). “Many of them were not even good candidates for Norplant because their population has higher rates of high blood pressure and diabetes, which makes Norplant a problematic birth control choice,” she told Truthout. In reviewing surveys filled out by IHS providers, Licata also found that many doctors said the target patient population for Norplant was 15 to 23 years old. “That was extremely wrong, because they hadn’t tested Norplant on that age group,” said Licata. “They had tested it on people who had already had children and were maybe moving toward menopause.”

“I’ve gotten some pushback on this, but I do consider the coercive use of Norplant a form of forced sterilization,” said Licata. “Some people will say, ‘But you can take it out.’ But five years of someone’s reproductive life is not insignificant. And in fact, I think saying, ‘You can take it out and have your fertility back right away’ makes the coercion more subtle, and easier to justify.”

Though LARCs are the most effective contraceptive products on the market, many reproductive justice activists have criticized the aggressiveness with which public health agencies promote them among low-income people, people of color and disabled people precisely because of this history. What’s more, “there is this notion that efficacy is the only thing that patients care about, and that’s really not true,” Monica McLemore, told Truthout. McLemore is a professor in the Child, Family, and Population Health Nursing department at the University of Washington School of Nursing and a distinguished researcher in reproductive health and justice.

“Especially for Black and Brown communities, this idea that the most efficacious method, you know, ‘set it and forget it,’ is best, that’s just not resonant with some people,” said McLemore, pointing out that side effect profiles are very important to many birth control users. For personal safety reasons, some people may also need a form of birth control that’s totally undetectable to a partner or others, whereas for other people that may not be a concern. People also use birth control for many reasons that have nothing to do with preventing pregnancy, such as controlling acne, or like Johnson, stopping their menstrual period. “This idea that the efficacy of preventing pregnancy is the only profile that people would want to consider, in my view, is very patriarchal,” said McLemore.

The other challenge with LARCs is that you need a medical provider to remove them — and as Fran Hoepfner recently detailed in a harrowing essay for Gawker, many people who go to their doctors with this request get “no” for an answer. As in Hoepfner’s case, the reasons for refusal are often vague; sometimes doctors warn patients that removal would be too painful or too much of a hassle. Other times, doctors may question a patient’s desire to become pregnant or their choice to use a less effective contraceptive method. Some have resorted to removing their own IUDs, and while this is possible, studies have found that few people are able to do it successfully. The only way to remove a contraceptive implant is to cut it out — something that would obviously be dangerous for a person to attempt at home.

Medical providers who press LARCs on their patients often believe they are doing the “right” thing by encouraging people to use a more effective method. Licata pointed out that this belief is often rooted in racism, and sometimes ageism, whether providers are aware of it or not. McLemore added it may also have to do with abortion stigma.

“The narrative that there’s something wrong with abortion, or that there’s something wrong with using it for family planning, is really problematic,” she said, suggesting that the goal of reducing abortions drives many clinicians to insistently recommend LARCs and dismiss other birth control options that are more likely to “fail.”

“We need to accept that people are smart enough to make these decisions for themselves,” McLemore said.

It is true that in our current climate, many people do feel safer using a LARC or even a permanent form of contraception — whether it would have been their first choice or not. Calla Hales, 32, is the executive director of A Preferred Women’s Health Center, which operates abortion clinics in North Carolina and Georgia. Hales recently gave birth to her second child, and opted to have a tubal ligation, considered a permanent form of birth control, during her planned C-section. If it weren’t for Roe’s overturn, she told Truthout, she probably would have waited a few years to decide whether or not she wanted more children.

As someone who operates abortion clinics, Hales acknowledges that she has more resources at her disposal than the average person when it comes to getting an abortion, even if she did need to travel out of state. But having had one child in the early part of the pandemic, and now having another shortly after the fall of Roe, Hales decided she didn’t want to risk getting pregnant again. “Ultimately, this was a decision that I could live with,” she said.

Ellie, a 26-year-old in Louisiana who asked to be identified by her first name only, told Truthout she was relying on condoms as birth control before the Supreme Court’s decision. It was working for her, but Louisiana residents are now nearly 700 miles from the nearest abortion clinic. Ellie doesn’t want children, so she chose to get a copper IUD in August. “I knew that if I were to get back on birth control, I would probably choose the copper IUD, but I wanted to think about it more, or wait a little longer,” she said. “I liked my doctor, but I was kind of afraid to say that I would get an abortion if I got pregnant. I didn’t want that recorded anywhere.”

Ellie said her doctor didn’t seem to understand the stress she was feeling around the choice. “I just wish I had been able to make the decision when I wanted to,” she said.

“People’s contraceptive needs change over time,” said McLemore. “We need to teach clinicians this notion that, whatever your personal feelings or your personal thoughts are, we are to elicit patients’ preferences. We are to elicit patients’ values. And to provide that basic information to allow them to make the decisions they need to make for themselves. That’s our only role.”