Invisible, Responsible Women in Sweden – Planning Pregnancies, Choosing Contraceptives

ABSTRACT

In this study I explore discourses of contraception and reproduction, which are drawn upon and reproduced in Swedish official online sources on contraceptive advice, through the theoretical frameworks of biomedicalization and reproductive justice. The analysis yielded three interwoven themes: 1) women in need of contraceptives have to balance discourses of exogenous hormones as both an “unnatural” threat to their bodies and as desirable, effective regulators of the same “naturally unruly” body; 2) in search of a “perfect contraceptive fit”, it is the woman who needs to accommodate to available methods, rather than the other way around; 3) women are made discursively invisible, while simultaneously being constructed as individually responsible for reproduction. Underpinning all these themes is the discourse of rational, responsible choices, of exerting agency by choosing the right contraceptive. In the era of biomedicalization, finding a “contraceptive fit” becomes a moral and gendered health practice demanding thorough self-surveillance. The rational woman, exercising control over her reproduction and body, by planning her pregnancy with safe contraceptives, emerges as the only possible position. Recognizing that women’s and fertile person’s reproductive choices are made amid a societal context, with differing personal resources and experiences, would bring us even closer to reproductive justice.

KEYWORDS:

• Contraception
• biomedicalization
• women’s agency
• reproductive justice
• Swedish health care

Remember: There is always a protection against pregnancy that suits you. Even if you tried one or several methods that you weren’t comfortable with, don’t give up.

Quote from the section on contraceptives at UMO.se, an official public health care website for youth provided by the Regions of Sweden

In the medical community, scientific consensus has long promoted the benefits of hormonal contraception, both for effective pregnancy prevention and treating period-related conditions such as dysmenorrhoea (Sitruk-Ware et al., 2013). The medical discourse on contraceptives is submersed in a feminist progress saga, perhaps best illustrated in this opening speech from the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in 2014:

Our imperative, as obstetrician-gynecologists, is to champion the vital importance of contraception and advocate at every level to expand access. The moral imperative extends beyond contraception, family planning, or any particular sphere of feminist engagement. (…) Women constitute half of humanity; empower women, and we double our productivity, our intellectual capacity, and hence our ability to preserve and enhance the world we inhabit. (Espey, 2015, p. 196)

Among women using hormonal contraceptives, however, a different narrative is often present. The feminist denunciation of hormonal methods has its roots in the women’s health movement of the 1970s, developing the idea that medical institutions were inherently patriarchal and unreceptive to women’s needs and wishes. It high-lighted the many unwanted side-effects of high dose oestrogen as well as the partly eugenic motifs and racist trials behind the Pill (Carson, 2018; Tone, 2002). Numerous investigations inspired by qualitative methodologies have found that many women are sceptical about hormonal methods, and also unhappy with what are considered medically less serious side-effects, such as breast tenderness or mood disturbances (Ekstrand et al., 2005, Wiebe, 2012). Methods that enhance a feeling of control during intercourse, such as the diaphragm, are often preferred, although less effective in preventing pregnancy (Alspaugh et al., 2020; Dehlendorf et al., 2015). Many women report that their complaints are not taken seriously by health care representatives (G. Falk et al., 2010). A discrepancy between the medical community, pushing for effective contraceptives without the risk of unplanned pregnancy, and women in need of contraceptives who resist these effective hormonal methods to a higher degree than anticipated, thus becomes visible.

The particular health systems, styles of medical communication, and societal norms of a country or region also affect contraceptive practices. Sweden has a long tradition of liberal sexual politics and promoting gender equality, and is often considered one the most gender-equal countries in the world (Arousell et al., 2017; Ekstrand, 2008). Contraceptives and informing about them has been legal since 1938, the same year that abortions was conditionally legalized. The contraceptive pill was approved soon after its introduction in 1964 and the hormonal intrauterine device (IUD) in 1966. Active encouragement of fathers’ participation in child care as well as prenatal care has been part of Sweden’s gender equality agenda for decades (Jungmarker et al., 2010). Sweden’s paid parental leave policy wants to “encourage both parents’ caregiving responsibility and close relationship to the infant, and to encourage dual breadwinning and stimulate women’s participation in the labour market” (Lidbeck et al., 2018). The gender equality discourse is also present in contraceptive counselling, where women’s participation in the labour market has been shown to be an ideological motif (Arousell et al., 2017). Despite the active effort of engaging men in reproductive matters, feminist studies have pointed to the gendered labour divide in contraceptive responsibility wherein women are expected to take responsibility for contraception in committed heterosexual relationships (Ekstrand, 2008; Fennell, 2011; Wigginton et al., 2015).

Today, hormonal contraceptives are an integrated part of the lives of women and fertile persons in Sweden. Hormonal methods are completely subsidized by the government for women up until 20 years of age. Sweden is unique in the sense that nurse midwives, rather than physicians, are the main providers of contraceptive counselling and prescriptions (Lindh, 2014). Youth clinics are available in every municipality and provide contraceptive counselling as well as condoms free of charge, up until 23–25 years of age. The combined oral contraceptive pill is the most commonly used contraceptive method for adolescents, while the hormonal intrauterine device (IUD) dominates for women over 29 years (Lindh, 2014; Lindh et al., 2010; Swedish Medical Products Agency, 2014). The latter is a form of long-acting reversible contraceptive (LARC) method, in which the copper spiral and contraceptive implant are also included. These methods are actively advocated for by the medical profession today, particularly for younger women, since they are not user-dependent and thus the most effective in preventing pregnancies (Kopp Kallner et al., 2015; Lindh, 2014). The “morning after pill”, or emergency contraceptive, is available over the counter at pharmacies while condoms and diaphragms can be bought in stores or over the internet. Sterilization is rather uncommon for all genders in Sweden and only allowed after the age of 25.

An explicit goal in Swedish reproductive health care is to limit the number of unwanted pregnancies and, even though it is less clearly articulated in later policy documents, the relatively high number of abortions compared to neighbouring countries (G. Falk, 2010; Lindh, 2014; National Board of Health and Welfare, 1990; Sedgh et al., 2015). Within the medical community, unplanned pregnancies are framed as risky, since both prenatal conditions and pregnancy outcomes have been shown to be poorer on a population level, and an “increase health promoting planning behaviour” is seen as desirable (Stern et al., 2015). Contraceptive compliance, with good accessibility and communication on contraceptive regimens, is seen as key to this, and a body of work within a risk-taking framework investigating non-use of contraceptives in Swedish adolescents exists (Ekstrand, 2008; G. Falk et al., 2010; Lauszus et al., 2011). UngKAB15, a large national survey from 2015 investigating sexual health in 7,775 young Swedish persons aged 16–29, found that most young people primarily used the Internet and official sites from public health care, such as 1177.se and UMO.se, as a source for information regarding sexuality and contraception (Public Health Agency of Sweden, 2017).

The above-mentioned tension between the medical community wanting women to use effective contraceptives and scepticism among the intended users, becomes extra poignant in Sweden because of excellent availability of contraceptives. How well-read official health sources communicate about contraceptives thus becomes interesting in exploring the power relations involved. Against this background, the aim of this article is to explore the broader discourses of contraception and reproduction that are being drawn upon and reproduced in Swedish official health care online sources. How are hormonal contraceptives and non-hormonal alternatives discussed? How is the ideal contemporary contraceptive user constructed? How and where are trust and responsibility allocated and what power relations are involved in contraceptive communications?

The article is organized as follows. First, after having introduced the Swedish contraceptive and reproductive health context, the concept of biomedicalization and a gendered health imperative will be presented, followed by two central analytical devices framing the analysis: the neoliberal, post-feminist disciplinary subject and the notion of reproductive justice. Then follow a presentation of the material and methodology, a thematized discourse analysis of the texts, and a concluding discussion.

Theoretical Reflections

Biomedicalization and Post-Feminism

The process of medicalization, extending medical authority into fields previously outside its scope, began at the turn of the last century. During the past decades, this process has intensified and been reinforced through new technoscientific innovations and an ever-growing biomedical sector to what some scholars conceptualize as biomedicalization (Clarke et al., 2003). Where the concept of medicalization describes how medical authority is used as a rationale for control over biomedical phenomena and people (Zola, 1972), biomedicalization extends to transformation of these same phenomena. This process is tightly associated with economic growth of the biomedical sector, technoscientific advances such as home diagnosing and health monitoring tools (for example, fertility apps and early pregnancy testing) and alterations in production and distribution of biomedical knowledge, as well as a focus on health and technoscientific transformations of bodies and identities (Clarke et al., 2003).

In a biomedicalized society, health itself has become increasingly central. That is, how to maintain and minimize threats to health, rather than just managing and treating illnesses and diseases, is of increasing concern not only for the medical professions and the biomedical industry, but for every individual. Being and staying “healthy” has been transformed into a moral incentive. This health prerogative requires two things: constant attention to risk within a discourse of prevention and risk factors, and self-surveillance through new knowledges and technologies, creating novel medicalized identities and forms of internalized self-governance (Clarke et al., 2003; Rabinow, 2005).

Biomedicalization and the transformation of health are not gender-neutral processes. Moore (2010) discusses how self-surveillance and body-consciousness are traditionally female attributes based on a notion of the (female) body as uncontrollable and in need of refining, rendering the healthy body a distinctly female project. Women are constructed as responsible for not only their own unruly bodies but for the whole family’s health, and found guilty when ill health strikes. Preventative and risk assessment services are mainly marketed towards women, as a way of “taking control” of one’s health (Kelly, 2008). Health is therefore increasingly a gendered project, and in “doing health” today, we are, a number of scholars argue, also “doing gender” (Moore, 2010). It has also been claimed that femininity itself has become more of a bodily property, mainly within a post-feminist logic (Gill, 2007). Post-feminism can be described as a standpoint emerging in popular media in the 90s, that takes feminist conquests for granted, assuming women and men have equal opportunities in every aspect of life, and hence, all differences are individual and freely chosen (McRobbie, 2008). Gill (2007) builds on Foucauldian ideas of surveillance and defines post-feminism as:

a distinct sensibility [that] include the notion that femininity is a bodily property; the shift from objectification to subjectification; an emphasis upon self-surveillance, monitoring and self-discipline; a focus on individualism, choice and empowerment; the dominance of a makeover paradigm; and a resurgence of ideas about natural sexual difference.” (p 147)

The post-feminist sensibility has the self-discipline and surveillance in common with the biomedicalization process, but is distinctly gendered in how this effort and emotional labour is poured into achieving a position as a desirable heterosexual subject. Post-feminism is also closely related to a neoliberal logic, where all practices are presumed to be made by free choices in a free market (Brown, 2005), “no longer constrained by inequalities or power imbalances whatsoever” (Gill, 2007, p. 152), and thus rendering critique at a structural, political level nearly impossible. A fundamental theoretical frame of this article is the parallel and intertwined processes of biomedicalization and post-feminism, that set the stage for the ideal neoliberal disciplinary subject: the liberated woman in constant need of self-discipline, self-surveillance and internalized objectification.

Gendered Hormones and Birth Control

How hormones, more specifically the “female hormones” of oestrogen and progesterone, are imbued with meaning is central to understanding discourses around hormonal contraceptives. Although the biological reality is complex and all “sex hormones” impact many different organs in the bodies of animals of all sexes, these hormones have been described as simple chemical messengers of femininity and masculinity, ever since their discovery at the beginning of the twentieth century. Oudshoorn describes how the hormonal model has developed:

...into one of the dominant modes of thinking about the biological roots of sex differences. Many types of behavior, roles, functions and characteristics considered as typically male or female in western culture have been ascribed to hormones. In this process, the female body, but not the male body, has become increasingly portrayed as a body completely controlled by hormones. (Oudshoorn, 1994, p. 8)

Irni (2013) develops the concept of how hormones, besides chemical effects, have a unique cultural power and affect us through a material-discursive interplay that also that has real effect on bodies. She argues that a feminist approach to sex hormones should not be reduced to a critique of the medicalization of women’s bodies through hormonal products, but should take “account for the context-specific power relations within which many of the existing ‘hormonal changes’ come to materialize” (Irni, 2013, p. 53). Using a framework of bio/medicalization solely as a critique of medicine is not only reductionist but can hide the fact that modern medicine alleviates suffering and has very real positive consequences for human lives (Purdy, 2001). However, it is still crucial to examine how biomedical expansion is legitimized or denied, in particular when such efforts construct both individuals and their behaviours as risky or abnormal (Pickersgill, 2009).

Previous studies have found that medical texts on birth control “universalize and essentialize women based on their ability to reproduce” while ignoring heterogeneity of women’s experiences (Carson, 2018). To understand contraceptive advice and the practices that are encouraged, it is thus necessary to move away from a dichotomous view of bio/medicalization as good or bad, while at the same time examining how suitable non/reproduction is constituted through biomedicalization. In their research on discourses surrounding extended cycle-birth control Kissling (2013) and Gunson (2016) both discuss how the use of “nature” or naturalness works within a neoliberal logic to make non-menstruation the desirable choice, which also happens to align with a controlled, neoliberal subject who’s body is docile and permits constant productivity. Gunson argues that “The natural has the effect of obscuring the ways in which reproduction is politicized and oversimplifying the complexities of material bodily functions” (2016, p. 316), meaning “nature” cannot be treated as a singular entity with morals of itself, but the interplay between social spheres, bodies, medical science and the environment needs to be acknowledged.

I use reproductive justice as a point of departure in my analysis. Reproductive justice is a theoretical framework based in community activism that centres oppressed women’s experiences to recognize that societal context and differing resources available shape reproductive health for individuals (Ross & Solinger, 2017). The notion of “reproductive choices” has been challenged within this framework since these choices are only presented within a very narrow neoliberal frame, where access to contraceptives as well as abortion, a safe environment to raise children, and who is considered a respectable mother, are conditioned based on intersecting social inequalities (Price, 2011; Wilk, 2020). For example, a disparate prescribing pattern of HC has been observed in which women of colour or low income are disproportionately frequently prescribed LARCs (Dehlendorf et al., 2010), which could be interpreted within a reproductive justice framework as these women being considered “unfit” mothers (Ross & Solinger, 2017). The reproductive justice movement thereby recognizes that reproductive choices, such as contraceptive use, are made within a frame of possibilities that differ for each fertile person, based on embodied experiences stemming from intersectional locations, rather than positioning those in need of contraceptives as purely rational agents making choices in an unconstrained market.

Methodology and Methods

My aim in the selection of these texts is to grasp and explore the broader discourses of contraception and reproduction that are being drawn upon and reproduced in official online sources. To do this, I am inspired by the tradition of critical discourse analysis (Fairclough, 2013). Discourse analysis is based on the concept that language is a form of social practice, and that analysing texts can reveal sociocultural functions. Discourses organize our views of the world and social interactions. Critical discourse analysis furthermore acknowledges that discursive events work ideologically and contribute to relations of dominance (Fairclough, 2013). Dominant discourses form taken-for-granted truths and can justify the elimination of particular ideas, behaviours and individuals, while sanctioning others (Cheek, 2004). By normalizing certain ways of speaking about a subject, of acting and being in the world, discourses become powerful. A critical discourse analysis also entails exploring what, or whom, is not spoken about or is missing from the specific discourse. My purpose in taking this critical approach is to make visible that which is taken for granted: more precisely here, discourses of reproduction and contraception.

Official internet information sources concerning contraceptives, directed at the general population in Sweden, was analysed. The two official public health care websites provided by the Regions of Sweden (administrative and geographical regions consisting of several counties that are partly self-governing and economically responsible for health care), one directed at youth (https://UMO.se) and the other at adults (https://1177.se), were examined. The website 1177.se is a combined information resource with texts on diverse health care topics written and fact-checked by health care personnel, as well as an administrative site for citizens to carry out health care errands. UMO.se was launched as a “digital youth centre”. Its description reads “UMO is a webpage for everyone between 13 and 25. At UMO.se you can get knowledge about the body, sex, relationships, mental health, alcohol and drugs, self-worth and a lot more” (UMO.se). In addition to those, the website of the largest non-profit organization for reproductive health and rights in Sweden, RFSU (ad verbatim “The national organization for sexual enlightenment”) was analysed (https://RFSU.se).

All websites have a similar structure in their information on contraceptives, that can be found under the tabs “sex”/“sexual health”/“sex and relationships” at UMO, 1177 and RFSU respectively, with a first page that briefly describes contraceptive methods and links to and/or a side menu with specific methods. All three websites have specific pages for all available methods in Sweden, which are: condom, emergency contraceptive pill, combined contraceptive pill, progesterone-only pill (low-dose, called mini-pill and medium dose called middle-pill in Swedish), the contraceptive ring, implant, injection and patch, hormonal IUD, copper IUD, diaphragm, contraceptive apps/computers and safe periods, withdrawal method and sterilization. The pages were constructed in a similar fashion with an introductory paragraph, explanation of the mechanism of action, instruction for usage, average cost, pregnancy protection efficacy and finally advantages and disadvantages/side-effects (this last section was named “when is this contraceptive suitable/not suitable” at the 1177 website). All reversible methods were included in the study. Quotes are translated from Swedish to English and I have aimed to stay as close as possible to the original wording to capture the meaning.

For the analysis, I read each text and performed initial rough coding where I made note of words or phrases being used to describe different contraceptive methods and the presumed contraceptive user. Texts were re-read, and codes were categorized into emerging themes, which were then mapped out in greater depth through tracing patterns of ideas and language within and across texts. The data was read multiple times in order to ensure rigour and develop precise categories that captured the relevant constructions present in the texts. Rather than pay attention to the scientific value of medical claims being made in these texts, I focused on what was being communicated or represented, and how this was done.

The Ideal Contraceptive User: Navigating Choice

Three themes emerged from the analysis, each one within its own field of tension of un/natural, im/perfect and un/gendered. The first theme explores exogenous hormones as a norm, however “unnatural” and undesirable. The second theme departs from the concept of a “perfect contraceptive fit” and what it requires. The final theme deepens the discursive investigation to look at what the “gender neutral” language in these contraceptive texts means. The notion of gendered individual choice and agency can be traced throughout the thematization, which is followed up on in the concluding remarks.

Un/Natural—Exogenous Hormones as a Non-Desirable Norm

A diaphragm is a contraceptive without hormones that is used together with a diaphragm-gel.(…)

Advantages of a diaphragm:A diaphragm that is used correctly provides a good protection against an unwanted pregnancy. A diaphragm is hormone-free. (RFSU)

Vaginal diaphragmAdvantages:Can be used many times. It does not affect the body since it does not contain hormones. Environmentally-friendly. (UMO)

Withdrawal methodAdvantages: It does not affect the body in any way. (UMO)

A contraceptive method being free from hormones was in itself presented as an advantage, as can be seen in the above quotes from the UMO and RFSU websites. The capacity of not “affecting the body” of the user is desirable, and contraceptive hormones are thus constructed as a threat, something exogenous that has the potential to change the body in unwelcome ways. However, this discourse of desirable bodily integrity, or undisturbedness, also underlines what is taken for granted here: that any possible effect is about hormonal influence. A condom or diaphragm, or withdrawing during intercourse, does have obvious and immediate physical impact on bodies and could have lasting effects through allergies or local irritation, but it is not conveyed via hormones and seemingly does not “count”. Furthermore, non-hormonal methods and even the hormonal fluctuations of the untampered menstrual cycle were measured against hormonal contraceptives, that thus become the model contraceptive agent:

When is the diaphragm suitable? The diaphragm is suitable if you don’t want or can use a pregnancy protection method containing hormones.(1177)

When the IUD is in place it constantly gives off a small dose of hormone that goes into the body. That means the body get an even uptake of hormone. (UMO)

While not containing hormones could be described as an advantage in a contraceptive method, containing hormones was not described as a disadvantage, but as a fact possible to navigate around, or a positive trait:

The body needs time to get accustomedThe hormone in the mini-pill affects the body and it often needs a little time to get used to it. You can get discomfort in the beginning that disappears later. This can, for example be breakthrough bleeding, headaches, acne, low mood or decreased libido. (UMO)

Positive effects from the combined pillThe hormones in the combined pill can make the discomfort of heavy periods, cramping and PMS less. Some kinds of contraceptive pills also have a very good effect on acne. The contraceptive pill reduces the risk of ovarian cancer, uterine cancer and colon cancer. (1177)

In my material exogenous sex hormones in the form of contraceptives are constructed as both a threat to the (female) body and a desirable regulator of the same body. The particular cultural power of hormones becomes relevant in this context (Irni, 2013). Within this tension of danger and desirability, the will to normalize hormonal contraception in a cultural context that understands sex hormones as potent messengers and disruptors, and as signifiers of gender itself, becomes visible.

Hormones as signifiers of anything needs to be understood in context. With the expansion of biomedical sciences, the body as an entity has faded from the discursive view and been exchanged with ever smaller pieces of biological relevance: organs, tissues, cells, hormones, genes and molecules (Braidotti, 1989). This development allows certain biological compounds to take on a meaning well beyond their chemical, context-dependent mechanisms. It becomes possible to detach “hormones” from the body with its ever-changing flow of information and give them new discursive significance. This discursive shift is visible in my material. Hormones, in this case oestrogen and progesterone, are treated as simple, separate entities possible to disconnect from their biological and social web of meaning with certain (wanted or unwanted) effects on the body. Of interest here is that the focus on these “detached” hormones and their potential action on the body helps obscure other possible narratives of contraception such as, for example the social and relational. The decision to start birth control is not made in a social vacuum, but by real people with emotions and relationships interwoven in an unequal societal fabric.

Contemporary research has shown that women often prefer “natural” contraceptive methods and are sceptical about hormonal methods because they are considered “unnatural” (Alspaugh et al., 2020). In a government-initiated Swedish survey directed at youth, one question regarded the reason young women had not been using hormonal contraceptives in the last 12 months and 25% of respondents answered that they did “not want to use hormonal methods” (Public Health Agency of Sweden, 2017). That the question was posed at all can be seen as an indication of how hormonal methods are desirable and the reason for not using them needs to be questioned.

The un/natural tension can be traced back to the invention of the contraceptive pill and subsequent encyclical Humanae vitae by Pope Paul VI in 1968, in which he officially labelled hormonal contraception as artificial and thereby forbidden (Tone, 2002). The “unnaturalness” of hormonal contraceptives, although consisting of hormones present in all human bodies, was thereby used as a way of legitimizing a continued influence on female reproduction by the church. While many feminists championed hormonal contraceptives and access to them evidently changed many lives for the better, a parallel critique of patriarchal medical institutions that disregarded women’s experiences of side-effects and general needs also grew, feeding into the “natural is best” narrative (Carson, 2018). Exogenous hormones are clearly not viewed as “natural” in this material, but as something alien that can disturb the body, but that also have desirable properties. Looking at how menstruation was discussed reinforces this narrative. The fact that dysmenorrhoea often subsides and monthly bleedings get lighter or disappear altogether, and that this is possible to control yourself, was mentioned as an advantage in all webpages for all hormonal methods. Gunson (2016) argues that the approval of extended cycle-regimen of the combined pill in 2003 was “a landmark attempt by the pharmaceutical industry to shift dominant public discourses about women’s menstruation”, towards non-bleeding as both natural and desirable. In the texts analysed here, the shift Gunson describes has successfully occurred and a new discourse is established. Menstrual suppression is not discussed as a medical issue but as a taken for granted option. For the modern woman in a biomedicalized society, menstruation should be an option.

The advantages of hormonal contraceptives for both effective pregnancy prevention, and for alleviating embodied experiences of pain, extensive bleeding, and anaemia, should not go unmentioned in a critical examination of reproduction as a biomedicalized arena (Purdy, 2001). The access to these drugs has given many women increased autonomy and freedom, although not equally distributed across and within societies. However, it’s interesting to note that by constructing hormonal contraceptives as the norm and hormones as central to well-being, reproductive control becomes equated with hormonal control. In Gunson’s words, hormonal contraceptives have “become an entrenched part of women’s embodied landscapes” (2016, p. 321), as they chemically influence hormonal levels while at the same time changing our way of thinking about reproduction, menstruation, autonomy, and control (Roberts, 2002). The dominance and effectiveness of hormonal methods has medicalized reproduction and menstruation to an extent that it is impossible not to relate to them as practical regulators of a potentially “messy” body (Moore, 2010). What is noteworthy is the tension that women in need of contraceptives have to balance: exogenous hormones as both a potential, “unnatural” threat to their bodies and as a desirable, effective regulator of the same “naturally unruly” body.

Im/perfect - The Promise of a Perfect Contraceptive Fit

Most users have no side-effects from their contraceptives. But if you start using a contraceptive with hormones its common to have minor side-effects during the first time period. That is because the body needs time to adjust. Usually the side-effects disappear within the first three months.These are some side-effects you can have: low mood, less sex drive, acne, tender breasts, headaches.You could get one or two side-effects, but it’s uncommon to get all side-effects at the same time. If you have been using your contraceptive for more than three months and still have side-effects, you should talk to your prescriber. (UMO)

Side-effectsAll contraceptives that contain hormones affect the body, but since the hormonal IUD gives off such a small amount of hormone, side-effects are uncommon. Some who use the hormonal IUD get acne, low mood or decreased libido. Some get irregular bleeds during the first months. Most side-effects disappear within six months. You can change to another contraceptive if you are suffering from the side-effects. (1177)

It is also important to consider your medical history when choosing contraception. If, for example, you have had a blood clot or have severe migraines, you should avoid contraception that contain oestrogen. The midwife or doctor who is helping you with contraception will ask you about this. (1177)

Blood clots are a serious and feared side-effect of hormonal contraception and clear medical guidelines exist to minimize the risk (Swedish Medical Products Agency, 2014), which is plainly expressed in the material, as in the above quote from the first page of the website 1177. Other side-effects, more common but less serious, attain less attention. It is stressed that most side-effects are temporary, indicating that they should be tolerated. Mood changes, weight gain, and irregular bleeding are the most common reasons for discontinuing hormonal contraceptive methods (Lindh, 2011; Rosenberg & Waugh, 1998; Sanders et al., 2001; Simmons et al., 2019). By down-playing or not acknowledging embodied experiences that do not constitute medical emergencies, such as irregular bleeding or low mood, these experiences are regarded as irrelevant. Even if side-effects are down-played, women are not expected to tolerate them for too long and are encouraged to seek out help if they have side-effects that last more than three months (or six months for the hormonal IUD, which has the lowest occurrence of pregnancies and is therefore encouraged as a first-hand choice (Kopp Kallner et al., 2015; Lindh, 2014)).

The word “safety” occurred frequently in the material, but only in relation to pregnancy prevention, and never when discussing side-effects. The following quote is from the introductory page at UMO.se.

How you protect yourself against pregnancyBefore you start having intercourse, it’s important that you get a protection against pregnancy if you don’t want children. The responsibility for pregnancy protection lies both on you who can get pregnant and on you who can get someone pregnant. Protection against pregnancy is also called contraceptive agents or birth control methods. There are birth control methods where the risk of becoming pregnant is small or very small if used in the correct way.

The very safest is:Hormonal IUD, copper IUD, implant

Other safe protections against pregnancy:The pill, the ring and patch, the low dose and medium dose pill, the shot, condom, femidom*

There are also methods that are less safe and the risk of getting pregnant is bigger. Especially if you are young and have an irregular cycle.

Unsafe methods:Safe periods and birth control apps, withdrawal method, diaphragm

Which protection you should useWhich protection you should choose is affected by different things, for example if you have any diseases, which protection you like best, and how you are as a person. Maybe you should have another protection than the pill if you have a hard time remembering to take a pill every day. A midwife or a doctor at the youth clinic can help you find the protection that is most suitable for you.

*I have directly translated what was written in the original text, but the naming of different hormonal methods for a general audience differs in Swedish and English. The combined contraceptive pill containing both oestrogen and progesterone is usually just called “the pill” in English, and “p-piller” (P as in preventive) in Swedish. The low-dose and medium dose progesterone pills are called “mini-piller” and “mellan-piller” (literally “mini-pill” and “medium-pill”, without specifying hormonal content). The contraceptive injection is known by its brand name Depo-Provera in English, but is just referred to as “p-spruta” (p-shot) in the text. In this quote taken from the introductory page it’s therefore not possible for the reader to discern the hormonal content of the methods, but that is specified in the specific pages for each method, which are reached by following the links.

The aim here is clearly to give medically-relevant information in an accessible way. A contraceptive method’s effectiveness in preventing pregnancy is undoubtably of great importance, with real-life implications. Acknowledging that does not, however, make the context and the way this information is communicated irrelevant (Purdy, 2001). Although a contraceptive’s ability to prevent pregnancy is important, it is neither the only relevant safety measure since serious side-effects with impact on health or even life do occur, nor the only factor of relevance to women using it. Contraceptive methods that enhance women’s sense of immediate control, such as the diaphragm or pills, are often preferred even though they are less efficient in preventing pregnancies (Alspaugh et al., 2020; Dehlendorf et al., 2015). Possible, serious side-effects of hormonal methods, such as cancer or infertility, are rare and often exaggerated in women’s own narratives compared to a scientific consensus (Alspaugh et al., 2020). Providing the dominance of the medical consensus and interest in keeping unplanned pregnancies low, the rationale for down-playing side-effects and focusing on safety as pregnancy prevention becomes clear. Using “safety” in this way, together with the common phrase “protection against pregnancy”, as well as directly addressing pregnancy as a risk, frame the unplanned pregnancy as a threat within these texts. Safety is thereby constructed as protection against not just any pregnancy, but against the unplanned pregnancy. Youth is pointed out as an especially risky period for unwanted pregnancies, and the desirable pregnancy is thus constructed as only occurring later in life.

The withdrawal method can be suitable if you are planning to become pregnant, soon and it doesn’t matter if it happens earlier than planned.(1177)

The planned, adult pregnancy is the goal and the only rationale for using a contraceptive method less apt for preventing pregnancy is if a planned pregnancy is already imminent, as stated in the above quote.

How do I use the pill? (…)You take a pill at the same time every day for at least three weeks. You can decide yourself which time during the day you want to take your pills. It can be a good idea to take them in conjunction with another recurring activity, such as brushing your teeth or eating breakfast. Whatever time you choose, it’s good to set an alarm in the beginning. This decreases the risk of you forgetting your pills. There are also “pill-apps” for download on your phone.

Do this if you don’t want to have a periodYou can get rid of your period completely or just postpone the time when you get it by eating pill charts together.Start on a new chart right after the last hormone-pill on the chart. If you have a chart with sugar-pills this means that you leave those and start on a new chart. When you do that you get no period.To make postponing your period work as well as possible it’s good to first eat your pills according to the chart for two months. That way you’re reducing the risk of break through bleeding. It’s common to have breakthrough bleedings if you try to postpone your period by eating pill charts together when you just started on the pill.

If you have a breakthrough bleedMost who postpone their period bleed after a while. Pause for four days if you bleed. (1177)

This short section from the page on 1177.se on the combined pill is filled with the seemingly contradictory discourses of choice and rigid regulation. The second person language of “you can decide” and “you choose” is intermingled with rather complicated instructions for how these choices are best carried out. It appears as though it’s possible to choose when or if a period bleed should take place, when in fact it requires thorough self-surveillance and discipline, and even then there’s no guarantee the body will react as planned. An interesting fact is that even though menstruation was mainly framed as inconvenient and unnecessary, the possibility that some contraceptive users would want to have a period was also acknowledged. Thereby not only timing of, but the very existence of, menstruation is also located within the discourse of individual choice. Again, while acknowledging the potential for alleviating suffering that period suppression can have, it has also been argued that menstrual suppression is a way of creating docile, productive individuals that contribute to the neoliberal economy without the nuisance of monthly bleeding or hormonal fluctuations (Kissling, 2013; Wilk, 2020).

Wigginton et al. (2015) discusses in their study of Australian women using hormonal contraceptives how contraceptive practices have been feminized and women position themselves as responsible not only for preventing pregnancy but also for finding the perfect contraceptive to do so. The reader is not explicitly referred to as a woman in my material. The fact that the text is written in second person, paired with how all contraceptive methods except the condom and withdrawal are to be used by someone with a female reproductive system, most commonly a woman, still implicates this female responsibility.

Remember: There is always a protection against pregnancy that suits you. Even if you tried one or several methods that you weren’t comfortable with, don’t give up.To use a protection against pregnancy does not mean that you are protected against STDs. To protect yourself against both pregnancy and STDs, use a condom. (UMO)

You might have to do some trial and error, some like a certain method and others prefer another. Since there are many different protections, the prospect of finding something that works is great. (1177)

To consider if you are using birth control apps and computers:The method does not protect against STDs.You can never be completely sure when you ovulate, even if you have regular periods.The method can lead to pregnancy if you have unprotected intercourse during the fertile period according to the app.To keep track of ovulation and count days can be a nuisance and you might not be able to have intercourse right when you want to. (1177)

The diaphragm is less suitable if you want to be completely spontaneous, since using the diaphragm demands some planning. (1177)

Wigginton et al. (2015) found that women go to lengths to find a “contraceptive fit”, no matter how many previous negative experiences or side-effects, another female method could always be considered. To minimize side-effects by surveilling your own body also became the woman’s responsibility and was interpreted as an act of agency (Wigginton et al., 2015). In the quotes above, the promise of the “perfect contraceptive fit” is explicitly spelled out. “There is always a protection against pregnancy that suits you” indicates that the choices are both endless and possible to individualize. The urging “don’t give up” further enhances the feeling that it’s the individual woman’s responsibility to find a contraceptive that suits her (and her partner). Wigginton et al. (2015) locate their findings of the female responsibility to find a contraceptive fit within a broader discourse of (hetero)sex and heterosexuality, where spontaneity and pleasure during (hetero)sex should be prioritized, but with discordant gender distribution of both responsibility and pleasure. That contraceptives ideally should not interfere with “natural” (hetero)sex becomes visible in this material when drawbacks with diaphragms and birth control apps are presented as being less spontaneous. It has been argued that inscribed in menstruation from the start is the responsibility of reproduction and possible motherhood, whereas male sexual maturity is marked by representations of future pleasure such as ejaculation (Grosz, 1994). In these texts, pleasure is only mentioned as a possible absence, lower sexual desire as a side-effect of hormonal methods. What is excluded can be just as important as what is included. By never addressing the driving force for sexual encounters but solely focusing on the obligation of pregnancy prevention, women are again created as rational and responsible for reproduction, exercising agency purely through responsible contraceptive choices.

Although contraception is subsidized and generally accessible in Sweden, not all women have the same possibility to prioritize or access health care, particularly in a contemporary setting of down-sizing public health care, an issue voiced within the reproductive justice-movement (Ross & Solinger, 2017). In my material, it is stressed that women should contact their prescriber themselves in case of dissatisfaction with their contraceptive. Follow-up visits are generally not scheduled in this type of care in Sweden. The (hormonal) contraceptive user is thereby constructed as rational, resourceful, and responsible in her quest for the perfect contraceptive fit.

The promise of the perfect contraceptive fit thus includes no side-effects, perfect protection against unwanted pregnancy and being able to be spontaneous during (hetero)sex. However, the reality of contraceptive choices is imperfect. The underlying gendered health prerogative becomes visible when women need to take responsibility for pregnancy prevention, minimizing side-effects and tracking their cycles, requiring constant planning, self-surveillance and self-discipline. It becomes obvious that it’s the woman who need to accommodate to available methods, whether it’s by “letting the body adjust” for six months, trying another female-controlled method, or being content with some “minor” side-effects, rather than the other way around. A critical reading of the contraceptive discourse shows that “the problem” is not constructed as the available birth control methods, but the unruly female body.

Un/Gendered—Inclusive Language or Disembodied Discourse?

This is how you use the vaginal ringYou place the ring in your vagina, in a similar way that a tampon is inserted. You can’t feel the ring when it is in place, not during intercourse either. It gives off hormones all the time that goes directly into the body. That means the body gets an even uptake of hormones compared to the pill, when you take one pill a day.(…)The ring causes you to not ovulate. It also affects the secretion in the cervix so it becomes sticky and thick. That makes it hard for sperm to enter the uterus. The ring also makes uterine lining thin so that it can’t receive a fertilized ovum. (UMO.se)

This is how birth control apps and computers workSome birth control apps and computers use the body temperature you have when you wake up. You measure your temperature yourself and fill in the results in the app or computer. To be able to measure the temperate in this way you need a thermometer with two decimals. A regular thermometer does not work. (1177.se)

Withdrawal method* is a way of protecting against pregnancy that means you interrupt the intercourse. That is, the penis is withdrawn from the vagina before ejaculation. (UMO.se)

Drawbacks with withdrawal methodThe method has several uncertain elements. It’s of importance that the penis-carrier reacts in the right moment before ejaculation to be able to interrupt in time. (RFSU.se)

*In Swedish, the term used is “interrupted intercourse” (avbrutet samlag), a name that in itself points to a male-oriented norm where intercourse culminate with male ejaculation.

At 1177.se and its sister-website UMO.se, the words “woman/women” is never mentioned, neither is “man/men”, but gendered body parts and fluids, such as uterus, vagina, ovum, cervical mucus, penis and sperm are often referred to. RFSU.se interchangeably uses a passive language and the informal second person address of the other websites, but also refers to “women” in a few of their texts of hormonal methods and to “penis-carriers” in the withdrawal method. The language choices at 1177.se and UMO.se need to be understood in context. Removing men and women from all texts on these websites (not only those regarding contraceptives) was a conscious decision. In a document titled “Woman—avoid” at 1177.se, the following rationale is given:

We do not write the words woman, man, boy or girl where it’s not necessary.We avoid the words in our texts for several reasons:

• - We use the informal form of “you” (du) in all our texts. It is a direct way of addressing the reader that makes them feel included. Using “you” is practical in all circumstances where the gender is unknown, or doesn’t matter. (…)

• - In health care it’s important to be correct about facts and anatomy. We can use the illness endometriosis as an example. It does not foremost depend on you being anatomically a woman, but that hormones makes tissue grow outside the uterus. (…)

• - Everyone does not identify as a man or a woman. By avoiding those words in the texts and instead using the informal form of “you”, we include more people. It is of extra importance since transgender people have worse health than the average person, according to studies. Our language directives partly emanates from the discrimination act (Diskrimineringslagen).

The aim is thereby clearly to be informal, inclusive, and transgender friendly by using a second-person address and removing certain words referring to the sex of an individual, in an important and societally-relevant effort to present an inclusive democratic agenda. The question still remains, though, as to what happens in that process, and what is communicated when explicitly gendered language is removed, and only body parts and hormones remain. To focus on organs, tissues and hormones rather than the body as a whole has been the general direction in medicine for decades, as the development within biomedical sciences has allowed for ever more detailed analysis. This has also meant that the body as such is no longer a discursive phenomenon that needs to be addressed (Braidotti, 1989). This is true of reproductive narratives as well. In their investigation of modern reproductive narratives in Norway, Lie et al. (2011) found that rather than talking about men and women, reproduction was framed through a biological lens, focusing on the cell level.

We observe how, in contemporary stories of conception, sperm and egg cells have increasingly become the entities that occupy center stage, even more so than the actual gendered persons themselves. This is a process whereby, on the one hand, egg and sperm cells may take on the meaning of women and men or, on the other hand, displace the association with the bodies from which they originate. (Lie et al., 2011, p. 231)

They reach the conclusion that the disassociation of biological processes from actual individuals bears the potential to both overthrow and enforce gender roles; the former by making room for new interpretations of reproductive realities and the latter by attributing egg and sperm cells the same gendered qualities as men and women, establishing them as a biological facts. Traces of this discourse are visible in my material, as in the above on the vaginal ring from UMO.se quote where sperm seem to have a will to entering the uterus, which the ring prohibits.

However, the main discursive shift exhibited in these websites happens with the genderless second person address, where responsibility for contraception is reduced to having certain organs: most commonly a uterus, ovaries, and vagina. The social expectations and complex relational interplay that contraceptive practices encompass in real life is diminished to a purely rational, medical choice dictated by body parts. This focus on body parts creates a rather detached, disembodied discourse that also obscures the gendered imbalance in reproductive responsibility, which still lies heavily on women, even if the words are changed (Ekstrand, 2008; Fennell, 2011; Wigginton et al., 2015). The imbalanced responsibility is enhanced by how the “you” in these texts all refer to a person with ovaries, uterus and vagina, except for the texts on condoms and withdrawal method (where it’s not always clear whom is addressed, but sometimes it’s a person with a penis). The person that can become pregnant is clearly constructed as responsible for preventing this, a gendered divide in contraceptive responsibility previously found to be more pronounced with hormonal methods (Ekstrand, 2008; Fennell, 2011). Drawing on Wigginton et al. (2015) I would argue that the discourses of female reproductive control and responsibility, that becomes visible in this material, risks limiting the discursive space for shared responsibility and excluding the possibility of using and developing new male contraceptives. The disembodied discourse makes it impossible to address this responsibility imbalance by, for example, explicitly encouraging the involvement of male partners in contraceptive counselling, since uteruses don’t have partners. This choice is somewhat surprising, bearing in mind how important men are considered in prenatal care and childcare in Sweden (Jungmarker et al., 2010; Lidbeck et al., 2018). The line for male involvement seems to be drawn at a conceived pregnancy, while the woman or person with a uterus is accountable for everything that happens before.

The second person address, although meant to be informal and accessible, also sometimes lends itself to a disciplinary tone, as in this quote on progesterone only pills at UMO.se: “You have a low risk of pregnancy if you take the pills as you are supposed to”. Another issue is that the disembodied discourse is not necessarily gender-neutral or inclusive; for example the assumption that a person in need of a hormonal contraceptive has traditionally female anatomy, periods and hormonal fluctuations, all of which vary along the transgender spectrum. It’s not possible to discern, for example, which contraceptives could be used during testosterone treatment, information that could benefit transgender readers.

One could argue that these medical information websites are not the place for addressing power imbalances in society, but that would suggest it’s possible to disconnect medicine from society and ignore how biomedicalization functions as a both normative and transformative force (Clarke et al., 2003). Female contraceptive responsibility is still there in the texts despite the word “woman” being removed, only harder to pinpoint and critique. A parallel can be drawn to the post-feminist sensibility of how all choices are made out to be unconstrained by gender inequalities in a free market, rendering critique at a structural level difficult. Making gender invisible can be progressive and transinclusive, but it also comes at the risk of obscuring power imbalances. In other words, the biological narrative has emancipatory potential, but might also enforce gendered responsibilities. The consequences of reproduction are not gender-neutral, but exist in a context of intersecting power dimensions within which gender and gendered expectations are central and have real-life impact (Ross & Solinger, 2017). What happens in these texts is that women are made discursively invisible, while at the same time being constructed as individually responsible for reproduction.

The Invisible, Responsible Woman in Control of Her Reproduction

These informative contraceptive texts are part of a medical infrastructure that facilitates reproductive control and equality. Accessible information is imperative to enable autonomy in contraceptive choices and effective pregnancy prevention, such as that offered, for example by hormonal methods, are fundamental to achieve reproductive justice. Acknowledging the essential right to effective contraceptives and their positive impacts does not mean, however, that the aims and culture within which this field of medicine operates should go unexamined.

The analysis of reproductive discourses in these online texts has yielded three interwoven themes and conclusions: 1) women in need of contraceptives have to balance the discourses of exogenous hormones as both an “unnatural” threat to their bodies and as a desirable, effective regulator of the same “naturally unruly” body; 2) that in search of a “perfect contraceptive fit”, it is the woman who needs to accommodate to available methods, rather than the other way around; and 3) women are made discursively invisible, while at the same time being constructed as individually responsible for reproduction.

Underpinning all these themes is the discourse of the rational woman making responsible choices, of exerting agency by choosing the right contraceptive. These texts present contraceptive choices as plentiful and possible to individualize, while emphasizing safety and convenience and down-playing the side-effects of effective, hormonal methods. The interest in well planned, less risky pregnancies, that the medical community and state advocate, can be traced throughout this contraceptive advice.

Finding a “contraceptive fit” is a moral and gendered health practice demanding self-surveillance, but marketed as a form of self-expression (Wigginton et al., 2015). A “suitable” contraceptive suits a women’s lifestyle as well as prevents pregnancy. The female body is especially “at risk” within the gendered health prerogative of biomedicalization, for unplanned pregnancy, unwanted bleeding or mood effects, but the risk could be remedied by suitable choices, discipline, and self-surveillance (Moore, 2010). A situation of uncertainty, of doubt regarding whether to become a parent or whether to have sex, becomes discursively impossible, and what is more; forgetfulness, lust and lack of self-discipline that could lead to unplanned pregnancies becomes an individual failure. The most telling example might be birth control apps that require rigorous self-surveillance, but still might “fail” since the (female) body is unpredictable.

The disembodied, rational medical discourse in the material also obscures other, embodied narratives of contraception, such as pain and bleeding, or the “messy” relational driving forces and gendered expectations. Self-discipline and emotional labour in sexual and emotional relationships is expected to a much higher degree from girls and women, as the desirable heterosexual female subject is both available for sex and responsible for preventing any unwanted effects such as pregnancies (Gill, 2007). My material also shows how the ideal is that sex should be spontaneous, but pregnancy planned. The gendered power relations and expectations, both in intimate relationships and as a part of a biomedicalized society, are all concealed when choice of contraceptive becomes a seemingly easy shopping experience for a genderless person. Contradictorily, the rational woman exercising control over her reproduction and body, by planning her pregnancy with safe contraceptives, emerges as the only possible position. That this subject has been described as “white and middle class by default” (Tasker & Negra, 2007) further highlights the narrow repertoire of desired positions.

The goal of providing different contraceptives within a system apt to meet diverse reproductive needs constant effort. Readily available information on contraceptives is one important part, but also recognizing that women’s and fertile person’s reproductive choices are made amid a societal context, with differing personal resources and embodied experiences, would bring us even closer to reproductive justice.

Acknowledgments

I could not have written this paper without the unwavering support and ever helpful input from my supervisors at Lund University, Professor Juan Merlo and Professor Diana Mulinari. I would also like to thank Professor Isabel Goicolea at Umeå University for her insightful and generous comments.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by The Swedish Research Council (Vetenskapsradet) under Grant number [2017-01321].

Notes on contributors

Sofia Zettermark

Sofia Zettermark is an MD and PhD student in social medicine at Lund University, with a background in both gender studies and medicine. She is currently specialising as a primary care physisian. Her interdisciplinary thesis project, of which this article is a part, explore hormonal contraceptives and psychological health from different perspectives. She is driven by a wish to understand reproductive discourses and how hormonal contraception affect us: our bodies, relationships and society.