Taking matters into our own hands? Hierarchies of power and knowledge in online framings of IUD self-removal

Abstract

This article examines how intrauterine device (IUD) self-removal is framed in online sources containing the views of contraceptive providers. While research has explored power and knowledge hierarchies in clinical interactions between contraceptive users and providers, and has highlighted the safety of IUD self-removal, little is known about how self-removal is represented by providers in accessible online sources that may be relied upon by contraceptive users for information. A discourse analysis of 42 provider-generated online sources found that provider authority over contraception is reinforced through biomedical constructions of risk and safety in framings of self-removal. The data reveal how the sharing of self-removal experiences between IUD users via online platforms was perceived to threaten contraceptive provider expertise, resulting in the dismissal of users’ experiential knowledge. While some sources were supportive, the framings of self-removal discussed in this paper typically mirror the unequal power relations of in-person contraceptive user/provider interactions. The sources analysed therefore demonstrate how power and knowledge hierarchies are reproduced and extend beyond clinical interactions to the digital context, reflecting broader socio-structural controls over bodies, knowledge, and reproductive decision-making.

Keywords:

• IUD self-removal
• contraception
• knowledge
• online health information
• discourse analysis

Introduction

IUDs are a form of long-acting reversible contraception (LARC) that are at least 99% effective at preventing pregnancy (Centres for Disease Control and Prevention (CDC) 2016). The IUD is inserted through the vagina and placed in the uterus, typically during an appointment with a contraceptive provider, and can be used for 3-10 years depending on the type (CDC 2016). Provider removal often involves using a speculum to visualise the cervix and IUD strings, and the use of an instrument to grasp the strings and facilitate removal; however, IUD users may be able to grasp the strings and remove the IUD themselves, a decision that may be influenced by various barriers to accessing appointments (Amico et al. 2020), and at times experiences of coercion (Amico et al. 2016, 2017; Higgins, Kramer and Ryder 2016). In this article, I explore framings of IUD self-removal found in online sources authored by, or featuring quotes from, healthcare workers. As media texts, these sources are intended to communicate ideas to an imagined audience of contraceptive users to whom web searches are a key method for seeking health information (Cardin 2020).

Opportunities exist for both healthcare workers and individuals to access and generate health information online (Maslen and Lupton 2019), including about sexual and reproductive health (SRH) (Jiang and Ha 2020). Online health information is easily accessible and can be used for different reasons, such as an initial source before speaking to a healthcare worker or to complement their opinions (Jacobs, Amuta and Jeon 2017; Madden et al. 2016). Such interactions may align with notions of patient consumerism whereby people (are expected to) take responsibility for sourcing information to enhance their knowledge and engage in preventive health behaviours (Lupton 2013). Peer-generated content can fill knowledge gaps from lived experience (Cameron 2023) as interactions with the features of digital platforms may facilitate, generate, and mediate knowledge through the sharing of experiences. At the same time, commenting on content may enable mutual learning and support, the forging of connections, and possibilities for agency (Maslen and Lupton 2019). Such processes are significant in contexts where healthcare workers lack time to fully engage with patients (Maslen and Lupton 2019), particularly for marginalised communities who experience silencing and oppression in mainstream healthcare (Pearce 2018). For some, digital platforms may therefore operate as a ‘subaltern counterpublic’ (Fraser 1990) where their knowledge can be re-evaluated as credible, enabling a form of resistance to practitioner-led care and authoritative discourse (Maslen and Lupton 2019). However, healthcare workers have expressed ambivalence towards online health information due to concerns over accuracy and have questioned the extent of patient empowerment (Gressel et al. 2014; Maslen and Lupton 2019). Indeed, one study examining online IUD information found accuracy to be variable (Madden et al. 2016) which may heighten contraceptive providers’ concerns while also causing scepticism among information seekers, leading them to prefer provider information or provider-generated online content.

Contextualising IUD use: contradictions of control and epistemological struggles

The clinical but also resource effectiveness of IUDs has garnered praise from policymakers, contraceptive providers, and other professional bodies, while the efficacy, ease of use after initiation, and long duration of effectiveness may be appealing to users, as well as the sense of autonomy this method can afford (Higgins 2014). However, increased autonomy is not without its contradictions (Higgins 2014). IUD users often remain reliant upon health providers for insertion, removal and monitoring (Lowe and Rowlands 2022), and as advocates for reproductive justice have argued, intersecting systems of colonialism, racial capitalism, ableism, and cis-heteropatriarchy at the root of Western healthcare limit reproductive freedom (Ross and Solinger, 2017). These systems of power constitute moral/political economies that construct whose and what reproductive decisions are valued and encouraged, and whose are devalued and restricted (Saunders 2021), evidenced by long histories of unethical and coercive practices by contraceptive providers (Price 2010).

Injustices continue to shape contraceptive experiences when women and marginalised people are pressured to accept or targeted for LARC methods through public health interventions or tiered-effectiveness counselling, and have requests for removal denied by contraceptive providers (Amico et al. 2016, 2017; Brandi and Fuentes 2020; Higgins, Kramer and Ryder 2016; Manzer and Bell 2021, 2022). While effectiveness and ‘forgettability’ may be given as reasons by providers for the promotion of, and refusal to remove LARCs, such decisions cannot be separated from constructions of appropriate/inappropriate reproduction and the control exerted over contraceptive use (Gomez, Fuentes and Allina 2014).

Contraceptive provider control over contraception can be situated within the broader emergence and later dominance of medicalised obstetrics and gynaecology which led to the systematic exploitation and surveillance of bodies, and the subordination of local and experiential knowledge and its dissemination between communities; for example, the devaluing of traditional midwives’ knowledge and its superseding by biomedical knowledge (Ross and Solinger 2017). For Foucault (1975), the power of medical knowledge affects how bodies, health, and illness are understood and managed as the biomedical takes precedence and ‘transforms social issues into diseases’ (Lupton 1997, 99). Biomedical truth claims are rooted in positivist notions of standardisation and objectivity accessible through the study of institutionalised medicine, which aids in foregrounding this knowledge as authoritative and prestigious (Rose 2007).

Biomedical knowledge is considered distinct from and superior to the experiential knowledge held by people, which is often dismissed on the grounds of being subjective and not ‘fitting’ within medical paradigms, particularly for women and marginalised groups (Davis 2019a; Lupton 1997). Feminist scholarship has traced how biomedicine has objectified and pathologised women’s bodies, particularly in relation to menstruation, pregnancy, and menopause (Grosz 1994; Price and Shildrick 1999). This informs a broader socio-cultural stigmatisation that constructs women as not trusted to know or have control over their bodies (Berndt and Bell 2021), and therefore corporeal regulation is expected in compliance with medical authority (Lowe 2005). However, despite its subordination, experiential knowledge is often considered crucial to health decision-making, offering relational and embodied understandings that may add to, or challenge, more medicalised perspectives (Davis 2007).

A Foucauldian lens allows for an understanding of knowledge hierarchies during interactions in clinical contexts (Lupton 1997), including those between contraceptive providers and users (Berndt and Bell 2021). Qualitative research with providers in the USA has shown how users’ experiential knowledge of contraceptive side-effects such as pain, heavy or irregular bleeding, mood changes, and weight gain are regularly dismissed by providers (Berndt and Bell 2021; Higgins, Kramer and Ryder 2016; Mann, Chen and Johnson 2022). The minimising and individualising of users’ experiences contributes to their construction as passive and their role as knowledge producers not to be trusted (Davis 2007). Even when claiming to support users’ active participation in their own care, studies have shown that health providers consider it a fulfilling aspect of their job to encourage acceptance of biomedical knowledge which is believed to be ‘truer’, and express frustration when their advice is not followed perceiving this as distrust in medical expertise (Berndt and Bell 2021; Mann, Chen and Johnson 2022). Prioritising the biomedical and its apparent objectivity limits the possibility of centring users’ autonomy and recognising the complexity of their needs, potentially heightening feelings of distrust and leading to disengagement from care (Manzer and Bell 2021). Barriers to care that result from knowledge and power hierarchies, and material barriers of cost and accessibility, are important to consider when contraceptive users are removing their own IUDs.

IUD self-removal

Research exploring IUD self-removal is nascent and has predominately focused on the views of contraceptive users and providers in the USA. One study exploring hypothetical views on self-removal found that IUD users perceived it as potentially eliminating barriers to contraceptive provider removal but remained uncertain about possible complications (Amico et al. 2018). While there may be concerns related to self-removal such as partial expulsion, incomplete removal, or rare instances when the IUD fractures or becomes embedded in the uterus (Cartwright et al. 2022), these are complications that can also occur during routine IUD use or provider removal (Amico 2023). Indeed, when given the opportunity to self-remove in a clinical setting Foster et al. (2014) found that while only 1 in 5 participants could self-remove, no complications arose for the 190 users who attempted to do so, and those who were successful¹ reported decreased pain in comparison to provider removal.

Regarding providers’ views, Amico et al. (2018) found self-removal was not considered unsafe by providers, but some expressed concern about being ‘out of the loop’ in contraceptive decision-making. Resonating with these findings, a recent study (Amico 2023) showed that while providers were broadly supportive of and described counselling for self-removal, this was only in particular circumstances (e.g. if users were planning to travel, or were concerned about returning for removal, or not being able to discontinue use themselves). SRH organisations in the USA such as the Society of Family Planning (see Glaser et al. 2021), the Reproductive Health Access Project (RHAP), and Partners in Contraceptive Choice and Knowledge (PICCK), have also emphasised the safety of self-removal in response to COVID-19 lockdowns, and more broadly in circumstances where access to healthcare is limited or denied. This support is reflected in survey data collected from providers across the USA demonstrating the prevalence of, or increase in, counselling for self-removal during the first year of the pandemic (Fay, Traore and Amico 2023; Weigel et al. 2020), and evidenced by the creation of online self-removal guides by some organisations (PICCK 2022; RHAP 2021). Despite research highlighting the safety of self-removal and support amongst some providers, opposition remains, along with narrow views of motivations for self-removal in which it is suggested users ‘impulsively’ remove IUDs (Manzer and Bell 2022). In the UK, the Faculty of Sexual and Reproductive Health (2023) advises against self-removal recommending that providers will ensure correct removal, and minimise the risk of complications, trauma and unintended pregnancy. In contrast, Manzer and Bell (2022) argue that failure to inform contraceptive users about self-removal and its safety is antithetical to the principles of patient-centred care and entrenches provider control over contraception.

Research has also found that some IUD users have shared self-removal experiences via online platforms. Amico et al. (2020) and Broussard and Becker (2021) analysed IUD users’ motivations for self-removal as described in Internet forum posts and YouTube videos respectively, finding broadly similar reasons from their analysis: the impact of negative side-effects and difficulties accessing provider-removal due to cost or lack of appointments. Users have been found to feel supported by the visibility of self-removal experiences online (Stimmel et al. 2022), with high levels of engagement and comments on videos said to suggest reassurance and gratitude for the information shared (Broussard and Becker 2021). Regarding complications, only four of the 1742 forum posts analysed by Stimmel et al. (2022) described inability to self-remove due to pain, bleeding, or resistance with no other complications stated, and in some posts, users reported being informed by providers that self-removal was safe even though they would not recommend it.

Methods

Not dissimilar to the approach that may be taken by those seeking self-removal information online, a search was undertaken on Google between July and September 2021 using the keywords in Table 1. To be included, sources had to discuss IUD self-removal (sources only discussing provider removal were excluded) and be written in English, although no geographical limits were applied to the searches. Forty-two sources published from 2014-2021 were then selected for analysis (see Table 2 for those referred to in this paper). Criteria were not set for authorship, but sources analysed were either written from a clinical perspective, by a clinician or quoting a clinician, and pieces written by contraceptive users were excluded. Many of these latter pieces resembled blog entries on more personal platforms, and the decision was made to exclude them due to not having consent from contraceptive users who hold less power than clinicians or journalists publishing highly visible and accessible online articles. The analysis therefore focuses on framings that reflect ‘common-sense’ medicalised knowledge as opposed to the experiential knowledge of users.

Table 1. Search terms used.

Terms used
IUD/Coil self-removal
Removing IUD/coil by myself
Taking out my own IUD/coil
How to remove your IUD/coil at home
Remove/ing IUD/coil at home
Can you remove IUD/coil yourself
IUD/coil DIY removal
Contraceptive coil DIY removal
DIY IUD/coil removal

Table 2. List of sources on IUD self-removal referred to in this paper.

Title	URL
Everything You Need to Know Before You Try to Remove Your IUD at Home	https://www.healthline.com/health/birth-control/iud-removal-at-home
Contraceptive Pearls: IUD Self-Removal	https://www.reproductiveaccess.org/resource/contraceptive-pearls-iud-self-removal/
Can You Remove an IUD on Your Own?	https://www.webmd.com/sex/birth-control/features/iud-remove
Don’t remove your own IUD. Please.	https://www.kevinmd.com/2016/07/dont-remove-iud-please.html
Planned Parenthood: How does IUD removal work?	https://www.plannedparenthood.org/learn/birth-control/iud/how-does-iud-removal-work
Should you remove your own IUD?	https://www.bedsider.org/features/958-should-you-remove-your-own-iud
No, You Should Absolutely Not Remove Your IUD At Home	https://www.self.com/story/remove-iud-at-home
Yes, You Can Remove Your Own IUD, But You Probably Shouldn’t	https://lifehacker.com/you-can-remove-your-own-iud-but-you-probably-shouldnt-1847165056
What to Expect During Your IUD Removal	https://www.verywellhealth.com/what-to-expect-during-an-iud-removal-906771
7 things to know before getting your IUD removed	https://www.insider.com/getting-iud-removed-tips-things-to-know-2018-6#your-medical-provider-should-always-remove-your-iud-this-is-no-time-for-diy-5
IUDs, Types, Side Effects, and Effectiveness	https://www.emedicinehealth.com/birth_control_intrauterine_devices_iuds/article_em.htm
IUD pros and cons	https://allbodies.com/health/birth-control-options/iud-pros-and-cons/
Viral TikTok video of IUD removal at home prompts warning from health authorities	https://www.theguardian.com/society/2021/sep/24/viral-tiktok-video-of-iud-removal-at-home-prompts-warning-from-health-authorities
What Doctors Want You To Know If Your IUD Expiration Is Coming Up	https://www.bustle.com/wellness/getting-iud-replaced-doctors

Discourse analysis was used to examine how the language in online sources reproduces, creates, and sustains power relations (Foucault 1972). Discourse analysis is concerned with understanding how certain ideas, meanings, and actions are take for granted and accepted as ‘common-sense’; that is, how these circulate socially and culturally to become dominant, resulting in the exclusion or ‘subjugation’ (Foucault 1980) of alternatives. The analysis therefore aimed to explore what is taken for granted and who (or what systems and institutions) benefit from ‘common-sense’ biomedical framings of self-removal. In this study, I initially read each source, then copied it into a Word document and uploaded to NVivo 12 for coding, noting words and phrases used to describe self-removal, self-removers, healthcare workers, and contraception more generally. Analysis proceeded iteratively, rereading sources multiple times and looking for patterns in language within and across sources to consider how meanings and representations operate, and their connection to social structures and certain forms of knowledge. The analysis that follows does not make claims to generalisability but is potentially indicative of the broader socio-cultural mediation of IUD self-removal representations.

Findings

Medicalising IUD removal

IUD removal was presented in online sources as a distinctly medical practice. This was done by framing removal as an otherwise straightforward procedure that involves pulling on the strings attached to the bottom of the device, but one that should only be carried out by contraceptive providers:

You should never try to remove an IUD… A health-care professional usually can remove an IUD very simply by carefully pulling the string ends at a certain angle.

(Stoppler, emedicine health, 2020)

Little strings hang down through the cervix into the vagina, which is a helpful way to check that your IUD’s not falling out, but they also make it quite easy to take out—for a medical professional. That’s the only person who should be taking out your IUD, ob/gyn Sherry Ross, M.D., tells SELF…’It was put in by with someone with expertise…Someone taking it out should have the same expertise’. (Barnes, Self, 2016)

The simplicity of removal is noted, but extended only to providers who possess ‘correct’ knowledge of how to remove IUDs, echoing in-person interactions where providers consider their knowledge as ‘truer’ than users’ (Berndt and Bell 2021; Mann, Chen and Johnson 2022). Reflective of Foucauldian perspectives on the power and control exerted by biomedical knowledge, the skills learned from the study and practice of institutionalised medicine legitimise the management of contraception and the bodies of contraceptive users, which providers are considered to hold expert knowledge of. As one article put it, ‘Your OB-GYN is a skilled and trained professional who knows a lot about the particulars of your uterus’ (Jitchotvisut, Insider, 2018).

Sources that framed self-removal more positively also began by situating it within provider removal:

IUD removal is usually easy-freaking-peasy. Typically, a healthcare provider just pulls on the string that hangs from the device, the ‘T’ arms fold in, and the little bugger comes out. Given that, you may be wondering if it’s OK to remove the device on your own at home. The short answer: It’s best to have your IUD removed by a healthcare provider. As Kimberly Langdon, an OB-GYN puts it, ‘IUD removal is a medical procedure.’ But if that’s not feasible, at-home removal can be an option. (Kassel, Healthline, 2020)

Here, colloquial language is used to create a casual tone, and in the final sentence self-removal is presented as a valid option when provider removal is not accessible. IUD removal is framed in a more relatable way and is shifted from the gatekept sphere of institutionalised medicine to the everyday, despite provider removal being recommended as a first-line option. The legitimacy of self-removal is then demonstrated in the remainder of the Healthline piece through the inclusion of step-by-step guidance on how to self-remove. This advice is written primarily by a journalist (whose work was medically reviewed), with quotes from doctors interspersed throughout: ‘Ready to go fishing? Slide one finger into your vagina and see if you can feel the string. ‘The string is very, very thin’, Langdon says. So don’t be discouraged if it takes you a minute to locate’. A more relatable framing is brought together with the biomedical knowledge of a healthcare worker, which aids in giving ‘credibility’ to self-removal. However, research has shown that providers perceive the informal tone of some online contraceptive information to be ‘unprofessional’ and ‘incongruent with counselling styles’ (Gressel et al. 2014), implying this is not legitimate knowledge.

Perceived motivations for self-removal

Resonating with Foucauldian understandings of the power of medical knowledge, the biomedical was also privileged in the sources analysed when considering motivations for self-removal and constructions of risk and safety. Sources opposing self-removal recognised some reasons that may lead IUD users to self-remove; however, the often-complex barriers to provider removal and how these may be experienced, are not fully acknowledged:

If cost or long waiting times for an appointment are the reasons you’re Googling ‘remove IUD at home’, Ross suggests going to a Planned Parenthood or a similar clinic. Depending on your financial and health insurance situations, they may discount the removal price or be able to work out a payment plan you find doable (or even offer it for free!). (Barnes, Self, 2016)

Financial and time constraints may prevent or be incurred by attending appointments even if offered at a lower cost, and challenging interactions with providers, along with the stigma experienced in medical settings (Berndt and Bell 2021; Davis 2019b), may make provider removal inaccessible and unsafe for some. In the sources analysed, decisions to self-remove were also framed narrowly and as individually motivated:

Even though it may be tempting, you should never try to remove your IUD by yourself. (Stacey, Verywell Health, 2021)

You can have an IUD removed any time with a quick visit to a healthcare provider. But what if you want to try taking out that little T on your own?… Why bother visiting a healthcare provider? ‘If your provider can’t see you right away, there are still options’, says Dominguez (Certified Nurse Practitioner). If you’re not having complications but just aren’t happy with the IUD and want it out ASAP, you can try getting in touch with local clinics or urgent care centres to see if there are providers available who can fit you in on short notice. (Bedsider, 2016)

Here, self-removal is framed as individually chosen: a tempting choice for those who can feel the IUD strings and want to save time. The question posed as to why users should ‘bother’ attending appointments implies there is a lack of awareness regarding the benefits of provider removal, obscuring the complexity of decision-making and barriers to appointments and clinical interactions. The advice to attend an urgent care or local clinic implies care preferences are not important, thereby minimising the needs of contraceptive users for whom accessing any available care may not be convenient or safe.

The excerpts also reflect provider perceptions of contraceptive users as ‘difficult’ and ‘noncompliant’. As a result, not following provider guidance is framed as an individual problem, as opposed to being the consequence of a structural barrier to care and contraceptive use (Mann, Chen and Johnson 2022; Morison 2023). These individualised framings reflect neoliberal conceptualisations of choice and subjectivity evident in providers’ understandings of contraceptive decisions during in-person consultations (Manzer and Bell 2022; Morison 2023).

In other sources, barriers to provider removal are framed in a more relational and empathetic way:

IUDs are typically removed by clinicians… There can be numerous barriers to this arrangement such as difficulty scheduling an appointment, concern about cost, and clinician refusal of patient’s request for removal. Unsurprisingly, these barriers can raise patients’ concerns about ability to retain control over their own reproductive health. Additionally, patients may hesitate to choose a contraceptive option that requires not one, but two pelvic exams. (RHAP, 2020)

The insertion and removal process can be physically uncomfortable and potentially triggering. (Mandrachio, All Bodies, n.d.)

It’s possible to get your IUD removed for free or low cost, and by an affirming provider. And that stands even if your IUD insertion was costly or done by a provider who was not (ugh—sorry, loves) affirming. That said, if getting to a provider isn’t possible because you can’t afford the removal or childcare for when you’re at the appointment, or some other reason, there are safe and less safe ways to remove the IUD at home. (Kassel, Healthline, 2020)

In the above, IUD removal is situated as a medical practice, but there is recognition of social, structural, emotional and physical barriers as valid motivations for self-removal. These framings differ from narrow and individualised framings, with provider and self-removal both presented as legitimate options.

Constructing risk and safety

In the sources analysed, self-removal was typically framed as a risky practice that could result in severe physical complications, reflecting the privileging of biomedical understandings of risk over experiential contraceptive knowledge (Berndt and Bell 2021):

[T]here’s a chance you could hurt yourself if you try to take your own IUD out.

(Planned Parenthood, n.d.)

There’s a lot of potential for serious injury if you can’t see what you’re doing (obviously) and aren’t trained in removal. (Thorpe, Bustle, 2015)

‘I would discourage self-removal of IUDs for safety reasons’, Sherry Ross M.D. says, citing possible pain or infection if you cut or scratch your vagina in the process of grabbing on to the IUD or yanking it out. ‘It’s a little Cirque de Soleil if you’re doing it yourself’. (Barnes, Self, 2016)

In the above accounts, self-removal is cautioned against and risk is emphasised– risk that could be avoided by attending a removal appointment. IUD users’ embodied knowledge is dismissed, particularly in the final excerpt when suggesting users do not know how, and cannot be trusted to, self-remove (‘yanking’ ‘Cirque de Soleil’). Studies exploring in-person contraceptive counselling have identified similar themes in which providers dismiss the experience and severity of side-effects as risky and unsafe to users, and prioritise contraceptive efficacy and pregnancy prevention (Berndt and Bell 2021; Morison 2023).

In other sources, consideration is given to risks and complications that may arise when removal is performed by providers:

‘There is a risk, but it’s the same whether a clinician removes it or a woman removes it’, Foster says, noting that the main risk is a drop in blood pressure in response to having your cervix touched. ‘The same can happen during intercourse or a pelvic exam’,. ‘It’s rare and doesn’t change whether the woman is doing it or a clinician’. (Morgan, WebMD, 2020)

In the above excerpt, which draws on quotes from self-removal researcher Diana Greene Foster, risk is presented as related to the practice of removal itself as opposed to who is carrying it out, the knowledge they possess, and where this is positioned in an epistemological hierarchy.

Denying users’ expertise

So far, it has been shown how biomedical epistemology shapes understandings of IUD use, removal, and conceptions of safety in online sources. I now show how the sharing of self-removal knowledge on online platforms was framed as a threat to provider knowledge and expertise.

Dismissing self-removal and shared knowledge practices

Research exploring IUD users’ posts about self-removal on Internet forums and YouTube has noted a sense of reassurance and gratitude for the sharing of these experiences (Amico et al. 2020; Broussard and Becker 2021). In contrast, the sharing self-removal experiences online was often framed disparagingly in the sources analysed:

Removing one’s own IUD is apparently ‘a thing’. There are even YouTube videos of women sharing their experiences. If you can get a medical degree from Google then why not get your OB/GYN residency from YouTube? (Gunter, KevinMD.com, 2016)

Family Planning Victoria CEO, Claire Vissenga, said she found it very concerning that ‘DIY could pass as healthcare’. (Cassidy, Guardian, 2021)

[D]on’t try to remove it yourself, no matter what you read on the Internet about how ‘easy’ it is. (Thorpe, Bustle, 2015)

In the above, echoing the narrow framings of motivations and conceptions of safety, self-removal is presented as an Internet-generated fad not to be taken seriously. A condescending tone is apparent when suspicion is raised not only over self-removal, but also when users sharing self-removal experiences online are discredited and dismissed. In excerpts one and two there is a sense of concern and frustration with self-removal experiences being shared online, which appears to be interpreted as a threat to medical expertise from contraceptive users who are depicted as purposively discarding biomedical knowledge. This resonates with existing research that shows while healthcare workers may claim to support patient-centred care, they also frequently raise concerns about the challenge to medical authority arising from individuals being involved in their own care and decision-making (Berndt and Bell 2021; Mann, Chen and Johnson 2022; Manzer and Bell 2022; Morison 2023).

Distancing IUD removal from the everyday

Emphasising the need for biomedical knowledge was one way in which removal has been medicalised, and a similar approach is adopted to distance self-removal from the everyday practices and experiential knowledge of contraceptive users. In some accounts, such distancing was made apparent through reference to the specific skills and medical equipment typically required to perform removal:

[G]et it removed by a proper gynaecologist, who has all kinds of little tricks to make sure it comes out safely, including an internal camera, cytobrushes, and IUD hooks (don’t check pictures of those if you’re squeamish). (Thorpe, Bustle, 2015)

Pulling an IUD out, when you know what you are doing, is not rocket science. It is technically a very easy medical procedure. Most of the time. A speculum is inserted, and we look at the cervix, grasp the string with forceps, and pull…You need training to know how much to tug and when to stop. The more you have inserted and removed the more you know how much force you can use. Then there is the direction to pull. If you have never instrumented a uterus for any reason, and you don’t know what an acutely retroverted and retroflexed uterus (or acutely anteverted and anteflexed) means and how to tell if that’s the case you might not know sometimes you should angle ever so slightly in a certain way as you pull. (Gunter, KevinMD.com, 2016)

The appeal to medical skills, technology, and language in the above excerpts reinforces the idea that removal is not an everyday practice but a clinical one in which what is observable is given precedence. As argued by Freeman (2014), healthcare workers frequently assert dominance through access to and overreliance on the visual: they can see the cervix and the IUD and have access to tools and technology that bolster their knowledge and credibility. In instances of removal complications, visualisations and medical instruments may be necessary; yet, as discussed, successful self-removal is typically attributed to IUD string length, which indicates that medical ‘tricks and tools’, are not always needed.

In the sources analysed, guidance on the process of self-removal was often related to everyday practices or settings. This was evident in a step-by-step guide on how to self-remove, and in an article that was cautious about self-removal but compared the ease of provider removal with removing a tampon:

From a standing position, prop one of your feet on a tub ledge or toilet. Then ‘take a stance similar to the one you’d usually use to insert a tampon’, Langdon says.

(Kassel, Healthline, 2020)

When you get an IUD removed, your provider simply pulls on the strings, like removing a tampon. The IUD should come right out. (Skwarecki, Lifehacker, 2021)

Similar familiarisation strategies can be found in research on self-managed abortion (Broussard 2020) where experiences are likened to menstruation or miscarriage, creating a greater sense of control through relatability in the context of abortion stigmatisation and criminalisation. However, in the provider-generated sources analysed, self-removal familiarisation strategies were dismissed:

You don’t take out your own appendix. (Cassidy, Guardian, 2021)

Hearing that it’s like pulling out a tampon—and knowing that IUDs have little tampon-like strings attached—can make some people think they should literally take matters into their own hands. (Jitchotvisut, Insider, 2018)

It’s not like a tampon. (Thorpe, Bustle, 2015)

The familiarity that may come from descriptions of self-removal is rejected in each of these excerpts. Contraceptive users are condescended and their knowledge dismissed by the suggestion they are unaware of the difference between menstrual products and IUDs, and when equating removal with more invasive medical procedures. These discursive strategies have the effect of solidifying biomedical authority over contraception whilst repudiating the experiential knowledge and agency of contraceptive users.

Discussion

This analysis extends existing evidence on the unequal power relations and knowledge hierarchies in face-to-face contraceptive counselling to show how medical authority and its disempowering effects are reproduced in online spaces. Despite some examples of synergy between knowledge bases, a stark dichotomy is created between the biomedical knowledge of contraceptive providers and the experiential knowledge of IUD users regarding self-removal, reflecting Foucauldian conceptualisations of power and hierarchy. In the accounts above, biomedical knowledge is discursively safeguarded when framed as superior and authoritative, and through the individualising and disparaging of self-removal. Removal is presented as a simple and safe procedure only if the ‘remover’ possesses the ‘correct’ biomedical knowledge, skills, tools, and technology to carry it out.

Narrow understandings of motivations for self-removal and biomedical framings of risk and safety further normalise the medicalisation of contraceptive use and reinforce positivist underpinnings of biomedical knowledge as objective truth. Lack of critical attention to the barriers and intersecting oppressions that shape experiences of contraceptive care fails to consider the complexity of contraceptive use, and how provider removal may not fit with people’s lives or meet their needs. The online narratives of self-removers are absent from this paper meaning conclusions cannot be drawn about their motives or understandings of safety; however, reflections can be made on the broader context in which self-removal occurs as demonstrated by existing scholarship showing how user/provider interactions and coercive counselling can influence contraceptive decisions and disengagement from care. It is important to recognise multiple understandings of what constitutes safety and risk: for some, attending appointments and interacting with providers in a medical context can feel risky, as can having embodied experiences dismissed and requests for removal denied.

In the sources analysed, the sharing of self-removal experiences online was framed as a cause for concern and as minimising providers’ authority and expertise. The belittling of lived experience, familiarisation strategies, and overall dismissal of self-removal reinforces an epistemological hierarchy in which contraceptive knowledge is gatekept, and the knowledge generated and bonds of solidarity created when experiences are shared online are rejected, reflecting wider control and surveillance over bodies, knowledge, and reproductive decision-making. The sense of threat evident in some of the sources mentioned perhaps indicates how online self-removal accounts can pose a challenge to medical authority. Sharing and learning from experience is an important agential capacity and form of collective resistance to a lack of accessible and appropriate care, generated with and through the affordances of social media. Attempts to discredit self-removers in the sources analysed further denies their agency and allows biomedical power to reproduce itself in online spaces when the status quo is felt to be threatened.

Despite the dominance of biomedical representations, some sources did manage to frame self-removal more empathetically. This was often done by including the views of providers who emphasised IUD removal as requiring medical expertise in the first instance at least. In these accounts, biomedical and everyday understandings of IUD removal and self-removal were at times brought together, offering a more synergistic epistemic relationship. Echoing literature that demonstrates the potential of online spaces and health information as avenues for empowerment, and studies showing the support of service providers for self-removal, framings such as these can amplify users’ experiences and disrupt common-sense knowledge by offering alternatives to biomedical authority.

However, these framings were not the norm, and may have been influenced by the barriers to accessing LARC appointments resulting from COVID-19. Despite many sources with negative framings being published from 2015-2019, those published in 2021 when this research was carried out were also not supportive of self-removal. A brief search for more recent sources shows that many continue to reflect the disparaging tone and safeguarding of biomedical notions of risk and safety evident in the sample discussed in this paper. An illustrative example of this tendency can be seen in a headline from a UK tabloid newspaper: ‘Doctor warns never to try dangerous at-home IUD removal due to sepsis risk’ (Wroe 2023). In much the same way as in-person interactions, a struggle over meaning is evident here, and persists in online representations of self-removal.

In order to make informed decisions, contraceptive users must have access to a full range of options and appropriate information from a variety of sources. Future studies should engage with IUD users about their interest in self-removal and ways to relay information to potential users about self-removal as being an option, while also remaining attuned to discursive framings of self-removal in online health information and possible changes over time. Crucially, research is needed with IUD users to ensure their voices are heard on the care they wish to receive, and what they envision as best meeting their needs and protecting their autonomy, including the role that online information and support may play in this.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

No funding was received for this research.

Notes

1 In their study, Foster et al. (2014) found IUD string length contributed to successful self-removal (see also Malo et al. 2017).