Abstract
The future of hormonal contraceptives in the United States is uncertain. Some theorize that framing used around gender-affirming care in the 2023 legislative session—including arguments that it contributes to a growing mental health crisis among young people and that off-label use is backed by low-quality evidence and akin to experimentation—will be used to generate moral panic and fuel legislative action to restrict hormonal contraception. Meanwhile, abortion advocates caution that some prominent antiabortion activist groups categorize all hormonal contraceptives as abortifacients and would seek to ban them by the same laws that ban surgical or medication abortion.
These concerns about restrictions on contraception are not purely hypothetical. The Supreme Court has been willing to recognize some types of contraceptives as abortifacients for purposes of avoiding a federal mandate of contraceptive coverage since Burwell v. Hobby Lobby Stores, Inc., Justice Thomas's concurrence in Dobbs v. Jackson Women's Health Organization specifically called out Griswold v. Connecticut, which, along with Eisenstadt v. Baird, paved the way for access to contraceptives without government interference, as a case the Court should reconsider. A handful of conservative politicians have enthusiastically echoed his position. Legal attacks on Title X family planning services threaten continued access to contraception for minors. Many crisis pregnancy care centers, a popular funding target of many conservative legislatures, refuse to prescribe contraception if they provide any medical care at all. And federal legislative efforts to enshrine access to contraceptives into law, such as the Right to Contraception Act, have, to date, failed.
Though certainly cause for increased vigilance, whether broader concerns about the continued availability of all forms of hormonal contraception will come to pass is, at present, unknowable. However, ongoing dialogue about contraception on social media provides a glimpse into public sentiment about available options in the cohorts most directly impacted. 1 Research in this space underscores three key takeaways about the present and future of contraceptive access.
First, pregnancy prevention is not always a patient's only priority—nor should it have to be. For example, patients may value avoiding synthetic hormones for a variety of personal reasons, ranging from a desire to be “more natural” to concerns about side effects. 2 However, social media may also fuel “hormonophobia,” or negative framing and scaremongering about hormonal contraception. 3 This phobia is largely driven by personal experience rather than scientific evidence. 4 Fear may ultimately lead to reduced use. Unfortunately, scientific nuance does not always come across on social media. Objectively, all contraceptive options—be they hormonal or nonhormonal—come with risks and benefits. However, content creators tend to underscore the risks of hormonal options while minimizing the risks and overemphasizing the benefits of nonhormonal options. 5 Factual claims are regularly made without substantiation, and waving around the unfolded FDA package insert for prescription hormonal contraceptives is a common shorthand for “this product is dangerous” by virtue of the fact that the paper is very large, and the font is very small. 4
Second, patients may feel the need to “do their own research” because they do not trust physicians to have honest conversations about nonhormonal contraceptive options. Our research has shown that content creators often frame provider interactions negatively. 4 Many indicate feeling ignored or upset after medical appointments, insufficiently informed about contraceptive options, and pressured to use hormonal contraceptives. This finding aligns with previous social media research 6 and among the general population. 7 As a result, clinician encounters may not be perceived as a reliable option for comprehensive, fact-based patient education, and individuals may instead choose to seek information about hormonal contraception from user-generated content.
Third and finally, the population-level risks of social media-driven contraceptive messaging are not uniformly shared. Misinformation and disinformation about hormonal contraception can profoundly affect health disparities and medical mistrust among historically marginalized groups. Social media content that discourages hormonal contraception and negatively portrays interactions with providers and reproductive health professionals 1,4 may exacerbate existing disparities. Women of color disproportionately show concern about contraceptive side effects. 8 Given the rise in contraceptive content that negatively frames provider interactions and highlights negative side effects, social media may fuel additional medical mistrust, leading to decreased utilization of hormonal contraception and gynecological services among marginalized groups. This may contribute to unintended pregnancy and delayed care, further widening health disparities and hindering progress toward equitable reproductive health outcomes.
A growing body of literature exploring social media messaging around contraception highlights what patients may be experiencing and thinking and what they will find if they turn to sources of information beyond the clinic. 9 Providers should consider these findings to inform patient care and work toward meaningful informed consent that contextualizes risks and benefits. To this end, clinicians must be prepared to provide comprehensive and inclusive reproductive care and engage in shared decision-making when given the opportunity. This necessarily includes affording time and attention to a full spectrum of hormonal and nonhormonal contraceptive options, even if a particular option falls outside a provider's prescribing preferences.
If patients do not receive what they perceive to be trustworthy and complete information in the clinic, they will look elsewhere. What they find when they seek alternative forms of reproductive health education on social media may contribute to increased rates of unintended pregnancy. Worse, it may help foment the conditions necessary to build the type of widespread social backlash to hormonal contraceptives about which those on the frontlines of reproductive rights advocacy are actively raising the alarm. At the very least, it may generate apathy about the importance of hormonal contraceptives, which may stifle the political momentum necessary to counter any legislative efforts to limit access.
We have not reached the limits of retrenchments in reproductive autonomy that gained momentum in the wake of the Supreme Court's decision in Dobbs. Understanding how those most impacted by restrictions currently view contraception and reproductive care helps ground those hypothetical risks in reality. Studying how social media users and influencers frame these topics is critical to developing strategies to counter this content's broader effects. Social media may be influencing the contraceptive debate, but it does not have to control the narrative.