Abstract
Almost half of pregnancies in the United States are unintended, despite the availability of highly effective forms of birth control. Women often cite side effects as a reason for stopping hormonal birth control, and most research on the topic comes from a medical perspective. In this study, I analyze hormonal contraceptive side effects from a social perspective that highlights the link between cultural messages about gender and women’s contraceptive behavior. Drawing on data from interviews with 88 women, I argue that the gendered emphasis on women’s appearance and emotionality shapes women’s perceptions about the seriousness of hormonal contraceptive side effects, like weight gain and emotional volatility, and their propensity to stop use as a result. Contrary to understandings of side effects as a purely medical aspect of use, the gender analysis elucidates the ways that particular side effects are imbued with social meaning that can undermine women’s goals to prevent pregnancy.
Introduction
While the advent of the birth control pill in the 1960s gave women greater control over their fertility, the unintended pregnancy rate in the United States remains high, despite the widespread use of “the pill” and other highly effective forms of hormonal birth control. Recent estimates show that 49 percent of pregnancies in the United States were unintended in 2006, a figure that is nearly unchanged from the 48 percent of pregnancies that were unintended in 2001 (Finer and Zolna 2011). While couples have several contraceptive options to choose from, “the pill” is the most widely used form of reversible birth control in the United States (Mosher and Jones 2010). Recent research suggests that women exercise great control over the use of the pill (and other hormonal methods), and couples commonly transition from using condoms to using solely hormonal methods in long-term relationships (Fennell 2011; Reed et al. 2011). Unlike the male condom that is worn externally, hormonal methods enter a woman’s body via some mechanism (e.g., ingestion or injection) to prevent pregnancy. Despite this difference, very little research examines the ways that hormonal methods like the pill influence women’s experiences of their bodies or how gender shapes these experiences.
A growing literature documents the centrality of negative experiences with side effects in women’s dissatisfaction with hormonal methods and consequent inconsistent use. Women often report mood changes, weight gain, and nausea (Brunner Huber et al. 2006; Rosenberg, Waugh, and Burnhill 1998), but reports of side effects can differ across methods. Regardless of the side effect experienced, many women cite dissatisfaction with side effects as the reason that they stopped using hormonal birth control, with reported percentages ranging from as low as 30 percent to as high as almost 60 percent (Littlejohn 2012; Westhoff et al. 2007). Further, in a nationally representative study of unmarried people ages 18-29, 36 percent of women who were concerned that the pill would cause weight gain, and 40 percent of those who thought it likely to cause severe mood swings, said that these potential side effects decreased their chances of using the pill (Kaye, Suellentrop, and Sloup 2010). 1 Recent qualitative research also suggests that women who report experiencing side effects are less likely to always use birth control consistently with their partners than are women who do not (Reed et al. 2011). Of course, not using birth control (or using it inconsistently) is a major factor contributing to pregnancy (Jones, Darroch, and Henshaw 2002; Santelli et al. 2007).
Drawing on rich data from in-depth interviews with 88 women from diverse racial and socioeconomic backgrounds, I show that cultural messages about gender shape women’s experiences with hormonal forms of birth control, and that the importance they place on certain side effects impairs their ability to prevent pregnancy. I suggest that researchers have tended to neglect hormonal contraceptive side effects (whether perceived or actually experienced), perhaps based on the perception that such experiences reflect a medical aspect of use, obscuring our understandings of the social aspects of pregnancy prevention and the ways that gender influences women’s contraceptive behavior. Using a gender lens that emphasizes cultural messages about women’s appearance and emotionality, I show how side effects like weight gain and emotional volatility are imbued with negative meaning that influence women’s decisions to stop using hormonal birth control despite their desire to prevent pregnancy. This gender analysis illuminates the ways that the use of methods that give women greater control over their fertility are also bounded by the traditional gender constraints placed on them.
Literature Review
Hormonal birth control is more than 99 percent effective at preventing pregnancy (Trussell 2011), but all hormonal methods pose risks of side effects. Hormonal birth control can cause mood changes (Creinin et al. 2008; Oinonen and Mazmanian 2002), nausea, headaches, and breast tenderness (Hatcher et al. 2008), among other side effects. While there is mixed evidence about the association between the types of hormonal contraception and weight changes, the evidence suggests that “the shot” does indeed cause weight gain (Beksinska et al. 2010; Berenson and Rahman 2009). Despite understandings of side effects as a medical aspect of hormonal birth control use, gender norms can play an important role in women’s understandings of weight gain and mood changes, two of the more commonly reported side effects.
Women (and, increasingly, men) face strong cultural pressure to have their appearance align with idealized cultural images. The idea that men and women should look a particular way is a central component of the social construction of the gendered body (Lorber and Martin 2011). In the United States, mainstream messages about female attractiveness emphasize thinness (and large breasts), with thin white women serving as the ideal beauty standard (Furnham, Dias, and McClelland 1998; Grogan 1999). These messages not only put pressure on women to meet an unrealistic standard but also devalue the bodies of women of color and larger women (Lovejoy 2001).
The unequal emphasis placed on women’s appearance and unrealistic beauty standards result in differences in how men and women think about their bodies and, I suggest, in the tolerance that women have for weight gain as a side effect of their hormonal birth control. Girls and women are more likely to be dissatisfied with their bodies (Bearman et al. 2006; Feingold and Mazzella 1998; Paxton et al. 1991), more concerned with weight (Phares, Steinberg, and Thompson 2004; Pliner, Chaiken, and Flett 1990), and more likely to have eating disorders like anorexia than are boys and men (American Psychiatric Association 1994). Moreover, while Black women tend to be more satisfied with their bodies than white women (Molloy and Herzberger 1998; Parker et al. 1995; Stevens, Kumanyika, and Keil 1994), they still evaluate thinner women as more attractive than larger women (Hebl and Heatherton 1998) and are still less satisfied with their bodies when they are overweight than are women who are not (Stevens, Kumanyika, and Keil 1994). The emphasis on thinness in the United States may explain why American women express concerns about weight gain as a side effect to hormonal birth control that women in contexts where thinness for women is not so highly valued (and may, in fact, be devalued) do not necessarily share. For example, while women in the United States say that they are less likely to use hormonal birth control because of fears of weight gain (Kaye, Suellentrop, and Sloup 2010), women in Egypt did not cite weight gain as a reason for stopping their hormonal method (despite gaining weight) (Hassan, El-Nahal, and El-Hussinie 1999), and women in Cambodia not only perceived weight gain as a positive side effect of hormonal birth control, but some actually stopped use because of weight loss (Sadana and Snow 1999). This literature suggests that while hormonal birth control methods may cause weight gain, the larger cultural scripts about the meaning of thinness can drive women’s interpretations of the weight changes that they attribute to their birth control.
Cultural messages about gender can also shape women’s perceptions of their emotions while using hormonal birth control, as they strive not only to navigate mood changes, but also to grapple with the negative meaning attached to the emotions that they experience. Depictions of women’s emotions as out of control and irrational compared to men’s have been key in the historical construction of feminine emotion (Shields 2007), which makes navigating emotional expression particularly tricky for women. Men have historically been seen as rational beings with the ability to control their emotions, but women’s emotion has been seen as “dangerously unregulated” (Shields 2007, 104). The construction of the premenstrual woman in contemporary times has served to only further such an understanding of women’s emotion. While the prototypical woman is seen as an inherently emotional being, the premenstrual woman is not only emotional but also angry, hormonal, and out of control (Chrisler and Caplan 2002; Figert 2005). The significance of the widespread recognition of premenstrual syndrome (PMS) lies not only in pathologizing women’s emotions around the menstrual cycle but also in the idea that even particular emotions for women when they are not “PMSing” are attributed to an irrational, premenstrual state (Figert 2005). Thus, while women are expected to be emotional, they simultaneously contend with constructions of feminine emotion as irrational, and with having emotions like anger deemed gender inappropriate. Given widespread knowledge of gender stereotypes of emotion, the larger cultural messages that communicate the appropriateness of the kind and degree of emotion that women should express likely influence women’s understandings of the mood changes that they experience while using hormonal birth control.
In this study, I build on previous scholarship by shedding light on the complex negotiations that women make in their daily lives as they strive to manage gendered expectations of their bodies and emotions. Although women’s body dissatisfaction is well documented, this analysis contributes to the literature by demonstrating how women’s experiences of their bodies are constrained by gender norms, even when weight gain results from a resource vital to achieving a central goal in their lives—preventing pregnancy. The analysis also builds on the literature by demonstrating how women internalize the meaning of feminine and rational emotion, aiding in the construction of their emotions on hormonal birth control as irrational and negatively shaping their understandings of their moods while using these methods. Examining gender and emotion in the domain of hormonal contraceptive use demonstrates how some women attempt to resist stigmatized emotion by stopping hormonal birth control, even though such attempts at resistance may make them more susceptible to unintended pregnancy. In joining the literatures on body image and emotion, this analysis helps understand how the larger constellation of gendered forces constrain women’s behavior in a domain where they are perceived to have substantial control and where gender norms are presumed largely irrelevant (beyond the division of labor in contraceptive decision making). Advancing this uniquely sociological approach contributes to the very important task of understanding unintended pregnancy, uncovering one reason why hormonal birth control fails in practice despite women’s strong desires to avoid conception.
Methods
This study uses data from the College and Personal Life Study, an in-depth interview study of 103 women aimed at understanding the reasons that women who do not wish to become pregnant do not always consistently use birth control. The interviews were conducted between 2009 and 2011 by a research team of which I was a part. The study was affiliated with Stanford University and the University of California, Berkeley. We recruited participants from four college campuses in the San Francisco Bay Area (two community colleges and two four-year universities) using email announcements and flyers posted on campus. Using different campuses allowed us to interview women from a variety of socioeconomic backgrounds—from very poor women who took community college courses to fulfill work requirements needed to receive temporary financial assistance, to women from much more affluent backgrounds attending elite universities. Most interviews occurred on the college campus of each participant. 2
To ensure that the sample included sufficient numbers of women who had experienced a pregnancy and those who had not, we used theoretical sampling. We recruited participants using two different flyers. Each advertisement stated that to participate in the study, the woman had to have never been married, be between the ages of 20 and 29, and be a full- or part-time student at the school at which the flyer was posted. To recruit women who had experienced a pregnancy, the first flyer also stated that the woman must have ever been pregnant—“whether or not [she] had the baby”—to participate. 3 For the flyer not requiring a pregnancy, the requirements instead stated that the woman must have ever had sexual intercourse with a male to participate.
Interviews lasted between one and two hours and participants received $50 as compensation for their time. The interview gathered information on the participant’s career and educational aspirations, sexual history (with detailed information on contraceptive use with each partner), previous pregnancies (if any), experiences with contraception, and attitudes about contraception and abortion. A professional transcription company transcribed interviews verbatim and the transcripts were coded using the qualitative analysis software program NVivo.
This analysis focuses on women who had ever used hormonal birth control, excluding 15 women who had never done so. Women had used all forms of hormonal birth control: the pill, shot, ring, patch, implant, and (hormonal) intrauterine device (IUD). 4 As Table 1 shows, 88 women had ever used hormonal birth control and 67 reported experiencing negative side effects. Forty women were white, 23 were Black, 13 were Latina, 10 were Asian, and 2 were Native American. Forty-three attended a four-year college and 45 attended a two-year community college. The average age of women in the study was 22.
Summary of Sample Characteristics for Women in the Analysis of Gender and Hormonal Contraceptive Side Effects
Note: Analytic sample includes 88 women who had ever used hormonal birth control.
Source: College and Personal Life Study, 2009-2011.
Results
In the analysis that follows, I discuss how the negative meaning attached to weight gain and emotionality shaped women’s experiences using hormonal birth control and their dissatisfaction with results. I conclude the analysis by demonstrating how women’s dissatisfaction with these side effects influenced pregnancy outcomes, noting the nontrivial proportion of women who stopped using hormonal contraception and the number who experienced a pregnancy as a result.
Hormonal Contraceptive Side Effects, Gender, and Appearance Norms
As discussed previously, women face strong pressures to be conscious of their bodies and are not exempt from these pressures simply because they use hormonal contraception. Of the 67 women who reported negative side effects while using hormonal birth control, 39 percent reported weight gain. Women who believed that hormonal birth control caused their weight gain and felt bothered by the perceived side effect faced difficult decisions. Among other options, they could try to combat the weight gain, switch to another form of hormonal birth control, stop using hormonal contraception altogether, or continue using the method even though the weight gain made them unhappy. 5 For many women who stopped use because they felt bothered, the weight gain was not solely a matter of slight changes in their bodies. Instead, it resulted in changes that they perceived as dramatic, and it deeply affected their self-esteem.
Trisha, a 22-year-old Black woman who stopped taking the birth control pill because of weight gain, said, “I gained a lot of weight when I was on birth control and I just didn’t like it, like the weight thing bothered me. I felt like I was scared and kind of weak. So I was like, ‘I don’t like this. It’s making me fat.’” When asked how she knew that it was caused by her birth control method, she replied: I’m pretty sure it was. I never got it confirmed by a doctor, but I know that they said that that was one of the side effects that could happen if you took birth control pills . . . which is exactly what happened, and when I stopped using birth control pills, I didn’t gain weight like that. So I was, like, “It had to be the pills.” I wasn’t letting it slide. I was, like, “It’s those pills that are ruining me.”
Although she could not be certain that the pill caused the weight gain, she believed that it did, and the weight gain served as more than an inconvenience for her. It also affected how she thought of herself generally. In her eyes, the weight gain was ruining her, not just her body.
Weight gain was not limited to women using the pill, however. Several other women discussed “hating” hormonal birth control because it was making them “really fat” and feeling unhappy with their appearance, while a few discussed having to buy new clothes because they had outgrown older apparel. Kristen, a 22-year-old Asian woman, described her experience on the shot, saying, “I did the Depo shot for a year and I gained so much weight. I was, like, back to my pregnancy weight and . . . I felt really fat and really ugly and . . . I was, like, ‘Oh, my gosh, this isn’t working.’” 6 Although women acknowledged that hormonal birth control was important for preventing pregnancy, their nontrivial experiences with weight gain and other side effects placed them in an uncomfortable position. As a 20-year-old white woman who stopped taking the pill because it was making her “too fat” said, “You want to have sex but you have to take something to not get pregnant. It kind of sucks. I’ve been meaning to go to my doctor but instead I don’t want to gain the weight. There’s all these repercussions with everything you do.” Her comment demonstrates a common theme among women who felt dissatisfied with side effects: They felt that they should use hormonal birth control if they wanted to prevent pregnancy, but the discomfort associated with use made them reluctant to continue.
Other women did not stop using hormonal contraception because of weight gain, but instead would not begin using particular hormonal methods because they feared weight gain as a side effect. Marion, a 22-year-old Black woman who had used the pill, said, I can handle taking a pill, but taking a shot . . . I heard how people gain weight. I am very small. I have a lot of issues, you know, body issues. So for me to think about being big, that would be psychologically taxing on me. I wouldn’t even want to put myself in a position where that could happen . . . I heard that it fucks you up.
Although several women preferred a hormonal method other than the pill because of the perceived inconvenience of taking a pill every day, Marion expressed a precise preference for the pill over the shot because she does not associate the pill with weight gain. Her remarks highlight the complexity of deliberations over birth control: In deciding whether or not to use a particular method, she thinks not only about preventing pregnancy but also about how hormonal birth control will influence her perceptions of herself. While Marion explicitly mentions body issues, most women who discussed stopping (or not using a form of hormonal birth control) because of weight gain did not discuss serious preexisting body image issues. Instead, they discussed their fears of weight gain in the context of more routine preoccupations with body size (e.g., not wanting to be “fat,” seen as a normal preference, while not characterizing themselves as being overly preoccupied with body image).
Although weight gain—almost always perceived as a negative side effect—could make women unhappy with their birth control and their bodies, some side effects could also make them feel better about themselves in ways that might be expected based on messages about beauty. Some women discussed being happy when hormonal birth control decreased acne, others were happy when it increased their breast size, and a few were disappointed that they did not get bigger breasts as they had initially hoped. 7 Lisa, a 21-year-old white woman, describes feeling “much more confident and sexy” during the time of the month when her “boobs got bigger” on hormonal birth control and feeling “sadder” during times when they were smaller. Indeed, when “they’re really as full as they get,” she thinks, “Yeah. I’m hot. I’m gonna wear a low-cut shirt.” Although her comment that she feels “hot” when her breasts are bigger fits into a discourse that tightly circumscribes the standards of feminine beauty, the side effects that she experienced nonetheless allowed her to meet a standard that she could not when she was not using hormonal birth control. Even when negative side effects accompanied hormonal birth control, at least one woman still capitalized on the benefits. For Claire, a 20-year-old Asian woman, although she gained a lot of weight and would “break out like crazy,” during the time that she had bigger breasts, “[she] was definitely showing them off.” Rarely, however, did an increase in breast size or other positive side effect serve as sufficient motivation to continue use in light of negative side effects when the woman used hormonal birth control primarily to prevent pregnancy.
In every case but one, women’s discussions of their decisions to stop or switch hormonal methods because of weight gain centered on their own evaluations of their bodies, not the comments of others. One woman discussed how her boyfriend noticed her weight gain on hormonal birth control, but, consistent with the literature, all other discussions revealed that women carefully policed their own bodies. Claire said, “You don’t just gain weight out of nowhere . . . I gained so much weight. It was noticeable and . . . I couldn’t even wear my T-shirts and stuff. It was bad and I just felt shitty.” The timing of the weight gain and her inability to fit into her clothes made her attribute the weight gain to her hormonal birth control, and like other women, she felt unhappy with the side effect. Brianne, a 21-year-old white woman, attributed the inability to lose weight to her hormonal birth control. She said, Well, I started realizing that, at first, I was gaining weight and I was, like, “Okay, this is not working out right now.” So I started working out. I was working out really hard, and yet I wouldn’t lose any weight and I was still gaining and it didn’t make any sense. . . . I was, like, “This is not right.”
As the literature shows (Tiggemann and Lynch 2001), women are accustomed to monitoring their own bodies in attempts to meet cultural standards of beauty. This analysis extends the literature by showing that women feel pressure to meet beauty standards even when they perceive weight gain as beyond their control and when weight gain fears can compromise their ability to prevent pregnancy.
Women’s discussions of weight gain on hormonal birth control did not vary dramatically by race (contrary to expectations from the literature), nor did they differ by education. Recall that while Black women are more satisfied with their bodies than white women (Molloy and Herzberger 1998), overweight Black women are still more likely to be dissatisfied with their bodies than their counterparts who are not overweight (Stevens, Kumanyika, and Keil 1994). This may explain the unexpected uniformity of weight discussions by race—Black and white women are dissatisfied with their bodies when they are overweight, and many women who felt dissatisfied with weight gain perceived dramatic changes in their bodies. Interestingly, although the data did not reveal differences in discussions of weight gain, there were differences in reports of weight gain—both by race and education. White women and those from four-year colleges were less likely to report weight gain than were women of color and women from community colleges, respectively. While only 32 percent of white women and 34 percent of four-year-college women who had experienced negative side effects reported weight gain, the percentages for women of color and community college women ranged from 40 percent to 57 percent.
Hormonal Birth Control Side Effects, Gender, and Emotion
Many women reacted negatively to their hormonal birth control because they believed that it made them emotional. Of the 67 women who experienced negative side effects, 33 percent discussed dissatisfaction with how their method made them feel. Women most often discussed hormonal birth control’s effects on two emotions—anger and sadness. The meaning that they attached to their emotional responses shaped their aversion to the methods—namely, hormonal birth control made them feel crazy. I suggest that women felt dissatisfied with the side effect, and some stopped or switched hormonal methods, because they wanted to avoid nonnormative displays of emotion and having their emotions labeled as irrational.
Several women either switched methods or felt reluctant to use hormonal methods in the future because they felt that the methods made them cry “for no reason.” Clarissa, a 28-year-old white woman, switched methods after her doctor linked her mood changes to the pill. Describing her experience, she said, “Well actually, there was one time where I did try [the pill] and I felt literally crazy on it . . . [it] definitely made me feel very different when I was on it. And it was just, like, I felt very emotional. You know, crying at, like, a bug on the floor, that type of thing.” While Clarissa switched methods because of side effects, some women felt reluctant to use other hormonal methods at all. Amanda, a 21-year-old white woman who used the pill, said, I felt like my hormones were going crazy, mentally, everything. I was just, like, “Whoa.” . . . It made me super emotional, like how you feel when you’re PMSing, but it was extreme. There wasn’t, like, butter in the fridge, and I would cry about it, and I was, like, “What’s wrong with me? This is not normal.”
Responses like Clarissa’s and Amanda’s not only foreground emotionality as a negative characteristic, but also explicitly demonstrate the connections that women made between high emotionality and irrationality. Although women are expected to be more emotional than men, they are also aware that there are appropriate times to experience and express such emotion. Crying at times that felt inappropriate to them resulted in feelings that birth control made them crazy and abnormal.
Other women disliked hormonal birth control because it made them feel angry. Miranda, a 28-year-old white woman, said, “It also did make me very bitchy, very bitchy the first few days after I had a new shot. You need to do it every three months, you know. The first few days afterwards, I was beastly to everybody. I had such a short temper.” Miranda was not alone in describing experiences where birth control triggered angry reactions. Vanessa, a 22-year-old white woman, described a similar situation: When I got back on [the pill], that’s when I started going, I was just nuts. And everybody was noticing, I was going just crazy. I was just so angry; I just felt angry on it. I was just, like, “What is going on with my body?” And it would turn out, like, somebody would just say something or somebody would reach over into my french fries—I remember one incident my sister was . . . she didn’t really ask me if she could dip her hands in my food and she just kind of did. And I was, like, “DON’T DO THAT ANYMORE,” and she was just, like, “Oh, like, here’s your french fry back, you can have your french fries.” But I was just so tweaked out on it. I felt like, “Ohhh.” Maybe it was the dosage, I don’t know.
As Vanessa’s response suggests, the notion that other people noticed women’s anger while they were on birth control bolstered feelings that it was not just their own perceptions of changes, but, rather, actual changes in their personalities. Vanessa eventually switched hormonal methods after her mother suggested that the pill was making her “whacko.”
Unlike women’s discussions of weight gain, which focused on how they themselves noticed changes in their bodies, women’s discussions of emotion side effects more often centered on managing their emotions with friends, family, and romantic partners. When women discussed family and friends, they focused on how these people noticed emotional changes, while their accounts of anger with boyfriends demonstrated how hormonal birth control could inspire turmoil in their relationships. Jane, a 21-year-old Asian woman, said, “I tell my friends that when I was on the pill, I was crazy. I was not myself. I was highly emotional . . . I couldn’t go a couple days without being angry and I’m sure that made life for my boyfriend hell because I was constantly yelling at him. . . . I wanted there to be a pill for him to take that would mess with his mood swings so that he would understand and so that he would be more sympathetic.” While other women may understand that hormonal methods can affect emotions (as did Vanessa’s mother), navigating changing emotions with her boyfriend proved particularly difficult for Jane because he could not understand her experience. She used the pill until her relationship ended, but felt like a “totally different person” when she stopped. Helen, a 22-year-old Asian woman, also experienced anger, but she did not stop use because she learned to “control” her emotions: I always suffered from PMS and I was slightly moody, and then after I started taking the pill, it was just, like, just way worse. . . . And my boyfriend definitely noticed and I would apologize and he could see the difference too, how much worse it got, but I would always, after the fact, I would just be, like, “I’m so sorry.” And after a while, I learned to control it.
When asked how she learned to control her anger, she replied, “Just because of heightened cognitive functioning. I would just be, like, ‘Okay, I’m really upset; I’m just gonna chill out for a little while.’ So I was better able to control it.” In Helen’s case, learning to “control” her emotions meant controlling how she responded. Her experience illustrates the subtle ways that gender norms can shape emotional expression. Although she continued to feel angry, she focused her energy on not communicating her emotion. Doing so made her better able to manage the side effect.
Although women from all racial backgrounds reported emotion side effects, Black women and Latinas were much less likely to discuss emotion side effects than were white and Asian women; community college and university women discussed emotion side effects at similar levels, however. While 45 percent and 57 percent of white and Asian women, respectively, who reported negative side effects discussed emotion side effects, 15 percent of Black women and 13 percent of Latinas did so. Considering racial differences in discussions of emotions highlights the importance of both race and gender in the social construction of women’s emotions. It is nonnormative for women to express anger, but for Black women, “[Anger] is considered an essential characteristic of Black femininity” (Morgan and Bennett 2006, 490). I suggest that while Black women may also experience anger and mood swings using hormonal birth control, the change may be less salient. Obviously, this is not because Black women are simply angrier than other women, as the stereotype holds. Instead, changes in anger may be less salient for Black women because they are perceived as angry even when they do not use hormonal birth control. Thus, what is nonnormative for white women is assumed for Black women.
Hormonal Contraceptive Side Effects and Consequences
Although many women believed that they should use hormonal birth control to prevent pregnancy, as this analysis shows, experiencing weight and emotion side effects rendered pregnancy prevention more difficult than simply remembering to use the method. Of the 67 women who reported negative side effects with hormonal birth control (see Table 1), 40 (60 percent) reported weight gain or emotional volatility. 8 Most women continued using hormonal birth control despite their negative experiences with these side effects, but a nontrivial proportion stopped hormonal contraception (35 percent) or switched hormonal methods (28 percent) as a result. 9 There were education and race differences in stopping or switching hormonal methods, with university women stopping at lower levels than community college women and Latinas stopping or switching at lower levels than women of other races. Examining women’s experiences with unintended pregnancy vis-à-vis their contraceptive histories demonstrates the consequences of their decisions not to continue using their hormonal method. Thirty-six percent of the women who stopped using hormonal birth control because of weight or emotion side effects experienced an unintended pregnancy as a result, compared to 20 percent of those who continued and 9 percent of those who switched hormonal methods. 10 While fewer women in this study experienced an unintended pregnancy due to switching hormonal methods, women who switch and those who stop using hormonal methods altogether have higher rates of unintended pregnancy than women who do not stop use (Raine et al. 2011).
Discussion and Conclusion
This study examined women’s experiences with side effects to hormonal birth control to understand why they decide to stop using hormonal contraception, and how these methods influenced their experiences of their bodies. Contrary to common understandings of side effects as merely medical aspects of use, the analysis shows that women’s interpretations of, and reactions to, their hormonal birth control side effects were influenced by gendered messages about women’s bodies and emotions.
As the results show, although women who stopped hormonal birth control because of weight gain side effects wanted to avoid pregnancy, the weight gain posed challenges to continued use. I argue that the weight gain resulted in dissatisfaction because women evaluate themselves against idealized beauty images that emphasize thinness. Their experiences of their bodies on hormonal birth control did not align with this image. Rather than just preventing pregnancy, they found that hormonal birth control resulted in weight gain that made them feel “fat” and “ugly,” and this became more central than increasing their chance of getting pregnant, leading them to stop use.
Women who experienced side effects involving emotions (e.g., sadness) felt dissatisfied with hormonal birth control because the side effects made them feel irrational. Cultural messages about women’s emotion frame them as emotional beings, but the notion that particular emotions are irrational and negative for women is also central to this discourse (Shields 2007). When women felt that hormonal birth control made them more emotional, they labeled this as negative in every case and, worse, felt “crazy” for exhibiting a particular emotional response (e.g., crying). Women often felt dissatisfied enough to stop using the birth control, even in situations when stopping use meant using less effective non-hormonal methods, usually condoms or withdrawal, which they sometimes used inconsistently.
Although this study focused on the relationship between cultural messages about gender and women’s experiences of their bodies on hormonal birth control, the results of the study have implications beyond hormonal birth control and unintended pregnancy. First, they suggest the importance of cultural messages about gender for medicine, generally. As discussed previously, weight gain is a potential side effect for a variety of other medications, including antidepressants and medications for bipolar disorder or diabetes (Leslie, Hankey, and Lean 2007). With normative pressure placed on women to maintain thin physiques, weight gain may also serve as an impediment to continued use of other medications. That the social construction of gendered bodies could have negative consequences for use of important medications is alarming. Second, the results also have implications for gender differences in body image and mental health. Given the research showing that women are more dissatisfied with their bodies than are men, how does the idea that hormonal birth control may result in even more dissatisfaction affect our understanding of women’s body concerns? Moreover, how do feelings of being “crazy” on hormonal birth control influence women’s mental health and feelings of control? These questions are especially important given the number of women who use hormonal birth control in the United States.
It is important to note some limitations of the study. First, the results cannot be generalized to the U.S. population. The sample was socioeconomically and racially diverse, but the women were young (ages 20-29) and unmarried, and it was not a probability sample of unmarried women of those ages. Thus, it is possible that the meanings attached to side effects may be different for the average woman, although results from quantitative analyses of nationally representative surveys also show a high level of discontinuation of hormonal contraceptives because of side effects (Littlejohn 2012). Another potential limitation is the lack of clarity about whether women actually experience side effects or just attribute any changes to their hormonal birth control—it is impossible to tell whether hormonal birth control caused the weight gain or mood changes that women reported in the study, or whether they incorrectly believed the source to be their hormonal birth control. This limitation is less concerning, however, because of the study’s focus on the meaning of side effects. Whether women actually experienced side effects or misattributed changes to their hormonal birth control does not change the meanings that they associated with these experiences nor their relationship to larger cultural messages about thinness and feminine emotionality.
The sociological analysis of women’s experiences with particular side effects to hormonal birth control presented in this study extends our understanding of gender by demonstrating that such experiences are not merely medical aspects of use, bereft of gendered meanings. Instead, cultural messages that privilege thinness for women and stigmatize particular emotional responses shaped the meanings that women attached to weight gain and emotional experiences, and it is often these meanings that led them to stop using hormonal birth control, undermining their goals to prevent pregnancy. As research on women in other contexts shows, weight gain itself does not have to be negative; it can, in fact, have positive meaning (Sadana and Snow 1999). This study shows, however, that messages about gender aid in the construction of weight gain and emotion side effects as negative in the United States—side effects that make women “fat,” “ugly,” and “crazy.” Examining women’s experiences with hormonal contraceptive side effects shows how women negotiate gendered meanings in their daily lives. While women’s decisions to stop their hormonal birth control may increase their risk of getting pregnant, doing so also allows them to try and meet idealized beauty standards and resist stigmatized emotion. The analysis shows that even when American women have adequate access to effective hormonal methods of birth control, their experiences using these methods are still bounded by some of the traditional gender constraints that they encounter in other domains.
Footnotes
Acknowledgements
I thank Paula England, Joya Misra, and anonymous reviewers for their helpful comments.
This research was supported in part with funding from the Elfenwork Foundation’s Collaboration on Poverty Research, a joint venture between The Stanford Center on Poverty and Inequality and the Multidisciplinary Program in Inequality and Social Policy at Harvard University’s John F. Kennedy School of Government.
Notes
Krystale E. Littlejohn is an assistant professor of sociology at Occidental College. Her projects examine the social dimensions of birth control use as a window into understanding unintended pregnancy and the role of race in shaping partnership for multiracial people in the United States.