Dissecting "Sweetening the Pill," a Completely Frustrating New Book on Birth Control
Historically, the birth control pill is revolutionary. Today, it's nearly mundane. In the 50 years since its approval, the Pill has radically changed contraception, placing it directly in the hands of women, changing the way they plan their lives, the way conduct their relationships, and—of course—the way they have sex; in 1993, The Economist named the Pill one of the "Seven Wonders of the Modern World." Now, it's part of the everyday lives of 10.5 million American women.
That's not to say that the birth control pill is not beyond reproach. For one thing, it has a problematic history of being tested on women of color: Its earliest form, which contained 100 times more progestin and more than three times more estrogen than today's version, was tried primarily on Puerto Rican women who experienced strong side effects due to the high level of hormones. After its approval, several states that were especially stingy with their healthcare resources in communities of color were suddenly able to fund birth-control programs—a disparity that was rightfully called into question. And though the Pill has gotten safer over the years, in the early 1970s the high-hormone pills markedly increased a woman's risk of blood clots—a risk that is mirrored today in claims against the Yaz brand of pills.
Such criticisms leave room for a very real feminist critique of not only the birth control pill, but of our society's understandings of medication, healthy female bodies, and contraceptive literacy. I had hopes that Holly Grigg-Spall's Sweetening the Pill: Or How We Got Hooked on Hormonal Birth Control might provide that. Grigg-Spall (a one-time Bitch guest blogger) seems to view herself as uniquely brave enough to launch this analysis of the Pill, asserting that others view oral contraceptives as "a wonder drug beyond criticism" and that, for the liberal-minded, "any criticism is considered irresponsible, playing into the hands of those on the Right who want to see them banned." Grigg-Spall presents herself as the one person willing to speak a controversial truth to the power of a cultural hegemony invested in upholding the Pill as the predominant form of contraception. Unfortunately, the truth she's speaking just isn't rooted in our best sources of knowledge.
Other reviewers, notably Lindsay Beyerstein at Slate and Lauren O'Neal at The New Inquiry, have expertly dissected Grigg-Spall's pill-as-patriarchal-plot premise without denying the profit motives of the pharmaceutical industry, the occurrence of side effects, and the existence of sexism in medicine and misogyny in most discussions of women's bodies (and their regulation). So as not to retread their thorough takes, I'll focus here on how Grigg-Spall's polemic stands up to a range of scientific findings on the Pill.
Sweetening the Pill's narrative begins with Grigg-Spall discussing her negative experiences with the Pill, and then discovering online communities of people with similarly poor outcomes. She describes Yaz (the brand of pill she was taking) as "the most complained about drug on the Internet," though one wonders how that metric was established—you can find online forums for bad experiences with nearly any medication on the market. Nevertheless, from her correspondences with this community of disillusioned "pill refugees," Grigg-Spall draws the conclusion that, "On the pill no woman's body is capable of functioning at its optimum level… every woman taking the pill will experience, over time, impaired physical and mental health." What are these impairments? Cancer, osteoporosis, anxiety, depression, urinary tract infections, bleeding gums, hypoglycemia, hair loss, muscle weakness, and lowered sex drive, to name just a few.
When assessing Grigg-Spall's claims, it's essential that we remember that all prescription drugs (and most over-the-counter ones) have long lists of potential side-effects that the vast majority of users will never experience. There are also plenty of contraindications telling you not to take a certain drug if you have a history of any number of conditions. Not all medications are right for everyone, and the Pill isn't any different. In fact, given the varying bodies, biologies, and contraceptive needs of American women, we should not expect the birth control pill to be appropriate for all of them. If this were the scope of Grigg-Spall's argument, I would wholeheartedly agree. Instead, she asserts that the Pill is irredeemably risky and bad for all women.
Grigg-Spall has a notable disdain for scientific research, if her extremely sparse citations are any indication. (At one point she writes, "scientific researchers only find what they start out looking for.") And while she frequently groups together all forms of hormonal birth control (including the ring and hormonal IUDs), these drugs are far from monolithic. For example, in methods where hormones are delivered directly to the uterus, the effective dose the rest of the woman's body receives is lower, and may result in few systemic side effects. Furthermore, different brands of pills contain different dosages and combinations of different hormones, as well as varying numbers of placebo pills per month. All of these factors impact the amount of hormones a user receives and, consequently, may impact the number of side effects experienced. The daily dosage has dropped over the past 50 years—when the FDA approved the Pill in 1960, it was for a 10-milligram dose; most pills today have around 3 milligrams—and with with women's experiences have changed. Research conducted when dosages were significantly higher will not necessarily provide us with insight into how the Pill is experienced today.
With all this in mind, let's look at a few of her claims more closely.
• The Pill causes hair loss. Women with a history of hair loss might find that condition exacerbated by the Pill. For some of these women oral contraceptives, combined with antiandrogen steroids, are a useful treatment.
• The Pill causes muscle weakness. One research study has shown that female athletes on the Pill did gain less muscle mass than counterparts not using hormonal birth control—though, importantly, they did still gain muscle.
• The Pill affects sex drive. The claim that hormonal birth control can lower sexual drive is supported, as is the finding that among women with sexual dysfunction, oral contraceptive use was associated with long-term elevation of sex hormone-binding globulins. In other words, using the Pill might alter your body's testosterone levels, even after you stop taking it. (Grigg-Spall goes so far as to suggest that the diminishment of libido leads to women seeking plastic surgery to appear more sexual.)
• The Pill contributes to osteoporosis. A 2000 scientific review of 13 studies examining the relationship between Pill use and bone density found that in nine studies, there was actually a positive effect between oral contraceptive use and bone density. (The remaining four showed no effect). Researchers concluded that the pill had a favorable effect on bone mineral density.
• The Pill causes cancer. When Grigg-Spall writes: "Hormonal contraceptives are ranked by the World Health Organization as a class one carcinogen alongside tobacco and asbestos," her diction serves to make this ranking sound as frightening as possible. In fact, the WHO report actually classifies combined oral contraceptives as a Group 1 (not "class one") carcinogen, stating that they "modify slightly" the risk of cancer by reducing the risk in some sites and increasing it in others, while acknowledging that these risk assessments are based on older, higher dose contraception and concluding that, for healthy women, "the health benefits outweigh the health risks." (Also on the list of Group 1 carcinogens? Alcoholic beverages and sunlight.) As far as the research, some studies have shown an increased risk of breast cancer, while other studies have shown none.
But the crux of Sweetening the Pill's argument is that the Pill is mentally and emotionally damaging to women: "Hormonal contraceptives have caused women to lose their jobs, their relationships, friendships and hindered them in achieving their goals" and "women on the pill describe feeling detached from reality, numbed, foggy headed." She reports facing both depression and anxiety while on the Pill (in addition to anxiety—ironically, mostly around the possibility of pregnancy —while off the Pill). Yet, once again, the research disagrees with Grigg-Spall's assessment that all women on the Pill share these outcomes. As might be expected, studies have instead shown that women with previous histories of mood disorders were slightly more likely to experience such adverse mood effects. These effects were not found in women without such histories. Another study found that "mood effects experienced by most women are beneficial." Women with histories of depression who do experience mood effects while on the Pill are likely to stop taking the Pill —as they should, given its impact on them. This, however, undermines Grigg-Spall's argument that women are pressured to continue taking the Pill even when it has adverse effects for them.
Perhaps most frustratingly, while Grigg-Spall continually insists that the experiences of those like her are universally ignored, suppressed, and discredited, she then does the same to every women who's had a great—or even a neutral—experience with the Pill. In her estimation, all women on the Pill are "indoctrinated" and "women's acceptance of the pill [is] not a sign of their liberation but an illustration of the internalization of this misogyny." She dismisses Marxist feminist writer Laurie Penny's love of the Pill, saying "she has swallowed the idea of pill taking as a liberating act" and leaving no room for the possibility that, for Penny and others, taking the Pill may, in fact, be a liberating act. This dismissal is galling, especially coming from a writer who clamors for others to acknowledge the validity of her own lived experience. As a feminist, I won't brush aside the experiences of individual women like Grigg-Spall, and I would expect her to offer other women the same respect. (Although, as an academic, I won't allow scary generalizations to be made from one person's experience when research suggests such sweeping claims are inappropriate.)
In many ways, Grigg-Spall's arguments are eerily reminiscent of right-wing pundits who dismiss the disruptive potential an unplanned pregnancy can have in a woman's life: she states critically, "we see that unwanted pregnancy is framed as the worst possible event in a woman's life, centrally because it will prevent her personal progression" and asks, "how do we decide what is an unwanted pregnancy and what is a 'happy accident'?" She does not recognize that an unplanned pregnancy might, truly, be the worst possible event in a woman's life, or that "we" have no business deciding if an unplanned pregnancy is derailing or serendipitous. In these sentiments, she seems to be aping the "make lemons from lemonade" ideology of social conservatives who view every pregnancy as a reason to be joyful, and thus justify the removal of women's bodily autonomy. I see very little feminism underpinning Grigg-Spall's logic.
None of these comments are intended as defenses of hormonal birth control (though they will likely function that way) but, rather, as insights into what the best available research tells us about these medication. None of this means there's not more room for progress—but Holly Grigg-Spall closes most of the opportunities available for such progress by effectively making enemies of those most likely to be her allies. She dismisses pharmaceutical companies out of hand as motivated only by profit, and writes off most physicians solely as salespeople for Big Pharma. She believes, as mentioned earlier, that researchers only find what they set out to find. She writes that "women are attacked for voicing their discontent with the contraceptive choices offered to them"—attacks levied, according to her, not by conservatives opposed to contraception broadly, but by "the liberal Democrats [that want] to see every woman on long acting hormonal contraceptives" and allowed by the "third wave feminist approach to reproductive rights [which] isolates women."
A 2004 report from the Institute of Medicine entitled "New Frontiers of Contraceptive Research" (funded by the Bill and Melinda Gates Foundation, which Grigg-Spall skewers as well because of their efforts to make hormonal contraceptives more accessible in developing countries) discussed the slow progress that contraception has made since the advent of the Pill, and made recommendations for how research might go forward to improve the options available. The preface to the report stated:
In 1965, Gregory Pincus wrote that his interest in fertility regulation was stimulated primarily by Mrs. Margaret Sanger, who visited him and expressed the hope that a relatively simple and foolproof method of contraception might be developed through laboratory research. The result of that visit was research that led to the development of the oral contraceptive pill. This vision of how science can serve humanity should continue to guide us in the development of the next generation of contraceptive products.
How Grigg-Spall intends to work towards that vision without the help of progressive funders, liberals, feminists, physicians, or research scientists, I am unsure. But perhaps the rest of us might work towards that vision without wasting much time reading Sweetening the Pill.
WHAT TO READ INSTEAD OF SWEETENING THE PILL: I recommend historian Elaine Tyler May's America and the Pill: A History of Promise, Peril, and Liberation, Linda Gordon's The Moral Property of Women: A History of Birth Control Politics in America, and Elizabeth Siegel Watkins's On the Pill: A Social History of Oral Contraceptives, 1950-1970, all of which were consulted in the writing of this review.
Gretchen Sisson is a research sociologist at Advancing New Standards in Reproductive Health (ANSIRH), a think-and-do tank within the department of Obstetrics, Gynecology, and Reproductive Science at the University of California, San Francisco.
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