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Dissecting "Sweetening the Pill," a Completely Frustrating New Book on Birth Control

package of birth control pills

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 pillsThe cover of Sweetening the Pill

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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Comments

12 comments have been made. Post a comment.

The only problem I have with

The only problem I have with the pill is that in my experience it seems like the "must have" contraceptive. Most girls as they become sexually active are told by friends and family that they "should be on the pill" and it's encouraged by some teachers and councillors in high school.
While it's great that women have to ability to control their own bodies/reproductive systems, I feel that there is this pressure for young girls to be on the pill that doesn't happen equally with men and their forms of hormonal birth control or even condoms. Hormonal birth control for men is still not really something that people do in Australia, at least to my knowledge.
This said, I don't think there is anything inherently wrong with hormonal birth control or the pill. I had some ups and downs with mine but now I really feel like I know what's up with my body. I think the problem is how it's favoured over other forms of birth control before accessing whether or not your body will tolerate it, and leaves women in the position of being the one who has to "make sure she doesn't get pregnant" (which basically later leads to blame and shame of single, poor or working mothers who had unexpected children)

I agree with you, and that is

I agree with you, and that is my big beef, as well. We have a very very meager amount of real education around birth control. There is very little counseling by doctors and very little research into health history before a prescription of a big time DRUG.

And a big fat YES to the end of your post, as well.

Wow. I remember when this

Wow. I remember when this chick had her bitch blog. I would say that all of the criticisms raised here of the book could easily be applied to that blog.

I'm one of those women who has had a very positive experience one birth control. I actually take ocella(generic yaz) and my experience has been neutral to positive. I started taking it to deal with depression, severe cramping and to lengthen my cycle. Without birth control, I'd get a period every two weeks. It's not the end of world, but there's a risk of anemia, etc. Besides the depression (that took heavier artillery), the birth control pretty much did the job with no side effects.

But I wasn't about to share that perspective with her. It wasn't a conversation. She treated any commenter who disagreed with her like they just didn't get it. I never bothered to comment. It seemed like a fool's errand. I guess she could have used her time as a bitch blogger to test her theories, hear different perspectives, and let her thinking evolve a bit in the way it can when let others challenge us. But she didn't. Needless to say, I feel strangely vindicated.

Sweetening the Pill

The Pill is not necessarily the panacea or holy grail of medecines. When I was 12 I was offered it to treat heavy periods. I didn't get to take them [ my mum refused to have them prescribed to her Catholicism] although my periods thankfully settled down. I later found out that it may stunt growth in girls under 17 , by oestrogenising bone plates and making them harden prematurely , which prevents further growth. As a 6 feet 2 woman that may not have been a problem for me , but for other girls who knows ?

Originally the artificial manufacture of progesterone [ on which the Pill was based ] was done to treat infertility in married women, not to help them but to fulfill their role as broodmares. http://content.time.com/time/magazine/article/0,9171,1983884,00.html Maybe the Pill deserves as much scrutiny as any other medcine.

Hormonal birth control wasn't a good fit for me

I just wanted to offer a perspective from a woman who briefly tried hormonal birth control.

I was on the pill for one month in my early twenties. My gynecologist prescribed a brand (I forget which) that had been around for a while and had a good track record. I began taking it primarily for birth control reasons, but I was pleased to find out that I had none of the horrible dysmenorrhea I had experienced since high school. Unfortunately, I am one of the people who suffers depression from hormonal birth control; for the month I took the pill I literally cried every day and picked fights with the people in my life for no reason. I didn't know what was happening at first, but when I consulted my mother she said it was likely the pill. I called my doctor who confirmed that as the likely source and she said that I should discontinue using it.

My doctor told me that the spike in hormone levels from a daily pill might have exacerbated, or even caused, the depression. She also said that a delivery method that was more consistent through the day might help. At the time the patch had recently (ie. within a few years) come out, so we decided I would try that. It was, indeed, better than the pill. I was able to stay on it for a year, although I still experienced depression.

Eventually I decided to give up on hormonal birth control because I wanted my mental and emotional stability back. Looking back on it, I wish I had been in a position to try a low-hormone IUD. Maybe that would have worked out better for me, but my doctor never mentioned the possibility of an IUD and by the time I realized it was a viable option I was about to go overseas for at least two years.

Unlike Grigg-Spall, however, I don't think that my personal negative experience is applicable to all women. I hope in the future that there are even more birth control options, not just for women but for men as well. At this point, though, what I want more than anything is a non-hormonal birth control option that would fix my dysmenorrhea (instead of just barely managing it, like the NSAIDs I take do).

Looking back on my experiences, the thing I regret most is that I had no comprehensive education on birth control when I was younger. My school barely touched the subject, my parents never brought it up (I don't think we ever had a sex talk, actually), and I wasn't sent to a gynecologist until after I became sexually active. I only seriously started researching birth control methods after my negative experiences with the pill and patch.

Anyway, thanks to the author for reading through that book so the rest of us don't have to.

I've had some extensive

I've had some extensive social media contact with Ms. Grigg-Spall (she is pretty darn sensitive about her book, I'll say!) and I wrote about it on my blog: http://halfwaytoamidlifecrisis.wordpress.com/

Stop using men's tactics to attack other women

So she's too sensitive. Hmmmm.

Isn't that the charge men often level at women who dare to defend their views?

Sensitive=too emotional=not rational=you need to be medicated/suppressed/silenced/marginalized. "There, there. Take this pill like a good little feminist. We know better than you."

It is a lazy, intellectually dishonest way to put someone down.

And you just proved Holly's point: She cannot speak out against the Pill without backlash and name-calling and unfounded personal attacks worthy of a "Real Housewives" reunion, which frankly is comparatively more civil than some of the behavior I have seen toward her and her book. Except this is not about Lisa Vanderpump's tea party or Adriana Moura's wedding. This is about a chemical that we are all supposed to accept as good and liberating without any regard to the consequences for our health and our bodies.

Kristin, One problem with

Kristin,
One problem with Holly is not that she's "too sensitive," it's that she fails to engage in responsible discussion around her subject matter. She refuses, and dismisses any with a different opinion, or other input. Nothing is as black and white as she is trying to make it out to me.

Another problem is that she is portraying herself as an expert on a medical topic, and she is far from that. And that is just dangerous.

Where this whole "accept it and take it regardless" notion of the pill is really bizarre and entirely baffling. Perhaps you all should take issue with the particular prescribers who gave you that message, rather than villianize an inanimate medication (one that has been extremely beneficial to a massive number of women at that).

Grigg-Spall abuses science, and therefore, women

A "menu" of contraceptive options is important, and we should inform people about the risks and benefits of all methods. In her book and interviews, Grigg-Spall focuses only on the risks of hormonal methods and misrepresents/ignores much of the scientific evidence.

Grigg-Spall writes that "The pill significantly increases women’s risk of developing heart disease and breast, cervical and liver cancers." A recent study of over 17,000 women suggests that the oral contraceptive pill has no effect on non-reproductive or breast cancers, increases the risk of cervical cancer, and decreases the risk of uterine and ovarian cancer (Vessey 2013). While Grigg-Spall briefly acknowledges that the pill may reduce ovarian and uterine cancer, she does so only by hyperbolically suggesting that "We are told the pill is something close to an immunization against uterine and ovarian cancer." I've never heard anybody suggest that the pill is a vaccine; but would be interested in seeing such quotes if Grigg-Spall can produce them.

Grigg-Spall also states that hormonal contraception increases vaginosis; in fact, a recent systematic review by Vodstrcil et al (2013) concludes that hormonal contraceptive use is associated with a significant decrease in bacterial vaginosis. These are just a few examples; an exhaustive list would be, well, exhausting.

Concerningly, Grigg-Spall exaggerates the efficacy of fertility awareness methods (FAM). She refers to one German study to make the erroneous claim that all FAM methods can have a failure rate comparable to hormonal methods. She fails to mention that the estimate from that study is applicable to one specific type of FAM (symptothermal method) not to all FAM methods (such as Standard Days Method, TwoDay method, or Ovulation method), which have lower efficacy. Though efficacy may not be the top priority for all women, it is imperative that we provide clear, high-quality information so folks are not misled into an unintended pregnancy.

Enhanced communication about fertility awareness methods, and enhanced access to a variety of contraceptive options, should be (and already are!) priorities for the field of reproductive health (which Grigg-Spall incorrectly and negligently argues is comprised of individuals focused singularly on "population control"). It remains critical that people are provided with clear, unbiased information about the effectiveness, risks, and benefits, of all methods, to make an informed decision. Those who truly care about women's health would be careful not to distort scientific information or exaggerate method efficacy (perhaps in order to sell books).

My experience with the Pill

I was put on the pill mostly to regulate my periods (I have PCOS -- polycystic ovarian syndrome) and to possibly reduce my excess face and body hair. I was put on a couple of different ones, and there were a couple of pluses: I had regular periods for the first time, and they were much lighter than my usual semi-annual floods; the cramps I got were better too. The second one started giving me really intense migraines (I'd only had like 5 migraines in my whole life before, and I was 29 at the time). I didn't think it was worth it to stop right away, and didn't really connect the pill with the migraines until a friend mentioned she'd started getting migraines on the same pill I was on. I stopped the pill, but guess, what, the migraines continued. I am now 47 years old, and it has been over 25 years since I stopped the pill, but I still get cyclical migraines. If I had known that would be a permanent side effect, I would have not started it. Ironically, I never needed the pill to prevent pregnancy (I had to use fertility treatments to get pregnant), so it's not really taking control of my body. I was letting drugs do unknown things to my body.

Correlation doesn't not equal

Correlation doesn't not equal causation. You're assuming that it's the pill that made the migraines happen more frequently, but you don't actually know that they're related. The fact they continued after you went off of the pill just makes it seem even more likely that the cause is from something else.

Birth control pills can change the occurrence of migraines due to changes in your hormones. They can make them better or worse. However there is no logical reason to why it'd stay that way after you stop taking the bc. Your hormone levels won't be forever changed after taking the pill. Ironically, birth control pills have been used to help reduce the frequency and severity of menstrual-related migraines.

Anyway I hope you figure it out.

you don't know untill you are "aware" of your body

10 years on the pill, because all the people said it was the best option and of course I was so afraid of get pregned. I stopped one, 3 month and it wasn't enough to realize the changes, but because I wasn't aware of my body changes.
I started very young at 20, and it was "fear" what mooved me.
No doctor told me about any side effect.
I gained weight, but thought I was getting older and started to do exercises and eat less. I started to note that maybe I wasn't so active.... but maybe that was to "grow up"... maybe the stress. A little bit high colesterol and sugar... getting older again or maybe "genetic". I started, years later, to get nausea everytime I was on car..... well, maybe I have a not known problem....
I always said that the pill was neutral. Untill I leave it.
All this problem disappeared. I start to feel in more deeply ways. I realized I was so able to get on fire with libido! I did not know.
To do exercises started to be easier, I gain muscular force! I have never got nauseas again!!! My blood levels are normal.... I started to be less depresive.... and more empowered of my live. Hormones mediate our perception of the world and maybe a lot of things you think are your fault while on the pill, are not and it is the pill!! Other hormonal balance is simply better for you!