- Report released today finds that almost half of those using LARC – the most effective method of contraception which include coils, implants and injections and generally require provider fitting and removal - said they felt under pressure to accept this method, and many experienced challenges seeking removal.
- The report, produced by BPAS, Decolonising Contraception, Shine Aloud UK, and the Division of Health Research at Lancaster University, is based on qualitative research into the experiences of LARC users and practitioners, using a human rights approach to examine whether some groups are disproportionately targeted for LARC use based on assumptions about their capacity to avoid unwanted pregnancy or suitability for motherhood.
- 43.8% of respondents stated that they had felt pressure to use LARC, and of those who had sought removal, more than half (56%) also faced difficulties, including one participant trying to cut an implant out of her own arm. Others lied about now being in a same-sex relationship to achieve removal.
- The report explored how particular groups may experience pressure to accept a LARC, including Black and women of colour, those with physical or mental health issues, younger women, those with a previous use of abortion or emergency contraception, drug and alcohol users, women with higher BMIs, and those who have had children removed.
- The report emphasised the significant advantages offered by LARC methods, but that these may be undermined if users felt their choices were not respected or that removal would be challenging if they decided against continued use.
- Preliminary recommendations include a focus on equitable access for all those who request LARC, including for removal of LARC methods and the availability of resources to ensure full contraceptive counselling and the ability to make a choice with full understanding of the advantages and disadvantages from the full range of methods.
- Further research is also needed into the feasibility and acceptability of self-removal of IUDs and IUS, which could encourage more women to try these methods in the knowledge they can stop using them when they wish.
Research published today by BPAS, Shine ALOUD UK, Decolonising Contraception and Lancaster University into the provision of Long-Acting Reversible Contraception (LARC) in the UK, has found that almost half of user of long-acting reversible contraceptives felt under pressure from medical professionals to accept these highly effective methods of contraception.
Between December 2019 and May 2020, we conducted research with a range of LARC users and professionals about the goals, challenges, and realities of LARC care; our research found that nearly half (43.8%) answered definitively ‘yes’ that they had felt pressure to use LARC.
The qualitative study looked in particular at the experiences of those from marginalised groups who may be disproportionately targeted for LARC uptake based on assumptions about their ability to avoid unplanned pregnancy or concerns about their suitability for pregnancy and parenthood, due to their physical or mental health, and who may feel under pressure to accept this method in exchange for access to services (including medications) and support.
One participant of a workshop for Black and People of Colour described how the “experience was really, really bad because it was just like the doctor pretty much being like ‘you’re really promiscuous’”. Other interviewees also explained how their BMI was used as clinical reason to insist on LARC: “The whole thing was just effectively about how fat I am”.
Alongside issues for some users in accessing the method in the first place, with clinics considerable distances away, participants also described their challenges when seeking to have their LARC removed, with one reporting; “I became so distressed that I couldn’t get it removed even though I didn’t want it in my body anymore that my mum and I tried to cut it out ourselves.”
The report evaluated these experiences against the World Health Organisation’s (WHO) standards for human rights in contraception services, focusing on accessibility, informed decision-making, and non-discrimination, conclude that the sector requires some improvement to deliver person and rights centred LARC services.
As the pandemic continues to exacerbate already existing issues in a fragile sexual and reproductive health service, the report also examines how funding cuts and the fragmentation of services can jeopardise access to appointments and reduce the range of contraception available. Straightened resources may make it even harder for Healthcare Professionals to dedicate the time needed for comprehensive contraceptive counselling, as was already evident in our research.
Clare Murphy, Chief Executive of BPAS, said: “LARC can be a brilliant method that gives women the most effective protection against unwanted pregnancy. But like all technologies, it can be used to control as well as liberate. No woman should feel pressured into accepting LARC based on judgments about her sexuality or suitability for pregnancy and parenthood, and the experiences uncovered in this research give us real cause for concern.
“We need effective methods that women themselves are able to control. Self-administered contraceptive injections are now becoming more widely available, and we would like to see greater research into self-removal of coils, so women are not dependent on a provider to regain their fertility. This report shows us how much work we still have to do to deliver a genuinely woman-centred contraceptive framework”.
Dr Annabel Sowemimo, Co-director of Decolonising Contraception & Community Sexual & Reproductive Health Doctor said: “As both a provider and a user of LARCs I recognise the reproductive freedom that they provide to many contraceptive users however, a discussion on how they have historically been misused and the circumstances under which they are a times offered is long overdue. There has been some evidence for several decades that marginalised groups are more likely to be subject to contraceptive coercion and have their reproductive rights challenged.
“This is historically bound up with perceptions that some groups because of factors such as race, class or those living with a disability cannot be good parents. Despite, hearing many examples of such incidences in my daily practice, there has yet, to be a comprehensive study on this issue within the United Kingdom (UK). This study shines a light on the experiences of these groups and is a vital opportunity to explore better models of contraceptive provision not just in UK but globally. We can no longer afford to think about contraceptive provision in the absence of wider structural concerns.”
Rianna Raymond-Williams of Shine ALOUD UK said: “There is a disturbing and painful history of contraceptive coercion and forced sterilisation on Black women and women of colour which continues to be ignored. The lack of cultural memory within medicine and specifically sexual and reproductive health care continues to leave people and communities misunderstood and silenced.
The report provides an insight into the lived experiences of service users accessing contraceptive care from providers. Some people have spoken about being rushed to choose particular contraceptive methods, not being trusted to use other contraceptives methods and ultimately feeling like a number instead of a person when accessing care. There is a desperate need to reimage and redesign how contraceptive services are delivered in the long-term to better meeting the needs of those accessing them, thereby allowing service user to have better experiences and more control over their reproductive health.”
Dr Rachael Eastham, Senior Research Associate at Lancaster University said: “The report presents findings based on the lived experience of people with LARC promotion, use and removal and highlights how the system of provision as it stands can create pressure for users (and providers) to make certain decisions or behave in certain ways. The experiences included offer an important reminder of the ways that these pressures, for example, to save money or focus on specific ‘vulnerable’ populations can impact users rights and contribute to widening inequalities, however unintentionally. Critically considering this system in our research and its historical roots is intended as a constructive call to action to help us safeguard users rights and professional’s standards as we proceed in a precarious landscape already compromised through austerity measures and the impacts of Covid-19.” Rachael Eastham
Dr Mark Limmer, Senior Lecturer at Lancaster University said: “The experiences of the users who contributed to this report highlight the continuing social inequalities in the promotion and provision of LARC in the UK and point the way clearly to the need to embed such provision in a commitment to upholding the rights of users to accessible and non-discriminatory sexual and reproductive health services. The recommendations in the report, drawn from the experiences of LARC users and providers present a road map to policy makers and commissioners towards providing everyone with equitable, rights-based access to the contraception that best meets their needs.”
Taylor Burgess, Yale Law School Bernstein International Human Rights Fellow hosted by BPAS, said: “Everyone has the right to make their own free decisions about whether to use contraception, what kind, and when to stop. People should be able to access care in a local area, within a reasonable time and on an equal basis with others. The report demonstrates that the UK is presently falling short of these standards. It invites a critical conversation on how to make the basic rights to informed consent, access and non-discrimination a reality for all people in the UK.”
Black and women of colour
Barriers to access included failures to include Black and people of colour users in posters, marketing, and other service resources such as dummies, making it hard to relate. Racist stereotypes around sexuality, promiscuity and young parenthood impacted care and comfort. Likewise, racial bias in pain assessment meant black and people of colour weren’t taken seriously with their concerns and were forced to over-prepare for appointments.
“I've never seen a Black dummy where they actually had some like fake black skin and put an implant underneath it to show and normalise it for like young Black people what it looks like underneath the skin. And that’s kind of the basis of most sexual health demonstrations with dummies, they are always a white skin tone so I can never see myself in it or know what it would look or feel like almost. Even though I can see it.” NUMBER ONE, 25, Interview
“HOW they talk to you as a young Black woman. In particular parts of the UK, it’s like, ‘oh this is very typical of you’, or ‘you’re just a number, deal with it’, you know. ‘Take some ibuprofen’, or you know, ‘take another anti-inflammatory’. And it’s like: why don’t you just help me?” Kelly, 25, workshop
Disabled people and those with mental health issues
Those with disabilities and mental health issues often felt their autonomy was undermined, with clinicians assuming they “knew best” over the user’s preferred contraception method.
“Although I’ve got no learning or mental disabilities, it sometimes from my experience, when you see someone physically disabled it’s sometimes questioned whether their mental capacity is you know as average, yeh that’s the best way to explain it really.” NIA, 29, Interview
“I wish I had been taken more seriously both times I had LARC and struggled with the side effects. When I spoke to a contraceptive medical professional about my mental health on the implant, I remember them asking me if anything else was going on in my life to make me feel that way, as it was unlikely to be the implant. I feel like I wasted a long time not believing myself and felt instantly better when I had it removed after two years.” Anon, 28, SURVEY
“A lot of people with Depo will end up with no bleeding. And heavy bleeding is difficult to cope with if you’ve got learning disabilities, it’s very upsetting, you know.” JANET, LARC Professional: Clinical
Younger women and teen pregnancies
Younger women tended to feel they were pressured to use LARC over any other method to contraception to ensure they didn’t have a teen pregnancy. This went hand-in-hand with assumptions about personal responsibility and lifestyle, often intersecting with race.
“Contraception is really pushed, especially like something that will stop you getting pregnant for 4 year takes you from an underage pregnancy into a pregnancy in your 20s, and I think that’s why it was sold to me at that age” Anna, 29, Interview.
“I think I was like 17-ish then so it was just like “oh, she’s gonna have a teenage pregnancy and she’s gonna be another Black single mother” and I'm like […] I understand the fear, and sometimes it does kinda feel like: “oh, it's exactly like what my parents are saying.” But then it's also like: you're not my parents and I do kinda want to feel like I'm a respected person when I come to the clinic.” DA, 20, Interview
Those who have previously experienced state intervention
The general assumption has been that these people are incapable of looking after children or themselves, and therefore responsibility for preventing pregnancy should be taken out of their hands.
“So I think that there are certain groups of women that, as a health official you feel that you would like to give them LARC. You would like them to have a LARC. For example, women who've had their children removed, or drug and alcohol users, or women who've had multiple previous abortions, that you might feel like, that you, you’d want to talk to them in more detail about LARC and say: "look, you know, would you consider it, this might maybe suit you."” HELEN, LARC professional: Clinical
“Just because you lose your children doesn't mean that you have no control over your fertility. It's a massive social assumption, in my view. And that if you lost your children the idea that you wouldn’t want another child is also a really erroneous assumption. Wanting another child is the only, might be the only hope that you have. And actually having some control over your fertility might be the only control you have left. The idea that one day you might be able to have another child, is might be the only hope that keeps you alive.” LYNN, LARC Professional: Social
These sentiments, that practitioners know what’s best, were echoed by LARC users with concerns around informed decision-making: “At this point I didn’t actually have any information that I could fight my own corner about, part from that’s not what I choose, I don’t feel comfortable with this. … And I felt that she should be giving me that information and those options rather than just telling me what she wanted me to do.” LAUREN, 30, Interview
This lack of self-determination extended to accessibility in accessing care for LARC removals when needed, culminating in one respondent trying to remove their contraceptive implant themselves after multiple attempts with GPs, sexual health services and even private practices: “I became so distressed that I couldn’t get it removed even though I didn’t want it in my body anymore that my mum and I tried to cut it out ourselves! We gave up because it hurt too much […] I still have the scar on my arm where I tried to remove it myself.” ANON, 22, Survey
Preliminary recommendations include ensuring LARC provision centres the following:
- Legitimacy – working to ensure modes of LARC provision always have a ‘legitimate’ (non-discriminatory) aim and outcome e.g. welfare. This includes working to directly tackle stereotypes related to race, sex, gender, age and other characteristics of LARC users.
- Accessibility– equitable access including for removal of LARC methods. This includes consideration of who is included and excluded by a LARC service or initiative.
- Resources - to permit time, safe space, conversation and information sharing to support fully informed consent.
- Challenge – challenging assumptions and norms about LARC. A recognition that there is no universal ‘one size fits all’ in relation to LARC and wider SRH services.
For more information, please email firstname.lastname@example.org or call 07570 707134.
BPAS is a charity that sees almost 100,000 women a year for reproductive healthcare services including pregnancy counselling, abortion care, miscarriage management and contraception, at clinics across the UK. It supports and advocates for reproductive choice.
BPAS also runs the Centre for Reproductive Research and Communication, which seeks to develop and deliver a research agenda that furthers women’s access to evidence-based reproductive healthcare, driven by an understanding of women’s perspectives and needs. You can find out more here.
BPAS intends to launch a not-for-profit fertility service in 2021, to provide ethical, evidence-based, person-centred care that supports patients. We intend to only charge what it costs to provide a safe, high-quality, and accessible service to patients who may be unable to access NHS-funded care.
About Decolonising Contraception
Decolonising Contraception (DC) is a non-profit, community interest company founded in 2018 by a collective of Black and people of colour (BPOC) working in Sexual & Reproductive Health (SRH) who believed that not enough was being done to address the structural, cultural and historical determinants of Sexual & Reproductive Health (SRH). In particular, DC seeks to explore how access varies for BPOC as well as other socially marginalised groups. We believe that with a targeted approach, which creates spaces for BPOC with sex educators from the different communities we can help to address the disparities in SRH. We also work with educational institutions and policy makers to help meet the needs of our communities.
DC challenges the sector and individuals to understand the colonial history of sexual & reproductive health, discuss modern practices, and initiate new conversations about reproductive justice. This movement exists to support those accessing contraception and other sexual health services to feel empowered, and be able to make informed choices even if that means initiating difficult and uncomfortable conversations.
DC is currently running our digital sex education intervention, The Sex Agenda which includes a podcast, zine and workshops. You can have a listen to our podcast here.
About Shine Aloud UK
Shine ALOUD UK (SAUK) is a social enterprise that uses creative media and peer-led training to empower young people and adults who work with young people to achieve better sexual health outcomes. As an organisation, we are aware of the challenges and barriers young people experience when accessing sexual and reproductive health care. In particular, we understand that Black and minoritised young people experience increased challenges due to issues of institutional racism, discrimination and bias. Through the work that we do, we aim to provide a voice to young people to share the challenges and barriers they face in the hope that their voices can help to lead and create change long term.
Rianna Raymond-Williams, who is the founder of Shine ALOUD UK has worked in sexual and reproductive health for the last 10 years. She has recently secured a studentship from Glasgow Caledonian University in London where she will be exploring how Black women in the UK make sense of their sexual health identity. Alongside her doctoral research, Rianna also works as a sexual health advisor for the National Health Service (NHS) where she provides STI and HIV results, contraception information, safer sex counselling and safeguarding and third-party referral depending on the needs of patients.
About The Division of Health Research at Lancaster University
The Division of Health Research at Lancaster University specialises in high quality health research. Our expertise contributes to improved health, wellbeing and safety for individuals. We enhance the skills of a wide range of people, both lay and professional, in providing services. This enhances human capital for individuals, organisations and services in the public and private sectors.
We provide an authoritative voice in research and education and are valued globally, nationally and regionally for the quality and policy/practice relevance of our research, education and training and for our contribution to knowledge exchange. This improves service provision and care through better-prepared professionals, practitioners, policymakers and health researchers.
Member of the Division of Health Research come from a wide range of academic disciplines and professional backgrounds. Rachael Eastham and Mark Limmer specialise in qualitative health research with particular focus on sexual and reproductive health and the related health inequalities. Rachael has a prior background working in women’s service and sexual health services and Mark has a background in public health policy and practice work related to sexual health including the UK Teenage Pregnancy Strategy, relationship and sex education and HIV services.