A great deal of public discussion has been sparked by the recent determination of the Department of Health and Human Services that it would, under the legal authority of the new health care law, require health insurance plans to cover the costs of hormonal contraception. Much of that discussion has focused on the nature and importance of religious freedom, since the directives would require some institutions, such as Catholic hospitals and universities, to provide health insurance coverage for things that are contrary to Catholic moral teaching. To a lesser extent, the HHS regulations have provoked some renewed discussion—at least among Catholics, but perhaps more generally among religious conservatives—about the morality of contraception itself, a topic that had seemed closed as a topic of genuine inquiry for the last generation.
The HHS directives should also give rise to another discussion, one that so far has not been undertaken: a discussion not of the legality of the mandates, nor of the morality of contraception, but of the physical costs of contraception, of the negative consequences it may have for the health and well-being of the women who use it. This aspect of the question has been all but totally ignored. For their part, the liberal partisans of the HHS mandates speak as if hormonal contraception is simply an unmitigated good, a clean gain, for women. Indeed, their argument suggests that such contraception is so unequivocally good that there can be no reasonable argument about the propriety of mandating its coverage as a health care benefit.
This assumption deserves to be challenged because it is untrue. That is, hormonal contraception carries certain physical costs in addition to the benefits touted by its proponents. Unless these costs are frankly acknowledged, American women will be in no position to make an informed choice about whether or not to use contraception. Yet presumably Americans of all ideological persuasions could agree that women should be in a position to choose or reject contraception based upon full knowledge of its potential physical consequences.
The popular view of contraception as an unmitigated good is based upon a naïve understanding of science’s ability to intervene in natural processes. Modern people are understandably impressed by science’s ability to manipulate nature, to divert it to courses more acceptable (or apparently more acceptable) to human well-being than it would take if left to itself. We are often more impressed, however, than would be justified on closer examination. It is, after all, impossible to interject technological control into any natural system without incurring some undesirable consequences. Liberals understand this very well when the issue is non-human natural systems—the “environment.” They can easily tell you the problems that are caused by cutting down trees, mining coal, or burning oil.
But a woman’s body is a natural system like any other. It is devised by nature—for a portion of the woman’s lifespan—to be capable of becoming pregnant, to be fertile. Medical science cannot simply turn that fertility on and off like a light switch. It is rather to be expected that suppression of fertility through the use of birth control pills will carry certain physical costs for the woman who does it. The evidence bears out this expectation. In discussing these consequences we divide them into two categories: health risks and costs to physical well-being.
The existing scientific literature suggests that the long-term use of birth control pills is associated with increased risk for certain serious, and potentially deadly, health problems. A 2009 Mayo Clinic study noted a doubling of the risk of breast cancer in women who had used birth control pills for more than eleven years. Similarly, another recent study, funded by the National Institutes of Health, found that longer duration of use of hormonal contraception, as well as earlier first age of use, increased risk of breast cancer. Specifically, the study found that women who started using birth control pills before age 18 were at 1.9 times the normal risk level for all forms of breast cancer, and that women 40 and younger were at a 4.2-fold increased risk of triple negative breast cancer, one of the worst forms, which accounts for between 10 and 17 percent of all breast cancer cases.
Some forms of hormonal birth control have also been associated with increased risk for blood clots. Yaz, which was for several years the top-selling birth control pill, was discovered to almost double the risk for blood clotting, which can be lethal. There were about ten deaths per year among Yaz users during the period from 2004 to 2008, although the actual number of fatalities may be higher. Finally, birth control pills are harmful for the cardiac health of women who suffer from atherosclerotic disease. Those who use birth control pills usually cannot know whether they are assuming this additional risk, since it is generally financially impractical to screen for atherosclerosis prior to the use of birth control.
While these problems are admittedly only risks and not certainties attending the use of birth control, it is also worth noting that they do not necessarily represent all of the risks involved. That is, birth control pills may in some cases be more perilous than we know. The aforementioned Yaz had been approved by the FDA and was in use for several years before its connection to blood clotting came to light. Similarly, the author of the aforementioned NIH study on birth control and breast cancer noted the “scarcity” of studies of this link, and hence the need for “further research” on it.
Birth control pills also tend to carry costs to physical well-being. Use of birth control pills is associated with an increased incidence of unpleasant things such as depression, mood swings, weight gain, impeded weight loss, headache, upper respiratory infection, sinusitis, nausea, menstrual cramps, acne, breast tenderness, vaginal candidiasis (commonly known as “yeast infection”), bacterial vaginitis, and urinary tract infection. Although normally not life-threatening, such physical ailments are certainly not insignificant to those who suffer them.
Moreover, they are especially noteworthy to the extent that they bear negatively upon the supposed benefit of contraception: sexual freedom. Sometimes the proponents of contraception present it as preventing pregnancy, but anyone with elementary knowledge of biology knows that pregnancy can be prevented even more reliably by refraining from sexual intercourse. Contraception’s real benefit, then, at least as its advocates see it, is sexual freedom, the ability to enjoy sex without unwanted consequences. The side effects mentioned above, however, put a serious dent in the argument for this benefit. Obviously, a woman suffering from some or even one of the physically unpleasant consequences of birth control will not be able to enjoy sexual activity as much as she otherwise might. This is especially evident in the case of several of the ailments noted above, the ones (such as vaginitis, urinary tract infection, and vaginal candidiasis) that involve vaginal discomfort.
Indeed, one commonly found side-effect of hormonal birth control is a decrease in libido or sexual desire. Whether this arises independently or is itself caused by some of the other disorders and discomforts noted above is immaterial to the basic fact that contraception, which is promoted as a means to sexual happiness, can in fact diminish a woman’s sexual happiness. The promise of contraception is that women will be able to have sex whenever they want to, but a closer look reveals that it might well make you not want to very much. Put another way, its claim to be a pure benefit is compromised to the extent that it diminishes the enjoyment of that which it puts within such easy reach. Access to more apples is not a pure gain if a larger percentage of the apples are spoiled and taste bad.
We do not claim that these risky and unpleasant side-effects render contraception immoral. The morality of contraception depends on philosophic arguments we are not making here. Nor do we claim that the bad side-effects are so severe as to justify a ban on contraception on public health grounds. We merely hold that these side-effects are often ignored in our public discourse, but that a truly free decision of women to use or not use them—as well as a truly free decision of voters whether to use government to promote them—depends on a frank acknowledgement of their costs along with their alleged benefits.
Carson Holloway is a political scientist and the author of The Way of Life: John Paul II and the Challenge of Liberal Modernity (Baylor University Press). John Safranek, MD, is a medical doctor practicing in Nebraska. He also holds a PhD in philosophy from the Catholic University of America, and his writings have appeared in the Hastings Center Report, the Texas Review of Law and Politics, and the University of Colorado Law Review.