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Planning families

September 12, 2010

A few days ago, I got to share some of my experiences, methodologies, and ideas about working in women’s health with a group of Catholic leaders from around Asia. They were gathered in Siem Reap for a five-day conference on peace and justice. I used my chance to address them to share about the potential – and the risks – of making a preferential option for women to work against gender based violence. The point that provoked the most discussion was that the church should be helping women and men access comprehensive sex education.

Obviously, this is controversial. I knew that going in. But I also knew there was no way I could honestly address the topic they asked me to speak about, violence against women, without suggesting that some of church’s social teachings were oppressive, rather than liberating, for women and men alike.

I wasn’t sure what to expect, but overall I found the group receptive and willing to consider the implications of a radical preferential option for the poor. Even if some participants did not agree, I’m glad to have had the chance to stir up conversation, to suggest that sometimes doing the just thing is exactly the opposite of what the Vatican would have us do, to challenge the pure reconciliation model of domestic violence counseling that the church often employs.

I wasn’t surprised when one woman at the conference approached me afterwards with a question. In a hushed tone, she said, “After everything you said, I’m afraid you might be telling women to use condoms. Are you?”

I told her the truth: that out of respect for Church teaching, we do not include contraception in our formal lessons (and subsequently focus on areas of health other than safe sex) but that neither my staff or nor I would ever lie or withhold information from a woman who asks about options for STI prevention or contraception.

“But why can’t you teach natural family planning?”

I mean no disrespect to people who have chosen natural family planning (NFP), or the rhythm method, as their strategy for birth spacing. But I can’t imagine suggesting it as a viable option for women here.

First, to practice NFP requires daily knowledge about one’s menstrual cycle, body temperature, and vaginal discharge. Many couples in the U.S. even attend workshops to learn how to optimize this method. For women who can’t read, gathering that data and keeping track of it is a lot to ask.

Second, many women don’t have regular hormonal or menstrual cycles. I meet women every week who haven’t had periods in years (but have had babies in the meantime), who get their period every two weeks, who have been spotting every day for a month. I suspect (but have no way to prove) that for some women, these irregularities are the result of chronic malnutrition. Regardless of the cause, going for comprehensive blood work, pap smears, and exams with an OBGYN is not an option, and neither is tracking their ovulation.

Third, the rate of effectiveness, estimated between 74-88%, just isn’t that great. If women are serious about not wanting to get pregnant, there are other options that require no daily maintenance, are not dependent on diet, and are much more reliable.

Finally, many (if not most) times that married Cambodian couples have sex, the men initiate, and the women go along, whether they want to have sex or not. The expectation that a woman should have sex with her husband at any time is pervasive and persistent. It wouldn’t occur to me to counsel women to refuse their husbands sex for twelve consecutive days each month, because it’s probably not something that they would be able or willing to follow through on, without risking marital harmony or violence.

I opened my talk in Siem Reap by explaining that I’m coming from a feminist liberation theological perspective. Based on those teachings, I believe that truth and God are found in lived experiences, especially those of people on the margins. From what I’ve heard and seen from women in Cambodia thus far, natural family planning is not realistic, safe, or liberating.

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4 Comments leave one →
  1. Alice permalink
    September 12, 2010 11:34 pm

    Althought I imagine your conversation ended there, I’m definitely curious as to the responses NFP proponents can offer to point #3, as well as #2. For any outreach that’s aimed at women, #3 is a fundamental and unavoidable issue, and I truly am curious as to how those who advocate NFP exclusively reconcile that position with the day-to-day reality of this work.

    Kudos to you for initiating a difficult conversation, and to the attendees for engaging in conversation, despite disagreement.

  2. September 12, 2010 11:53 pm

    Thanks Alice!

    People who use NFP in more developed countries can have success rates up to 97% or even 99%, but this is with detailed tracking of body temperature and discharge, and strict adherence to abstain from sex on fertile days.

    This article mentions a study from India where women were effectively using NFP and had an extraordinarily low birth rate. It also says that most failures of NFP are the result of intercourse on days known to be fertile, highlighting the necessity of a cooperative partner who is also committed to NFP.

    To me, the most important thing is that we understand the context (economic, environmental, social, political, etc.) before we start offering “solutions” based on different areas and lifestyles.

  3. September 13, 2010 3:53 pm

    Speaking as an NFP proponent to each of your points:

    First, there is ample evidence that NFP can and is used effectively by women in third world countries, those with poor education, and those who live in poverty. Probably the most effective organization working in these areas is the Billings Method (currently making good progress in China), which is a mucus-only approach and does not require the use of a thermometer. There is also evidence of even blind women being successfully taught NFP, and no one can dispute the success of Mother Teresa and her order, who continue to teach NFP to the poor of Calcutta and elsewhere. My organization, the Couple to Couple League, currently has teachers active with poor and poorly educated couples in Zambia, Cameroon, Nigeria, South Africa, and South America.

    Second, no matter how regular or irregular a woman’s cycles are, modern NFP is effective. Rhythm was not effective because it was based on a statistical “average” cycle of 28 days, and not every women’s cycle is 28 days every month (or even ever). Modern methods of NFP read the signs of the body day-by-day, and a woman discerns her fertility based on that daily information. So no matter when her fertile window comes in the cycle, she will know it. This is why variability in cycle lengths is not a problem with modern NFP.

    I find it interesting that Meg pointed to the study in India showing a very low birth rate, but that information wasn’t allowed to stand on its own as it was followed up with a “but” (in this case, “but most failures of NFP are the result of intercourse on days known to be fertile”). Uh, no kidding. Just like most pregnancies that result with condom use are the result of not putting it on correctly; or, most pregnancies that result while on the pill are the result of missing doses. It is disconcerting that while this is routinely done when talking about natural methods, no one touts the effectiveness of artificial methods and feels the need to follow that up by citing the human errors that often cause their less-than-perfect effectiveness.

    Third, when quoting effectiveness rates, we should try to use up-to-date information. And, let’s not quote method effectiveness rates (perfect use) for everything else (the Pill is 99% effective), and user effectiveness rates (actual practice) for NFP.

    One of the most recent, well-done scientific studies on the Sympto-Thermal Method of NFP was done in Germany in 2007 (P. Frank-Hermann, J.Heil, C. Gnoth, et al. “The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study,” Human Reproduction, 2007, 1-10). It found a method effectiveness of 99.6% and a user effectiveness of 92.5%. For the record, Contraceptive Technology lists a typical use (user effectiveness) rate of 85% for the condom (http://www.contraceptivetechnology.org/table.html)

    Finally, the one point that I wholeheartedly agree with Meg on is that in terms of the cultures that she is working in, NFP may indeed be difficult due to the need to have both partners on board. We believe NFP should be always be taught within its moral context and not merely as a method of family planning. It differs from all other methods from a moral perspective in that it upholds the God-given dignity of both spouses. Nothing about either partner – as God created him or her – is compromised or changed for convenience. If fertility is present on a given day, and a new life is not what is best for the family at the moment, then the couple abstains until the fertile time has passed. No wife has to ingest chemicals (insert a device, take a shot) to tamper with her fertility in order to be available to her husband. No man has to withhold a natural part of himself (semen, via a condom) or alter himself surgically in order to be available to his wife at all times. Instead, fertility is respected and the couple wait until they can give a complete gift (intact, as God designed) of themselves to each other. Artificial methods compromise human dignity because one or both of the parties involved need to alter how they were designed by God. Marital relations are supposed to reflect the marriage vows, which involve a complete gift of self (for better, for worse). Spouses are supposed to say “I take you as you are” rather than “I take you on my terms, and I don’t like your fertility.”

    Of course, what God meant sex to be and what is reality are often worlds apart, and it likely would seem absurd to most Cambodian men to abstain during the fertile time of his wife’s cycle because he so highly values how she was created by God to be his most suitable partner. We live in a crazy, mixed up, fallen world and we miss the big picture because our own personal wants and needs overrule what is often right. Of course married people have a right to sex with their spouse. But so often we want it on our terms only (sterile), and there is a multi-billion dollar a year contraceptives industry able and willing to help us get what we want. But that doesn’t make it right.

    Meg and others like her are working in difficult situations, trying to find solutions that offer real hope. I contend, however, that even in a culture where the attitudes of men often outweigh the needs or wants of women, offering condoms in order to preserve marital harmony and prevent violence is a false solution, because it is perpetuating the notion that the woman should be available as a sexual release for a husband who cannot or will not abstain temporarily. This is a woman who is being used, not loved, like it or not. And for a woman to participate in this is to say, “Go ahead and use me; at least I won’t get hurt (i.e., pregnant).” This is probably an exaggerated comparison, but why not also pass out football padding and equipment to women who get hit by their husbands so that they won’t get hurt?

    That being said, I would hope that in the various approaches that are being taken to help women, that there could be educational programs to challenge some of these cultural attitudes that enslave women to various degrees, rather than just throwing a bandaid (condom) at a very real problem. A tall order, I know.

    • September 13, 2010 9:34 pm

      Hi Ann,
      Thanks for your thoughtful and detailed response! I’m glad to hear from a NFP advocate.
      I’m in villages today, but will try to reply to your points later today or tomorrow when I’m back in the office.
      In the meantime, anyone else want to weigh in?

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