There are times in life when women and couples need to space, avoid or postpone pregnancy. This total time period of managed birth control, non-consecutively, can typically last anywhere between 10 and 25 years.
When trying to decide about which birth control method/s to use, we usually prioritize those methods that will be the most effective statistically, safe, hassle-free and easy to use. We most likely consult with a gynecologist for their opinion too.
For some, it is a simple, technical decision without serious consequence. For others, it can be challenging and complicated. Couples don’t often consider how a method might affect their intimate relationship and sexual experience.
If physicians are uncomfortable discussing sexuality in general, they are not likely to talk about the sexual side-effects of common birth control methods in particular. Beyond the general discomfort, the issue is far off the clinical radar screen for most. We are not talking about something rare or unusual but actually something quite common and disturbing. Let’s just call it the elephant in the bedroom that is sometimes hard to see.
During our 35+ fertile-bearing years, most of us are focused on avoiding or postponing pregnancy for shorter or longer periods of time. While there are at least 20 different methods of contraception available, it is unfortunate to face the statistic that 40-50% of all pregnancies are actually unintended. Why is that?
Among other reasons, we know that using contraception over time correctly and consistently, is not easy to implement. The research literature shows that during these years, 30% of all women are trying up to five different methods. Up to 50% report low satisfaction with the methods they are using, so they stop or switch within the first year of use.
There are tens of thousands of research articles about contraception in the scientific literature. There are less than 100 which have examined the influence of birth control methods on the sexual experience. So it should come as no surprise that physicians ignore or dismiss this issue and women and couples often suffer in silence.
We know that doctors tend to prioritize statistical efficacy and ease of use when communicating about and recommending contraception to their patients. Gynecologists may mention the typical side effects of hormonal methods like spotting, nausea, breast tenderness and headaches while in the same breath, emphasize that these are usually short-term effects only. Not a word is uttered about how various methods might impact the “pleasure factor.”
The paradox of hormonal birth control
We need contraception so we can separate pregnancy and parenthood from pleasure and intimacy. The whole point of contraception is to be able to separate the fear of pregnancy from pure pleasure in intimacy and “letting go”. What’s the gain of taking precautions if the sexual experience is diminished as a result?
All methods come with a price and have advantages and disadvantages that affect people differently. We are guinea pigs. We have to put a method in our bodies before we know its effect.
Women and men are often caught between a rock and a hard place because it is never easy to reach the desired goals of achieving high efficacy on the one hand, while enabling maximum pleasure on the other.
Even though its men who are fertile 24/7 and women only a few days of the month(!), most methods are for women and only a few exist for men.
Birth Control methods can be divided into seven main categories:
- Hormonal birth control, including pills and IUDs which secrete hormones
- Non-hormonal IUDs
- Barriers like diaphragms and cervical caps
- Spermicides
- Natural methods and variations
- Male methods like condoms, withdrawal
- Sterilization methods like tubal ligation and vasectomy
All methods impact the sexual experience, in both positive and negative ways. Nearly all methods have some effect on our bodies and biology, our psychological and emotional health and our social and interpersonal interactions with sexual partners.
If we think about sexual pleasure as an umbrella, there are many spikes which help to support it: desire/libido, arousal, self-image, lubrication, orgasm, spontaneity, and couple dynamics. Sexual pain/discomfort is also a factor (see graphic).
This article will provide a brief overview of each type of method with a summary of the ways in which that method can either enhance or diminish the sexual experience. So here we go.
Hormonal birth control
Hormonal birth control come in different forms: pills, vaginal rings, patches, injections and implants which contain both synthetic estrogen and progesterone, or progesterone-only formulations. The latter is typically recommended for breast-feeders and those with certain familial cancer histories who should not be using estrogen.
When secreted naturally during the menstrual cycle, estrogen and progesterone not only prepare the body for ovulation and pregnancy on a cyclical basis, they also have important functions on nearly all organs in our body. This means that our natural hormones impact our overall health and not just our fertility. When synthetic combinations of these hormones are used, the effects can vary.
Advantages
- Hormonal birth control offers tremendous freedom, autonomy and a sense of control among users. They allow for maximum spontaneity and peace of mind.
- When used correctly, they are very effective (over 90%). That means being able to “let go” and enjoy sexual intimacy.
- They can provide definite relief and calm while adding quality of life for women who suffer from cycle irregularity, menstrual pain, fibroids and other gynecological problems.
- These methods can also help stabilize mood for women who experience severe premenstrual tension (PMT) and premenstrual dysphoric disorder (PMDD ).
Disadvantages
- Hormonal birth control can reduce libido in users because they can lower the “desire” hormone, testosterone (T), which circulates in the blood stream. Women produce testosterone in their ovaries and adrenal glands in smaller amounts than men do, but this smaller amount is no less important for women’s libido and interest in sex than it is for men. Hormonal methods reduce testosterone by increasing another hormone called SHBG (sex hormone binding globulin) which blocks T.
- Hormonal birth control can cause recurring yeast (candida) infections. Vaginal dryness and pain can be the result of low natural lubrication. Research is beginning to document another downside to hormonal birth control ,- that lower T in women can actually reduce sexual sensations and cause the labia to shrink in size.
- Research has shown that even after Hormonal birth control is stopped, T-levels can remain low for a long period of time. Hormonal birth control can also cause headaches, migraines and mood swings including depression and anxiety.
- Hormonal methods can affect our mood by lowering the amount of brain chemicals (neurotransmitters) which communicate with the rest of the body. The main brain chemicals affected are GABA, serotonin and dopamine, which are related to sleep, relaxation, stress and overall well being.
- Based on the symptoms that women experience, most gynecologists compare the use of hormonal methods to a state of “pregnancy,” because women may experience weight gain, breast changes, and nausea.
- On the other end of the spectrum, other health professionals liken it to the body being in a state of “menopause” because these methods can cause vaginal dryness, lower libido and sexual pain. Each woman will have her own, unique experience.
Long-Acting Reversible Methods (IUDs)
These offer the same benefits as other hormonal methods and are considered even more effective, statistically.
Advantages
- Hormonal IUD’s truly enable sex to feel “natural.” They are literally hassle free because the device sits in the uterus typically for up to five years.
- Hormonal IUDs typically reduce cramps, PMS, and make periods lighter. Some will stop menstrual bleeding. Sexual desire, mood and spontaneity could definitely be enhanced in cases like this.
- Since IUDs confer even higher efficacy than other methods (like pills), they can only improve confidence and a worry-free atmosphere regarding unintended pregnancy.
- These methods can help each partner focus on their own and their partner’s pleasure.
Disadvantages
- Regular non-hormonal, copper IUDs tend to cause spotting and irregular bleeding between periods as well as heavier and longer menstrual bleeding.
- For many women, especially nidda-observant women, these side effects will cause stress, frustration and fewer days of intimacy with their partners. These side effects can completely derail a woman’s sense of control and sexual self image.
- They can cause pelvic cramping and pain, acne, headaches, breast swelling and weight gain.
- Up to a third report depression after removal.
- Sometimes the male partner can feel the string which can cause an unpleasant sensation to the penis.
- In terms of the relationship, if a woman experiences unpleasant side effects, her sexual desire and libido could be negatively impacted.
- Likewise, the male partner may experience his partner’s side effects in a way which decreases his desire and pleasure as well.
- The sexual side effects of IUDs will really depend on the body-mind effects caused by the device in a particular person.
- Even though many women are willing to pay the “sexual price” and use an IUD because of its alleged high efficacy, it’s important to remember that lots of women get pregnant with IUDs.
Female Barrier Methods
Diaphragms, cervical caps and female condoms can impact the sexual experience and couple dynamic in different ways.
Advantages
- These methods allow for control and peace of mind, especially if skill and experience are acquired beforehand. When male partners initiate and learn to insert the device themselves, this can enhance the overall experience of trust and intimacy together.
- Male involvement with barrier methods signals a desire to be an equal and active partner in the shared responsibility for safeguarding a couple’s sexual health.
- These methods do not interfere with hormonal mechanisms so desire, libido, and natural lubrication are not affected.
- When used correctly and consistently, these methods can achieve a high efficacy rate.
Disadvantages
- Although they can be inserted ahead of time and allow for a high degree of spontaneity, they can also hinder spontaneity because they are something you have to find time for and “take care of” before engaging in intercourse.
- Barrier methods may not necessarily be conducive to intimacy and sensuality if a woman is uncomfortable touching her body or inserting a device into her body.
- The use of barrier methods can alter the sexual experience depending on if a sexual relationship is new vs being long-term and when sexual intercourse occurs more frequently vs less.
- Some male partners may feel the barrier during intercourse and this might affect their level of pleasure.
- For observant Jewish men, knowing that their ejaculate fluid is blocked from moving freely into the woman’s body could cause a “spiritual” barrier which diminishes their overall sexual experience.
Spermicides
There are many varieties of spermicides on the market: sponge, suppositories like Pharmatex or ENCARE, and vaginal contraceptive film (VCF) which comes in different forms like foam or individual vaginal applicators.
There are chemical spermicides and also natural gels made of natural acids which more women are using today. These include Caya gel, which is used with a diaphragm, and Phexxi, a vaginal contraceptive gel that changes vaginal pH to become inhospitable for sperm.
Advantages
- These methods do not interfere with desire, arousal or mood as they are non-hormonal. They are woman-controlled and easy to obtain.
- They are relatively easy to use.
Disadvantages
- They can interfere with spontaneity if inserted after oral sex, for example.
- Some of these products require a 5-15 minute wait time and some are only active for up to an hour.
- In a minority of cases, the chemical formulations can cause itching or burning.
- When used in a new relationship, they could be awkward.
- Over time, when chemicals break down in the vagina, there could be aesthetic issues around smell, taste, and spermicidal fluids leaking from the body.
- If used on their own (without an additional male method), these methods are considered less effective than those discussed above.
Natural Methods
There are about 20 variations of Fertility-awareness-based methods. These can be divided into three categories:
- Methods based on calculation/calendar/past cycle lengths to predict fertile days
- Apps and devices which “predict” current and future fertile days based on various parameters like menstrual cycle changes and/or basal body temperature tracking.
- Fertility Awareness Method (FAM) and other Sympto-Thermal Methods (STM’s) based on the reproductive hormones which control the body, cycle and fertility. These methods enable women to identify their “fertile window” based on the daily observation of 2-3 fertility signs in real time (basal temperature, cervical secretion and cervical position). They are “observational” methods and involve no calculations or prediction.
Comments about the impact of natural methods on sexuality and the sexual experience will be limited to group C, because FAM and STM methods are considered the most rigorous and effective among the natural methods.
Fertility Awareness Method
Advantages
- Couples who successfully integrate FAM/STM’s into their sexual relationship gain a sense of control and confidence.
- There is nothing more empowering than a woman who has a strong and confident connection with her body, who trusts her body and knows on a daily basis when she is and is not fertile.
- Self efficacy and enhanced body image can have a huge impact on sexual intimacy and pleasure because the user knows her body and exactly when she can truly “let go” and flow with sensual pleasure without any fear of an accidental pregnancy.
- With partner support and involvement, there is greater equality, mutuality and shared responsibility.
- After learning to implement the method, couples can enjoy complete freedom and spontaneity for up to ¾ of the cycle.
- For niddah-observant couples this time is typically 10-12 days on average.
- FAM/STM’s work best in stable relationships and when personal goals and values are in sync with the method and the couple’s lifestyle.
- They can even help strengthen the relationship when both partners desire taking equal responsibility for their sexual health.
Disadvantages
- It takes 7- 10 hours to formally learn FAM and a few months of experience to develop essential skills and confidence for effective use.
- It can reduce spontaneity during the fertile days of the cycle (less than a week, when high estrogen can trigger a higher libido). If couples desire sexual intimacy and intercourse during these days, they need to rely on two back-up methods simultaneously, for increasing efficacy. These method/s require a high level of commitment, motivation, discipline, maturity and responsibility.
- If the male partner is not supportive of the method, it could negatively impact the overall sexual experience.
Male methods
Male methods, such as condoms and the withdrawal method, are widely available and safe when learned and used correctly. Both methods can add stress to the woman because she has to completely trust her partner in order to “let go” and enjoy herself. For some women, when a man takes responsibility for protection, it can offer added value to the sexual experience.
Condoms
Advantages
- Women can enhance their partners’ arousal by taking an active role and rolling it on to an erect penis.
- Condoms offer an aesthetic benefit for those who don’t like the messiness of sexual fluids leaking on their bodies.
- For men who have erection issues or who experience early ejaculation, condoms can help inhibit orgasm.
- There is spontaneity… up to a point.
Disadvantages
- condoms can lessen arousal sensations and can affect erection time and control. They can sometimes induce performance anxiety and stress, particularly in a new relationship.
- Prolonged penetration with a condom can cause dryness and pain for a woman. Some men and women have an allergy or sensitivity to latex (which can be solved by using non-latex condoms).
- Condoms can decrease orgasm intensity in men. And there is always the possibility of a condom breaking, even with correct use and experience.
- Many men are reluctant and even refuse to put on a condom because of the discomfort and inconvenience it causes in terms of their sexual arousal. This situation can have a serious negative impact on a woman who feels like her partner is being selfish, inconsiderate and dismisses the importance of condoms in preventing sexually transmitted diseases.
The “pull-out” method
Advantages
- The “pull-out” method is the oldest method in human history and certainly offers the possibility of spontaneous and natural sex.
- It doesn’t interfere with his or her sensations or hormones.
Disadvantages
- Withdrawal does not protect against sexually-transmitted infections. This is important in a one-time or short term relationship.
- Withdrawal can be risky if the man lacks full control because of alcohol or cannabis use.
- When men have to “pull out” to prevent ejaculation, this can seriously interfere with their level of sexual satisfaction and a woman’s ability to reach peak arousal and orgasm.
- There is also the possibility (albeit small) of unintended pregnancy if sperm remains in the pre-cum from a previous ejaculation.
In short, both methods have their advantages but can interfere with spontaneity and the flow of passion (unless there is a positive attitude and acceptance of the methods). Male methods, together with abstinence, are particularly problematic in Jewish law and are usually viewed as unacceptable.
Sterilization methods
While unpopular and hardly available in Israel, sterilization deserves a mention. In North America and Europe, up to 25% of women choose tubal ligation and a smaller percentage of men choose vasectomy from a certain age as their choice of contraception.
Discussion
This review raises a number of issues and questions. Whose pleasure is at stake? We know from research and surveys that women are more likely to concede their pleasure over their partner’s and that women report giving preference to their partner, which often translates into forfeiting her own pleasure.
When a woman experiences sexual pain, she is more likely to keep going, grin and bear, at the expense of her enjoyment. Why do women care more about their partner’s pleasure than their own? It has a lot to do with the religious and cultural scripts about what is supposed to happen in the bedroom. As a result of traditional gender roles and expectations:
- Women are more invested in meeting their partner’s needs
- There is often a power gap in equality between the sexes
- Many women believe they don’t have the same right to sexual pleasure as a man does.
- Women get mixed messages from society about what it means to be sexual as opposed to being sexy.
- Pain and physical discomfort have been normalized for women – periods, childbearing and sex. In other words, “it’s supposed to hurt.”
When women and couples contemplate and juggle their contraceptive options, they will benefit greatly by asking where pleasure fits into the puzzle. It is not always easy to prioritize competing values.
Couples want high efficacy, safety, comfort, health, peace of mind, spontaneity, freedom, easy access, naturalness, halachic acceptability, low economic and psychological costs, and a method that does not interfere with sexual pleasure.
Unfortunately it is not possible to obtain all these values in any one choice. If your pleasure is being compromised, then it may be worthwhile to check if your method might be part of the problem.
Using contraception is neither “technical” or simple. The stress from side effects and the possibility of unintended pregnancy is real and complicated because it involves so many aspects of a woman’s body and mind: her hormones, menstrual cycle, overall health and quality of life, her sexuality, fertility, self-image, and interpersonal relationships.
One size does not fit all and there is no perfect, ideal method. All exact a price. So it is important to consider the needs of both partners and not just the methods themselves.
Using birth control should not come at the expense of personal pleasure, fulfillment and satisfaction. If your method/s diminishes desire, arousal, sensations, pleasure, moods and ability to orgasm, then maybe it is time to re-evaluate.
Just being aware of how methods may be diminishing your senses and pleasure is a first step to acknowledging a problem, talking about it and moving towards finding a new solution.
This article is based on a joint presentation by Michal Schonbrun and Joanne Zack-Pakes on behalf of the Rotem Center, Sept 30, 2020.
