Not only the quality or safety of the prevailing contraceptive methods is problematic but also the institutional contexts through which these
methods are administered. What we might call the social relations of the clinic, as they apply to reproductive health care, directly affect women’s contraceptive use in ways that in some instances impede rather than facilitate contraceptive effectiveness. This is particularly true for teenagers, with whose special needs gynecological practice and clinical bureaucratism are sometimes out of touch.
Physicians and clinics function as "gatekeepers" to accurate knowledge and assurance about contraceptive alternatives for teenage girls,82 and their authority (to prescribe or withhold) can sometimes have a negative influence on contraceptive use. What this has meant for teenage patterns of contraception is a pervasive tendency toward pill use and then discontinuation that may result from the procedures of doctors and family planning clinics as the sole sources of birth control information and services. Zelnik and Kantner document the "massive shift to oral contraception" that occurred among U. S. teenagers in the 1971-76 period, which coincided with the doubling of federal funds for family planning services. While private physicians are still the providers of birth control for the majority of white teenagers, 58 percent of black teenagers and 44 percent of white teenagers are serviced by organized clinics.83 It is interesting to compare patterns of contraceptive use among teenage clinic patients with those among the teenage population as a whole, including those who rely on "drugstore methods." While the pill is the most frequently used method among teenagers who use contraception, there would appear to be a large difference in its frequency depending on where birth control is obtained. According to a National Center for Health Statistics survey of visits to family planning clinics, 77 percent of teenage clinic patients in 1978 became or were pill users.84 In contrast, Zelnik and Kant — ner’s survey of teenage contraceptive use in metropolitan areas, which includes teenagers who have never visited clinics or gynecologists as well as those who have, indicates a 46 percent decline between 1976 and 1979 in pill and IUD use among white teenagers, who have a total rate of pill use that is only 38 percent, compared with 51 percent among black teenagers.85 Black teenagers, who rely on family planning clinics in significantly higher proportions than whites do, have a 40 percent greater likelihood than whites (in the 15-17 age group) of using the pill and are twice as likely to use the pill at first intercourse.86
The ironic thing about this institutionalized reliance on the pill is that, rather than result in more effective contraception among teenage women, it may result in less. This is so because when women stop taking the pill, as they frequently do because of unpleasant side effects or because of doctors’ recommendations, no viable alternative is presented or seems acceptable. With regard to private physicians as birth control dispensers, studies have documented a pattern of systemic "M. D. mismanagement" of young women’s contraception: recommending the pill and the IUD virtually to the exclusion of other methods; prescribing the pill as a means of "regulating" women’s menstrual periods without sufficient discussion of birth control; and periodically taking patients off the pill, or removing their IUD, because of clinical contraindications or just "for a rest," without providing information or advice about contraceptive alternatives. The failure of physicians to counsel patients thoroughly about safer alternatives to the pill may be even greater than usual among teenage wqmen, poor women, and non-English-speaking women, whom doctors tend to regard as incompetent to handle such methods as the diaphragm.87 Another researcher quotes a number of subjects whose pregnancies resulted from having been told by their doctors they should "go off" the pill periodically, or having experienced nausea or depression or other symptoms that discouraged continuation and not having succeeded in finding an acceptable alternative. One woman reported: "I went and got a regular gynecologist— you know, here in town—and he told me that you are supposed to go off your pills every two years and some doctors say every four years, because, I guess, you become sterile. That’s what he made it sound like— you would become sterile if you didn’t go off of them. So, I went off of them for three months and that’s when I got pregnant."88
Having surveyed this pattern of misinformation and neglect among one hundred repeat abortion patients at his clinic in Nassau County in 1974-75, Dr. Joel Robins concluded that their contraceptive failures were mainly due not to "reliance on abortion as a substitute for contraception" but to "inadequate or inaccurate advice" from their doctors. He recommended, among other things, that physicians be educated about how to provide contraceptive and reproductive information to young patients, that "nonprescription methods of contraception" be made "widely and easily available," and that "paraprofessional counselors" substitute for physicians or other medical personnel whose "lack of interest or time" so impedes their ability to deliver birth control services adequately 89
It is not only misinformation that results in contraceptive failure but also the intricate social processes through which bits of information about reproductive biology and birth control techniques are perceived and either absorbed or shelved away. It comes closer to the truth to say that "although sex is a social act, contraception is rarely thought of as a set of social skills. Thus, teenagers learn about the pill or the condom, but they do not learn how to apply this knowledge in social situations"90 or how to connect the technique with the experience (real or fantasied) that the social situation conjures up. The question for feminists is not simply whether physicians or clinic personnel "manage" women’s reproductive lives poorly or adequately; rather, it is whether or under what conditions "management" by professionals allows young women, and men, to know what they need to know to make their way through the thicket of sex and reproduction.
The very notion of family planning is obviously inappropriate to the sexual and contraceptive needs of young unmarried people, who are not "planning families" but negotiating relationships and/or sexual adventures (including the separation from family). Moreover, the atmosphere and professional/bureaucratic procedures of the clinic or the "sex education" classroom may have the effect of containing birth control within a sterile discourse on "sex hygiene" and medical problems that severs it from its real connections, especially for teenagers, with sexuality as it is constructed for them—a sexuality formed out of relationships, love, and danger. From a feminist perspective, the separation of birth control from sex may inhibit knowledge that is useful, that connects the experience of the body to feelings and to sensual social life. Birth control as a knowing and effective "social act" thus requires a basic transformation of the modes through which knowledge is transmitted; the understanding and choosing of techniques have to be integrated with discussions of gender relations and heterosexual experience in the concrete world. In fact, the feminist health movement began during the 1970s to make such a transformation, to transcend the isolation of birth control techniques from sexual and social experience.
At first glance, it would seem that nearly every available technique is ill suited to the sexual and contraceptive conditions of young teenagers. The pill, the most widely promoted method, seems to imply that sex has become part of one’s daily life, like brushing your teeth, and it requires frequent contact with physicians, who may not be sympathetic or sensitive. In addition, we still do not have adequate long-term clinical studies to show conclusively that the pill is not hazardous for younger women if taken over a number of years. The problems of the IUD (bleeding, pain, expulsion, PID) make it intolerable for most teenagers. The condom and withdrawal rely centrally on male cooperation, which is even less likely from men who are young and uncommitted; and the diaphragm implies an ease of communication with male partners and a comfort with one’s own body that may be in direct opposition to the tentativeness and sense of mystery and change that characterize the adolescent girl’s body image. Also, many women (of all ages) dislike the diaphragm because they find it "messy" and unromantic. Only about 4 percent of U. S. teenagers who use contraception use a diaphragm.91
Earlier, however, I argued against this focus on techniques as misplaced, as a technological determinism that disregards the underlying social relations that give birth control methods a particular function and context. The association of the pill not only with heterosexual activity but with sexual availability is a cultural artifact, not a pharmaceutical given. Moreover, it is the endemic social relations of the clinic in an age — and gender-stratified society, and particularly the relationship between male gynecologists and adolescent girls, that makes the procedures surrounding "medical methods" (apart from their health risks) an onerous experience. Those relations are not intrinsic to the methods or to any technical form. Similarly, how young women understand and relate to their bodies is a social question, subject to radical change, as the impact of feminist ideas and practices about birth control and sexuality during the 1970s began to show.
Our Bodies, Ourselves represents a radical transformation of traditional modes of "knowing" about the intimate realms of women’s reproductive and sexual life. Reduced to its essentials, the feminist way of knowing places technical information (medical, method related, resource oriented) in the context of personal and bodily experiences of women as they are lived and reexamined in the social frameworks of gender, class, and hetero — or homosexuality. The body is "reorganized" within its social situation; women are given access to what they need to know, to gain control over their fertility and sexuality, through what they already know (e. g., about what relations with boys and men have been like).92 This is a way of knowing, a discourse, that has become accessible to millions of young women, not only through a popular book, but also through a network of feminist self-help clinics in cities where feminist organization is strong; and, probably most important, through the penetration of the clinics by feminist ideas and personnel. Symptomatic of this influence are modes of counseling and group discussion that reveal a feminist commitment to simultaneously assuring women’s health, maximizing their control, and expanding their consciousness about their conditions as women.
One example of this process occurred in an established, mainstream clinical setting. It illustrates that a safe and highly effective method such as the diaphragm can be accommodated to the sexual patterns and needs of most women in a learning context where openness about sexuality, collectivity rather than isolation, and careful instruction and counseling are emphasized. In the early 1970s, with feminist consciousness and concern about the pill in full swing, researchers at the Margaret Sanger Research Bureau in New York studied a group of more than two thousand mostly unmarried women, around 10 percent of them teenagers and 10 percent nonwhite, who became diaphragm users through the bureau’s program. Most of the women were high school graduates or attending high school, and "some 28 percent were either low — or marginal-income women. . . ." These women were counseled fully, in a group discussion led by a nurse, about all available methods of contraception and their "advantages and disadvantages." They were instructed precisely in the use of the diaphragm, their own anatomy, self-examination, and every precaution necessary to maximize the diaphragm’s effectiveness and ease. Most of this occurred in a group setting. The results were an overall continuation rate, over a period of twelve months, of around 84 percent.93
In the youngest group, aged 13-17, only two pregnancies occurred—the lowest number for any age group—and only 25 percent of the women (44 out of 175) discontinued the method, for "personal reasons," during the two-year period of observation. The authors of the study attribute this success to the thorough counseling, "which bolstered the patient’s self-confidence," and "the participation of personnel who believed in the method and who possessed the skill and patience to teach it. . . ,"94 If the methods of contraception inherently discourage effective teenage use, then one would be hard pressed to explain why a steadily growing majority of teenagers who engage in sexual intercourse use contraception successfully and avoid unwanted pregnancy. The development of a "new and imaginative approach" to contraception designed for teenagers (e. g., a "morning-after" device that can be easily hidden from parents, doesn’t rely on men, and doesn’t require a prescription) would not transform the social relations and cultural mixed messages that impede some women from using contraception,95 We need to account for the fact that, especially among very young women, the rise in abortions sometimes results from using no contraception of any sort, safe or unsafe. At the same time, we need to understand that problem as basically rooted in social, sexual, and political arrangements, not moral or technological failure; to see technological failure as growing out of the politics of sexuality and reproduction. But even after those arrangements are transformed in ways we have not yet begun to imagine, abortion will remain necessary for women. For "perfect" contraception—that defies human error, unforeseen circumstances, or medical risk—is an illusion.