The current generation of fertile adults has not known a time when contraception was not safe and easily available. As a result, they have grown up with the unquestioned belief that was expressed with the arrival of the oral contraceptive pill: you can have ‘sex without reproduction’.
But is this really true? Has there really been a rupturing of the link between sex and pregnancy? The abortion rate would seem to indicate not. While unwanted pregnancy does not account for all cases of abortion performed annually in Australia (as opposed to abortion where the pregnancy poses a threat to the mother’s life, for example), it certainly accounts for most of them. In fact, one of the factors that drove the demand for accessible abortion was the belief that it was no longer necessary to accept pregnancy as an inevitable consequence of being sexually active. But regardless of what our society would like to think, the reality is that fertile couples who engage in sexual relations will always have a chance of becoming pregnant.
Yet the myth that sex is no longer connected to child-bearing persists, and the thought that there might be ethical objections to the use of contraceptives in marriage does not occur to many Protestant couples. We may take time to consider which form of contraception we should use, but very few couples pause to consider whether they should use it at all. We are used to the worldly idea that we can control our child-bearing just as we can control (at least, we like to think so) most other areas of our lives. It is interesting to note, however, that contraception was opposed by Protestants from the time of Luther right through until 1930, when the first institutional moves towards its acceptance occurred. Even today, many churches (most notably the Roman Catholic Church) reject most forms of artificial contraception.
Is it morally permissible for married Christian couples to use contraceptives? There are at least two important ethical questions to be answered:
- Is it ever morally permissible for Christians to use contraception?
- If so, are there any particular methods of contraception that should be avoided?
This chapter will look at both of these questions. I apologize in advance that doing so will take some time—but the issues are complex and have a long history. The chapter falls into three parts:
1. A brief history of contraception, which looks at how views towards contraception have developed and changed in Christian history (depending on level of interest, some readers may wish to skip this section).
2. A theology of contraception, which looks at the Bible’s teaching on whether it is morally permissible for Christians to use contraceptives.
3. Understanding different contraceptives, which looks at the wide range of contraceptives available, and at the moral implications of using each of them.
In all of this, my intention is not to make anyone feel guilty for past choices. I would like to encourage you to think about this subject prayerfully, and use the information given to inform your future choices.
1. A brief history of contraception
There are ancient Egyptian records dating from between 1900 and 1100 BC providing recipes for women to avoid pregnancy. Formulas include ingredients such as crocodile dung, honey, acacia tips and dates, which were smeared around the vulva or placed in the uterus in an attempt to prevent sperm from entering the uterus. Ingredients like sodium carbonate appear in recipes for contraceptives in European literature, so it is likely that some of this knowledge persisted to Christian times. We can be confident that the withdrawal technique was known amongst the Hebrews by the story of Onan (Gen 38:8-10). The Talmud contains references not only to this technique, but also to pessaries, sterilizing potions and sterilizing surgery. Ancient Graeco-Roman society was educated by Aristotle’s History of Animals and Pliny’s Natural History. Although these writers were more interested in the underlying science, they did give instructions for contraception. By the second century AD, the Greek gynaecologist Soranus of Ephesus wrote about the association between ovulation and fertility, and promoted a flawed version of the rhythm method. He also gave information on potions and pessaries, as well as a rather less scientific method of contraception which involved the woman getting up after sex, squatting, and sneezing loudly to dislodge the sperm! (Don’t try that one at home.) Some of his contemporaries recommended an ointment to be applied to male genitals (possibly as a spermicide), and amulets (perhaps suggesting, if magic was worth a try, that none of the known contraceptives were particularly reliable). Soranus’ book, Gynecology, was the most important guide to contraception not only during the time of the Roman Empire but also, through the Arabs, throughout medieval Europe.
There is no doubt that knowledge of contraceptive techniques existed in biblical times. Use of them, however, was not thought to be common in Israel due to the value placed on child-bearing in the Old Testament. God blesses humanity in Genesis 1:28, and commands the man and woman to “Be fruitful and multiply”. This instruction is repeated after the flood (Gen 9:1), and in Deuteronomy, Israel is told that God “will love you, bless you, and multiply you. He will also bless the fruit of your womb… There shall not be male or female barren among you” (Deut 7:13-14). (See further biblical references to contraception below.)
While the use of contraceptive methods is not thought to have been widespread amongst the Hebrews, there is no doubt that it was widespread amongst the Romans. Although sexual immorality was rampant in the late Roman Empire, so was childlessness and declining birth—so much so that laws were introduced to ban contraceptives in an attempt to increase the population size. It is unlikely that the Jews or the New Testament Christians would have been ignorant of such a prevalent social phenomenon.
Philo (20 BC-50 AD) was the earliest Jewish philosopher to discuss contraception, and he is thought to provide an example of Jewish thought on marriage at the time of Jesus. He was influenced by the Stoics, an austere school of Greek philosophy. The Stoics mistrusted emotion and tried to control bodily desires by rational thinking. They were more interested in justice than in love. Marriage based on passion, therefore, was suspect. According to Stoic beliefs, there must be another reason for marriage, and plainly that was reproduction. While Philo rejected the Stoic elimination of all emotion, he nonetheless regards overly strong desire for one’s spouse as a source of wickedness: “Now even natural pleasure is often greatly to blame when the craving for it is immoderate and insatiable… as the passionate desire for women shown by those who in their rage for sexual intercourse behave unchastely, not with the wives of others, but with their own”. From other writings, it seems that ‘behaving unchastely’ refers to having sexual intercourse for pleasure. He interprets the Old Testament as teaching that God blesses married couples who have intercourse specifically for children, such as Abraham and Sarah, and curses those who don’t, such as Onan, who used Tamar without impregnating her (Genesis 38). His writings influenced a number of second-century Church Fathers.
Noonan comments that the development of Christian doctrine is usually a response by the Christian community both to meditation on Scripture and to the pressures of the environment. Further development of an early Christian doctrine of contraception is thought to have been a reaction to the two most influential attitudes in the Greco-Roman world—the Gnostics and the secular pagans.
The Gnostics were a heretical sect within early Christianity who regarded the physical world as evil and corrupt. For the Gnostics, true spirituality was mystical and non-physical. Accordingly, they believed in total celibacy and condemned marriage as a sinful impediment to true spirituality and godliness, bolstering their arguments by appealing to the example of Jesus. They pointed to those parts of the New Testament (such as 1 Corinthians 7) that teach that singleness and celibacy are valid options for Christians.
Clement of Alexandria (c150-215 AD) argued against the Gnostics that marriage was legitimate, its purpose being procreation. He turned to the law of nature as described by Paul in Romans 2:15 to construct a natural law of marriage, contrasting the natural and purposeful act of procreation with both sexual license and forced abstinence within marriage. He taught that to have sexual intercourse in marriage “other than to procreate children is to do injury to nature”.
Thus ‘nature’ became a key factor in orthodox Christian teaching, and has been the basis for Roman Catholic teaching on sexuality ever since. Interestingly, the early Church Fathers (such as Origen, Clement, Ambrose and Jerome) used the concept of ‘nature’ in three distinct senses. One sense compared sex and the sowing of a field. The idea here was that a pattern discovered in a process uncontaminated by humans was ‘natural’, and so could safely be translated into law for humans. In a second sense, the natural was seen to be what animals do—once again, since human sin was not involved, such activity could be held up as a universal pattern for behaviour. The third sense of ‘natural’ related to what was observed in the human body, particularly the function of different organs—so the fact that ‘eyes are to see with’ told us what was natural to eyes. Such functions were held to be self-evident, requiring no further proof; and they were not necessarily seen in context of the whole body.
In summary, the natural law approach led the early Church Fathers to conclude that sexual desire was evil, as it could lead a man to use his wife for purposes other than procreation. Once you sow the seed, you should wait for the harvest, not keep sowing more seed upon it. While a husband should love his wife, love and sex were seen as separate. This meant that sex for pleasure alone, sex during menstruation, sex during pregnancy, sex in old age and sex with contraception were all evil. Unnatural sexual acts were also condemned.
There were some dissenting voices. In the late third and early fourth centuries, Lactantius and St John Chrysostom defended Paul’s teaching that marriage was not just for parenthood but also to promote sexual purity, implicitly allowing some license for more frequent sexual union in marriage. However, they did not extend their arguments to allow for contraception.
Church opposition to contraceptive use is most strongly influenced by the writings of Augustine of Hippo (354-430 AD). As a young man, Augustine was involved for 11 years with a new religion, Manicheanism, which promoted frequent non-procreative intercourse and abortion. It is thought that Augustine’s teachings on sex and contraception were a direct reaction to his involvement with the Manichees, against whom he wrote two books within a year of his conversion.
Augustine held that the purpose of marriage, and therefore of sexual intercourse within marriage, was procreation. He reasoned that if, as the Bible teaches, man and wife become one flesh in sexual intercourse (Gen 2:24; Matt 19:5; Eph 5:31), then man becomes all flesh in intercourse, which is a threat to his spiritual freedom. Marital sex must therefore have an external purpose to justify this danger (i.e. procreation). Furthermore, in opposition to the heretical teaching of Pelagius, Augustine taught that since original sin was transmitted through sexual generation, sexual desire (which he saw as bad) had to be balanced by the good of possible procreation. Otherwise, sexual relations, even within marriage, were sinful. He opposed contraceptive use even within marriage as morally corrupt, suggesting that it turned matrimonial intercourse into prostitution and the wife into a harlot. He used the story of Onan as an example of judgement for avoiding the propagation of children in marriage. He particularly opposed the method of ‘natural family planning’, which was the contraceptive strategy used by the Manichees. (It is ironic that the main method singled out and condemned by such a prominent church spokesman on sexual matters is the only one allowed by the Catholic Church today.)
Augustine summarized his position by claiming that the goods of marriage are offspring, fidelity and symbolic stability—proles, fides, sacramentum. There is no mention of love between spouses. Procreation was only to be avoided by complete abstinence. And, according to his reading of the Bible, since virginity is preferable to marriage, continence in marriage is also preferable to intercourse. Augustine’s powerful presentation of the case against contraception was hugely influential, and persisted within the Western church for 1000 years.
In the centuries following Augustine, opposition to contraception and sexual pleasure in marriage continued within the church largely unopposed. Pope Gregory ‘the Great’ (pope from 590-604), managed even to ‘out-Augustine’ Augustine not only by limiting married intercourse to the purpose of procreation, but also by condemning any pleasure gained during the exercise. Since most people found it difficult to separate the two, copulation itself became an unavoidably sinful activity. Contraception was unthinkable. Gregory did not consider this policy to be anti-marriage or to be a new doctrine, citing Psalm 51:5 (“in sin did my mother conceive me”).
The monastic movement, which did so much to preserve and pass on Christian teaching during the period from 500-1100, was also staunchly opposed to contraception. The monastic attitude to sexuality and contraception is reflected in their ‘penitentials’—lists of sins, each with prescribed penances. Looking at penitentials written between the sixth and 11th centuries, the contraceptives described are potions drunk by women. While we don’t know how seriously penances were enforced, use of contraception was seen as a serious sin, with penance by fasting for 7-15 years (bread and water only). This indicates the gravity with which contraceptive use was viewed. At the same time, anal or oral intercourse was also regarded as a serious sin, often viewed more seriously than homicide or abortion. (This suggests that control of lust was the key factor, rather than the protection of life.) Coitus interruptus (the withdrawal method) earned a penance of up to 10 years. Intercourse where the woman is on top of the man was rejected on grounds that it impedes procreation (actually untrue) and is ‘doglike’. It received a penance of 40 days (and even more if it was customary behaviour).
The most significant outcome of the penitentials for the doctrine of contraception was the text Si aliquis, which became canon law in the 13th century. Its first expression was as follows: “If someone (Si aliquis) to satisfy his lust or in deliberate hatred does something to a man or woman so that no children be born of him or her, or gives them to drink, so that he cannot generate or she conceive, let it be held as homicide”.
In 1230, Pope Gregory IX directed Dominican monk Raymond of Pennaforte to make a collection of decrees (the Decretals), which was to become Catholic Church law for the next 685 years. Si aliquis was included, with artificial contraception once again being equated with homicide. Along with 6 centuries of sexual behaviour interpreted by the penitentials, this created the mentality that marriage was for procreation, that sexual behaviour beyond the ‘missionary’ position was objectionable, and that contraception was evil.
By this time, the Catholic Church’s opposition to contraception was settled, based on the natural law approach pioneered by Clement, on Augustine’s teachings, on the rules and penances of the monks, on Si aliquis, and on a consistently expressed theology that saw procreation as the only legitimate purpose of marital intercourse.
Thomas Aquinas (1224-1274 AD) provides us with the classical expression of the Catholic view. Highly influenced by the teaching of Augustine, he took Genesis 1:28 to mean that the procreation of children is the primary purpose of marriage. He promoted ‘natural law’, arguing that what is in nature comes from God himself, and that while using contraception may not seem so severe a sin as, say, sins which harm our neighbour, it is still in fact a sin against God. Thomas condemned contraception because it was homicide (it destroyed potential life), it was against nature (by frustrating the aim of intercourse, which was insemination), and it destroyed marital relations (by violating the main/only purpose of marital intercourse). In this presentation, the ban against contraception could rationally be argued as necessary for the good of man. It is noteworthy that in the case of a woman being unable to conceive due to sterility or pregnancy, intercourse was not deemed unnatural. It was not the lack of procreation but the avoidance of depositing semen in the vagina that made the act ‘unnatural’.
Thomas reinforced the norm that became the basic assumption of later writers: heterosexual marital coitus, the man above the woman, with insemination resulting. This is the ‘natural’ act, established by God, deliberate departure from which is an offence against God. The gravity of the offence lies either in the harm done to the potential human life or in the frustration of the normal process of preserving the human race. Thomas also accepted the ideal of married love, and considered it possible to have marital intercourse without sin, as even animals seemed to enjoy sex.
I will not continue the story of the Roman Catholic approach to contraception, except to say that although Augustinian ideas were challenged and sanctions softened, and contraception was no longer viewed as homicide but simply as a violation of the purposes of marriage, contraception remained condemned.
With the arrival of the Reformation, Protestant church leaders such as Martin Luther and John Calvin broke with Roman Catholicism on many subjects. However, on contraception they remained largely in line with Catholic doctrine. Luther largely held to Augustinian teaching on sexuality, as well as emphasizing that children are a blessing from the Lord (Gen 1:28). Calvin argued for three purposes of marriage: companionship (Gen 1:27; 2:18, 21), procreation (Gen 1:28), and the controlled exercise of God-given sexuality (Gen 2:22). He rejected the idea that singleness/celibacy was a superior state to marriage. Both Calvin and Luther opposed contraception on the basis of Genesis 38. Noonan suggests that the Protestants’ holding of the Catholic line encouraged the Catholic Church not to change its position. The Protestant position on contraception remained largely unaddressed until the 19th century. Discussion did not really proceed beyond the condemnation of coitus interruptus on the basis of the story of Onan. Meanwhile, the use of contraceptives quietly spread.
In the late 19th century, in response to lobbying by Protestants, legislation began to be passed in the United States to suppress contraceptive use. Laws such as the Comstock Act, passed in the United States in 1873, prohibited distribution of contraceptives and birth control information (on grounds of it being obscene material). Such laws not only limited access to information about contraception but also created a public perception that contraception was to be equated with pornography (which may explain why the discussion of contraception was often seen as shameful). It was not until 1960 that the United States Supreme Court overturned a law in Connecticut that prohibited the use of contraceptives by married couples.
By the 1920s, the physiology of reproduction was being understood accurately for the first time, and the calendar rhythm method was introduced in 1932. At the same time, the birth control movement grew in the late 19th and early 20th centuries in response to the Comstock laws. Led by Margaret Sanger and Marie Stopes, the movement used arguments about the need to limit population growth in view of available resources, and the need to save poor women from abortion in the event of unplanned pregnancy. The turning point came in 1930 when Anglican bishops at the Lambeth Conference controversially voted to approve limited contraceptive use within marriage—a reversal of the strong opposition voiced ten years previously. The 1930 resolution recognized that there may be moral grounds for restricting parenthood and that limited use of contraceptives was permissible:
Resolution 15: The Life and Witness of the Christian Community—Marriage and Sex
Where there is clearly felt moral obligation to limit or avoid parenthood, the method must be decided on Christian principles. The primary and obvious method is complete abstinence from intercourse (as far as may be necessary) in a life of discipline and self-control lived in the power of the Holy Spirit. Nevertheless in those cases where there is such a clearly felt moral obligation to limit or avoid parenthood, and where there is a morally sound reason for avoiding complete abstinence, the Conference agrees that other methods may be used, provided that this is done in the light of the same Christian principles. The Conference records its strong condemnation of the use of any methods of conception control from motives of selfishness, luxury, or mere convenience.
Voting: For 193; Against 67.
The Roman Catholic Church responded with Casti Connubii (‘On Christian Marriage’), an encyclical written by Pope Pius XI. He reiterated the Augustinian teaching that the goods of marriage were offspring, fidelity and sacrament, with offspring the primary good. God had spoken to all married people when he commanded them to “Increase and multiply, and fill the earth”. He reinforced the ban against contraception, but made an ambiguous comment about the ‘rhythm method’ of birth control, which was seen as a possible endorsement. (The confusion did not clear until 1951, when Pope Pius XII formally approved the rhythm method for all Catholic couples.)
Contraception was formally approved by the United Church of Canada in 1932, the Federal Council of Churches in the United States in 1931, and the Lutheran bishops of Sweden in 1952. In each case it was noted that the decision needed to be made carefully by individual couples according to their consciences and in light of scriptural teaching. Most Protestant denominations have since followed suit.
In the early 1960s, the oral contraceptive pill became available. R Albert Mohler Jr has noted that:
Lacking any substantial theology of marriage, sex, or the family, evangelicals welcomed the development of ‘The Pill’ much as the world celebrated that discovery of penicillin—as one more milestone in the inevitable march of human progress and the conquest of nature.
Protestant contraceptive use continued, unquestioned.
The next Catholic Church pronouncement came in 1968 with Humanae Vitae (‘Of Human Life’), issued by Pope Paul VI. It was expected that he would relax the traditional stand on contraception, in keeping with the recommendations of a papal commission and the spirit of the Second Vatican Council (1962-1965). But it was not to be. He proclaimed that “each and every marital act [of sexual intercourse] must of necessity retain its intrinsic relationship to the procreation of human life”. He pronounced that both the unitive meaning (where the married couple grow in love and companionship) and procreative meaning (where the potential for children is realized) of the sexual act within marriage are to be realized in every sexual act. The traditional opposition to artificial contraception was reiterated.
The motivation for Roman Catholic teaching is understandable: “to experience the gift of married love while respecting the laws of conception is to acknowledge that one is not the master of the sources of life but rather the minister of the design established by the Creator”. However, while wanting to acknowledge God as the one on whom all life depends (Job 1:21), Protestants do not agree with the Catholic view that observing God’s design in nature can be a reliable guide to establishing a theology of marriage and contraception. We derive our beliefs not from observation of nature but through careful reading of Scripture. Furthermore, we would not agree with the implication that contraception is as offensive as abortion, as Humanae Vitae seems to suggest.
The contemporary Protestant view recognizes the validity of sexual intercourse for “completion of marital fellowship” independent of any intention to conceive children. The resolution of the 1930 Lambeth Conference first permitted contraceptive use when chosen according to “Christian principles”. In the discussion of contraception in his multi-volume Church Dogmatics, Protestant theologian Karl Barth argues that the unitive aspect is the “first essential meaning” of sexual intercourse, and that intercourse does not need to be associated with the desire for children. He advises that use of contraception is permissible at times in marriage, but that the decision to use it should be “under the divine command and with a sense of responsibility to God, not out of caprice”. Such “Christian principles” and “divine commands” can only be worked out if we look to the ultimate guide for Christian ethical decision-making: the Bible.
2. A theology of contraception
From our historical overview we can see that the contemporary Protestant position on contraception has not been the prevalent view in the history of Christianity. How has the modern Protestant view been formed? How have we decided that it is permissible for sexual intercourse in marriage to be used for the unitive purpose only?
As we seek the Bible’s guidance on the subject of contraception within marriage, we need to look at its teaching on the purpose of marriage, and the place of sex within marriage.
This teaching begins with the divine command of Genesis 1:28 to Adam and Eve: “Be fruitful and multiply and fill the earth and subdue it”. This command is repeated to Noah and his sons after the flood (Gen 9:1). We can then see it being worked out through the story of Israel. The promise of plentiful offspring was an important part of God’s covenant with Abraham in Genesis 15, and continued through his sons. The Old Testament ends with God’s reminder through Malachi that he desires to see “godly offspring” as a result of marriage (2:15). Indeed, in one sense the whole Old Testament story is a working out of God’s promise in the garden of Eden that, through the descendants of Eve, a saviour will be raised up (Gen 3:15). This promise culminates in the New Testament with the coming of Christ.
The Old Testament considers children to be a blessing:
Behold, children are a heritage from the Lord,
the fruit of the womb a reward.
Like arrows in the hand of a warrior
are the children of one’s youth.
Blessed is the man
who fills his quiver with them! (Ps 127:3-5)
Your wife will be like a fruitful vine
within your house;
your children will be like olive shoots
around your table.
Behold, thus shall the man be blessed
who fears the Lord. (Ps 128:3-4)
Marital intercourse is seen as a duty in the Old Testament:
“If [a man] takes another wife to himself, he shall not diminish her food, her clothing, or her marital rights.” (Exod 21:10)
In the Mishnah (the Rabbinic teachings recorded in the Talmud), Rabbi Eliezer is recorded as saying that the frequency of conjugal duty “for men of independent means was every day, for laborers twice a week, for ass-drivers once a week, for camel-drivers once in thirty days, for sailors once in six months”. According to the Rabbinic school of Shammai, if a man vowed to avoid intercourse with his wife, the period should not be more than two weeks, and according to the school of Hillel it was only one week.
In the New Testament there is less emphasis on procreation, and discussions of marriage include mention of the legitimate place of celibacy. For example, Jesus’ discussion of marriage in Matthew 19:10-12 opens up the possibility that some will choose to make themselves eunuchs (i.e. renounce marriage) for the sake of the kingdom. Paul also identifies chosen celibacy as a gift that allows the receiver to remain free from the troubles of this world, and instead to be concerned with the Lord’s affairs and pleasing him (1 Cor 7:32-35). Some also see Revelation 14:1-5, where John sees 144,000 who have not defiled themselves with women, as being a further commendation of celibacy—although in light of the symbolic nature of Revelation, it is best not to push this verse too far.
While there is little specific teaching in the New Testament on the procreative aspect of marriage and sex, it is very possible that this was simply a given. When Paul commended the mutual duty of marital intercourse (1 Cor 7:2-5), it is unlikely he did not expect children to result—although it is noteworthy that he doesn’t actually mention procreation in the entire passage.
Some have suggested that there is a significant difference between the Old and New Testaments on this issue. Karl Barth, for example, argues that since the coming of Christ, the propagation of the human race as commanded in Genesis 1:28 has ceased to be an unconditional command. The Old Testament necessity to procreate the “holy sequence of generations” has reached its goal in the birth of Jesus. In the Christian community, therefore, heirs do not have the same significance that they did in Israel, because all men are children of God through their spiritual unity with the Son of God (John 3:6). Marriage remains as a valid option for God’s children, but it now represents Christ and his community (Eph 5:22-33; 2 Cor 11:2). This new state of affairs explains why it is no longer shameful to bear no children, or to be unmarried, as all God’s elect are part of Christ’s bride and will be invited to the marriage feast of the Lamb.
Christopher Ash has challenged this view. He notes that the forward-looking character of the Old Testament was focused not only on the Messiah, but also on the building of Israel and the continuance of humanity. He notes that the genealogies do at times follow the Davidic line, but not always (e.g. Genesis 10, 36). He questions the idea that pious Israelites sought offspring through marital intercourse only with the hope of contributing to the genealogy of the Messiah, because this would make the whole ethical underpinning of marital intercourse a kind of ‘procreational lottery’. Besides, Ash adds, if that is the case, there is the irony that the Messiah was eventually conceived without parental intercourse.
Whilst the difference between the Testaments can easily be overstated on this point, the emergence and endorsement of chaste singleness in the New Testament supports the claim that God does not require all humans to reproduce. This establishes the honour of the single person’s vocation. However, it does not clarify what married couples should do. As long as the world lasts, someone has to provide the human generations needed to rule and care for it. But does that mean that all married couples need to have the maximum number of children possible, or, in fact, any children at all?
Even in the Old Testament, there are suggestions that maximal propagation of the human race was never God’s intention. Proverbs 5:18-19, for example, calls upon the husband to delight himself in his wife; and Song of Songs is famous for its celebration of the delights of sexual love. Neither passage mentions children. Marital intercourse is not portrayed in these passages as merely a procreational duty. According to Pope Paul VI in Humanae Vitae, marriage is honoured only when every act of marital intercourse is open to the conception of a child. But Anglican theologian Oliver O’Donovan points out that this claim fails to recognize that sexual intercourse over the course of a marriage has its own cumulative quality, building intimacy in the context of regular physical union during the whole of the life together. The use of contraception does not reduce marital sex to the same level as a series of one-night stands, which the Pope’s view could seem to imply.
Furthermore, we know that not every act of sexual intercourse results in a child. It is not physically possible. God did not make women fertile for the whole of their adult life (unlike other animals). Whilst some couples, sadly, are completely sterile, all couples experience episodes where procreation simply is not possible—for example, during the infertile phase of a woman’s monthly cycle, and after menopause. Even if we were to build our theology of contraception on the observation of nature (as Roman Catholicism does), we would be forced to conclude that while procreation is naturally inherent to the marriage overall, it cannot be so for each and every sexual act.
Nonetheless, it is evident that God encourages child-bearing as the norm in marriage, even if it is not always possible. Apart from the original divine command to be fruitful, God encourages his people to increase in number, even in times of adversity (Jer 29:6). Similarly, in the New Testament widows are encouraged to remarry and have children (1 Tim 5:14). Biblical eschatology doesn’t overturn or contradict the created order. That is, God’s will for married couples in ‘the last days’ is the same as it was in ‘the first days’; they are to be open to having and welcoming children. The burden of proof would seem to rest on anyone who wanted to argue that children are no longer inherent to God’s purposes for marriage.
Some authors have identified prohibitions against specific forms of contraception in verses such as Deuteronomy 23:1, where we are told that “No-one whose testicles are crushed or whose male organ is cut off shall enter the assembly of the Lord”. However, this is more likely a condemnation of corrupt Canaanite religious practices involving castration than a prohibition against male sterilization. Whatever the case, we are no longer bound by such requirements under the new covenant.
Onan has the dubious honour of providing the one explicit example of contraceptive practice in the Bible:
And Judah took a wife for Er his firstborn, and her name was Tamar. But Er, Judah’s firstborn, was wicked in the sight of the Lord, and the Lord put him to death. Then Judah said to Onan, “Go in to your brother’s wife and perform the duty of a brother-in-law to her, and raise up offspring for your brother”. But Onan knew that the offspring would not be his. So whenever he went in to his brother’s wife he would waste the semen on the ground, so as not to give offspring to his brother. And what he did was wicked in the sight of the Lord, and he put him to death also. (Gen 38:6-10)
According to the later Levirate law (Deut 25:5), Onan’s duty was to raise an heir for his deceased brother by having intercourse with his brother’s widow, Tamar. But because the child born from this relationship would not be considered his, he intentionally did not complete the sex act with Tamar to avoid impregnating her. He appeared to accept the obligation placed upon him to marry his sister-in-law, but then failed to carry it through. It was a repeated sin. While this story has often been used in support of a contraceptive ban for Christians, Onan’s subsequent punishment was unlikely to be because he used a contraceptive method.
We have noted above that contraceptives were known and widely used in biblical times. If all contraceptive use was forbidden, we would expect to see it mentioned in the text. However, a passage such as Leviticus 20:10-21, which contains a long list of sexual crimes, contains no mention of a prohibition on contraceptive practices. If use of contraception deserved the death penalty, how much more would we expect it to appear? It is more likely that Onan’s punishment was due to his failure to honour his dead brother and obey God’s command. His motives were sensual and selfish, agreeing to have intercourse but preventing conception so that his own inheritance would not be diminished by the birth of a nephew. Although the penalty for defying the Levirate law in Deuteronomy was public shaming, Onan’s actions were particularly exploitative. He displeased God, and God judged him by putting him to death.
The Bible, then, does not expressly forbid contraception. Does it specifically endorse it? In 1 Corinthians 7, Paul permits abstinence from sex within marriage for spiritual purposes, but only as a temporary and mutually agreed practice:
Do not deprive one another, except perhaps by agreement for a limited time, that you may devote yourselves to prayer; but then come together again, so that Satan may not tempt you because of your lack of self-control. (1 Cor 7:5)
United States theologian John J Davis sees this as implying a larger principle where “Christian couples have the right to choose to ‘override’ the usual responsibility to procreate (Gen 1:28) for a season in order to pursue a spiritual good”. However, considering the restrictions placed on this activity by the apostle (i.e. that this is the exception, not the rule; that it is only for a set time for a specific reason, after which the couple is to come together again; and that it does expose you to moral danger), it is very hard to see that Paul is recommending abstinence in this passage as a regular method of birth control. Indeed, the passage does not even discuss child-bearing, but rather the need to be united sexually in marriage in order to be holy.
In the absence of any scriptural prohibition against contraception, and given that the Bible was written in a world where contraception was well known and widely practised, it would seem that there is a legitimate place for contraception in marriage. If this is the case, when is it acceptable?
The Genesis account of creation, where mankind is commanded to procreate, helps us approach this question. If we consider that humanity is made in the image of God and called to be God’s representatives in the world, we are not only dependent on God, without whose help no child is born (cf. Gen 4:1), but we are also persons who are free to make choices, whether good or bad (Gen 2:16-17; Gal 6:7-8). We have the responsibility to act as good stewards—as parents as well as individuals. As parents, it is not enough just to beget offspring; we are also called to nurture our children as they grow. And we know from our ethical framework that we should seek to have godly motives and perform actions that are consistent with God’s will.
With regard to our motives, as mentioned previously, we should begin sexual relations with the understanding that parenthood may be a consequence (sex without children being a myth). In view of the Bible’s high regard for children, any attempt to avoid their birth must be done with a clear conscience and not for arbitrary or self-interested purposes. If we seek to honour God in all our decision-making, we will be aware that such self-interest is clearly opposed to God’s will. However, even when our motives are right, decisions are not always simple and some situations are clearer than others.
Contraception may have a place in Christian marriage when its purpose is to time the arrival of children. Birth control allows married couples time to strengthen their love and commitment at the beginning of a marriage, before the arrival of children. Care of newborns can be demanding and tiring, and contraception can give the couple time to prepare for parenthood.
Since the responsibilities of parenting extend beyond birth, factors such as temporary financial or ministry restrictions may make timing of the arrival of children an important consideration. In 1 Timothy 5:8, Paul tells us that we are to provide for our relatives and especially our immediate family. This suggests that parents need to be responsible stewards regarding their ability to support children, and be realistic about how many they can effectively provide for. And ‘provision’ includes physical, emotional and spiritual needs. The wellbeing of children already born may require extra time between children to allow for the proper fulfilment of parental responsibilities—especially if, for example, a child is born with a disability. Such decisions should be made prayerfully and jointly between husband and wife, and with an awareness that God may overrule our plans.
A couple may have valid reasons for deciding against having children. In our fallen world, there may be times when a couple may long for the blessing of children, yet sadly see this path as unwise given their particular circumstances. For example, if we view contraception as an expression of permissible medical care for promoting health, it is possible to envisage how it might be used for such a purpose. Some contraindications to child-bearing will be straightforward, if tragic—such as life-threatening complications for the wife if she became pregnant. Selflessness may lead a mother to pursue parenthood regardless of risk while trusting God for deliverance, but it could also be argued that in the face of expected complications, it is better stewardship to preserve the woman’s life. Sometimes it is the child who would bear the burden of a poor outcome, such as through complications of pregnancy or inherited genetic disease. In such a situation some parents may pursue other means of becoming parents, for example through adoption.
Often contraindications to child-bearing may be less straightforward and require clinical judgement on the part of medical staff, as well as prayerful consideration by those involved. Reasons to consider putting off child-bearing may include seasons of poor physical or psychological health. The same decision by two different couples may derive from entirely different motives, so we must be careful not to judge others. The decision to use contraception should be made consciously, thoughtfully and with the desire to glorify God in our choices. This is not a place for legalism.
However, none of this is to say that we should choose not to have children merely from our own selfish motives. In our ethical framework, motives are important. It is wrong to avoid having children (by using contraceptives) simply to make our lives more convenient or affluent.
Some argue that it is wrong to bring children into a world in which evil is so prevalent. But as theologian Stanley Hauerwas has argued, “Christians do not place their hope in their children, but rather their children are a sign of their hope, in spite of the considerable evidence to the contrary, that God has not abandoned this world”. While Jeremiah was instructed not to marry and have children because of the coming judgement (Jer 16:1-4), once the exiles were in Babylon he wrote encouraging them to build families (29:6) as a sign that God had not forgotten his promise and would in time bring them back from captivity (29:10-14). Procreation is aligned with hope.
There are Christian couples who say they have chosen to be childless so that they may “please the Lord” (1 Cor 7:32-35), but this is faulty on at least two levels. Firstly, the passage in 1 Corinthians is discussing the situation of an unmarried Christian, for whom the intended purposes of marriage are not relevant. Secondly, it implies that an increased commitment to ministry is pleasing to God in a way that the nurture of children is not.
While I am conscious that sometimes couples who are childless through infertility are wrongly accused of selfishness, in other circumstances selfishness is indeed the reason for childlessness. There are websites dedicated to supporting those who make the choice to be ‘childfree’. They regularly deny the charge of selfishness, but the reasons given for their choice include reluctance to change lifestyle, avoiding stress on their relationship, and not wanting to take responsibility for children. Rodney Clapp sees this as a logical outcome of a society which has become increasingly individualistic, with autonomy promoted as an important ethical value: “What could hinder my autonomy more than responsibility for children, who will surely impose their own expectations and limitations on my life?” I am not saying these claims are unfounded. Research into childfree couples in recent years has repeatedly shown that they tend to be happier and wealthier than their child-bearing peers. But that is not the point.
As Oliver O’Donovan has written:
A deliberate intention to prefer other goods (such as career or wealth) to the good of children, would, in my opinion, constitute a lack of understanding consent and so, in traditional terms, a ground of nullity. A couple who do not see what children have to do with it are as far from understanding marriage as a couple who do not see what permanence has to do with it. But I would wish to distinguish very carefully between this couple and another who, while seeing quite clearly what children have to do with it, are persuaded for reasons that seem good to them (their age or health or genetic endowment, for example) that this good cannot be realized in their own marriage. There is a reluctant ‘intention’ not to have children which is perfectly compatible with a full understanding of marriage.
But overall, justifiable reasons for avoiding children will be relatively few. It is not up to us to redesign the model of marriage we are given in the Bible and to which we commit at our wedding. Most marriages will be open to children at some point—in fact, we are to welcome children as a good gift from God.
Children as a gift
The Western world is far more affluent than any society before us. Sadly, our affluence at times seems to make us more selfish rather than less. We can now see in our society the growing acceptance of a lifestyle that excludes children entirely and allows adults to live in a completely self-centred way. In such communities, children may be seen not so much as a gift but as a threat. Life is fast-paced in the city and children make us less efficient. Kathryn Blanchard says that for Christian couples within this milieu, there is a risk that contraceptive freedom paradoxically “ends up being troubling (rather than a relief) to… Christian consciences, in that children are no longer seen as gifts from God but as consumer choices in need of explanation”. This endangers the ability of Christian couples to truly welcome children. It robs us of the space to slow down and offer children the open hospitality that we ourselves have received from a gracious, loving God. In a perfect world we would have many children, and would greet them with relaxed joy and not time-pressured expectations. It is a form of Christian freedom to allow God to bless us in this way if he so chooses.
Christopher Ash has summed it up well:
If the Creator declares procreation a blessing, given to us to enable us to participate in the privilege of being his stewards in this world, we ought to value this as gift and blessing. It may be, and often is, an alarming blessing (because we are not sure if we can cope with it), an inconvenient blessing (impacting deeply on lifestyles) and a costly blessing, but it is to be esteemed as blessing not curse. This ought to be our fundamental attitude with regard to procreation.
3. Understanding different contraceptives
If we accept that contraceptive use can be ethically permissible for Christians, our next question relates to whether our choice of contraceptive is morally important. Answering this question is necessary to help us judge whether our actions will be pleasing to God. However, to answer this question we first need to understand the biology of conception.
Women of child-bearing age will usually produce an egg every month, which comes from the ovary and is released into the fallopian tube (ovulation). During sexual intercourse, sperm is released from the man’s penis and travels from the vagina through the cervix into the womb and into one of the fallopian tubes. If there is an egg there, fertilization can take place.
In our biology lesson in chapter 2, we saw that this is the first step of conception. Therefore, you might be forgiven for thinking that a contra-ceptive (i.e. something which opposes conception) would just be working to keep the sperm and egg apart. Not so. Contraceptives usually work in one of three ways:
- by stopping production of eggs
- by preventing the egg and sperm from coming into contact with each other
- once the embryo has been formed, by preventing it from implanting in the uterus.
However, any action occurring after fertilization means that a human life is already present when it occurs. How can a device with such an action be labelled a ‘contraceptive’?
Some history is needed to understand the marketing of contraceptives. After the introduction of the oral contraceptive pill (OCP) in 1958, Albert Rosenfeld was concerned that rather than only preventing the sperm from fertilizing the egg (the classic definition of ‘conception’), the pill might also terminate embryonic human life by inhibiting implantation (which you may remember occurs at the end of the first week). Since such interference would occur after conception, he realized that some people would say this represented an abortion. He recommended the ‘solution’ to this problem suggested by Dr AS Parkes of Cambridge: “Equate conception with the time of implantation rather than the time of fertilization—a difference of only a few days”. That is, he got around the fact that these drugs might cause the termination of a pregnancy by changing the definition of when a pregnancy started—because if there were no pregnancy, you couldn’t say you were causing an abortion. (Whether this abortive mechanism does actually operate for the pill is still not clear, as we will see.)
Following Rosenfeld’s logic, the subsequent printing of the American College of Obstetricians and Gynecologist’s terminology text in 1972 saw a deliberate change of the definition of ‘conception’. The accepted scientific view that conception was the result of the process of fertilization was altered to define ‘conception’ as implantation. As a result, the link between fertilization and conception was broken. Pregnancy was still defined as “the state of a female after conception and until termination of the gestation”, but the text now dated a pregnancy (and by implication a human life) from the time of the implantation of the embryo into the wall of the mother’s uterus. Under the new definition, any device that prevented the embryo from implanting in the uterus could be marketed as a contraceptive.
There are then two categories of marketed ‘contraceptives’: those that prevent fertilization, and those that cause an early abortion by acting after fertilization. Note that those who made this definitional change had no authority to do so—they weren’t embryologists. Despite many medical textbooks adopting the new definition, current respected embryology textbooks still mark conception (and human life) at fertilization. Very few doctors currently practising are aware of this definitional change.
Two kinds of contraceptive
Now, if as Christians we hold that human life begins at fertilization, we need to separate these two categories, since we would say that contraceptives that act prior to fertilization are ethically acceptable, whereas those acting after fertilization are not. We have already established that God’s law prohibits the destruction of a human embryo. However, working out which contraceptive methods fit into which category is not a completely straightforward process, as we will see below.
First we must consider how a contraceptive works. This can be a problem because, surprisingly, it is still not known exactly how some standard contraceptives work. Such research is hampered by the fact that it is difficult to know exactly when fertilization occurs in any individual woman. It also seems that contraceptive manufacturers are quite happy to have some doubt surrounding the precise mechanisms of contraceptives, as it makes it more difficult for pro-lifers to object to them on factual grounds. I will do my best to clarify how particular contraceptives work as I discuss each one.
In the discussion of individual contraceptives below, effectiveness ratings are included as failure rates. No contraceptive works perfectly. Sometimes they fail. Failure rate refers to how well it works in terms of preventing pregnancy, and the way it is listed refers to the percentage of couples who will become pregnant in the first year of use. It does not refer to how ethical it is in terms of function. I have included this information not only because reliability will obviously be a factor worth considering when choosing a contraceptive, but also because some people have the idea that by making ethical choices in this area they are opening themselves up to the risk of unreliable birth control. The figures don’t support this.
In this chapter, failure rates are recorded as a range between ‘consistent and correct use’ (which looks at how well the method of contraception works if used perfectly according to the instructions) and ‘as commonly used’ (which takes into account someone forgetting a dose or experiencing drug interactions, and other aspects of real life). ‘Failure rate’ of using no method at all is 85%, meaning that 85% of couples will become pregnant in the first year if no contraception is used.
Check with your doctor regarding how a particular contraceptive method should be used, any risks involved, and how long you need to be using it before it starts working properly.
Choosing a contraceptive
A final note of caution: this section is not designed to take the place of the medical consultation that is necessary to ensure contraception will be safe and appropriate for your own situation. This is because choosing which contraceptive you would like to use involves consideration of more than ethics alone. Once you have determined which contraceptives are ethically permissible, you will also need to take into account factors such as the state of your health, side effects of different methods, availability and cost. Before deciding which one suits you, I recommend you discuss the issue with your doctor. Most doctors will be happy to take your ethical position into account while exploring the alternatives.
Some people may reject a certain contraceptive (such as the pill) because of the social context in which it was developed. I would suggest that while this may make us look at an individual method more carefully, it should not lead us to reject it out of hand. Ethics is a rational process of inquiry that, in medical decision-making, should be based on the facts.
This chapter discusses the use of contraceptives for the purpose of avoiding pregnancy. The discussion below assumes that the reader is in a Western industrialized society. There may be different ethical factors to consider in a developing country where maternal mortality and associated newborn mortality need to be taken into account.
For convenience I will group the various methods under the following headings:
- Hormone contraceptives
- Barrier contraceptives
- Intrauterine Devices (IUDs)
- Fertility awareness
- Male contraceptives
- Other methods
- Permanent contraception
- Emergency contraception
a. Hormone contraceptives
There are two main types of hormone contraceptive formulations available:
- combined, which contain both an oestrogen and a progestin (a synthetic form of the natural hormone progesterone)
- progestogen-only, which contain only progesterone or progestin.
It is easier to understand how these contraceptives work if you are aware of the normal 28-day human female reproductive cycle. The changes that occur in the ovary and uterus during each cycle serve to develop and release the egg for possible fertilization by the sperm, and prepare the endometrium (uterine lining) for implantation of the fertilized egg.
During the first half of her menstrual cycle, an egg develops in a follicle of a woman’s ovaries in response to a hormone stimulus (follicle stimulating hormone, or FSH). The follicle increases oestrogen production, which acts on the uterus to stimulate growth of the endometrium. It reaches a peak about one day before ovulation (release of a mature egg into the fallopian tubes). The surge of oestrogen stimulates her pituitary gland to secrete another hormone (luteinizing hormone, or LH), which in turn triggers ovulation.
The follicle that released the egg then transforms into another type of cell (a corpus luteum) under the influence of LH. The corpus luteum produces high levels of oestrogen and progesterone, which stimulate continued growth of the endometrium to prepare it for implantation of an embryo if there is one. During an ovulatory cycle, estradiol levels increase by 10-16 times, and progesterone increases by 20 times, compared to pre-ovulatory levels. If fertilization does not occur, the corpus luteum reduces in size and stops secreting hormones, leading to the shedding of the endometrium as a menstrual period. If fertilization does occur, the corpus luteum continues to secrete its hormones for 8-10 weeks until the placenta takes over production of the hormones to support the pregnancy.
INSERT DIAGRAM 6: menstrual cycle
There are several different types of hormone contraceptives, including the oral contraceptive pill, progestin-only pills, implants and injectables, and hormone-containing patches and rings. As they vary in method of action and effectiveness, they will be considered individually.
(i) The oral contraceptive pill (OCP)
Also known as the combined oral contraceptive (COC), the birth-control pill and ‘The Pill’, this is an oral contraceptive that contains low doses of two hormones—a progestin and an oestrogen. There are many brands available that vary in strength and other factors, but they essentially all work the same way. The OCP is taken daily for 3 weeks followed by a week when either a sugar pill or no pill is taken before resuming the OCP.
OCPs inhibit follicular development and prevent ovulation as their primary mechanism of action. This is achieved through suppression by progestin of the release of FSH and LH. Oestrogen was originally included in the OCP for better cycle control (stabilizing the endometrium to reduce breakthrough bleeding), but was also found to inhibit follicular development and help prevent ovulation. This means there is no egg available to be fertilized.
A secondary mechanism action of all progestogen-containing contraceptives is inhibition of sperm penetration through the cervix by decreasing the amount and increasing the viscosity (stickiness) of the mucous in the cervix. This reduces the chance that sperm will be present to do the fertilizing.
The OCP also has a third effect. It makes the lining of the womb thinner and hostile to the embryo. These changes to the endometrium may prevent implantation of an embryo in the uterus, should one be present. If the first two mechanisms failed and this post-fertilization mechanism did operate, then use of the OCP may sometimes cause early abortions, in which case its use is unethical. However, if this third mechanism does not operate alone, then there are no ethical objections to use of the OCP. Although in scientific terms this controversy is currently unresolved, my own view is that the weight of evidence supports OCPs as being ethically acceptable—but see appendix I for a fuller discussion of these issues.
It is well known that the mechanism of the OCP is less reliable in suppressing ovulation in certain circumstances: in the first month of use, when a dose is missed, when the tablets are not absorbed from the gut (e.g. due to vomiting and diarrhoea), and when other drugs interfere with the pill (e.g. some antibiotics). At these times I would advise using an alternative method of contraceptive (such as a condom). This is because the OCP will be less effective, not because I think you are risking an early abortion. You need to discuss these things with your doctor, but they explain why the OCP failure rate is wide at 0.3%-8.0%.
For added security, to reduce the likelihood of ovulation you could consider shortening the pill-free interval to 4 days on a regular basis, or recommend 2-, 3-, 4-monthly or continuous extended use of the pill. Monophasic pills (where there is the same amount of oestrogen and progestin in each pill) are recommended for extended use. It is important to take the time to educate patients regarding the significance of the pill-free period—that is, that missing a pill at the start of a packet or extending the pill-free period for more than 7 days significantly increases the chance of ovulation occurring.
As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risk for those who wish to avoid this, it is recommended that a couple use a barrier method of contraception until after the woman’s second period when ceasing the OCP.
(ii) Extended cycle and continuous use birth control pills
These are usually known by their brand names: Seasonique, LoSeasonique, Lybrel (all contain levonorgestrel and ethinyl estradiol).
In 2003, the FDA approved use of extended regimen birth control, which was intended to let women have fewer periods (withdrawal bleeds) or none at all. It has a similar makeup to older OCPs but is packaged differently. The extended use involves taking one pill for 84 days continuously, followed by a different pill for 7 days, which means a woman will have only 4 periods a year. The continuous use is just one pill taken without a break, with no period until she stops. At this stage it is thought that extended use pills are as safe as the conventional pill in the short term (obviously no long-term studies are available yet), and of similar effectiveness, although details of the failure rate are not known at the time of writing. Missing a period is safe—but many women are reassured by the appearance of a period, to know that pregnancy is unlikely. Ethics of use will be similar to the OCP (see above).
Seasonique and LoSeasonique are taken 84/7. Lybrel is taken continuously. They currently have limited distribution.
You will recognize this application as similar to tricycling conventional OCPs, which has long been done by women wanting to avoid a monthly withdrawal bleed. This has often been used to treat endometriosis, dysmenorrhea and other menstruation-associated symptoms. Personal preference to avoid menstruation has become a common reason for use of the new formulations, especially amongst teenagers. Please see prescribing information for details of use and side-effect profile. At present the exact efficacy is unknown and there is no available data at this time concerning the long-term effects of menstrual suppression on a woman’s overall health. There exists concern in the medical field that increasing the amount of hormones typically taken by a woman may have an adverse effect on her long-term health, but there is no data to confirm or disprove this.
Whatever you decide with your spouse on this matter, do not use the pill if the conscience of either of you forbids it. Everything that does not come from faith is sin (Rom 14:23b). This implies that an action performed against the voice of an informed conscience can never be right.
(iii) Progestin-only injections
The most commonly used progestin-only injectables are DMPA (medroxyprogesterone acetate; e.g. Depo-Provera, Depo, Megestron, Petogen) and NET-EN (norethisterone enanthate; e.g. Noristerat, Syngestal). They are packaged in the form of an injection that is given regularly (3-monthly for DMPA and 2-monthly for NET-EN for greatest effectiveness). They are usually given into the muscle, and from there the hormone is slowly released into the bloodstream. (A newer formulation of DMPA called depo-subQ provera 104, or DMPA-SC, is injected under the skin and has similar effects.)
These contraceptives mainly work by suppressing ovulation (so there is no egg), and they also thicken cervical mucus (to slow down the sperm) and make the endometrial lining thinner. The dose of progestin used reliably suppresses ovulation, so there is never an egg available to be fertilized. As there is no embryo created, the other mechanisms of action do not contribute to the contraceptive effect. Just because they are capable of blocking implantation does not mean these drugs ever have to use this back-up mechanism. They are therefore ethically acceptable, so long as they are injected on time. They can be used in breastfeeding from 6 weeks after childbirth. They have increased effectiveness compared to other medications because you don’t have to remember to take a pill every day. Failure rate is 0.3%-3.0%.
In these drugs, progestin suppresses ovulation through the hypothalamic-pituitary-ovarian axis, controlling LH and FSH release so the ovum does not mature. To ensure suppression of ovulation it is important that the injection period is never exceeded. It is possible for minimal follicular activity to occur towards the end of the injection period in some women. For extra confidence that ovulation is suppressed, you could offer injections more frequently—for example, every 10 weeks for DMPA instead of the usual 12.
As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects can occur while ovulation is being re-established. To avoid any risk for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s first period after stopping Depo-Provera.
(iv) Combined injectable contraceptive
Monthly injectables, also called CICs, contain the two hormones—a progestin and an oestrogen—similar to the oral contraceptive pill. This makes them different from DMPA and NET-EN, which contain progestin only. Two common combinations are medroxyprogesterone acetate (MPA)/estradiol cypionate (Ciclofem, Ciclofemina, Cyclofem, Cyclo-Provera, Feminena, Lunella, Lunelle, Novafem) and norethisterone enanthate (NET-EN)/estradiol valerate (Mesigyna, Norigynon). They work primarily by preventing the release of eggs from the ovaries (ovulation). There are few long-term studies for monthly injectables, but researchers assume they are similar to the OCP in effect. This means that the ethics for using this formulation will be similar to that of the OCP (see above). Injections need to be given regularly every 28-30 days. Failure rate is 0.05%-3%.
As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risk for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s first period after stopping monthly injectables.
(v) Progestin-only pill (POP)
This is a pill that contains only a low dose of progestin (levonorgestrel or norethisterone). It is also called the mini-pill (because it is a low dose), or by its brand name: Femulen, Micronor, Microval, Noriday, Neogest, Norgeston. It is often prescribed for breastfeeding women (starting 6 weeks after the birth) as it does not contain oestrogen, which can reduce milk production. It may also be recommended for older women who smoke, as taking oestrogen greatly increases the risk of developing a blood clot in this group.
POPs appear to work by thickening cervical mucus so that the sperm cannot get through and inhibiting ovulation so there is no egg (both pre-fertilization effects), and by making the endometrium hostile to an embryo (a post-fertilization effect). When used alone (without breastfeeding), the low dose of progestin makes it unreliable in terms of suppressing ovulation, with estimated ovulation rates with ‘typical’ use averaging at about 50%. It is also not guaranteed to block all the sperm from getting through. This means that it will be possible for a sperm and egg to unite and create an embryo that may not be able to implant in the endometrium, because the POP may have made the lining of the uterus too thin to allow the embryo to implant and develop normally. Therefore, as it will sometimes work post-fertilization if used alone, it will be an unethical choice for Christians under these circumstances. When used alone, failure rate ranges from 0.3%-8.0%.
The POP is more successful in suppressing ovulation when combined with breastfeeding, provided it is taken conscientiously (at the same time every day). The timing is important because the contraceptive action decreases rapidly after 24 hours. Under these conditions, failure rate ranges from 0.1%-3.0%. Suppression of ovulation would make this contraceptive ethically acceptable. As weaning begins, the risk of breakthrough ovulation and therefore use of the post-fertilization anti-implantation mechanism increases. As soon as the baby starts getting nutrition from somewhere other than breastfeeding, the woman should use different or additional (barrier) contraception. (See lactation amenorrhoea method, below, or progestin-only injectables, above, for alternatives for breastfeeding women.)
Research on POPs has been limited. It is thought that when they do interfere with ovulation, POPs work by suppressing the mid-cycle peak of LH and FSH. It is critical that POPs be taken at the same time every day to be maximally effective. A formulation of the POP using desogestrel 75 mcg (Cerazette) is more reliable in suppressing ovulation than older forms (with evidence of 97% anovulation), and the manufacturers of Cerazette now advertise the flexibility of a 12-hour ‘missed pill’ window that is similar to OCPs. Cerazette is not available in all countries.
If a woman menstruates regularly while taking a POP, it is unlikely that her ovulation has been suppressed. While no bleeding may indicate ovarian suppression, it may also indicate pregnancy.
As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risks for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s second period after stopping the POP.
Implants (Implanon, Jadelle, Zarin, Femplant) are small plastic rods or capsules that are usually inserted under the skin of the inner arm by a healthcare worker. They continuously release a progestin at a very slow rate. They work by thickening cervical mucus (to prevent the sperm from getting through) and suppressing ovulation (so there is no egg). They also cause some changes to the endometrium (but less than other progestogen-containing contraceptives). Implants are similar to the POP in the way they work, but they have a much lower pregnancy rate because compliance is not a problem (you don’t have to remember to take a pill every day). Etonogestrel (Implanon) implants are so effective in suppressing ovulation that it is fair to say they operate prior to fertilization. Just because they are capable of affecting implantation in the endometrium does not mean they ever have to use this back-up mechanism. This makes them an ethical choice. There are other types of implants that release the hormone levonorgestrel (e.g. Jadelle, Norplant II, Sino-implant II sold as Zarin, Femplant), which are less reliable in their suppression of ovulation and so would not constitute an ethical choice. Implants need to be replaced after a period of 3 (etonogestrel) or 4 (levonorgestrel) years. Implants are considered the most reliable contraceptive method; failure rate is only 0.05%-0.05%. The pregnancy rate associated with the use of Implanon is very low (fewer than one in 1000 over 3 years).
Studies show that ovulation may occur towards the end of the 3-year period, so if a woman wanted extra reassurance that ovulation would be avoided you could consider replacing Implanon every 2½ years instead of the usual 3 years.
There is no research into the residual effects of hormonal contraceptives when they are stopped. In the case of Implanon, we cannot be sure whether it continues to act partially after ovulation has returned. We do know that Implanon has less impact on the thinning of the endometrium than other progesterone-only contraceptives, and so is unlikely to interfere with implantation by this effect. However, if your patient wants to be sure to avoid any post-fertilization action, she should use a barrier method of contraception until after her second period after the Implanon is removed.
(vii) Combined patch
The combined patch (Evra, Ortho Evra) is a small adhesive plastic patch worn on the skin that continually releases two hormones, a progestin (norelgestromin) and an oestrogen (ethinylestradiol), through the skin into the bloodstream. The patch is replaced once a week for 3 weeks and then no patch is worn for a 4th week at which time a withdrawal bleed takes place, and then you start again with a new patch. Method of action and ethical challenges are similar to the OCP (see above). Failure rate is 0.3%-8.0%.
At the time of writing, Evra has been associated with potentially life-threatening complications that should be considered when prescribing contraceptives. The incidence of complications is greater with Evra than with a typical OCP, due to the proportionally greater percentage of oestrogen the woman is exposed to by the topical route. Evra is not available in all countries.
For increased effectiveness of ovulatory suppression you could advise using patches continuously for 2 or 3 cycles (6-9 weeks), followed by a shorter rest interval (4-6 days).
(viii) Combined vaginal ring
The combined vaginal ring (NuvaRing) is a small flexible vaginal ring about 5 cm in diameter that you insert vaginally once a month. It contains hormones similar to those in the OCP (oestrogen/ethinylestradiol and progesterone/etonogestrel). The hormones are absorbed into the bloodstream through the lining of the vagina. It is inserted at the beginning of a menstrual cycle and removed after 21 days, allowing the withdrawal bleed, and then a new ring is inserted after a 7-day break. Method of action is similar to the OCP. For the ethical challenges, please review the OCP section above. Experience is limited but failure rate appears to be 0.3%-8.0%.
As with the combined patch, is possible to increase confidence that ovulation has been suppressed by using 3 or 4 rings in a row without a break.
b. Barrier contraceptives
Physical barriers placed between the sperm and egg always work before fertilization because they prevent the embryo from being formed. This makes them all ethically permissible for Christians. To be reliable, devices need to be in good condition and used according to directions. Several alternatives are available.
(i) Male condom
The male condom looks like a balloon before you blow it up. It is a mechanical barrier made of latex, polyurethane or natural membrane. It fits over the husband’s erect penis and prevents fertilization by stopping semen and therefore sperm before, during and after intercourse. Failure rate is 2%-15%. Problems with condom failure can be caused by manufacturing defects but are more often due to incorrect use. For instance, latex condoms should not be used with oil-based lubricants such as baby oil or petroleum jelly (Vaseline) because they can damage the latex. While using spermicide with a condom would seem likely to increase contraceptive protection, it has never actually been proven to do so. Some condoms are manufactured with a spermicide coating anyway.
(ii) Female condom
These are generally known by their brand names: for example, Care, Reality, Femidom. A female condom consists of a pouch made of thin polyurethane or latex with flexible rings on both sides. It fits loosely inside the woman’s vagina and prevents fertilization by stopping sperm from entering the cervix. Failure rate is 5%-21%.
(iii) Diaphragms, cervical caps and the sponge
These are barriers made of soft rubber or latex, or polyurethane foam (the sponge), which are inserted into the vagina before sex to cover the cervix. The diaphragm is a shallow, dome-shaped cup with flexible rim, which also covers part of the vagina; the cervical cap and the sponge are designed to fit over the cervix only. Use with spermicide (see below) is recommended to improve effectiveness. They come in different sizes and need to be fitted by a trained provider, but are then inserted by the wife when needed. They work by stopping the sperm from entering the cervix, and the spermicide kills or disables the sperm. Failure rate is 6%-16% for diaphragms used with spermicide. Failure rate for cervical caps is different depending on whether a woman has previously given birth (26%-29%) or not (9%-16%). This difference is thought to be related to whether the couple is just delaying pregnancy or trying to avoid it altogether, which influences how careful they try to be. The sponge has a failure rate of 9%-32%. Note that it has been reported that use of vaginal barriers is associated with Toxic Shock Syndrome, a rare but potentially fatal illness.
Spermicides are creams, jellies, gels, pressurized foam or pessaries (tablets) that are inserted deep in the vagina, near the cervix, before sex. They are designed to break the membrane of sperm cells, which either slows their movement or kills the sperm. This stops the sperm from meeting the egg and so avoids fertilization. The most common spermicide is nonoxynol-9 (Gynol II), which causes damage to the vaginal wall when used frequently. Spermicides need to be applied each time you have sex—for example, if you have sex more than once in an evening, you need to reapply the spermicide each time. Alone, spermicides are considered less effective than if used with a barrier method: failure rate is 18%-29%. This is a bit misleading, because you are always meant to use them with a barrier method. Foams and sponges are the most reliable.
New non-toxic spermicides are currently being developed, as well as spermicidal microbicide gels (BufferGel, PRO2000 gel), which aim to provide dual protection against pregnancy and sexually transmitted infections (including HIV). These gels act by making the vagina more acidic so that both sperm and infections are unable to survive. It is applied in the vagina before sex, and in trials has been used with a diaphragm. If this product became available it would be ethically permissible, as it would act before fertilization.
c. Intrauterine devices
Intrauterine devices (IUDs, also known as coils—the shape of early IUDs) are small, usually T-shaped devices that are inserted into the uterus through the vagina and cervix by a healthcare provider. They can stay in place for a number of years, depending on the type. Almost all types of IUD have one or two threads tied to them that hang through the cervix into the vagina. Even though they have been around for a long time, the contraceptive effect is not completely understood. All IUDs appear to induce an inflammatory reaction that changes the chemical climate of the entire genital tract. This is a result of the body recognizing that the IUD is foreign, and trying to destroy it. In humans, the cells that are produced to do this flow out of the uterus into the fallopian tubes. The main outcome of this is thought to be a reduction in the rate of fertilization. This means the common belief that IUDs work mainly by stopping an embryo from implanting in the wall of the uterus is incorrect. But while we cannot be sure exactly how they work, we do know that it is possible for the sperm to reach the egg when there is an IUD in place, because occasionally a case of ectopic pregnancy (pregnancy where the embryo implants in the fallopian tube) occurs with this method. This means there can be a post-fertilization effect that makes this method ethically unacceptable.
There are two types of IUD with frames: inert (or copper-bearing) IUDs, and hormonal IUDs, which release progestogen. There are also two frameless (implantable) types of IUD: copper-bearing and hormone-releasing.
(i) Inert and copper-bearing IUD
Most non-hormonal IUDs contain copper, which increases the toxicity for sperm and egg. (Some may also contain silver, which has a similar effect to copper.) This, along with the chemical changes in the reproductive tract, damages the egg and sperm before they meet, reducing the rate of embryo production. But if an embryo is created, the altered environment means that its chance of survival becomes worse as it approaches the uterus. Although they mainly act before fertilization, there is definite evidence that inert and copper IUDs can work after fertilization. This means that they are not ethically acceptable as a form of contraception for those who value human life from the time it is created. Failure rate (copper-bearing IUD) is 0.6%-0.8%. The copper IUD is sometimes used after unprotected intercourse for emergency contraception (see below).
(ii) Hormonal IUD (Mirena)
These IUDs are impregnated with a hormone, levonorgestrel, which is similar to the hormone progesterone. In some places they are distinguished from copper IUDs by being called ‘intrauterine systems’ (IUS). They have some systemic effects such as thickening cervical mucus (inhibiting sperm movement through the cervix) and reducing the thickness of the endometrial lining. Despite the addition of hormones, there is evidence that not all women who use a progestin IUD have unfavourable cervical mucus, and for most women the dosage is insufficient to suppress ovulation. The main effect is local. The IUS causes damage to both sperm and eggs, interfering with the way they function and reducing survival, and so decreasing the rate of fertilization. It also lowers the chance of survival for any embryo that might be formed in the fallopian tube before it gets to the uterus. This last mechanism operates after fertilization, making the IUS an unethical choice for contraception. Failure rate is 0.2%-0.2%.
d. Fertility awareness
Fertility awareness methods involve teaching a woman to recognize when she is fertile, or able to become pregnant. Couples use this information to time unprotected intercourse. There are no ethical objections to this method of contraception.
(i) Natural family planning (NFP)
NFP (also called ‘periodic abstinence’) is an umbrella term for many different types of fertility awareness methods. By identifying on which days the woman can become pregnant, a couple can avoid pregnancy by either abstaining from vaginal intercourse or using another method of ethical contraception (usually a condom or other barrier method) on those days. The aim of each method is to reduce the number of days of abstinence in each menstrual cycle as far as possible without risking conception. There are several methods available, and fertility indicators can be used alone or in combination to identify the fertile period. Use of more than one indicator is more effective.
Methods of telling when a woman is fertile include the following:
- Calendar-based methods involve keeping track of days of the menstrual cycle (e.g. the calendar method, standard days method and calendar rhythm method).
- Cervical secretions can be observed for changes around the time of ovulation (e.g. ovulation [Billings] method).
- Basal body temperature (BBT) or body temperature on waking can be measured through the month. It goes up after ovulation (e.g. two day method, BBT method, temperature method).
- Sympto-thermal method or multiple index method uses all the available indicators of fertility to indicate infertile and fertile phases of the month.
Using these methods, a woman can learn to assess her fertility without the use of a computerized device.
Computerized fertility monitors are also available, which may track basal body temperatures, hormonal levels in urine, changes in electrical resistance of a woman’s saliva, or a mixture of these symptoms. For example, Persona detects luteinizing hormone and oestrogen (the hormones that control your cycle), and the WinBOM Charting System can be used with the Billings method. Lady-Comp is a variation of the rhythm method, as is CycleBeads. These are meant to identify the days on which you are at significant risk of becoming pregnant, and on which you should avoid intercourse if prevention of pregnancy is intended.
This technique will not suit every couple. You must be highly motivated to stay aware of the woman’s body cycle and keep track of the days, and both husband and wife must be committed to the program. The fertile window is usually 8 days, and vaginal intercourse should be avoided during that time. We are instructed in 1 Corinthians 7:5 that abstinence within marriage is to be undertaken only by mutual consent. However, though it sometimes causes stress, many couples have reported that this style of contraception has increased intimacy and strengthened their marriage as they share responsibility for contraception. Some have reported that the periodic abstinence has kept their sex life fresh and entertaining. And this contraceptive is free and always available!
The Roman Catholic Church approves of NFP while opposing use of other ‘artificial’ contraceptives (such as those listed above). While NFP does differ in terms of equipment required, the intention is the same (to avoid pregnancy), and deliberate action is still taken to prevent fertilization with the outcome of (hopefully) avoiding pregnancy. Accordingly, I do not consider NFP to be superior in ethical terms to other ethically permissible methods described in this chapter.
There’s an old joke: “What do you call a couple who uses the rhythm method? Parents!” But this is no longer necessarily the case. Failure rate of NFP is 3%-25%. Pregnancy rates will vary for different types of fertility methods, with calendar/rhythm methods used alone being the least reliable. One German study found NFP to have a failure rate as low as 0.3%, which is similar to the OCP. It depends on the users and the regularity of the woman’s cycle. NFP needs to be taught by a trained instructor and used carefully to be this reliable.
(ii) Lactation amenorrhoea method
The lactational amenorrhoea method (LAM) is the strategic use of breastfeeding as a contraceptive method. Breastfeeding normally results in amenorrhoea (no menstruation). This reflects a delay in the return of fertility after giving birth, which is mainly due to the baby’s suckling (of the mother’s nipples) blocking ovulation through hormone release. The length of this delay cannot be reliably predicted or detected. With LAM, a new mother uses frequent breastfeeding without supplementary feeds for the first 6 months as a way of preventing pregnancy. When used properly, so long as bleeding has not returned, LAM is more reliable as a contraceptive than the mini-pill (failure rate is 0.9%-2.0% compared to 0.3%-8.0%). The technique can be learnt through centres that teach natural family planning. It needs to be followed carefully, but does not involve periods of abstinence. Extended LAM (more than 6 months) is less effective.
e. Male contraceptives
When some women describe what they want as a male contraceptive, it looks something like a pregnant man in labour. I don’t think that’s coming anytime soon! However, there are other developments on the horizon.
(i) Male hormonal contraceptives
This type of contraceptive is still at the research trial stage. It involves giving hormones to men in order to reduce sperm production, and is given as an injection, an implant, patches or pills. If it did reliably remove sperm from the ejaculate then it would be an ethical choice of contraceptive, as that would make fertilization impossible. (You need both the egg and the sperm for fertilization to take place.)
(ii) Contraceptive vaccine
A class of contraceptives based on immunocontraception is being investigated. Theoretically, the vaccine acts against a chemical involved in fertilization in the body, stopping it from functioning normally. If this product were available it would be ethically permissible, as it would not cause the loss of an embryo.
(iii) Other methods
Other strategies aimed at reducing sperm production (spermatogenesis) and/or function are in the pipeline. These include techniques such as heating the testes and blocking the vas deferens (the tube that carries the sperm from the testis) with plugs, traditional Chinese medicine plant Tripterygium wilfordii and other medications such as Adjudin, enzyme inhibitors and even blood pressure medicine. If the contraceptive is aimed entirely at blocking sperm production or function, it will be ethically permissible as it will always act before the embryo is formed.
f. Other methods
(i) Coitus interruptus (withdrawal method)
The withdrawal method is really self-explanatory. It involves the husband withdrawing his penis from his wife’s vagina before ejaculating outside the vagina. He keeps his semen away from her external genitalia. It works by keeping the sperm outside the woman’s body, so fertilization cannot occur. As mentioned above, it has a long history and is the only contraceptive method explicitly mentioned in the Bible. It is more effective than using no contraceptive technique, but challenges in its timing can cause anxiety between couples attempting to avoid conception. It requires a high degree of self-control if it is to be done properly. It therefore has the potential to reduce the pleasure of the marital act, and we know from Scripture that pleasure is an important aspect of marital sex.
However, it is free, is always available, does not cause weight gain, and is known to be acceptable to many married couples. There are no specific ethical objections to its use. The decision to use this method should be based on mutual preference. Failure rate is 4.0%-27.0%. It is possible to fail even if the withdrawal is properly timed, because the pre-ejaculate (fluid that comes out of the penis before the semen) can sometimes contain sperm. Effectiveness can be increased with the use of spermicide.
Abstaining from vaginal intercourse is the most reliable way to avoid pregnancy in a fertile woman. But is it a contraceptive method that Christians should use?
Some writers see a justification for abstinence in Old Testament regulations. Sexual intercourse was to be avoided during menstruation (Lev 15:24, 18:19, 20:18), after childbirth (Lev 12:1-8), and by men before special missions (Exod 19:15; 1 Sam 21:4-5)—though in the Leviticus passages it was not forbidden completely. These practices would not have been intended as a form of birth control, since by avoiding intercourse at the time of menstruation the couple would be more likely to come together immediately after this period of abstinence, at a time when the woman is more likely to be fertile. This would act in a way directly opposite to contraception. The restrictions on men are not specified, but do not suggest an extended time (less than 3 days in the Exodus passage). Furthermore, these passages are not placed in the context of a discussion of sexual relationships within marriage.
The Bible teaches that sexual intimacy is to be the norm within marriage:
The husband should give to his wife her conjugal rights, and likewise the wife to her husband… Do not deprive one another, except perhaps by agreement for a limited time, that you may devote yourselves to prayer; but then come together again, so that Satan may not tempt you because of your lack of self-control. (1 Cor 7:3-5)
Within marriage, abstinence should be practised only for specified time periods, by mutual agreement for the purpose of prayer. Then the couple should resume sexual relations due to the moral danger that abstinence represents. The apostle certainly does not encourage total abstinence, since that would encourage the temptation to immorality—which, according to Paul, is the opposite of what sexual relations in marriage are intended to do.
According to the Bible, married couples are to engage in regular sexual intercourse. Abstinence is not a long-term birth control method that should be used by married Christian couples.
(iii) Abortion (surgical, RU-486)
Of the estimated 208 million pregnancies that occurred worldwide in 2008, 33 million (16%) resulted in unintended births and 41 million ended in induced abortions (20%). The Guttmacher Institute sees unintended pregnancy as one of the main drivers of abortion. Modern society’s belief that procreation does not have to result from sexual relations has meant that some couples see abortion as a way of ‘avoiding’ pregnancy.
Several methods of abortion are available depending on the stage of pregnancy. Induced abortions include surgical procedures and/or the use of medications such as RU-486. RU-486 is not a contraceptive. It was specifically designed to cause abortions. All forms of induced abortion are ethically wrong to use as contraceptives, as they directly lead to the death of an unborn child. While it is possible for a late-term abortion to accidentally result in a live birth, this is never intended; and in early pregnancy, abortion is uniformly fatal for the unborn child. We do not have definitive data regarding how many woman use abortion as a means of contraception. It is possible that women who have more than one abortion may be using it this way. For example, the only state in Australia that collects complete data on abortions is South Australia. In that state for the year 2008, of the 5,101 women who had terminations of pregnancy, 1,860 (36.5%) had had a previous termination.
Also known as centchroman, or trade names Saheli, Novex-DS, Centron and Sevista, ormeloxifene is a selective oestrogen receptor modulator (SERM), a class of medication that acts on the oestrogen receptor. It is a non-hormonal, non-steroidal oral contraceptive that is taken once per week (after the first 16 weeks, when it is advised to be taken twice weekly). It causes disruption in the menstrual cycle between ovulation and the development of the uterine lining, although its exact mode of action is not really known. It may delay ovulation, and seems to cause the lining of the uterus to build more slowly than usual. At the same time, if an embryo is formed ormeloxifene makes it travel more quickly through the fallopian tubes than normal. It is thought that this combination of factors creates an environment where, if an embryo forms, implantation is impossible. This means that ormeloxifene will not be an ethical choice for those who value human life from the time of fertilization. Failure rate (estimated from clinical trials) is probably around 2%-9%.
g. Permanent contraception
Sterilization as a means of contraception involves a surgical procedure that intends to prevent pregnancy on a permanent basis by physically blocking the egg and sperm from coming into contact with each other. It is clearly a true contraceptive that prevents fertilization, and in that sense is ethically acceptable.
However, we need to think about whether it is consistent with biblical teaching to permanently terminate a person’s fertility. Sterilization is seen as a convenient form of contraception for those couples who do not expect to desire more children. But therein lies the problem. We might not expect it, but we can’t predict what is in store for any of us. Even if you don’t want more children now, consideration should be given to future changes of situation, such as the death of a child or spouse, which may lead you to want more children after all. Young widows are instructed to remarry and have children in 1 Timothy 5:14. The decision to be sterilized potentially robs your future spouse of the opportunity to have children with you.
A study of over 11,000 women in the United States found that 5.9%-20.3% regretted sterilization. The largest score was for women 30 years of age or younger at the time of sterilization.
While some methods are potentially reversible, it is technically difficult to reverse sterilization and can never be guaranteed. Even when it is reversed, the fertility rate isn’t 100%. It is not the intention at the time the surgery is performed to make it reversible. (If you wanted reversible contraception you would use one of the methods above that is reliably reversible.)
Traditional arguments against sterilization tend to focus on the morality of purposely setting aside a bodily function or removing part of the body. Is this a proper way to treat the body as a “temple of the Holy Spirit” (1 Cor 6:19-20)? As previously mentioned, passages such as Deuteronomy 23:1, where those emasculated by cutting are forbidden from entering the assembly of the Lord, are thought to refer to a prohibition of Canaanite cultic practices. Jesus’ discussion about eunuchs in Matthew 19:10-12 is addressing the idea of not marrying, rather than celibacy in marriage, and points out that only those “to whom it is given” can receive this teaching. Neither passage is a discussion of contraception.
If we consider sterilization in the context of stewardship of the body, we might question whether surgical removal of part of the body is permissible for reasons of convenience, especially when safe and reliable alternatives exist. However, we can also use this as an argument for sterilization, since it may be good stewardship for some individuals (such as a woman whose body is not fit to carry another pregnancy to term) to ensure that future pregnancy is impossible.
A further argument against sterilization suggests that it makes one unable to fulfil the command of Genesis 1:28. But we have already discussed that this verse cannot represent a universal requirement to reproduce.
If we accept that there is a place for contraception at all, on the grounds that sexual intercourse has a unitive function that can operate independently of the procreative function, then it’s hard to see an objection to this particular form of contraception. It is reasonable to think that a couple may get to the point of believing they have as many children as they can responsibly provide for, and their desire to avoid the condemnation of 1 Timothy 5:8 (that “if anyone does not provide for his relatives, and especially for members of his household, he has denied the faith and is worse than an unbeliever”) leads them to consider sterilization. Furthermore, we know that fertility for women is never lifelong, as God has built into the female body a sterilization of sorts through the normal process of menopause.
If we understand the underlying theology of responsibility in relationships, we can distinguish good and evil motives for sterilization. There won’t be a general ‘yes’ or ‘no’ to sterilization; it will depend on each individual case. But the irreversibility of the procedure demands careful consideration, especially if you are in a younger age group.
If the motivation for sterilization is convenience and the desire to separate contraception from sex, or to avoid the necessity of daily tablet-taking, you could consider the use of a longer-term reversible contraceptive (such as Implanon) as an alternative.
If a couple decides to proceed with sterilization then unless there are other reasons for the woman to undergo surgery (for example, she needs to have a hysterectomy for fibroids anyway), it is preferable for the man to undergo a vasectomy. It is cheaper and safer than female sterilization. Because of its permanent nature, it is important that the person undergoing sterilization is fully aware of the consequences and consents freely to the operation.
(i) Female sterilization
There are two main ways to remove the reproductive capacity of women, both usually carried out under general anaesthetic. Failure rate overall is 0.5%-0.5%. (Failure of tubal occlusion can occur years after surgery.)
- Tubal occlusion: Tubal occlusion (‘tying the tubes’) involves blocking or removing part of the fallopian tubes so that the egg cannot reach the reproductive tract. This can be achieved by placing a band or clip over each fallopian tube, or electrically burning the tubes. Alternatively, the mid-part of each tube can be surgically removed. A newer technique called Essure involves placing tiny coils into each fallopian tube that promote the growth of scar tissue, which in turn blocks the tubes. This can be performed without general anaesthesia.
- Hysterectomy: Hysterectomy is the surgical removal of the uterus. While this is extremely effective as a form of sterilization, the operation is too risky to be performed for this purpose only.
(ii) Male sterilization
Vasectomy is the most common form of male sterilization. It is usually done under local anaesthetic, and involves cutting the vas deferens (the tubes that carry the sperm from the testes where they are made), so that no sperm enters the normal ejaculate. It involves a minor surgical procedure that removes a small part of the vas deferens or blocks it another way. It may not be fully effective for 3 months after the operation (and occasionally even longer), during which time an alternative form of contraception should be used. The man is considered sterile when his semen contains no sperm. (You can easily have a test to check.) Overall failure rate of male sterilization is 0.1%-0.15%.
(iii) Sterilization for non-contraceptive reasons
- Therapeutic sterilization: This is performed when a woman’s life or health is threatened by future pregnancy—for example, the removal of a damaged uterus. If there is a clear medical indication, sterilization in this situation is ethically justified as a necessary medical treatment, with the primary motivation being the preservation of health.
- Eugenic sterilization: The eugenics movement of the first half of last century championed the sterilization of people not thought fit to contribute to the human gene pool. It received government support in many countries, including Australia. In some parts of the United States, laws were passed providing for compulsory sterilization of ‘misfits’ including rapists, drunkards, epileptics and the insane. While these laws have since been repealed, the idea that some people should not be allowed to reproduce is still voiced. There are reports of disabled women and girls being sterilized without their consent in Australia with some eugenic motivation. Following Hurricane Katrina, Member of the Louisiana State Legislature John La Bruzzo proposed paying poor women US$1000 to be sterilized, to limit the numbers on welfare rolls. While he said his plan would be voluntary and would include incentives for men (to avoid gender discrimination), it also included incentives for college-educated, higher-income people to have more children. “What I’m really studying is any and all possibilities that we can reduce the number of people that are going from generational welfare to generational welfare,” he said.
The idea behind eugenics—that only humans with certain preferred characteristics should be born—is opposed to the biblical teaching that all humans are made in the image of God and are therefore valuable, regardless of their personal capabilities.
- Punitive sterilization: Punitive sterilization, such as castration, has been advocated as a punishment for criminals guilty of sexual crimes. Recently there has been discussion in a major medical journal regarding the pros and cons of surgical or chemical castration of convicted sex offenders. Those in favour (so long as the prisoner consents) mention the benefit offenders report from being released from sexual preoccupation, and being able to participate in psychological treatment programs they were previously too distracted to join. Those opposed question whether true consent is possible if the alternative is lifelong imprisonment, and also challenge whether it is ethical for doctors to act in the best interests of society rather than the best interests of their patients.
- Sterilization of the mentally disabled: Sterilization of the mentally disabled (usually of females) can be motivated by desire for contraception or to save the person involved from the distress associated with menstruation. This is a controversial topic that at times has had eugenic overtones (see above). In 2010, an Australian court considered the case of an 11-year-old girl, ‘Angela’, who had severe intellectual disability and seizures that were provoked by heavy menstruation despite her medication.
Discussion of how best to support the sexuality of a mentally disabled person is beyond the scope of this book, but should be multi-faceted and involve precautions to avoid abuse. Research consistently finds that rates of sexual assault of people with a disability are much higher than the general population. Despite evidence that approximately 20% of Australian women and 6% of men will experience sexual violence in their lifetime, there is no standard national data collection that includes the experiences of women with a disability. A study of Victoria Police data indicates that just over a quarter of all sexual assault victims were identified as having a disability. Of this group, 130 (15.6%) had a psychiatric disability or mental health issue and 49 (5.9%) had an intellectual disability. These data indicate that adults with a psychiatric and/or intellectual disability in particular are over-represented as victims of reported sexual assault, representing just 2.2% and 0.8% of the Australian population generally. This would indicate a need for policy reform for those at risk of such abuse, rather than their sterilization.
Sterilization of the mentally disabled on grounds that the offspring would be disabled is not justified. We know that mentally retarded individuals will not necessarily give birth to retarded children, and discrimination on the grounds of ability is contrary to the biblical teaching that all individuals are made in the image of God and therefore deserving of respect.
To remove without consent someone’s ability to reproduce is a violation of human dignity. Such a procedure should be performed without consent only if there is a serious threat to the life of the person concerned, as in the case above. Due to variation in degrees of retardation and levels of competence, each case should be considered individually. The option of long-term reversible contraception such as Implanon or Depo-Provera (which may also stop bleeding) should be considered as an alternative.
h. Emergency contraception (the ‘morning-after pill’)
In Christian marriage, the couple should think about contraception in advance of needing it so that decisions can be made thoughtfully. Emergency contraception will not be needed very often. However, since by definition you will not be expecting to use it, it helps to understand how ‘emergency contraception’ works, just in case.
Traditionally, those hoping to prevent conception after having unprotected sex might have tried douching. It is still tried today, often with water and spermicide. This is not a reliable form of contraception. Neither is douching with Coca-Cola (another favourite). Sperm have been detected in cervical mucous on their way to the uterus within 90 seconds of ejaculation. Douching only reaches the vagina, so by the time it is done it is usually too late.
A more common occurrence these days is for general practitioners and pharmacists to be approached by women requesting the ‘morning-after pill’ (MAP). This usually follows condom malfunction or unprotected intercourse during the previous 24 hours, and has been promoted as form of ‘retrospective contraception’. The common label of ‘morning-after pill’ is misleading, as some types work up to 120 hours after unprotected sex. Our society regards use of emergency contraception (EC) as a responsible course to follow if an unplanned pregnancy is unwanted.
There are several forms of EC available. The first is a copper IUD inserted soon after intercourse. The others are pills, listed below. Effectiveness varies, but none are 100% effective.
(i) Copper IUD
When a copper IUD is inserted into the uterus immediately after intercourse, up to 5 days after ovulation, it is very effective in preventing pregnancy. If ovulation has occurred at the time of insertion, the copper IUD works mainly by blocking implantation. If ovulation has not occurred at the time of inserting the IUD, it will act in a similar way to long-term use, which (as noted above) is primarily by toxicity for sperm but also involves effects after fertilization. Therefore this method is unethical regardless of when it is administered.
It is not known exactly how levonorgestrel (Postinor-2, Levonelle, NorLevo, Plan B, Plan B One-Step, Next Choice) works in the emergency situation. If it is taken before the LH surge (which triggers ovulation), it will usually inhibit ovulation and probably thicken cervical mucus. If taken after ovulation, it is less clear. There is little evidence to suggest a direct anti-implantation effect. If it is not administered in time to block ovulation, it is likely to fail.
It is difficult to be prescriptive about ethics when the exact method of action is unknown. There would be no doubt of the morality of using this medication if the woman were known to be pre-ovulatory in the monthly cycle at the time of use (see below), because there would be no egg available for fertilization. After ovulation there is no point in taking it, due to the side effects of the medication and the likelihood of failure. If there is an embryo in place at the time, it is likely to stay there.
(iii) Ulipristal acetate
Ulipristal acetate is a more recent morning-after pill, usually known by its brand name: ella, ellaOne. It blocks the action of the hormone progesterone. When taken immediately before ovulation is to occur, ella postpones follicular rupture (release of the egg). The likely primary mechanism of action is therefore inhibition or delay of ovulation; however, according to the manufacturer, alterations to the endometrium that may affect implantation may also contribute to efficacy. The dose is one tablet taken as soon as possible, up to 120 hours (5 days) after unprotected intercourse. It is not available in all countries.
If ulipristal is taken before ovulation it would be an ethical choice, as no egg would be released and therefore no fertilization would occur. However, if taken after ovulation, it is possible (given the current state of knowledge) that if an embryo were created it would be unable to implant in the uterus. Ulipristal would therefore be an unethical choice. See below for how to determine the timing of ovulation in this situation.
According to the manufacturer, ulipristal acetate is an orally active, synthetic progesterone agonist/antagonist. It reversibly blocks the progesterone receptor in its target tissues (uterus, cervix, ovaries, hypothalamus) and acts as a potent anti-progestational agent. Studies have shown that when compared with levonorgestrel, ulipristal was no less effective in preventing pregnancies when administered within 72 hours of unprotected intercourse, but was more effective when administered later (within 72-120 hours). Meta-analysis suggests that ulipristal may be more effective than levonorgestrel from day one and throughout the entire 5-day period following unprotected sexual intercourse.
(iv) The combined hormone (Yuzpe) method
The Yuzpe method involves a high dose of a combined pill that contains both oestrogen and progesterone. When given within 72 hours of unprotected intercourse, if ovulation has not yet occurred it may be suppressed or delayed by the intervention. If ovulation has occurred, the Yuzpe method normally causes shedding of the endometrium and if an embryo already exists it will be lost in the menstrual flow.
Women who use the Yuzpe method are at risk of causing an early abortion if they are unaware of where they are in their ovulatory cycle at the time (which is usually the case). However, if they did know where they were in their cycle, they could take the medication to suppress or delay ovulation so that the egg would not be available for fertilization, and so reduce the likelihood of pregnancy. This would be a true pre-fertilization contraceptive effect.
(v) RU-486 (mifepristone)
RU-486 (mifepristone) was developed specifically to cause medical abortions. It is sometimes called the ‘morning-after pill’ but in fact it is not a contraceptive. Some authors have suggested that it should be used as an emergency contraceptive.
Determining the timing of ovulation in the emergency setting
Pro-life doctors have developed a protocol that allows review of the hormone levels (oestrogen and progesterone) in the woman presenting after unprotected intercourse. These tests show where she is in her ovulatory cycle, which allows the doctor to determine whether she is in a potentially fertile phase and assess whether she really is at risk of pregnancy. As a result, doctors can reassure those women who are in one of the infertile phases that they do not need any ‘treatment’, and so will not be exposed to the significant side effects of these drugs. If she is in the period of possible fertility prior to ovulation, it is possible that one of the morning-after pill regimes may be able to delay ovulation long enough to prevent fertilization without harming a pregnancy if it has already begun. If ovulation has occurred or is imminent, emergency contraception could be operating by causing an abortion, and will therefore be unethical. Note that there are contraindications to the use of some of these methods, which should be checked with a doctor before use.
In cases of rape
In the case of rape, care of the woman in crisis needs to be multi-dimensional, and this cannot be fully addressed in this book. The ovarian hormone tests mentioned above will give valuable information to the woman regarding her risk of pregnancy. There has been little research done on the effect of abortion after rape, but some studies suggest that women who continue a pregnancy following rape do better than those who abort.
Heather Gemmen, who wrote about her experience of rape, describes her experience in the hospital that night. Her doctor gave her a hormone tablet that, he said, “changes the environment of the uterus so the egg cannot implant”. After clarifying that the pill would stop an embryo from implanting, and that this represented early abortion, she was nevertheless encouraged to take it. She wrote, “Death does not seem so gruesome or final when you are holding it in your hand in the form of a tiny pink pill”.
A woman in this situation is incredibly vulnerable emotionally, and it is easy to see how she could be persuaded to act against her conscience. The immediate offer of non-abortifacient (non-abortion causing) contraception, if applicable, can avoid risking any further trauma resulting from her guilt about complicity in abortion. Such procedures attempt to delay ovulation beyond the time the rapist’s sperm would be able to survive, so reducing the chance of pregnancy. This is ethically appropriate, and it is important the woman involved is told so. (Read Heather’s inspiring story to see what happened next.)
The chapter on abortion contains further discussion of what should be done in this situation. It should be noted that in the case of rape, it is accepted in orthodox Catholic theology that attempted postponement of ovulation by taking hormonal contraceptives is legitimate, as the goods of marriage do not exist in this circumstance (so they cannot be destroyed by the use of contraception).
For doctors and pharmacists
Health professionals can find themselves in a difficult situation when a patient requests a type of contraceptive that the health professional thinks is unethical. Provision of emergency contraception can raise particularly difficult ethical questions for those health professionals who are expected to provide this legal alternative to patients who request it. It is especially stressful if the woman is extremely anxious (which is not unusual).
Some doctors have found it helpful to place a discreet sign in the waiting room advising patients before the consultation that only contraceptives acting before fertilization will be available. Few jurisdictions oppose doctors’ right of conscience on this issue. Pharmacists may find it more difficult, especially if they are not senior staff in the pharmacy. It may be possible to reach an agreement with other staff not to have to provide contraceptives that you oppose on moral grounds. At present in my state of NSW, there is no legal requirement for pharmacists to stock any particular therapeutic device or treatment. Check the legalities for your jurisdiction. Australian Pharmacist John Wilks has not stocked oral contraceptives or condoms for many years. He chooses not to stock the MAP on medical grounds, because it breaches his duty of care consistent with the Pharmaceutical Society of Australia’s Code of Ethics, principles 1.1 and 1.2.
Regardless of your approach to emergency contraception and its provision, it is important to take this opportunity to sympathetically counsel the woman who presents. Apart from the protocol to assess fertilization risk (above), important issues to raise include the availability of support for the victims of rape or incest, and the need for future contraception so this situation does not rise again.
This is an opportunity for you to explore the woman’s (and possibly man’s) attitude towards keeping a pregnancy (either as the primary move or after possible EC failure), as it is possible that no-one else will raise this as a possibility. Being aware of support services for pregnant women in your area will allow you to provide practical assistance to those who initially see early abortion as their only choice, even if that is not what they really want.
Sometimes it is only when we take a stand that others start to think more carefully about their choices.
In summary, then, we have the following categorization of available contraceptives:
||Caution needed (see text)
- Progestin-only injections (DMPA, NET-EN)
- Implanon implant
- Fertility awareness methods: natural family planning and lactation amenorrhoea method
- Barrier methods: cap, condom, diaphragm, sponge, spermicide
- Withdrawal method
- Oral contraceptive pill
- Progestin-only oral pill (mini-pill)
- Combined injectable contraceptive
- Combined vaginal ring
- Combined patch
- Emergency contraception (morning-after pills)
- Jadelle, Norplant implant
- Intrauterine devices and systems (IUDs and IUSs)
- Abortion (including RU-486)
We learn from this chapter that the easy availability of reversible contraception has reduced the tolerance for unplanned pregnancy. The societal expectation is now that failure of contraception, or even failure to use contraception, is appropriately dealt with by elective abortion. But is that what women really want?