thesis statement for birth control research paper

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An Evidence-Based Update on Contraception

Contraception is widely used in the United States, and nurses in all settings may encounter patients who are using or want to use contraceptives. Nurses may be called on to anticipate how family planning intersects with other health care services and provide patients with information based on the most current evidence. This article describes key characteristics of nonpermanent contraceptive methods, including mechanism of action, correct use, failure rates with perfect and typical use, contraindications, benefits, side effects, discontinuation procedures, and innovations in the field. We also discuss how contraceptive care is related to nursing ethics and health inequities.

Contraception is widely used in the United States, with an estimated 88.2% of all women ages 15 to 44 years using at least one form of contraception during their lifetime. 1 Among women who could become pregnant but don’t wish to do so, 90% use some form of contraception. 2 Thus, nurses in various settings are likely to encounter patients who are using contraception while presenting for a vast range of health care needs. Nurses will have many opportunities to support such patients by coordinating contraceptive use with other treatments, such as by identifying medications that interact with contraceptives or are teratogenic. Some patients, meeting with a nurse on an unrelated matter, may even seize the moment to ask questions about contraception.

Patients are best prepared to make informed decisions about contraceptive use when they have evidence-based information; nurses can better support patients’ reproductive goals by cultivating their own knowledge base. This article will prepare nurses at various practice levels and practice settings to meet the needs of patients who are current or potential contraceptive users. It describes the major categories of nonpermanent contraceptive methods and provides evidence-based updates. We also discuss inequities in contraceptive care that nurses can address using their current clinical knowledge and a reproductive justice approach.

In its position statement on reproductive health, the American Nurses Association (ANA) has asserted that clients have the right to make reproductive health decisions “based on full information and without coercion,” and that nursing professionals must be prepared to discuss “all relevant information about health choices that are legal.” 3 Similarly, the American Academy of Nursing has issued policy recommendations that support “access to safe, quality sexual and reproductive health care and reproductive health care providers.” 4 Aligning with these policies means that, across settings and in accordance with their scope of practice, nurses should be prepared to provide contraceptive counseling, services, and referrals.

Moreover, adopting a reproductive justice approach to care delivery can potentially improve the quality and equity of reproductive health care and outcomes significantly. 5 Reproductive justice is a human rights framework that aligns with the ANA’s Code of Ethics for Nurses with Interpretive Statements , 6 , 7 and functions simultaneously as a theory, a practice, and a strategy. For more details, see Reproductive Justice . 5 , 7 Understanding contraception and contraceptive care in the context of both nursing ethics and reproductive justice will help nurses be best prepared for providing optimal care.

CONTRACEPTIVE METHODS: KEY CONSIDERATIONS

Three main considerations commonly arise in discussions of contraceptive methods: method safety and contraindications, failure rates, and return to fertility.

An important source for data about method safety comes from the Centers for Disease Control and Prevention (CDC): the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC), 8 which categorizes the safety of contraceptive methods in accordance with the specific health concerns of patients (see Table 1 8 ). In this article we’ll highlight the common contraindications and drug interactions categorized as U.S. MEC 4: “A condition that represents an unacceptable health risk if the contraceptive method is used.” 8 We recommend that readers familiarize themselves with the U.S. MEC, which includes a comprehensive list of such conditions; it’s available free online ( www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf ) and as an app.

U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC): Categorization of Safety for Specific Health Conditions 8

Failure rates represent a way to assess the efficacy of various contraceptive methods. For a given method, the failure rate is the percentage of users who have an unintended pregnancy during the first year of use; a lower failure rate indicates higher efficacy. For context, consider that up to 85% of women who have unprotected intercourse will experience an unintended pregnancy within a year. 9 Failure rates for perfect and typical use of a given contraceptive method are also distinguished. Perfect use reflects method use when instructions are followed exactly and consistently; typical use reflects real-life use, when the method may not be used consistently or perfectly.

Many people have questions about the timing of return to fertility after stopping contraceptive use. The return to fertility is relatively rapid after cessation of almost all hormonal and nonhormonal methods, with the exception of depot medroxyprogesterone acetate (DMPA). For example, in one study among women who discontinued combined hormonal contraception, pregnancy rates were 57% at three months and 81% at 12 months after cessation. 10 Conversely, ovulation may not resume for 15 to 49 weeks after one’s last DMPA injection, according to one systematic review. 10

Method safety, efficacy, and return to fertility are not the only considerations that influence contraceptive choice. It’s important for nurses and other providers to understand that individuals will value different features of various contraceptive methods. Personal preferences (such as for a hormonal or nonhormonal method, ease and comfort with mode of use, partner acceptance, effects on the sexual experience, strength of desire to avoid pregnancy, and religious or spiritual beliefs and practices), medical considerations (such as whether the method protects against sexually transmitted infections [STIs], potential side effects), and structural factors (such as immediate and ongoing costs, ability to begin or stop use without needing access to health care)—all of these elements play a role. 11 – 14 Seeing the whole picture will better equip nurses to help patients choose a method most aligned with their preferences and needs.

In this article, we describe the most common nonpermanent contraceptive methods; summarize their efficacy, mechanisms of action, uses, common adverse effects, and contraindications; and review the modes of administration of each type. Emergency contraception lies beyond the scope of this article and is not addressed.

HORMONAL CONTRACEPTIVES

Combined hormonal contraceptives.

(CHCs) are among the most commonly prescribed and well-researched types of medication in use. 1 , 15 Synthetic estrogen and progestin revolutionized modern family planning when this combination first came on the market in pill form in 1960. Today CHCs can be delivered through a pill, patch, or vaginal ring with similar failure rates: less than 1% with perfect use and 7% to 9% with typical use. 9 , 16 , 17

In CHCs, both progestins and estrogen inhibit the hypothalamic–pituitary–ovarian axis, which controls the reproductive cycle (see Figure 1 ). 18 Progestins prevent pregnancy by inhibiting the luteinizing hormone (LH) surge, thus suppressing ovulation, thickening the cervical mucus, lowering fallopian tube motility, and causing the endometrium to become atrophic. 18 Estrogens prevent pregnancy by suppressing follicle-stimulating hormone (FSH) production, which prevents the development of a dominant follicle. 18 Progestin is responsible for the majority of both contraceptive action and side effects; the addition of estrogen helps prevent irregular or unscheduled bleeding. 9

The Hormonal Regulation of Ovulation

At left: the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to secrete the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH stimulate the growth and maturation of the ovarian follicles. The mature follicle secretes estrogen, inhibiting the hypothalamus from further GnRH production (until the next reproductive cycle). At right: after ovulation, blood levels of LH and FSH fall, and the ruptured follicle, now a corpus luteum, secretes estrogen and progesterone to prepare the uterine lining for fertilization and implantation. Adapted with permission from Encyclopædia Britannica, © 2013 by Encyclopædia Britannica, Inc.

Traditionally, users take CHCs for three weeks, then placebo pills or nothing for one week. The hormone-free week prompts “withdrawal bleeding,” caused by withdrawal from active CHC ingredients, that mimics the menstrual cycle and may provide assurance that the user isn’t pregnant. 18 Nurses can educate their patients that withdrawal bleeding is not actual menses and isn’t clinically necessary. 18 , 19

Common side effects of CHCs include lighter, shorter periods (40% to 50% reduction in menstrual flow); irregular bleeding (breakthrough bleeding or spotting); amenorrhea; nausea; breast tenderness; emotional lability; headaches; and reduced premenstrual syndrome symptoms (such as bloating, cramping, and acne). 18 CHCs are also associated with reduced risk of ovarian, endometrial, and colon cancer, and are essential in treating polycystic ovarian syndrome. 18 As with other methods, it’s difficult to predict which individuals will experience which side effects and how severe these will be. Certain side effects, particularly amenorrhea, may be considered beneficial by some people but unacceptable by others. 20 These may be referred to as “noncontraceptive benefits” of these methods.

CHC contraindications (U.S. MEC 4–category conditions) include being age 35 years or older and smoking 15 or more cigarettes per day; being less than 21 days postpartum; having a systolic blood pressure of 160 mmHg or greater, or a diastolic blood pressure of 100 mmHg or greater; having had major surgery with prolonged immobilization; experiencing migraine with aura; and being at elevated risk for recurrent deep vein thrombosis or pulmonary embolism. 8

CHCs are still effective when taken concurrently with many medications, including most commonly used antibiotics. But concurrent use of certain medications—including rifampin (Rifadin) or rifabutin (Mycobutin) therapy, the antiretroviral drug fosamprenavir (Lexiva), and certain anticonvulsants—can reduce CHC effectiveness. 8 In such cases, use of a nonhormonal backup contraceptive method is recommended.

Numerous CHC pills are currently available on the market. Typically, pills contain a ombination of 10 to 35 mcg ethinyl estradiol and one of the four generations of progestins. Different formulations have different side effect profiles, so patients may need to try another formulation if an undesirable side effect occurs.

Pills should be taken at about the same time every day to maintain ovulation suppression. This frequent dosing is one of the major drawbacks of pill use, and missing a pill is common, regardless of age. 16 In general, nurses should counsel patients that a missed pill should be taken as soon as it is remembered. Ovulation suppression is not guaranteed if more than 48 hours have elapsed since the last pill was taken. Missing a single pill will have little effect on effectiveness, but if two pills are missed, the most recent pill should be taken as soon as possible, and a backup method (such as condoms) should be used for seven days. 18

Pills can be initiated at any time. A “Sunday start” has been popular in the past because it typically ensures that the withdrawal bleed does not occur on weekend days. Recently, a “quick start,”starting the pill on the day of visit, has become more popular because, at least initially, it’s associated with better adherence, and there is no increase in the incidence of irregular bleeding. 21

Extended and continuous use are increasingly popular dosing regimens. Extended use involves using the CHC for longer than the typical month-long cycle, thereby giving the user an extended time between withdrawal bleeds. This can be achieved by taking pills specifically designed for such regimens or by simply skipping the placebo pills in a 28-day pill pack (though users will run out of pills more quickly). Continuous use involves taking CHCs without interruption for an indefinite time. Extended and continuous use regimens have been associated with improved ovulation suppression, increased medication adherence, high user acceptability, decreases in scheduled bleeding, and less breakthrough bleeding over time. 19 , 22 Moreover, decreasing or eliminating periods can be preferable for patients who have period-related mood changes, headaches, painful cramping, heavy menses, or other estrogen-related changes. While extended and continuous use regimens have primarily been studied regarding CHC pills, there is evidence of similar efficacy among CHC patch and vaginal ring users. 23

CHC transdermal patch.

The CHC transdermal patch (Xulane), a thin square about two inches across, contains 150 mcg norelgestromin and 35 mcg ethinyl estradiol (see Figure 2 ). It can be placed on the stomach, upper arm, buttock, or back, and must be completely attached to the skin to be effective. The patch is replaced every week for three weeks; during the fourth week no patch is worn and a withdrawal bleed occurs. Weekly application is appealing for those who don’t want the burden of daily pill taking. In 2014, the patch became available as a generic product.

The Transdermal Patch

While contraindications for CHCs apply to all delivery methods, there are some additional concerns with the patch. Findings from early research suggested there was an increased risk of venous thromboembolism (VTE) with the patch compared to CHC pills, but later research has yielded conflicting results. 24 , 25 The U.S. Food and Drug Administration (FDA) recommends that the same guidelines regarding VTE be applied to both methods: CHC pills and the patch should be avoided in patients at high risk for clots, such as those who have a history of or current VTE or surgery requiring immobilization. 24 , 26 The patch also causes skin irritation in about 20% of users, though only about 3% discontinue the method for this reason. 17

CHC vaginal ring.

The ring (NuvaRing) is a clear, flexible ring about two inches in diameter that is placed in the vagina for 21 days and removed for seven days to allow for withdrawal bleeding; it’s replaced monthly (see Figure 3 ). It releases 15 mcg/day of ethinyl estradiol and 120 mcg/day of etonogestrel. Users can simply place the ring in the vaginal canal themselves. As with the patch, the less frequent applications can be appealing and can lead to increased adherence. 17 The ring’s internal placement ensures the steady delivery of hormones, which allows for lower serum concentrations than occur with either the patch or pills. As a result, the ring generally has milder side effects than are seen with other CHC delivery methods. 17 Some users may experience increased vaginal irritation and discharge. 17 There is also some evidence of reduced vaginal dryness, which may appeal to perimenopausal women and others who tend to experience such dryness.

The Vaginal Ring

Ring users may have concerns about their risk for pregnancy if the ring is removed intentionally or accidentally. The ring can be removed for up to three hours without diminishing its contraceptive effect. This gives users the option of removing it during sex if they prefer. The manufacturer recommends rinsing the device in cool or lukewarm water prior to reinsertion. 27 If the ring is out for more than three hours, users should take extra steps to protect against pregnancy. As with any device, users should consult the package insert for more specific instructions.

Progestin-only methods

include pills, injections, implants, and intrauterine devices (IUDs). Without concomitant estrogen, progestin-only methods pose less risk of VTE than CHCs. 28 While the safety of the CHC pill, patch, and ring are addressed collectively in the U.S. MEC, the progestin-only methods are given separate safety profiles. Like CHCs, progestin-only methods require a prescription.

Progestin-only pills (POPs).

POPs are generally made with first-generation progestins, and dosage amounts are substantially lower than those found in any CHC. Like CHCs, POPs should be taken at the same time of day. They are used continuously, with no hormone-free interval. Despite their pharmacokinetic differences, failure rates are often reported together: Hatcher and colleagues report that for both types of pills, the failure rate is less than 1% with perfect use and 7% with typical use. 9 That said, POPs have a higher failure rate when not taken at the same time every day, because effective drug levels are maintained in the bloodstream for only 22 hours. 9 Nurses should caution patients that they must be vigilant about adhering to the dosing schedule. The most common side effects of POPs are unscheduled bleeding and spotting, likely due to the shorter daily window of efficacy and the absence of estrogen. 18

POPs are considered safe in many clinical scenarios wherein CHCs are contraindicated (as noted above). As with CHCs, patients should use a nonhormonal backup method when taking certain medications, including rifampin or rifabutin therapy, the antiretroviral drug fosamprenavir, and certain anticonvulsants. 8

DMPA injection.

DMPA (Depo-Provera) is available as a 150 mg/mL intramuscular injection or a 104 mg/mL subcutaneous injection given every 12 to 13 weeks. 18 , 29 Injections must be administered by a provider. The failure rate is less than 1% with perfect use and 4% with typical use. 9 In addition to the aforementioned progestin mechanisms of action, DMPA also affects the hypothalamic–pituitary–ovarian axis at the hypothalamus, inhibiting ovulation through suppression of gonadotropin-releasing hormone. 18

Irregular periods are a common side effect. One systematic review found that, after a year of regular use, only 12% of DMPA users had regular periods and 46% had amenorrhea. 30 Although personal preferences vary, amenorrhea may be seen as beneficial by patients with anemia, endometriosis, fibroids, dysmenorrhea, or menorrhagia. 9 Other potential side effects include weight gain, impaired glucose metabolism, bone mineral density loss, headache, and mood changes (specifically depression). 18 Because DMPA is one of the more discrete methods available, it may appeal to people wishing to keep their contraception private.

DMPA has few contraindications and almost no drug interactions. Additional benefits include decreased risk of endometrial cancer and pelvic inflammatory disease, reduced incidence of epileptic seizures, and reduced frequency of sickle cell crises. 9 , 29

Implants and IUDs containing progestin, as well as IUDs without hormones, are collectively referred to as long-acting reversible contraception (LARC). LARC insertions and removals are within the scope of practice of advanced practice clinicians, including NPs and certified nurse midwives. Once inserted, LARCs involve little user effort to maintain contraceptive efficacy.

The single-rod implant (Implanon, Nexplanon), which is about the size of a matchstick, is inserted in the upper arm and can remain in place for up to three years (see Figure 4 ). The implant contains 68 mg of etonogestrel that is released incrementally at slowly diminishing rates, from 60 to 70 mcg/day initially to 25 to 30 mcg/day by the end of the third year. 31 Failure rates with both typical and perfect use are below 1%. 9 The most commonly reported reasons for discontinuation include irregular bleeding (10%), emotional lability (2%), and weight gain (2%). 32 The implant method can appeal to people who want a long-term, reversible, highly effective method but are uncomfortable with having devices in the vagina or uterus or with insertion procedures at those sites. 18 The implant is safe for the vast majority of people, though there are contraindications for some specific conditions, such as active breast cancer. 8

The Single-Rod Implant

IUDs with progestin (also called intrauterine systems [IUSs]).

With both typical and perfect use, IUDs have failure rates below 1%. 9 Those with progestin alter the cervical mucus such that sperm cannot pass through the cervix to access the upper reproductive tract.

Four levonorgestrel (LNG) IUDs are available on the U.S. market, with similar effectiveness but varying doses, duration, and side effects. 33 The naming convention uses a number to indicate the average number of micrograms of LNG released per day. The LNG-IUS 20 (Mirena) and LNG-IUS 12 (Kyleena) can be used up to five years. The LNG-IUS 20 (Liletta, designed as a lower-cost version of Mirena) can be used up to four years, and the LNG-IUS 8 (Skyla) up to three years. The LNG-IUS 12 and LNG-IUS 8 are smaller in size, which makes insertion easier. Amenorrhea occurs in 20% of LNG-IUS 20 users after one year, in 12% of LNG-IUS 12 users after one year, and in 12% of LNG-IUS 8 users after three years.

Contraindications to IUD use include current purulent cervicitis, chlamydia infection, gonorrhea infection, or pelvic inflammatory disease at the time of insertion. 21 If pelvic inflammatory disease develops after insertion, a course of antibiotics may be prescribed, and removal may be warranted.

Despite their safety and efficacy, IUD use in the United States is lower than in other parts of the industrialized world. 34 IUDs have a fraught history, the legacy of which may affect patient and provider attitudes (see Are IUDs Safe? 8 , 9 , 35 – 40 ). This is slowly starting to change, and recent substantial declines in unintended pregnancies are attributed, in part, to an increase in the use of LARCs. 41

NONHORMONAL METHODS

Nonhormonal methods include the copper IUD, barrier methods with and without spermicides, and behavioral methods. Nonhormonal methods generally have fewer risks and side effects because, by definition, they don’t involve exposure to exogenous or synthetic hormones. As with hormonal methods, the effectiveness, safety, and ease of use of various nonhormonal methods are important user considerations and will strongly influence individual choices.

Copper IUD.

The most effective reversible nonhormonal method is the copper IUD (Paragard), which has a failure rate below 1% with both typical and perfect use; the device can be used for up to 10 years, and must be inserted by a skilled provider. 9 , 42 Copper ions are spermicidal. The copper IUD does not affect ovulation or timing of the menstrual cycle, but it is associated with heavier menstrual bleeding and cramping. 43 In a three-year Australian study among 211 users, of the 59 women who discontinued use though still requiring contraception, 28 did so because of heavy bleeding. 44 This side effect may be felt more acutely by users switching from a hormonal method that lessened their normal flow; anticipatory guidance from nurses can help prepare such users for this possibility.

The copper IUD may be an appealing option for those who are limited by contraindications to CHCs or progestin-only methods. In addition to the aforementioned contraindications for progestin-containing IUDs, copper IUDs are contraindicated for women with copper allergies, uterine infections, or uterine cancer. 8

Barrier methods (with or without spermicides)

include condoms and diaphragms used at the time of intercourse. Efficacy is highly dependent on user behavior, and failure rates with typical and perfect use vary widely. For the male condom, failure rates with typical and perfect use are 13% and 2%, respectively; for the female condom, 21% and 5%, respectively; and for the diaphragm, 17% and 16%, respectively. 9

Condoms are available over the counter. Those made from polyurethane or latex prevent the transmission of STIs, including HIV infection. Nonlatex condoms made of lambskin are available for individuals with latex sensitivity, but don’t protect against STIs.

Diaphragms are inserted into the vaginal canal such that they block the cervical os and can be placed up to an hour before intercourse. They require a prescription, and have traditionally come in multiple sizes, thus requiring fitting by a provider. Diaphragms are used with a spermicide to increase their effectiveness. In the United States, all commercially available spermicides contain nononoyl-9 (N-9) and are sold over the counter. N-9 may cause irritation or allergic reactions, and increases the risk of urinary tract infections. 8 The irritation can cause genital lesions, which may increase the risk of HIV acquisition. For women with HIV, N-9 irritation is suspected of increasing viral shedding, which increases the likelihood of transmission to partners. Thus, spermicide use is contraindicated in people at high risk for contracting HIV and is not recommended for people who have HIV. 8

Behavioral methods

include withdrawal, lactational amenorrhea (LAM), and fertility awareness-based methods (FABMs). Withdrawal (often called “pulling out”) involves removal of the penis from the vaginal canal during intercourse but before ejaculation. The failure rates are 20% with typical use and 4% with perfect use. 9 Withdrawal requires good communication and mutual agreement, as well as adequate physical control by the ejaculating partner. Research indicates that only a very small proportion of individuals use withdrawal as their primary contraceptive method; but because it’s also commonly used in conjunction with other methods and might not be considered a “real” method, its use may be underreported. 45 Withdrawal may be an option for people who don’t want to use other contraceptive methods for religious or cultural reasons.

LAM relies on the natural suppression of the LH surge that occurs during exclusive breastfeeding. It’s highly effective when infants are exclusively fed breast milk on demand, when infants are under six months of age, and when the woman has not yet resumed menses. 18 If breastfeeding is nonexclusive or the infant is older than six months, efficacy drops.

FABMs involve avoiding unprotected intercourse during an estimated fertile window, which is determined through a variety of strategies of varying effectiveness. There are limited data about failure rates for each approach 46 ; but collectively, the FABMs appear to have failure rates of 15% with typical use and from 0.4% to 5% with perfect use. 9 These methods may involve tracking the menstrual cycle, basal body temperature, cervical mucus, or LH levels in order to calculate the likely fertile period. Midcycle, the LH surge preceding ovulation is followed by an increase in progesterone, causing a small but measurable increase in basal body temperature. The timing of ovulation varies, even among women with similar cycle lengths. 47 Some FABM users might not fully comprehend how the method works, 48 and nurses can help them reach a better understanding of their menstrual cycle.

Although FABMs have traditionally been a low-tech contraceptive method, several mobile apps that support FABMs are now available. An app user inputs the relevant data, and the app uses an algorithm to generate fertility window predictions. Apps algorithms vary, as does the accuracy of their predictions. 49 , 50 Nurses should explain to patients that most health apps aren’t regulated by the FDA, and very few have been evaluated in peer-reviewed scientific studies. 51 In one study, nearly 20% of FABM apps contained erroneous medical information. 50 Moreover, there is evidence that some app companies’ advertising overstates their product’s efficacy. 52

For recent developments in contraception, see Innovations in Hormonal and Nonhormonal Methods . 53 – 62

DISPARITIES IN ACCESS AND USE

Because of economic hardship and institutionalized racism, homophobia, and transphobia, many people have compromised access to the full spectrum of contraceptive options. Studies indicate that such socioeconomic factors play a role in the higher rates of unintended and unwanted pregnancies observed among Black and Latina women compared with white women in the United States, as well as influencing user preferences. 14 , 63 Black and Latina women tend to report lower rates of overall contraceptive use and prescription contraceptive use, but higher rates of condom use and tubal ligation or sterilization. 64 , 65

Disparate patterns of contraceptive use and options are also related to bias and discrimination within the health care system. Barriers to high-quality contraceptive care may emerge in the forms of limited knowledge about contraceptive options, limited access to health care generally, receiving biased care from providers, and reproductive coercion. For example, there is evidence to suggest that providers are more likely to recommend IUDs to Black and Latina women with low socioeconomic status than to white women with such status. 66 Explanations for this pattern include that some providers subconsciously see certain women (that is, women of color or low socioeconomic status) as “not needing” more children, needing a lower-maintenance method, or needing more help to effectively prevent pregnancy. 67 But pressuring certain patients into using LARCs undermines their reproductive autonomy and risks continuing historically coercive and racist U.S. contraception policies. As frontline providers, nurses can address these disparities by engaging in reflexive nursing practices and working to undo institutionalized racism. 68

Members of sexual and gender minorities—including those who identify as lesbian, gay, bisexual, queer, transgender, or gender nonbinary—also require access to contraceptive services. But they often have limited access to safe, affirming health care of all types. Members of these minorities have pregnancy and childbearing histories, plans, and desires as diverse as those of any other population. Many nonheterosexual women have been pregnant and given birth, and many have a desire to do so. 69 Others regularly have sex that could lead to pregnancy, and need and want reliable and consistent contraception. 70 , 71 Still others may rarely or never have penile–vaginal intercourse, and use contraception mainly for its noncontraceptive benefits, such as menstrual regulation, or acne or endometriosis treatment. 72

Many transgender or nonbinary individuals who have a uterus and ovaries are capable of becoming pregnant through penile–vaginal intercourse. 73 Testosterone therapy in transgender men is not a reliable contraceptive method, though this misconception is common. 74 Access to effective contraception may be especially critical for transgender men or transmasculine people, since many desire menses suppression. 75 , 76 Clinical and anecdotal evidence also suggest that menstruation and pregnancy may trigger or heighten feelings of gender dysphoria or may put safety at risk by “outing” one as transgender or transmasculine. 77 , 78 Some members of these minorities may achieve amenorrhea and pregnancy prevention with sterilization. Others may want to stop menstruating but retain the possibility of becoming pregnant later in life. Nurses can let such patients know that this may be possible with progestin-only IUDs. Estrogen-containing contraceptives may cause amenorrhea but are contraindicated in people on masculinizing hormone therapy.

An essential component of patient-centered nursing practice is the delivery of individualized care; this includes avoiding assumptions about a patient’s reproductive health priorities and needs based on membership in a particular group. Individuals from any marginalized or stigmatized group who have experienced bias and discrimination in health care might have learned to expect the same from future encounters. It’s important for nurses in all clinical settings to understand how such history can affect patients’ current experiences and the nurse–patient relationship. By applying nursing skills such as taking thorough health histories, listening actively to patients’ reproductive health priorities, and referring patients to appropriate health care services, nurses may be able to improve these relationships and clinical outcomes.

It’s vital that nurses in all settings and specialties stay current on the latest evidence regarding contraception. First, this is essential to fulfilling the World Health Organization’s recommendation to provide comprehensive contraceptive patient education 79 and the ANA’s ethical mandate to support the reproductive self-determination of all patients.6 Second, nurses can provide better patient-centered care if they can competently address patients’ family planning concerns and questions with current and evidence-based knowledge. We recognize that this is challenging, as new types of contraception, hormonal formulations, delivery systems, and indications for use are always being developed. For a list of resources that will help nurses stay up to date, see Resources for Nurses . Lastly, actively addressing the concerns of patients from stigmatized groups will ultimately contribute to efforts to resolve disparities in contraceptive care and work toward reproductive justice for all.▼

Reproductive Justice

Reproductive justice is grounded in the following four principles, which posit that it’s a human right 5 , 7

• to become pregnant and have children, and to determine how one wishes to give birth and create families.
• to choose not to become pregnant or have children, and to have access to options for preventing or ending pregnancy.
• to parent one’s children with dignity—including by having access to essential social supports, safe environments, and healthy communities—without fear of violence from individuals or the government.
• to disassociate sex from reproduction, as healthy sexuality and pleasure are essential components of a full human life.

While the goal of reproductive justice is to address the systems and structures that create reproductive health inequities, making sure that people who need contraceptive services receive high-quality care is a crucial step toward that goal.

Are IUDs Safe?

Current intrauterine devices (IUDs) are among the most effective, safe, and convenient contraceptive methods available. 8 , 9 But there was a time when this was not the case. It’s important for nurses to understand why, as lingering fears and reservations about IUDs are incongruent with current recommendations.

In 1971, a new IUD called the Dalkon Shield was introduced and was on the market for three years. Its use was soon associated with increased risk of pelvic inflammatory disease, spontaneous abortion (often late in pregnancy), ectopic pregnancy, and infertility. But it took 10 years for the magnitude of the problem to fully emerge. Many factors caused these adverse events, some specific to the device and others specific to the state of the medical field. One of the biggest design flaws of the Dalkon Shield was its multifilament tail string. IUDs typically have monofilament tail strings that help providers to remove the device. But because removal of the Dalkon Shield required additional force, a cable-style, multifilament string was used. In contrast to monofilament strings, the multifilament string served as an easy vector for bacteria—such as those that cause chlamydia or gonorrhea—to move quickly from the vagina to the uterus. This led to a fivefold increase in pelvic inflammatory disease among women using the Dalkon Shield compared with those using other IUDs and a sevenfold increase in pelvic inflammatory disease among Dalkon Shield users compared with women using no contraception. 35 Poor screening for and identification of sexually transmitted infections exacerbated the problem. Moreover, the manufacturer initially claimed it was safe to leave the Dalkon Shield in place when pregnancy did occur; this practice resulted in miscarriage, septic abortion, and several deaths. 36

For a time, virtually all IUDs disappeared from the U.S. market, and fears about their use have persisted. 37 Yet all current IUDs are approved for use in nulliparous women, adolescents and teenagers, and women at increased risk for pelvic inflammatory disease. Notably, the American Academy of Pediatrics recommends IUDs as a first-line contraceptive method for adolescents. 38 The use of current IUDs is not associated with infertility, and fertility returns very rapidly upon removal. 39 , 40

Innovations in Hormonal and Nonhormonal Methods

Hormonal contraceptives., combined hormonal contraceptives..

In 2018, the U.S. Food and Drug Administration (FDA) approved a new progestin–estrogen combined hormonal contraceptive, segesterone acetate plus ethinyl estradiol (Annovera). This is a vaginal ring that is placed for 21 days; removed, cleaned, and stored for seven days; and then reinserted for the start of a new cycle. 53 The ring, which is slightly larger and thicker than the ethinyl estradiol–etonogestrel monthly ring (NuvaRing) and can be used for up to 13 cycles (one year), might be a good option for women who have difficulty picking up birth control at a pharmacy on a regular basis, are at risk for losing insurance coverage, or travel frequently. Unlike the NuvaRing, which requires refrigeration prior to dispensing, Annovera does not require refrigeration for long-term storage.

Progestin-only contraceptives.

The possibility of self-administration of depot medroxyprogesterone acetate (DMPA) by subcutaneous injection is being explored. There is evidence that self-administration improves method continuation. 54 Interest has been documented among current DMPA users, who may encounter barriers obtaining or refilling their usual prescription. 55

Nonhormonal contraceptives.

Single-size diaphragm..

In 2014, the FDA approved a single-size silicone diaphragm (Caya). 56 This single-size option means that users no longer have to be fitted by a provider, although like other diaphragms it requires a prescription. In one study, 76% of users could correctly position this diaphragm with written instructions, and 94% could do so with coaching. 57 The single-size diaphragm is described as fitting “most women,” though it will not fit those who previously used a diaphragm sized 50 to 60 mm or 85 to 90 mm. 58 According to the manufacturers, contraindications include having a current vaginal infection, severe pelvic floor or uterine descent, small or absent retropubic recess, acute or frequent bladder infections, and being within the first six weeks postpartum. 58 Users are instructed to insert the diaphragm before intercourse and to use it in combination with a water-based spermicidal gel. Several compatible gels are available. One study of a newer, lactic acid–based gel found its effectiveness comparable to that of gels containing nonoxynol-9. 59

FDA-approved, fertility awareness–based method (FABM) mobile app.

Resources for nurses, u.s. medical eligibility criteria for contraceptive use.

www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html

A detailed document, a summary chart, a digital app, a slide set and more are available for reference regarding contraceptive safety for patients with specific health concerns.

U.S. Selected Practice Recommendations for Contraceptive Use

http://dx.doi.org/10.15585/mmwr.rr6504a1

These recommendations address common, often controversial or complex issues regarding initiation and use of specific contraceptive methods with an eye toward application in the clinical setting. The site includes helpful charts and algorithms.

Centers for Disease Control and Prevention: Reproductive Health: Contraception

www.cdc.gov/reproductivehealth/contraception/index.htm#Contraceptive-Effectiveness

The site includes a link to a chart showing the comparative effectiveness of contraceptive methods and abbreviated instructions for use.

www.bedsider.org

Consumer-oriented, evidence-based decision aids about contraceptives are featured, including an interactive “method explorer” and numerous topic-specific articles and videos.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

A podcast with the authors is available at www.ajnonline.com .

For four additional continuing nursing education activities on the topic of contraception, go to www.nursingcenter.com/ce .

Birth Control

1 empowerment through choice: the evolution and impact of birth control.

The Evolution of Women’s Control over Reproductive Choices It’s crazy how something so small in the past can grow to be something so massive in a short amount of time. Over time, women have been mistreated, underappreciated, and have been forced to not have control of many different situations. But over time, women have regained […]

2 Media Framing and the Birth Control Movement: Reproductive Rights Struggle

Struggles Amplified: Media’s Role in Reproductive Rights Debates In July 2018, Republican Congressman Jason Lewis’s inappropriate and sexist views about women were revealed in a CNN article. The congressman, who is known to be controversial, said that women who voted in favor of health insurance coverage for birth control “were not human beings and were […]

3 OTC Birth Control: Revolutionizing Access for Women’s Health

Executive Summary Contraception is effective in improving health and well-being in women while reducing health care costs from unintended pregnancies and abortion. Women’s access to birth control is inadequate, and oral contraception should be available over the counter in Kentucky. Introduction Contraception is recognized by the Centers for Disease Control and Prevention as one of […]

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4 Navigating the Intricacies of Birth Control: Unveiling its Impact on Cardiovascular Health

Abstract: Oral Contraceptives (OC) and Birth control pills can cause a lot of side effects in the human body. Taking birth control pills increases the risk of having a stroke or heart attack. Based on the case report, a woman entered the hospital with unknown causes of how she was having artery blocking. That woman […]

Home — Essay Samples — Nursing & Health — Public Health Issues — Birth Control

Birth Control Essay Examples

Birth control essay topics and outline examples, essay title 1: birth control methods and their impact on reproductive health and family planning.

Thesis Statement: This essay explores various birth control methods, their effectiveness, and their impact on reproductive health and the ability to make informed family planning decisions.

• Introduction
• Overview of Birth Control Methods: Contraception Options and Their Mechanisms
• Effectiveness and Safety: Evaluating the Reliability and Risks of Different Methods
• Reproductive Health: Discussing the Positive and Negative Effects of Birth Control
• Family Planning: Examining the Role of Birth Control in Decision-Making
• Access and Education: Addressing Barriers and Promoting Awareness
• Conclusion: Empowering Individuals to Make Informed Choices

Essay Title 2: The Societal Impact of Birth Control: Shaping Gender Equality, Family Dynamics, and Healthcare Policies

Thesis Statement: This essay delves into the societal consequences of birth control, including its role in promoting gender equality, influencing family structures, and shaping healthcare policies.

• Gender Equality: Analyzing How Birth Control Empowers Women and Promotes Equal Opportunities
• Family Dynamics: Exploring Changes in Family Size, Planning, and Roles
• Healthcare Policies: Investigating the Accessibility and Regulation of Birth Control
• Ethical Considerations: Discussing Moral and Religious Perspectives
• Global Impact: Examining Birth Control in the Context of Population Control and Development
• Conclusion: Reflecting on Birth Control's Evolving Role in Society

Essay Title 3: Birth Control Education: Promoting Comprehensive Sexual Health Programs for Informed Choices and Safer Practices

Thesis Statement: This essay advocates for comprehensive sexual health education programs that equip individuals with knowledge about birth control options, safe practices, and informed decision-making.

• Sexual Health Education: The Importance of Providing Comprehensive and Accurate Information
• Birth Control Methods: Teaching About Options, Effectiveness, and Risks
• Safe Practices: Promoting Responsible and Consensual Sexual Behavior
• Addressing Myths and Misconceptions: Dispelling Common Misinformation
• Role of Schools and Parents: Collaborative Approaches to Sexual Health Education
• Conclusion: Fostering a Knowledgeable and Empowered Youth

Comparative Analysis of Drug Abuse Potential

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The Effectiveness of Birth Control

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The in Vitro Fertilization

Teenage pregnancy: health concerns and the ways to prevent, analysis of low fertility rate and its outcomes, addressing women's rights in africa, examining the impact of donald trump's presidency on healthcare, and societal tensions, relevant topics.

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SYSTEMATIC REVIEW article

The effects of hormonal contraceptives on the brain: a systematic review of neuroimaging studies.

• 1 Center for Clinical Research in Psychosis (TIPS), Stavanger University Hospital, Stavanger, Norway
• 2 Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
• 3 Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
• 4 Department for Caring and Ethics, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
• 5 SESAM, Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
• 6 Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway

Background: Hormonal contraceptive drugs are being used by adult and adolescent women all over the world. Convergent evidence from animal research indicates that contraceptive substances can alter both structure and function of the brain, yet such effects are not part of the public discourse or clinical decision-making concerning these drugs. We thus conducted a systematic review of the neuroimaging literature to assess the current evidence of hormonal contraceptive influence on the human brain.

Methods: The review was registered in PROSPERO and conducted in accordance with the PRISMA criteria for systematic reviews. Structural and functional neuroimaging studies concerning the use of hormonal contraceptives, indexed in Embase, PubMed and/or PsycINFO until February 2020 were included, following a comprehensive and systematic search based on predetermined selection criteria.

Results: A total of 33 articles met the inclusion criteria. Ten of these were structural studies, while 23 were functional investigations. Only one study investigated effects on an adolescent sample. The quality of the articles varied as many had methodological challenges as well as partially unfounded theoretical claims. However, most of the included neuroimaging studies found functional and/or structural brain changes associated with the use of hormonal contraceptives.

Conclusion: The included studies identified structural and functional changes in areas involved in affective and cognitive processing, such as the amygdala, hippocampus, prefrontal cortex and cingulate gyrus. However, only one study reported primary research on a purely adolescent sample. Thus, there is a need for further investigation of the implications of these findings, especially with regard to adolescent girls.

Introduction

Synthetic sex hormones became available as contraceptive drugs in the 1960's, and they are currently being used by more than 100 million women worldwide ( Christin-Maitre, 2013 ). In the US, it is estimated that 88% of all women of fertile age have utilized this type of birth control at some point in their lives ( Daniels and Jones, 2013 ). Sex hormones consist of androgens, estrogens and progesterone, and in vivo they are synthesized in the gonads, the adrenal glands and the brain. They profoundly impact the brain during fetal life , exerting epigenetic effects and directing development along male or female trajectories by influencing a variety of molecular and cellular processes. Moreover, they affect regional gray matter volumes and neural connectivity associated with psychosexual and other behavioral functions ( Hines, 2006 ; Josso, 2008 ; Peper et al., 2011 ; McCarthy and Nugent, 2015 ).

Converging lines of evidence from animal literature, as well as cognitive and affective neuroscience involving human subjects, suggest that these hormones continue to shape the brain postnatally , also during adolescence ( Herting et al., 2014 ; Schulz and Sisk, 2016 ). In adulthood, they modulate brain areas involved in cognitive and emotional processing, and they are implicated in mood and anxiety disorders ( Comasco et al., 2014 ; Toffoletto et al., 2014 ; Garcia et al., 2018 ). If the synthetic sex hormones contained within hormonal contraceptives (HC) ( Christin-Maitre, 2013 ) interact with sex hormone receptors in the brain, they have the potential to interfere with multiple neurohormonal regulatory mechanisms and neural structures involved in emotion, cognition and psychosexual behavior ( Fuhrmann et al., 2015 ; Schulz and Sisk, 2016 ). To date, neuroimaging research on the effects of HC use on the structure and function of the brain has not been systematically reviewed. The potential for influencing brain plasticity and hence altering brain structures and behavioral outcomes has therefore not been fully elucidated.

Plasticity represents an intrinsic ability of the nervous system to adapt its structure and function in response to endogenous and exogenous environmental demands. This ability persists throughout life ( Pascual-Leone et al., 2005 ). However, there are periods of life when the brain exhibits an increased degree of plasticity and is particularly vulnerable to environmental changes. The perinatal phase is such a period. In 1959, Phoenix et al. proposed that perinatal sex hormones exert an organizing effect on the brain, with ensuing consequences for behavior ( Phoenix et al., 1959 ). They found that prenatal exposure of female guinea pigs to testosterone masculinized their later mating behavior, and they went on to demonstrate similar findings in female rhesus monkeys, who displayed masculinized play patterns following prenatal testosterone treatment. Their claim was that, perinatally, testosterone has an organizing effect on the brain, while the hormonal events of puberty have an activating/deactivating effect on the anatomical structures previously organized.

Several researchers have since expanded on, and in part refuted, this theory. Schulz and Sisk presented evidence from animal studies suggesting that sex hormones may have an organizing effect on the brain long after birth, gradually declining and ending approximately at the resolution of puberty ( Schulz and Sisk, 2016 ). Beltz and Berenbaum (2013) provided further support for the theory of continued ability of sex hormones to exert permanent effects in humans by showing that early puberty, and thus early exposure to adult-levels of sex hormones, in men was associated with better performance in a mental rotation task ( Wai et al., 2010 ). Consequently, adolescence might also be a period sensitive to organizing effects of sex hormones; and the effects may be stronger, the younger the individual is when exposed.

During adolescence, several brain areas, in particular the prefrontal cortex (PFC), undergo extensive structural maturation through processes such as synaptic pruning, reorganization and myelination ( Petanjek et al., 2011 ; Blakemore, 2012 ). The brain's functional architecture also undergoes maturational processes of optimizing connectivity in functional networks ( Sherman et al., 2014 ). This prolonged developmental shaping and reorganization of neural circuits has implications for understanding the vulnerability of the brain during this period, as the plastic brain is the platform for learning and developing as well as for psychopathology and cerebral disease.

While endogenous sex hormones have well-documented effects on the brain, the influence of their synthetic counterparts, progestins and ethinylestradiol, which are most commonly used in oral contraceptive pills ( Christin-Maitre, 2013 ), has been less extensively explored. However, there is reason to believe that also synthetic sex hormones could have a significant neural impact, particularly if taken when the young female brain is developing into its adult form. Behavioral effects of HC have been shown in cognitive tasks such as mental rotation and verbal expressional fluency ( Beltz et al., 2015 ; Griksiene et al., 2018 ), and of more serious concern is the demonstrated association between these drugs and various affective adversities. Thus, Skovlund et al. conducted a large national cohort study in Denmark, where they collected and compared data from the National Prescription Register and the Psychiatric Central Research Register. They found a correlation between the use of HC and a subsequent first diagnosis of depression and the use of antidepressants. The increased risk of these adverse outcomes was noted to be the highest in adolescent women ( Skovlund et al., 2016 ). The Skovlund group also investigated associations between HC intake and suicidal behavior and they found an increased risk for both attempted and committed suicide. Again, the increased risk was highest in adolescent women, and it peaked within 2 months of intake debut ( Skovlund et al., 2018 ).

In order to assess the prevalence of HC use among Norwegian adolescents, we queried the Norwegian Prescription Database regarding usage of drugs ( Norwegian Prescription Database, 2019 ) according to the Anatomical Therapeutic Chemical (ATC) code G03A (Hormonal contraceptives for systemic use). This database provides data on these drugs from 2004 to 2018, and it is possible to query separately for age groups such as 10–14 and 15–19. The usage for girls between the ages of 10 and 14 has more than doubled from 2004 to 2018, and in 2018 about 1.2 percent of all 10–14-year-old girls used some form of systemic HC. The numbers for girls between the ages of 15 and 19 have been quite stable at about 40 percent throughout the same period. Thus, a substantial proportion of young girls use these drugs and the usage has increased rapidly among the youngest adolescent girls in Norway.

The central aim of this review was to identify and critically appraise all peer-reviewed empirical studies published in English concerning human subjects that have investigated the effects of HC on brain structure and function through digital neuroimaging techniques, such as magnetic resonance imaging (MRI) and functional MRI (fMRI), as well as positron emission tomography (PET), electroencephalography (EEG) and magnetoencephalography (MEG).

Our main hypotheses were that HC use affects both brain structure and function in humans, and that there are effects on brain structures known to differ statistically in men and women, such as the PFC, hypothalamus, amygdala and hippocampus ( Cahill, 2006 ), as well as on brain structures involved in visuospatial and verbal cognition. Additionally, we hypothesized that HC use have the most pronounced effects on brain structures if used during early adolescence.

This review was conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2009 ), and it was registered in the PROSPERO International Prospective Register of Systematic Reviews (Registration number: CRD42019142427).

Literature Search

Studies employing neuroimaging techniques to measure possible HC effects on either brain structure or function were considered. In order to be included, the studies should (a) be primary empirical studies, (b) be conducted on women of fertile age using HC, and (c) have either a separate control group of naturally cycling (NC) women of comparable age or have HC users constitute their own controls by performing repeated assessments under NC and HC conditions. Thus, case reports, literature reviews and experimental studies with no control group were excluded. We included articles published in English from 1990 and up until February 2020. Studies older than the 90's are based on imaging techniques not comparable to those of modern neuroimaging.

Stage One Search

The review was carried out in two stages. The first stage consisted of an exploratory search using PubMed and Google Scholar. PubMed covers most studies involving neuroscience and related fields, and Google Scholar indexes most broadly of all peer-review databases. We first combined the keyword “contraceptives” with “brain,” “cognition,” “emotion,” and “motivation” and searched the databases. We selected and read relevant review articles. The knowledge gained from this process was used to decide on keywords for the stage two searches.

Stage Two Search

Following the initial exploratory search, systematic searches were carried out, employing a two-pronged approach aiming to identify structural and functional neuroimaging studies separately. In Table 1 , the PICOS criteria for the searches are described.

Table 1 . PICOS search.

We first combined search terms such as “contraceptive agent” and “birth control” with terms descriptive of structural neuroimaging such as “magnetic resonance imaging,” “computed axial tomography,” and “diffusion tensor imaging.” We searched for these terms in titles, abstracts and keywords as well as MESH- and Emtree-terms. Titles and abstracts were scanned, excluding articles not meeting our inclusion criteria. Finally, full texts were read in order to identify measures and methodological detail, further excluding ineligible articles. See Appendix 1 for a comprehensive list of search terms.

The second systematic search was carried out using the same search terms describing HC, this time combining them with terms aiming to identify functional neuroimaging studies. Relevant terms were “functional magnetic resonance imaging,” “positron emission tomography,” “electroencephalography,” and “event related potentials.” The same procedures of selection were carried out and relevant articles were retrieved. The stage 2 searches were carried out in February 2020.

A final reference and citation search strategy was employed to ensure that all relevant studies were identified. This implied scanning reference lists in the included articles as well as articles that cited the included papers, after a consensus selection process as described below.

After completing the systematic searches, the authors MKB and KKB independently read the keywords, abstracts and titles and divided articles into “included,” “excluded,” and “undecided” categories. After the initial assessments, full texts were read, and the researchers discussed the criteria and revised the “undecided” articles until all citations were either included or excluded.

Quality assessment was not done using a rigid framework resulting in a single numeric score, as the studies differed regarding dependent variables and design. However, we applied the validity typology of Donald Campbell and Thomas D. Cook ( Cook et al., 1979 ) in order to assess threats to construct, internal, external and statistical conclusion validity. This was done as the study designs and outcome measures were heterogenous, necessitating a flexible approach for quality assessment. These dimensions of validity encompass most of the common causes of bias and validity threats regarding causal inference. Three levels of validity were applied: low, intermediate and high. Low validity implies that there was a validity threat serious enough to fundamentally invalidate the study. Intermediate implies that there were validity threats, but that they were outweighed or resolved to a degree that they were unlikely to seriously bias or confound the study. High means that there were no validity threats for the dimension in question. The assessment was done by authors KKB and MKB and in case of disagreement, consensus was reached through discussion and independent re-reading of the study in question. With regard to statistical power, the combination of small sample size and lack of assessment of statistical power implied a classification of low statistical conclusion validity. In neuroimaging studies, it is difficult to determine a general “too small” sample size, but in the absence of power analyses, we chose a cutoff of n < 20 within the HC group to classify sample size as small.

Structural Neuroimaging

Following the initial exploratory search, a systematic search for structural neuroimaging studies yielded a total of 11,228 hits from the different databases, after removing duplicates. After scanning titles and abstracts, 11,213 citations were excluded. Finally, the full texts were read in order to identify measures and methodological details, further excluding five articles. Thus, 10 articles were deemed eligible for inclusion, based on the aforementioned criteria. No additional articles were found after doing citation searches and reference list reviews. See Figure 1 .

Figure 1 . Flowchart Structural Search.

Functional Neuroimaging

A second systematic search pursuing functional neuroimaging studies yielded 572 articles, after removing duplicates. A total of 23 articles qualified for inclusion following the same procedures of selection. No additional articles were found after performing citation searches and reference list reviews. See Figure 2 .

Figure 2 . Flowchart functional search.

See Tables 2 , 3 for an overview of the included articles.

Table 2 . Overview of articles concerning the effect of HC on brain structure.

Table 3 . Overview of articles concerning the effect of HC on brain function.

Results From the Structural Studies

Most of the included structural studies reported differences between HC users and NC women, as reported in Table 2 .

Summary of the Structural Studies

All the structural studies tested differences in various brain structures in users of different types of HC as compared to present non-users. The studies were mostly cross-sectional and observational in nature, with the exception of one study ( Lisofsky et al., 2016 ) which was a quasi-experimental pre-post study where a self-selected group of women starting HC use was compared with non-users. However, even in this study, previous use was unaccounted for. Hence no study investigated HC naïve women. The sample size ranged from 14 to 60 in the HC groups and from 14 to 89 in the control groups. The age range was 18–40 years in both HC and control groups except for the study by Frokjaer et al. (2009) who reported an age range of 18–45 years in the HC group and 18–79 years in a female and male control group. De Bondt et al. (2015a) studied “young women” but did not specify age span. A variety of neuroimaging techniques were employed, including DTI-MRI, volumetric MRI, spectroscopy MRI and PET.

HC in Studies on Sex Differences

Several of the studies concerning brain structure were not primarily focused on HC effects on the brain per se . Rather, they included HC users in order to investigate whether HC use is an important confounder or moderator in studies on sex differences in the brain. Thus, the aims, methodologies and hypotheses were heterogeneous with regard to HC effects. Four studies ( Frokjaer et al., 2009 ; Pletzer et al., 2010 ; De Bondt et al., 2016 ; Pletzer, 2019 ) explicitly argued that earlier neuroimaging studies on sex differences in the brain did not account for potential confounding effects of HC use in women. These studies assessed brain morphology as related to differential vulnerability to mood and anxiety disorders in men and women. For instance Pletzer et al. (2010) , found that NC women had larger prefrontal brain volumes than both men and HC women, and that men had larger hippocampal and amygdalae volumes than women. In a more recent publication, Pletzer pooled and analyzed data from previous publications and noted smaller gray matter volumes in hippocampal and parahippocampal areas in HC users as compared to NC women ( Pletzer, 2019 ). De Bondt et al. (2016) noted that gray matter volumes and PMS symptoms correlated differently in NC and HC groups, whereas Frokjaer et al. (2009) used cortical serotonergic receptor binding as a measure of potential for affective disturbances but discovered no effects of neither sex nor HC use.

Furthermore, as related to whether HC masculinize or feminize brain structure, Pletzer et al. investigated HC effects on the brain depending on the androgenicity of the progestin component of the HC ( Pletzer et al., 2015 ). They found that anti-androgenic progestins promoted larger gray matter volumes in temporal areas such as the fusiform face area and the parahippocampal place area and further related these changes to improved performance in a face recognition task, when comparing with NC women. They also found that users of androgenic progestins had smaller frontal areas compared to NC women.

Brain Structures Involved in Cognition and Emotion

A couple of studies specifically focused on HC effects on brain structures known to participate in the processing of emotion and/or cognition. Lisofsky et al. (2016) , in a pre-post quasi-experiment with a control group, found decreased gray matter volumes in the amygdala after 3 months of contraceptive intake in women starting HC use after a period on not using HC. They noted that this structural alteration was related to positive affect, whereas no changes in cognitive performance were detected. One study ( Petersen et al., 2015 ) investigated areas involved in the salience network and found cortical thinning in such areas. They were not able, however, to determine whether these changes were causally or merely indirectly related to the use of HC.

The Effect of Menstrual Cycle and HC on Brain Structure

One research group has published a series of articles where HC effects were contextualized regarding natural hormonal variation in the menstrual cycle. All these articles had Timo DeBondt as first author. The articles were based on overlapping samples and all assessed the effects of HC as compared to hormonal effects in the menstrual cycle on brain structure ( De Bondt et al., 2013a , b , 2015a ). Using diffusion tensor imaging, they found a significant increase in mean diffusivity in the fornix in an HC group as compared to a group of NC women ( De Bondt et al., 2013b ). In the same sample, they also reported that gray matter volume in anterior cingulate cortex (ACC) was negatively associated with estradiol levels in the NC women, whereas this finding could not be replicated in the HC group ( De Bondt et al., 2013a ). De Bondt et al. (2015a) also examined gamma aminobutyric acid (GABA) concentrations, seeking to find possible correlations between GABA concentration in the PFC, menstrual cycle phase, HC use and premenstrual syndrome (PMS) symptoms. They did find increased prefrontal GABA in the NC group at ovulation, whereas no changes were seen during the cycle in the HC group. No significant correlations with endogenous hormones or PMS symptoms were detected.

Adolescent HC Users

None of the structural studies directly investigated effects of HC use on the adolescent brain. Most samples included teenagers from the age of 18, but results were not separated according to age, and as such intermingled with effects on adult brains. This makes it impossible to assess differential or graded effects on younger brains.

Results From the Functional Studies

Functional measures were reported in 21 different articles as summarized in Table 3 .

Summary of Functional Studies

Functional studies were mainly conducted using task based and/or resting state fMRI. In addition, one group used PET and one group EEG. The research groups evaluated cognitive tasks, emotion processing, fear learning, reward and motivation as well as pain inhibition and resting state networks, related to intake of various types of hormonal contraceptives. Only two studies were randomized controlled trials (RCTs) ( Gingnell et al., 2013 , 2016 ), whereas the rest were observational, quasi-experimental or observational with repeated measures within one menstrual cycle. Sample size range was 8–55 in both HC groups and female control groups. Age span was 16–45 years, except in three studies ( Vincent et al., 2013 ; De Bondt et al., 2015b ; Smith et al., 2018 ) which provided no information about age, and four studies where only mean age was provided ( Pletzer et al., 2014 ; Hwang et al., 2015 ; Scheele et al., 2016 ; Smith et al., 2018 ; Hornung et al., 2019 ). One study ( Mareckova et al., 2014 ) additionally assessed an adolescent sample aged 13.5–15.5 years with 55 participants in both the HC and the NC control group. The functional studies were also heterogenous with regard to aims and approaches as well as design and methodology.

Emotion Processing, Fear, Anxiety, and Stress

In line with the scope of some of the structural studies, several of the functional studies investigated brain functions involved in affective processing.

Gingnell et al. (2013) conducted an fMRI RCT with a sample of women with a previous history of HC-induced adverse mood. The subjects were assessed at baseline and once during the last week of the 21 day HC/placebo treatment period. An emotional facial expression matching task was administered. Hemodynamic BOLD (Blood-oxygen-level-dependent) responses to angry or fearful expressions differed between groups and within the HC group when comparing pre-treatment and treatment scans. During the last week of the treatment cycle, the HC group showed decreased reactivity in the bilateral frontal gyri, both compared to the placebo group and to the pre-treatment scans. They also showed decreased reactivity in the left middle frontal gyrus and left insula compared to the placebo women. The changes in brain reactivity were accompanied by more depressed mood, mood swings and fatigue, compared both to the control group and to pre-treatment. The placebo group also showed decreased amygdala reactivity in the last set of scans, whereas this change was not found in the HC group.

Altered amygdala reactivity was also found by Petersen and Cahill ( Petersen and Cahill, 2015 ) who used fMRI to compare reactions related to arousing, negatively valenced images in HC and NC women. They found that HC women had significantly lower amygdala reactivity upon viewing emotionally arousing images.

Investigating the interaction effects of sex hormones and cortisol, Merz et al. (2012) found fMRI activation differences in amygdala, hippocampus and the parahippocampal gyri as a function of interaction of HC use and cortisol administration on implicit emotional learning using a fear learning paradigm. Administration of cortisol reduced amygdala activation in all groups but dampened neural activation in the left hippocampus and in the left anterior parahippocampal gyrus only in NC women. In HC women, hippocampal and parahippocampal activation was enhanced with increased levels of cortisol. In a later study ( Merz et al., 2013 ) Merz et al. evaluated the interaction between endogenous cortisol and the neural correlates of fear expression. There was an interaction between cortisol and HC use, as cortisol levels correlated with BOLD contrasts in the amygdala between conditioned fear stimuli only in HC users.

Fear conditioning was also applied by Hwang et al. (2015) , studying fMRI fear responses as well as extinction learning and recall, as related to HC and sex hormone status. HC women had lower activation in the posterior insular cortex, middle cingulate cortex, hypothalamus and amygdala compared to NC women with high levels of estrogen during fear conditioning.

An fMRI “traumatic” film viewing paradigm was utilized by Miedl et al. (2018) to assess the effects of endogenous estradiol and synthetic sex hormones on the neural processing of trauma exposure using films depicting severe interpersonal violence vs. neutral films in NC and HC-using women. The HC group showed increased insula and dorsal ACC activity relative to NC women upon viewing traumatic films.

Two different fMRI studies investigated effects of the pheromone-like steroid androstadienone. Hornung et al. (2019) evaluated differences in attention bias in HC vs. NC women when presented with fearful, angry and happy faces in a “dot probe” task and whether androstadienone affects attention bias. There were no behavioral attentional bias differences, no BOLD response differences and no effects of androstadienone. Similarly, Chung et al. (2016) explored the influence of androstadienone during psychosocial stress in HC, NC and in men using the Montreal Imaging Stress Task. The NC women showed increased activation of the left somatosensory association cortex as well as right pre-motor and supplementary motor areas under the placebo treatment when faced with stress, as compared to HC women. Under treatment with androstadienone, no significant differences were observed between the female groups.

The only included event-related potential (ERP) study was published by Monciunskaite et al. (2019) and employed emotional visual stimuli when comparing women using anti-androgenic HC with NC women. The main finding was that the HC group showed blunted late ERP amplitudes to negative emotional stimuli when compared to NC women.

Reward and Motivation

fMRI effects of HC on erotic stimulation and monetary reward was investigated by Abler et al. (2013) and Bonenberger et al. (2013) , respectively. Abler et al. presented erotic videos and pictures to HC users and NC women. The MRI scans revealed no between- or within group differences upon viewing these. However, compared to HC users, the NC women in their follicular phase showed increased activation in the bilateral anterior insula, dorsomedial PFC and left inferior parietal lobe, as well as in the bilateral inferior precentral gyrus upon expectation of erotic stimuli. In their luteal phase they had higher activation in the anterior and posterior middle cingulate cortex. Bonenberger et al. examined how the use of HC might alter neural reward processing in a monetary incentive task. In whole-brain analyses, NC and HC women did not differ upon expectation of a monetary reward. An ROI analysis did, however, show enhanced activity in the left anterior insula and inferior lateral PFC in HC users, relative to NC women in their follicular phase.

The interaction of oxytocin and HC regarding perceived partner attractiveness in relation to HC use was studied by Scheele et al. (2016) . Subjects were randomized to receive either oxytocin or placebo prior to participating in a passive face-viewing fMRI paradigm. NC and HC pair-bonded women were shown photographs of their romantic partner, matched unknown men, a familiar woman, and a matched unfamiliar woman. Administration of oxytocin was found to enhance ratings of attractiveness of romantic partners compared to unknown men in the NC women, but not in the HC women. NC women showed increased activity in the nucleus accumbens and ventral tegmental area upon viewing their partners, relative to the HC women. The interpretation was that HC can disrupt romantic partner attachment.

HC modulation of fMRI activation upon seeing different food cues was investigated by Arnoni-Bauer et al. (2017) who hypothesized that there would be an association between sex hormones and eating behaviors. Participants were shown images of high calorie foods as well as non-edible items. fMRI activation in the HC group was similar to that of the luteal phase in the NC women. Food related brain activation was assessed also by Basu et al. (2016) who tested the effects of depot medroxyprogesterone acetate (DMPA) on food motivation using a quasi-experimental pre-post design with subjects acting as their own controls. Eight women were investigated with MRI while looking at images of high-calorie and low-calorie foods, as well as neutral, non-food objects. Eight weeks after the DMPA injection increased activation was observed in frontal and postcentral areas upon viewing food, when comparing to baseline. The high-calorie images induced highest activation in cingulate and frontal areas, when comparing to baseline.

A final study of motivational effects of HC was conducted by Smith et al. (2018) who performed a PET study to assess sex differences in dopamine release in inferior frontal areas as well as the dorsal and ventral striatum. They administered D-amphetamine to NC and HC women, as well as to men, to elucidate possible sexually dimorphic neural and hormonal contributions to addiction. They measured changes in dopamine D2 and D3 receptors in the participants, but found no significant effects of HC.

Perception of Pain

Vincent et al. (2013) delivered noxious thermal stimuli to HC and NC subjects while in an MRI scanner, aiming to establish whether there was a reduction in the descending pain inhibitory system in the HC group. Serum sex hormone levels were assessed, and participants were asked to rate the intensity of pain for each stimulus delivered. The researchers found that a subgroup of HC women who had decreased testosterone levels required significantly lower temperatures to feel pain, relative to the NC control group. Imaging data showed significantly reduced activity in the rostral ventromedial medulla in response to the noxious stimuli in the low testosterone women, suggesting that failure to engage pain inhibition at this level might be involved in the increased sensitivity to pain in this group. NC women showed higher amygdala activation when compared to high testosterone HC women, but this was not seen when comparing with the low testosterone HC women.

Cognitive Tasks

Gingnell et al. (2016) published an fMRI RCT on the effects of HC on brain reactivity during response inhibition, where participants were asked to complete a go/no-go inhibition task. All participants were scanned at baseline and again during the last week of a 21-day treatment cycle. Only the women in the HC group improved performance significantly. HC women showed decreased reactivity in the right orbitofrontal cortex during correct response inhibition. Based on these findings the authors suggest that the use of HC does not necessarily have a negative impact on cognitive control and that, if anything, it might lead to a slight improvement.

Pletzer et al. (2014) assessed fMRI activations during two different numerical tasks which in previous studies had shown systematic sex differences in behavioral performance. HC users were compared to NC women in the follicular and luteal phases of their menstrual cycles, as well as to a group of men. They tested the assumption that brain effects of the synthetic form of progesterone in HC could be induced either by androgenic influences of these progestins (HC group should resemble men), by progestogenic influences (HC group should resemble the luteal group) or through an attenuation of endogenous steroids (HC groups should resemble the follicular group). The HC women resembled the follicular women the most regarding behavioral performance, but their BOLD response resembled that of the men in both cognitive tasks. The main conclusion drawn by the authors was that brain activation patterns in the HC users resembled that of men, but that no behavioral resemblance could be established.

Also employing cognitive tasks in which sex differences have previously been shown, Rumberg et al. (2010) employed fMRi scanning during a verb generation task which consisted of thinking about verbs corresponding to nouns being presented. They found increased activation in the right superior temporal lobe in HC women compared with NC women in their menstrual phase, and in the right inferior frontal cortex comparing with NC women in their mid-cycle phase.

Social cognition was evaluated by Mareckova et al. (2014) in a study on the influence of hormones on face perception. They recruited women using HC as well as NC women and performed fMRI scans while the women were shown ambiguous and angry faces. Both groups underwent fMRI scanning twice, once during the mid-cycle phase and once in the menstrual phase in both groups. Scans revealed stronger BOLD activation in the right fusiform face area in response to both ambiguous and angry faces in the HC groups as compared to the NC group.

Resting State and Functional Connectivity

Two of the research groups employed resting state fMRI to study the brain in the absence of tasks. Petersen et al. (2014) measured salivary hormone levels and compared brain activity in the anterior default mode network (DMN) and executive control network (ECN) in early follicular NC women, luteal NC women, HC users in active and inactive pill phases. They found that both endogenous hormone fluctuations and administration of synthetic sex hormones were associated with changes in these networks. De Bondt et al. (2015b) assessed hormone levels as well as symptoms of PMS in NC and HC women in addition to conducting fMRI analyses, but found no significant alterations in the DMN or ECN as a result of neither menstrual cycle phase nor the use of HC. They did, however, observe a positive correlation between PMS-like symptoms in women using HC and functional connectivity in the posterior part of the DMN.

Only one functional study ( Mareckova et al., 2014 ) investigated HC effects on a purely adolescent sample. This sample included teenagers from the age of 13.5–15.5 years. In this study, ROI findings from experiments done on adult participants ( Mareckova et al., 2014 ) were replicated. The teenagers using HC showed increased activity in the left fusiform face area of the temporal lobe upon viewing video clips of faces with ambiguous facial expressions.

In summary, most of the identified neuroimaging studies found effects of HC usage on the female brain, mainly in areas involved in emotional and cognitive processing. However, methodological challenges in almost all the included studies limit our ability to accurately interpret their results and render our main hypotheses to some extent unresolved. The studies by Gingnell et al. (2013 , 2016) were the only RCTs concerning the effects of HC. The sample consisted of women with previously reported HC-induced adverse mood, and the articles demonstrated that in women with adverse mood effects, HC may influence negative emotional reactivity and neural networks involved in cognitive inhibition.

Most of the other studies also found effects of HC use on brain structure or function, but these studies had major methodological problems with regard to internal validity or statistical conclusion validity resulting from using familywise uncorrected analyses of MRI-images or small sample sizes. Thus, although we discuss the possible implications of the findings, the reader should keep in mind that these studies are potentially biased. An overview of bias can be found in Supplementary Table 1 and methodological limitations are described in detail in a concluding section. Further, there was only one study with a sample of women in early adolescence, and this was a self-selected convenience sample and hence it may be biased. Thus, our hypothesis regarding effects in adolescence remains unresolved.

Implications of Structural and Functional Alterations

Most of the included studies indicate that several brain alterations are associated with the use of HC substances. We will discuss the most robust and convergent findings.

Several studies showed effects in areas of the brain known to be implicated in affective processing. Brain mechanisms involving affective changes caused by using of HC are crucial, due to their direct implications for mental health. This point is made convincingly by the register studies by Skovlund et al. showing that HC usage increases depression and suicide risk and that the effects are larger for the youngest women ( Skovlund et al., 2016 , 2018 ). According to Gingnell et al. (2013) the use of a combined HC has the potential to negatively affect mood and to induce changes in brain reactivity in structures involved in the processing of fear and other forms of negative affect. In the present review, their studies ( Gingnell et al., 2013 , 2016 ) were the strongest in terms of design, and are the only neuroimaging RCTs ever to be performed on functional brain effects of HC. The studies' risk of bias were small, but the researchers only included women with previously reported negative affect in response to the use of HC. Consequently, their sample is not representative for the general female population and external validity is hence limited. However, the study does contribute explanatory findings that are valid for women who experience adverse mood as a side effect of HC use. The women randomized to receive HC showed depressed mood after 1 month of use. This was linked to lower activity in frontal and insular brain areas upon viewing images of angry and fearful facial expressions, as compared to women randomized to receive placebo drugs. In the latter group, less amygdala reactivity was seen in response to images of emotional facial expressions upon a second exposure to these stimuli, whereas a difference upon re-exposure was not seen in women randomized to receive HC drugs. The researchers hypothesized that this might be indicative of decreased amygdala habituation in HC women, and as such attributed the deteriorated mood to an increased vigilance to emotional stimuli.

Further, several other studies in this review, shown in Tables 2 , 3 , indicate that HC use may affect structures in fear detecting and fear learning circuits in the brain, such as the amygdala. Amygdala functioning is strongly related to fear and learning of fear responses. This is clinically relevant, as fear learning is involved in phobias and other anxiety disorders ( Phelps and LeDoux, 2005 ; Adhikari et al., 2015 ; Hu et al., 2017 ). However, the findings are inconsistent, and the studies are heterogenous and confounded by lack of control regarding the androgenic and anti-androgenic effects of the progestins involved. Thus, a balanced interpretation would be that HC use likely affects fear circuits, but that the underlying mechanisms of such effects are not yet understood.

Several studies focused on cognition. The inferior and middle frontal gyri, in particular on the right side of the brain, are associated with inhibition and attentional control ( Booth et al., 2005 ; Aron et al., 2014 ). In a 2016 RCT, Gingnell et al. (2016) found decreased activity in the right middle frontal gyrus in HC women during a repeated go/no-go inhibition task, both comparing to the pre-treatment cycle and to the NC women. No difference in performance was detected at baseline, but the behavioral performance of the HC women improved more than that of the NC women in the retest session. The authors speculated that this might mean reduced effort in maintaining inhibitory control in the HC women leading to an enhanced inhibitory control in women taking these drugs. Thus, the reduced BOLD activations may be interpreted as increased efficiency and not as an expression of behavioral disinhibition.

Many of the included studies showed effects on the parahippocampal gyrus, both structurally ( Pletzer et al., 2010 , 2015 ; Lisofsky et al., 2016 ) and functionally ( Merz et al., 2012 ; Lisofsky et al., 2016 ). The parahippocampal gyrus is highly interesting in the context of sex hormones, as it is involved in encoding spatial layout of three-dimensional “scenes” ( Furuya et al., 2014 ). Spatial cognitive ability is one of the cognitive functions where the largest sex differences have been shown ( Voyer et al., 1995 ). However, none of the included studies focused on visuospatial cognition, where functional effects of the identified structural findings would be expected. The structural findings are inconsistent, as Lisofsky et al. (2016) found decreased parahippocampal volume in HC users, whereas Pletzer et al. (2010) found increased volume. Pletzer et al. suggest that an explanation may be that some progestins in HC are androgenic while others are anti-androgenic. They found larger gray matter volumes in the parahippocampal gyri in users of anti-androgenic progestins, but not in users of androgenic progestins, both compared to NC women. The Lisofsky article did not report the specific type of progestin, leaving this inconsistency unresolved.

Facial perception is a process considered to be important for social cognition which is a cognitive function where sex-differences have been found. The fusiform face area plays a role in facial recognition ( Axelrod and Yovel, 2015 ) and effects in this area was reported in the structural studies by Pletzer et al. (2010 , 2015) as well as the functional Marečková studies ( Mareckova et al., 2014 ) conducted with adult and adolescent samples. These studies found increased BOLD response in the fusiform face area upon viewing ambiguous and angry faces. The Marečková findings also provide a link between duration of HC use and extent of impact on the brain, as the activity in this area was increased as a function of length of use. The authors suggest a long-term plastic adaptation of the brain related to the use of HC. Thus, HC may influence social cognition, although the functional implications are unresolved.

Several research groups found functional effects of HC use in areas involved in the regulation of reward and motivation. The researchers used food-related, romantic, and sexual as well as monetary stimuli as a means of measuring such effects. The most important areas in the brain regarding reward, involve the dopaminergic mesolimbic structures such as nucleus accumbens in the striatum as well as the ventral tegmental area (VTA) ( Arias-Carrion et al., 2010 ). Oxytocin-releasing neurons terminate on these areas and oxytocin is thought to mediate reward ( Peris et al., 2017 ). Changes in these systems may affect all forms of motivated behaviors, thus having important effects in all areas of life. For instance, the study by Scheele et al. (2016) which assessed perceived partner attractiveness, found that upon viewing the partner's face, treatment with oxytocin increased the behavioral evaluation of partner attractiveness as well as BOLD responses in the nucleus accumbens and the VTA, in the NC group. This was not found in the HC group. The possible implication is that HC may attenuate partner-bonding. This remains speculative but should be explored further due to the seriousness of the potential consequences. The studies on sexual, monetary and food-related rewards ( Abler et al., 2013 ; Bonenberger et al., 2013 ; Basu et al., 2016 ) suffer from possible retest effects in only some of the subjects, post-hoc finding present only in an ROI based analysis and a small sample, respectively, thus presenting with reduced validity.

Lack of Pure Adolescent Samples

In addition to hypothesizing about the ability of HC to affect structural and functional aspects of the brain, we expected effects to be larger in adolescent subjects than in adult subjects. However, as we identified only one neuroimaging study ever to be performed on a purely adolescent sample, this hypothesis remains unresolved and the effects of such drugs on developing brains remain undetermined. The studies included many older subjects, making it impossible to disentangle potential differences between effects on the adolescent brain and effects on the adult brain. None of the studies investigated structural changes related to the use of HC in drug-naïve teenagers, but rather included convenience samples with mostly adult subjects. Only one functional study ( Mareckova et al., 2014 ) included a strictly adolescent sample, but there was no direct comparison with older subjects, nor any statistical test of age-covariates.

Given the evidence from the animal literature, as well as clinical registry studies such as that by Skovlund et al. (2016 , 2018) , which strongly indicate an increased vulnerability of the brain during adolescence, combined with the fact that girls are using these substances from an early adolescent age, we argue that there is a strong need for future studies to be carried out on adolescent use of HC.

Methodological Limitations in the Included Studies

We applied the validity typology of Donald Campbell and Thomas D. Cook ( Cook et al., 1979 ) which encompasses 4 types of validity threats with regard to our ability to make causal inferences: Internal validity, external validity, statistical conclusion validity and construct validity. While all types are important, low internal validity is paramount as is concerns whether an intervention was the likely cause of an effect. Thus, internal validity mainly encompasses confounders. See Supplementary Table 1 for a summary of the quality evaluation.

With the exception of Gingnell et al. (2013 , 2016) , none of the studies randomized participants to receive either HC or placebo, and most of the studies were observational with no inclusion of HC-naïve women. Hence, only the Gingnell studies reached high internal validity. The combined structural and functional MRI study by Lisofsky et al. (2016) achieved intermediate internal validity as they employed a pre-post quasi-experiment with control group, because even though the subjects self-selected to use HC, risk of bias was lowered due to the longitudinal design, enabling comparisons of within and between group effects. Yet, this design cannot control for effects of previous use. While this is true also for Gingnell, they explicitly aimed to generalize to a population of previous users. Thus, as stated previously, the Gingnell study cannot be generalized to the population of all women.

The conclusion regarding internal validity is that all studies, except the ones by Gingnell et al. were susceptible to bias and confounding due to selection phenomena and unobserved variables. Convenience sampling without disclosed detail concerning recruitment, as well as lack of randomization and control groups in almost all of the included studies, makes it impossible to ascertain causality.

Furthermore, most studies had poor control regarding type of substance currently or previously used, and no control for age at start of previous use, leading to low external validity. This critique also pertain to the Gingnell RCTs, as it is only possible to generalize to women with previous negative mood effects while using HC.

Most studies had low statistical conclusion validity, with small samples, resulting in low statistical power, making negative findings difficult to interpret, but also to an increased risk of false positive results ( Button et al., 2013 ). Many of the findings were also based on ROI analyses without familywise error (FWE) corrected whole brain analyses. ROI areas can be chosen based on post-hoc considerations, and so there should be a strong theoretical and/or empirical basis for choice of ROI areas. Several studies also employed whole brain analyses without correction for FWE. This may have led to type 1 errors.

Thus, while most studies found effects of HC on brain function or structure, confounding cannot be ruled out. While different studies had different methodological problems, the main source of low validity was self-selection in all of these studies, with the exception of the Gingnell studies. Thus, we discuss the effects of self-selection in the next paragraph.

The Impact of Sampling Bias and Self-Selection

Self-selection is a major internal validity threat in all of the non-randomized studies and is highly problematic in the present context. Choosing or not choosing to use HC may be influenced by various psychological factors that are associated with differences in brain structure and function. Mental and behavioral functions are, to a large extent, determined by brain function which ultimately is determined by brain structure. Thus, in the absence of randomization, self-selection by choosing or not choosing to use contraceptive drugs could be caused by psychological factors that are at least partly determined by brain function or structure. This could lead to serious confounding that could threaten internal validity.

Delayed sexual debut or sexual abstinence are examples of behaviors that may in part be determined by differences in brain function or structure when contrasted with being sexually active. Personality factors such as extraversion are central in this regard. In a large Dutch study, extraversion was found to affect friendships which again affected sexual debut and behavior ( van Leeuwen and Mace, 2016 ). A meta-analysis including altogether 420,595 subjects showed that extraversion was clearly positively associated with sexual activity ( Allen and Walter, 2018 ). Extraversion is further associated with distinct resting state fMRI patterns, such as increased long-range functional connectivity ( Pang et al., 2017 ). Structurally, it is associated with smaller gray matter volumes in the bilateral basal ganglia and increased dopamine receptor density in the striatum ( Baik et al., 2012 ). Also, negative associations with right PFC volumes have been found ( Forsman et al., 2012 ). This exemplifies how closely sexual activity is related to personality, which is further associated with differences both in brain function and structure. It thus illustrates how self-selection may have seriously confounded the included studies.

Another important source of possible bias is discontinued use of HC due to negative side effects. Different women may experience different side effects, and if such effects are not independent from brain function or structure, this will bias the finding. Thus, women who have chosen not to continue using HC will not be included in studies on effects of such drugs, unless the design of the study is a randomized design, and not based on self-selection.

As almost all the included studies were non-randomized case control-studies they might have ignored factors like these, and this might have introduced a strong sampling or selection bias. If the researchers had used only drug-naïve subjects for both controls and HC users, one could eliminate possible confounding effects of earlier use on their brains. By also employing longitudinal designs with drug-naïve subjects and pre-usage measures of brain-behavior relationships, validity could be further increased.

Contraceptive Content and Routes of Administration

There is a wide variety of HC drugs available, and these might affect the female brain in different ways. The orally administered drugs can be combination pills that commonly consist of ethinylestradiol and a progestin, or progestin-only formulations. They may have different cycle regimens, such as mono-, bi-, tri-, and quadriphasic as well as flexible regimens. Both the estrogen and the progestin contents of these pills have been gradually lowered over the years in an effort to reduce side effects ( Christin-Maitre, 2013 ).

Different types of formulation may also be associated with different side effects. Some progestins are considered to have androgenic properties, while others may have anti-androgenic effects on brain and behavior ( Pletzer and Kerschbaum, 2014 ; Giatti et al., 2016 ). Progesterone may lead to reduced testosterone action due to affinity for the enzyme 5α-reductase, and this may reduce conversion of testosterone into the more potent dihydrotestosterone ( Pletzer and Kerschbaum, 2014 ). Combined oral contraceptives with a progestin content considered to be anti-androgenic, such as drospirenone and desogestrel, have been postulated to be favorable in terms of mood symptoms in comparison with progestins displaying an androgenic profile ( Poromaa and Segebladh, 2012 ).

Alternative administration routes have also been developed over the years, such as vaginal or transdermal. Long-acting reversible contraception (LARC) such as progestogen-releasing intrauterine devices as well as injectable substances and implantable devices are effective contraceptive options that have become increasingly popular in the past decades ( Kavanaugh et al., 2015 ). Several of the included studies have recruited participants not using the same drug and/or using different routes of administration, and other studies do not provide information about these variables. This introduces the chance of committing type II errors and hence neglecting to uncover effects of the given drugs, since other drugs studied simultaneously, but having a different profile, may have counteracted or canceled out the effects on a group level.

Conclusions

This review found evidence that the use of HC can alter both structure and function of the brain. Furthermore, it contributed to accentuating the need for future research on HC and the ways in which they may affect the brain. There is a need for systematic research that considers the differences in formulation and administration of the various contraceptive drugs, employing a longitudinal, within-subject design with matched and randomized control groups consisting of HC-naïve subjects.

The impact of structural changes in the brain on functional outcomes such as motivational factors, affective phenomena and cognitive abilities should indeed be further investigated. Given the well-known sex hormone-dependent brain plasticity ( Schulz and Sisk, 2016 ), adolescence may be seen as a window of both increased opportunity and increased vulnerability, where implications of interference with endogenous processes could be far-reaching and affect emotional, relational, educational and vocational aspects of life. As a substantial number of women start using HC at a young age ( Martinez et al., 2020 ), these are issues that need to be scientifically addressed in order to provide female adolescents with individualized and informed contraceptive choices.

Author Contributions

MB: initial draft. MB and KB: conception/design and acquisition. All authors: analysis, interpretation of data, revision, final approval, and agreement to be accountable for all aspects of the work.

This project was partially funded by a research grant provided to author MB by Stavanger University Hospital, Psychiatric Division.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.556577/full#supplementary-material

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Keywords: hormonal contraceptives, brain, neuroimaging, MRI, PET, EEG

Citation: Brønnick MK, Økland I, Graugaard C and Brønnick KK (2020) The Effects of Hormonal Contraceptives on the Brain: A Systematic Review of Neuroimaging Studies. Front. Psychol. 11:556577. doi: 10.3389/fpsyg.2020.556577

Received: 28 April 2020; Accepted: 25 September 2020; Published: 27 October 2020.

Reviewed by:

Copyright © 2020 Brønnick, Økland, Graugaard and Brønnick. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Marita Kallesten Brønnick, mk.bronnick@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• How to Write a Thesis Statement | 4 Steps & Examples

How to Write a Thesis Statement | 4 Steps & Examples

Published on January 11, 2019 by Shona McCombes . Revised on August 15, 2023 by Eoghan Ryan.

A thesis statement is a sentence that sums up the central point of your paper or essay . It usually comes near the end of your introduction .

Your thesis will look a bit different depending on the type of essay you’re writing. But the thesis statement should always clearly state the main idea you want to get across. Everything else in your essay should relate back to this idea.

You can write your thesis statement by following four simple steps:

• Start with a question
• Write your initial answer
• Develop your answer
• Refine your thesis statement

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Table of contents

What is a thesis statement, placement of the thesis statement, step 1: start with a question, step 2: write your initial answer, step 3: develop your answer, step 4: refine your thesis statement, types of thesis statements, other interesting articles, frequently asked questions about thesis statements.

A thesis statement summarizes the central points of your essay. It is a signpost telling the reader what the essay will argue and why.

The best thesis statements are:

• Concise: A good thesis statement is short and sweet—don’t use more words than necessary. State your point clearly and directly in one or two sentences.
• Contentious: Your thesis shouldn’t be a simple statement of fact that everyone already knows. A good thesis statement is a claim that requires further evidence or analysis to back it up.
• Coherent: Everything mentioned in your thesis statement must be supported and explained in the rest of your paper.

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The thesis statement generally appears at the end of your essay introduction or research paper introduction .

The spread of the internet has had a world-changing effect, not least on the world of education. The use of the internet in academic contexts and among young people more generally is hotly debated. For many who did not grow up with this technology, its effects seem alarming and potentially harmful. This concern, while understandable, is misguided. The negatives of internet use are outweighed by its many benefits for education: the internet facilitates easier access to information, exposure to different perspectives, and a flexible learning environment for both students and teachers.

You should come up with an initial thesis, sometimes called a working thesis , early in the writing process . As soon as you’ve decided on your essay topic , you need to work out what you want to say about it—a clear thesis will give your essay direction and structure.

You might already have a question in your assignment, but if not, try to come up with your own. What would you like to find out or decide about your topic?

For example, you might ask:

After some initial research, you can formulate a tentative answer to this question. At this stage it can be simple, and it should guide the research process and writing process .

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Now you need to consider why this is your answer and how you will convince your reader to agree with you. As you read more about your topic and begin writing, your answer should get more detailed.

In your essay about the internet and education, the thesis states your position and sketches out the key arguments you’ll use to support it.

The negatives of internet use are outweighed by its many benefits for education because it facilitates easier access to information.

In your essay about braille, the thesis statement summarizes the key historical development that you’ll explain.

The invention of braille in the 19th century transformed the lives of blind people, allowing them to participate more actively in public life.

A strong thesis statement should tell the reader:

• Why you hold this position
• What they’ll learn from your essay
• The key points of your argument or narrative

The final thesis statement doesn’t just state your position, but summarizes your overall argument or the entire topic you’re going to explain. To strengthen a weak thesis statement, it can help to consider the broader context of your topic.

These examples are more specific and show that you’ll explore your topic in depth.

Your thesis statement should match the goals of your essay, which vary depending on the type of essay you’re writing:

• In an argumentative essay , your thesis statement should take a strong position. Your aim in the essay is to convince your reader of this thesis based on evidence and logical reasoning.
• In an expository essay , you’ll aim to explain the facts of a topic or process. Your thesis statement doesn’t have to include a strong opinion in this case, but it should clearly state the central point you want to make, and mention the key elements you’ll explain.

If you want to know more about AI tools , college essays , or fallacies make sure to check out some of our other articles with explanations and examples or go directly to our tools!

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A thesis statement is a sentence that sums up the central point of your paper or essay . Everything else you write should relate to this key idea.

The thesis statement is essential in any academic essay or research paper for two main reasons:

• It gives your writing direction and focus.
• It gives the reader a concise summary of your main point.

Without a clear thesis statement, an essay can end up rambling and unfocused, leaving your reader unsure of exactly what you want to say.

Follow these four steps to come up with a thesis statement :

• Ask a question about your topic .
• Write your initial answer.
• Develop your answer by including reasons.
• Refine your answer, adding more detail and nuance.

The thesis statement should be placed at the end of your essay introduction .

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10 Essential Essays About Women’s Reproductive Rights

“Reproductive rights” let a person decide whether they want to have children, use contraception, or terminate a pregnancy. Reproductive rights also include access to sex education and reproductive health services. Throughout history, the reproductive rights of women in particular have been restricted. Girls and women today still face significant challenges. In places that have seen reproductive rights expand, protections are rolling back. Here are ten essential essays about reproductive rights:

“Our Bodies, Ourselves: Reproductive Rights”

bell hooks Published in Feminism Is For Everyone (2014)

This essay opens strong: when the modern feminism movement started, the most important issues were the ones linked to highly-educated and privileged white women. The sexual revolution led the way, with “free love” as shorthand for having as much sex as someone wanted with whoever they wanted. This naturally led to the issue of unwanted pregnancies. Birth control and abortions were needed.

Sexual freedom isn’t possible without access to safe, effective birth control and the right to safe, legal abortion. However, other reproductive rights like prenatal care and sex education were not as promoted due to class bias. Including these other rights more prominently might have, in hooks’ words, “galvanized the masses.” The right to abortion in particular drew the focus of mass media. Including other reproductive issues would mean a full reckoning about gender and women’s bodies. The media wasn’t (and arguably still isn’t) ready for that.

“Racism, Birth Control, and Reproductive Rights”

Angela Davis Published in Women, Race, & Class (1981)

Davis’ essay covers the birth control movement in detail, including its race-based history. Davis argues that birth control always included racism due to the belief that poor women (specifically poor Black and immigrant women) had a “moral obligation” to birth fewer children. Race was also part of the movement from the beginning because only wealthy white women could achieve the goals (like more economic and political freedom) driving access to birth control.

In light of this history, Davis emphasizes that the fight for reproductive freedom hasn’t led to equal victories. In fact, the movements driving the gains women achieved actively neglected racial inequality. One clear example is how reproductive rights groups ignored forced sterilization within communities of color. Davis ends her essay with a call to end sterilization abuse.

“Reproductive Justice, Not Just Rights”

Dorothy Roberts Published in Dissent Magazine (2015)

Dorothy Roberts, author of Killing the Black Body and Fatal Invention , describes attending the March for Women’s Lives. She was especially happy to be there because co-sponsor SisterSong (a collective founded by 16 organizations led by women of color) shifted the focus from “choice” to “social justice.” Why does this matter? Roberts argues that the rhetoric of “choice” favors women who have options that aren’t available to low-income women, especially women of color. Conservatives face criticism for their stance on reproductive rights, but liberals also cause harm when they frame birth control as the solution to global “overpopulation” or lean on fetal anomalies as an argument for abortion choice.

Instead of “the right to choose,” a reproductive justice framework is necessary. This requires a living wage, universal healthcare, and prison abolition. Reproductive justice goes beyond the current pro-choice/anti-choice rhetoric that still favors the privileged.

“The Color of Choice: White Supremacy and Reproductive Justice”

Loretta J. Ross, SisterSong Published in Color of Violence: The INCITE! Anthology (2016)

White supremacy in the United States has always created different outcomes for its ethnic populations. The method? Population control. Ross points out that even a glance at reproductive politics in the headlines makes it clear that some women are encouraged to have more children while others are discouraged. Ross defines “reproductive justice,” which goes beyond the concept of “rights.” Reproductive justice is when reproductive rights are “embedded in a human rights and social justice framework.”

In the essay, Ross explores topics like white supremacy and population control on both the right and left sides of politics. She acknowledges that while the right is often blunter in restricting women of color and their fertility, white supremacy is embedded in both political aisles. The essay closes with a section on mobilizing for reproductive justice, describing SisterSong (where Ross is a founding member) and the March for Women’s Lives in 2004.

“Abortion Care Is Not Just For Cis Women”

Sachiko Ragosta Published in Ms. Magazine (2021)

Cisgender women are the focus of abortion and reproductive health services even though nonbinary and trans people access these services all the time. In their essay, Ragosta describes the criticism Ibis Reproductive Health received when it used the term “pregnant people.” The term alienates women, the critics said, but acting as if only cis women need reproductive care is simply inaccurate. As Ragosta writes, no one is denying that cis women experience pregnancy. The reaction to more inclusive language around pregnancy and abortion reveals a clear bias against trans people.

Normalizing terms like “pregnant people” help spaces become more inclusive, whether it’s in research, medical offices, or in day-to-day life. Inclusiveness leads to better health outcomes, which is essential considering the barriers nonbinary and gender-expansive people face in general and sexual/reproductive care.

“We Cannot Leave Black Women, Trans People, and Gender Expansive People Behind: Why We Need Reproductive Justice”

Karla Mendez Published in Black Women Radicals

Mendez, a freelance writer and (and the time of the essay’s publication) a student studying Interdisciplinary Studies, Political Science, and Women’s and Gender Studies, responds to the Texas abortion ban. Terms like “reproductive rights” and “abortion rights” are part of the mainstream white feminist movement, but the benefits of birth control and abortions are not equal. Also, as the Texas ban shows, these benefits are not secure. In the face of this reality, it’s essential to center Black people of all genders.

In her essay, Mendez describes recent restrictive legislation and the failure of the reproductive rights movement to address anti-Blackness, transphobia, food insecurity, and more. Groups like SisterSong have led the way on reproductive justice. As reproductive rights are eroded in the United States, the reproductive rights movement needs to focus on justice.

“Gee’s Bend: A Reproductive Justice Quilt Story From the South”

Mary Lee Bendolph Published in Radical Reproductive Justice (2017)

One of Mary Lee Bendolph’s quilt designs appears as the cover of Radical Reproductive Justice. She was one of the most important strip quilters associated with Gee’s Bend, Alabama. During the Civil Rights era, the 700 residents of Gee’s Bend were isolated and found it hard to vote or gain educational and economic power outside the village. Bendolph’s work didn’t become well-known outside her town until the mid-1990s.

Through an interview by the Souls Grown Foundation, we learn that Bendolph didn’t receive any sex education as a girl. When she became pregnant in sixth grade, she had to stop attending school. “They say it was against the law for a lady to go to school and be pregnant,” she said, because it would influence the other kids. “Soon as you have a baby, you couldn’t never go to school again.”

“Underground Activists in Brazil Fight for Women’s Reproductive Rights”

Alejandra Marks Published in The North American Congress on Latin America (2021)

While short, this essay provides a good introduction to abortion activism in Brazil, where abortion is legal only in the case of rape, fetal anencephaly, or when a woman’s life is at risk. The reader meets “Taís,” a single mother faced with an unwanted pregnancy. With no legal options, she researched methods online, including teas and pills. She eventually connected with a lawyer and activist who walked her through using Cytotec, a medication she got online. The activist stayed on the phone while Taís completed her abortion at home.

For decades, Latin American activists have helped pregnant people get abortion medications while wealthy Brazilians enter private clinics or travel to other countries. Government intimidation makes activism risky, but the stakes are high. Hundreds of Brazilians die each year from dangerous abortion methods. In the past decade, religious conservatives in Congress have blocked even mild reform. Even if a new president is elected, Brazil’s abortion rights movement will fight an uphill battle.

“The Ambivalent Activist”

Lauren Groff Published in Fight of the Century: Writers Reflect on 100 years of Landmark ACLU Cases (2020)

Before Roe v. Wade, abortion regulation around the country was spotty. 37 states still had near-bans on the procedure while only four states had repealed anti-abortion laws completely. In her essay, Groff summarizes the case in accessible, engaging prose. The “Jane Roe” of the case was Norma McCorvey. When she got pregnant, she’d already had two children, one of whom she’d given up for adoption. McCorvey couldn’t access an abortion provider because the pregnancy didn’t endanger her life. She eventually connected with two attorneys: Sarah Weddington and Linda Coffee. In 1973 on January 2, the Supreme Court ruled 7-2 that abortion was a fundamental right.

Norma McCorvey was a complicated woman. She later became an anti-choice activist (in an interview released after her death, she said Evangelical anti-choice groups paid her to switch her position), but as Groff writes, McCorvey had once been proud that it was her case that gave women bodily autonomy.

“The Abortion I Didn’t Want”

Caitlin McDonnell Published in Salon (2015) and Choice Words: Writers on Abortion (2020)

While talking about abortion is less demonized than in the past, it’s still fairly unusual to hear directly from people who’ve experienced it. It’s certainly unusual to hear more complicated stories. Caitlin McDonnell, a poet and teacher from Brooklyn, shares her experience. In clear, raw prose, this piece brings home what can be an abstract “issue” for people who haven’t experienced it or been close to someone who has.

In debates about abortion rights, those who carry the physical and emotional effects are often neglected. Their complicated feelings are weaponized to serve agendas or make judgments about others. It’s important to read essays like McDonnell’s and hear stories as nuanced and multi-faceted as humans themselves.

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About the author, emmaline soken-huberty.

Emmaline Soken-Huberty is a freelance writer based in Portland, Oregon. She started to become interested in human rights while attending college, eventually getting a concentration in human rights and humanitarianism. LGBTQ+ rights, women’s rights, and climate change are of special concern to her. In her spare time, she can be found reading or enjoying Oregon’s natural beauty with her husband and dog.

Population Growth Control Thesis

Introduction, culture and traditions, political economy, gender and sexuality, health care, works cited.

Birth control or control of population growth has been a raging debate for centuries because it is a sexual issue that religion, traditions, politics, and the entire society has silenced and laden it with lots of taboos.

During the ancient times, sex and sexuality had been under immense silence as no one was supposed to talk about it in public places. According to Foucault, sex has been a secret affair because there has been so many forces that reduced it to silence, but has recently loosened up and allowed people to question the intricacies of sex (78).

Realizing that sex has been secret and silenced for centuries, modern society is struggling to unravel the mystery behind sex through various discourses. In the late 18th century and early 19th century, population growth rate of the world was growing exponentially. For instance, in the United States, women had an average of seven children, and thus, necessitated control of population.

Although governments saw the need to control population growth, various religions and cultures were against it, for they perceived reproduction as a natural process that needs no interference. Religions, cultures, and politics have been grappling with the issue of population growth because while some perceive it a societal issue, others perceive it as a reproductive issue of women.

Discourses in culture, religion, politics, education, health, feminism, sexuality, gender, race, and class show that birth control is an issue that touches on women’s health, and therefore, women have the right to control population growth.

During ancient times, culture and traditions imposed many taboos on sex and sexuality in that societal values determined matters related to reproduction. Since men dominated society, they had powers to determine the number of children that their wives should have in marriage. Men had powers to decided ethics regarding sex as they imposed taboos to restrict how women perceive their sexuality and reproduction.

Foucault asserts that sex exists in a binary system of right and wrong, legal and illegal, permitted and forbidden, which shows that it is subject to law and power (83). The law and power associated with sex gave men powers to have control over women and decide their sexuality, gender and reproduction.

Cultures and traditions suppressed women, for they did not give them freedom to champion for their rights as members of the society with reproduction capacity (Berreman 400). Due to male chauvinism that dominated the society, issues involving sex and women were in deep silence and under the domain of men because taboos imposed many restrictions.

Evolution of cultures and traditions from ancient times to modern society has led to empowerment of women and diminishing of taboos, which restricted women from advocating for their rights. The adoption of various cultural and traditional practices, from various parts of the world, led to development of civilized culture and traditions that recognize exceptional needs of women and empower them.

Sex and sexuality transformed from silence state into public debates due to the emergence of many discourses. Discourses have significantly enhanced perception of gender, sexuality and humanity, which subsequently led to the emergence of the need to control population.

Luker argues that, counter normative approach to sexuality is an effective discourse that has empowered women by restructuring and configuring societal power (29). In spite of cultural taboos that restrict women from having power to control their sexuality and reproduction, modern society has made significant strides towards empowering women in matters of birth control.

Society has different members with different attributes that classify them into races and classes. Race and class influence how people perceive the essence of population control. In the society, race and class determine social status and power of an individual. Ability of women to control their sexuality and reproduction in spite of societal pressure depends on racial and class prejudices of the society.

Conventionally, whites are privileged race relative to blacks, hence making them to have a higher social class than blacks. Luker debates that, due to diversity of race and classes, people have used different contraception methods because of their unique beliefs, traditions, and cultures (54).

Since whites have a high social classes and race, their family lifestyles of having few children has formed the basis of civilization. Blacks are aping whites’ culture because they have empowered their women to have control over their reproduction and sexuality. Trends of population growth show that, blacks have high growth rate, yet they have lower social class because most are living below the poverty level.

Critical analysis of race and class shows that, white women have control over their sexuality and reproduction; thus, they have low reproductive rate. On the other hand, black women have limited control over their sexuality and reproduction, which explains why they have high reproductive rate. Therefore, it means that privileged race and high social class are factors that empower women to regulate the sexuality and reproduction.

Regions have played a critical role in restricting control of population through their teachings on morality and spiritual matters. Dominant religions of the world like Christianity, Islam and Hindu have been against control of population using contraceptives and abortion.

Religious leaders assert that, the use of contraceptives and abortions as means of controlling population is contrary to divine teachings, and thus an abomination to God. Nevertheless, diverse religions perceive control of population as a moral, as well as, a spiritual issue that an individual or political entity has no power to dictate.

Therefore, religions perceive that women have no right over their sexuality and reproduction because they fall under family, which is an integral unit of society. A moral society has responsibility of ensuring that every family adheres to religious principles that reflect divine values and virtues.

According to Teltsch, Pope Paul IV issued encyclical banning artificial birth control methods because there are against Christian teachings (17). The encyclical triggered mixed reactions not only among Catholics but also in healthcare systems across the world.

Many Catholics perceived banning of artificial methods of family planning as a bold move that deserves praise, while others perceived it as retrogressive move that would deprive women of their sexual rights. Mixed reactions among population showed that, birth control would continue to be a raging debate until women attain right to their sexuality.

Religions perceive procreation as a divine gift that God gave to humanity; thus, they have a responsibility of ensuring that families should comply with divine principles to respect marriage as a divine institution. According to Islam, use of contraceptives and legalization of abortion is an abomination and sin that God does not support.

Muslims believe that control of population using contraceptives is unspiritual because it promotes prostitution and promiscuous behavior in the society. Moreover, abortion is not only an immoral act but also a crime because it involves murdering of innocent fetus, which has no power to protect itself unless religion and society protect it.

Srikanthan and Reid explain that, Muslims believe that a family is a basic unit of society, which depends on sex for procreation purposes according to the will of God (132). They believe that use of artificial methods in control of the population is contrary to the will of God and detrimental to humanity due to loss of morals.

With time, religions have come to realize that population control is a critical issue in the society that is subject to many factors apart from religious teachings. Ancient religions depicted sexuality from divine perspective, but current religions have reduced it to moral levels where people can have their own opinions.

Thus, in modern society, there are no explicit religious principles that outline recommended contraceptive methods except abortion. Various religions agree that abortion is a crime unless done under a medical condition that threatens life of mother and baby. In response to economic, legal and social pressures, diverse religions have recommended different methods of population control.

According to Srikanthan and Reid, catholic recommends abstinence and rhythmic method, while Islam supports coitus interruptus and some contraception methods that are safe, legal and temporary (132). Hence, disparity in religious beliefs has led to diversification in contraceptive methods.

Trends of contraception methods among religions show that women have ultimate decision on the nature of contraceptives that they use in controlling population. Although religions can recommend kinds of contraceptives that women should take, they cannot force anyone, hence women have the power to decide their reproductive health.

Population control is a political issue since it relates to economic growth and welfare of population of a country. Demographic experts are warning that exponential growth of population signal impending disaster since economic resources are diminishing gradually.

Since population growth is going to strain diminishing resources, many countries are trying to use various means of contraception to slow down population growth and stabilize economic growth sustainably. Increase of population in one country threatens the sustainability of resources in other countries since resources flow according to factors of demands and supplies.

To achieve a stable political economy, politicians are formulating policies and regulations, which are essential in regulating population growth. A country with the capacity to regulate its population has assurance of better economic growth and improved welfare of the people because there is sustainable utilization of resources.

A country with uncontrolled population growth has no future prospects because it cannot sustain its own people with time. Michelle asserts that, empowering women to advocate for their rights, and have access to family planning methods are ethical and most effective means of controlling population growth (34).

Stable economy requires that every woman should have an average of two to three children to guarantee both sustainability of resources and maintain stable growth rate of population. From a perspective of political economy, control of the population is a matter that is in the sphere of women, and thus they deserve to have right to their sexuality and reproduction.

Countries with exponential growth of the population are now advocating for birth control by use of contraceptives and abortion to eliminate unwanted or unplanned pregnancies. Unplanned pregnancies are a serious burden to women because it affects their welfare state by restricting them to childbearing lives.

Siow argues that, availability of birth control pills and legalization of abortion has significantly improved welfare of women because they can postpone marriage, pursue their careers and accumulate wealth while indulging themselves in sexual activities (3). The importance of the contraceptive pill became evident in 1970s when number of women who join universities and colleges increased markedly.

Hence, use of contraception and legalization abortion is an effective way of not only regulating population growth but also empowering women to focus on their careers as their male counterparts.

For centuries, childbearing has been basic responsibility of a woman in the society because men dominated their sexuality. However, advent of contraception methods and legalization of abortion has enabled women to make an informed decision on when to have children without any undue pressure from men.

Realizing that men have been dominating society, as well as their sexuality, women began to advocate for their empowerment through ideology of feminism. Feminism is an ideology, which asserts that, men and women have equal capacities in the society for it seeks to dispel cultural and traditional beliefs that have led to marginalization of women.

The society had perceived women as weak and different from their men counterparts, hence weaker gender. Such perception led to the emergence of gendered roles in the society because women had limited roles of childbearing, but men had unlimited roles, which allowed them to pursue their careers and develop their human capital leaving women behind.

According to Seidman, Fischer and Meeks, feminists advocated for equal treatment before the law and socio-economic terms (44). Feminists argued that gendered roles emerged in the society because men correlated their sexuality with gender, yet they are quite different entities.

They claim that sex is biological condition while gender is a social construct that men created, so that they can determine their place and roles in society. Thus, if men perceive women as equal partners in the society, then they will not impose unnecessary restrictions on their sexuality and reproduction. Gender inequality is restricting women from advocating for their rights and accessing various family planning methods.

To emancipate themselves from dominance of men, feminists targeted political arena as means of fostering their feminism agenda. In 19th century, women in the United States did not have the right to vote; therefore, feminists struggled extremely hard to ensure that they obtained the right to vote. After attaining the right to vote, women continued advocating for their rights by competing for political positions.

With time, more women joined politics so that they could exercise their power effectively towards empowering themselves in the society that men have dominated. Political positions accorded powers to women, which significantly transformed the perception of women as mere weaker gender, since they demonstrated that they had equal capacity as men.

Seidman, Fischer and Meeks state that, women who entered politics made marked contribution to emancipation of women since they advocated for affirmative action (45).

Affirmative action enabled formulation of policies and laws that led to empowerment of women in the society, for it recognized their vulnerability to dominance of men. Thus, making women have reproductive rights by allowing them to have access to contraceptive methods and abortion is also going to support affirmative action.

Education has also empowered and liberated women in modern society. During ancient times, women have been groping in darkness because they had limited education regarding sexuality, reproduction and careers. Men dominated various fields of knowledge and restricted women to childbearing because culture and tradition dictated so.

However, as more women went to school, they started gaining knowledge concerning sexuality, reproduction and career development that emancipated them from cultural and traditional shackles that men had imposed on them. Luker contends that schooling of women was a significant step that enabled them to compete effectively in family, community, and political spheres of society (56).

Currently, it is quite evident that men and women have equal opportunities in the society because they perform similar duties, have same careers and equal rights. Given that birth control relates to women’s health, it is imperative that women should have reproductive rights of deciding types of birth control that they use.

Improved health care services of reproduction have enabled women to make informed choices concerning methods of contraception. Healthcare system has provided numerous contraceptive methods that suit various needs of women, hence, allowing women to control conception and their sexual activity.

Prior to the emergence of numerous contraceptives in the market, women relied on their husbands to prevent them from conceiving. Then, common methods of preventing contraception were coitus interruptus, abstinence, and rhythmic method, which entirely depended on men; hence, women did not have the capacity to control of their sexuality and reproduction.

According to Srikanthan and Reid, emergence of contraceptives such as pills and intra uterine devices gave women power to control conception and their sexuality (134). In modern society, women can decide whether to conceive or not without necessarily consulting their partners. Therefore, since contraceptives are readily available as over the counter drugs, women should have right to control their sexuality and reproduction.

Additionally, healthcare system has provided an option of abortion following legalization of abortion. Legalization of abortion has considerably enhanced powers that women have in reproduction because statistics shows that out-of wedlock births have reduced significantly.

In the modern society, women cannot accept to give birth to a child out of wedlock because it is extremely expensive, and it is going to ruin their potential of getting another husband. The modern society has few single mothers, as compared to the recent past, because legalization of abortion has provided a means for women to terminate unwanted pregnancies.

Siow reasons that, the availability of legal abortion has reduced the bargaining power of women for marriage, since they can control their sexuality and reproduction, unlike earlier when fear of pregnancy compelled them to get married (2). Hence, legalization of abortion has demonstrated that women need power over their sexuality and reproduction for them to control population effectively.

Control of population growth elicits immense controversy in the society since it clashes with cultural, traditional and religious beliefs of the people. Matters of sexuality and reproduction date back to ancient times when society held firmly to the taboos, which restricted women from exercising full control of their bodies.

Religion strictly asserted that family is a basic unit of society with procreation powers bestowed on it; hence, control of population using contraceptives and abortion is detrimental to the society and family, as well. However, various governments across the world realized that control of the population has economic benefits for it promotes economic growth and sustainable utilization of resources.

Feminists then emerged and advocated for empowerment of women through affirmative action, which enabled women to obtain more powers to control their sexuality and reproduction.

Recently, improved healthcare system enhanced reproductive health by improving accessibility to various methods of contraception and abortion following legalization. In view of all these developments, it is quite evident that modern women have control over their sexuality and reproduction, thus have right to control population growth.

Berreman, Gerald. “Race, Caste, and Other Invidious Distinctions in Social Stratification.” Race Class 13.1 (1972): 385-414.

Foucault, Michel . The History of Sexuality, Volume 3. New York: Knopf Doubleday Publishing Group, 1990.

Luker, Kristin. When Sex Goes to School: Warring Views on Sex and Sex Education Since the Sixties . New York: W.W. Norton & Company, 2007.

Michelle, Goldberg. “Skirting the Issue; Debates about Population Growth are Missing the point: Women Need More Control over Their Fertility and Lives.” Los Angeles 17 May 2009: 34.

Seidman, Steven, Fischer, Nancy, and Meeks, Chet. Introducing the New Sexuality Studies . New York: Routledge, 2011.

Siow, Aloysius. “Do Innovations in Birth Control Technology Increase the Welfare of Women?” University of Toronto (2002): 1-46.

Srikanthan, Amirrtha, and Reid, Robert. “Women’s Health: Religious and Cultural Influences on Contraception.” Journal of Obstetrician and Gynaecology 30.2 (2008): 129-137.

Teltsch, Kathleen. “Rise in Birth-Curb Services Is Likely to Continue.” New York Times 31 July 1968: 17.

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IvyPanda. (2022, April 15). Population Growth Control. https://ivypanda.com/essays/birth-control-thesis/

"Population Growth Control." IvyPanda , 15 Apr. 2022, ivypanda.com/essays/birth-control-thesis/.

IvyPanda . (2022) 'Population Growth Control'. 15 April.

IvyPanda . 2022. "Population Growth Control." April 15, 2022. https://ivypanda.com/essays/birth-control-thesis/.

1. IvyPanda . "Population Growth Control." April 15, 2022. https://ivypanda.com/essays/birth-control-thesis/.

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IvyPanda . "Population Growth Control." April 15, 2022. https://ivypanda.com/essays/birth-control-thesis/.

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The “Standards for Privacy of Individually Identifiable Health Information” otherwise known as the “Privacy Rule” was issued by the US Department of Health and Human Services in 2002 based on the requirement of the Health Insurance Portability and Accountability Act of 1996 to protect health information. This new rule contains clauses for the protection of minors, who may or may not opt to disclose their health information to their parents or personal representative.

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Birth Control (Argumentative Essay Sample)

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Birth Control

One of the most debated aspects today is whether to control birth or let nature take its course. Before the 20th century, sex was a sensitive issue, and it was reserved for people in marriage. This was a time when the members of the society honored moral behaviors and abstinence was one of the core values. Birth control was highly condemned as the morals of the society would prevent negative issues such as abortion although a lack of birth control let to a high population which was dangerous for the limited resources. In the late 20th century, the societies had lost morals and people engaged in sex anyhow leading to unplanned pregnancies and abortions that put the lives of the women at risk. To prevent such risk behaviors and to control the escalated population, countries began legalizing birth control, and today almost every country has adopted birth control. While some people still protest birth control, it is a good idea as it helps women to improve their health, control population and reduce joblessness and poverty in the modern societies.

Birth control helps women to prevent pregnancy until when the body has recovered from the previous birth and conceive again when in good health. Without birth control, women would get pregnant at short intervals leading to deteriorated health, emotional and psychological disturbances which adversely affect their health condition. Some would resort to abortions when they get unplanned pregnancy, putting their lives at risk and also risking infertility. Hence, birth control helps women avoid such scenarios that put their health at risk.

Also, birth control has greatly helped in controlling the exploding human population and contributes towards peaceful nations. If it were not for birth control, the population would have gotten out of control. The consequences of overpopulation are clear. The high population would augment the scramble for limited resources which would lead to crisis and eventually spark a war among the people. There have been instances where pastoralists in developing countries fight over the pasture, how about if the people were competing for a scarce resource? People would fight over the scarce resources leading to insecurity and hostile world to live in. Thus, birth control is important in controlling overpopulation and preventing its problems.

Also, birth control is necessary because it prevents joblessness and poverty. Uncontrolled and frequent pregnancies deny both spouses time to work as they nurse the children. This reduces their working days in a year lowering productivity. Aside, the frequent births will contribute to many children depending on the less productive parents. This results in high poverty levels. Birth control would help in controlling pregnancies and allowing both parents to have time for work. Thus, birth control creates time for job seeking and reduces poverty as the parents earn incomes.

On the other hand, opponents would argue that birth control interferes with nature and prevents the conception of more beneficial human beings to God’s creation. However, this argument should not be welcomed since it does not consider the danger of overpopulation as enumerated above. Another counter argument would be that birth control measures lead to health risks such as high blood pressure and weight gain. However, birth control methods such as the use of condoms and vasectomy do not pose any risks. Furthermore, birth control methods have been improved to prevent side effects. Hence, birth control stands out beneficial to humankind.

Therefore, birth control is beneficial to man as it helps in improving women health status, controlling overpopulation to prevent negative issues such as crimes and war and minimizing joblessness and poverty. Birth control limits population growth and reduces scramble for few resources. It also helps women to plan pregnancies and have time for work hence reducing a number of non-working women and reduces poverty levels. It has prevented a situation whereby women would have children frequently as if birth machines and allowed them time to recover their health from previous births. Ideally, birth control is necessary for the world nations.

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