Breaking the Cycle: How Increasing Access to Female-Controlled Contraception Can Empower Low-Income Adolescent Females

Carleen Su

2016 Science Prize in Expository Writing

Abstract

Disadvantaged neighborhoods often generate a sense of hopelessness among adolescents, and a female adolescent’s perceived lack of control over her life outcome may affect her confidence to advocate for her sexual health. This exacerbates an existing structural sexual disempowerment that discourages women from taking initiative in sexual experiences, as long-standing public health efforts aimed at reducing unplanned pregnancies that only distribute male condoms put women in the position of depending on the male’s willingness to use condoms. Providing access to female-controlled contraception — specifically female condoms — could empower low-income adolescent women to take greater control of their own lives by not only expanding their options of contraception and thus, reducing the likelihood of an unplanned pregnancy that could lead them to remain in a disempowering situation of poverty, but also providing the opportunity to challenge a structural sexism that expects women to submit to their sexual partners.

Adolescents growing up in extreme poverty are likely to live in neighborhoods in which they are exposed to unemployment, violence, and teen pregnancy, and such an environment may generate a sense of powerlessness in maintaining their sexual health (Bolland et al. 2006). For teenagers growing up in communities such as the South Bronx, for example, where half of its adult residents have not graduated high school and teenage pregnancies are relatively common (Waddell et al 2010), it may feel very difficult to find a way out of a cycle that has already taken root in their community. Children born to teen mothers are more likely to drop out of high school, face unemployment, find themselves in similar situations of poverty, and become teen parents themselves (Schuyler Center 2008). Due to the often intergenerational nature of many negative outcomes, adolescents may feel discouraged by what they may view as their destiny. In fact, when surveyed, 23.4% of 2,468 inner-city adolescents, some as young as nine years old, agreed with the statement, “I might as well give up because I can’t make things better for myself” (Bolland 2003:149). This suggests that the hopelessness that they sense within their environments quickly becomes internalized and prevents them from taking positive actions in their own lives. These circumstances have serious implications for adolescent women in particular. Women who do not feel confident in their ability to determine the course of their lives are less likely to advocate for their sexual health (Waddell et al. 2010). Indeed, for women who live below the federal poverty line, the rate of unintended pregnancies is more than five times that of women whose income is more than twice as much (Finer and Zolna 2011), which demonstrates a difficulty in taking control within a sexual relationship and preventing unplanned pregnancies.

Current public health interventions that only distribute certain kinds of contraception further perpetuate the powerlessness of low-income adolescent women. One possible alternative to these forms of contraception is the female condom, which could give a woman more agency than what is currently available. There is significant variation in the kinds of contraception that are available to adolescents among states, cities, and individual school districts, but there is no evidence that female condoms are discussed or are available. Many high school websites will say that they distribute condoms, but never specify whether this includes female condoms, and others have school-based health centers that offer intrauterine devices (IUD) or birth control pills without parental consent, but don’t seem to offer female condoms. While IUDs or birth control pills may offer protection from pregnancy, it is important for an adolescent woman to have access to a barrier method that can not only protect against pregnancy, but also protect her from sexually-transmitted diseases, without relying on her partner’s use of a condom. Thus, female condoms are uniquely able to give females the opportunity to protect themselves and take control of their sexual health, and should be made available to girls who live in poverty. Increasing access to and awareness of female condoms not only can provide increased protection against unplanned pregnancies and sexually-transmitted diseases that may negatively impact an adolescent woman’s life outcome, but also has the potential to empower her to challenge existing gender norms that defer power primarily to men and take greater agency over her sexual health.

The perception of the inevitability of negative outcomes that low-income neighborhoods often perpetuate may result in adolescent women surrendering their sexual autonomy to their partners at the cost of safe sex. Low-income adolescents are significantly less likely to use contraception than their wealthier counterparts, and research has shown that their decision not to use birth control is predominantly connected to a sense of powerlessness and general skepticism about themselves and their future opportunities (Waddell et al. 2010). This resignation and lack of confidence make it more likely that an adolescent woman will not advocate for her sexual health and, instead, succumb to her partner’s desire to have unprotected sex. In contrast, a confident woman will view herself as an equal partner and be more capable of negotiating for her own sexual health. In fact, women who are confident in their ability to convince their partner to use contraception are 21 times more likely than other women to have used contraceptives in their most recent sexual experience (Meekers et al. 2002). This suggests that those who are more sexually assertive are more likely to engage in safe sex, as their confidence gives them the ability to negotiate for protection and increases the likelihood that contraception will be used.

However, perhaps the biggest determining factor in the degree of sexual assertiveness that adolescent women adopt, and thus, their ability to successfully advocate for condom use, is the amount of agency that they feel that they are entitled to in their sexual relationships, which is influenced by broader societal norms. Currently, our culture propagates a sexual script for heterosexual relationships that places women in the position of submitting to the desires of their more dominant male partners, who are seen to take on the role of not only initiating the sexual situation, but also determining the sexual activities. These norms shape adolescents’ expectations about how men and women should act in sexual situations, and adolescent women may feel hesitant to advocate for themselves sexually, particularly when doing so would contradict the cultural expectation that they should not take initiative in sexual situations (Sanchez 2012). In fact, in a study of adolescent sexuality, researchers found that teenage boys seemed to take a more active role in their sexual experiences, and they tended to recount the various strategies that they had used in order to secure sex, whereas the girls related the experience of their first sexual encounters as something that just “happened to them” (Sanchez 2012:168). This suggests that beliefs about male dominance and female submissiveness dramatically shape young adolescents’ sexual behavior even during their first sexual experiences, and the failure to empower women during their adolescent years may reinforce deeply embedded assumptions about the degree of agency that women should have. In fact, in a study of women in the United States, ranging in age from 14 to 25, many of them reflected that they did not believe they had the right to make decisions about their birth control (Rickert, Sanghvi, & Wiemann 2002). This finding is alarming, as it suggests that many adolescent women not only do not feel confident enough to take initiative over their sexual health, but also do not feel that this is something they, as women, should do at all. For example, Shanterrica Piper, who became pregnant at age 14 and subsequently dropped out of high school, reflects that for contraception, she only used condoms if her partner brought them and never considered that she could have taken a greater role in making sure that they used birth control. Now 19, Shanterrica laments her ignorance of other options, feeling that she “could’ve gotten more than what I did get,” had she been more aware that she could have taken more agency in her sexual health. She adds, “When you want respect, you have to respect yourself to get it” (Martin 2015:1). This moving sentiment demonstrates the urgent need to provide low-income adolescent women with female condoms that give them the opportunity to challenge stereotypical sexual scripts and advocate for themselves.

Sexist attitudes about the degree of agency that women should have in a sexual encounter are reflected and exacerbated by the Food and Drug Administration’s failure to establish the female condom as an equally safe and effective means of birth control as the male condom, which reinforces a culture that gives women significantly fewer options to maintain their sexual health. When the female condom was first presented to the FDA in 1993, because of limited information of its protection against STDs in comparison to the male condom, the FDA classified it as a Class III medical device and specified labelling that marked the female condom as the alternative (Cimons 1993). However, after more than 20 years and countless published clinical studies that have demonstrated the equivalent efficacy of female condoms and support the reclassification to match its male counterpart, which enjoys a favorable Class II status, the female condom still remains in the category reserved for devices that pose serious risks, such as implantable pacemakers and breast implants (Beksinska et al 2015). The FDA’s decision to continue to hold the female condom in a lesser status, despite overwhelming evidence, has created a longstanding perception of the female condom as inferior to the male condom, and their failure to recognize the legitimacy of female-controlled contraception continues to suggest that men should be the main determinants of female sexual health. Additionally, widespread campaigns that sought to prevent unintended pregnancies or the spread of sexually-transmitted diseases established that women should either change the number or types of their sexual partners or encourage their partners to use condoms (Rosenberg and Gollub 1992). Such messages put the burden on women to change their lifestyles and the people they engage with, or become better negotiators for condom use with their sexual partners. Propagating the idea that the best way for a female to protect herself from unintended pregnancies or sexually-transmitted diseases is to rely on others continues to miss opportunities to empower women.

It is important to make female condoms more readily accessible for adolescent women, as research shows such types of contraception are just as effective at preventing pregnancy and the transmission of STDs as male-controlled ones, if not more (French et al. 2003). Because these types of contraception can be used on the woman’s initiative without needing her partner’s cooperation or knowledge, she is better able to guarantee her own health and protect herself from sexual risks. Furthermore, researchers found that introducing female-controlled contraception such as female condoms and encouraging their use made women more likely to protect themselves by using more contraception in general. In fact, after an intervention in which sexually-active women received either female and male condoms or only male condoms, the reported use of barrier methods for those who were given both types nearly doubled (Artz et al. 2000). The fact that the simple addition of female condoms as an option enhances overall contraceptive use and results in greater protection is remarkable, and suggests that because female condoms give females greater agency, they have more negotiating power with their sexual partners. The discussion between two sexual partners about protection no longer ends if the man refuses to use a male condom. The introduction of female-controlled birth control shifts the conversation from whether or not a condom should be used to “which” condom to use (French et al. 2003). This not only increases the likelihood that some sort of contraception will be used in the encounter at all, but also leads to greater equity in the relationship. Many women who were provided free access to female-controlled contraceptives reflected, “We decided to take turns— sometimes he used his, and sometimes I used mine” (French et al. 2003:438). It is evident that female condoms enhance the position of the female as an equal partner, such that refusing sex is no longer a woman’s sole means of protecting herself (Gollub 2000). We must educate adolescents to view female-based contraception as an equally legitimate and effective alternative to the traditional male condom. Offering low-income adolescent women more choices and resources for contraception that they can control will give women more power in their relationships and empower them to take the initiative to make sure that they are as protected as possible in all sexual experiences (Rosenberg and Gollub 1992).

Female condoms can play an integral role in empowering low-income adolescent women and giving them the opportunity to develop a greater sense of self-advocacy in many ways. For example, it has been demonstrated that increasing access to female condoms can increase overall contraceptive use and reduce the likelihood of an unplanned pregnancy (French et al. 2003), which prevents negative life outcomes that could otherwise make it difficult to escape disadvantaged situations. Often, in low-income neighborhoods, the feelings of hopelessness that adolescents have toward the prospect of a better future may make it more likely that an adolescent woman who has become pregnant will surrender to the negative situation and view it as evidence that nothing she does can change her fate (Bolland 2003). Having little confidence to self-advocate and be proactive can lead a pregnant adolescent to decide to drop out of high school if she has difficulty keeping up academically or experiences the stigma or shame often associated with teen pregnancy, and she might eventually lose hope altogether about returning to school or finding a well-paid job (Schuyler Center 2008). Thus, by preventing unplanned pregnancies, female condoms can eliminate unnecessary hardship in adolescents' lives and offer them the opportunity to realize their potential and break a negative cycle of teenage pregnancy and poverty that is difficult to reverse. In addition, female condoms empower women by giving them the opportunity to advocate for themselves sexually and challenge existing gender norms that expect them to be submissive. Taking control of their own reproductive health may have positive effects on their perceived sense of control over the rest of their lives and increase their confidence in their ability to advocate for themselves.

Ultimately, although public health initiatives of the past have largely failed to appreciate that the value of female condoms extends far beyond simply preventing unplanned pregnancies and the transmission of STDs like its male counterpart, it is not too late to act now and provide adolescents free access to contraceptives that give women greater control over their sexual health. Considering the fact that adolescent experiences form the foundation of an individual’s life, it is crucial to prioritize the empowerment of teenagers, particularly those growing up in disadvantaged neighborhoods. Providing access to female condoms has the potential to break what is often an intergenerational cycle of poverty, and we should not underestimate the positive effect that such a simple policy could have on the lives of many.

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Carleen Su

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