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Abstract

This study explores how Swedish women narrate experiences of hormonal contraceptives through utilizing the frameworks of biomedicalization and reproductive justice, adding a social justice perspective previously lacking. Ten in-depth interviews were conducted with women who had experience of using hormonal contraception. Political narrative analysis illuminated how these women moved narratively both chronologically, from the teenage years to adulthood, and through social positioning, in their contraceptive stories. Two different, often conflicting, discourses of hormonal contraceptives emerged, which the women constantly negotiated. These can be described as (1) a biomedical interpretative prerogative, promoting hormonal methods as an easy fit for everyone, and negating the diverse lived experiences of women, and (2) a simplified critical media and online discourse, painting hormonal methods as an enemy to female health. From a reproductive justice standpoint, these stories illuminate that age is a relevant intersectional location, and even privileged women in a country known for its ‘gender equality agenda’ can experience subtle yet very real, reproductive coercion, when agency becomes constrained to choosing hormonal contraceptives within a dominant biomedical script. Even though critique of the mechanistic prescription of hormonal contraception is rather ubiquitous, the opposition in these narratives does not take the form of rejection of biomedical knowledge, rather the biomedical paradigm is internalized and incorporated into the embodied knowledge. This study shows that upstream factors such as gendered social injustices, reproductive norms, and a biomedical expansion are intricately interwoven with embodied experience of hormonal contraceptive use. It is important to acknowledge that distinct lived experiences of mood or personality change in women using hormonal contraceptives are contextual and dependent on intersectional location. I propose no simple panacea, but when a state-sanctioned biomedical prerogative puts all emphasis on individual reproductive planning behaviour, it obscures structural inequalities and narrows imaginable life trajectories.

Keywords

Biomedicalization contraception narrative analysis reproductive justice Swedish health care

Introduction

When I talked to my midwife, she said, ‘But there are no studies that show you can feel bad when on the pill, there is no causality’. And I’m like, ‘OK, so what I am feeling is just a figment of my imagination then? I know a lot of people who share my experiences. I don’t know if it’s just part of being human, what we’ve experienced, or if it’s our contraceptives that caused it’.

- Catrine.

This article explores how Swedish women in their late 20s and 30s narrate experiences of hormonal contraceptives. Catrine is one of the young women I met who shared her practices of using, changing, and evaluating hormonal contraceptives and, in that process, reflecting on her subjectivity and position in the world.

Different dominant discourses within the arena of hormonal contraception in Sweden create a field of tension. The medical- and state-sanctioned description of reproductive risk, and unplanned pregnancies and abortions that are best mediated by safe hormonal contraceptives (Bellizzi et al., 2020; Lindh, 2014; Stern et al., 2016), stands in rather stark contrast to the media scepticism focused on side effects and negative individual experience (Bitzer, 2017). Medical scholarship agrees that hormonal contraception is highly effective in preventing pregnancy and useful for relieving heavy periods, dysmenorrhea, and premenstrual dysphoria (Lindh, 2014; Maguire and Westhoff, 2011). However, side effects are frequent and the most common reason to discontinue treatment (Simmons et al., 2019), a discontinuation that is itself problematized (Castaño and White, 2013). The mass media, and more recently social media, has been quite adamant about a heightened risk of adverse mood effects, sexual dysfunction, depression, and even suicide while using hormonal contraceptives, often dramatizing medical news (Bitzer, 2017; Foran, 2019).

In Sweden, hormonal contraceptives are subsidized for young women, and contraceptive advice is freely available at clinics for youth up to the age of 25 years. Long-acting reversible contraceptives (LARCs), such as the intrauterine devices (IUDs), are comparably more common in Sweden than in neighbouring countries, but the combined pill is still popular among young women (Lindh et al., 2017). Contraceptive counselling and prescribing are carried out by midwives, rather than gynaecologists (Lindh, 2014). Midwifes are encouraged to offer LARCs as a first choice, especially for young women, with a reduction in the number of abortions used as a rationale (Mödrahälsovårdsenheten Region Stockholm, 2023). It is uncommon to have a personal gynaecologist caring for reproductive needs over time, and with growing demand and recent substantial public healthcare sector cutbacks, it has been increasingly hard to find a general practitioner (Hall, 2013). Swedish primary healthcare lacks continuity in the sense that it is difficult to meet the same provider twice. Against this backdrop of a risk-averting medical discourse, public sector cutbacks limiting access, and a strong incentive for individual reproductive planning with hormonal contraceptives, a reproductive justice viewpoint becomes particularly important for exploring contraceptive experiences in Sweden.

Contraceptive choice and experience as a contextual process

A large body of qualitative work on compliance with hormonal contraceptive regimens exists, investigating mainly teenagers’ non-use of contraception, often explicitly locating the research within a reproductive-risk-reduction discourse, both internationally (Brown, 2015; Brown et al., 2007; Kabagenyi et al., 2016; Lessard et al., 2012; Peremans et al., 2000) and in Sweden (Ekstrand et al., 2005; Falk et al., 2010; Svahn et al., 2021). Not only unwanted but also unplanned and mistimed pregnancies, particularly teenage pregnancies and abortions, are problematized as risky, often by providers attributed to contraceptive (and thereby individual) ‘failure’ (Berndt and Bell, 2021; Stern et al., 2016). A biomedical emphasis on effectiveness, rather than personal preference, has been found in contraceptive information (Carson, 2018; Zettermark, 2023) and in contraceptive counselling meetings (Dehlendorf et al., 2016; Gomez et al., 2014). A biomedical paradigm is favoured by providers, where quantifiable, biological knowledge is seen as objective and true and should lead to rational, effective contraceptive choices, leaving women defying this paradigm as vulnerable to blame (Berndt and Bell, 2021; Stevens, 2018). Within this logic, investigations of barriers to contraceptive use have often emphasized individual-level barriers such as ‘lack of knowledge’ or ‘fear of hormones’ (Asker et al., 2006; Bharadwaj et al., 2012; Hellström et al., 2019; Robakis et al., 2019; Svahn et al., 2021), overlooking the broader social context and power dynamics within which these barriers operate (Berndt and Bell, 2021). Even studies looking at institutional or social factors often treat these as static, organizational, or individual features, rather than placing them within a context of power dynamics and ‘upstream’ elements such as values, implicit standards, and norms that regulate thoughts and behaviours regarding reproduction (Carvajal and Zambrana, 2020; Morison, 2023).

As many scholars have shown (Fulcher et al., 2021; Inoue et al., 2015; Littlejohn and Kimport, 2017), the reduction of complex motifs and situated, embodied decisions based on pluralist knowledge to simple and non-informative categories of contraceptive discontinuation is problematic. Challenging the reductive biomedical approach, feminist scholars have explored contraceptive choice and experience as a contextual process, affected by embodied experiences of side effects (Hoggart et al., 2013; Hoggart and Newton, 2013; Littlejohn, 2013), romantic relationships (Brown, 2015), provider attitudes and interaction (Berndt and Bell, 2021; Dehlendorf et al., 2013; Gomez et al., 2018; Lowe, 2005), racism and ageism (Gomez et al., 2014; Price, 2011; Senderowicz, 2019), and risk-assessment (Geampana, 2019; Littlejohn and Kimport, 2017), as well as the broader reproductive norms of respectable womanhood and motherhood (Downey et al., 2017; James-Hawkins and Sennott, 2015). This scholarship has also highlighted the feminization of reproductive responsibility where women not only bear the physical burden of contraceptive use but also are constructed as responsible for the emotional and practical aspects of family health work (Brown, 2015; Fennell, 2011; Kimport, 2018; Wigginton et al., 2015).

Although previous scholarship provides crucial insight into specific aspects of contraceptive experience, such as the teenage initiation of the pill (Brown, 2015), the contraceptive consultation (Littlejohn and Kimport, 2017), side effects (Geampana, 2019; Littlejohn, 2013), and adult contraceptive negotiations (Wigginton et al., 2015), cohesive perspectives on the contraceptive journey are scant (Morison, 2021, 2023). Downey et al. (2017) used qualitative content analysis of in-depth interviews with Black and Latina women in the United States to explore experiences of evidence and contraceptive decision-making throughout their reproductive lives. They found that women drew on cumulative contraceptive experiences influenced by numerous life aspects, continuously evolving through an iterative and reflective process, when choosing a contraceptive method (Downey et al., 2017). James-Hawkins and Sennott (2015) studied how childbearing norms affected the views of low-income US women on their own teenage pregnancies and contraceptive ‘failures’, showing that gendered narratives of hyperfertility and being ‘young and dumb’ negatively affected their experiences. A life course perspective and how contraceptive practice relates to upstream contextual factors of intersecting power dynamics are insufficiently explored, particularly outside of the United States (Morison, 2021, 2023).

Theoretical considerations

Reproductive justice has been brought forward as a powerful tool to analyze and change reproductive injustices (Ross, 2017). Based on the theoretical foundations of intersectionality (Crenshaw, 1991; Price, 2011), reproductive justice is simultaneously an activist movement and theoretical framework that centres vulnerable women’s reproductive realities (Daniel, 2021). It is fruitful for exploring ‘how reproductive lives and experiences are contoured by socio-political complexities and crisscrossing power dynamics that proceed along multiple interconnected axes of difference’ (Morison, 2023: 175). My theoretical understanding of reproductive justice departs from the feminist standpoint theory, where women’s perspectives are seen as vital to challenge the male bias of prevailing perspectives (Narayan, 2004), and women’s accounts of practice and oppression are relevant in analyzing the power dynamics and social institutions shaping that experience (Collins, 2004).

Power dynamics visualized through a reproductive justice lens are thus paramount to understanding reproductive experience, but so is the painstaking medicalization of reproduction in the last century, since it has implications on social control of women (Burfoot and Güngör, 2022). This is why biomedicalization will also be used as a theoretical point of departure. Biomedicalization is a framework aimed at capturing the expanding dominance of biomedical discourse in the past decades beyond the extension of medical authority already in place (Clarke et al., 2003). It refers to the modern technoscientific transformation of health and illness and transformations of bodies, social institutions, and values associated with it (Clarke et al., 2003). Located within a medical discourse of prevention, risk factors, and an ever-increasing possibility for self-surveillance through new technologies, biomedicalization creates an individual health prerogative, with health as a moral obligation. Medicalized self-governance, attention to risk, and self-surveillance become internalized (Clarke et al., 2003). This process is by no means gender-neutral but feeds into the concept of the female body as unruly and in need of chastening (Martin, 1987; Moore, 2010). The gendered aspect of biomedicalization becomes poignant in a reproductive context and will be used in this study, together with a reproductive justice framework, to highlight processes that would remain hidden otherwise. The distinctive and, in the reproductive arena, intertwined concepts of biomedicalization and reproductive justice create a productive analytical tension, as both identify medical hegemonic discourses on gender and women and illuminate gendered visions of social justice. They can be utilized together to visualize how power is contextualized and negotiated in contraceptive practice and knowledge, exposing tensions and fractures within the neoliberal ideal of rational women who choose effective contraceptives with ease.

In Sweden, the individual reproductive health paradigm is dominant in both policy and academia, with a few exceptions (Gunnarsson Payne, 2018), and to my knowledge, no previous study has investigated contraceptive experiences in Sweden through a reproductive justice lens. The aim of this study was to contribute to a richer understanding of Swedish women’s experiences of using, changing, and discontinuing hormonal contraceptives and exploring how these experiences are interwoven with social injustice. I asked how Swedish women navigate the different dominant discourses on hormonal contraception: Which contraceptive stories are possible, and which are not? What do these narratives tell us of the contemporary micro- and macro-political landscapes? How can notions of power within this field be understood from a reproductive justice perspective?

Methodology and methods

Drawing on the standpoint strand of reproductive justice, this study was designed to capture life stories of contraceptive use, through in-depth interviews and narrative analysis, aiming to question prevailing understandings of reproductive lives and to generate new, more emancipatory, and fair ideas (Morison, 2023; Ross, 2017). Alexander (2022) defines this approach as allowing for exploration of ‘the interplay of micro and macro social systems in a particular moment of a person’s life’ (p. 158). This corresponds well with the tradition of political narrative analysis where stories are seen as useful to investigate connections between micro- and macro-political levels and their positioning within a certain community or context (Andrews et al., 2013). A narrative analysis placed within a reproductive justice framework can thus provide the rich and nuanced understanding of human experience needed to grasp the interconnected embodied, relational, biomedical, and political forces of dominance that shape changing contraceptive practices and understanding throughout the reproductive life. The analytical approach was inspired by Oikkonen’s (2013) separation of narrative manifestation, the content of the story told, and its underlying logic, the organizing basis forming a comprehensible form for the story:

As an organizing logic, narrative is a textual engine that keeps the story going. Such a motor turns representation into particular spatially and temporally organized patterns, producing the sense of movement that we tend to identify with narrative. The familiarity of these patterns makes certain narrative events and textual outcomes seem likely while rendering others highly improbable (p. 298).

During early spring 2021, I conducted 10 in-depth interviews in Swedish with adult women who had experience with using hormonal contraceptives. The women that contributed to this study were recruited through social media forums dedicated to female health, as well as snowball sampling from my own social media networks. They were between 27 and 37 years of age. They were all born in Sweden, had some post-secondary education, and the majority had a university degree. All but two of the women interviewed lived in a larger city. They were all currently in a romantic relationship. Two women had children; one was currently pregnant. These women represent a rather socially dominant and growing white urban middle class that takes part in the public discussion on contraceptives. Each interview lasted about an hour and was transcribed verbatim. I first read the interviews in their entirety, to gain a comprehensive sense of the narratives. I then re-read them and entered data related to contraceptive experience and negotiations with dominant reproductive discourses into a spreadsheet and inductively analyzed for patterns and themes. Next, I looked for narrative building blocks, turning points, and recurrent narrative manifestations. Then I derived overarching types of stories and organizing logics from the thematization of narrative manifestations. Finally, I revisited the thematization and re-read the narratives through the lens of the two organizing logics, to ensure soundness and lack of redundancy. Ethical approval was obtained from the Swedish Ethical Review Authority in Stockholm, Sweden (Dnr 2020-06682).

The chronological and positional narratives

I identified two different types of organizing logics in these stories of hormonal contraceptive use, each with different narrative manifestations: the chronological and the positional. These distinctive narratives both demonstrate connections between micro- and macro-political levels and negotiations with dominant discourses, but in different ways. The chronological story can be described as a familiar threefold narrative of inexperience followed by growth, of perseverance in spite of setbacks, and of a positive resolution.

The chronological growth saga

Coming of contraceptive age

The beginning of the chronological story, starting with hormonal contraception, often entails what seems an almost mechanistic prescription for hormonal contraceptives. In her story of when she started using contraceptives, Esther mentioned the self-evident nature of going on the pill as a teenage girl who becomes sexually active:

The first time I used hormonal contraceptives I was about 16 and it’s quite common, first boyfriend I had . . . and it felt kind of like ‘the done thing’ (laughter) when you’re a teenager, become sexually active, to [go to] the youth centre and get the pill.

Most women start using hormonal contraceptives because of a heterosexual relationship, but there were also examples of starting because of acne or ovarian cysts. In Bella’s story discussed in the following paragraph, the introduction of hormonal contraception came before the sexual debut, not because of medical issues, but because of the presumption of a future heterosexual relationship accompanied with the risk of an unplanned pregnancy.

I started because . . . the youth centre talked kind of like ‘but the pill is something you start taking, so which one do you want?’ I didn’t have a boyfriend or . . . it was not like it was a contraceptive purpose really. It was just something that was like, ‘It can be good so you get a regular period’. It wasn’t a big deal really. It was kind of ‘You should start taking these, you will need it so you might as well start now’. . . . it just continued and I was never introduced to something non-hormonal. No one ever mentioned the alternatives that can be used as protection that is not taking extra hormones.

A common trait in these opening sections is a visit to the youth health centre and being prescribed the pill by a midwife, without hesitation. A normative sex life, with heterosexual intercourse that can lead to pregnancy, is clearly expected, as well as the medical will to limit possible teenage pregnancies. In these recounts of the teenage years, the women describe themselves as passive recipients of contraceptives, and a coercive element dependent on age, when no options are presented, is clearly visible.

Perseverance in finding the perfect fit

The next narrative section is a period of perseverance in trying out different contraceptives, despite often painful setbacks such as side effects, self-doubt, and a feeling of not being heard. Georgia recounted:

I had constant breakthrough bleeds. I had small mini-bleeds all the time. It could be that one day I did not have a bleed, maybe, but by and large it was constant. They usually say that you should give it three months. So, I gave it three months and then they said I should continue and that sometimes it could take longer. So, I think I had some for almost six months. Then changed and had that for six months. Well, it didn’t improve at all. (. . .) It’s been the hardest part, not to actually have ‘breakthrough bleeds’, but the psychological part of not knowing. Like, will something come today? You don’t feel hygienic, all those kinds of things. And that really affects my mood.

Georgia depicted a long period of physical suffering that also affected her mental state. She persevered for the recommended period of 3 to 6 months and also in trying out different hormonal methods for 10 years. In Georgia’s narrative, the strong expectation of a potential hormonal contraceptive fit also created internal doubt and criticism. Recognition from a midwife finally changed the course of Georgia’s difficulties and made it possible for her to come to terms with a non-hormonal method. In her narrative, departing from the path of hormonal methods became conceivable only when a medical professional legitimized the choice.

Joanna described herself as a robust, happy person that never suffered from anxiety or depressive symptoms. She also tried out different kinds of hormonal contraceptives during her teenage years and told me about an episode when she was taking progesterone-only pills in her early 20s:

I became like really shut down emotionally and like nothing was particularly fun, nothing was particularly boring, it was just . . . no real highs or lows, it was just some kind of even . . . everything was sort of semi-boring. So, I had it like that, it was subtle at first and then, after a year or so, I started feeling no, this is weird, it shouldn’t be like this. It was when I studied to become a nurse . . . I stood and waited for the train. It was a very snowy, icy, and cold winter and there was a lot of pack ice on the platform. And I remember I stood there on the platform and thought, God you really have to be careful here so you don’t fall down, you could slip in front of the trains here. And I remember that thought didn’t at all make me like ‘Oh no, I have to be careful so I don’t fall down’ or fill me with any fear, it was just, ‘Okay (shrugs shoulders) . . . then I’ll do that’. And that scared me a little bit, because I also felt that this is not how I am really feeling.

Joanna portrays a change in her mood that was subtle at first, with a creeping realization that something was wrong, culminating in a narrative turning point at the train station. Her own thought that she did not care anymore if she lived or died scared her into realizing something was really wrong. Joanna’s story continued with how she stopped taking the pill and felt better but tried once more after the birth of her first child and realized again that it adversely affected her mood.

Joanna’s story is, like the stories of almost all the women interviewed, one of perseverance in both continuing a hormonal method despite the side effects and trying out new hormonal methods when these effects became severe enough. The suffering in these narratives is tangible, yet seldom articulated as an injustice realized at the time. Years are spent bleeding, being sad, or questioning oneself. The women were continuously evaluating whether the side effects were bearable or the pregnancy protection safe enough, whether their bodies or mental states were changing, revealing an ever-ongoing inner evaluation during these years. The constant self-surveillance is normalized in these narratives, exposing the degree to which a biomedicalized logic is internalized.

Coming to terms with a contraceptive method

The chronological growth saga ends on a surprisingly unanimous and optimistic note, with varying current contraceptive methods. Three women use a hormonal method, six use a non-hormonal method, and one is in a same-sex relationship. Frida and her husband agreed on vasectomy after she expressed her desire to quit hormones:

It’s always been side effects and even if the IUD worked well, it’s still something you put in your body and you have no fricking idea what it’s doing there. Two pregnancies, two deliveries, I just felt . . . let this little body get some rest now. Also, from a point of justice, that my body has taken one, several, for the team. Not to say the least with pregnancies. And now it’s your body’s turn, for fuck’s sake. It’s only fair (laughter). And if you don’t want to, we use a condom and that’s not a problem. But now I, this body, it’s done its part and now let it be. It was an inner feeling in some way. (. . .) I mean it’s not possible to even compare the sense of self-worth or self-confidence that I have now compared to that of an insecure teenager or 20-something . . . it’s a decision that lies 100% with me, what I do with my body. It has not always been like that. And it’s a classic, how we view women in society. The female body, it’s not her own but exists to please others in different ways in looks and function. So, I guess it’s a classic, the female body is more public property in a way that the male is not.

Frida described how her embodied reproductive experiences made her feel as if her body had ‘done its part’. She elaborated on how a sense of bodily autonomy and self-confidence developed with age, something that allowed her to express her wish for a shared contraceptive responsibility later on. Frida concluded with a feminist remark, connecting her own experiences of growing self-assertion in relation to her own body to gendered power imbalances in society. Here, the personal growth story became meaningful within a macro-political context of progress.

Doris had a different story. She questioned her experiences of the pill as a teenager, when she felt ‘down’ and quit. She was critical of the widespread scepticism against hormonal methods and expressed how this might have hindered her from finding a solution to her premenstrual dysphoric syndrome (PMDS) earlier. Her resolution came in the form of a hormonal method:

I’ve had this skepticism that I think a lot of people have concerning the pill and how it can affect . . . and maybe read in a little too much into symptoms that might not have been true . . .. But I’ve had extreme issues with PMS, or maybe I should describe it as PMDS . . .. And around five months ago I got Prionelle, and I’ve never felt so good as I do now! I’m thinking, well, it’s been a lot of talk about hormones, hormonal contraceptives and I’ve been kind of afraid to use it and how it will affect me . . . and now finally I’m a stable person.

Throughout the chronological narratives, these women navigated both the dominant medical discourse advocating for hormonal methods, the introduction of the pill becoming a stark example, and a sceptical media discourse, illustrated earlier by Doris. The lived experiences were often only allowed to make sense when midwives, as representatives of the medical community, confirmed them. Using a reproductive justice lens, the stories show that these women, although relatively privileged, are constrained by social injustices and medically defined expectations of socially acceptable reproduction.

The positional narratives

Within the organizing principle of the positional narrative, the easily recognizable story components of temporal movement are not as apparent, but instead the main ‘textual engine’ is the movement through social positioning, of identification with some communities or discourses and disidentification with others. Two main themes of narrative manifestations emerged: One was more outward oriented, where dis/identification with different societal opinions on hormonal contraceptives became explicit, and the other more inward looking, reflecting on the authentic self.

Dis/identification – the sensible adult in-between

Certain opinionated groups were experienced by the women interviewed as ‘unnuanced’, meaning they admitted only one stance on hormonal methods, either unanimously good or bad. A continuous positioning of oneself in opposition to these ‘extreme’ or ‘unnuanced’ groups can be traced throughout the narratives. In Ester’s words, the ‘new green wave natural health hippies’, leading a ‘witch-hunt on hormonal contraceptives, calling it poison’, were contrasted to the medical community that habitually insists on hormonal methods. The women interviewed carved out a sensible middle position, reflecting on how different online communities would be biased and how people with more extremist views tended to preach their position louder. Helena criticized the polarization and concurrently expressed empathy for, and disidentification with, those women who ‘ended up on the margins’, identifying instead with a rational, sensible position where critical thinking could be combined with trust in the medical experts:

People are so very scared, maybe in vain. And skeptical about things that, after all, are science. Or you should be skeptical about science, but the professionals . . . somewhere you have to trust the professionals and I feel, it’s a dangerous trend when people stop doing that. It’s no good when people question everything, always. It would be great if it was a reflective questioning, but when it’s more . . . that you dismiss things because you should, or because you read it somewhere. Then it’s not a positive trend. Then again maybe they outweigh each other, it wasn’t great how it was when I went to upper secondary school, with no questioning at all. So, if they pull in different directions, maybe the middle way will be, be good. But it’s a shame for those who end up at the margins then, on this scale.

Another aspect of the sensible position mentioned was being conscious of risk. Ester talked about her current use of condoms plus a fertility tracking app in relation to protection against unwanted pregnancy. She emphasized how she weighed the risks carefully, discussing how as an adult she could be as ‘responsible or irresponsible as I’d like to’. She came back to how teenagers were encouraged to use hormonal methods:

Well, as a teenager your brain is not fully developed, has no fully developed consequence thinking. So, we have to do something, so there’s no teenage pregnancy and you have to have an abortion. I believe that’s why there is this push toward hormonal contraceptives in particular. Because I don’t know what the statistics had looked like otherwise but . . . well it’s hard to say. Had I heard from a like 16-year-old that they use like natural cycles and like a condom sometimes . . . okay, that sounds irresponsible. But it’s exactly what I’m doing! (laughter).

The sensible, adult position that Ester inhabited was thus created through disidentification with age-specific irresponsible ways of reasoning. Simultaneously by distancing herself from the irresponsible teenager, though, she reflected on how the society helped to create these age-specific rules.

Authenticity – is it me or the hormones?

The discussion about being your authentic self, and how exogenous hormones possibly interfere with authenticity, resurfaces in different ways in the narratives. One of which is the reflection on conditions that must be in place in order to fairly evaluate a hormonal method, illustrated in the following paragraph by Frida. She recounted an episode before having children when she stopped taking the pill:

Yeah, and it was also a period, years, well a lot of things happened in life. I moved, changed city two times, a long relationship ended. I changed jobs and had a job that really affected my health badly. I don’t think it was possible to notice because there were so many feelings anyway. So, it was more after I’d had a stable life for a while on the pill, and a stable life without the pill, that I noticed the difference. I felt more. Stronger in a way. And foremost, foremost actually that I experienced that when I was happy, I became happier. Closer to laughter, sort of. Yeah, more. Then I felt cheated. It is rather a lot of years’ worth of feelings, or many years’ laughter so to say, that I didn’t get.

Frida voiced that her authentic self was happier without the pill than when she was on the pill, but it was impossible to realize sooner, since so many variables affect mood.

Not only the experience of, but also the possibility of, mood and personality change, of losing sight of the authentic self, becomes relevant in navigating hormonal contraceptives, as exemplified by Doris, Catrine, and Helena in the following paragraphs. Doris talked about how she was sceptical of hormonal methods when she was younger, something she now regrets. She used the copper IUD for a while because she was ‘absolutely opposed to hormonal contraceptives’, here explaining why:

Fear of gaining weight, fear of becoming affected, becoming different, slower. Without noticing myself. I think that’s the worst-case scenario, everyone who speaks of how they were on the pill for 10 years and when they stopped, they all of a sudden became new people! But that they didn’t realize it themselves and that’s . . . yeah, that’s what I was afraid of.

Doris described how a ‘story of a changed self’ due to hormonal contraceptives was an ever-present and frightening scenario that had to be navigated. The scariest part could be that it was not even possible to realize that you were not yourself. Catrine, who is quoted in the beginning of the paper, told a similar story of the fear of becoming ‘a different person’ on hormonal contraceptives. She verbalized the internal conflict that arose when her own, and her friends’, experiences did not align with the dominant medical discourse and were disregarded.

Helena related to the same prevailing macro-story, expecting to become a different person when removing her hormonal IUD, only to realize that nothing happened. She went on to reflect on ‘getting to know her body’ without exogenous hormones, exhibiting yet another aspect of authenticity in relation to hormonal contraceptives; that is, getting to know your ‘authentic body’:

I mean, it was exciting to remove the IUD and be like: how does my body work without the IUD? (sarcastic) Apparently exactly the same. I mean I hoped that I would become happy and energetic, oh everything will be amazing when I remove the IUD . . . but well, it didn’t happen. I really feel the same except I got my period back and that’s fun. Or, it’s not fun, but it’s good to get to know your body a bit again, since the cycle changes over . . . I mean it’s been 10 years since I was naturally cycling now. It’s fun to be reminded that the body works like it’s supposed to. But, now I’ve done it, I might as well put an IUD back in.

Helena saw a regular period as a sign of a healthy reproductive body but valued the freedom of non-menstruating life more highly. Ester, on the other hand, perceived the fluctuations in mood when naturally cycling, and being able to track them closely through technology, as having inherent value:

. . . youth cent elementespecially when you have this app where you more or less can follow where you are, you get a great awareness of it too. So that feels like a rather big advantage that I’ve gotten to know my cycle, and my body, and gotten this greater awareness around it.

Ester emphasized the advantages of ‘getting to know yourself’ and also shared the data with her boyfriend. Ester framed menstrual tracking as playful and fun but also recognized how much data were needed to make the fertility algorithm in the mobile application work. This route to authenticity was conditioned on utilizing biomedical technology and knowledge for self-surveillance.

Discussion

In this narrative analysis of hormonal contraceptive experiences in Sweden, two types of organizing logics emerge: One is chronological, where age becomes a relevant location for understanding contraceptive experience, and one positional, in which the narrative is driven by social rather than temporal movement. Throughout these narratives, two different, often conflicting, discourses of hormonal contraceptives emerge that the women interviewed constantly negotiate. These can be described as follows: (1) a biomedical interpretative prerogative, promoting hormonal methods as an easy fit for everyone, and negating the diverse lived experiences of women, and (2) a simplified critical media and online discourse, painting hormonal methods as an enemy to female health. These discourses frame the experience of starting on the pill, where a medicalized view of reproductive risk makes the introduction unquestionable. They affect the interpretation of symptoms that could be side effects, create doubt, guilt, and the need for ever-more self-surveillance, in search of a contraceptive fit – with or without hormones – and the authentic self. Finally, they act as a backdrop when coming to terms with a contraceptive method, requiring dis/identification with extreme viewpoints and an acceptance of pluralistic knowledge. These aspects will be discussed in relation to previous scholarship discussed further.

In the recounts of the teenage years, the women described the initiation of the pill as mandatory, unquestioned in relational spheres, and strongly encouraged by medical representatives. When no other option but a hormonal method is presented, it can be argued that a coercive element is present in the contraceptive meetings (Morison, 2021). Senderowicz (2019) problematizes the narrow definition of ‘contraceptive coercion’ as ‘violence’ and argues that coercion sits on a spectrum, where strong encouragement and lack of options also can become a form of force. From a reproductive justice standpoint, these stories illuminate that age is a relevant intersectional location, and even privileged women in a country known for its ‘gender equality agenda’ (Arousell et al., 2017) can experience subtle yet very real reproductive coercion. This process does not have to be malevolent, or even intentional, in the individual contraceptive meeting, but it stems from a dominant state-sanctioned, institutionalized biomedical understanding of reproductive risk (Berndt and Bell, 2021; Geampana, 2019). Young women are branded as ‘irresponsible’, unfit potential mothers, and therefore in need of ‘safe’ hormonal methods (Hawkes, 1995). The coercive element of hormonal contraceptive initiation became clearer, and more upsetting, to the women in hindsight, when they reflected on and compared their early experiences to their current contraceptive situation and cumulative reproductive life experience. The narratives thus gain strength as analytical categories from being treated as coherent stories. Downey et al. (2017) found that women’s contraceptive choices were an iterative, continuous, reflective process, which is in line with my findings. In addition to that, however, I find that these reflections and knowledge based on personal experiences also invite criticism of structural reproductive injustice, and thus may have emancipatory potential.

Yet, emancipation is not possible alone. Feeling alone, articulated as abandonment both by the medical institution that first initiated the use of hormonal methods and by the medical community as a whole that is indifferent to side effects and reproductive health matters, runs through the next narrative block of perseverance in finding a contraceptive fit (Wigginton et al., 2015). The solitary micropolitical scenery in these narratives highlights the impact of macro-political structures, such as the Swedish healthcare system, where follow-ups are scarce, and the patient seldom has their ‘own’ midwife or gynaecologist (Hall, 2013). The absence of community, feminist organization, and male partners is also striking in these narratives during young adulthood. Although a heterosexual relationship is the dominant rationale for using contraceptives, the men are not present in discussions of contraceptive methods. The responsibility of using, evaluating, and changing contraceptive methods, as well as the tangible embodied suffering, both physical and emotional, is female, and lonesome. Wigginton et al. (2015) discuss how Australian women go to great lengths in finding a contraceptive fit, and how agency is afforded through the embodied practice of self-surveillance to find a method with minimal side effects. They argue, along with other scholars, that naturalization of female responsibility in finding a contraceptive fit, in addition to downplaying the physical burden of side effects, hides the emotional and relational work involved in preventing pregnancy (Fennell, 2011; Kimport, 2018; Wigginton et al., 2015). This relational, embodied work has been called fertility work (Bertotti, 2013). In my material, the fertility work is striking and unambiguous and carried out for decades by the women interviewed. Biomedicalization is a relevant process in understanding modern fertility work (Berndt and Bell, 2021). Although contextual and embodied experience has been found to be highly relevant for women using contraceptives (Berndt and Bell, 2021; Downey et al., 2017; Kimport, 2018; Lowe, 2005), the discursive dominance of effective hormonal methods as objective biological facts casts these other modes of understanding and regulating fertility as suspicious. Georgia’s story of bleeding, anxiety, and changing hormonal methods for a decade makes this tension visible. By showing how the strong expectation of reproductive freedom through hormonal contraceptives can be something that inhibits this very freedom, it highlights how agency within a dominant biomedical script becomes restricted to choosing hormonal contraceptives.

The women in this study are remarkably content with their current contraceptive method, even when side effects still prevail. Finding a suitable option, with or without hormones, could be interpreted as part of growing into an adult, responsible, and self-confident woman within a neoliberal political context that values independence and choice (Brown, 2005). However, the process of creating a rational, responsible adult self that adequately judges reproductive risk involves more than chronological ageing. Social positioning and disidentification with certain groups, such as the ‘unreasonable hippies’, ‘health care professionals not admitting complexities’, and ‘irresponsible teenagers’, is paramount in these narratives. The construction of teenagers as irresponsible is linked to reproductive norms (Hawkes, 1995), which clearly change throughout life. Geampana (2019) describes that women older than 30 years seem ‘less concerned about an unplanned pregnancy’ (p. 1524) and therefore more prone to using less-efficient non-hormonal methods. This shift in conceptualization of pregnancy risk and contraceptive choice, connected to personal, relational, and societal factors, is made explicit in my material as well. For example, Ester, who is in her late 20s, jokingly pointed out that she would consider her own contraceptive practices to be irresponsible if practised by a teenager.

Scholars have argued that, from a reproductive justice perspective, voices of reproductively privileged women are also of interest when explicitly recognized as such, to provide insight into systems of inequality (Morison, 2023; Rice et al., 2019; Ross, 2017). The relative ease with which these rather privileged white women negotiate an adult position of contraceptive content, particularly while using a less-efficient method, could be understood as a white privilege of being constructed as a respectable (potential) mother and responsible contraceptive user and of fitting the default white and middleclass, neoliberal subject (James-Hawkins and Sennott, 2015; Smart, 1996; Tasker and Negra, 2007). Racialized systems of oppression influence contraceptive counselling, with professionals disproportionately more frequently prescribing LARCs to women of colour (Dehlendorf et al., 2010; Gomez et al., 2014, 2018). A Swedish study showed that contraceptive counsellors use ‘gender equality ideals’, and participation in the work force, as a rationale to push for effective contraceptive methods for multiparous racialized women (Arousell et al., 2017), displaying how the macro-political landscape of gendered reproductive norms and neoliberal production ideals affect the micropolitical contraceptive interaction. The lack of stories of adult contraceptive coercion in my material could elucidate how privilege shields certain women from the repercussions of racialized reproductive norms.

Berndt and Bell (2021) investigated interactions in the contraceptive consultation and found that the hierarchical division between providers’ biomedical knowledge and women’s embodied knowledge became a barrier to contraception when the hierarchy was taken for granted and women’s concerns were dismissed. Similarly, although not focused on contraceptives but hormones in a broader sense, Berg and Lundgren’s (2022) exploration of Swedish women’s relationship to hormones found two conflicting narrative frameworks: either incorporating a medicalized view and advocating for more medical knowledge to take control or distancing to ‘see beyond the body’ and refuse to be reduced to hormonal fluctuations. The stark division between biomedical and embodied knowledge, and between a wish for more medicalization and a renunciation of it, is not as clear in my material. Even though critique of the mechanistic prescription of hormonal contraception is rather ubiquitous, the opposition in these narratives does not take the form of rejection of biomedical knowledge. On the contrary, distancing from the ‘natural health hippies’, who advocate dismissal of Western medicine in general, and exogenous hormones in particular, is pervasive. The women commented on how personal negative experiences of hormonal contraceptives are amplified by social media and online communities, creating an unfair ‘witch hunt’. Rather, the biomedical paradigm is internalized and incorporated into the embodied knowledge, perhaps best illustrated by Ester’s joyful tracking of her menstrual cycle. This method requires rigorous self-surveillance in addition to data-driven technology: taking the temperature every morning and evaluating vaginal discharge, mood, and libido throughout the month (Wilkinson et al., 2015). The internalized biomedicalized self-governance is not only taken for granted (Clarke et al., 2003) but also seen as liberating. The naturalization of this female self-surveillance (Moore, 2010), combined with a plethora of contraceptive technologies presented as simple and empowering, can obscure the arduous, and fundamentally gendered, reproductive work needed to use hormonal contraceptives, which is evident in these narratives.

Finally, several notions of authenticity emerged as narrative focal points in this study. The authentic body, mainly as one ‘undisturbed’ by exogenous hormones, naturally cycling, became one locus of interest, as also other scholars have found (Geampana, 2019; Kimport, 2018). More prominent, however, is the ever-present ‘story of a changed self’, the expectation that hormonal contraceptives could change mood, and even personality, in a substantial way. Tension arises when the personal narrative collides with the culturally prevalent discourse (Andrews et al., 2013), as when a midwife negates a distinct embodied experience as a possible mood side effect, or when the removal of a hormonal IUD does not lead to any personality changes. Both the biomedical and hormone-critical discourses mediate value systems and regulate contraceptive understandings and choices. They frame the interpretation of certain experiences, offer solace, fuel anger, and give the will for biopolitical change, such as when a woman feels robbed of years of happiness and feels passionate about how teenage girls of today should not have to suffer the same ordeal. Ultimately, they also shape contraceptive choices, such as persevering with a hormonal method or abstaining from it because of the fear of ‘becoming someone else’, and possibly not even realizing it.

In a biomedicalized society, there is a poignant ontological divide between the medical profession’s use of categorization, clear cutoffs, and biochemically verifiable pathology and the unnumbered but often distinct lived experiences of mood or personality change in women using hormonal contraceptives that are contextual and dependent on intersectional location (Berndt and Bell, 2021; Downey et al., 2017). This study shows the importance of acknowledging that embodied experience, ambiguous symptoms, fearing or wanting certain changes, or questioning oneself based on prevalent contraceptive macro-stories are intricately interwoven with upstream factors such as gendered social injustices, reproductive norms, and a biomedical expansion. I propose no simple panacea but suggest that when a state-sanctioned biomedical prerogative puts all emphasis on women’s individual reproductive planning behaviour, it obscures structural inequalities and narrows imaginable life trajectories.

Footnotes

The author thanks her supervisors prof. Juan Merlo and prof. Diana Mulinari at Lund university for continuous support,and the latter for incisive and generous comments on this text throughout the writing process. She is also deeply grateful to the women who generously gave their time and shared their experiences during the interviews.

Data accessibility statement

The research project follows Swedish ethical legal frames and guidelines and was approved by Swedish Ethical Review Authority in Stockholm,Sweden (Dnr 2020-06682). To ensure anonymity,original interviews are stored at a data deposit at the centre for gender studies at Lund University (LUSEC safety deposit),to which only the researchers included in this project have access. The key to the coded transcribed interviews,as well as the unidentified transcribed interviews,is held on a password-protected LU computer. Unidentified transcribed full interviews can be provided to a second party for review after renewed ethical application and approval by a Swedish Ethical Review Authority.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This research was funded by a Swedish Research Council Grant (2017-01321).

ORCID iD

Sofia Zettermark

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‘They all of a sudden became new people’: Using reproductive justice to explore narratives of hormonal contraceptive experience in Sweden

Abstract

Keywords

Introduction

Contraceptive choice and experience as a contextual process

Theoretical considerations

Methodology and methods

The chronological and positional narratives

The chronological growth saga

Coming of contraceptive age

Perseverance in finding the perfect fit

Coming to terms with a contraceptive method

The positional narratives

Dis/identification – the sensible adult in-between

Authenticity – is it me or the hormones?

Discussion

Footnotes

Data accessibility statement

Declaration of conflicting interests

Funding

ORCID iD

References