Kristina Saunders, Lecturer in Sociology
Since the leaked US Supreme Court draft opinion on Roe v. Wade and its eventual overturning in June 2022, heightened attention has been drawn to self-managed abortion (SMA) (Gerson, 2022; Becker and McMahon, 2022). The World Health Organisation (WHO) (2020) support the provision of SMA, and some governments have continued to allow early medical abortion via telephone consultation that was introduced during COVID-19 lockdowns (e.g. Scottish Government, 2022). However, the groundwork for this vital care pathway was laid by feminist networks – particularly in the Global South (Löwy and Corrêa, 2020) – who have long worked to facilitate access to abortion, often at the risk of their own safety and possible criminalization (Thomas et al, 2021). Support for, and facilitation of, self-managed care has historically offered an alternative to care provided in harmful political and medico-legal structures, and can encourage bonds of solidarity in resistance to reproductive injustices (Pizzarossa and Nandagiri, 2021). SMA also broadens understandings of what constitutes safety in abortion care outside of dominant constructions (Nandagiri, 2022) encouraging a rethinking of reproductive care, and reproduction itself, as socially, emotionally, and relationally constituted (Nandagiri, 2022; VanGelder, 2021; Saunders, 2021).
In this piece, I tease out my ongoing thinking about self-managed care and contraception, in response to fears surrounding the wider consequences of the Supreme Court decision on abortion (Michelson, 2022). Specifically, I will focus on the perhaps lesser known practice of self-removal of intrauterine contraceptives (IUCs) by contraceptive users, who then share their experiences via online platforms (Amico et al, 2020; Broussard and Becker, 2021). In doing so, I will think through the social and political logics of self-removal to show how contraceptive decisions are situated in and shaped by contexts of inadequate care and coercive structures. Self-removal may therefore be a necessary practice for navigating and resisting such structures and increasingly uncertain feminist futures.
Long-acting reversible contraceptives (LARCs) include: IUCs (the intrauterine device/system (IUD/S)); the subdermal implant, and contraceptive injection. The United Nations (2019) estimated that 256 million contraceptive users worldwide aged 15-49 used LARC methods, with 159 million using the IUD. IUCs are 98% effective, and once inserted during an appointment with a healthcare professional can be used for three-10 years depending on the type (FSRH, 2019). Upon expiration, IUCs are removed during an appointment by pulling on the strings attached to the bottom of the device. IUCs, and LARCs more generally, may therefore be appealing to users due to the sense of freedom afforded from the convenience of these methods and the ability to avoid pregnancy (Manchikanti Gomez et al, 2018). This is in comparison to more labour intensive methods with typically higher failure rates such as the contraceptive pill, the effectiveness of which relies upon users to take daily, collect regular prescriptions, and often schedule more frequent appointments with providers.
LARCs’ garner praise from policymakers and clinicians due to their effectiveness in preventing pregnancy and their cost and resource effectiveness (Higgins, 2014). That LARCs are not user controlled but are underpinned by provider-dependency is also appealing to policymakers (Lowe and Rowlands, 2022), which when combined with ideologies of ‘appropriate’ reproduction as shaped by intersecting power dynamics (Saunders, 2021), can lead to LARCs becoming susceptible to coercive policy and prescribing frameworks (Wale and Rowlands, 2021). This is evidenced by the targeting of marginalized groups who are pressured (or coerced) to use LARCs (Higgins, 2014; Senderowicz, 2019; Lowe and Rowlands, 2022), and provider refusal to remove LARCs upon user request (Amico et al, 2016, 2017; Burgess et al, 2021; Saunders, 2019). Further issues include painful insertion and removal of LARCs (BBC, 2021), and often severe side effects or complications from use (Hoggart et al, 2013; Saunders, 2019; Wale and Rowlands, 2021). Cuts to sexual and reproductive health (SRH) services have a direct impact on accessing timely and suitable appointments for contraception, and have been exacerbated during the pandemic (Lewis et al, 2021), and in some healthcare contexts, the cost of LARC insertion/removal constrains contraceptive decision-making (Amico et al,2020).
Decisions about contraceptive uptake and continuation are therefore often made in the context of coercion and inadequate health systems that are failing contraceptive users. As a result, some IUC users take matters into their own hands and self-remove their contraceptives outside of mainstream healthcare settings. A small number of studies carried out in the US have explored self-removal, focusing on contraceptive users’ feelings about and ability to self-remove in supervised clinical environments (Foster et al, 2014), while others have considered why users self-remove. Amico et al (2020) and Broussard and Becker (2021) examined motivations for self-removal as discussed by users on internet forums and YouTube respectively, and found broadly similar reasons from their analysis: the impact of negative side effects, and difficulties accessing provider-removal due to cost or lack of appointments. In these studies, IUC users also discussed how reading about others’ self-removal experiences was encouraging (Amico et al, 2020), and high levels of engagement and comments on videos seemed to suggest gratitude for the information shared (Broussard and Becker, 2021).
Existing self-removal research provides a valuable insight into how contraceptive decisions are shaped by inaccessible systems that restrict autonomy. It is therefore not difficult to imagine how self-removal may be deemed necessary by users in order to care for themselves and ‘opt out’ of inadequate mainstream care. Considering the motivations for self-removal and the sharing of experiences online, and the wider coercive context of LARC policy, might we begin to make sense of self-removal as a form of self-care, as users respond to and resist inadequate mainstream care and create bonds of solidarity through the sharing of knowledge online?
Though not referring to IUC self-removal, the WHO (2022) recognizes the potential of self-care in SRH, and define self-care as:
the ability of individuals, families and communities to promote their own health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health worker.
Along with enhancing autonomy, in this definition, self-care may also involve collaboration with healthcare professionals. But forms of self-care have existed long before and outside of formal health systems, such as the work of traditional midwives (e.g. National Aboriginal Council of Midwives (NACM)), and underground feminist networks who helped facilitate access to abortion (see Gago, 2022). Self-care may be practised for a range of reasons such as convenience, or because practices are established traditionally and culturally and passed through generations (Narasimhan et al, 2019). People may also ‘opt’ for self-care to avoid inappropriate, unaffordable, or inaccessible healthcare and due to experiences of discrimination (see Davis, 2019 on obstetric racism).
In Audre Lorde’s writing on her experience of living with cancer, self-care entails a radical and urgent slowing down which allows her to preserve herself for political work, indeed, self-care for Lorde is itself a political act. Lorde (1988, 106) also situates her turn to self-care in the wider context of neoliberal reforms that decimated social supports, and within the sexist and racist structures that institutionalized medicine is founded upon:
From the moment I was ushered into the doctor’s office and he saw my x-rays, he proceeded to infantalize me with an obviously well-practiced technique. When I told him I was having second thoughts about a liver biopsy, he glanced at my chart. Racism and Sexism joined hands across his table as he saw I taught at a university. “Well, you look like an intelligent girl,” he said, staring at my one breast all the time he was speaking. “Not to have this biopsy immediately is like sticking your head in the sand.” Then he went on to say that he would not be responsible when I wound up one day screaming in agony in the corner of his office!
He dismissed my concerns with a wave of his hand, saying, instead of answering, that I really did not have any other sensible choice.
I would like to think that this doctor was sincerely motivated by a desire for me to seek what he truly believed to be the only remedy for my sickening body, but my faith in that scenario is considerably diminished by his $250 consultation fee and his subsequent medical report to my own doctor containing numerous supposedly clinical observations of obese abdomen and remaining pendulous breast.
What can be gleaned from Lorde’s writing is that self-care may constitute resistance to the violence of intersecting oppressions and medical authority, and is therefore about the everyday struggle against systems ”that stand in opposition to wellness for marginalized people” (Kim and Schalk, 2021: 329). Kim and Schalk (2021:329) draw attention to Lorde’s emphasis on the need to make informed decisions about her health as a crucial component of self-care that involved seeking knowledge from various sources outside of formal healthcare; doing her own reading into medical literature; using alternative medicine, and speaking to other people living with cancer – pointing to a more holistic and relational approach where guidance is shared within communities. Self-care may therefore offer an alternative to mainstream systems for those who are discriminated against, and have challenging or stigmatizing interactions with healthcare professionals who belittle and dismiss their concerns and embodied knowledge. This may be the case for some IUC users whose requests for removal are denied, whose concerns are not taken seriously, and who struggle to access appointments, but can then turn to the internet to find guidance on self-removal from those who have attempted it.
Self-care for Lorde was also understood as coexisting with formal medical care:
[A]ttending to my own health, gaining enough information to help me understand and participate in the decisions made about my body by people who know more medicine than I do, are crucial strategies in my battle for living”
(Lorde, 1988: 110).
Lorde’s perspective here perhaps resonates with the WHOs definition quoted above, where self-care can involve a dynamic relationship between individuals and healthcare professionals. But this vision of self-care is at times difficult to imagine. In my ongoing research exploring framings of self-removal in online contraceptive information, I have found that self-removal is dismissed by healthcare professionals as an internet fad, and the sharing of self-removal experiences on platforms such as YouTube is discussed in a condescending way and viewed almost as a threat to medical authority and expertise. There is also an assumption that contraceptive users are self-removing because they can, and healthcare professionals quoted in online information infuse self-removal and associated notions of safety, risk, and care with bio-medical and individualized understandings, making little or no reference to the structural and contextual conditions that shape IUC use. When the experiences, understandings and knowledge bases of contraceptive users and providers conflict in this way, the reality of self-care as a collaborative endeavour becomes harder to envision.
To establish care that is socially and contextually safe, van der Waal and van Nistelrooij (2022:9) suggest a radical reimagining of relations with healthcare professionals and a need to take stock of what prevents relationalities, so as to prioritise “interwovenness, community and solidarity”. But is care that centres relationality – such as that which takes places in both online and offline communities – best organised outside of institutions that we know to be violent? In my doctoral research (Saunders, 2019), I argued for the need to move away from individualized understandings of reproductive decision-making and experiences/delivery of care, and move towards relational and embodied understandings. My interview with a doula, Sam, found that care delivered in the community outside of mainstream services can prioritise relationality by taking embodied knowledge seriously and recognising each person’s contexts and experiences as shaping their reproductive decisions, and how they experience and wish to access care. Sam felt that doulas should be available to everyone, but was anxious about the prospect of this care being provided via formal health services due to “politics, money, and staffing coming into clinical decision making” (Saunders, 2019: 181), suggesting that the inclusion of this care within the mainstream could result in its co-option by the very individualized and neoliberal logics that doulas’ work attempts to resist. Some community collectives are explicitly informed by abolitionist perspectives that believe justice is best achieved through dismantling oppressive institutions, including public healthcare in the UK (e.g. Healing Justice London, 2022), and building towards community-led alternatives. A similar ethos underpins the work of Barcelona-based collective, GynePunk, who recognize the legacies of inadequate care and mistreatment in obstetrics and gynaecology, advocating instead for a decolonial, ‘DIY’ approach to care and the creation and sharing of care practices by and between communities (Chardronnet, 2015).
Self-removers disrupt dominant constructions of care and safety by taking matters into their own hands and sharing experiences online. These practices open conversations about what care is needed and what care can be, and are important to reflect upon when uncertainties remain over what contraceptive provision – including access to and insertion/removal of IUCs – will look like as reproductive freedoms are ever under threat. How self-removal is understood by those who have attempted it is worthy of further exploration to gain a deeper understanding of how care may be reformed, or indeed transformed.
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