Turn this abstract into a 6 slide presentation:  How contraceptives affect women’s sexual well-being is critically understudied. Fortunately, a growing literature focuses on sexual aspects of contraception, especially hormonal contraception’s associations with libido. However, a more holistic approach to contraceptive sexual acceptability is needed to capture the full range of women’s sexual experiences. We conducted a narrative literature review of this topic, working with an original sample of 3,001 citations published from 2005 to 2015. In Part 1, we draw from a subset of this literature (264 citations) to build a new conceptual model of sexual acceptability. Aspects include macro factors (gender, social inequality, culture, and structure), relationship factors (dyadic influences and partner preferences), and individual factors (sexual functioning, sexual preferences, such as dis/inhibition, spontaneity, pleasure, the sexual aspects of side effects, such as bleeding, mood changes, sexual identity and sexual minority status, and pregnancy intentions). In Part 2, we review the empirical literature on the sexual acceptability of individual methods (103 citations), applying the model as much as possible. Results suggest contraceptives can affect women’s sexuality in a wide variety of positive and negative ways that extend beyond sexual functioning alone. More attention to sexual acceptability could promote both women’s sexual well-being and more widespread, user-friendly contraceptive practices.

Previous article
View issue table of contents
Next article
Access to safe, effective contraception is both a public health and feminist imperative. Family planning products and services are associated with a range of health benefits, including reduced unintended pregnancies, improved infant health, and lowered pregnancy-related morbidity and mortality (Kavanaugh & Anderson, Citation2013). Successful fertility control also leads to many social and economic benefits for women, from educational attainment and personal autonomy to relationship stability and satisfaction (Sonfield, Hasstedt, Kavanaugh, & Anderson, Citation2013). Thus, contraceptive access and acceptability are critical to both sexual and social health.

A severely understudied aspect of contraceptives is their sexual acceptability, or how methods influence the user’s sexual experiences, which can in turn influence family planning preferences and practices. Though contraception is expressly designed for sexual activity, we know little about how contraceptives affect women’s sexual functioning and well-being. This “pleasure deficit” (Higgins & Hirsch, Citation2007) is even more striking when compared to research on male-based methods (Oudshoorn, Citation2003) or even newer multiprevention technologies for women, such as microbicides (Jones et al., Citation2009; Martin et al., Citation2010; Mathenjwa & Maharaj, Citation2012; Sobze Sanou et al., Citation2013; Tanner et al., Citation2009; Woodsong & Alleman, Citation2008; Zubowicz et al., Citation2006). Researchers and policymakers have recognized that limited uptake of these latter methods will result unless they are sexually acceptable (i.e., do not hinder or interfere with sexual pleasure) for both partners. In comparison, portrayals of female-based contraceptives in the scientific, media, and public policy spheres are almost entirely de-eroticized.

Researchers have documented a number of reasons why we consider contraceptives more a medical than a sexual good (Granzow, Citation2007; Hensel, Newcamp, Miles, & Fortenberry, Citation2011). For example, advocates from the late 19th through the end of the 20th century sought medical and legal respectability for birth control, thus downplaying its potentially sexually revolutionary aspects—especially for women (Tone, Citation2006). Even today, while advertisements for male condoms and erectile dysfunction medications highlight sexual pleasure and enjoyment as the products’ main selling points, few erotic scripts of contraceptives used by women exist in mainstream culture, illustrated in both contraceptive advertisements (Medley-Rath & Simonds, Citation2010) and pornographic films (Shachner, Citation2014). The state can also devalue women’s sexuality in place of narratives around motherhood—as evidenced, for example, in laws surrounding health care reform and over-the-counter access to emergency contraception (Burkstrand-Reid, Citation2013).Footnote1 School-based sexuality education similarly focuses on the harms versus the pleasures of sex (Connell, Citation2009; Goldman, Citation2008), especially for girls and young women (Fine, Citation1988). Clinically, care providers may lack both tools and time to discuss sexual issues with patients (Akers, Gold, Borrero, Santucci, & Schwarz, Citation2010; Bombas et al., Citation2012), and providers may be especially unlikely to inquire about sexuality in relationship to new contraceptive methods (versus, say, menopause) (Kottmel, Ruether‐Wolf, & Bitzer, Citation2014). Public health programs and policies can also both reflect and perpetuate dominant gendered assumptions about women’s sexuality—for example, with female condom programs focusing on reproductive health outcomes versus sexual rights (Peters, van Driel, & Jansen, Citation2013), or with adolescent pregnancy prevention policies that emphasize “sex is not for fun” and that young women should be sexually uninterested (Goicolea, Wulff, Sebastian, & Öhman, Citation2010). All these phenomena underscore the notion that contraception is a medical versus a sexual good; they also contribute to mixed messages about whether contraceptives should be sexually acceptable at all for women.

Despite these reasons, while contraception certainly helps people maximize their health, women do not have sex in order to use contraception. Rather, women engage in sexual activity for a range of recreational, relational, and personal reasons. Overlooking these reasons will not only fail to recognize women as full sexual agents but also limit people’s willingness to use contraception (Gomez & Clark, Citation2014; Lessard et al., Citation2012).

After all, though contraceptives need to be effective to prevent pregnancy, they also need to be acceptable so women will use them. However, despite decades of research, we still face questions about how to make these products as acceptable and appealing as possible, and many women are unsatisfied with their method and/or are using their method inconsistently. For example, in a study of 1,840 new contraceptive users in the United States, after 12 months of use only 41% of pill users were “very satisfied” with their method, and 45% of women using oral contraceptives at baseline discontinued using this method at some point during the year (Peipert et al., Citation2011). The limited success of contraception is also affected by personal use practices that contribute to a large gap between perfect-use and typical-use failure rates for many methods.Footnote2 For example, the typical-use failure rate of combined oral contraceptives (9%), the most popular method of contraception in the United States (Daniels, Daugherty, & Jones, Citation2014), is 30 times worse than its perfect-use failure rate of 0.3% (Trussell, Citation2011). The overwhelming majority of “contraceptive failures” attributed to methods such as oral contraceptive pills (Jones, Darroch, & Henshaw, Citation2002) and male condoms (Sanders et al., Citation2012) are due to behavior on the part of the users, not malfunctions of the products themselves (Sanders et al., Citation2012). Better documenting sexual acceptability could potentially help explain why women dislike, discontinue, and/or use certain methods inconsistently. Ultimately, attending to sexual acceptability could also improve contraceptive practices—and women’s lives—by matching women with contraceptive methods that they will like and use over time.

Encouragingly, in recent years, reproductive health researchers have shown progressive interest in how contraception affects women’s sexual functioning and how sexuality may influence people’s contraceptive choices and practices. Scholars have published several reviews on this topic, particularly in terms of hormonal contraception and sexual functioning (Burrows, Basha, & Goldstein, Citation2012; Schaffir, Citation2006; Stuckey, Citation2008; Welling, Citation2013). This growing body of research suggests significant associations between contraceptives’ sexual acceptability—particularly with regards to the domain of sexual function—and how consistently and continuously women use these methods. However, given the relatively nascent state of this research, significant knowledge gaps remain.

First, this literature could benefit from a review of the larger method mix. Though there are scant reviews of hormonal contraception (Burrows et al., Citation2012), intrauterine devices (IUDs) and implants (Sanders, Smith, & Higgins, Citation2014), and oral contraceptives (Davis & Castano, Citation2004), comparatively few reviews examine a wider range of methods—including male condoms and their influences on women’s sexual experiences (and not men’s alone). Condoms are one of the most commonly used contraceptive methods in the world and are the only currently available method that protects against both pregnancy and sexually transmitted infections (STIs). Although a systematic review of all studies on all methods of contraception is beyond the scope of any one article, we endeavor to capture at least a wider swath of the method mix. Doing so will enable us to compare and contrast the range of methods available to individuals or couples seeking contraception.

A second critical gap is existing studies’ relatively narrow approach to sexual acceptability—sometimes with only a single question (Graesslin et al., Citation2009; Wiebe, Citation2010). When researchers have measured contraceptives’ sexual aspects, they most frequently use measures of classic sexual functioning such as arousal, desire (libido), lubrication, orgasm, satisfaction, and pain. The most common assessment tool is the Female Sexual Functioning Index (FSFI) (Rosen et al., Citation2000), which is used both in the United States and in studies all over the world. However, researchers use a large variety of scales and measures, many of which appear in Appendix A (online). (Please refer to Appendix A for detailed outlines of studies, methodologies, and measures used in contemporary contraceptive research). Most of these sexuality measures were originally developed to help identify sexual dysfunction, usually in midlife women experiencing sexual or other health problems, and may not serve particularly useful in identifying contraceptive-related sexual outcomes in younger, healthy women. Most scales also fail to measure partner- or relationship-specific aspects of sexuality (Manuel, Citation2013; Puts & Pope, Citation2013). For example, though contraceptive acceptability studies tend to document how methods affect bleeding, cramping, mood, or breast tenderness, rarely are such effects considered for their specifically sexual repercussions. Nor do studies tend to assess how individual sexual preferences for dis/inhibition or spontaneity may contribute to contraceptive acceptability. After all, sexuality encompasses myriad factors, from physiological function and sensation to broader psychological well-being (Cobey & Buunk, Citation2012), and contraception could affect all these experiences. Moreover, the broader sociocultural context conditions virtually all the potential pathways through which contraception can influence women’s sexuality. Needed is a model of contraceptive sexual acceptability that incorporates a wider range of sexual aspects, experiences, and influences.

This narrative review addresses both these gaps. In Part 1, we draw on the literature to define and operationalize a socioecological model for the sexual acceptability of contraception. In Part 2, we apply this model as we review the past 10 years of literature on the sexual acceptability of specific methods.