- The misconceptions that come with contraception
“I can’t get an IUD because I haven’t had children.” A casual statement thrown in mid conversation by a friend. The friend in question, shared that after much research, she wanted to get the Copper T-380 because it’’s a non-hormonal form of birth control. “At the time, I was on oral birth control and I wanted to switch to a non-hormonal method to stop having so many mood swings and other side effects,” she explained, speaking on why she opted for an IUD. However, she was sent away by a well-known sexual health NGO in Sri Lanka, with a number of excuses like “it might be too painful and it has a greater chance of coming out”.
She was suggested the contraceptive implant (Jadelle) which is a form of hormonal birth control, but it caused severe hormonal reactions in her and she was experiencing severe mood swings and bad acne flare ups. “I remember getting mad at literally every person I spoke to. I got it removed in a month or so and went back to daily contraceptives which worked better for me than the implant,” she said, adding that she would still prefer a non hormonal contraceptive.
The use of modern contraception among Asian women is less than the global average. In Asia, a majority of unintended pregnancies are due to using traditional contraceptives or no methods which lead to increased unsafe abortion.
Cultural attitudes, lack of knowledge of methods and reproduction, socio demographic factors, and health service barriers are the main obstacles to modern contraceptive practice among Asian women, but women aren’t the only ones who have faced a cultural wall when intending to purchase contraceptives.
In conversation with Dhananjaya – a man in his mid-20s – told us: “You should know how tough it is to buy condoms here. Each time you get judged by the person working the counter. Last time I got a box of condoms, I was asked if I was sure I wanted them… I think I wouldn’t ask them if I wasn’t sure,” he shared, adding that he could only imagine how bad it would be for a girl to try and buy a condom or, god forbid, plan B.
Writer Nadeesha Paulis, in her late 20s, however, shared that she had never had a bad experience obtaining contraceptives and the process had always been smooth for her. We are left to assume that this stigma circles around areas heavily rooted in culture and tradition and fails to accept the ever-changing world.
The legalities
Speaking to Brunch, Family Planning Association Sri Lanka (FPA-SL) Director Public Affairs, Policy and Advocacy Sonali Gunasekera strongly stated: “Contraception is not illegal in Sri Lanka; anybody can get contraception wherever they want.” She also said that all Government clinics give free contraception, so people could access whatever contraceptives they wanted. “Even the morning after pill is legal and can be obtained over the counter – in countries like the UK, you need a prescription, but here it is not required,” she said.
We asked her if there were certain conditions attached to obtaining certain contraceptives – needing to have had a child to obtain an IUD for example – to which she explained that if one were to go to a Government organisation, they would advise anyone getting married. “The midwives don’t approach unmarried people; so as soon as you’re going to get married or registered, the midwives will approach you and give you information on contraceptives and options,” she said.
Since FPA-SL is an NGO, Gunasekera informed us that they do give services to whoever seeks them. She also shared that Sri Lanka had a very high contraceptive prevalence rate amongst men and married women. “As a country, our rate is high compared to other South Asian countries. It is very commonly used islandwide so there is no taboo as such surrounding it unless people decide they don’t want to use it because of side effects.”
We asked her if she saw a lack of information or use amongst unmarried women, to which she said yes. “Unmarried women are more savvy than the current married population so they probably get information from the internet, but it is not like they have a lack of information. However, when it comes to the Government, it doesn’t actively give information,” she explained.
What does the doctor say?
Colombo North Teaching Hospital (CNTH) Senior Consultant Obstetrician and Gynaecologist and Sri Lanka College of Obstetricians and Gynaecologists Immediate Past-President Dr. Pradeep de Silva commenting on whether or not Sri Lanka legally administers contraceptives like IUDs, shared that anyone who said women needed to have had children was assuming that one hadn’t had sexual intercourse before. “To insert a contraceptive device, first you must put something into the vagina, but having said that, the system that we use in Sri Lanka is not for the people who have never had children,” he told us. Further explaining, he said that the specifications were for a womb that had had a baby, else the IUD could go through the womb, damaging it.
He also added that the IUD we have in Sri Lanka – the Copper T-380 – wasn’t suitable for anyone who hadn’t had children. “If you want a specific one, then you would have to order off Amazon or such places.” He also noted that other contraceptives like implants were accessible to the general public although there may be a shortage currently due to all the restrictions.
Although Dr. de Silva stated that the IUD available here was not safe for women, according to a study published by the International Journal of Women’s Health, perforation (a hole that develops through the wall of a body organ) of the uterus occurs at the time of IUD insertion at a rate of one to two per 1,000 insertions. A study that included more than 21,000 insertions through pooled data from multiple international studies estimated the rate of perforation to be 1.5 per 1,000 insertions for the Copper T-380A. The only factors the study noted associated with an increased risk of perforation include skill of the clinician and anatomic factors, such as a stenotic cervix or an immobile or a retroverted uterus. According to the study, no particular IUD has been found to be easier to insert or more likely to perforate than the others.
Going back to our conversation with Gunasekera of the FPA-SL, we asked Dr. de Silva if he deemed the FPA providing women with IUDs unethical, and if, in his opinion, it shouldn’t be administered to women who hadn’t given birth before. “It is not unethical, it is impractical because the womb is really small – it is like fitting a big tyre into a mini cooper.”
Dr. de Silva also stated that before approaching family planning clinics, one should always consult a gynaecologist. “It should be inserted only by a doctor. Even if it’s a nurse, it should be done under the supervision of a doctor.”
For a second opinion we spoke to a well-known Gynaecologist and Consultant Community Physician on whether there were such terms and conditions to obtaining one. “Anyone can obtain an IUD, there is no legal barrier as such, but it is tradition when we are offering to the public health midwives, that they (the couple) should be married or living together or something along those lines,” she commented. She also explained that this was mostly because of “virginity issues” and the concept of not inserting something inside your vagina, but asserted that if the client requested, there could not be an issue and an IUD would be given.
When speaking about the health risks of an IUD insertion for a woman who had not borne a child, she informed us that there were some slight risks. “It’s not that there are very big risks – when you are inserting a foreign object into the uterus, there could be reactions and certain issues and infections might arise,” she said, emphasising that although there was a possibility, it was very rare. She explained that their usual procedure was to offer a cocktail of contraceptives – that all have positives and negatives – to the client to choose from, and depending on the client’s needs and situation, they analyse and identify the best method for that particular person, although again, she highlighted that “the client’s preference comes first”.
Since we were on the topic of contraception and its taboos, we asked Dr. de Silva for his opinion on the standard of sex education children received in Sri Lanka. “I think by about Grade 8, everyone is fairly aware of what happens. These days the internet is available and so many things can be accessed through sites like YouTube so everybody must know what it is,” he told us.
One could argue that the point of sex education is to prevent children from learning incorrect details on sex through easily accessible pornographic content on the internet that never paints a picture of reality; but we must admit the internet is a great tool for education when its use is monitored and used responsibiy.
On an endnote, he also questioned the need for sex education in Sri Lanka at all. “We have our culture and our norms; should we say our norms are not appropriate and adopt another culture?”
With all these mixed opinions, we are left to wonder how much of a role culture and tradition and other old school learnings play in still dictating what a woman does with her body.
