Sexual Psychology – Critical Reflection #4 – Due Fri 12/3

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The Psychology of Human Sexuality, Second Edition. Justin J. Lehmiller. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Companion Website: www.wiley.com\go\lehmiller2e

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CHAPTER OUTLINE

Introduction, 288 Sex Education, 288 Sex Education in Cross-Cultural Perspective, 293 Contraception, 294 History, 294

Types of Contraceptives, 295 Choosing the Right Contraceptive, 303

Pregnancy, 304 The Psychology of Trying to Have a Baby, 305 Psychological Changes During Pregnancy and After Birth, 306 Abortion, 306

Sex Education, Contraception, and Pregnancy

©Monika Adamczyk/123RF.COM.

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

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11 Sex Education, Contraception, and Pregnancy288

Introduction

When and where did you first learn about sex? There is a surprising amount of variability in how people answer this question. Some people learned from a sex education course taught in middle or high school, whereas others learned from parents, friends, books, Wikipedia, or perhaps even pornography. Obviously, each of these sources could provide very different information, and even among those who learned from their school, there can be a staggering difference in content from one curriculum to the next. This wide range of experience tells us that children and adolescents are not getting standardized information about sex, and this is part of the reason unintended pregnancy, abortion, and sexually transmitted infections (STIs) are as common as they are. One goal of this chapter is to shed some light on the nature of sex education in the twenty-first century and to examine how different types of programs impact adolescents’ and adults’ sexual attitudes and behaviors.

In addition, we will consider the topics of contraception and pregnancy. Our discussion of contraception will provide a review of some of the most common forms of birth control on the market today and consider some of the unique benefits and drawbacks of each. In my experi- ence, far too many college students tend to think that condoms and birth control pills are their only options when it comes to pregnancy prevention, and research has found that there are many misunderstandings about just how effective different forms of birth control really are (Eisenberg et al., 2012). There are also some little-known psychological side effects of hormo- nal birth control worth considering.

We will finish this chapter by discussing pregnancy. In particular, we will focus on the psy- chological effects associated with trying to get pregnant, as well as psychological changes that occur during pregnancy and after birth for both partners. We will also address the topic of abortion, including the most common reasons for ending a pregnancy and the psychological effects abortion can have on women and men.

Sex Education

Despite the fact that the vast majority of parents believe their children should receive a fairly thorough sex education, a surprising number of kids fail to get it (NPR,  2004). The problem is that many parents feel too embarrassed to talk to their kids about sex (Walker,  2001), so they pass the responsibility off to the schools. That would not necessarily be a bad thing if the schools were providing kids with the information they need, but it turns out that many school- based sex education programs are teaching insufficient and, in some cases, incorrect informa- tion (Committee on Government Reform, 2004). Schools are only partially to blame, though, because in the United States, governmental mandates to provide sex education to adoles- cents do not necessarily even require that the information given is medically accurate! In fact, whereas 24 states mandate sexual education for students, only 13 require that accurate infor- mation be provided (Guttmacher Institute, 2016). Apparently, many US lawmakers believe that students should indeed learn about sex, just not the information they actually need to know.

The end result is that, in far too many cases, kids simply are not learning what they should. Many of them end up turning to their peers and porn for answers; however, those sources tend to impart less than reliable information (see chapter  15 for more on this). Many adolescents therefore embark on their first sexual experience with a profound lack of knowledge about sex and the human body, which helps to explain why there are so many unintended teen pregnan- cies and why young people have the highest rates of STI acquisition (in fact, young people aged 15–24 make up about half of all new STI cases in the United States each year; CDC, 2012a).

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Sex Education 289

Adolescents in the United States have higher rates of unintended pregnancy and STIs com- pared to other Western industrialized nations, including France, Germany, the Netherlands, and Australia (Alford & Hauser, 2011; Weaver, Smith, & Kippax, 2005). In the United States, the birth rate for teenage women aged 15–19 is 24.2 per 1,000, with a public cost of nearly $10 billion each year (CDC, 2016). These sexual health disparities are not a result of US teens being more sexually active; rather, what appears to be going on is that US teens are less likely to use condoms and other forms of contraception than their counterparts in other Western countries (Alford & Hauser,  2011). In recent years, usage of contraceptives among US teens has been rising while the birth rate has been falling—in fact, the teen birth rate in the United States is currently at a historic low (CDC, 2016). However, despite this improvement, the United States continues to lag behind many other nations in this regard.

Why are US teens less likely to use condoms and contraception? Although there are many factors contributing to this (including cultural differences in the acceptability of teenage sexual activity and access to condoms), a major element in this equation is inadequate sex education. As some evidence of this, let us look at a study of US women who have had an unintended pregnancy and were asked why they did not use contraception to try and prevent it. As seen in Table 11.1, nearly half of all women surveyed said they “did not think they could get pregnant” (Mosher & Jones, 2010). If that many women do not understand when pregnancy can occur, it is clear that we simply are not teaching people enough about sex or about their bodies.

In the United States, a culture war has been waged over the past few decades over the content that should be covered in school-based sexual education. This has resulted in three different methods of teaching adolescents about sex. First is the abstinence-only approach, in which the focus is teaching kids to abstain from sex. Information on obtaining and using contracep- tion and condoms is not provided. Second is abstinence-plus, where kids are still taught that abstinence is the best policy, but they are provided with information on contraception and condoms so that students who decide to have sex are prepared. Third is comprehensive sex

Figure 11.1 Sex education courses often contain insufficient and, in some cases, inaccurate information about sex and sexuality. ©Marek Uliasz/123RF.COM.

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11 Sex Education, Contraception, and Pregnancy290

education, in which abstinence is not emphasized as the primary goal. Instead, students are provided with a wide range of information and the focus is developing responsible decision- making skills when it comes to sexual activity. Advocates of the abstinence-only approach argue that providing too much information promotes teenage sex, whereas advocates of the more inclusive approaches argue that some teens will have sex no matter what they are told, and they need to learn how to protect themselves. What do you think about these different approaches? Weigh in with your opinion by checking out the Your Sexuality 11.1 box.

US survey studies find that Americans’ support for abstinence-only education is low, with support remaining relatively steady in recent years at about 15% (Moore, 2015; NPR, 2004). By and large, American parents support abstinence-plus (46%) or comprehensive education (36%; NPR,  2004). Despite the fact that support for abstinence-only education is low, it is widely taught, and advocates of this approach have had great success in attracting federal funding for such programs. In fact, a survey of principals in middle and high schools found that 30% of US schools were teaching abstinence-only (NPR,  2004). The United States is unique among Western countries in having this high prevalence of abstinence-based education. However, abstinence-only programs do not appear to be particularly effective in achieving their goals and may have the counterintuitive effect of exacerbating the sexual health issues facing teenagers.

For instance, a study of 1,719 teenagers in the United States examined the link between type of sex education received and sexual health outcomes (Kohler, Manhart, & Lafferty,  2008).

Table 11.1 Reasons women did not use contraception before an unintended pregnancy.

Reason Percentage of women reporting that reason

Did not think you could get pregnant 43.9% Did not really mind getting pregnant 22.8% Concerned about side effects of birth control 16.2% Did not expect to have sex 14.1% Male partner did not want to use contraception 9.6% Male partner did not want you to use contraception 7.3%

Note: Women could select more than one answer. Data obtained from Mosher & Jones (2010).

Your Sexuality 11.1 What Should School-Based Sex Education Look Like?

Experiences with school-based sex education vary widely, ranging from awkward to awesome. Think for a moment about what your experience was like (if any). Do you think you learned what you needed to know? Using your own experiences as a guide, imagine that you have the oppor- tunity to design a sex education course that your own child might take. How would your course deal with the following issues?

● At what age or grade would your course begin? ● Would students be separated by sex, or would everyone learn together? ● Would your course be mandatory or would attendance be optional depending upon the

desires of the other children’s parents? ● Would abstinence be the ultimate goal of your course? Why or why not? ● After the course, would students have the opportunity to access condoms and/or birth control

for free and without their parents’ knowledge?

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

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Sex Education 291

Results indicated that, compared to comprehensive sex education, abstinence-only did noth- ing to reduce rates of sexual activity, teenage pregnancy, and STIs. In fact, this study found that students who received comprehensive sex education had a 50% lower risk of teenage preg- nancy than students who received abstinence-only! Several other studies have reported similar effects. For example, research has found that in US states where abstinence-only sex education is more widespread, teenage pregnancy rates are the highest (Stanger-Hall & Hall, 2011).

Thus, it does not appear to be the case that providing comprehensive sex education encour- ages students to have sex or to attempt riskier behaviors; rather, it is a lack of information that tends to be problematic. Some have argued that the abstinence-only approach may also be potentially harmful in the sense that it ignores the needs of certain groups. For instance, we know that most teenagers are sexually active and that the average age of first intercourse in the United States is 17, with some starting much sooner than that (CDC, 2012b), for reasons dis- cussed in chapter 10. Failing to provide information about condoms and contraception there- fore does an active disservice to teens who eventually become sexually active. Abstinence-only programs also frequently ignore the sexual health needs of gay, lesbian, bisexual, and transgen- der youth by leaving sexual orientation and gender identity out of their programs entirely and by promoting sexual intercourse within heterosexual marriage as the ideal. Moreover, a study by the US Department of Health and Human Services found that more than 80% of abstinence- only programs contained scientific errors, taught false information, and promoted gender stereotypes (Committee on Government Reform, 2004). For example, some programs falsely claimed that HIV is spread via sweat and tears, which, as we will see in chapter  12, is not true. Others claimed that condoms are not effective at preventing the spread of STIs, and that women need “financial support” while men need “admiration.”

In addition to the fact that some abstinence programs teach students incorrect information, these programs may also leave students with the impression that safe sex and pleasurable sex are at odds with one another. By using scare tactics (e.g., STIs) as a way of motivating students to practice safe sex, these programs imply that condoms and pleasure just are not compatible. This association is further reinforced by the popular media, which usually depicts sex as highly pleasurable, while completely avoiding the topic of safety. Sex education programs might be well-served by reconceptualizing safe sex in pleasurable terms because if we can make safe sex seem more desirable to students, they may be more inclined to practice it. To that end, several sex education organizations have begun a mission of promoting pleasurable safe sex by using techniques such as eroticizing the use of condoms (e.g., learning how to make the application of a condom sensual), teaching couples how to have better sex, and helping people to improve their sexual communication (Philpott, Knerr, & Boydell, 2006).

Related to this, sex education programs might also do well to frame messages about con- traception in positive terms rather than negative terms. As some support for this idea, longi- tudinal research has found that young adults are more likely to use condoms themselves after receiving positively-framed messages that emphasize the success rate of condoms compared to negatively-framed messages that emphasize the failure rate of condoms (Garcia-Retamro & Cokely, 2015). Thus, attention must be given not only to the content of the information included in sex education programs, but also the way it is framed.

Thus, to best address the sexual health needs of teenagers, school-based sex education must go beyond talking only about abstinence and the dangers of sexual activity. However, changing what schools are teaching will not resolve all of the issues. Parents also need to play a more active role in their children’s sex education because schools cannot teach everything and kids need a safe and reliable resource to go to when they have questions. For some practical sugges- tions on increasing sexual communication between parents and their children, see the Digging Deeper 11.1 box.

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Digging Deeper 11.1 When and How Should You Talk to Your Kids About Sex in the Age of Internet Porn?

How are adolescents learning about sex today? By pointing, clicking, and streaming through an endless supply of Internet pornography (Bowater, 2011). Online porn is now the default form of sex education for a growing number of kids because they are not getting the information they need elsewhere. Many of us find this prospect kind of scary. Although it is unlikely that you can prevent your children from searching for porn, what you can do is teach them about sex in a responsible way so that porn does not become their “how-to” guide for sex and relationships.

When it comes to teaching kids about sex, most parents do not know what they should say, how they should say it, or when it should happen. As a result, many parents do not talk about sex at all, or they do not address it in a serious way. This is a shame because, by a wide margin, teenagers report that their parents are the most influential figures in their lives when it comes to making decisions about sex, and most teens report that they would have an easier time post- poning sexual activity if they could talk more to their parents about sex (Albert, 2010). So when should you have “the talk” and what should you say?

1) Initiate the talk about sex early. Too many parents want to wait until their kids are older or until the time seems “right.” However, the longer you wait, the less likely it is that the talk will hap- pen, or if it does, it may be too little, too late. Admittedly, it is more difficult with boys than it is with girls to determine the “right” age, because girls’ menstruation provides a natural segue into talking about sexual development. However, consider that some kids are searching for online porn as early as age 6 (Dima, 2013)! With that in mind, it tells us that both boys and girls need a relatively early lesson with age-appropriate content.

Figure 11.2 Talking to kids about sex can be an awkward and embarrassing experience for some parents, but it is important to not let that stop the conversation. ©Golden Pixels LLC, 2013. Used under license from Shutterstock.com.

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Digging Deeper 11.1 (Continued)

2) Find out when and what your kids are learning about sex in school, and be prepared to fill in the gaps. Consider attending the sex education program your kids will be exposed to or speak with your child’s teacher about what will be covered. You do not want to assume that your kids are getting all of the knowledge they need. Just consider that about one-third of teenage boys and girls report receiving no formal instruction regarding contraceptive use in school (Martinez, Abma, & Copen, 2010). You need to know what the school is providing so that you can supplement it and answer questions.

3) Recognize that uncertainty and embarrassment are common reactions for any parent in this situ- ation. Please do not avoid having the talk because you do not know how or because your parents never had the talk with you. Few people know what they are supposed to say in this situation, and there is not one “correct” way to do it. You may find the talk embarrassing, but if you are worried that you will not have the right words or be able to describe things well enough, bring out some pictures and books to help, or try to tie the conversation in with things that you see together on television.

4) Do not leave all of the hot-button and serious issues off of the table. The talk that you have about sex should include more than just the mechanics of how babies are made, because your kid wants (and needs) to know more than just the basics. Topics such as sexual orientation, mas- turbation, oral sex, and sexual assault should all be addressed too. You might think that teach- ing your kids how to avoid pregnancy is the only goal here, but keep in mind that vaginal intercourse is just one of many sexual activities teenagers might pursue and that not all chil- dren are heterosexual.

5) Keep the conversation going and be sure to talk about relationships too. Finally, keep in mind that “the talk” is not a one-time thing. This is an ongoing conversation. New questions are bound to come up and it is impossible to teach someone everything in the span of one conversation. Also, remember that your talks should not focus exclusively on sex—it is important to talk about relationships too. Developing healthy relationships is something most of us learn by trial and error. For many of us, sex, love, and intimacy go together, so try to relate these to one another over the course of your talks.

Note: Reprinted with permission from Sex and Psychology (www.lehmiller.com).

Sex Education in Cross-Cultural Perspective

Up until this point, our discussion of sex education has focused primarily on the United States, where there is currently an inconsistent patchwork of programs. It is important to note, how- ever, that other countries have adopted a much more unified approach. For example, let’s con- sider the Netherlands, a nation where comprehensive sex education has been mandated for all students since 1993 (Weaver et al.,  2005). In their sex education classes, Dutch students are required to learn about not just pregnancy and STIs, but also sexual orientation, respecting differences and sexual diversity, and developing the skills necessary to establish healthy sexual and romantic relationships, such as sexual communication and decision-making (Bell, 2009). Dutch teachers are also given training in how to lead a sex education class and they do not have major restrictions placed on the topics that they can address. If students express interest in a topic, it is fair game for their teachers to cover it. This stands in stark contrast to the United States, where state laws sometimes require teachers to ignore certain topics (e.g., sexual orien- tation), even when students ask questions about them.

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Beyond the Netherlands, other countries that mandate comprehensive sex education for all adolescents include Sweden, Australia, France, and Germany. The specifics of the approaches utilized in each of these countries certainly varies quite a bit, but all of them are similar in that they recognize teenagers as sexual beings and strive to provide them with accurate informa- tion and resources that will help them to lead healthy sex lives. The benefits of taking such an approach are evident: on almost all sexual health metrics (i.e., teen birth, abortion, STI, and contraceptive use rates), these countries tend to fare much better than the United States (Bell, 2009).

Contraception

Although contraception is often discussed in the context of sex education, the focus is usu- ally on condoms and birth control pills. In reality, however, there are dozens of methods and techniques that can help reduce the odds of pregnancy resulting from sexual activity. Before we detail these methods, let us begin with a brief history of birth control because I think it will give you a greater appreciation of both the sheer number of methods available today and their ease of use.

History

The concept of birth control is not new. In fact, we can trace the origins of fertility regula- tion back to the ancient Greeks and Egyptians. For example, one of the earliest known contra- ceptives was a diaphragm made out of crocodile excrement mixed with honey that Egyptian women would insert into the vaginal canal to block passage of sperm (Jutte, 2008). Why croco- dile dung? I do not know, but suffice it to say, this was probably not the best idea. Other creative (and more sanitary) techniques emerged over time, such as jumping up and down or squatting and sneezing after sex as ways of expelling semen from the vagina. However, as you might imagine, these were not particularly effective methods either, and were probably rooted more in superstition than anything else.

In the 1500s, condoms made their debut (Youssef, 1993). The earliest condoms were either made of linen or animal intestines. It is not clear how effective those early condoms were, but it is possible that they had at least some efficacy, given both their popularity and the fact that condoms made from animal intestines are still produced and sold today (marketed as “skin” or “natural skin” condoms). Despite the fact that condoms were first developed centuries ago, they did not become cheap and widely available until recently. Mass production of condoms did not occur until the 1800s when vulcanized rubber was invented; however, those condoms were as thick as the tires on a bike and (obviously) were not particularly appealing, let alone pleasurable. When latex rubber condoms were developed about a century later, the fit and feel of condoms was forever altered and they really caught on.

Contraception took another massive leap forward in the 1950s when scientists developed the first birth control pill. However, they had to be very sneaky when seeking approval from the US Food and Drug Administration because, at that time, contraceptives were illegal throughout much of the country and the world more broadly. In a clever bit of marketing, instead of asking for the pill to be approved as a contraceptive, they asked for it to be approved as a treatment for menstrual disorders (Eig, 2014). This meant that, upon its public debut, the pill’s packaging warned that pregnancy prevention was a potential side effect. This is kind of funny considering that pregnancy prevention is what the pill was expressly designed to do! In the end, this turned

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out to be one of the rare cases in which people started lining up for a drug because they wanted to experience a side effect.

In the United States, it was not until 1965 that the Supreme Court made a landmark ruling in Griswold vs. Connecticut that marital couples had a right to privacy that extended to the use of contraceptive devices. Previously, people in some US states could not necessarily even get things like condoms if they wanted to due to legal prohibitions. As a result, many were forced to turn to homemade contraceptive remedies, including (I hate to say it) Coca-Cola douches. Just so you know, while Coca-Cola does indeed have spermicidal qualities, lab tests have found that Diet Coke is superior (Umpierre, 1985). That said, soda is not an effective contraceptive and is not recommended for such purposes because flushing the vagina with your favorite carbonated beverage can cause vaginal infections or, even worse, embolisms (i.e., air bubbles in the bloodstream that can block the flow of blood). In addition, sperm travel far too quickly for any type of post-sex douche to have significant contraceptive effects.

Fortunately, women and their partners have a multitude of far more effective and less scary options for birth control in the modern world due to scientific advances. In the following sec- tion, we will consider the major classes of contraceptives legally available and their unique strengths and weaknesses.

Types of Contraceptives

Behavioral Methods The goal of behavioral methods of birth control is to prevent or reduce the odds of pregnancy by altering one’s behaviors. The major advantage of this class of methods is that they are easy on your wallet and pose no health risks (unlike hormonal contraceptives). However, these behaviors are challenging to implement perfectly because they require excellent relationship communica- tion and because, as we noted in chapter 9, people have a limited ability to exert self-control. The major behavioral methods include abstinence, outercourse, withdrawal, and fertility awareness.

The strict definition of abstinence would be zero genital contact, but some people interpret this differently. For instance, consider the results of a study of 298 Canadian college students who were asked to determine whether each of 17 different behaviors were allowed according to their own personal definition of abstinence (Byers, Henderson, & Hobson, 2008). Results indi- cated that there was not 100% agreement on any behavior. Most participants felt that behav- iors such as kissing (92.2%) and oral contact with the breasts (77.4%) were permissible during abstinence, and very few thought that penile–vaginal intercourse (6.8% without orgasm, 7.5% with orgasm) and penile–anal intercourse (11.1% without orgasm, 8.1% with orgasm) were permissible. Participants were more split on whether genital touching (59.2% without orgasm, 48.6% with orgasm) and oral sex were acceptable (43.7% without orgasm, 39.1% with orgasm). As you can see, there is no universal definition of abstinence, so it can be hard to know exactly what someone means when they say they are “abstinent.” That said, if one’s definition prohibits penile–vaginal intercourse, abstinence is the only guaranteed way of preventing pregnancy because it would not allow semen to come into contact with the female reproductive tract.

Outercourse refers to any type of sexual activity other than penile–vaginal intercourse. Thus, outercourse may mean very different things to different people, but the basic goal (simi- lar to abstinence) is preventing sperm from entering the vagina. This will virtually guarantee pregnancy prevention, assuming that nothing slips and goes where it is not supposed to go during sexual activity.

Withdrawal, also known as coitus interruptus and “pull and pray,” refers to removing the penis from the vagina prior to ejaculation. This method provides some protection from preg- nancy, but is not perfect because (1) the pre-ejaculate secreted by the Cowper’s glands has the

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11 Sex Education, Contraception, and Pregnancy296

potential to contain active sperm (as discussed in chapter 3) and, perhaps more importantly, (2) some guys are not particularly good at judging when they are going to ejaculate. How effec- tive is withdrawal? For this and the other contraceptive methods that follow, we will discuss effectiveness in terms of both perfect use and typical use. For purposes of this book, perfect use will tell you the percentage of women who will not get pregnant over the course of a year if they utilized a given method consistently and never made a mistake. However, perfect use is rarely achieved in the real world, so you should pay more attention to typical use rates, which provide the same information, but account for human error. With that said, withdrawal is 96% effective with perfect use, but only 78% effective with typical use (Trussel, 2011). Thus, while withdrawal is better than nothing, it is not something you can bank on in practice. To compare perfect and typical use rates for all forms of contraception covered in this chapter, see Table 11.2.

Fertility awareness refers to a class of methods that attempt to inform women when they are most likely to be fertile so that they can temporarily abstain from vaginal intercourse or use barriers. There are many possibilities here, including the standard days method, which involves plotting the menstrual cycle on a calendar to determine which days are likely “safer” to have sex, and the symptothermal method, which involves checking for biological indicators of ovula- tion (e.g., cervical mucus consistency and body temperature). When a woman is ovulating, the consistency of her cervical mucus resembles egg whites, and her body temperature immedi- ately after awakening in the morning will be slightly elevated. Overall, effectiveness rates for fertility awareness methods are similar to withdrawal (see Table 11.2), but biological methods tend to be more effective than the calendar method.

Table 11.2 Typical and perfect use effectiveness rates for various contraceptives.

Method

Effectiveness rates

Typical use Perfect use

No method 15% 15% Spermicide 72% 82% Fertility awareness methods 76% 95–99.6% Withdrawal 78% 96% Female condom 79% 95% Male condom 82% 98% Diaphragm 88% 94% Oral contraceptives (combined & progestin-only)

91% 99.7%

Contraceptive patch 91% 99.7% Vaginal ring 91% 99.7% Depo-Provera 94% 99.8% IUD 99.2–99.8% 99.4–99.8% Contraceptive implant 99.95% 99.95% Female sterilization 99.5% 99.5% Male sterilization 99.85% 99.9%

Note: Numbers indicate the percentage of women who will not become pregnant after one year of use. Adapted from Trussel, J. (2011). Contraceptive failure in the United States. Contraception, 83, 397–404, with permission from Elsevier.

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Barrier Methods The purpose of barrier methods is to prevent sperm from reaching the uterus during penile– vaginal intercourse. These methods are good for people who do not have sex on a regular basis because they do not need to be practiced every day in order to be successful. However, part- ners have to use them every time and use them correctly to avert unintended pregnancy. This class of methods includes male and female condoms, spermicides, and cervical barriers (i.e., diaphragms and cervical caps).

Male condoms consist of a thin latex (or polyurethane, for people with latex allergies) sheath that covers an erect penis during sexual activity. Condoms are one of the most popular meth- ods of birth control in use today (Mosher & Jones,  2010) and offer a major advantage over other contraceptives in that they also provide some protection against STIs. With perfect use, condoms are 98% effective at preventing pregnancy, but when you factor in human error, that drops to 82% (Trussel, 2011). Why? A review of 50 condom use studies revealed 14 common errors people make when using condoms (Sanders et al., 2012). In some studies, up to 51% of participants reported putting a condom on after intercourse had already started, up to 45% reported removing a condom before intercourse was over, and nearly half reported condom application errors that increase the likelihood of breakage, such as failing to leave space at the tip to collect semen or failing to squeeze air from the tip while putting the condom on. Other errors included failing to withdraw promptly after ejaculation (which can allow semen to leak out of the condom), using latex-incompatible lubricants (e.g., oil-based), and (I wish I did not have to say this) re-using the same condom multiple times. Is it any wonder typical use rates are as low as they are?

Female condoms are a polyurethane pouch that lines the interior of the vagina. The penis is then inserted through a ring that sits outside of the vaginal opening. On a side note, although these are called “female” condoms, they are sometimes used by men who have sex with men during anal sex for STI protection. Female condoms are not as widely used as male condoms (and, in fact, it can be difficult to even find them in some places), but some women opt for them because they prefer female-controlled methods of contraception and/or because the external

Figure 11.3 Fertility awareness methods utilize a variety of techniques to advise women of their fertile periods, during which time they will either abstain from sex or use barriers. ©Gunita Reine/123RF.COM.

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ring may provide some degree of clitoral stimulation during sex. Effectiveness rates are similar to male condoms, but slightly lower overall (see Table 11.2).

Spermicides are chemicals that are placed inside the vagina that attempt to kill or disable sperm for a certain period of time. Although spermicides come in many different forms (i.e., foams, creams, jellies, and suppositories), they all have about the same effectiveness rate. With perfect use it is 82% and with typical use, 72%. Because of the relatively low effectiveness rate even with perfect use, spermicides are perhaps best coupled with other methods of birth con- trol, such as condoms and diaphragms.

Cervical barriers are devices that obstruct sperm from entering the cervix. These devices include the diaphragm and cervical cap. The only difference between the two is that the dia- phragm is larger and covers the upper portion of the vaginal wall as well. Before insertion, cervical barriers are usually lined with a spermicide to provide additional protection. After sex, the diaphragm must remain in place for at least six hours to prevent live sperm entering the cervix. On the plus side, one of these devices can last up to a year or longer with regular use, but it must be inserted prior to each sex act and requires that the woman is very comfortable with her own body. Diaphragms are 96% effective with perfect use, and 88% effective with typical use (Trussel, 2011).

Hormonal Methods Hormonal forms of birth control have the effect of temporarily reducing female fertility. They accomplish this through a combination of three factors: (1) preventing ovulation, (2) thickening the cervical mucus in order to make it more difficult for sperm to enter the uterus, and (3) altering the uterine lining to make it impossible for a fertilized egg to implant (Kiley & Hammond, 2007). The main advantages of these methods over others are increased effectiveness and the estab- lishment of a predictable menstrual cycle. The main disadvantages are hormone-related health risks, the potential for medication interactions, possible weight gain, and sexual side effects (e.g., reduced sexual interest and arousal); however, the side effects vary widely depending upon which specific contraceptive is being used and each woman’s unique body chemistry.

Figure 11.4 Female condoms are less well-known and utilized than male condoms; however, both are desirable in that they provide at least some protection from STIs. ©nito, 2013. Used under license from Shutterstock.com.

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There are two main types of hormonal methods: combined (i.e., joint administration of estrogen and progestin) and progestin-only. The combined hormone methods can take many forms, including the pill, the contraceptive patch, and the vaginal ring. The way these methods differ is in terms of how the hormones are administered and the required “maintenance.” With the pill, hormones are administered orally with one pill each day. With the patch, hormones are absorbed through the skin via a patch that is replaced weekly. With the ring, hormones are absorbed through the vaginal tissues via a ring that is replaced once per month. One other important difference between these methods is that, unlike the patch and ring, the pill comes in dozens of different formulations, meaning it is easier to find an oral contraceptive to match a given woman’s body chemistry. It is partly for this reason that the pill remains one of the most commonly used methods of birth control (for some sense of the most popular forms of contra- ception among women in the United States, see Figure 11.7). Effectiveness rates for all three of these methods are identical: 91% with typical use and 99.7% with perfect use (Trussel, 2011).

For women who cannot take estrogen for health reasons (i.e., women who smoke or are at high risk of heart disease), several progestin-only methods of birth control are available, including the progestin-only pill, the hormonal injection, the hormonal intrauterine device (IUD), the contraceptive implant, and emergency contraception. Compared to the combined methods, the progestin-only methods (other than the pill) typically cost more money up front (if they are not covered by insurance), but this is balanced out by much longer-lasting protection. Side effects are similar to the combined hormone methods, but irregular bleeding is more likely to occur.

While the progestin-only pill is similar to the combined pill in terms of how it works and its effectiveness, the other methods work quite differently. The hormonal injection (Depo- Provera—see chapter  4 for other uses of this drug) is administered once every three months

Figure 11.5 Combined hormonal methods of contraception come in a variety of forms and dosages to meet women’s needs, such as the contraceptive patch. ©Tomasz Trojanowski/123RF.COM.

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and provides very long-lasting fertility reduction. In fact, it can take nearly a year for fertility to resume once injections are stopped, compared to just a few weeks for oral contraceptives. That said, one unique risk to the hormone injection is the potential for bone density loss; however, such effects appear to be reversible when injections are discontinued (Scholes, LaCroix, Ichikawa, Barlow, & Ott, 2005). The hormonal IUD is a small, plastic device shaped like a “T” that is inserted into the uterus by a physician. It lasts the longest of all contraceptives currently on the market (it can prevent pregnancy for up to five years!) and is so highly effective that it is sometimes referred to as “reversible sterilization” (MacIsaac & Espey, 2007). The contraceptive implant is a tiny plastic rod that is surgically implanted into the upper arm. The implant secretes hormones for several years and provides long-lasting effects. All three of these methods (injection, IUD, and implant) are highly effective with both typical and perfect use (see Table 11.2). However, each of these deliv- ery mechanisms is subject to a few disadvantages. One is that, although the effects are reversible, it is not necessarily quick or easy to turn fertility off and on. In order to address this limitation, researchers are currently exploring the possibility of regulating hormone delivery through micro- chips implanted under the skin. These microchips would be remote controlled, such that women could turn their own contraception off and on as desired at the press of a button. While that sounds incredibly convenient, some worry that such a high-tech system could open the door to potential “contraceptive hacking” if the devices fall into the wrong hands. Also, microchips do not address the other drawback of all hormonal methods of birth control, which is that artificially changing hormone levels can produce side effects. For women who want a long-lasting and highly effective contraceptive that minimizes side effects, there is an IUD made of copper. It works just as well as the hormonal IUD, with the copper ions acting as a spermicide inside the uterus.

One additional progestin-only method is emergency contraception (EC), a hormone pill that is meant to prevent pregnancy after an instance of unprotected intercourse (e.g., as a result of a broken condom or a sexual assault). These pills may be taken up to five days after unprotected sex and they work by preventing a fertilized egg from implanting in the uterus. Please note that if implantation has already occurred, EC will not affect it. In other words, EC will not cause an abortion, which is one of the most common misconceptions about how this drug works. How effective is EC? The label for Plan B (one of the most popular forms of EC) cites an 89% reduc- tion in likelihood of becoming pregnant if taken according to instructions. In the United States, EC is currently legally available to women and girls ages 15 and older and can be purchased over

Figure 11.6 An IUD sits inside the uterus like this and can remain in place and effective for up to five years. ©guniita/123RF.COM.

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the counter (i.e., without a prescription). In the event that EC is difficult or impossible to access (e.g., if your local pharmacy chooses not to keep it in stock or it is not affordable), it is possible to mimic the effects of EC by ingesting a hefty dose of combined hormone birth control pills; however, it is important to consult with a health care provider to determine the correct dosage.

Psychological effects of hormonal contraception Most women realize that being on a hormonal contraceptive means putting up with a few side effects, such as weight gain, mood changes, or nausea. However, one side effect you almost never hear about is the fact that hormonal methods of birth control may alter women’s sexual behaviors and the types of men that heterosexual women are attracted to. Before we get into specifics, please note from chapter  3 that there are four phases of the menstrual cycle, with ovulation being the fertile period (i.e., the point with the highest probability of conception). During ovulation, several hormones are released that prep the body for a potential pregnancy; however, in addition to causing changes in the reproductive tract, these hormones affect the female brain, thereby modifying female sexual preferences and behaviors in several ways.

First, when women are near ovulation, their grooming habits and clothing choices change, seemingly in an effort to appear more attractive. As support for this idea, research has found that participants can pick out photographs of women taken while they were ovulating compared to photos taken during other phases of the menstrual cycle because ovulating women appear to go for “nicer” and “more fashionable” outfits that show more skin (Haselton, Mortezaie, Pills- worth, Bleske-Rechek, & Frederick,  2007). In addition, in a study where women engaged in online clothing shopping at different stages of the menstrual cycle, researchers found that ovu- lating women put a greater percentage of sexy items in their shopping carts than nonovulating women (Durante, Griskevicius, Hill, Perilloux, & Li,  2011). Also, if you recall from chapter  4, ovulating strippers earned higher tips than strippers who were using hormonal contraceptives (Miller, Tybur, & Jordan,  2007), another finding that suggests women’s behaviors may change throughout the menstrual cycle. Other research has found that when women are ovulating, the pitch of their voice (Bryant & Haselton, 2009), their body movements (Fink, Hugill, Lange, 2012), and their bodily scent change in ways that increase their attractiveness to men (Havlícček, Dvorčáková, Bartoš, & Flegr, 2006). Such findings raise legitimate questions about the oft-stated notion in many biology textbooks that human females have “concealed ovulation.”

Second, heterosexual women are attracted to different types of men during ovulation. Spe- cifically, ovulating women show an exaggerated preference for short-term sexual relationships

Not using 38%

All other methods

18%

Female sterilization

17%

“The pill” 17%

Condoms 10%

Figure 11.7 Contraceptive use patterns among US women ages 15–44. About 62% of women of childbearing age actively use some form of contraception. ©Mosher & Jones (2010).

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with guys who have masculine faces, hot bodies, and lots of confidence (think Channing Tatum, Hugh Jackman, and other guys who have been named “Sexiest Man Alive”) compared to women at other stages of their cycle (Gangestad, Thornhill, & Garver-Apgar, 2005). This preference is not just visual either. During ovulation, women prefer men who have deeper voices (Puts, 2005), as well as the bodily scents of “manlier” men (Gangestad & Thornhill, 1998). Evolutionary psy- chologists have reasoned that this is because masculine guys offer the best genetic material for making babies because masculine features are supposedly a sign of a strong immune system (Gangestad & Buss, 1993). The idea is that masculine features are a product of high testosterone, but testosterone actually suppresses the immune system. Thus, for a hypermasculine man to sur- vive this immunosuppression, he has to have very strong, disease-resisting genes to begin with. If that is the case, then why is masculinity not universally preferred across the menstrual cycle? Perhaps because women see masculine men as less reliable partners who are more likely to cheat (e.g., O’Connor, Re, & Feinberg,  2011). Masculine men are therefore only seen as good sexual partners during those periods where his genetic benefits can be conferred to a woman’s offspring; women’s preference for these men declines when no such reproductive benefits are possible.

So what happens when women take hormonal contraceptives? These ovulatory shifts in mating preferences and behaviors get wiped out. For one thing, these women do not show the same cycli- cal sexual desire for masculine men. Also, in the study of exotic dancers, women who were on the pill did not see an increase in tips at any point during the month, suggesting that they did not alter their style of dress and behavior in the same way as naturally-cycling women (Miller et al., 2007). Perhaps even more fascinating is research demonstrating that women taking oral contraceptives seem to pick more reliable partners and have longer-lasting relationships than their naturally- cycling counterparts, perhaps because women on the pill show a more stable preference for a certain type of guy (Roberts et al., 2012). One caveat to this research is that most work looking at

Figure 11.8 Heterosexual women report greater attraction to masculine men like Channing Tatum when they are ovulating compared to other stages of the menstrual cycle. ©s_bukley, 2013. Used under license from Shutterstock.com.

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how hormonal contraceptives are related to female sexual behavior has focused on the combined hormone pill. While it is likely that all hormonal contraceptives would have similar psychological effects, this has not yet been systematically studied.

Other Methods There are several other methods of birth control available, including male and female steriliza- tion. Sterilization is the most common form of birth control in the United States and through- out the world (see Figure  11.6). Female sterilization is known as tubal ligation and involves clamping or severing the fallopian tubes so that any eggs released cannot come into contact with sperm, thus making fertilization impossible. One reason this has become an incredibly popular form of birth control is because it empowers women by allowing for greater control over desired family size (Klibanoff, 2014). This is particularly desirable to women in develop- ing nations where regular access to contraceptives is limited and potentially costly. By contrast, male sterilization (i.e., vasectomy) involves severing or sealing the vas deferens so that sperm can no longer become part of the seminal fluid. Both vasectomies and tubal ligations are con- sidered permanent and although it may be possible to have them surgically reversed, it is not guaranteed. In addition, both procedures are low risk, do not impair sexual performance or function, and are virtually 100% effective at preventing pregnancy (Trussel, 2011).

Most of the methods of birth control covered in this chapter involve regulating female fertil- ity in some way. Aside from vasectomies, are there any other ways of biologically regulating male fertility? Some scientists think so. See the Digging Deeper 11.2 box for more on this grow- ing area of research.

Choosing the Right Contraceptive

There are lots of decisions to be made when it comes to choosing a contraceptive, and what is right for one woman and her relationship may not necessarily be right for others. Certainly, effectiveness is one important consideration, but you also need to look at potential side effects, convenience, and individual comfort. It is also vital to take into account how much protection you want from STIs, because aside from strict abstinence, condoms (both male and female) are the only method that can reduce risk from a wide range of infections. Your best bet is to consult with a health care provider about your concerns and current physical condition and to communicate with your partner about your goals and sexual health needs.

Figure 11.9 Sterilization involves severing the fallopian tubes (female) or vas deferens (male) in order to eliminate the possibility of conception. ©Stocktrek Images/Getty Images.

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Pregnancy

We will round out this chapter with a brief discussion of pregnancy. As mentioned above, the menstrual cycle exerts profound effects on female psychology at different stages. Perhaps not surprisingly, the hormonal changes that occur during and after pregnancy can have a range

Digging Deeper 11.2 How Close Are We to Having a Male Version of “The Pill?”

It is a simple biological fact that regulating female fertility is less complicated than regulat- ing male fertility. Just think about it: is it easier to try and stop one egg per month from being released, or to try and stop up to a half billion sperm from being released per ejaculation? Despite this challenge, some scientists have been hard at work trying to create the male equivalent of the pill and their research has yielded some promising new developments.

For the past few decades, there have only been two options for female-attracted guys who want to ensure they do not accidentally get a woman pregnant: use a condom or get a vasectomy. Unfor- tunately, these options represent two extreme ends of the spectrum. Condoms must be used cor- rectly and consistently each time, and some guys complain of dulled sexual sensation. Vasectomies eliminate these concerns because after surgery, there are no special precautions to take and no loss in sensation. The downside of vasectomies is that they are expensive and are not guaranteed to be reversible. Thus, if a guy thinks he might want to father future children, he is probably better off sticking with condoms. Is there any way to get the best of both worlds? Is there something that neither reduces sexual sensation nor runs the risk of creating permanent infertility?

A handful of procedures may have such potential. One is something reported in the media as the “testicular zap,” in which a specialized ultrasound is performed on the testicles. A study test- ing this on rats found that two 15-minute ultrasounds administered two days apart had the effect of significantly reducing sperm count (Tsuruta et al., 2012). It is yet to be determined whether this would have the same effect in humans and how often it would need to be performed, but this technique is promising for its noninvasive nature.

Another procedure involves injecting a polymer into the vas deferens. This polymer stays in place and disables sperm as they pass by. It is known as Reversible Inhibition of Sperm Under Guidance (RISUG; Sharma, Chaudhury, Jagannathan, & Guha, 2001). Despite the rather unfortu- nate name and acronym, it sounds more pleasant than the testicular “zap.” This procedure does not affect sperm production; rather, it serves to immobilize sperm before they can exit the body. It is supposedly reversible by flushing the polymer out of the vas deferens. RISUG is currently undergoing clinical trials. Related to RISUG is a product known as Vasalgel, a polymer injected into the vas deferens that blocks the flow of sperm entirely while it is in place. It is also in the test- ing and development phase.

One final procedure worth mentioning involves the application of hormone gels to the skin. What men do is apply two hormone gels to the skin each day, one containing progestin and the other testosterone. At the levels administered, these hormones suppress sperm production, with clinical trials showing great promise (Roth et al., 2014); however, more work remains to be done, including the development of an easier to use formulation.

Before those of you with scrotums get excited about being zapped, injected, and gelled, I should warn you that we are a way off from any of these methods becoming widespread around the globe. We do not have enough evidence of the effectiveness of these procedures and their potential long-term side effects to start performing them routinely. For the time being, you will probably want to keep that condom drawer fully stocked.

Note: Reprinted with permission from Sex and Psychology (www.lehmiller.com).

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of psychological effects as well. We begin by addressing the psychological changes associated with trying to get pregnant before moving on to the changes that occur after a child has been conceived.

The Psychology of Trying to Have a Baby

The act of trying to get pregnant can be both exciting and stressful. The nature of the experi- ence is dependent upon how long the couple has been trying, how much pressure the part- ners put on one another, and whether there are any fertility issues present. The more that sex starts to become a rigidly structured chore, the more performance pressure there is, and the longer a couple tries to get pregnant unsuccessfully, the more stressful things end up being. Stress effects are particularly pronounced among couples in which one or both partners are facing fertility problems (Oddens, den Tonkelaar, & Nieuwenhuyse, 1999). The prevalence of infertility varies across countries, but the estimated median prevalence is 9% (Boivin, Bunting, Collins, & Nygren,  2007). This means that about one in ten couples will have difficulty con- ceiving within a year. Infertility is something that can affect both men and women. As a result, it is important for both partners to be checked. It should be noted that infertility is not just a stressor faced by heterosexual couples; same-sex couples who are trying to have their own biological children may grapple with this as well. Having a baby is equally stressful regardless of the sex and sexuality of the parents involved and the way that the child is being conceived.

Of course, it is important to note that not all pregnancies are planned. Whereas a planned pregnancy usually results in feelings of joy and relief, unintentional pregnancies can have a much wider range of effects. Some people may be very pleased by the surprise, while others have a difficult time adapting to it. In general, unplanned pregnancies are more likely to result in the parents feeling stressed and powerless regarding the changes that are about to occur (Clinton & Kelber, 1993).

Figure 11.10 Trying to have a child and the transition to parenthood are stressful events for people of all sexes and sexualities—not just for heterosexual couples. ©Maria Dubova/123RF.COM.

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Psychological Changes During Pregnancy and After Birth

There are many stereotypes about pregnant women perpetuated by the popular media, with one of the most common being that pregnant women are unstable and irrational, exhibiting wild mood swings. In reality, however, the psychological effects of pregnancy vary, and it is not just pregnant women who experience psychological changes—their partners do as well.

One of the more common changes is depression. In fact, in the industrialized world, rates of female depression vary from 7 to 15% during pregnancy and are about 10% postpartum (i.e., after pregnancy; O’Keane, & Marsh,  2007). Why does this affect so many women? For one thing, the act of being pregnant and raising a new child is demanding both physically and psychologically. However, there are direct biological effects of pregnancy as well, because pregnancy-related hormone changes affect the portions of the brain that regulate mood (O’Keane & Marsh,  2007). The risk of depression is particularly pronounced in women with a past history of mood disorders. It is important to note that pregnancy-related depression can also occur in nonpregnant partners. For instance, research has found that about 10% of fathers experience depression during either the prenatal or postpartum periods (Paulson & Bazemore, 2010).

Changes in sexual interest and behavior are also common during pregnancy. For instance, up to half of women in survey studies report worrying that sex while pregnant will harm their baby (vod Sydow, 1999). Specifically, many women who have male partners are concerned that their child will be traumatized or “poked” during vaginal intercourse. As a result, this may decrease the frequency of sexual activity and reduce enjoyment for both partners, which can create stress and relationship turmoil. However, you will be glad to know that vaginal intercourse during pregnancy is generally safe as long as both partners are in good health and the pregnancy is not high-risk. In fact, research has found that the majority of heterosexual couples have sex up until the seventh month, and about one-third report having sex up until the ninth month (vod Sydow, 1999); however, different inter- course positions may be necessary later in the pregnancy to make the woman more comfortable.

Finally, major psychological changes often arise when problems are encountered during the pregnancy. For instance, the discovery that the fetus possesses a major birth defect can be highly distressing to the parents. The same goes for very premature births in which functional development is not yet complete. In addition, some pregnancies end spontaneously in miscar- riage. In fact, it is estimated that 15–20% of pregnancies end in miscarriage (American College of Obstetricians and Gynecologists,  2011). Although most miscarriages occur early on, and may not necessarily even be detected in some cases (i.e., when it occurs before the pregnancy is known), miscarriages sometimes happen much later on. In such cases, the effect can be psy- chologically devastating for the parents. Research suggests that clinically significant depression and anxiety are common among women following a miscarriage, as are feelings of guilt (Frost & Condon, 1996). Although most research has focused on the psychological effects on mothers, miscarriage can also result in emotional disturbances for partners and surviving children.

Abortion

When a pregnancy is unwanted, an elective abortion is sometimes pursued. Abortion is a catch-all term for a number of different medical procedures capable of ending a pregnancy. Abortions that occur within the first few weeks of pregnancy can be accomplished with medi- cations, whereas later abortions require more involved surgical procedures. No matter when or what methods are utilized, voluntarily ending a pregnancy is controversial. Some people believe it should never happen, others believe it should only happen under certain circum- stances, and some believe it should always be a viable option. The purpose of this section is not to wade into that debate, but rather to address why abortions are sometimes sought, their

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psychological effects, and what can be done to reduce the number of unintended pregnancies so that fewer women find themselves in the position of having to make this difficult decision.

Women cite multiple reasons for pursuing abortions. For instance, a study of 671 women from the southern United States revealed that the most commonly cited reasons were as follows (note that women could indicate more than one reason): not being able to afford a child (48.2%), not being ready for children (39.9%), not wanting additional children (35.8%), being in an unstable relationship (21.8%), being too young for kids (25.1%), and having personal health problems (9.5%; Santelli, Speizer, Avery, & Kendall, 2006). Based upon these reasons, it is clear that almost all of these women were seeking abortions because their pregnancies were unintended.

How do women feel after having an abortion? A separate study of 442 women who were followed for two years after undergoing the procedure revealed that the majority (72%) were satisfied with their decision and a similar number reported that they would have done the same thing again (Major et al., 2000). That said, this study also revealed that 20% of the women expe- rienced at least one episode of clinical depression after the procedure, and 1% met the criteria for post-traumatic stress disorder or PTSD (for more on the nature of PTSD, see chapter 15). Experiencing depression prior to the pregnancy was a very strong predictor of experiencing depression after the abortion. Thus, although the vast majority of women who get abortions do not regret doing so, some women are unhappy with the outcome. Less research exists on men’s psychological reactions to their partner’s abortions, but existing studies paint a similar picture: most men report being satisfied with their partner’s decision to have an abortion, but some report psychological pain and sadness afterward (Kero & Lalos, 2004).

Given that so many abortions are pursued as a result of unplanned and unwanted pregnan- cies, it would seem logical to assume that with better sex education and greater access to effective contraception, we could dramatically reduce the abortion rate, an outcome that most people would probably see as a good thing. Consider that fewer abortions would mean that public health clinics would have more resources available for addressing other urgent sexual health needs (e.g., STI screenings), and fewer women would be faced with a decision that can be incredibly difficult and stressful. So is this possible? Research suggests that it is. Peipert, Madden, Allsworth, and Secura (2012), recruited 9,256 US women at high risk of unwanted pregnancy to participate in a longitudinal study. All participants were given free contraceptive counseling and received their choice of birth control. Most women opted for either the IUD or contraceptive implant. Results revealed that study participants evidenced significantly lower rates of teen pregnancy and abortion compared to the national average. For instance, across the three years of the study, the abortion rate among participants fluctuated between 4.4 and 7.5 per 1,000 women, while the national rate stood at 19.6 per 1,000. These findings suggest that reducing teen pregnancy and abortions can be effectively achieved through better edu- cation and access to free contraceptives. Such efforts would likely have the added benefit of dramatically reducing rates of STIs, the topic we turn to in the next chapter.

Key Terms

abstinence-only approach abstinence-plus comprehensive sex education abstinence outercourse withdrawal perfect use

typical use fertility awareness male condoms female condoms spermicides cervical barriers combined hormone methods

progestin-only methods emergency contraception tubal ligation vasectomy abortion

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Discussion Questions: What is Your Perspective on Sex?

● Parents have mixed feelings about the discussion of masturbation, homosexuality, and abor- tion in school-based sex education courses. Do you think these topics should be addressed? Why or why not?

● How do you define “abstinence?” What sexual behaviors can someone engage in and still be considered “abstinent?”

● Do the psychological effects of hormonal contraceptives make you think any differently about this form of birth control? Do you think women should be aware that this type of birth control could potentially alter their behaviors and the partners they are attracted to?

References

Albert, B. (2010). With one voice 2010: America’s adults and teens sound off about teen pregnancy. The National Campaign to Prevent Teen and Unplanned Pregnancy. Retrieved from http://www .thenationalcampaign.org/resources/pdf/pubs/wov_2010.pdf (accessed September 5, 2013).

Alford, S., & Hauser, D. (2011). Adolescent sexual health in Europe and the US. Retrieved from http://www.advocatesforyouth.org/component/content/article/419-adolescent-sexual-health- in-europe-and-the-us (accessed September 5, 2013).

American College of Obstetricians and Gynecologists (2011). Early pregnancy loss: Miscarriage and molar pregnancy. Retrieved from http://www.acog.org/~/media/For%20Patients/faq090.pdf ?dmc=1&ts=20130603T2022576459 (accessed September 5, 2013).

Bell, K.J. (2009). Wake up and smell the condoms: An analysis of sex education programs in the United States, the Netherlands, Sweden, Australia, France, and Germany. Inquiries Journal, 1(11), 1–3.

Boivin, J., Bunting, L., Collins, J.A., & Nygren, K.G. (2007). International estimates of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care. Human Reproduction, 22, 1506–1512. doi:10.1093/humrep/dem046

Bowater, D. (2011). Pornography is replacing sex education. Daily Telegraph. Retrieved from http://www.telegraph.co.uk/education/educationnews/8961010/Pornography-is-replacing-sex- education.html (accessed September 5, 2013).

Bryant, G.A., & Haselton, M.G. (2009). Vocal cues of ovulation in human females. Biology Letters, 5(1), 12–15. doi:10.1098/rsbl.2008.0507

Byers, E.S., Henderson, J., & Hobson, K.M. (2009). University students’ definitions of sexual abstinence and having sex. Archives of Sexual Behavior, 38, 665–674. doi:10.1007/s10508-007- 9289-6

CDC (2012a). Sexual risk behavior: HIV, STD, & teen pregnancy prevention. Retrieved from http://www.cdc.gov/HealthyYouth/sexualbehaviors/ (accessed September 5, 2013).

CDC (2012b). Key statistics from the National Survey of Family Growth. Retrieved from http:// www.cdc.gov/nchs/nsfg/key_statistics.htm (accessed September 5, 2013).

CDC (2016). Teen pregnancy in the United States. Retrieved from http://www.cdc.gov/ teenpregnancy/about/ (accessed September 12, 2016).

Clinton, J.F., & Kelber, S.T. (1993). Stress and coping in fathers of newborns: Comparisons of planned versus unplanned pregnancy. International Journal of Nursing Studies, 30, 437–443. doi:10.1016/0020-7489(93)90053-W

Committee on Government Reform (2004). The content of federally funded abstinence-only education programs. Retrieved from http://spot.colorado.edu/~tooley/HenryWaxman.pdf (accessed September 5, 2013).

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

C o p yr

ig h t ©

2 0 1 7 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

References 309

Dima, B. (2013). Case study: Kids & online threats. Retrieved from http://www.bitdefender.com/ media/materials/white-papers/en/Bitdefender-CaseStudy-Kids.pdf (accessed September 5, 2013).

Durante, K.M., Griskevicius, V., Hill, S.E., Perilloux, C., & Li, N.P. (2011). Ovulation, female competition, and product choice: Hormonal influences on consumer behavior. Journal of Consumer Research, 37, 921–934. doi:10.1086/656575

Eig, J. (2014). The birth of the pill: How four crusaders reinvented sex and launched a revolution. New York: WW Norton & Company.

Eisenberg, D.L., Secura, G.M, Madden, T.E., Allsworth, J.E., Zhao, Q., & Piepert, J.F. (2012). Knowledge of contraceptive effectiveness. American Journal of Obstetrics and Gynecology, 206, 479.e1–e9. doi:10.1016/j.ajog.2012.04.012

Fink, B., Hugill, N., & Lange, B.P. (2012). Women’s body movements are a potential cue to ovulation. Personality and Individual Differences, 53, 759–763. doi:10.1016/j.paid.2012.06.005

Frost, M. & Condon, J.T. (1996). The psychological sequelae of miscarriage: A critical review of the literature. Australian and New Zealand Journal of Psychiatry, 30, 54–62.

Gangestad, S.W., & Buss, D.M. (1993). Pathogen prevalence and human mate preferences. Ethology & Sociobiology, 14, 89–96. doi:10.1016/0162-3095(93)90009-7

Gangestad, S.W., & Thornhill, R. (1998). Menstrual cycle variation in women’s preferences for the scent of symmetrical men. Proceedings of the Royal Society of London. Series B: Biological Sciences, 265, 927–933. doi:10.1098/rspb.1998.0380

Gangestad, S.W., Thornhill, R., & Garver-Apgar, C.E. (2005). Adaptations to ovulation: Implications for sexual and social behavior. Current Directions in Psychological Science, 14, 312–316. doi:10.1111/j.0963-7214.2005.00388.x

Garcia-Retamero, R., & Cokely, E.T. (2015). Simple but powerful health messages for increasing condom use in young adults. Journal of Sex Research, 52(1), 30–42. doi: 10.1080/00224499.2013.806647

Guttmacher Institute (2016). State policies in brief : Sex and HIV education. Retrieved from: http:// www.guttmacher.org/statecenter/spibs/spib_SE.pdf (accessed March 15, 2016).

Haselton, M.G., Mortezaie, M., Pillsworth, E.G., Bleske-Rechek, A., & Frederick, D.A. (2007) Ovulatory shifts in human female ornamentation: Near ovulation, women dress to impress. Hormones and Behavior, 51, 40–45. doi:10.1016/j.yhbeh.2006.07.007

Havlíček, J., Dvořáková, R., Bartoš, L., & Flegr, J. (2006). Non-Advertized does not Mean Concealed: Body Odour Changes across the Human Menstrual Cycle. Ethology, 112(1), 81–90. doi:10.1111/j.1439-0310.2006.01125.x

Jutte, R. (2008). Contraception: A history. Cambridge, UK: Polity Press. Kero, A., & Lalos, A. (2004). Reactions and reflections in men, 4 and 12 months post-abortion.

Journal of Psychosomatic Obstetrics & Gynecology, 25, 135–143. doi:10.1080/01674820400000463 Kiley, J., & Hammond, C. (2007). Combined oral contraceptives: A comprehensive review. Clinical

Obstetrics and Gynecology, 50, 868–877. doi:10.1097/GRF.0b013e318159c06a Klibanoff, E. (2014). Why sterilization is the most popular form of family planning. NPR. Retrieved

from: http://www.npr.org/sections/goatsandsoda/2014/11/17/364112100/why-sterilization-is- the-most-popular-form-of-family-planning (accessed March 15, 2016).

Kohler, P.K., Manhart, L.E., & Lafferty, W.E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42, 344–351. doi:10.1016/j.jadohealth.2007.08.026.

MacIsaac, L., & Espey, E. (2007). Intrauterine contraception: The pendulum swings back. Obstetrics and Gynecology Clinics of North America, 34, 91–111. doi:10.1016/j.ogc.2007.02.004

Major, B., Cozzarelli, C., Cooper, M., Zubek, J., Richards, C., Wilhite, M., & Gramzow, R.H. (2000). Psychological responses of women after first-trimester abortion. Archives of General Psychiatry, 57, 777–784. doi:10.1001/archpsyc.57.8.777

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

C o p yr

ig h t ©

2 0 1 7 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

11 Sex Education, Contraception, and Pregnancy310

Martinez, G., Abma, J., & Copen, C. (2010). Educating teenagers about sex in the United States. NCHS Data Brief, 44. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db44.pdf (accessed September 5, 2013).

Miller, G., Tybur, J. M., & Jordan, B.D. (2007). Ovulatory cycle effects on tip earnings by lap dancers: Economic evidence for human estrus? Evolution and Human Behavior, 28, 375–381. doi:10.1016/j.evolhumbehav.2007.06.002

Moore, P. (2015). Poll results: Sex ed. Retrieved from: https://today.yougov.com/news/2015/01/07/ poll-results-sex-ed/ (accessed September 12, 2016).

Mosher, W.D., & Jones, J. (2010). Use of contraception in the United States: 1982–2008. National Center for Health Statistics. Vital and Health Statistics, 23(29). Retrieved from http://www.cdc. gov/nchs/data/series/sr_23/sr23_029.pdf (accessed September 5, 2013).

NPR (2004). Sex education in America: An NPR/Kaiser/Kennedy School poll. Retrieved from http://www.npr.org/templates/story/story.php?storyId=1622610 (accessed September 5, 2013).

O’Connor, J.J.M., Re, D.E., & Feinberg, D.R. (2011). Voice pitch influences perceptions of sexual infidelity. Evolutionary Psychology, 9, 64–78.

Oddens, B.J., den Tonkelaar, I., & Nieuwenhuyse, H. (1999). Psychosocial experiences in women facing fertility problems—a comparative survey. Human Reproduction, 14, 255–261. doi:10.1093/humrep/14.1.255

O’Keane, V., & Marsh, M.S. (2007). Depression during pregnancy. British Medical Journal, 334, 1003–1005. doi:10.1136/bmj.39189.662581.55

Paulson, J.F., & Bazemore, S.D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. JAMA: Journal of the American Medical Association, 303, 1961–1969. doi:10.1001/jama.2010.605

Peipert, J.F., Madden, T., Allsworth, J.E., & Secura, G.M. (2012 in press). Preventing unintended pregnancies by providing no-cost contraception. Obstetrics & Gynecology, 120, 1291–1297. doi:10.1097/AOG.0b013e318273eb56

Philpott, A., Knerr, W., & Boydell, V. (2006). Pleasure and prevention: When good sex is safer sex. Reproductive Health Matters, 14, 23–31.

Puts, D.A. (2005). Mating context and menstrual phase affect women’s preferences for male voice pitch. Evolution and Human Behavior, 26, 388–397. doi:10.1016/j.evolhumbehav.2005.03.001

Roberts, C.S., Klapilova, K., Little, A.C., Burriss, R.P., Jones, B.C., DeBruine, L.M., Petrie, M., & Havlíček, J. (2012). Relationship satisfaction and outcome in women who meet their partner while using oral contraception. Proceedings of the Royal Society B, 279, 1430–1436. doi:10.1098/ rspb.2011.1647

Roth, M.Y., Shih, G., Ilani, N., Wang, C., Page, S.T., Bremner, W.J., . . . & Amory, J.K. (2014). Acceptability of a transdermal gel-based male hormonal contraceptive in a randomized controlled trial. Contraception, 90, 407–412. doi:10.1016/j.contraception.2014.05.013

Sanders, S.A., Yarber, W.L., Kaufman, E.L., Crosby, R.A., Graham, C.A., & Milhausen, R.R. (2012). Condom use errors and problems: A global view. Sexual Health, 9, 81–95. doi:10.1071/SH11095

Santelli, J.S., Speizer, I.S., Avery, A., & Kendall, C. (2006). An exploration of the dimensions of pregnancy intentions among women choosing to terminate or to initiate prenatal care in New Orleans, Louisiana. American Journal of Public Health, 96, 2009–2015. doi:10.2105/ AJPH.2005.064584

Scholes, D., LaCroix, A.Z., Ichikawa, L.E., Barlow, W.E., & Ott, S.M. (2005). Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception. Archives of Pediatrics & Adolescent Medicine, 159, 139–144. doi:10.1001/ archpedi.159.2.139

Sharma, U., Chaudhury, K., Jagannathan, N.R., & Guha, S.K. (2001). A proton NMR study of the effect of a new intravasal injectable male contraceptive RISUG on seminal plasma metabolites. Reproduction, 122, 431–436.

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

C o p yr

ig h t ©

2 0 1 7 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

References 311

Stanger-Hall, K.F., Hall, D.W. (2011). Abstinence-only education and teen pregnancy rates: Why we need comprehensive sex education in the U.S. PLoS ONE 6(10): e24658. doi:10.1371/journal. pone.0024658

Trussel, J. (2011). Contraceptive failure in the United States. Contraception, 83, 397–404. doi:10.1016/j.contraception.2011.01.021

Tsuruta, J.K., Dayton, P.A., Gallippi, C.M., O’Rand, M.G., Streicker, M.A., Gessner, R.C., . . . Sokal, D.C. (2012). Therapeutic ultrasound as a potential male contraceptive: Power, frequency and temperature required to deplete rat testes of meiotic cells and epididymides of sperm determined using a commercially available system. Reproductive Biology and Endocrinology, 10(7). doi:10.1186/1477-7827-10-7

Umpierre, S.A. (1985). Effect of Coke on sperm motility. New England Journal of Medicine, 21, 1351. doi:10.1056/NEJM198511213132111

von Sydow, K. (1999). Sexuality during pregnancy and after childbirth: A metacontent analysis of 59 studies. Journal of Psychosomatic Research, 47, 27–49. doi:10.1016/S0022-3999(98)00106-8

Walker, J.L. (2001). A qualitative study of parents’ experiences of providing sex education for their children: The implications for health education. Health Education Journal, 60, 132–146. doi:10.1177/001789690106000205

Weaver, H., Smith, G., & Kippax, S. (2005). School-based sex education policies and indicators of sexual health among young people: a comparison of the Netherlands, France, Australia and the United States. Sex Education, 5, 171–188. doi:10.1080/14681810500038889

Youssef, H. (1993). The history of the condom. Journal of the Royal Society of Medicine, 86, 226–228.

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-19 18:24:44.

C o p yr

ig h t ©

2 0 1 7 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .