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The IUD in Me: On Embodying Feminist Technoscience Studies Chikako Takeshita

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a University of California , Riverside, USA

Published online: 09 Mar 2010.

To cite this article: Chikako Takeshita (2010) The IUD in Me: On Embodying Feminist Technoscience Studies, Science as Culture, 19:1, 37-60, DOI: 10.1080/09505430903558021

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The IUD in Me: On Embodying Feminist Technoscience Studies

CHIKAKO TAKESHITA

University of California, Riverside, USA

ABSTRACT This article traces my personal and academic journey through two ‘IUDs in Me’ interlacing personal encounters with the IUD with formal research findings from academic work. I demonstrate that reflecting on my own embodiment of the IUD while conducting academic research on the same technology helped me understand how social and historical conditions constructed my reproductive choice as an American consumer of the device and how such ‘choice’ is constrained by the scientific community’s willingness to develop birth control methods, medical practices, and corporate profitability. Personally enjoying the IUD and benefiting from studying it academically, I was faced with a moral dilemma between my own empowerment and the disempowerment that many other women experienced in relationship to this technology. As a way to hold my personal body politics accountable towards feminist struggles for reproductive freedom, this essay scrutinizes my bodily experiences by reading them critically against socio-historical and political contexts. I contend that such reflexive embodied scholarship helped illuminate how ‘differences’ among women were implicitly calculated and actively configured by IUD developers, who constantly revamped the research and discourse around the device over the last several decades in response to changes in social interests, political stakes, and scientific findings. I argue that my reflexive and embodied feminist technoscience studies led to a fruitful theoretical investigation into how the creation of various ‘ideal’ users mirrors the transnational political economy of women’s bodies.

KEY WORDS: Intrauterine device (IUD), feminist technoscience studies, reflexive embodied scholarship, construction of contraceptive users, political economy of women’s bodies, menstruation regulating technology

Science as Culture Vol. 19, No. 1, 37 – 60, March 2010

Correspondence Address: Chikako Takeshita, Women’s Studies Department, University of California, Riverside, 900 University Avenue, CA 92521. Email: [email protected]

0950-5431 Print/1470-1189 Online/10/010037-24 # 2010 Process Press DOI: 10.1080/09505430903558021

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Introduction

In the spring of 2002, I went to a Planned Parenthood clinic to get an intrauterine device (IUD).1 While I was on the examination table in the classic feet-up-in- stirrups position, the nurse held my hand and said: ‘you might feel a little cramp’. The doctor carefully slid into my vaginal opening an inserter loaded with a ParaGardw IUD, also known as the CuT-380A, shaped like a ‘T’ and bearing 380mg of copper. The perpendicular arms of the T are folded against the vertical stem when the device is loaded into a 1/8-inch-diameter straw-like inserter. As the doctor gently pushed the inserter through my cervix up into the uterus, I squeezed the nurse’s hand and tried to distract myself by looking at a humorous poster pinned to the ceiling, apparently placed there to make patients like me feel comfortable. The arms popped open inside the uterus as the inserter was extracted and the device resumed its T-shape. The IUD would now sit in my uterine cavity, releasing tiny amounts of copper and preventing pregnancy for up to 10 years. The insertion was completed in a few minutes. The cost of the IUD was $250.

This article traces my personal and academic journey through two ‘IUDs in Me’, interlacing personal encounters with the IUD with formal research findings from academic work. Reflecting on my own embodiment of the IUD while conducting academic research on the same technology helped me understand how social and historical conditions constructed my reproductive choice as an American consu- mer of the device and how such ‘choice’ is constrained by the scientific commu- nity’s willingness to develop birth control methods, medical practices, and corporate profitability. Personally enjoying the IUD and benefiting from studying it academically, I faced a moral dilemma between my own empowerment and the disempowerment that many other women experienced in relationship to this technology.

As a way to hold my personal body politics accountable towards feminist struggles for reproductive freedom, this essay scrutinizes my bodily experiences by critically reading them against socio-historical and political contexts. Such reflexive embodied scholarship helped illuminate in my research how ‘differ- ences’ among women were implicitly calculated and actively configured by IUD developers, who constantly revamped the research and discourse around the device over the last several decades in response to changes in social interests, political stakes, and scientific findings. I argue that my reflexive and embodied feminist technoscience studies led to a fruitful theoretical investigation into how the creation of various ‘ideal’ users mirrors the global political economy of women’s bodies.

At the time I got my own IUD, I had been researching its history for a few months for my dissertation project in Science and Technology Studies (STS) (Takeshita, 2004b). The decision to insert the device in my own uterus was for both personal and professional gains. Personally I was in a new relationship and

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I wanted a convenient birth control method. I chose the IUD because it does not require a daily regimen of pill-taking and it is a cost-effective long-term method that needs no replacing for many years. These precise features were originally considered to be ideal for population control when the Population Council in New York initiated IUD development in the early1960s.2 Developers believed that the reproductive capacity of women in the global South needed to be brought under control on a long-term basis and that the pill was unsuitable for this purpose because it required the users to use it correctly and consistently (Dugdale, 2000; Onorato, 1990; Tone, 1999). Hence, at its inception, intrauterine contraception was envisioned as the one-time insertion method that can be forgot- ten about while the device prevented excess fertility and averted the threat of population explosion.

The IUD indeed met my needs, but it was not something that I could forget about. Its side effects, namely the heavy bleeding, painful cramping, and longer menstrual period, were definitely noticeable every month so that I was reminded each time that I had a foreign object inside my uterus. I often pondered how the side effects must have been far worse for women who used the method decades ago. At that time developers had purposely made the devices bulkier, and thus more irritating to the organ, believing that covering a larger area of the uterine cavity made the device more effective in preventing pregnancy (Tietze & Lewit, 1962). I also shuddered at the thought of doctors dismissing female patients’ complaints when women were actually suffering from serious infections (Grant, 1992).

I coped with the side effects reasonably well with the help of abundant feminine hygiene products, ibuprofen, and some self-convincing that my symptoms were normal and nothing seriously dangerous. Overall, I was quite satisfied with my ParaGard. But, I wondered, what about women in the global South, who may not have access to all the modern amenities and may have had the device inserted against their wishes? How might they be experiencing the device? I felt ambiva- lent about my personal empowerment brought to me by the IUD, knowing that numerous women were disempowered by the same technology. I also worried that women who lost their fertility during the 1970s due to injuries associated with IUD use might question my commitment to feminist analysis. I was compelled to ask myself what my responsibility was as a feminist scholar whose actions and academic work engaged the experiences and exploitation of other women. This question became a sticking point and, later, a motivation behind interrogating the issue of inequality more theoretically in my study of the device.

When I first got the IUD, however, I only had a vague idea of how having the device inserted would affect my academic work. I thought I might benefit profes- sionally from an IUD insertion because colleagues I respected also had personal bodily relationships with the subjects they studied. A fellow PhD candidate, Wairimu Njambi, had written her dissertation on female circumcision, a

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procedure she had undergone in her native country of Kenya (Njambi, 2000). Likewise, one of my mentors, Martha McCaughey, had authored a book on women’s self-defense training, which she herself practiced (McCaughey, 1997). They struck me as possessing unique insight and authority to speak about their research findings as a result of their experiences with the topics at hand. They were also practicing feminist epistemology, a position that refuses to pose as value-neutral, objective, unbiased researchers or disembodied knowers (Harding, 1991; Haraway, 1988). Njambi and McCaughey were literally exercis- ing embodied subjectivities: they were creating knowledge from perspectives that come from bodies situated within the very subjects they studied. As someone aspiring to follow their footsteps, I found their personal and bodily relationships with their research most appealing.

Following the insertion, I too became an embodied knower. Keeping to a feminist research methodology that anchors objectivity in accounting for the researcher’s own values, social positions, and relationship with the research subject, I had to be reflective about who I was—a satisfied IUD user generating an academic analysis and a feminist critique of the device. I was naı̈ve, though, to think that embodiment would somehow turn me into an authoritative knower. Having a device did not ‘put me in touch’ with other IUD users or help me know them better. Instead it made it clearer that my situatedness—the historical, geographical, and social position that I occupy as an educated woman living in the United States 40 years after the contraceptive method was revived—shaped my own experience, which was not easily comparable to that of other women due to our grossly different positionalities. Knowing that classic feminist critique of the IUD regarded the device as inherently oppressive, potentially dangerous, and prone to abuse (Grant, 1992; Hartmann, 1995; Tone, 1999), I felt slightly uneasy with my own positive relationship with the device. Would I be regarded as betraying women if I cast this technology in a positive light as it related to my own experience? As I carried on with my academic work in my IUD body, the nagging question that I struggled with was how to make sense of my own body politics in my feminist study of the history of this technology.

My embodiment of the contraceptive method became the ‘personal’ stake in trying to figure out a way to produce knowledge about a technology that has affected the lives of numerous women without diminishing their experiences. As I reflected on the position that my body occupies in the transnational political economy of contraceptive research, I began to see how my embodiment was related to that of other women through the history of IUD research. This has led me to the task of developing a theoretical framework to account for the body/technology relationship of ‘diverse’ women, who are ‘implicated’ by con- traceptive development.3 This article, thus, narrates how a reflexive embodied scholarship emerged from reflecting on the ‘IUDs in Me’ and what I learned about them through academic studies.

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Why the IUD?

What is remarkable about the IUD is that it is the first modern long-acting revers- ible contraceptive method to be broadly distributed. The number of users has grown to over 150 million in the last 50 years, the majority of them residing in the developing world. There, the IUD is the second most prevalent method of fer- tility control after female sterilization, with 21% of contraceptive users relying on the device. Fourteen percent of contraceptive users in the developed regions use the IUD, ranking fourth after the pill, the male condom, and female sterilization (D’Arcangues, 2007).4 The method is alive and well in international family plan- ning programs; projects aimed at improving IUD distribution in various countries of the global South are underway (Salem, 2006). In the United States the method has suffered a negative reputation due to the Dalkon Shield fallout during the 1970s and lawsuits that drove pharmaceutical companies to withdraw their IUD products from the American market during the 1980s. Nevertheless, the contra- ceptive method is seeing a resurgence in popularity owing to a recent television advertisement of the new hormone-releasing device, which I discuss below.

There are a number of books on the Dalkon Shield tragedy (Grant, 1992; Hawkins, 1997; Hicks, 1994; Mintz, 1985; Perry & Dawson, 1985) and several articles analyzing the inception of the device as a population control tool predi- cated on the subjugation of underprivileged women (Dugdale, 2000; Meldrum, 1996; Tone, 1999). I explicate the episode in greater detail in the next section. The lack of comprehensive historical investigation into the IUD is conspicuous when compared to the abundant scholarship on hormonal contraception (Briggs, 2002; Clarke, 1998; Marks, 2001; Oudshoorn, 1994, 2000; Watkins, 1998). The pill is understandably more exciting since it involved the discovery of sex hor- mones, is associated with the birth control movement and the sexual revolution, and is the most popular method in the global North. For feminist scholars, it has also been important to critique how the pill was tested in a problematic fashion on women of color. The IUD, on the other hand, may have been over- looked by scholars of the global North because its distribution has been primarily overseas and its scientific aspect is seemingly insignificant. Nonetheless, those involved in international family planning assistance recognize the important role that intrauterine contraception plays in the reproductive health of women in the global South. It was through a conversation with one such person that I became interested in the IUD as a research topic.

As I came to learn, scientific activities around this device were far from mundane. In fact, they offered a rich site of analysis for how contraceptive researchers overcame obstacles for their technology to be widely accepted. IUD developers had to answer questions about its safety and criticism that the provi- der-dependent method takes reproductive control away from women. They also had to shape the device into a marketable product and avert allegations of it being an abortive method. Thus, in my research I detailed how the acceptability

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of the IUD had been negotiated over the past four and a half decades. I argued that IUD developers conducted scientific studies to garner the contraceptive method a status of properly tested medical device, reasserted the device’s safety after the Dalkon Shield fallout, maintained its legitimacy in international family planning, and reshaped it as a contraceptive ‘choice’ for all women and as a consumer product (Takeshita, 2004b).

A Brief History of the IUD, 1960 to the mid-1980s

At this point, I want to offer an abbreviated historical sketch of the IUD’s devel- opment to help situate my own experiences and research. The modern IUD was revived in the early 1960s bolstered by two primary concerns—population and profit. Population control advocates believed that population explosion in the global South would lead to famine, economic collapse, environmental demolition, political turmoil, states converting to communism, and global instability (Hart- mann, 1995). Hormonal contraceptives had just become available, but IUD enthu- siasts deemed the pill to be only suitable for Western upper-middle class women, who they considered deserving of a contraceptive with higher effectiveness and who were trusted to use it correctly and consistently (Onorato, 1990; Tone, 1999). Promoting the IUD, Alan Guttmacher, a medical doctor and former presi- dent of Planned Parenthood announced:

As I see it, the IUD’s [sic] have special application to underdeveloped areas where two things are lacking: one, money and the other, sustained motiv- ation [to prevent excess fertility]. No contraceptive could be cheaper, and also once the damn thing is in the patient cannot change her mind (quoted in Watkins, 1998, p. 70).

In other words, the IUD was thought to make long-term pregnancy prevention easily achievable; the device was ‘imposable’ by a third party, who only had to convince a woman once to have ‘the damn thing’ inserted in her (Clarke, 2000). Early IUD developers, hence, imagined inserting the device by the masses in women of color in order to take control of their fertility. The Population Council was most instrumental in facilitating the development and scientific studies of the method for the next several decades.

Feminists have especially been wary of how this technology has been imposed on women with little attention to individual reproductive desires and health. Some governments, such as those of Indonesia, China, and Vietnam, have indeed mobi- lized the contraceptive method to limit each nation’s birth rate using coercive and semi-coercive means (Gammeltoft, 1999; Greenhalgh, 1994; Hartmann, 1995). Other examples of abuse can be found in healthcare providers who pass judgments on who should be barred from reproducing. For example, indigenous women in Mexico were reportedly targeted heavily for IUD use, and medical

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staff inserted devices without the women’s knowledge or proper consent immedi- ately after childbirth and abortion procedures (Ortega et al., 1998; Thompson, 2000). In the US, poor teenagers who were deemed unreliable pill users were pre- scribed the Dalkon Shield during the early 1970s (Rauh & Burket, 1975). Women of color who gave birth at the Los Angeles County Medical Center during the 1970s were aggressively recommended to go on the IUD (Gutiérrez, 2008). More recently, women with addictions have been offered cash in exchange for IUD insertion (Bland, 2002). Problematic use of IUDs that undermines marginalized women’s reproductive rights persists beyond historical and geographical boundaries.

Running parallel to concerns about population control were desires for profit, often at the expense of women’s health. During the 1960s, scientists who were enthused by the idea of using IUDs to restrain excess births were not terribly con- cerned about potential health risks. They assumed that the infections observed in some women were unrelated to the device and treatable by antibiotics, and there- fore should not deter promoting the contraceptive method (Tietze & Lewit, 1962). After the market success of the pill, several different models of the IUD were released in the US by pharmaceutical companies anticipating they would make a profit from another birth control method. In the early 1970s, an especially poorly designed device called the Dalkon Shield was aggressively marketed to American women including college students and those who had never given birth (nulliparous women). The Shield, and to a lesser extent other models, caused sterilizing injuries to numerous women and killed several users who suffered overwhelming infections (Mintz, 1985). After the deaths of Dalkon Shield users were brought to the attention of the US Congress in 1973, a flurry of health risk studies examining the relationship between IUD use, pelvic inflam- matory diseases (PID), and infertility finally emerged.

Planned Parenthood recalled the Dalkon Shield and the US Food and Drug Administration imposed a moratorium on the selling of the Shield in 1974. More than 300,000 women filed a class action lawsuit against the manufacturer of the Dalkon Shield during the 1980s (Bacigal, 1990). After several lawsuits hit other IUD manufacturers, all but one minor company withdrew their products from the American market by the mid-1980s because they were no longer profitable (Forrest, 1986).

Objectionable usage of the device, along with concerns about safety and profit- ability, did not kill the IUD, however. The copper-T device I obtained named ParaGard is a product that was reintroduced to the American market with the support of the Population Council in 1988 in order to re-establish public confi- dence over the contraceptive method.5

My Copper-T: Embodying the ‘Safe’ IUD User

A few weeks before my ParaGard insertion, I called the local Planned Parenthood clinic to set up an appointment. A friend of mine who volunteered there had told me

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that the female doctor was ‘really cool’, but on the phone she initially seemed rather curt. Her immediate response to my request for an IUD was: ‘Are you married?’. Alarmed by the disapproving tone in her voice, I stumbled while answering ‘no’. Without missing a beat, she fired more questions in rapid succession: ‘Are you going to get married? How long have you been with this man? Are you faithful to each other? Are you two committed to each other for a long term relationship?’.

I was taken aback and scrambled to give the ‘right’ responses while trying to sound earnest. I got genuinely worried that she was going to refuse to give me an IUD. Why was she asking me such personal questions about my sex life? Then I recalled reading about user screening questions that were now somewhere in my pile of dissertation materials. I vaguely remembered that young childless women were discouraged from using the device due to an assumption that these women were more prone to contracting sexually transmitted diseases from multiple sexual partners.

At this moment, I promptly volunteered the following information in an attempt to put an end to the doctor’s interrogation: ‘I am in my late thirties. I already have one child and I do not plan to have another soon. Even if I were to try in the future and was unable to conceive, I would probably blame my age rather than the IUD’. This statement, which was not entirely a lie, indeed satisfied her, and she agreed to put me on the device.

What was going on in this phone conversation? I was rather amazed when I successfully persuaded the doctor by spontaneously presenting myself as a good candidate for IUD insertion. Inspired, I returned to work to find out in more detail what social and scientific factors shaped the formation of the ‘ideal’ user that corresponded with someone like myself.

Reconstructing the Safe Technology/User

The new profile of an ‘ideal’ user emerged through the process of recovering the contraceptive method from the Dalkon Shield fallout. The controversy over the device’s safety started to unravel just as the Population Council was getting ready to release the Copper-T as the next generation IUD (Dugdale, 1995). To the dismay of its supporters, the withdrawal of IUD products by American pharmaceutical companies during the 1980s made an impression upon the medical community and the public that the contraceptive method must be danger- ous. Its reputation overseas, where the device played more significant roles in limiting family sizes, also became vulnerable. The deteriorating image of the contraceptive method created a need to rehabilitate the IUD as a safe technology. Redefining who should be considered an ‘appropriate’ user became a major component in the scientific studies that helped restore the safety of the device. The rehabilitation involved several steps as I describe below.

The first step in reasserting the overall safety of the IUD involved isolating the Dalkon Shield as uniquely dangerous. Several epidemiological studies on PID

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and/or tubal infertility associated with IUD use suggested that the Dalkon Shield carried elevated risks compared to other IUDs (Cramer et al., 1985; Daling et al., 1985; Kaufman et al., 1983; Vessey et al., 1981). Furthermore, a study conducted by Howard Tatum, the inventor of the T-shaped IUD, suggested that the material used for the tail of the Dalkon Shield served as conduit, or a wick, for bacteria to travel from the vagina to the sterile uterus (Tatum, 1975).6 It is now widely accepted that the unique tail of the Shield contributed to the large number of women who suffered infections. By combining the wicking tail theory and epide- miological studies that compared different models of IUDs, the Population Council was able to hold the Dalkon Shield culpable, while legitimizing other IUDs developed, tested, and promoted by its researchers.

The second step in securing the future of the IUD entailed placing the blame on the users’ sexual activities. Some epidemiological studies suggested that there might be some correlations between the number of sexual partners and elevated risk of contracting PIDs (Burkman, 1981; Cramer et al., 1985). Highlighting this aspect, IUD supporters concluded that not the device, but sexually transmitted infections (STI), which are believed to be more easily contracted by women with multiple sex partners, accounted for the increased health risks found in IUD users. This notion was used as an intimidation tactic by Dalkon Shield defendant lawyers, who insisted that the plaintiff reveal private sexual behaviors. While these studies neatly localized IUD risk to promiscuous sexual behavior, they also generated a new profile of a ‘safe’ user, namely a woman in a mutually monogamous relationship with no prior history of PID.

The third step involved eliminating women who have never had children from the IUD user base—at least in the United States. What was particularly tragic about the Dalkon Shield incident was that many women whose ability to become pregnant was destroyed due to injuries sustained in the reproductive organs had never had a child. I personally know at least two colleagues who suf- fered infections resulting from Dalkon Shield use. One was in college and the other had just married when they obtained their Shields in the early 1970s with the promise that this modern technology would support their sexual liberation and reproductive responsibility. Both are convinced that they endured additional health risks, ectopic pregnancies and a rare form of uterine cancer resulting from damages done to their reproductive organs by the Shield. Neither of them has biological children. Such stories of the Dalkon Shield fallout, and perhaps more so the media attention on the lawsuits, gave the American medical commu- nity the impression that inserting IUDs in nulliparous women was particularly unwise. As a result, when ParaGard was released in the US, it was exclusively marketed to women who already had children.

The assertion that mothers are safer than childless women is based on social factors rather than biological imperative. It is assumed that older women who are married with children are likely to be mutually monogamous, whereas young single women are thought to be sexually promiscuous and hence more

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susceptible to contracting STI, and therefore, are not safe to use IUDs. Apart from having a smaller uterus, however, there is no clear indication that younger women and women without children should not use an IUD. The World Health Organization (WHO) guidelines do not proscribe IUDs to nullipar- ous women, noting that potential benefits of preventing pregnancies, which can pose higher health risks to some women, may outweigh the presumed risks associated with the contraceptive method (WHO, 1996). Hence, the mothers- only standard promoted in the US has not been strictly followed overseas. Further undermining the idea that IUDs are only for mothers, ParaGard’s new American distributor since 2006 now markets the product to women without children. The company cites a new safety study, which found copper IUD users to suffer no more infertility than non-users, as the reason for changing the user criteria for its product (Hubacher et al., 2001). But, it is also a crafty move to differentiate the ParaGard from its rival product Mirenaw and to expand the market base.7

When ParaGard was introduced in 1988, however, American doctors still feared that they might face litigation should a patient experience complications while or after using an IUD. There was also a presumption that women who already had children were less likely to care or complain than childless women in the event of experiencing infertility. Childless women, then, were regarded as particularly ‘risky’ patients not only because they might engage in riskier sexual activities, but also because they were believed to be more litigious should infertility result. In light of this, the Population Council did the logical thing in its effort to secure the reputation of the device as ‘safe’. The Council limited its use to a population that appeared to be the safest both socially and medically, and assured doctors that proper screening of users and informed consent practices would prevent malpractice suits.

Safety measures for IUDs have improved over time around the world. Safe usage of the device must also incorporate proper medical care as well as the ability for women to make decisions about its use for themselves based on the knowledge of their sexual practices. In an optimal condition, the method can be safely used by women of all ages. But, my above analysis shows that the status that the IUD enjoys as a ‘safe’ technology cannot simply be attributed to techno- logical progress and improved medical practices. From a constructivist position on technological development, the successful reintroduction of the contraceptive method to the American market required the rehabilitation of the device through social, scientific, and discursive negotiations over its acceptability (Bijker et al., 1987; Callon, 1986; Latour, 1996; MacKenzie & Wajcman, 1985). Part of this effort involved invoking social beliefs about women’s sexual behavior and the likelihood to file a complaint in the process of reconstructing the ‘safe’ IUD user as an ‘older monogamous mother’. Someone like me. By rede- fining the appropriate user, developers were able to argue that the technology was actually inherently safe and that it had just been inserted in the wrong women in

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the past. A safe technology, then, was co-produced with a safe body through scien- tific invention and social imagination in the post-Dalkon Shield era of the history of the IUD.

The Political Economy of ParaGardw

Although the ParaGard had been on the market for many years, women who sought IUDs in 2002 were not always having their wishes granted because many doctors still viewed the contraceptive method as potentially troublesome and feared litigations (Devoe, 2002). My feminist doctor was not necessarily fearful of litigation, but she was being extra cautious in making sure that I was a ‘safe’ user.

Upon convincing my doctor to give me an IUD, I felt rather smug about having used my wits to exercise my so-called choice, thanks to my researcher’s knowl- edge of the contraceptive method. I willingly submitted myself to the informed consent procedure as any good educated female patient would do, certifying that I had read, understood, and accepted all the possible side effects and health risks.

Originally, informed consent procedure was conceived as a patient’s right to medical information and informed decision making (Faden & Beauchamp, 1986; Watkins, 1998). But, during the ParaGard introduction, it was pitched more as a way for physicians and the manufacturer to protect themselves with documentation in case of a malpractice suit. Hence, a more reflective analysis of my own actions now is that I readily played the role of an ‘ideal’—consenting and safe—user, thereby successfully enrolling myself in the network of discourses and practices that were established by IUD supporters.

Furthermore, I became part of the global socio-technical network that upholds the IUD as a favorable family planning method. The withdrawal of products from the American market in the mid-1980s not only seriously damaged American physicians’ confidence in the contraceptive method, but also raised suspicions in the international family planning community that a method too dangerous for American women was still being promoted overseas (Ramirez & Starrs, 1987). Putting the Copper-T back on the US market signaled to the rest of the world that IUDs were indeed safe enough for American women and therefore appropri- ate in other countries. Although ParaGard was advertised as bringing back a much needed contraceptive to American women, the distribution capacity of the small single-product company was extremely limited, and IUD usage rate in the US continued to plummet, while overseas users grew (Piccinino & Mosher, 1998). Hence, the significance of creating an ideal user like myself was the permission it gave to the continued IUD distribution to a different kind of ideal user, namely one whose fertility was targeted as part of social engineering. As the IUD was rearticulated as a contraceptive product for American mothers, ‘our

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contraceptive choice’ became intricately interwoven with ‘control over their excessively fertile bodies’ (see Figure 1).8

The hormone-releasing IUD, Mirena, adds another layer of complexity to this interdependency between the reproductive options for women whose rights, health, and fertility are valued differently in the global political economy.

My Mirena: The Pleasure of a Flexible Body

After 15 months, I ended my Copper-T usage in order to conceive. Eight weeks after the birth of my second child in 2005, I requested an IUD again. I was eager to try out Mirena, a new IUD that continuously releases small amounts of levo- norgestrel instead of copper inside the uterus. This time, the healthcare provider made me fill out and sign a questionnaire designed to ensure that the patient requesting the device had had a child, was in a monogamous relationship, and had no other preexisting contraindications.9 I was prepared to pay about $500 for the device, but was pleasantly surprised to find out that my health manage- ment organization (HMO) in southern California had recently started covering the entire cost. Another ParaGard would have lasted me 10 years as opposed to only five years, but I chose the Mirena in order to experience the additional

Figure 1. The IUD in me/us/them. Credit: Chikako Takeshita.

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benefit of lighter periods that the hormone induced. As I illustrate below, I once again willingly submitted myself to the norms set up for contraceptive consu- mers by desiring less menstrual bleeding. Only this time, my ‘ideal’ body was a product of excluding the bodies of those who were previously targeted by IUDs.

The Making of the Hormone-releasing IUD

The idea of adding hormone to the plastic device manifested from IUD developers’ desire to improve the method’s efficacy in controlling population growth. They expected that this innovation would have positive impacts on both contraceptive reliability as well as retention rates. Initial experiments of intrauterine proges- tin-releasing capsules suggested that the hormonal effect improved pregnancy prevention. Yet researchers pointed out disappointedly that the hormone only lasted a few months to a year at the most, which was too short for the contraceptive to be an effective one-time intervention method (Scommegna et al., 1970). They nevertheless continued to take interest in hormone-releasing devices when they discovered that they decreased menstrual blood loss rather than increased it like other IUDs. Women in underdeveloped regions tended to be more anemic and IUD developers were worried that heavy menstrual bleeding caused by bulky plastic devices would deteriorate the users’ health (Huber et al., 1975). Research- ers also believed that women often rejected the contraceptive method because excess bleeding interfered with their lives in cultures that prohibited menstruating females from performing certain tasks (Piotrow, 1979). Hence developers hoped that lightened menstrual bleeding would increase the acceptability of the hormone-releasing IUDs for women in the global South.

Clinical trials, however, showed that hormone-releasing IUDs had just as high a discontinuation rate as other IUDs. The 1981 World Health Organization study on how women experience menstruation in different cultures explains in part why such a result is not surprising (WHO, 1981). The study suggested that the majority of women around the world found any changes in their menstrual patterns cultu- rally unacceptable. Less or absence of bleeding was found to be equally objection- able as increased bleeding in cultures where menstruation is considered to maintain a woman’s health by purging bad blood and where periods are seen as a sign of fertility and/or not being pregnant. The WHO study concluded that the majority of women were not prepared to accept a contraceptive method that induced amenorrhea (absence of menstruation). Furthermore, hormone-releasing IUDs disrupt menstrual patterns in unpredictable ways for the first few months, causing heavier bleeding and/or irregular small bleedings called spotting. Spot- ting increased the number of days a woman bled, which caused disruption in some women’s daily and sexual activities. The developers’ enthusiasm towards offering the hormone-releasing IUD to women of the global South slowly waned as they began to see these setbacks (Takeshita, 2004b).

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Researchers turned instead towards more ‘modern’ users who appeared to be ready to accept decreased menstrual bleeding for one reason or another.10 When a much more potent synthesized progesterone became available, a Finish scien- tist affiliated with the Population Council took the lead and developed what became Mirena, a levonorgestrel-releasing IUD that lasts for five years. One in five Mirena users were found to eventually stop menstruating altogether and most other users’ periods lightened after a period of irregular bleeding. Physicians experimenting with Mirena touted it as a ‘therapeutic intrauterine system’, which, in addition to its contraceptive effect, relieved symptoms of difficult menstruation such as severe cramping, pain, and bleeding (Population Council, 1996). In an opportunistic move, the device’s side effect—lighter or absence of periods—was construed as a marketable benefit for progressive contraceptive users.

My Bloodless Liberation

After the insertion of Mirena, I had several months of irregular bleeding as pre- dicted and then my periods became lighter and tapered off to eventually become almost completely nonexistent. When I found out how comfortable it was to use Mirena, I realized that I had acquiesced to the pain and bleeding induced by the Copper-T as an unavoidable cost of using an IUD. As someone not particularly attached to menstruation as something that defines my femininity, I enthusiastically welcomed Mirena’s side effect. I loved the fact that without periods I did not have to worry about making a mess or carrying around feminine hygiene products when there were enough other demands put on me at work and home. I was thankful for no longer having to endure terrible cramps and bloating that distracted me from more important matters. As an environmentalist, I also felt good about not having to pollute the earth with tampons and sanitary napkins, which I believed surely must make up a lot of landfill waste. This was an extre- mely liberating corporeal experience.

When I think about my ‘bloodless liberation’, I am reminded of what feminist STS scholar Adele Clarke once said about women as users being ‘configured by technoscience’ in contraceptive research (Clarke, 2000, p. 40). Fifty years ago, scientists developing the oral contraceptive observed that their test subjects were distressed when the hormone caused their menstruation to stop (Oudshoorn, 1994). Pharmaceutical companies were also worried about being accused of alter- ing a woman’s ‘sacred’ cycle if the pill stopped menstruation altogether. Believing that women wished to feel that they were menstruating normally and in order to create a marketable drug, pill developers built the 7-days-every-21-days bleeding period into the product. Meanwhile, women were not necessarily told that this was an artificial menstruation, which is actually a hormone withdrawal response caused by switching to the sugar pills. Consequently, a ‘normal’ woman with a regular four-week menstrual cycle was configured and produced by technoscience.

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Significantly, the norm of women’s menstrual cycles is being rewritten and their bodies reconfigured today with new contraceptive products like Mirena. This new norm is advocated in a book titled Is Menstruation Obsolete? written by two Popu- lation Council affiliated researchers, who argue that it is scientifically unnecessary for women to have monthly periods because our ancestors had far fewer menstrual cycles over their life time than modern women (Coutinho & Segal, 1999). Quoting Margaret Sanger, the most famous birth control activist, the authors project that women would welcome medical manipulation of menstruation intervals because ‘no woman is completely free unless she has control over her own reproductive system’ (Sanger, quoted in Coutinho & Segal, 1999, p. 164). It should be noted that the authors of the book have also been instrumental in the development of IUDs and were aware that Mirena and other birth control methods can induce amenorrhea.

Just a few years after the book was published, pharmaceutical companies put monthly bleeding out of fashion. In the last several years, a number of oral contra- ceptives that make women bleed less frequently than the traditional 28-day cycle or fewer than the seven-menstruating-days have appeared on the market. Seaso- nale and Seasonique from Duramed Pharmaceuticals induces menstrual-like bleeding every 84 days; a rival product, Loestrin 24 Fe from Warner Chilcott reduces monthly bleeding to three days or less; and the latest product, Lybrel from Wyeth Pharmaceuticals, eliminates bleeding entirely.

Feminist scholars Laura Mamo and Jennifer Fosket point out that by casting periods as messy, inconvenient, and undesirable, menstrual suppression offered a seemingly natural solution to a distinctly gendered problem (Mamo & Fosket, 2009). These products appear to be doing well even though they are often more costly to the consumers and despite concerns expressed by some doctors about the continuous use of hormones over many years, especially for young women (Loshny, 2004). Advertisements communicate that these products will liberate a woman, make her feel sexier, and prove that she is a rational decision maker. Reg- ulating how much and how often one bleeds is quickly becoming a consumer life- style choice that self-identified busy, progressive, enlightened, and sexually liberated women would presumably pay a premium to attain.

Although Mirena has not been marketed as a menstrual regulation method, its television commercial mentions ‘shorter lighter periods’, which has also been noted as an ‘additional benefit’ in materials provided to physicians.11 Word is getting around to potential users through the doctor’s office, Internet blogs written by current Mirena users, and word-of-mouth; this has been supported by conversations with my female college students, some of whom have apparently learned about this feature through various channels.

Women who choose menstrual-regulating birth control methods including Mirena turn themselves into what Emily Martin (1994) calls flexible bodies well-adapted to neoliberal capitalism. These bodies are productive and well- managed, clean and healthy, not overly reproductive, good consumers of high-

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tech products, and above all flexible. In addition to not having to worry about taking the pill every day, Mirena lets you forget about menstruation, thereby allowing a woman to allocate more time and energy to juggling a hectic schedule and multiple responsibilities that accompany the lifestyle of industrialized capitalist societies. As its promotional material declares, to use Mirena is to ‘love the freedom’ and ‘keep life simple’.12 My own experience confirms this. And thus, I find myself highly complicit in affirming the pleasure of the flexible Mirena body.

The Political Economy of Mirenaw

While Mirena is marketed as a high-end consumer product and enjoyed by well- to-do women in the North, women of the global South have for the most part become excluded from Mirena’s user base. High cost, for one, prevents access to the device by a broader public. Whereas developing countries can obtain the copper-T for as little as 25 cents a piece, Mirena can cost as much as $40 a piece.13 Although $40 is considerably lower than its price tag on the US market, Mirena is still too expensive for many countries in the global South to afford in their family planning clinics for the general population. Since copper- releasing devices are just as effective in preventing pregnancy, there is little incentive for development aid agencies such as the US Agency for International Development to assist the procurement of a high-end product like Mirena. While privileged consumers enjoy the comfort Mirena provides, its availability to women of the global South is limited and upfront cost is prohibiting for the poor and uninsured in the global North.14

In the global political economy, interest in women’s bodies of the global South mainly surrounds reproduction rather than productivity and consumption as they do in the global North. Hence, uneven access to Mirena is simply overlooked by IUD developers. Moreover, as I mentioned above, women in the global South are imagined to be backwards about their views on menstruation, a charac- terization that is consistent with ‘not being modern enough’ and by implication they are leading lifestyles that are ‘pre-capitalist’ and unworthy of the conven- ience Mirena users would enjoy. The stratified distribution of Mirena mirrors the global inequality in reproductive choice based on race, class, nationality, and modernity.

The 2008 Mirena TV spot adds an ironic twist to the racial economy of the device. The clip features an upper-middle class white mother with three young boys, who chose Mirena for the convenience it provides while she engages in various family activities.15 A voiceover indicates that one can simply remove the device if you decide to become pregnant again. The scene cuts over to the mother holding a beautiful baby girl and the commercial ends with a happy nuclear family of six in front of their two-story suburban home. This ad invites viewers who identify with the race, class, marital status, motherhood, and lifestyle of the woman in the clip to obtain a Mirena to help her smartly juggle career,

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parenting, and recreation—and to keep having more babies. It aptly represents what Patricia Hill Collins calls the logic of eugenics in American national family planning, where positive eugenics or the increased reproduction in middle-class white women are encouraged, while negative eugenics continue to be promoted in lower-class and minority populations (Collins, 1999).

Hence, the IUD as a contraceptive method performs heterogeneous roles: from a device aimed at restraining the fertility of underprivileged, non-white, and global South populations to a method used to maintain the reproductive capacity of white upper-middle class women, and various interests in between. I, like many other women, negotiated this space in between by exercising agency, but within constraints. These constraints were demarcated by the established norms of contraceptive practices specific to an historical moment, a geographic and cultural place, and an economic class.

Feminism and the IUD Body

In the end, what did embodying the IUD do for me personally and for my scholar- ship? What did I learn about myself through my academic work on the IUD? How did embodying my subject of research help advance my scholarship? Was I able to resolve the tension between my favorable embodied experiences with IUDs and my role as a feminist scholar, whose charge is to deliver a critical analysis of the contraceptive device?

Reading My IUD Body

I certainly learned a great deal about my body. Naturally, I gained a thorough understanding of how the contraceptive method I chose was developed and how it regulates my body. I also learned how multiple types of ‘ideal’ users were con- figured as social pressures and scientific findings drove IUD developers to find new ways to adapt the device to the changing environment and broader recipients. Two of these ideal users materialized in my body as I enacted the ‘safe’ monogamous mother and the global North consumer desiring a menstrual-free lifestyle. At the same time, I was made aware of how my body maps onto the transnational political economy of fertile bodies that are implicated in contraceptive research, which implicitly differentiate the family planning program clients from the consumers.

I do not mean to suggest that all family planning clients should be called oppressed, however. Although I do not directly study women who use IUDs, I am fascinated by their relationships to the technology and have written elsewhere about them based on reports authored by anthropologists and reproductive health practitioners (Takeshita, 2004a). Their accounts defy our dichotomous under- standing of the relationship women have with the device: that it must be either empowering or disempowering. Elisha Renne (1997) reports that rural Nigerian women refused the IUD based on their indigenous beliefs about how witchcraft

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causes infertility by turning the uterus. Susan Greenhalgh (1994) shows that Chinese women illegally removed IUDs to conceive another child, while villagers put pressure on local health officials to look the other way. My favorite story is about a Tajik woman who persuaded her husband to put her on the IUD by not letting go of him during the birth of their fourth daughter, which made him realize what an onerous task childbirth was (Harris, 2000). I am also moved by the story of midwives in Uzbekistan, who provided IUDs to tired mothers of mul- tiple small children so that they could hide their contraception from husbands who opposed birth control (Krengel & Greifeld, 2000). These stories show that women all over the world exercise their choice through and against IUDs within the limited material and social circumstances that they find themselves in.

Likewise, my own story is not entirely about being empowered or exercising full autonomy. Without a doubt, I, as a consumer, made my ‘choice’, purchased, used, and benefited from two versions of the device. At the same time, however, I surrendered my body to various norms—to be the mutually monogamous ‘safe’ user, who signs off on the potential risks, deals with (or alternatively welcomes) the device’s side effects, and comes back to the doctor’s office for check ups. This is a compliant, rather than an autonomous, embodiment—one that maintains the existing order of contraceptive practices. Dissecting my experience through an STS perspective illuminated how an individual’s contraceptive ‘choice’ is anchored in social and medical systems carefully designed to sustain the viability of contraceptive technologies.

Grappling with a Feminist Dilemma

Performing the ideal neoliberal user of the IUD while studying the same technol- ogy as a feminist scholar put me in an awkward position. On the one hand, I found the contraceptive method desirable for my lived life; on the other hand, my scholarly and feminist commitment compelled me to critique the problematic aspects of the device. As one way to address the dilemma, I adhered to a feminist research methodology, which foregrounds that every knower is a positioned subject, whose social positioning, including gender, race, class, age, and one’s life experiences, both enable and inhibit particular kinds of insight (Landsman, 1998; Layne, 1996). This approach stresses that it is morally and epistemologi- cally more sound to take responsibility for one’s embodied scholarship than to feign neutrality. By acknowledging that as a knowledge producer speaking from a body favorably altered by the technology, it stresses that the knowledge I create is partial, situated, and accountable. My work puts feminist epistemology into practice by admitting to my positive embodied relationship with the device I am analyzing.

This epistemological approach, however, does not exonerate me from exploita- tion, though I came to find in my work that the situation was not one defined by a clear choice between exoneration and complicity. The benefits I gained from using

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and studying IUDs are indebted to the sustained improvement made to the device over the last 50 years because of its importance to family planning programs that often target underprivileged women.

I searched for ways to reconcile my own desire to benefit from the IUD with my feminist objections to its problematic aspects that are rooted in the local and global discrepancies of power. Eventually, I found that a flawless reconciliation is impossible. But my unresolved ambivalence towards my embodied empowerment pushed me to further interrogate the role of privilege and oppression in contracep- tive development and theorize it in my work. It drives my research and encourages my pursuits as an STS scholar.

Reflexive Embodied Scholarship

My reflexive embodied theorizing started from exploring how the transnational political economy bears on my personal experience and vice versa. It is easy to say that my embodiment is dramatically different from women in the global South because of our disparate social positions. But, such understanding simply naturalizes inequality and privileges my advantageous status. To say that the context of use is all that matters also absolves the device as inherently neutral. STS training, on the contrary, taught me to analyze technologies as products of social relationships that are not politically innocent (Haraway, 1991; Winner, 1986). My way of making a contribution to feminist scholarship, then, is to find a way to talk about the politics of the body located within the material object and the scientific research that made the IUD what it is.

For this reason, this essay has focused on how ‘ideal’ users were configured and on revealing that differences among women were implicitly calculated in contra- ceptive research. With an unspoken understanding that they have the power as consumers to sue their providers, childless women in the global North were excluded from IUD usage by citing epidemiological studies that suggest young promiscuous women might contract more STIs. Meanwhile, nulliparous women in the global South, who pose no danger of raising legal complaints, were regarded as valid recipients of the method. So-labeled ‘differences’ among women are also embedded in the development of Mirena. The device was imagined to be for the masses until the target audience shifted to more ‘modern’ women, who prefer or benefit from less menstrual bleeding.

Unequal access to contraceptive choice and inconsistent safety standards do not accidentally happen nor are they solely determined by economic factors: at least in part they are rooted in how users are configured in contraceptive research. Yet, the scientific discourse tends to conceal differences when it makes claims to a univer- sal technology under the assumption that all women are biologically similar. Employing an STS lens helped me see that researchers played up or down women’s divergent needs and positionalities in their efforts to formulate a device that meets the demands of various socio-historical contexts.

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This essay also highlighted how the process of producing a viable contraceptive technology intertwined reproductive freedom and the enforcement of fertility control. As I traced here, the commercial distribution of the device we enjoy are byproducts of developing and maintaining a technology designed for ‘imposa- bility’. At one point, selling the device to middle-class Americans played a key role in sanctioning the IUD as an acceptable device for all women, even though many are given the device under very different circumstances. At a basic level, then, consumption of the IUD in the global North has had a hand in both the goals and outcomes of applications in the global South. Reflecting on how my embodiment is complicit in upholding the global political economy of women’s bodies helped me point out that an interdependent relationship has been estab- lished between the reproductive health practices of women whose lives have never crossed paths.

Interlacing personal narratives with research findings, this article described my journey as an embodied knowledge producer. I am still negotiating how to live and work through some of the contradictions that are inherent in a technoscientific world that is built upon social inequality and global relationships of power. One positive outcome has been the reflexive theorizing that embodiment imposed on my academic work. I am happy to have taken this journey.

Acknowledgements

The author is grateful to Juliet McMullin, Christina Schwenkel, Martha McCaughey, Saul Halfon, Jody Roberts, and the anonymous reviewers for their suggestions in the preparation of this article. Thanks especially to the co- editors, Wyatt Galusky and Ben Cohen.

Notes

1The Planned Parenthood Federation of America consists of 99 affiliates, has over $1 billion in annual budget, and provides reproductive health services and education from 880 locations to three million people in the United States. The organization originated as the Birth Control League, the first birth control clinic established in 1920 by activist Margaret Sanger.

2The Population Council is a New York based philanthropic organization established in 1952 by gifts from John D. Rockefeller III to lead efforts in finding solutions to overpopulation. The organization has led research efforts in various areas concerning population science and biomedical studies on fertility control and reproductive health.

3‘Implicated actors’ are those for whom contraceptive research ‘will be consequential, regard- less of their current presence’ (Clarke & Montini, 1993).

4China accounts for two-thirds of all IUD users worldwide with nearly half of its female contra- ceptive users on the IUD. The global distribution of the contraceptive method is uneven with high rates of usage in the Central Asian Republics and in several countries in Europe and the Middle East as well as Vietnam and Cuba. IUD prevalence is lowest in sub-Saharan Africa and North America.

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5The ParaGardw was first released in 1988 by GynoPharma, a small one-product company. Ortho-McNeil Pharmaceuticals, which has a much wider marketing ability than GynoPharma, purchased the ParaGard in 1995. Since 2006, Durmed Pharmaceuticals has sold ParaGard.

6A tail is a thread attached to the IUD that protrudes through the cervix into the vagina so that a physician can later remove the device by pulling on it. Sometimes the woman is advised to ‘check the string’ monthly to make sure it is protruding from her cervix, which lets her know that the device is still placed correctly.

7Mirena was put on the US market in 2001 by Berlex Laboratories, a subsidiary of Schering AG. Mirena is currently marketed by Bayer Pharmaceuticals after merging with Berlex.

8An image similar to this one was used to explain that ‘the IUD fits in the uterus as if in a pear’ to illiterate Mexican women during the 1980s. The copper-T device in this picture was once worn by the author between 2002 and 2003. Hence, the uterus-shaped pear in this photograph simultaneously represents ‘my contraceptive choice/the IUD in me’ and ‘the fertile bodies of the women in the global South’.

9‘IUD Questionaire [sic]’, Southern California Permanente Medical Group, Department of Ob/ Gyn, Kaiser Permanente, Riverside Medical Center (obtained April 2005).

10Implicit in the term ‘modern’ is binary concepts such as white/non-white, upper-class/lower- class, educated/uneducated, global North/global South, and scientific/superstitious. The ‘modern’ users share most, if not all, of the characteristics on the left hand side.

11Mirena promotional material for prescribing physicians, copyrighted 2005, Berlex, Inc., Motville, NJ (obtained October 2006).

12Ibid. 13The 25-cent figure for the copper-releasing device was quoted during the Fifth International

Symposium on Intrauterine Devices and Systems for Women’s Health held in New York on 27 – 28 October 2006. The US Agency for International Development price for the copper-T is $1.64. The organization does not supply Mirena. The International Contraceptive Access Foundation founded by the Population Council and the pharmaceutical company Leira Oy offers a limited number of donations and subsidized sales of Mirena to the public sector. See http://www.ica-foundation.org/ (accessed August 2009).

14Medicaid may cover Mirena in some states in the United States at different levels of reimbur- sement. Uninsured patients with income below the poverty level may be able to apply with their healthcare providers for a free device through the ARCH Foundation established by Berlex Laboratories, Inc. See http://www.archfoundation.com/ (accessed August 2009).

15Mirena Media Spotlight, broadcast 2008 – 2009 in the United States. At the time of writing this article, the commercial was available online at: http://www.youtube.com/watch?v¼ bYBHhw1GnR0 (accessed August 2009).

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