HSE's Sexual Health Awareness website - the rhythm method

[Neil]

http://www.yoursexualhealth.ie/your-con ... traception

I was shocked when I saw this:

Natural methods

Description: A woman keeps a daily record of her body temperature, changes in cervical mucus and other signs of ovulation. These tell her when she is most fertile and so when she should avoid sex or use a barrier method such as a condom or diaphragm. Natural methods should be learnt from a specially trained teacher or GP. Voluntary organisations such as ACCORD and NAOMI provide training. You will find contact details in the phone book.

Reliability: With careful use, 2 in every 100 women will get pregnant in a year. With less careful use, 2 to 20 women in every 100 will get pregnant in a year.

First of all, ACCORD are a Catholic group who are therefore obviously biased when it comes to sex and contraception, and as such should have no place on a supposedly medical website about safe sex. Secondly, the failure rate given here is ridiculous. From what I've read, the general consensus is that the rhythm method is totally unreliable, and the failure rate with typical use is 25%.

Am I overreacting, or is this grossly irresponsible of the HSE, particularly when you take into account the difficulty obtaining emergency contraception, and the fact that this website is clearly aimed at young people? (I'm not surprised, mind you).

I understand that there are people whose religious beliefs don't allow them to use barrier or other methods of contraception, but the medical profession should not be promoting unreliable methods like this just because they're kosher. A decent GP wouldn't recommend a homoeopathic treatment if real medicine would cure you.

Anyway, rather than just moaning, I sent an e-mail to yoursay@hse.ie . I'd advise anyone with a strong opinion on this to do the same.

-Neil

[ctr]

http://www.yoursexualhealth.ie/your-con ... traception

I was shocked when I saw this:

Natural methods

Description: A woman keeps a daily record of her body temperature, changes in cervical mucus and other signs of ovulation. These tell her when she is most fertile and so when she should avoid sex or use a barrier method such as a condom or diaphragm. Natural methods should be learnt from a specially trained teacher or GP. Voluntary organisations such as ACCORD and NAOMI provide training. You will find contact details in the phone book.

Reliability: With careful use, 2 in every 100 women will get pregnant in a year. With less careful use, 2 to 20 women in every 100 will get pregnant in a year.

First of all, ACCORD are a Catholic group who are therefore obviously biased when it comes to sex and contraception, and as such should have no place on a supposedly medical website about safe sex. Secondly, the failure rate given here is ridiculous. From what I've read, the general consensus is that the rhythm method is totally unreliable, and the failure rate with typical use is 25%.

Am I overreacting, or is this grossly irresponsible of the HSE, particularly when you take into account the difficulty obtaining emergency contraception, and the fact that this website is clearly aimed at young people? (I'm not surprised, mind you).

I understand that there are people whose religious beliefs don't allow them to use barrier or other methods of contraception, but the medical profession should not be promoting unreliable methods like this just because they're kosher. A decent GP wouldn't recommend a homoeopathic treatment if real medicine would cure you.

Anyway, rather than just moaning, I sent an e-mail to yoursay@hse.ie . I'd advise anyone with a strong opinion on this to do the same.

-Neil

Funny thing is, considering they are up front about the poor results I don't find much wrong with giving this information as long as it is accompanied with all choices including termination.

Information should be given in a neutral fashion though!

[UDS]

Um, the method described in the HSE website is not the rhythm method, but the fertility awareness method. (I confess to a certain fondness for this method, since my wife and I used it in reverse when we wanted to conceive, and were having trouble – and that worked for us.) Both methods rely on identifying fertile periods, but they use quite different mechanisms to do so, and the failure rate for one is not necessarily the failure rate for the other.

Having said that, the typical use failure rate quoted on the website is a range of up to 20%, which is not a thousand miles from the typical use failure rate of 25% quoted by Neil. Given that we are dealing with two different contraceptive methods, it’s entirely possible that the information given on the HSE site is correct. This would need to be checked before we could share Neil’s outrage.

As for ACCORD being a Catholic group, I don’t see that this is relevant. They are mentioned here as an organisation that provides training in fertility awareness contraception. The relevant questions are (a) do they provide training? And (b) is their training reliable, useful and accurate? If the answer to those questions is “yes”, they fact that they are Catholics has no bearing on the matter. (If anything, come to think of it, having a commitment to natural methods should give then an incentive to develop the expertise to develop good training skills, and to give out good information.) Ruling them out because they are Catholic is like ruling out the La Leche League as a source of information and support about breastfeeding because they have an ideological commitment to breastfeeding, or ruling out the Humanist Association as a source of information, support and resources about atheism or secularism because they have an ideological commitment to atheism and secularism.

[Neil]

I guess my reaction was a bit knee-jerk, but I still find it inappropriate considering the potentially high failure rate when compared to other methods.

My problem is not that ACCORD are a Catholic group*, but that they are recommended on what is supposed to be an impartial website. If the lobbying was strong enough (as has been seen in America) there would probably be a section on the website promoting abstinence.

(* Kind of... I also find it inappropriate for a website promoting sexual health and awareness to link to a site with an obvious hetero-normative bias - but that's a separate issue.)

[Ygern]

Just to clarify, the Fertility Awareness method is just the Rhythm Method plus some extra "signs" like a raised temperature etc. It is fair enough for the HSE to teach people how to identify when a woman is fertile; but it is misleading and inaccurate to suggest that it is a particularly effective means of birth control. While its advocates like to tote figures of a 2% failure rate, there are, as Neil points out, several studies that have put the failure are as high as 25%, which is I would suggest, puts its reliability and efficacy in question.

Again, so long as the HSE points out that there are many other more reliable and effective (and user-friendly) contraceptive methods available, I don't have a problem with them teaching people about it.

[greenwitch]

As a mother of young adult daughters, who are in non living together relationships I would be horrified if they thought this was a safe method of contraception.
When my girls were in the last year of primary school the school organised a nurse to come in and talk to the kids and my first daughter attended this talk. But when my second daughter reached the class a nun had taken over the organisation of the school and got accord in to give the talk. I rang to find out what information the kids would be given and was told some vague stuff about catholic relationships so I said ` and will this include information about condoms and STIs` etc. The nun was horrified and said that wasn`t in keeping with the schools ethos so I refused permission for my daughter to attend the talk. No point in confusing the child

[UDS]

It’s possible for all methods of contraception to identify both a “perfect use” failure rate, and a “typical use” failure rate. The latter is, I assume, based on certain assumptions about the diligence of a particular couple in practising the method concerned, and I think must be a somewhat “softer” figure than the perfect use failure rate. Presumably some couples are more competent or more diligent than others. I do observe that typical use failure rates do vary depending on who is quoting them; this presumably reflects different methods, bases and assumptions used to estimate them. But soft as it may be, the typical use failure rate is a relevant and useful figure, since relatively few couples are perfect.

The HSE webpage quotes both perfect use and typical use figures for all the contraceptive methods that it describes. There is much to be said for this. If nothing else, a wide gap between perfect use and typical use figures for a given contraceptive method indicates that a couple needs to be particularly committed to use that method successfully; this knowledge could obviously be useful to a couple in the choice they make.

There seems to be a tendency to single out fertility awareness methods of contraception as uniquely or outstandingly unreliable. I don’t think this is entirely justified, and it could contribute to a misleading perception about the reliability of other methods.

The HSE site suggests a typical use failure rate of up to 20% for the fertility awareness method; contributors to this thread (and this Wikipedia article) have suggested that the figure is more like 25%. This needs to be compared with the typical use failure rate for, e.g., the male condom, which is up to 25% (HSE) or 15% (Wikipedia). Even if we select the Wikipedia figures on the basis that they tend to favour the condom, the condom is 85% effective as against the 75% effectiveness rate of the fertility awareness method. A significant difference, yes, but not exactly an order of magnitude.

And, I should point out, the HSE website also mentions the cap-and-spermicide method, which on the Wikipedia figures, is less effective, both for perfect use and typical use, than the fertility awareness method (though the HSE doesn’t bring this out). Yet nobody in this thread has expressed any outrage about that. I can’t avoid the suspicion that people’s distaste for the fertility awareness method is based, not on the unique awfulness of that method, but on the fact that they disagree with at least some of the reasons why people tend to choose it. But, frankly, it is none of the HSE’s business – or ours – why a couple choose one method over another. The HSE’s job is to encourage them to consider the issue, and to give them useful and reliable information about the options open to them. I thought people of a secular mindset would favour non-directive counselling.

[Neil]

Surely they should have to give info on the old Roman honey-smeared-on-the-cervix method, or the ancient Egyptian trick of filling the vagina with dung. (Both of them seem to have had at least marginal success rates, which makes sense seeing as how sperm cells have difficulty passing through thicker substances). I mean, if they really want to be impartial...

[Ygern]

I tend to agree with you Neil

But seriously, I 100% agree that women and men should be taught how to identify fertility. In my opinion (considered and learned as it is) far too many young Irish people are leaving school in a state of the most stupifying ignorance about basic human biology.

But to suggest that this is a viable contraceptive option (especially for experimenting teens) is unconscionable. It is right down there on the bottom rung, only millimetres above the option that reads: Contraception? Hell no, I'm trying to get pregnant.

It may be fine within the confines of a permanent relationship where the sudden unexpected appearance of a baby is quite acceptable; it's most emphatically not ok in the case of young adults who are experimenting and still have Leaving Cert or College ahead of them.

Seriously, trying to claim that the failure rate, for example, of the IUD (the coil) is anything like the failure rate of the "Be Aware of your Cycle" failure rate is utterly disingenous and completely unsubstantiated by statistics.
The difference between less than 1% (IUD) and 20-25% (Cycle) is huge; especially when you take into consideration that the former requires nothing from the user after intial insertion and the latter requires constant and permanent monitoring.
For one thing, the upper end of the failure bar, as small as it is, on the IUD has nothing to do with user error, whereas the upper end on the Cycle Methods have everything to do with user error. And to be fair, there are so many biological reasons for indicators of the Cycle Methods being "off" that it is hardly surprising that genuine mistakes are made.

Either way, this says nothing about the HSE and its motivations. I have no experience of them, and I have no idea what their motivation is. But in an impartial overview of contraceptive methods; the "natural" method of observing the female cycle should not be recommended other than to long-term committed couples who are aware that they will be using the method most likely to result in a pregnancy.

[UDS]

Look, in many respects I couldn’t agree more. Fertility awareness contraceptive methods are not for everyone, and they are certainly not for couples whose relationships are intermittent, tentative, exploratory, etc. They’re not for me, as it happens. But I would point out that the HSE website also covers tubal ligation and vasectomy, also options which are not ideal for couples whose relationships are intermittement, tentative, etc. Nobody has been leaping up and down expressing “outrage” about that.

As you say, trying to claim that the failure rate, for example, of the IUD (the coil) is anything like the failure rate of the "Be Aware of your Cycle" failure rate is utterly disingenous and completely unsubstantiated by statistics.”. But the HSE site is making no such claim; on the contrary, it sets out the relevant figures quite clearly. Nobody reading the HSE site could be left with the impression that these are two equally reliable methods of contraception.

Now, the IUD suffers from some defects. It requires a doctor to insert it, and a doctor to remove it, and it continues to have a contraceptive effect for some time after it is removed. Depending on a couple’s circumstances, any of these could be a negative factor. Furthermore, some women are averse to the idea of carrying a surgically-implanted foreign object in their bodies for an indefinite period. I myself would have no such concerns, but I am not a woman and, even if I were, my lack of concern would be relevant to my contraceptive choices, not to anyone else’s. Similarly, there are women who are uncomfortable about pharmaceutical methods of contraception, and couples who have a distaste for barrier methods.

People who have such concerns, or who reject your or my preferred method for any reason which seems good to them, are entitled to information – clear, accurate and comprehensive information – about the options available to them, and the strengths and weaknesses of each. All of them.

As I said before, I’m concerned that objections to the fertility awareness method being mentioned, expressed in terms of its relatively high failure rate, actually have a different motivation. There are several barrier methods of contraception which have higher typical use failure rates than the fertility awareness method; one of them is mentioned in the HSE website. Nobody has objected to that mention. Why not? I think the truth is not that people consider the fertility awareness method to be excessively unreliable for consideration as a contraceptive option; rather, they are afraid that couples will chose it for the “wrong” reasons, i.e. for reasons which seem unpersuasive or insufficient to you and me.

But I do not think this is a good reason for attempting to keep people in ignorance, which is in effect what is being suggested. The notion that we should censor information of this kind, omitting all mention of a particular contraceptive method for fear that some people might choose it for reasons which do not seem good to us, is arrogant and offensive. People do not have to justify their contraceptive choices to you or me, and we have no business trying to manoeuvre them into making the choices we think they should make.