Who’s Afraid of Birth Control?

Photo-Illustration: by the Cut; Photo Getty Images

Reproductive rights are eroding around us. In recent weeks, a Texas woman was arrested and charged with murder for an alleged “self-induced abortion.” Though the charges were subsequently dropped, the episode felt like a warning. And it came amidst developments in legislation in Missouri and Oklahoma aimed at stripping away the protections that Roe v. Wade had long codified.

And so the moment is especially ripe for careful, nuanced storytelling in the broader world of reproductive care. A new film from director Abby Epstein and executive producer Ricki Lake, the actress and talk-show host, bills itself as a documentary examining the underdiscussed side effects of oral contraceptives and other hormone-based birth control. The project, The Business of Birth Control, raises some legitimate questions about informed consent: Do individuals taking hormonal birth control fully understand how it works and its potential side effects, and do they know what rare complications — like an increased risk of blood clots — to watch for?

But in wrapping these fair questions in heavy-handed storytelling that relies on anecdata and some sources with vested interests, and in brushing aside basic statistical principles like the distinction between correlation and causation, as well as general scaremongering, the film’s tactics are at best misguided and at worst dangerously manipulative. Rather than making the defensible case that hormone-based contraceptives might not be for everyone, the film frequently pushes further, suggesting repeatedly that they are for no one.

The film, which is based on a 2013 book by writer and activist Holly Grigg-Spall, is concerned with recontextualizing hormone-based contraceptives in both the realms of history and health care. It is of a piece with Epstein and Lake’s past film projects, which include the 2008 release The Business of Being Born, which promotes natural-birth methods and spawned a “grassroots phenomenon” among its dedicated audience of concerned women, as Entertainment Weekly put it.

The Business of Birth Control sets out to question the popular historical narrative of the pill’s introduction and subsequent widespread uptake in the 1960s and ’70s as an empowering development for women, and instead offers a competing view: one of women having been virtually brainwashed into delaying the decision to begin families so that they could become shoulder-padded, high-heeled cogs in a capitalistic system. (The film is perhaps at its most charming when it offers copious archival footage of office workers commuting half a century ago, or in the office, pressing clunky receivers between their ears and shoulders.)

Most of the film focuses on the health risks of oral contraceptive products and other hormone-based birth control. It is legitimate to raise questions about their safety. But it feels disingenuous to ignore, as the film largely does, the extensive exploration of these very questions, as well as the existing documentation of the answers to many of them, for which a preponderance of evidence exists in the form of clinical data, peer-reviewed scientific literature, and mainstream reporting.

Instead, the film posits that many people who menstruate lack a sophisticated understanding of their own anatomy and of the intricacies of their menstrual cycle. And so, it suggests, given these gaps in understanding, physicians prescribing hormone-based contraceptives aren’t doing enough to obtain informed consent from their patients.

Then, in a move that smacks of anti-science propaganda, the film devotes much screen time to a handful of grieving family members of young women who died while allegedly using hormonal contraception. Their heartbreak is palpable, and their advocacy earnest — which makes the filmmakers’ decision to trot them out and score their tearful interviews with maudlin chords all the more irresponsible. The filmmakers do viewers a disservice by providing us with these tragic instances of correlation presented incontrovertibly as causation, with hints that such harm is occurring on a grand scale. (It is not; a study that followed more than 120,000 women taking oral contraceptives over 36 years found that those on the pill were no more likely to die than those not taking it.)

If the pill doesn’t kill you, the film ominously suggests, it’s likely to alter the core of who you are. It offers interviews with young women who say they felt depressed or unlike themselves on the pill, and cites as conclusive scientific evidence a statistic from a single study out of Copenhagen that found those between ages 15 and 19 on oral contraceptives were 80 percent more likely to be depressed. But the film doesn’t bother to examine the weaker correlation (a 23 percent increase in likelihood) among women in their 20s and older, or other studies on contraceptives and depression that showed no such link.

“To fearmonger when the pill is such an important medication for so many women, not just for birth control, but for other noncontraceptive reasons, is shameful,” says Dr. Leah Millheiser, clinical professor of obstetrics and gynecology at the Stanford University Medical Center, after viewing portions of the film. She cited the decades of studies documenting the safety and effectiveness of approved oral contraceptives for eligible patients. She pointed out that, though some data has been inconsistent, the Food and Drug Administration has erred on the side of caution in warning that newer-generation hormonal drugs, like Yaz, might indeed carry a higher risk of blood clots than do older contraceptive pills — a fact that is reflected in the products’ labeling as required by the FDA. (Pregnancy itself carries a higher risk of blood clots than do oral contraceptives, she noted.)

And she explained that the standard of care requires physicians to have detailed conversations with patients considering oral contraceptives to identify characteristics that might make them a poor candidate for such treatments — factors that might range from blood disorders to a heavy smoking habit. So when patients do experience rare physical health problems, like blood clots, while taking oral contraceptives, Dr. Millheiser said, it’s sometimes because they have an underlying condition — a blood disorder or cardiovascular disease — of which they might not have been aware.

As for psychological side effects, she said, most women do not experience significant mood changes or depression on oral contraceptives. But they’re possible, and such changes need to be carefully monitored — especially in patients with a history of depression or among teenagers, as studies have shown the strongest correlations among young women and girls.

Nobody is talking about all these side effects, the film argues — no one is warning women of potential harm. But its message feels particularly muddled when it comes to laying out its vision of what satisfactory informed consent could look like. At moments, for instance, the film seems to be pushing for the FDA to issue a large-print “black box” label for all oral contraceptives, akin to the surgeon general’s warning on cigarettes. At other times, its sources mock the detailed inserts with information on side effects that do come with every package of medication, saying that no reasonable person would bother to read such warnings anyway. At still other moments, the film suggests no hormone-based contraceptive should be considered safe for market, and that the FDA’s judgments as to their safety and efficacy aren’t to be trusted — nor, presumably, its warnings?

The film also tries to make a case against birth control in stranger, more suggestive ways. In one scene, it presents the haunting prospect that people taking hormonal birth control operate in such an altered state that their ability to choose a suitable partner might be compromised; women who’ve gone off the pill, sources in the film warn, have realized they had chosen mates “more like ‘brother’ and less like ‘other.’” (“We have to be very cautious” of data that comes from only a handful of small studies, Dr. Millheiser said, noting that the data has not been reproduced in a larger study.*) Among its logical contortions is a provocative claim that the pill’s history of clinical trials is exceptionally racist, and by extension, those who take the pill today are somehow complicit in the vast specter of the genuinely repulsive and horrific history — and in some cases, present — of racist medical experimentation in this country. That significant and appalling context certainly must be acknowledged, studied, and actively repaired. Yet singling out hormonal contraceptives and discouraging people from using them on this basis defies reason.

In any case, all of this feels so frightening, doesn’t it? Blood clots. Depression. Accidentally settling down with a brotherly type. Women would be better off steering clear of all of that, the filmmakers plainly feel. And so the film’s second movement charts a smattering of women-focused start-ups and educators as they push dubious alternative strategies — predominately variations of the rhythm method. Here, they benefit from the trendiness of wellness, “self-care,” and their trappings. If women only used some tech and some spreadsheets — an app? — to track our vaginal discharge, if we only became better acquainted with the reflection of our own vulvas in a handheld mirror, we could become more in tune with our bodies’ subtle signals — and thereby become expert conception-dodging ninjas.

In one scene, an educator presents a “smart,” $300 basal-body thermometer called Daysy to a group of girls. The method involves charting one’s daily temperature to pinpoint the most fertile days in a menstrual cycle, around ovulation, when a person’s temperature tends to tick slightly higher. “It learns you for three months,” the educator explained, as the app collects information that it uses to begin to predict future cycles. “After three months, you can use it.”

The film does not disclose until the fine-print credits roll, though, that Valley Electronics, the company behind Daysy, is among its financial backers. (So are other proprietors of tools geared toward cycle-tracking methods, including Kindara, which makes a cycle-tracking app, and Michael Vardi, founder and CEO of Tempdrop, which makes a wearable temperature-tracking device.) A 2018 study on Daysy in the journal Reproductive Health, the authors of which included Daysy’s own medical director, was retracted the following year when researchers raised concerns about the accuracy of its contraceptive claims. Valley sued one of them, Chelsea Polis, for defamation, but lost its appeal in March.

Dr. Millheiser is sympathetic to patients seeking natural approaches to reproductive health, she said. But patients need to understand that these methods are much less effective at preventing pregnancy than the pill, she explained. A 2014 report from the Centers for Disease Control and Prevention showed that 24 percent of women using such fertility-awareness-based methods experienced an unwanted pregnancy within the first year — something else that the film doesn’t mention. “The risk of an unwanted pregnancy is huge,” Millheiser added, all the more so because now “in certain states, you can’t get an abortion.”

Though the risks and benefits of existing hormonal contraceptives have been well studied, it seems fair to want, as the film does, better options with fewer side effects. Pharmaceutical companies have largely slowed development of new contraceptive products, and even the nonprofit and government funding earmarked for developing birth-control drugs has been drying up. Challenging the status quo of available options feels worthwhile. So, too, does highlighting the importance of understanding what to expect in terms of potential physical or emotional changes when using hormonal contraceptives.

But the film’s tactics serve to undermine these valid observations. It claims to extol a version of feminist empowerment in which women should trust ourselves to become our own contraceptive experts. But its real message instead threatens to damage the trust that women put in our doctors, and in our very experience of our selves.

*Update: This story has been updated to clarify Dr. Millheiser’s comments about research into how the birth control pill affects attraction.

Who’s Afraid of Birth Control?