Every Girl I Knew Was On It

Why some women are questioning hormonal birth control.

Photo-Illustration: by Preeti Kinha; Photos: Getty
Photo-Illustration: by Preeti Kinha; Photos: Getty
Photo-Illustration: by Preeti Kinha; Photos: Getty

Every day since I was 15 years old, I have taken “the Pill,” a pale-pink tablet containing a combination of levonorgestrel and ethinyl estradiol, two chemicals that trick my body into thinking it’s pregnant so I can’t actually get pregnant. Since it came on the market in 1960, the Pill — a catchall term for a variety of oral contraceptives containing differing combinations of synthetic hormones — has been the most common form of birth control used in the United States, utilized at some point by four out of five sexually active women. While there are a number of other popular hormonal-birth-control methods, such as the IUD and the NuvaRing, none enjoy the popularity and cultural significance of the Pill.

In high school in Toronto in the early-aughts, it seemed like every girl I knew was put on it, for some reason or another, whether or not she was sexually active. This could be because, as science historian Elizabeth Siegel Watkins notes, marketing around the Pill began to change in the 1990s, with oral contraceptives being promoted not just as a birth-control method but as a “lifestyle” drug with a host of benefits, like treating acne or diminishing menstrual pain. Many of us went on the Pill and then stayed on it through young adulthood, without giving much consideration to the question of what long-term hormone usage might be doing; I took the Pill every day for 13 years without knowing much about it.

Until three months ago, when I quit. In a development that the Pill’s earliest advocates would likely find strange — and concerning, given the increasingly tenuous status of Roe v. Wade under a conservative Supreme Court — many women I know are beginning to question hormonal contraception, particularly its effects on mood and behavior. I wanted to know what was causing us to suddenly doubt something we had been swallowing for years without much thought at all, and how we feel now that we’ve stopped.

The current scientific consensus is that the majority of women do not experience adverse side effects from the Pill. Even so, Dr. Erika Banks, director of gynecology at New York’s Jack D. Weiler Hospital, said she’s noticed an increase in patients coming in with vague concerns about long-term hormone use. “I’m not really sure where they’re getting that information,” she said.

And yet there’s less conclusive data about the subtler ways the Pill might affect us when it comes to mood or sex drive or overall quality of life, all of which are harder to quantify. Some women who’ve quit the Pill told me they’ve seen a reduction in anxiety or depression; some have seen an increased libido. For others, the effects were more nebulous: I heard phrases like “more alive,” “more clear,” “more myself,” and “like a fog had lifted.” The more I spoke to people, the more obsessed I became with the idea that one little tweak to my hormonal network could be affecting everything I take for granted about myself. What might hormonal contraception be doing to our minds, our moods, our behavior? And if science hasn’t yet found a clear answer, how much does that matter?

It feels precarious to even be asking these questions right now, given the fact that women’s access to abortion and contraception in the U.S. is under siege. Nine states have passed legislation to ban abortion early on in pregnancy, though they are likely to get blocked in the courts; Ohio’s bill contains language that reproductive-rights advocates say could eliminate health-insurance coverage for contraception, including birth-control pills. Meanwhile, the Trump administration inches closer to defunding Planned Parenthood. The pro-choice climate that allowed our current wave of Pill skepticism to flourish is beginning to look like a thing of the past, and women’s ability to question their contraceptive choices feels increasingly like a luxury. As attacks on women’s bodily autonomy continue, quitting the Pill remains the purview of privileged women in liberal enclaves who have the time and resources to use things like non-hormonal IUDs and cycle-tracking apps — not to mention health care and therapists and access to abortions and morning-after pills when such methods fail. The Pill is still, for a great many women, the best and easiest option. Speaking about “influencers” who advise quitting the Pill without addressing the consequences of a lack of abortion care, Dr. Jen Gunter, a writer and ob-gyn, said, “I would say maybe these women should see what it’s like when people have to cross picket lines to get the kind of health care they need.”

Is it anti-feminist to question the Pill? It’s true that right now we need effective, accessible birth control more than ever. It’s also true that much of our current wave of Pill skepticism lives in that nebulous realm where fear of the medical Establishment and “wellness” trutherism intersect, one that — much like the anti-vaxx movement — easily veers into the realm of paranoia and pseudoscience. On the other hand, questioning the Pill can be viewed as stemming from the same feminist instinct that engendered the Pill’s rise: a desire to ask good questions and make informed decisions about one’s own reproductive future. It’s just that there never seems to be a good time to ask these questions. The daily onslaught against women’s reproductive rights makes it feel like expressing dissatisfaction with the status quo is an act of naïve privilege, even if it’s a status quo many women were not happy with.

Even though the Pill has given us freedom, it’s also the result of a culture that expects women to bear the costs — financial and otherwise — of preventing pregnancy. It’s also true that it comes with side effects that women have been expected to quietly accept. In 2016, a clinical trial of a promising hormonal contraceptive pill for men was halted for safety reasons. (Headlines at the time focused on the fact that a number of the men complained of adverse side effects, many of which may sound familiar, including acne and mood swings.) Maybe now, in this moment of exploding feminist rage, women have simply had it up to here with having to bear all these potential ill effects alone. It’s something Regan, 29, considered when she stopped taking the Pill — and when she persuaded her sisters and a lot of her closest friends to do the same. She lives in Toronto, where abortions remain relatively easy to access (for now). Now she says she uses condoms. “I really just had a moment of like, Okay, I’m doing this just so I can have unprotected sex — and at what cost to me?

What is the cost to women like me and Regan? Hannah, a 25-year-old Brooklyn-based writer and illustrator, went on the Pill to manage PCOS in her late teens. Soon after, she started fantasizing about walking into traffic. When she brought up her concerns with her doctor, she received a “weird amount” of resistance, so she went off the Pill on her own. Indeed, many of the women I spoke to say that health-care professionals failed to listen to their concerns about the ways the Pill was affecting them. It’s a valid concern. Women’s health — particularly mental health — has long been an understudied area. As Maya Dusenbery writes in Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, women suffer from both a trust and knowledge gap; doctors know less about how women’s bodies work than men’s, and women’s subjective stories are less often believed. Yet going off the Pill without professional guidance can be risky. Various health issues that existed prior to starting the Pill can recur. The biggest risk, of course, is that you could get pregnant. Most of the women I spoke to have replaced the Pill with other methods of birth control: condoms, other hormonal methods like the IUD (which could also have psychological effects), cycle-tracking apps, and the pullout method. These are of varying efficacy; the latter two, in particular, have high failure rates.

“Everyone has a different risk-benefit ratio,” says Gunter. “What if you were somebody with really difficult-to-treat depression and you decided to stop the Pill because of what you saw on social media, and then you had an unplanned pregnancy and were living somewhere where you couldn’t get an abortion? Definitely if you’re having depression, you should talk with your provider about whether contraception could be part of the picture. But it’s also important to remember that if you are at risk of getting pregnant, what’s going to be the plan? Because an accidental pregnancy is also not going to be good for your depression.”

In Hannah’s case, the psychological benefits of quitting the Pill outweighed any potential risks. Now she uses the Liletta IUD, which she got after extensive personal research, and conversations with her ob-gyn about how the hormones in the IUD differ from those of the Pill. “Within a few weeks of stopping the Pill, color returned to the world,” she told me. “It felt so cliché — like the episode of The Simpsons where Lisa goes on antidepressants and everything was all smiles. Within a few weeks the world was totally manageable, and I was like, Why did I wanna get hit by a bus so bad?

When it comes to the Pill’s effect on women’s mental health, we still hold only a handful of the pieces to what could end up being a many-thousand-piece puzzle. “Most of the research women hear about is all from the neck down — increased risk of this or that health problem — but they don’t really talk about what it does to the brain,” said Dr. Sarah Hill, a professor of psychology at Texas Christian University and the author of the popular-science book This Is Your Brain on Birth Control, which will be out this fall. The book is inspired by her research, but also by her own experience of quitting the Pill about ten years ago after being on it for a decade. “I feel like I climbed out of a black-and-white drawing into the real world,” she told me. “I had felt flat and one-dimensional, and suddenly I felt so much more vibrant and alive. It was like waking up.” Hill had been studying women’s mental health for over 15 years, yet it had never really occurred to her that the little pill she took every day might be affecting her psychology in dramatic ways. “I realized like, Oh yeah, that’s right, hormones influence the brain, and if you change hormones you’re going to change what women’s brains do.” She laughs. “It was a pretty embarrassing epiphany to have as a psychologist.”

One reason for the dearth of research on the Pill’s mental-health effects is that doing research on women is more complicated and expensive than on men, as a result of the need to take into account participants’ unique hormonal cycles. A 2012 review of the research noted that “surprisingly little” is still known about adverse-mood effects from oral contraceptives. Based on the studies we do have, about 4 to 10 percent of women report deterioration in mood (although it’s likely that not all of these are caused by the Pill). Then again, a similar fraction of women see improvements in mood on the Pill, particularly those who suffer from PMS or premenstrual dysphoric disorder.

In recent years, there have been new developments, though nothing conclusive. A much-publicized 2016 Danish study found a correlation between depression and hormonal-birth-control usage, noting that women on the Pill were 23 percent more likely to go on antidepressants. A 2017 Swedish study, on the other hand, found no increase in depression, but did find a general decrease in quality of life (mood, energy levels, etc.) in women who took the Pill for three months.

Without much scientific data to go on, it’s tempting to be swayed by anecdotal evidence like Hannah’s story, and the rise of social media makes sharing stories like these easier than ever. While Gunter says women have had concerns about being on long-term hormones for as long as she has been in practice and that they have traded scary stories about the Pill’s side effects for as long as it has been on the market, she sees social media as amplifying the conversation about its “harmful” effects. She points to “the illusory truth effect,” where the more you hear something, the more you believe it to be true. While she doesn’t discount women’s experiences, she notes that it can be hard to tease out cause and effect. “There’s a huge placebo effect if you think you’re going to feel better,” she said. “There’s also the nocebo effect. If I tell you the Pill is going to give you side effects, you’re more likely to have them.”

While there’s little risk in listening to friends or influencers when it comes to, say, the benefits of meditation or yoga, choosing a method of contraception based on word of mouth can be risky, particularly because the internet is rife with misinformation. In many ways, this proliferation of questionable science represents the dark undercurrent not just of social media but of our current wellness boom. Thus far, many of the outspoken anti-Pill advocates don’t have the most pro-science track record. Like anti-vaxx rhetoric, much anti-Pill literature is rooted in a deep distrust of pharmaceutical companies and mainstream medicine.

In her anti-Pill polemic Sweetening the Pill, soon to be a documentary, writer Holly Grigg-Spall argues that hormonal contraceptives are “tools for a patriarchal society to have a ‘hold’ over women’s bodies.” Suppressing our natural periods makes us more like men, she hypotheses — “docile bodies” less prone to the volatile swings of our “natural” female hormones, and more effective cogs in the patriarchal capitalist machine. (Grigg-Spall’s book was panned in Slate and The New Inquiry for being unscientific and cherry-picking evidence to fit her claims.) And then there’s Kelly Brogan, a “holistic psychiatrist” who has spoken at Gwyneth Paltrow’s Goop summit, who advises her patients to quit birth control. Brogan also doesn’t believe in psych meds, has expressed skepticism about the efficacy of vaccines, and believes HIV doesn’t cause AIDS. On a 2017 episode of the Joe Rogan podcast, she described birth control as “the ultimate tool for oppression of the modern woman” — an idea that is not only patently absurd but dangerous.

But while anti-Pillers like Brogan and Grigg-Spall think the Pill is bad for all women, most clinicians advocate instead for the importance of each woman’s taking an individualized approach. A lot of women who went on the Pill as teenagers say that, in hindsight, they didn’t feel they were given all the information. “I think part of the disservice that the medical community has done to women in this area is that they have not explored the complexity of individual differences in responses from some women,” said Dr. Tory Eisenlohr-Moul, an assistant professor and scientist at the University of Illinois at Chicago, who uses experiments to understand how hormones impact mood in women. Levels of estrogen and progesterone naturally fluctuate at different points in our cycles, which can affect mood in some women. The Pill makes it so the levels of these hormones are more stable throughout the month. While one woman may report feeling like a “zombie” on the Pill, disconnected from her emotions, another may report feeling more stable, calm, and happy. Eisenlour-Moul advises her patients to listen to their bodies, because we’re all different and we shouldn’t presume what worked for another woman will work for us. “The goal is to be a little more thoughtful about giving your body what it needs to thrive instead of just assuming that what has been true for someone else is sure for you or making the logical fallacy that natural is better. Give yourself more credit for being the unique brain and body that you are.”

Hill was in the former camp, and after she went off the Pill, she started to dig into the research. What she found is that there might be solid biochemical evidence for what you could call a “lack of vibrancy,” the general dullness or lifelessness that some women report. “Pill-takers have lower levels of estrogen and unbound cortisol than non-Pill-takers,” she told me. “And these hormones are part of the signalizing machinery that make us feel like ‘us.’ For example, we know that estrogen increases a woman’s attunement to courtship cues and flirtatiousness. And we know that cortisol is something that plays a role in helping our brains absorb meaning from our environments. Having lower levels of these hormones may make Pill-taking women’s brains less excitable and less able to absorb all of the depth of their experiences than non-Pill-taking brains. It may make life feel more flat.”

While only a small percentage of women suffer from severe depression on the Pill, Hill thinks that the number of women who have some negative psychological side effects is probably much higher. “Lack of vibrancy” may not be up there with unwanted pregnancy or major depressive disorder, but it’s certainly a big deal to the women who experience it. “I think the only time that doctors consider something a psychological side effect is when somebody goes into a full-blown clinical depression,” said Hill. “It’s pathetic that our mental health doesn’t get taken very seriously unless it’s the absolute rock bottom of the barrel.”

Hill’s book looks at how hormones can influence things like mood, sexual attraction, stress response, and a whole range of other things, and calls for more research into the effects of long-term hormonal contraceptives on both an individual and societal level. “This book is sort of making women aware of how their hormones work and how they’re really a key part of who we are,” she said. “You can’t change women’s hormones without changing women, and I think we’re just hitting the tip of the iceberg now in terms of how it can influence how we experience the world.” In rare cases, she said, women have gone off the Pill and found that things they’d felt certain of — like their work-life balance or their choice of partner—suddenly felt wrong. “There are women who built their whole lives when they were on the Pill, and they go off it and don’t know what to do because they feel like they don’t recognize it — they built a life that they don’t want anymore.”

Some women say the Pill drains their libido, and a number of studies have found evidence to support that (although, according to Psychology Today, less than half of 1 percent of the published research on the Pill has been on libido). But decreased sex drive is not just a side effect listed on a pamphlet. While it used to be enough of a miracle benefit simply to be able to have sex without getting pregnant, today sexual fulfillment is intrinsic to being a modern woman.

Of course, many women go off the Pill and feel worse, suddenly finding themselves in the grip of unexpected physical symptoms and tumultuous mood swings. As for me: I have been off the Pill for three months now. So far I have been using condoms, though it doesn’t feel like a long-term solution (they are awkward and I hate them). Yet I can’t deny that I feel better. I’m less anxious. It feels like a sharp edge has been removed; like I’m not vibrating at quite the same neurotic frequency that I’m used to. As great as this change is, it’s also difficult to process. If the Pill really has been increasing my anxiety, then could much of the past 13 years of emotional turbulence have been avoided simply by switching my birth control? It’s hard not to look back and wonder. It’s also hard to imagine any other birth-control method that would have provided the same ease and peace of mind about unwanted pregnancy throughout a tumultuous period of my life.

To be a woman in the world is often to be content with choosing from a buffet of unappetizing alternatives. I don’t know how hormonal birth control might have changed me, because no one does. At least now we’re starting to ask these questions — even if a satisfying answer still seems a long way off.

Every Girl I Knew Was On It