“Is it doing something to me?”: A qualitative study of the embodied experience of Irish women using the oral contraceptive pill

Introduction

The oral contraceptive pill (OCP) is the second most popular method of short acting contraception globally, after the male condom (United Nations, Department of Economic and Social Affairs, Population Division, 2019). The OCP is a safe and effective contraceptive, and is also prescribed for its non-contraceptive benefits, including treatment for heavy menstrual bleeding, anaemia and endometriosis. It has been proven to reduce risk of certain cancers (Bahamondes et al., 2015). Common physical side-effects reported include breakthrough bleeding, nausea, headaches, abdominal cramping, breast tenderness, and increased vaginal discharge or decreased libido (Basciani & Porcaro, 2022). While these side-effects are well-documented, the relationship between the OCP and mental health is not definite. Research in this area is limited, with conflicting findings. However, a landmark study conducted on over one million women between the ages of 15 – 34 (excluding women with a prior history of depression), found an increased risk of usage of antidepressants and first diagnosis of depression amongst women who used the combined OCP (Skovlund et al., 2016).

This widespread popularity of the OCP is also reflected amongst Irish women (Dublin Well Woman Centre, 2020). While the physical experience of taking the OCP is somewhat universal, the social and cultural Irish context requires further consideration. The landscape of reproductive rights and healthcare in Ireland has been transformed in recent decades. The sale and use of all contraceptives in the Republic of Ireland was illegal until 1979. The powerful medico-religious alliance within the strongly Catholic Irish society ensured the safeguarding of an agreed moral position on important health issues, namely contraception (Earner-Byrne, 2010). Subsequently, there has been rapid access to contraception and reproductive rights. Irish women now have access to abortion care, and recent legislation has made contraception free for females aged 17–35 (Department of Health, 2022).

Given this widespread usage, and changes in attitudes and legislation, it is important to ensure women’s experiences are central to the evaluation and redesign of women’s health initiatives in Ireland. Systemic reviews suggest little evidence to date relating to the Irish experience of contraception choice, use and behaviours (D’Souza et al., 2022; Pratt et al., 2014). The aim of this qualitative study is to examine the psychological and embodied experience of young Irish women who are taking the OCP. Through thematic analysis of semi-structured interviews, this study highlights decision-making and lived experience within the current social, cultural, and biological understanding of the OCP in the Irish context.

Methods

Analysis

Reflexive thematic analysis (TA) was used to analyse the transcripts. A realist, inductive, semantic approach was taken when analysing the data as this is an under-researched area with no pre-existing coding frames or analytic preconceptions. Analysis followed the six steps laid out by Braun and Clarke (2019). Transcribing the interviews allowed for familiarisation with the data. Initial themes were developed from codes generated from the data before being reviewed (see Table 2). Master themes were finalised, and patterns of shared meaning were conceptualised, underpinned by a central organising concept (Braun et al., 2014), to answer this research question.

As coding is an inherently subjective process, the lead author’s experience, skills, training and research values undeniably impacted on the development of codes, and they could be considered an “insider researcher” (Barrett et al., 2020), being female and of similar age and background to all participants. Viewing the researcher as an instrument, particular researcher characteristics may be more effective in eliciting detailed narratives particularly when discussing sensitive topics (Pezalla et al., 2012). Being an insider allows for the researcher to be viewed on a more equal footing and minimises the power differential between the researcher and participants. This can encourage rapport between participant and researcher (O’Connor, 2004), which can result in richer data (Dwyer & Buckle, 2009). However, this can also result in presumption on the part of the participant and researcher, who may provide or seek out insufficient detail when collecting data, consequently hampering efforts to achieving a greater depth of data (Blythe et al., 2013). This researcher engaged in some self-disclosure before the interviews to try and establish rapport with participants, in an act of reciprocity for the degree of openness and honesty that participants engaged in; and after, to bring the interview experience to a natural end. This researcher kept a reflexive research diary, and before beginning the study, made notes of any preconceptions in relation to participants’ experiences as well as engaging in reflexive discussion with the researcher supervisor. Reflexivity can be considered a continual process (Barrett et al., 2020), and was engaged in throughout the research project.

Findings

It should be noted that all names used in this section are pseudonyms and are not the real names of the participants.

The OCP is the second most commonly used type of contraception in Ireland, after the male condom (Dublin Well Woman Centre, 2020). While there were clear common themes and similar narratives which developed from all the data provided by participants, what was clear was the variety of experiences that participants experienced, specifically in terms of specific side effects experienced, circumstances regarding first use (i.e. age, primary reason, joint decision with another party, whether the first type used was suitable or whether several types were trialled until a suitable type was found), and whether the OCP had been discontinued or not. While no two participants seemed to share the same journey, thematic saturation was achieved early in the analysis as there were clear similarities across all accounts.

It is clear that using hormonal contraception, in particular the OCP, is a unique and personal journey for every Irish woman. Perhaps the individuality of each participant’s experience is one of the most significant learnings to be taken from this research project. However, three main themes were identified and are outlined below.

Discussion

The findings from this study add to the limited literature on the social, psychological and embodied experience of Irish women taking the OCP. Analysis of these experiences reveals that using the OCP is a complex experience, and the Irish women interviewed experienced tension and internal debate over decisions to use the OCP. This tension exists primarily across the following dimensions: embodied knowledge and experience, interpersonal relationships and taboo topics, and cultural and social cues. By deciding to use the OCP, participants felt they were sacrificing other areas of their health, physical and mental. This was amplified through the concerns expressed by all participants, that an additional daily dose of artificial hormones would impact on future fertility or result in changes to natural personality development. Previous research has shown the OCP has not been linked to decreased fertility following discontinuation (Barnhart & Schreiber, 2009; Girum & Wasie, 2018) yet this was an oft-cited concern for participants. This concern regarding fertility is in line with previous studies which found that users of contraception do not view doctors as “experts” in this area, and depend instead on other women in their social networks for information or validation of their contraceptive choices (Lowe, 2005). Unintended side effects were cited for many participants as their main apprehension before taking the OCP, or their main reason for discontinuation, similar to previous findings (Rosenberg et al., 1995; Shakerinejad et al., 2013).

Given the historic treatment of women’s health in Ireland, it is perhaps unsurprising that there still exists a lingering undercurrent of unease and mistrust from women towards the medical industries. In our analysis, this tension appears to manifest itself in the “battle” for control that Irish women appear to be facing. As illustrated above, the women interviewed experienced a dynamic and complex sense of agency over their contraceptive choices. While the OCP does provide women with control over their bodies and fertility, for many they also felt as if it has a degree of control over them.

Another interesting feature of the embodied experience of participants was the tension that existed in their interrelationships about this “taboo” topic. The discussions, or lack of, between participants and their parents speaks to the taboos that still exist in our society. It highlights stark differences in attitudes between generations towards sex, along with the reluctance of parents to admit that their child is at the age where they require contraception. As discussed in the previous section, the majority of participants had no familial support or input in their initial decision to begin using the OCP. For those who had maternal involvement, this input and open discussion was not sustained. Particularly revealing was the experience that some participants had of being warned not to tell anyone they were using it, even if it was to manage menstrual symptoms. It is worth considering the contrast in religious influence between generations and the lasting impact of this. Participants who grew up in self-described “traditional” and “Catholic” households expressed worry about their initial decision to begin using the OCP for contraceptive reasons. This point supports previous calls for more comprehensive sexual education, and given the lasting impact of the Catholic Church in education settings, there is further need to integrate evidence-based, inclusive sexual health education in education settings (O’Donoghue & Harford, 2022; Parker et al., 2009; Sherlock, 2012).

One other important aspect of the embodied experience of taking the OCP is the clear impact for a large proportion of women, on their mental health. Though the physical effects of the OCP have been well-studied (Dragoman, 2014), the understanding into the relationship between the OCP and mental health to date is mixed, and reliant on quantitative data (Anderl et al., 2020; Doornweerd et al., 2022; McKetta & Keyes, 2019). As highlighted by participants, many felt unaware of existing empirical findings and research. Irish GPs and educators should be made aware of the perceived responsibility that rests with them to relay this knowledge more transparently to participants. This lack of transparency and accessibility is subsequently perceived as a lack of interest or importance into the lived experiences of women.