Psychiatric aspects of contraceptive utilization

Psychiatric

aspects of contraceptive

utilization PETER

BARGLOW,

DAVID

KLASS,

Chicago,

M.D. M.D.

Illinois

Psychologic conflict regarding birth control may play a larger role in contraceptive failures than mechanical and physiologic factors combined. The authors discuss a number of these conflicts, which include motivational conflicts in implementing birth control and the symbolic meaning of birth control devices which decrease the likelihood of successful use of the device. In addition, various psychiatric symptom states are related to contraceptive failure. To minimize patient failures originating in emotional conflict, an obstetrician-gynecologist should adhere to the following principles: (1) Every woman’s motivation for family planning needs to be assessed. Usually the process of evaluation requires only a few minutes and one or two questions. (2) The individual patient should be matched properly with the optimal contraceptive means. (3) The gyneco!ogist must be alert for clues indicating psychiatric symptoms or even a need for psychiatric consuttation.

corroborates the MUCH EVIDENCE observation that emotionally healthy women are likely to achieve contraceptive success. Psychosexual maturity has been considered an indication of ability to tolerate oral contraceptivesl A capacity to plan ahead and a conviction that one has the power to control one’s life have been related to effective family planning2 Responsible, competent marital coupIes plan their families effectiveIy.3 Women who enjoy sexual intercourse are frequently described as likely patients for birth control success? High motivation in married women for sexual relations has been

correlated with high persistence in use of oral contraceptives.* On the other hand, intense motivational conflicts regarding birth control, the symbolic meaning of a specific contraceptive device, or a variety of psychiatric symptoms may interfere significantly with contraceptive success. It is important that the obstetrician-gynecologist be aware of the possible existence of these facts to ensure effective contraceptive utilization by his patients. Motivation

From the Department of Obstetrics and Gynecology and the Department of Psychiatry, Michael Reese Hospital, the Department of Psychiatry, Northwestern University Medtcal School, and the Department of Psychiatry, University of Chicago. Presented at a meeting Gynecological Society. y;;;ived for publication Accepted Reprint N&chrgan

for publication

of the Chicago October April

requests: Dr. Peter Ave., Chrcago,

7, 12, 1972.

Barglo.w, Illmors

problems

A conscious decision to request a contraceptive agent may conflict with a strong unconscious need for pregnancy on the part of the patient or her husband or partner. In one postpartum patient, a hidden unconscious desire for a pregnancy to re-establish a close contact with her obstetrician (a substitute for her father) sabotaged the obstetrician’s prescription for a contraceptive. A woman’s determination to avoid pregnancy may be undermined by the emotional needs of her husband. An emotional conflict of the husband based upon an unconscious

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need to repeatedly impregnate his wife may preclude the utilization of contraceptive advice. At other times, the male partner may discourage the use of oral contraceptives because of an unconscious fear that the contraceptive might make him sterile or impotent. An obstetrician-gynecologist can never permit himself to forget that his patient’s efforts to avoid pregnancy require the full cooperation of her sexual partner. Objections by the husband to the use of contraceptives is usually associated with a high failure rate.s Cultural, ethnic, and religious values may act to facilitate or inhibit the wish for children. For example, the cult of “machismo” (virility) is usually a psychological bar to reduction in family size. If a group wishes to gain political power through numerical increase, large families might be associated with high prestige. This was true in Germany during the Second World War. The barren woman is considered accursed in the Bible and is a person to be shunned in the Islamic religion. Such considerations are relevant to the potentially deleterious influence of the “Black movement on large-scale family Power” planning programs. Malcolm Xl0 wrote:

Obviously obstetrician-gynecologists ignore such contemporary social and attitudes. Selection

of

contraceptive

1, 1972 Gynecol.

cannot pressures

means

There are whites in this country who are still complacent when they see the possibilities of racial strife getting out of hand. You are complacent simply because you think you outnumber the racial minority in this country; what you have to bear in mind is wherein you might outnumber US in this country, you don’t outnumber us all

If there are or have been sexual conflicts resulting in guilt, shame, or inhibition, we often find an association of these conflicts with a specific contraceptive procedure or appliance. A woman with a conflict about handling her genitals might balk at the use of a diaphragm. I5 This is observed often with women who suffer from obsessive compulsive neurosis, who insist their partners use a condom. A condom may also have symbolic and somatic significance to the man so as to create impotence. Requests for therapeutic abortion may be associated with multiple psychiatric implications. In some cases, intensive psychotherapy with a psychiatrist may provide sufficient temporary emotional support and insight to enable the patient to undergo a change of attitude with the resulting development of a positive identification with the future child. Psychodynamically, there may be an unconscious equating of abortion with murder, and psychiatrically obtained insight may lead to a more successful, less destructive contraceptive effort in the future. It is advisable, when appropriate, that the empathic obstetrician-gynecologists recommend a brief delay in the final decision regarding abortion so that possible negative consequences can be carefully evaluated. Requests for sterilization frequently have psychiatric implications, especially when the

over

patient

desires

cedure cate.

than

the earth.

A recent issue of an important Black newspaper had a headline: “Steps Up ‘Pill’ Timetable to Wipe Out Black Race.“ll A contemporary Black leader recently told a Federal Commission that birth control “is a form of genocide . . . the destruction of the black people” (Chicago Sun Times, June mother23, 1971). I2 The stigma of unwed hood may constitute a “pseudo-moral barBlairI contraceptive usage.“13 rier to found that 25 per cent of Blacks considered family planning methods harmful to health.

a more

major

the case would

surgical

appear

pro-

to indi-

A 22-year-old married woman without children was referred for psychiatric evaluation. She had approached a gynecologist with a request for sterilization by hysterectomy, indicating that she disliked children and regarded them only as interferences with her career. She had a pulmonary embolism while ingesting pills and had become pregnant several years earlier, soon after being fitted with an intrauterine contraceptive device. The pregnancy was complicated by cystitis,

Volume 114 Number1

arthritis, and gastroenteritis, and the child was given up for adoption. The mother of this patient was paranoid and severely phobic during the patient’s childhood and clearly was never a suitable person for a positive maternal identification. The ambivalently loved and hated mother died several years earlier of pelvic carcinoma. Consciously, the request for hysterectomy reflected her wish for absolute certainty. Unconsciously, the wish for a major pelvic operation represented a masochistic self-mutilation to atone for death wishes toward her mother. The patient had her tubes tied without complications. Many studieP9 I7 suggest that hysterectomy has a higher psychiatric morbidity than tubal ligation. Genital areas are often connected with strong guilt feelings and anxiety, which may be temporarily relieved by a surgical or medical procedure.18l 19 Hormonal agents (orally used or implanted) present a special set of psychiatric problems. If a woman ingesting oral contraceptives has a conflict about pregnancy and responds to the “pill” with an increase in appetite, a subsequent unwelcome gain in weight, nausea, and breast enlargement, symptoms and signs associated with pregnancy, a psychoIogica1 contraindication of the particular contraceptive for that woman may be present. These symptoms, if not dealt with or understood, can give rise to serious depressive reactions. Benedek and RubinsteinzO have observed that the frustration of intensified passive, receptive needs, characteristic of the high progesterone levels of the luteal phase of the menstrual cycle or of pregnancy, may revive early oral (dependency) conflicts. The hormonal situation with the use of pills may create identical oral regression leading to depression. JarvP presented extensive analytic data of a woman unable to use the contraceptive pill, because it had the religious meaning of sin and the “holy wafer.” Adolescents who frequently “forget” to take the contraceptive pill or who become preoccupied with its medical dangers often have unwanted pregnancies. One of the main formulations derived from studies of adoles-

Psychiatric

aspects

of contraceptive

use

95

cent illegitimacy was that sexual contacts leading to pregnancy were motivated by attempts to break the mother-daughter tie.22 Such patients probably should be given an intrauterine contraceptive device to use until they have mastered the turmoil and impulsiveness of this developmental period. Psychopathology contraceptive

interfering efforts

with

A variety of psychiatric characteristics and symptoms have been associated with contraceptive failure. Intense unmet dependency needs have been mentioned frequently.3l 5, 23 Depressive tendencies also are often mentioned as a cause of family planning difficulties5j 24-26 Kanez7 postulates hormonal mechanisms that could exacerbate depressive symptoms in predisposed patients using oral contraceptive measures. However, oral agents are also alleged to diminish depression.83 28 Psychosomatic symptoms and a variety of functional complaints are common reasons for discontinuation of several contraceptive measures.g, 26-28 Such psychiatric problems interfere significantly with family planning. They constitute indications for special attention and discussion by the gynecologist. A request for contraception may sometimes even disguise a totally unrelated need for assistance as shown by this case. A married schoolteacher with one child was referred for psychiatric evaluation because of her wish to be sterilized. She wanted “one hundred per cent certainty” that another pregnancy was impossible. Her obsessional character structure was apparent as shown by her daily procedure for taking the oral contraceptive pill. At exactly 6:45 A.M., she begins to scrub her hands, sometimes repeatedly, since she has doubts about having washed them earlier. She takes a key she wears day and night on a string around her neck, examines the multiple locks of a suitcase for signs of forcible entry, unlocks the suitcase, and takes out the pill dispenser. She checks all apartment windows and doors to see that they are firmly closed and the blinds pulled. (This assures her that no one could spray any substance into the home which might destroy the potency of the pill.) She asks her husband what day of the

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week it is, checks the answer on the calendar, then reads and spells out the name of the day on the dispenser. Further details of this hour-long ceremony are redundant. However, from the description one may suspect that this patient’s compulsive, phobic rituals defend her against a more serious emotional disorder. There are

1, 1972 Gynecol.

some clinical evidence that either the sperm or the pregnant state symbolized the lifethreatening poison of a persecutor. An elective surgical procedure was considered inadvisable, and it was cautiously recommended she continue ingesting pills with periodic psychiatric consultation. Her psychiatric status has been stable for the past four years.

REFERENCES

1.

2 3. 4.

5. 6. 7. a. 9.

Orchard. W. H.: Med. J. Aust. 56: 872, 1969. ’ Keller, A. B., Sims, J. H., Henry, W. E., and Crawford. T. T.: Merrill-Palmer 0. Behavior Development, ;ol. 16, No. 3, 1970..Mischler, E. T., and Westoff, C. F.: Millbank Memorial Fund Q., New York, 1954. Chamnion. P.: In Boaue. D. T.. Editor: Sociologrcal Contributions to Family Planning 1957, Community and Family Research, Study Center, p. 112. Jones, G. S.: Obstet. Gynecol. Survey 25: 327, 1970. Lidz, R. W.: Fertil. Steril. 20: 761, 1969. Rainwater, L. W., and Weinstein, K. K.: And The Poor Get Children, Quadrangle, 1960. Ziegler, F. J., Rodgers, D. A., Kriegsman, S. A., and Martin, P. L.: J. A. M. A. 204: 97, 1968. Hill, R., Stycos, J. M., and Back, K. W.: The Family and Population Control, A Puerto -,

12. 13. 14.

Kashid, 1969, p. Chicago Chicago Blair, A.

L.: 9. Sun Sun 0.:

Muhammed

16.

“I

Rican Experiment in Social Change, Chapel Hill, 1959, University of North Carolina Press. IO. Malcolm X: Malcolm X Speaks, 1967, pp. 46-47. 11.

15.

Speaks,

October,

Times, June 23, 1971, p. 42. Times, February 9, 1971, p. 24. In Bogue, D. J., editor: Socio-

17.

18. 19.

20.

logical Contributions to Family Planning Research, Community and Family Study Center, 1967, p. 1. Reissman, C. K.: Am. J. Orthopsychiatry 38: 693, 1968. Barglow, P., Gunther, M. S., Johnson, A., and Meltzer. H. T.: Obstet. Gvnecol. 25: 520. 1965. ’ ” Stengel, E. Z., and Rayner, E. H.: J. Ment. Sci. 104: 389, 1958. Barglow, P.: OB/GYN Digest 8: 31, 1960. Menninger, K. A.: Psychoanal. Q. 3: 173, 1934. Benedek, T., and Rubinstein, B.: Psychomatic Medicine Monographs, 1942, Banta Publishing Co., vol. 3, Nos. 1 and 2, Chapter 10.

21. Jarvis, V.: Psychoanal. 22. Barglow, P., Bornstein, 23.

Q. 38: 639, 1969.

M., Exum, D. B., Wright, M. K., and Visotsky, H. M.: Am. J. Orthopsychiatry 38: 678, 1968. Westoff, C. F., et al.: Family Growth in Metropolitan America, Princeton, New Jersey, 1961, Princeton University Press. Kaye, B. M.: J. A. M. A. 186: 522, 1963.

24. 25. Orchard, 1969. 26. Wearing, 1963. 27. Kane, F. 28. Moos, R.

W.

H.:

Med.

J. Aust.

56: 872,

M. P.: Can. Med. Assoc. J. 89: 239, J.: Br. J. Psychiatry 113: 265, 1967. H.:

Arch.

Gen.

Psychiatry

1968.

29. Arnold, S.: Unpublished

data.

19:

87,