(Second in a four-part series)
The direct and compelling evidence of the strong, arguably causal connection between oral contraceptives (OCPs) and gravely adverse psychosocial outcomes, including suicide, comes from the three largest-ever studies which evaluated OCPs. These were the Royal College of General Practitioners study (47,174 women), the Oxford/FPA study (17,032 women), and the Walnut Creek study (16,638 women). They found strong and clearcut evidence in each case of increased rates of suicide and attempted suicide, as well as violent (intentional and accidental) deaths and mishaps. Pill users were 2.66 times as likely to attempt suicide as nonusers in the Royal college study, 4 times as likely in the Oxford/FPA study, and 2.53 times in the Walnut Creek study. It is fair and accurate to conclude that “the pill” is associated with excesses of suicide, mental illness, and even violent deaths and accidents.
In the Royal College study, divorce also had in interesting and noteworthy interaction with OCPs. The divorce rate of users was found to be double that of nonusers, and while divorce did not by itself explain the association of contraceptives with suicide attempts, it nonetheless strengthened that association. Therefore OCPs were found to have both a robust direct association with increased rates of suicide, accidents and violence unrelated to divorce, as well as an indirect association mediated by an association with increased divorce rates. This association with divorce is something also corroborated by other social science investigations, namely Dr. Robert Michael, Stanford economist, who found that OCPs were very likely responsible for the doubling in the American divorce rate from the 1960s to the 1970s.
The 1974 Royal College report moreover clearly shows that in addition to increased rates of divorce, suicide and suicide attempts, pill users experience a robust increase in the rates of psychosis, neurotic depression, and a nearly 5-fold increase in loss of libido when compared with nonusers. This cluster of bad outcomes is generally altogether referred to as the “psychosexual effects” of the pill. These unfavorable outcomes represent an especially striking and powerful indictment of oral contraceptive use when one considers that the study design and patient selection features tended to minimize these outcomes. Absent from the pill using group were the many women who had stopped taking the pill because of psychosexual and other complications before the study began, minimizing from the beginning the psychosexual complication rate by removing a group of particularly susceptible women.
The authors also adjusted the data for the effects of parity and cigarette smoking, but as we have seen at least some of the contraceptive harm may be expressed through parity and it is well-known that smoking is a marker of psychosocial distress, which in turn we suspect is at least partly due to contraceptive behavior. Even more than all of this, the 1974 report even found that OCP users smoked more often and smoked more heavily than nonusers. These and other factors lead us to believe that the report’s findings, damaging as they are, nonetheless grossly underestimate the psychosexual complications of contraception.
Isn’t suicide important? Isn’t suicide indicative of more severe depressive episodes? While staring these very unfavorable findings in the face, the authors of the Royal College report nonetheless, unbelievably, concluded that there was “no convincing evidence that oral contraceptive users have more severe depression than non-users”. But we think suicide certainly is a reliable marker of “more severe depression”. What can this unbelievable statement then be, other than a case of massive denial or obfuscation of the clear-cut meaning of the data? This mishandling of data unfortunately robs many innocently-contraceptive Christians of the opportunity to hear and see evidence which might move them to re-visit their convictions. Unfortunately most medical and scientific colleagues also are deprived of this critically relevant and crucial knowledge, and thus is it any surprise at all that they mistakenly accuse us of blindly following faith without evidence?
Ironically the analysis of the Royal College investigators unwittingly lends even more support to our contention that contraceptives cause psychological distress. Keen to avoid attributing these negative outcomes to the purely pharmacologic/hormonal characteristics of oral contraceptives, they instead focus on what they in a strangely noncommittal and nonjudgmental way call the “psychological effects of being a Pill user”. They note that the incidence of depression did not perfectly correspond to pill dosages, nor was there any relation to duration of pill use. Neurotic depression and the other psychosexual complications occurred in users regardless of parity, age, and cigarette smoking.
This suggested to them that neurotic depression with pill usage was “so dominant that it obscures the variations related to the other parameters”. This contraceptive effect was for the authors far more robust than expected for a purely pharmacological or hormonal effect. Moreover, the text even cites numerous previous studies in support of this notion of a predominantly non-pharmacologic, non-hormonal mechanism. In one contraceptive placebo study significant psychosexual complications occurred even when women merely thought they were taking the contraceptive pill but were merely on a placebo. On the other hand, in situations where pill research succeeded in isolating and testing a purely hormonal effect (excluding a contraceptive/psychological effect), few cases of mild depression occurred, and libido was unaffected.
In other words, there is potential psychological damage from intentional contraceptive practice, no matter which method may be used. And these findings agree with more recent work showing that compared to nonuse, oral contraceptive use adversely affects several measures of psychic well-being independent of measurable change in hormone levels. Users had significantly more difficulties with stress, control, and self-integration, and more often had unfavorable responses to stress which translated directly into negative emotional states such as anger, depression, suicidality, guilt, and resentment.
This data are commented on in a summary statement by a very well-heeled French psychoanalyst commenting on oral contraceptives and their psychosexual effects. Bourgeois says that the psychosexual complications of the pill stem from the unconscious and symbolic implications of sterilization, and from the implications of a purely “hedonic” sexuality with its associated guilt. He refers to a number of double-blind studies which he said prove that very few cases have purely hormonal causes, not only in line with the foregoing analysis but indicating the need for further study as well. (M. Bourgeois — Le psychiatre et les contr^oles de la procr`eation –L`Encephale, 1975, I, 259-263)
Agreeing with Bourgeois, based again on the evidence, the author decided to conduct an exhaustive review of all known relevant “pill” studies, especially with an emphasis on randomized, double-blind studies. This peer-reviewed published analysis concluded that the negative psychosexual and psychosocial complications of the pill are not primarily the result of the pill’s pharmacologic and hormonal properties, but rather the result of the intrinsically harmful and psychologically damaging effects of contraceptive practice itself, since they were in agreement with the foregoing data and since the data allowed for a reasonably probable exclusion of a purely hormonal/pharmacologic effect. This meant that however potent the hormonal activity of oral contraceptives, they are associated with very bad psychosexual sequelae above all because they are contraceptives, and not primarily because they are hormones. When oral contraceptives are associated with divorce and sexual dissatisfaction, it is mostly because contraceptive behavior has this adverse association. If oral contraceptives cause suicide, it would primarily be due to contraceptive activity causing suicide!
We ourselves in our own research found that women who have had a tubal ligation (studied here because it can be thought of as a form of “surgical contraception” which eliminates the chemical, hormonal, or pharmacological effect) also are 2.1 times as likely to report “stress interfering with sex”, and 1.79 times as likely to report having seen a physician for sexual problems in the previous 12 months. This prompted a special “Note from the Editor-in-Chief” in which Dr. Lawrence D. Devoe considered the findings “…both disturbing and possibly paradoxical since it might be assumed that once reproduction and sexual activity are unlinked, sexual satisfaction would be improved. Clearly, this study suggests that the opposite is true.” (Devoe, L. A Note from the Editor-in-Chief. J Reprod Med. 2007 Apr;52(4): 257.)
This author also notes, although admittedly with varying strength of the various lines of evidence in each case, that other investigators have also found evidence of links between the various nonhormonal contraceptives and the tendency to suicide or at least adverse psychosocial sequelae with them. Thus barrier contraceptives, the withdrawal method, and vasectomy have all been suspected by researchers to have a relationship with negative psychosocial sequelae, with varying strength of evidence found to support this suspicion.
Moreover, our 2004 paper on the true genesis of the emotional side effects of oral contraceptives agreed perfectly with these findings, and suggested in agreement with the Royal College investigators that contraception itself, no matter by which method, tends to have negative and even disastrous psychosocial sequelae associated with it. It must also be said that contraceptive psychosocial harm in women had been suspected by numerous well-respected psychiatric authorities, even including Freud, long before the advent of the oral contraceptive pill of the late 1950s.
A very sophisticated objection might be that it is not so much contraception per se but rather childlessness or the lack of parenthood which causes the psychosocial harm, as there has been a well-known interaction between parenthood and decreased suicide levels since the work of the sociologist Emile Durkheim over 100 year ago, and corroborated by other investigators since that time, especially Georg Hoyer. While a somewhat more difficult objection to overcome, this objection also allows us to take special note of the very serious relationship parenthood has with psychological functioning in women. In these investigations suicide has been shown in Western cultures to have an inverse relationship to parity, the childless woman having for instance six times the suicide risk of the mother of six. But the main instrument Western couples have employed in order to avoid parenthood during the century in which this data has been gathered has been contraceptive practice; i.e. the active sterilization of sexual activity so that fertility which otherwise might have been set into motion is actively frustrated, not merely deferred for the moment.
More importantly in the “big three” pill studies, especially the Royal College study, the association of suicide and other psychosexual sequelae with the pill was found to be far more robust than and independent of the effect of that with parity. This would not be expected if parity were a competitive explanation powerful enough to account for the excess suicides apart from contraceptive practice. In other words, if it were simply a matter of more children being needed to avert the risk of suicide, controlling for parity in the “big three” would certainly have greatly reduced the pill’s association with excess suicide and other adverse psychosexual sequelae, but it did not. This means the contraceptive-using mother of four was still at higher risk from suicide than the non-using mother of four or even fewer, despite the protection offered her by comparatively high parity. To summarize then, contraceptive practice in and of itself explains not only the pill-suicide relationship of the contraceptive studies, but very likely, in a hidden way, also the low parity-suicide relationship in landmark studies only indirectly studying contraceptive practice.
Finally some, whose prejudice in favor of contraception makes them unable to react to this “surprising” data with the calm acceptance shown by JRM editor Dr. Devoe, might consider the idea that contraception causes psychosocial harm to women intrinsically unacceptable. The root of this refusal to accept the data or more precisely its implications is very likely rooted in an invincible intellectual attachment to the idea that contraception and sterilization are a boon for women. But shouldn’t those thus attached ask themselves why it is that they so uncritically welcome the dissolution of the natural bond between sexual activity and reproduction, two things which after all in normal reproductive biology are united together? Would it really be so surprising that the pro-conceptive design concepts clearly recognizable from reproductive biology might have their counterpart in a designed reproductive “psycho-biology”, with the disruption at the physical level predicting a further and perhaps even more serious disruption at the psychological level?
© 2013. Dominic M. Pedulla MD. All Rights Reserved.