How Reversible are LARCs?
Dealing with doctors who refuse to remove IUDs
IUDs and other long-acting reversible contraceptives (LARCs) are often recommended for women who are poor, vulnerable, or otherwise going to have a hard time getting a pill prescription filled. For a long time, I’ve wondered about how easy it is for women in these circumstances to get an IUD removed.
If you use condoms for contraception, you can stop contracepting any night. If you use a shot, you have to wait until it wears off, no changing your mind in the middle. If you use the pill, you can stop taking it, and… an unpredictable amount of time later, you might conceive.
But an IUD means a trip to the doctor, which is a much bigger barrier for women without health insurance, without a relationship with a doctor, without trust in the medical system. I got to do a deep dive on this for the Institute for Family Studies here.
Over a six-month period immediately following IUD insertion, seven to 15% of women surveyed in a study tracking patients in four states considered discontinuing their IUD use. Of the 45 women in the study who considered getting their IUDs removed but did not ultimately desist, 14 women said they were unable to get their IUD removed because they could not get an appointment or because their doctor actively discouraged them when they did come into the clinic.
A qualitative study interviewed family medicine practitioners in the Bronx about their reactions to patients who sought early removal of their IUDs. Many of the doctors interviewed said they tried to steer patients to IUDs, which are more effective at preventing pregnancy than oral contraceptives or barrier methods. The researchers found that the doctors were often reluctant to accede to patient requests. “It’s a negotiation,” said one doctor, who urges patients to try to stick it out a few more months.
Some doctors were dismissive of patient concerns about bleeding and discomfort. One doctor told the researchers, “I think [the symptoms are] more annoying than anything else. I don't think it's because they're worried they're bleeding out, or they're worried that something's not working.” Some providers felt a sense of personal failure if they couldn’t convince women to stick with the method that the doctor felt best suited their reproductive plans.
There were a number of studies to draw on, including some on whether a woman can pull out an IUD at home, if she can’t reach a doctor… or if the doctor she sees refuses to help her. As I wrote:
Notably, 13% of the women who were interested in attempting to remove their own IUD said that one of their reasons was that “I thought it would hurt less than if a doctor/nurse did it.” Six percent said simply, “I did not want the doctor or nurse to do it.” It may seem strange to expect that a medical procedure would be less painful when done by an amateur at home rather than in a clinical setting by professionals, but these women’s expectations may have been shaped by their experiences in getting the IUD originally. Ignoring women’s pain is woven into the IUD experience, starting with the placement of the device.
Some of the programs that worked to get LARCs to vulnerable women thought carefully about every barrier that might prevent a woman from getting a LARC she was interested in, but seemed uninterested and uncurious about what barriers would prevent her from having a child when she felt ready.
This is an area where I think it’s natural for pro-lifers and pro-choicers to be able to work together. Many family planning programs smooth the way only towards one “choice” which makes it no choice at all.
Poor and vulnerable women risk the most if they get pregnant—having a baby during a vulnerable period of your life can make it much harder to get out of poverty. But they’re also the most at risk of being told that they’ll never be able to have children responsibly. And the risk of never “graduating” to the point where you’re allowed to have the children you long for is a pretty serious risk too.