The Contraception/Abortion Connection: Part 3

In which Scott Alexander and I continue a worthwhile discussion. (Part 1 and Part 2. (Scott is in quotes.))

Thanks once again for a really thoughtful response. And thanks for pointing me to the unintended pregnancy rate data – I was using teen pregnancies as a proxy, but this is much more interesting.

So you’re right that unintended pregnancies stay pretty constant. On the other hand, this article claims that change in percent unintended pregnancies that end in abortion only explains two points of the five point decrease in abortion rates. Unless I’m missing something, it is impossible to have a change in the abortion rate that isn’t explained either by the unintended pregnancy rate or the percent unintended pregnancies that end in abortion (unless people are aborting intended pregnancies, which doesn’t make sense). Possibly the difference is that our statistics aren’t from exactly the same years? It looks like yours come from comparing 2006-2010 to 2002, whereas mine come from comparing 2009 to 2008. Any thoughts?

I’m at loss to find the specific rate of unintended pregnancy between 2008-2009. If you can, please let me know. Of course, I would not be surprised if the abortion rate was lowered because of a simultaneous increase in the use of LARCs (as we’ve discussed, in an already contraceptive culture, improved contraception has been shown reduce already high abortion rates).

Second question. Suppose the government were to ban all contraception tomorrow, but not ban abortion. It seems to me that people might have a bit less unprotected sex when not wanting children, but certainly not stop entirely, and this would result in a HUGE spike in the abortion rate and probably turn us into one of those ex-Soviet countries you talk about where abortion *is* the contraception. Do you agree?

Yes.

If so, and you agree that having less contraception would lead to more abortions, why wouldn’t the opposite – having more contraception – lead to fewer abortions?

Without contraception, people — teens especially — experience several basic barriers to first entering the sexual market (that is, to first having sex): the risk of pregnancy, the risk of disease, psychological barriers (as in I-have-no-damn-clue-what-I’m-doing-hope-she-doesn’t-laugh-at-my-pitiful-attempts-at-being-a-sexual-dynamo), and moral barriers (into which we can lump religious concerns, parental concerns, and social concerns).

The promotion, acceptance, and use of contraception within an individual’s surrounding culture lowers this first-time barrier. Sex is now “safe,” meaning there is little to no risk of pregnancy and/or disease. Moral barriers are lowered, as having “safe sex” becomes the new ethical norm, as opposed to chastity. (Psychological barriers still remain, though I’d argue that they are reduced insofar as sex and contraception are made a part of public school curricula. (And by porn.)) Thus, increased contraception allows more people to enter the sexual market by, essentially, lowering the entry fee — reducing the difficulty of surmounting that first-time barrier.

Now what is sex, a casual abrasion of genitalia? No, it’s ecstatic, mystical, erotic and all the rest, stirring the Shakespeare and the Don Giovanni and lunatic in all of us. Thus, leaping that first-time barrier leads to what’s called “habit persistence.” First-time sex is not an isolated incident, but an initiation. People who’ve had sex for the first time are most likely going to have it again soon. As the study “Habit Persistence and Teen Sex,” (from which I take my basic understanding of this issue) pointed out: “Having sex in one year and not the next is rare.” (pg. 3) This is, quite simply, what our bodies were designed to do. The biochemical reality of sex is this — it binds us to our partner with dopamine and oxytocin and makes us want to do it again. So we do.

Now this sex life is not the same as our initial misplacing of virginity. Why, we should ask, if le Pill is 99.5% effective, do 8 out of 100 women get pregnant on it every year, and more in the next? Because, quite frankly, people suck at doing anything correctly over a long period of time. And it’s not really their fault. The very nature of sex makes it difficult. For instance, there’s the principle of risk compensation, which we spoke about earlier. You mentioned that the availability/promotion of contraception will make some people more likely to have sex than they would without the availability/promotion of contraception, and this is true. Risk compensation certainly counts for an influx of people over the first-time barrier and into the sexual market. But the principle of risk compensation also dictates that the availability/promotion/use of contraception may inspire those same people to engage in riskier sexual behavior, behavior that lowers the effectiveness of the contraceptive device.

Similarly, the very fact of sexual arousal reduces our decision-making capacity, indicating that sex lends itself to making dumb decisions about sex. (Really, that shouldn’t be shocking.)

The study “The Heat of the Moment: The Effect of Sexual Arousal on Sexual Decision Making”, published in the Journal of Behavioral Decision Making found that “sexual arousal had a strong impact on[…]judgment and decision making, demonstrating the importance of situational forces on preferences, as well as subjects’ inability to predict these inﬂuences on their own behavior.” Subjects were asked to answer questions regarding condom use while sexually aroused, and it was found that:

For all four condom-related questions, subjects in the aroused treatment indicated a lower likelihood of using a condom compared with subjects in the non-aroused treatment…when it comes to concrete steps involving condoms, sexual arousal changes one’s perceptions of the tradeoffs between beneﬁts and disadvantages in a fashion that decreases the tendency to use them.

So my basic point is this: Increases in contraception will (generally) not substantially reduce abortions because for all the effective, “sex-without-kids” it produces, it will also increase the overall number of people in the sexual market, who will, in a beautiful representation of humanity, screw up. To give this a little more weight, have the thesis from the Duke study:

Using aggregate data, researchers have found that restrictions on Medicaid funding of abortions or access to clinics reduced the number of adolescent abortions but either had no eﬀect or reduced the number of teen births (for example, Kane and Staiger (1996) and Levine, Trainor, and Zimmerman (1996)). For abortions to fall with no eﬀect on teen births, there must be a strong behavioral response in sexual actiivity. Similarly, using data from the United Kingdom, Paton (2002) found no evidence that nearness to family planning clinics reduced either the pregnancy rate or the abortion rate, with some evidence that family clinics increased the pregnancy rate, while Girma and Paton (2006) found no eﬀect of the availability of emergency contraceptives on teen pregnancies. Should contraception become more available, those who switch from unprotected sex to protected sex will lower the teen pregnancy rate, while those who move from abstaining to protected sex will increase the teen pregnancy rate due to contraception failure.

(I note, by the way, that a move to more effective methods of contraception is a different story, as it would be an improvement in the already-contracepting population, and probably not an incentive to leap the first-time barrier. (Basically, while teenagers might decide to have first-time sex because they got were handed condoms or Plan B at their school, their probably not going to get IUD inserts or hormonal injections and then decide to lose their virginity. (Probably.)))

Third question. What did you think of the claim in my original post that people interviewed at abortion clinics were disproportionately likely not to be on contraception? I thought that was probably my strongest argument and I’d be interested in hearing a response.

Bear with me while I muddle through this. I’ll put the quote here so people have a reference:

The two-thirds of U.S. women at risk of unintended pregnancy who use contraception consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies. The 19% of women at risk who use contraception but do so inconsistently account for 44% of all unintended pregnancies, while the 16% of women at risk who do not use contraception at all for a month or more during the year account for 52% of all unintended pregnancies.

First, just off the bat, I’ve been looking into it and still have no clue what the population “women at risk of unintended pregnancy” refers to. All fertile women? All sexually active women? I’d love help on that one, as Guttmacher is in the habit of throwing out the phrase (along with others) without defining it. Now, to business:

The vast majority of women in the Guttmacher quote practice contraception. The first two categories are (1) those who practice contraception well and (2) those who do not practice contraception well. The last category is still not women who don’t use contraception — they just haven’t used a contraceptive device in a month or more. (Assumedly, this includes women “at risk of unintended pregnancy” who don’t use contraception at all, but I imagine these are few.)

So in general, all three of these categories include women who are accepting and welcoming to the use of contraception. If it is this that Guttmacher, yourself and I have all agreed is the reason for contraceptions association with the abortion rate — that the use of contraception either promotes a philosophical shift which sees a child as an unintended, to-be-avoided consequence of sex and thereby creates a greater desire for abortion, or, contraception is used as a response to that same philosophical shift which simultaneously creates a greater desire for abortion. This philosophical shift does not necessarily go away just because a woman hasn’t been taking the Pill for a month.

Consider an example. Say a woman is dating a man, and she uses contraceptive pills perfectly for a year. She has no unintended pregnancy and thus no abortion. She is placed, by Guttmacher, into the first (2/3) category. Then she and her boyfriend break up. She no longer has any need for her contraceptive use, so she stops taking oral contraceptives (to save money/prevent side-effects/just because/whatever). A month later, she and her boyfriend have breakup sex. She gets pregnant. She gets an abortion. Now the next Guttmacher study comes around, and she is placed in the last category “16% of women at risk who do not use contraception at all for a month or more.” Can we, from this, generally say that the promotion, provision and use of contraception reduces abortion rates? Of course not. It seems to me that all we can say this: Of those already willing to use contraception, those who aren’t using contraception when they have sex will have more abortions than those who are using contraception badly, who will have more abortions than those who use contraception well. Which I would hardly argue against.

And a final point – I don’t share your intrinsic horror at a world in which everyone has an IUD, and the ethical issues are probably too complicated to get into here, but I do think we can engage on the likely demographic results. You say:

Somehow, I don’t have high hopes for it reducing abortion rates to a level in which we can sleep well at night (lol jk, we’re all sleeping well), because I worry that the greater the promise of “no-kids” a contraceptive device brings, the greater the likelihood of abortion in the event that the device fails. This seems to make sense: A married couple practicing withdrawal will probably be less likely to freak out over a pregnancy than a couple who have sacrificed 3 years of natural cycling with an IUD.

I think even if you’re right about the existence of such an effect, the numbers just don’t work out.

Let’s say that every couple has an IUD…no, actually, let’s go all the way and make it Implanon, the most effective contraceptive known – and that this has the most extreme possible effects – everyone has sex all of the time with no concern for abstinence, and every single time someone has an unintended pregnancy they choose abortion.

Implanon has a failure rate of 0.05%/year, so in this world, 0.5/1000 women of reproductive age has an unintended pregnancy each year, which she aborts. Compare this to the real world, where the abortion rate per women of reproductive age is 15/1000. We’d effectively be slicing the abortion rate by a factor of 30. That’s moving from a million abortions a year to only about 30,000. If you believe a fetus is a human life, that’s saving 970,000 people per year – pretty tempting for anyone remotely consequentialist.

Yeah well, anything is tempting for a consequentialist.

I kid. Regarding my proposed effect, I agree, it probably wouldn’t make much of a difference if everyone was on Implanon. But I have several issues with the Implanon scenario. First of all, the discontinuation rates. A 2008 study found that the overall discontinuation rate from 1-5 years of Implanon was 32.7%. If we knock out the 4.1% of women who discontinued to get pregnant, that’s 28.6% of women discontinuing use because they couldn’t tolerate the side-effects. This is a very generous discontinuation rate. A 2009 study of Australian women found that 50% discontinued Implanon after just two years. A study of women in Scotland found that “continuation rates were 89% (CI 84–91) at 6 months, 75% (CI 69–79) at 1 year, 59% (CI 52–63) at 2 years and 47% (CI 40–52) at 2 years and 9 months.” This study actually leads to my second issue with the Implanon scenario. It found that “one third (n=99, 39%) chose to use a second implant when the first one expired.” If, of those women who tolerate the side-effects of Implanon for the whole three years, only one third get a replacement Implanon, then we haven’t really solved any issues by suppressing everyone’s fertile cycle, even if it is and incredibly effective suppression. We’ve just delayed the issues, and in the meantime, have continued to impress the necessity of a separation of the act of sex from the possibility of having children. So, if I were a consequentialist, the scenario would only be tempting if you could convince me that women would keep using the contraceptive.

Here’s my question for you then. If our hypothetical scenario is that every woman suppresses her fertility, haven’t we already gone to far? Consider it in the offensive terms of obesity (I don’t have the creative power to use another example right now, many apologies). If, in order to reduce the obesity rate, our most ideal, effective strategy is to suppress the natural functioning of the human body by sewing the stomachs of all those “at risk for obesity” to half their size, haven’t we already missed the point? We are working against the nature of the body, working against our natural, healthy state of being, relying on technology to do what is entirely within human power to achieve, indeed, what is entirely humanizing to achieve, namely, harmony with the body. Wouldn’t it be wise, as we look at our culture, swiftly moving towards the promotion of the temporary sterilization of as many women as possible, to consider the possibility of backing up a few steps, and to stop seeing female fertility as a risk and — as I fear is the case — an enemy, and to instead consider the possibility that, if the reduction of abortion rates is achievable by human power (behavior change), we should seek that before we seek the bodily suppression of an entire sex?

Yours truly.