News Contraception

New Diaphragm Hits U.S. Market for First Time in 50 Years

Martha Kempner

Caya, a new single-size diaphragm, gives women who can't or don't want to use hormonal methods a new birth control option.

A newly designed diaphragm is hitting the U.S. market for the first time since the mid-1960s. Known as Caya, the new, single-size contraceptive device is comprised of a coiled nylon spring, a silicone cup, and a removal tab.

Caya is already widely available in Europe and was approved for sale by the U.S. Food and Drug Administration in September 2014. Its developers say Caya is easier to use than older models of diaphragms and believe that it’s a good option for women looking for non-hormonal methods of contraception.

The diaphragm was one of the original modern methods of contraception. Introduced in Europe in the 1880s, it was sometimes referred to as the Dutch Cap. It is a flexible dome-shaped cup that sits inside the vagina and covers the cervix, providing a barrier to sperm.

Women usually put a small amount of spermicidal jelly on the inside of the diaphragm for added protection, fold it in half, and insert it high into the vagina. It can be put in place hours before sex and used for multiple acts of intercourse over a 24-hour period.

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Most diaphragms come in a variety of sizes and women need to have a pelvic exam where a health-care provider determines which size is best for them. If a woman gains or loses ten pounds, or has a baby, she is told to return to her provider to be resized.

The diaphragm is 94 percent effective if used perfectly, and 88 percent effective under typical use. That means that out of 100 couples who say this is their primary method of contraception, about 12 will become pregnant in the first year. In comparison, under typical use, the pill is considered 91 percent effective and the intrauterine device (IUD) is more than 99 percent effective.

Fewer and fewer women in the United States have turned to the diaphragm as birth control in recent years. In 1982, 17 percent of sexually active women had ever used a diaphragm, compared to 3.1 percent in 2010, according to the National Survey of Family Growth.

The developers of Caya hope that this new product might attract more users.

Caya was created through a collaboration between PATH (a Seattle-based global health nonprofit), CONRAD (a reproductive health product development organization operated through Eastern Virginia Medical School), the U.S. Agency for International Development (USAID), and other partners. The ten-year development process included feedback from test users. The final product includes suggestions from those who tested prototypes, such as a removal tab that makes the diaphragm easier to remove, especially for new users.

In the United States, Caya is being produced and marketed by HPSRx.

“In talking with family planning providers about this single-size diaphragm over the past few months, their eyes ‘light up’ when they hear that a new diaphragm is coming to market and no fitting exam is required,” Bob Patane, HPSRx’s founder, said in a statement. “Reducing barriers at the provider level could help bring this new method to a whole new generation of women who have not known that diaphragms are even an option.”

Studies have shown that Caya has similar efficacy rates to traditional diaphragms and that correct use was easy.

“In the recently published contraceptive effectiveness study, 76 percent of women were able to insert and correctly position the diaphragm simply using instructions. With coaching, 94 percent of women were able to insert, correctly position, and remove the diaphragm,” Gustavo Doncel, scientific and executive director of CONRAD, said in a press release. “This should make it easier to provide and use consistently.”

Most of the new contraceptive methods introduced in recent years—such as the contraceptive ring or the new versions of the IUD—contain hormones similar to those found in the birth control pill.

Women who can’t use hormonal methods because of pre-existing medical conditions and those who don’t want to use hormones have few options in the market. The introduction of Caya may appeal to them.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”

 

“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.

Roundups Sexual Health

This Week in Sex: Some Men Base Condom Use on Women’s Looks

Martha Kempner

This week, a study suggests some men are less likely to have safer sex with women whom they find attractive. There's now a study of women's pubic hair grooming habits, and a lot of couples don't have wedding-night sex.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Men Less Likely to Have Safer Sex If Partner Is ‘Hot’

The old adage “Never judge a book by its cover” is apparently easily forgotten when it comes to judging potential sex partners. A new study in BMJ Open found that men said they were less likely to use a condom if their potential partner was hot.

In this small study, researchers showed pictures of 20 women to 51 heterosexual men. The men were asked to rank how attractive the woman was, how likely they would be to have sex with her if given the opportunity, and how likely it was they would use a condom if they did have sex with her. The results revealed that the more attractive a man found a woman, the less likely he was to intend to use a condom during sex with her.

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Men also rated how attractive they consider themselves, and the results showed that this was also related to condom use. Men who thought of themselves as more attractive were less likely to intend to use a condom.

Researchers also asked the men to estimate how many out of 100 men like themselves would have sex with each woman given the opportunity and finally, how likely they thought it was that the woman in the picture had a sexually transmitted infection (STI).

The results of these two questions turned out to be related: The men assumed that women whom other men would want to sleep with were more likely to have STIs.

This did not make the men in the study any more likely to intend to use a condom with those women. In fact, the men were most likely to intend condom use with women they found less attractive, even though they considered these women less likely to have an STI.

This was a small study with a relatively homogenous group of men ages 18 to 69 near Southhampton, England, and it measured intention rather than behavior.

Still, the results could present a challenge for public health experts if men are making condom decisions on a broader scale based on attraction rather than risk assessment.

How and Why Women Groom Their Pubic Hair

A new study published in JAMA Dermatology is the first nationally representative survey of U.S. women’s pubic hair grooming habits. The study included more than 3,300 women ages 18 to 64.

Overall, 84 percent of women had engaged in some pubic hair grooming. Pubic hair grooming was more common among younger women (ages 18 to 24); among white women; and among women who had gone to college.

Before you start thinking everyone is out getting Brazilians, however, grooming means different things to different women. Only 21 percent of women said they took all their pubic hair off more than 11 times, and 38 percent of women say they’ve never done so. Moreover, waxing lags behind the most popular hair removal methods; only 5 percent of women say they wax compared with 61 percent who shave, 18 percent who use scissors, and 12 percent who use electric razors. (Respondents could choose more than one answer in the survey.)

Most women (93) do it themselves, 8 percent have their partners help, and 6.7 percent go to a professional.

The researchers were most interested in the most common reason women groom their pubic hair. The most common reason was hygiene (59 percent), followed by “part of my routine” (46 percent), “makes my vagina look nicer” (32 percent), “partner prefers” (21 percent), and “oral sex is easier” (19 percent).

Tami Rowen, the lead author of the study and a practicing gynecologist at the University of California, San Francisco, told the New York Times, “Many women think they are dirty or unclean if they aren’t groomed.”

But while people may think that, it’s not true. Pubic hair actually exists to help protect the delicate skin around the genitals. Rowen and other doctors who spoke to the Times believe that women, especially teenagers, are taking up grooming practices in response to external pressures and societal norms as reflected in images of hairless genitals in pornography and other media. They want young people to know the potential risks of grooming and say they’ve seen an increase in grooming-related health issues such as folliculitis, abscesses, cuts, burns, and allergic reactions. As some may remember, This Week in Sex reported a few years ago that emergency-room visits related to pubic hair grooming were way up among both women and men.

This Week in Sex believes that women should be happy with their genitals. Keeping the hair that grows does not make you dirty—in fact, it is there for a reason. But if shaving or waxing makes you happy, that’s fine. Do be careful, however, because the doctors are right: Vulvas are very sensitive and many methods of hair removal are very harsh.

Wedding-Night Sex May Be Delayed, But That’s OK With Most Couples

Summer is a popular wedding season, with couples walking down the aisle, exchanging vows, and then dancing the night away with friends and families. But how many of them actually have sex after the caterer packs up and the guests head home?

According to lingerie company Bluebella—about half. The company surveyed 1,000 couples about their postnuptial sex lives and found that 48 percent of them said they did “it” on their wedding night. Most women in those couples who did not get it on that night said they were just too tired. The men, on the other hand, said they were too drunk or wanted to keep partying with their friends. (It is unclear whether the survey included same-sex couples.)

By the next morning, another 33 percent of couples had consummated their marriage, but about 10 percent said it took 48 hours to get around to it.

But whenever couples did have that post-wedding sex, the overwhelming majority (84 percent) said it lived up to their expectations.