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An Ethnography of Contraceptive Pill Users in a Central London Family Planning Clinic The London School of Economics and Political Science The Social Life of the Pill: An Ethnography of Contraceptive Pill Users in a Central London Family Planning Clinic Victoria Jane Boydell A thesis submitted to the Department of Anthropology of the London School of Economics and Political Science for the degree of Doctor of Philosophy, London August 2010 1 UMI Number: U615975 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U615975 Published by ProQuest LLC 2014. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 THeses F BriVSh ttxury o' POW*C® ■jnd >.utfvjiv&.bciance IW t ? Declaration I certify that the thesis I have presented for examination for the MPhil/PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without the prior written consent of the author. I warrant that this authorization does not, to the best of my belief, infringe the rights of any third party. 2 Abstract This is an ethnographic study of users of the oral contraceptive pill at a London specialist clinic. The pill was introduced in the United Kingdom in 1964 and is currently provided free of charge to twenty-five percent of British women. It has had a major impact on the sexual and reproductive lives of people in contemporary Britain. This ethnographic analysis of the pill contributes to our understanding of the cultural meanings and practices associated with the pill and shows some of the fundamental assumptions and expectations of pill users about their lives, including particularly ideas of femininity and nature. In this thesis, the central question of how the ‘natural facts’ of femininity are constantly negotiated in both private and public domains will be explored through the related examples of pregnancy, sex, and menstruation, as experienced and conceptualised by the women in this study. The ways in which these women use, think and talk about the pill demonstrate their efforts to balance the often contradictory demands made upon their bodies and persons in various social fields as they participate in social terrains once inhabited primarily by men. Therefore, a key argument will be that the social life of the pill is inseparable from the constitution of femininity and female bodies more broadly. This thesis contributes to the anthropological theory of “natural facts” by providing an example of how they are mobilised by women using the pill. It suggests that “natural facts” continue to provide a privileged ground for femininity. It adds to research on gender in the UK by illustrating the strategies employed by women at both symbolic and relational levels as they attempt to control their identities in the face of changing conventions and institutions. Finally, it is hoped that this ethnographic illustration of the experiences of pill users will provide insights relevant to the work of public health practitioners. 3 Table of Contents Acknowledgements 6 Abbreviations and Acronyms 7 Chapter One: Introducing the Pill 8 Introducing the Pill 12 A History of the Pill in Great Britain 16 Theoretical Approaches to Contraceptive Practices 19 ‘Natural Facts’ in Anthropological Theory 31 The Power of Natural Facts 39 The Natural Facts of Femininity 44 Structure of the Thesis 53 Chapter Two: Studying the Pill: the Methods and Setting of the Study 58 Methodological Precedents 59 Accessing the Field 62 Primary Fieldsites 63 Secondary Fieldsites 73 Fieldwork 75 Contraceptive Narratives 79 Methodological Limitations 83 Data Analysis 85 Chapter Three: Getting the Pill 87 Louise’s Story 89 Making an Appointment, or rather, Managing Time 92 Objectification through Registration, Histories and Examinations 93 Clients’ Strategic Participation in the Clinical Encounter 99 Clients’ Strategic Participation in Not-So-Routine Clinical Encounters 105 The Limits of Clients’ Strategies in Clinical Encounters 110 Conclusion 115 Chapter Four: Pregnancy and the Pill 117 Reflections on Pregnancy and Motherhood 118 The Pill and Planning Motherhood 130 The ‘Nature ’ of Achieved Motherhood 137 Conclusion 144 Chapter Five: Sex on the Pill 147 Contraceptive Choice and the Pursuit of Pleasure 148 Contraceptive Choice and Casual and Intimate Sexual Relationships 151 Achieving Companionate Relationships 159 Naturalising Achieved Sexual Intimacy 163 Conclusion 171 Chapter Six: The Pill and Menstruation 173 Menstruation as Disruption 174 ‘Controlling the Beast ’ 178 Optimal Periods and Working Bodies 183 Ambivalent Periods and Natural Femininity 192 Conclusion 198 4 Chapter Seven: Controlling Female Bodies 200 Body Talk: Accounts of Bodily Interruption 201 Pill Talk I: Accounts of Bodily Control 204 Pill Talk II: Accounts of Loss of Bodily Control 212 Ambivalent and Contradictory Accounts of the Pill 216 Conclusion: Accounting for Ambivalence and Contradictions 221 Chapter Eight: Conclusion 224 Implications of the findings for studies ‘natural of facts ’ 225 Implications for Understanding Femininity 229 Implications for Analysing Empowerment and Agency 234 Some Final Thoughts 238 Bibliography 241 Appendix One 273 Appendix Two 277 5 Acknowledgements I owe a special thanks to Dorrett Graham at the Margaret Pyke Memorial Trust Fund for her friendship and support throughout my fieldwork. I am grateful to the reception staff, nurses, doctors and others at the Pyke their co-operation and willingness to share their views, time and experiences, without which this thesis would not have been possible. I am grateful to all the women who took time out of their busy and demanding schedules to give me heartfelt accounts of their thoughts and experiences in relation to the pill. I hope that this thesis adequately and sensitively expresses their frank and unguarded accounts about the more intimate aspects of their lives and aspirations. I have a special debt to my colleagues and friends at the International Planned Parenthood Federation, namely Jennifer Woodside, Matthew Lindley and Valerie DeFillipo, who helped me balance my love of research with a passion for action over the last five years. As well as to my dear friends, Kristine Blokhus, Deirdre O’Kelly, Claire LaHovary, Ghislaine Laglantine, Nicholas Martin and Philippe Puyo-Tschanz, who have offered ongoing encouragement in the face of neglect. I have presented and discussed my work with many of fellow PhD students at the LSE and thank them for their comments. I am thankful to Carolyn Heitmeyer for insights and help. I am especially indebted to Judith Bovensiepen for her constant support throughout the long drafting process. The ever-timely and phenomenal insights of my thesis ‘co-parent’ and midwife, Katie Dow, are a significant part of this project. Finally, I am forever grateful to Benedetta Rossi for her ongoing encouragement and friendship without which I would have never continued. My supervisors, Fenella Cannell and Sarah Franklin, provided guidance, inspiration and encouragement. With their compassionate support and patience they have shepherded me through the PhD and have been truly invaluable in transforming my ideas into this thesis. My deepest gratitude and affection is for my family, my parents Robert Boydell and Elizabeth Boydell and my sister Stephanie Boydell, for enduring me over the last six years with much humour and love. 6 Abbreviations ALBs Arm’s Length Bodies COC Combined Oral Contraceptive DoH Department of Health FFPRHC Faculty of Family Planning and Reproductive Healthcare FPA Family Planning Association (UK) FSH Follicle-stimulating hormones GU Genito-urinary GP General Practitioner GRH Gondatropin-releasing hormone HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HPV Human Papilloma Virus IUD Intra-Uterine Device IUS Intra-Uterine System IVF In Vitro Fertilisation LARCs Long Acting Reversible Contraceptive LH Luteinising hormone MHRA Medicines and Healthcare Products Regulatory Agency NBCC National Birth Control Council NICE National Institute of Clinical Excellence NCT National Childbirth Trust NHS National Health Service NHS PASA National Health Service Purchasing and Supply Agency PCT Primary Care Trust POP Progesterone-Only Pill REC Research Ethics Committee STI Sexually Transmitted Infection WHO World Health Organisation Ug Microgram 7 Chapter One Introduction Early on any routine weekday morning, women gather in front of the street entrance to a public building in central London eagerly waiting for the doors to open. These women are dressed for work, with briefcases and laptop bags, and as they wait they are talking on the phone, checking their Blackberries and glancing at their watches. They huddle on the steps of this anonymous building, a building that could be any office block in the backstreets,
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