The [Inclusive] Contraception Project
Interview 2 - A young, Indigenous woman from a rural community
When you shared your contraceptive journey, you highlighted two aspects that deserve public and political attention: 1. the negative physical effects of taking oral contraceptive pills (OCP) and 2. the impact of being in an abusive relationship.
Tell me more about that time in your life and your struggles with contraception.
Well, I used contraception because of my relationship - that’s why I started and why I stayed on it. I was struggling with the frequent bleeding, both physically and emotionally. Obviously, bleeding that frequently is NOT a fun thing and super inconvenient. I don’t think many people would have put up with it for as long as I did. I was also struggling with the effects that it had within my relationship, how I viewed myself, and how I viewed my relationship. The way I was treated by my abusive partner at the time… I guess I just put a lot of blame on myself and internalized his comments. There were a lot of comments from my ex about my period and it became a center piece of my blame I guess, thinking I was gross or broken. A lot of that was frustrating. I had the view, partially from society but also from what he told me about my period, that I was acting crazy. I remember thinking “oh, you’re always bleeding and that’s why he is acting this way. He’s frustrated with you and it’s your fault because you’re always on your period. He’s just reacting to you because you’re crazy and hormonal.”
I look back now and realize I didn’t do anything wrong. At the time though, while really struggling with the physical and emotional effects of taking OCPs [oral contraceptive pills], my main concern was how it affected him. By focusing on how it affected him, it reiterated how everything was my fault, how I was to blame because I was so gross and unlovable.
I remember times where we would be in a group and he would be telling people how crazy I am because of my period and I was mostly just sad, not really anything else. He would use that to make me feel like I was emotional, distraught, like no one would want me. This distorted how I viewed myself, and ultimately why I allowed myself to continue being treated in that way. I also felt alone in this situation. I didn’t disclose to family, friends, or a doctor so it was lonely. This was partly by choice, but my abusive partner also limited my contact with other people. He didn’t like or allow me to see other people, including my parents, and so I just felt very isolated and I think that was another hard thing I was experiencing. When we moved locations, he used that as another point of control, that he had moved for me and so I felt like he had the right to tell me I couldn’t go anywhere or do anything. I ended up just sinking deeper into this hole and stayed there for too long not knowing how to get out and save myself.
The effect the OCPs had on my body caused major anxiety/stress and was super time-consuming to deal with, but it also affected my relationship, and subsequently my self-image. To this day, I struggle with anxiety and fears around sex, my period and becoming pregnant, and it’s taking a lot of work to undo the emotional damage of that relationship so I can have healthier future relationships. I still use a lot of avoidance tactics and it’s easy to slip into the mindset of self-blame and shame my body. I work hard to consciously pull myself back into reality and away from distortion in those moments, but it’s a work in progress.
Can you talk more about the physical effects taking the OCPs had for you?
Yeah, my period was regular before I tried contraception. After being on contraception, my period was always irregular, unpredictable, painful, and much heavier. I think a big component was the emotional stress I was under, so maybe it wasn’t entirely the pills, but I don’t know for sure. Everything started when I began taking OCPs. It was a very low point in my life. Physically, with the constant, heavy bleeding I was always super tired and feeling run-down - I won’t take the fatigue effects of anemia lightly as a future physician! I was also constantly bleeding through products (i.e. tampons/pads), so my clothes were stained, and I couldn’t keep my underwear clean. I just felt disgusted with myself, gross, and embarrassed. I never wore anything nice. It was expensive buying new underwear which I couldn’t always afford.
Overall, I was just exhausted physically and mentally, and didn’t see much value in myself. It was also super time-consuming to get to appointments every few months by bus or walking between full-time school and work. It was hard getting time-off, and the mental workload of managing contraception was heavy, let alone remembering to take a pill at the same time every day. I held onto all this physical stuff and told myself I was defective, broken. That’s why he was acting the way he was, so all I had to do was fix myself and things would be better. It was hard. If not contraception, I probably would have found something else to blame myself on too.
How did you access contraceptive care?
I did have a family doctor, but I didn’t trust him with these issues, mostly because I was really averted to seeing a male doctor, and I didn’t like him much. I mostly used walk-in clinics with mixed results. Also, I didn’t have a car and lived in a part of town that was very far from where my family doctor was, which is also why I would just walk to walk-in clinics that were closer. When I did manage to get to my family doctor, he often wasn’t there so I would see a medical resident or a different doctor. Accessing care was challenging and not consistent.
To be honest, at the time my understanding of how to access care was almost non-existent up until I entered medical school and started learning about various resource options. Even today, although I am going to be a doctor, I very much despise going to the doctor’s office myself. It has never been openly discussed in my family but the mistrust and anxiety surrounding accessing healthcare is a remnant of generational trauma and colonization that is so ingrained it is hard to explain. I never really knew other contraceptive options existed, let alone other ways to access care through e.g. youth clinics. My family didn’t often access the health system for help, it was just dealt with internally individually, or as a family/community, or it got swept under the rug.
Compared to all the other life stresses youth and young people face, how high on the list did contraception/pregnancy rank? E.g. compared to school, work, family, or peer stresses?
For me, it was super high on the list. Even though I didn’t care much about my own safety/wellbeing, I REALLY didn’t want to become pregnant. I had a lot of other life stressors at that time: my parents had just gotten divorced, a close relationship was going through a very hard drug addiction period, I had started university, I was working two jobs - I was stressed on a lot of fronts. However, contraception was just as much or more so on my mind every day. I had so much pregnancy anxiety. I spent a lot of money on pregnancy tests and would take at least one test a month if not two or three. I would take it at a gas station near my house, dump it, and then go home and act like everything was good. I obviously didn’t have a good reaction or a good experience with birth control, but I refused to stop it even though I hated it.
I have always wanted to be a mom one day. Everyone in my family had kids young, but I was terrified of being pregnant with him at that time. I believed for a long time something was wrong with me and it was my fault, so all I had to do was fix myself and everything would be ok.
It wasn’t until I left the country that I was able to see more clearly and shift the blame away from myself, and ultimately leave the relationship. Looking back, it’s hard to reconcile why I stayed so long in that relationship (3 years). I think my other life stresses at the time – my close relationship’s addiction, my parent’s divorce, my abusive relationship, my work, and my studies – all distracted me from properly managing my own health, wellbeing, and contraception. My reproductive and contraceptive stresses ranked high compared to these other life events, as I’m sure it does for many women.
Did poor access to contraception contribute to your becoming pregnant, and subsequently choosing an abortion?
I chose abortion because I felt that I wasn’t emotionally and physically in a place that I could bring a child into this world and feel happy with myself. I didn’t want to be a mom who was emotionally unavailable to give love to my kid. I recognized how the effects of the abuse and trauma inflicted on generations before me had an impact on my life. People just did not have the same emotional capacity to love and nurture because they were hurting, and it affected children whose needs weren’t met in the same way – the generational cycle would just continue.
At the time of my abortion, I wasn’t in a place to raise a child. I was still healing and working through a lot of emotional things in my life; I didn’t want this to affect my child. Also, with a child I wouldn’t have been able to pursue my dreams of higher education, my life would have stalled to become a mother. The abortion was my choice, but it also felt like I didn’t have a choice because my life was in shambles and I was emotionally wrecked.
In the beginning, what knowledge did you have about contraception? Where did you learn about reproductive health?
I think women talk to one another, and I had heard from my lab partner about how she’d just gotten an IUD [intrauterine device] and it was the best thing in the world for her. I had no idea what she was talking about, I only knew about condoms and pills. Everyone else I knew in high school was on the pill, like it was the default and the norm.
Initially, in my relationship we were using condoms, but he didn’t like them so eventually it was just the pill which was stressful for me. He thought condoms were just to prevent infections, so when the topic came up he would get angry thinking I was being unfaithful or accusing him of being unfaithful. After the relationship ended and the discussion with my lab partner, I started doing some searching on the internet and figuring it out on my own. I didn’t know anyone else in a situation like mine and have only recently started sharing my experiences with people I trust.
In terms of sexual education, when I was younger, what was taught to me was mostly about waiting for marriage and abstinence. I think this also played into my mindset as a reason why I stayed in the abusive relationship. Overall, as a young teenager I had a poor understanding of sexual and reproductive health. It’s been a big learning curve to overcome with the help of therapists and an understanding of human biology.
How has your current experience with an IUD been?
Good! I got it after I was pregnant and chose abortion. Because of my medical abortion, I was bleeding heavily (clots and all) for 6 months and decided to try an IUD that was inserted about 2 months after the abortion to try and control the bleeding. The bleeding was so bad, I would soak through thick pads at night.
After about a year on the IUD my period became more regular, still heavy, but at least predictable for the first time in many years. I know other friends on the IUD whose periods are essentially gone. Even though I still bleed for 6-7 days every month it is getting lighter and is at least regular! So, it’s going well, and I don’t have any other side effects. I wish I had an IUD inserted earlier!
If there had been a universal contraception policy – where you could access publicly funded prescriptions – how would that have changed your circumstances? How would it not have changed your circumstances?
If the policy only covered like OCPs, financially, I think it would have helped some. I was young working a starting job and not making much money. Other than financially, I’m not sure a universal contraception policy would have helped my situation greatly. Maybe if an IUD was publicly funded it would have been offered to me as an option. The OCP side effects I experienced were brutal – I would have loved a different option that allowed me more control and permanency. As my relationship went on, I lost more and more control over my body, pills felt too flimsy, and I was desperate to retain control over my reproductive health if nothing else in my life. Pills were not very private or secure, and would spark anger in him, “well why don’t you want to have a kid with me?” Paradoxically, he was threatening me not to become pregnant, but at the same time not wanting to use condoms, but also taking it personally I didn’t want a child with him. It was bad, he was always angry.
Having access to an IUD would have been a game-changer for me. For one, because my body responds to it much better. A regular period means freedom. For another, it would have reduced a major stressor during that tumultuous time in my life and a sense of control over my own body. I needed contraception I could trust, that would be effective, that wouldn’t be taken away from me, that was concealable, and that would be private. I wouldn’t have wanted him to know I had an IUD and keeping the more than $300 bill secret might have been hard. That would have been dangerous, but I would have done it to have the permanency.
If the IUD wasn’t covered, I would still have liked to have the option presented so I could save money for the upfront cost, knowing this might be dangerous too, but still worth it. If the IUD had been publicly funded and offered, this would have changed my world! I wonder what my life would have been like if I’d had an IUD earlier. Maybe I wouldn’t have as much anxiety, maybe I would have left the relationship sooner, or maybe I would have been able to focus on improving my life through education and work better. It’s funny how in medicine when we examine the pros and cons of OCPs, one of the pros is always that pills are temporary, and you can stop them at any time. For me, that was a HUGE con for OCPs.
Overall, I think having access to publicly funded contraception would have solved some of my problems, but not all of them. Ultimately, I became trapped in a bad relationship, and although appropriate contraception would have given me comfort and freedom, I might have still been stuck in that hole for a while. Contraception wasn’t my central problem, but certainly played into it.
The brunt of unwanted pregnancy prevention has historically fallen on women, and in abusive relationships, it is not uncommon for a partner to control access to contraception. Can you talk to us about what your experience was like?
I agree, the physical, emotional, and logistical work of contraception falls almost solely on women and girls. It’s a big responsibility put on young women and girls to manage. In my relationship, he didn’t want me to be on birth control or use condoms, but also threatened me against becoming pregnant. He also told me abortion wasn’t an option. He gave very specific threats of what he would do if I ever had an abortion, harm to me or to himself. So, I couldn’t win. It was very frustrating and isolating. I was so scared of becoming pregnant, but I was sexually abused and couldn’t deny him. I knew if I did become pregnant, I would have to hide it and get a secret abortion. The thought of that was SO stressful. I was really scared. Sooner or later, I knew it was only a matter of time whether we intended to get pregnant or not, but I knew I didn’t want a child in that environment. In my case, I had dreams for my future and having a baby with him at that point would have ruined that, but he didn’t care about my plans and studies, only his own.
I think women, girls, and people with uteruses think about pregnancy a lot, and ways to prevent it. I don’t think men give it much thought or realize how much it is on our minds. I had to carry the brunt of the abortion on my own as well which was significant. Now that I’m in a healthy relationship, I hope that when I have problems with birth control my partner can step up to the plate and take some responsibility. He has options too, and the blame shouldn’t be on the ‘defective’ or ‘difficult’ woman. It would also help if men could look at it as a partnership and help with the finances and mental workload. Mostly, an attitude change needs to happen and sharing of the contraceptive responsibility. Ultimately, it’s the woman’s choice but the men can help. And in terms of abortion, I would have liked to discuss this with my partner and have support while also considering his opinion. In the end, though, it is my body.
As a medical student who has already done a lot of work with vulnerable populations – sexual assault victims and intimate partner violence survivors - how do you envision providing care as a future physician and what are your career aspirations?
I would say that my personal experiences are very strongly associated with my career choice. My past is why I’m here in medical school. Medicine was never something I expected to achieve or something I planned for. One day I was just curious and looked up the MCAT. I ended up registering for an exam that day and got one of the last spots to quality for the medicine admissions cycle that year. I wrote the exam, completed the hefty application, and later got an acceptance letter. I don’t know how I did it, and even when I began classes I had zero faith in myself that I could do it. I am the only person in my family to attend post-secondary education on both sides. And after what I went through, I really didn’t see medicine as a viable option for myself, I thought I was too damaged. It was just some crackpot idea that for whatever reason I had the courage to pursue that day. I just keep going and try to heal along the way.
My family and I haven’t had good experiences in the healthcare system, so it motivates me to become an advocate for Indigenous people and become a great physician and healer. For example, one of the first times I went to a doctor seeking help (and I specifically requested a woman) I was basically turned away and not believed. I disclosed my situation and was hoping for resources or counselling, I knew I needed help but also couldn’t afford therapy. I walked away without any resources, no referral, nothing. Again, I just blamed myself and thought I was stupid for trying. It took me another 3 years to reach out again trying to access therapy.
Another time, I went to a walk-in to discuss the abortion when I found out I was pregnant. The male physician told me I had to talk to my partner about it first and bring him in for the next appointment. I was so scared, my brain was panicking thinking “I can’t get an abortion, what will he do”. That was super hard. When I entered medicine and started learning, I realized how things were supposed to work and what standard care was supposed to be like, so then I felt even more angry over the care my family and I have experienced. I’m still angry. I know good medicine and people are out there, but I feel betrayed, like I lost out.
It is also frustrating because sometimes our lectures in medical school don’t address these issues – what my family experienced and the barriers families like mine face. In terms of my peers, they’re good people but they don’t understand the effects of colonialism in the same way. They don’t feel it, they don’t live it. Sometimes it’s hard to relate and explain how accessing care can be dangerous.
I have so much hurt, in general, from the medical system so that it will inevitably shape how I practice and the communities I choose to serve. I would love to serve Indigenous communities and rural communities. Maybe even people who have experienced sexual assault or IPV survivors [intimate partner violence]. But I don’t think I’m far enough along my own healing journey to care for this population appropriately because I still feel so triggered by different situations.
For example, it’s hard to perform a sensitive pelvic exam on a woman or examine genital regions on our anatomy cadavers without having a panic attack. It’s ok by myself, but it’s harder with my peers around. It’s good our curriculum is covering these topics (cultural safety, sexual assault, IPV, and trauma-informed care), but it just hits close to home for me. Sometimes I have to pretend I know less when our class has discussions around these topics, so people don’t suspect my history. It’s an exhausting balance. My peers are also learning, so sometimes they make mistakes which can be triggering and hurtful. Anyway, if I could serve the IPV/sexual assault population one day, without burning out and keeping myself well, I will. If not, I have strong faith in my capacity to serve behind the scenes in research and other advocacy work to make change.
Quite simply, I wish to be the kind of physician that everyone feels welcome and safe to meet with, regardless of identity, gender, or life situation. I might not always be the best person to help them (I can’t be an expert in everything), but I will ensure they have other supports to get the care they need and deserve. I will walk along the journey with them, not just pointing the direction to go. This is my goal and dream.
From your volunteer and research experience, what additional barriers do some vulnerable populations face when accessing contraception?
First - in terms of gender and sexual identity, I think if you don’t fit a cis-gender, hetero-normative world it is going to be much more difficult. I think that dating violence and partner violence isn’t well known in this population, and men especially are not often viewed as victims or women as abusers. Transgender women also have trouble accessing contraception. For people who don’t fit the mold of ‘normal’ it can be really hard to access care and contraception if they don’t feel safe in the healthcare system. This needs to change.
Second – in terms of urban centers, I feel like these regions have more specific resources. For example, UBC Vancouver has the SASC [Sexual Assault Support Centre] and UBC Kelowna has the SVPro [Sexual Violence Prevention and Response Office] – supports specifically for students experiencing sexual violence. Plus, there are a ton of other community resources related to IPV in larger centers. Rural areas just don’t have this, there are very limited supports or resources to turn to. And if they do exist, you probably know the people working there, or they know you, or they know your abuser – nothing is private in a rural town. The same goes for accessing contraception in a rural town, people know and people talk.
My abuser used to ridicule and belittle me about contraception and my periods in front of me to a group of friends. My situation was very visible, and nobody helped, it was just swept under the rug. In a small community, people can know your health or relationship situation, and I felt a lot of shame about my constant bleeding from the OCPs. Compared to urban centers, in a rural community it can be hard to access confidential, safe care or escape bad relationships.
Third – people who are immigrants or non-residents. I’ve not experienced this, but from those I’ve spoken with it can be really hard to access contraceptive care and/or leave abuser relationships, especially when you’re worried about your legal immigration status in Canada. It is a very vulnerable place to be in, not sure of your rights, possibly without medical insurance, away from your support system. In addition, language can be a huge barrier to accessing appropriate contraception, as well as different cultural norms and understanding the options.
Fourth – as mentioned above: the effects of culture or religion. For example, in some religions perhaps contraception is not allowed, or women get stuck in abusive relationships because divorce is not an option. Contraception still has a lot of stigma associated with it, and there is a lot of misinformation out there.
Fifth – people who use substances. For people experiencing active addiction it can be really challenging to access healthcare for contraception because your lifestyle is so erratic or unstable. The finances might not be there either. Someone close to me who was trapped in an abusive relationship for a really long time and her abuser was also her access to substances. There was no way she could have accessed contraception because:
1. she felt unsafe around health professionals,
2. was not able to make or attend appointments due to substance use,
3. was controlled by her abuser, and
4. contraception is expensive.
Sixth - people who have disabilities. Now, this will depend on the nature of the disability (a VERY broad term), but this population may be more dependent on others to care for them who may or may not prioritize contraception. Also, people with disabilities may have different ways and capacities to communicate with healthcare providers, or an understanding of contraceptive options. I wonder sometimes if this is a blind spot for some health professionals who don’t have experience working with people with disabilities. I worry this population isn’t understood or cared for in the same way, and maybe get lost in referral limbo-land.
What message do you have for health professionals or health students regarding contraception and IPV?
As current or future healthcare professionals there are a few things I would like you to be aware of
when you are working with people who have experienced IPV and have trouble accessing contraception.
Please note, this is based on my opinion only and does not reflect others’ experiences. It is important as a medical professional to improve your ability to recognize signs of IPV and other forms of violence, and I hope you take the time to develop an understanding for yourselves.
Do not take your role lightly. Do not assume that someone else will have the conversation. If someone discloses something like IPV to you, you may be the only place they felt they could go, or they didn’t know who else to turn to. They may have never spoken these words aloud before and you could end up being another person that inadvertently silences them, whether you intended to or not. It is easy to be busy, and maybe you feel like you’re not the expert in IPV or contraception. But no one needs to be an expert to be a safe first point of care, and if you feel like the conversation is beyond your wheelhouse, then you have a responsibility to support the patient along the way until you can guarantee they receive appropriate care as determined by the individual.
People experiencing violence may not have a lot of contact with health services. You could be the gateway for them to access contraceptive or IPV resources. This could be a family doctor, a walk-in clinic doctor, an emergency doctor, or maternity and obstetric care professional – whatever your role, please ensure that if you’re chosen as a safe person that you do your best to provide them with resources or refer to a more appropriate person while supporting that transition.
For the person discussing contraception and IPV with you, it may not be easy to verbalize. They may be ready to admit all aspects of their experience to you (or themselves) – don’t push it. Walk with them instead and provide them with options and resources to better assess their safety or ensure they know where to go when they are ready to access care. The person might not be ready to talk, they might not be ready to make changes in their life, they might not be ready to contact other services/resources yet; there is no expected timeline and the situation is usually more complex than you could imagine. Be patient, and just be there.
Don’t have expectations. Those experiencing trouble accessing contraception because of IPV can be any gender, any sexuality, any race, any religion, and any socioeconomic status level. If you have expectations or assumptions, someone somewhere will be left out. Also, don’t have expectations for how people will process their experiences, how they will heal from their experiences, and when they will choose to change their situation – everyone is different. Ensure you understand where the individual is along their journey so you can meet them there and support them in their decision-making.
Thank you for making space for me to share my story. Contraception is so important to me. I’m not in this terrible situation anymore, but others are – I hope my story can help others in a similar situation and to also humanize the discussion around universal contraception – that’s all that really matters.