[ Editorials | Departments and Series | Index ]

Contraception UPDATE

Misconceptions and Ignorance About Sexual and Reproductive Health

L. L. Wynn, PhD; Angel M. Foster, DPhil, MD, AM; James Trussell, PhD

“On Sat. my boyfriend and I slept together, but since we had no protection, I asked him to keep his boxers on. And ejaculation did not occur. I’m currently on my menstral [sic] cycle, is there a chance that I might be pregnant? Should I take emergency contraceptives?” (E-mail sent to http://ec.princeton.edu, October 19, 2003. All quotes reproduce the spelling, grammar, and punctuation errors of the original e-mails.)

This is one of 1,134 e-mails sent over a 1-year period in 2003 and 2004 to The Emergency Contraception Website (http://ec.princeton.edu). We analyzed the content of those e-mails and found that ignorance or misconceptions about sexual and reproductive health were common, appearing in about 27% of all e-mails received, and the misconceptions could be grouped into 5 broad categories (Table).1 The complete study has been published elsewhere1; here, we summarize the findings, describe some common examples of the misconceptions, and suggest possible sources of misinformation. Finally, we discuss the clinical implications for health care professionals.

Click to enlarge

TABLE. Categories of Misinformation About Reproduction1

back to top

Thematic Categories of Misconceptions

Sexual Acts That Can Lead to Pregnancy

The most common type of misconception (n=79, or 7% of all e-mails) centered on the pregnancy risk from sexual acts that are unlikely to result in pregnancy. Writers asked if they could get pregnant from anal sex, oral sex, nonpenetrative sex, and sexual encounters too com-plex to reduce to a single-word descriptor, as the following
e-mail vividly illustrates:

“my friend (a girl) and i ended up hooking up with a guy we know. As i said, it was nuts.... i went down on this guy, then later i went down on my girl friend. later i started thinking! could his sperm be swimming around my mouth and then go up my friend’s kooch???!??!! DOES SHE NEED EC? i hope you can answer because we are for real wigging out!!” (E-mail received June 28, 2004.)

Almost one-half of these e-mails express fear about the pregnancy risk posed by pre-ejaculatory fluid.

Definitions of Protected Sex

A significant number (n=54, or 5%) of e-mails evinced a basic lack of knowledge about the pregnancy protection offered by hormonal contraception. We included in this category only e-mails in which the writer reported correct use of these contraceptive methods, and we did not include in this category e-mails in which the writer was concerned about pregnancy risk after missing a pill or being late in receiving the patch or an injectable contraceptive. While there is a small risk of pregnancy with all contraceptives, the risk is negligible for these highly effective contraceptive methods when used correctly.2 Yet many e-mails hinted that the women using these methods were not even sure why they were using them. Notably, many were not sure whether they were protected against pregnancy during the placebo week of the pill or patch.

Timing of Pregnancy and Pregnancy Testing

Forty-two e-mails (3.7%) re-vealed misconceptions about the timing of pregnancy, with many assuming that pregnancy can occur and be detected by home tests shortly after intercourse. Still others asked if they could have their period and still be pregnant. For example:

“if you are pregnant, you wont get your period, but what if yo [sic] have unprotected sex the day before your period, if you are pregnant, will you still get it the next day?” (E-mail received April 7, 2004)

A small number of e-mails asked if bleeding could actually be a sign of pregnancy, and 5 of these used the term “implantation bleeding” to express the belief that a fertilized egg implanting in the uterus can trigger vaginal bleeding that mimics a menstrual period.

Emergency Contraception

A similar number of e-mails (n=40; 3.5%) asked if emergency contraception (EC) pills could impair future fertility, be dangerous to an existing fetus, or even be life-threatening to women who took them. Another 27 e-mails (2%) revealed a belief that EC pills can cause an abortion.

The relatively low percentage of women who confused EC with the abortion pill and the small number of those concerned about the safety of EC are comforting, given the confusion that existed when EC first became available. However, we cannot assume that these figures represent the level of knowledge among the general public. The Emergency Contraception Website is an educational resource that defines EC and distinguishes it from medication abortion. It also contains numerous statements about the safety of EC. Thus, the small number of e-mails on that topic may simply indicate that many readers had their questions about EC answered before sending the questions reviewed in this study.

It is noteworthy that the least frequently asked questions were general ones about EC, which were answered elsewhere on the Web site, while the most frequently asked questions revolved around pregnancy risks in specific circumstances. Such individually tailored information cannot always be addressed with a generic list of “frequently asked questions.”

back to top

Sources of Misconceptions

More than a quarter of the e-mails received during the period of 2003 to 2004 manifest substantial misconceptions or ignorance about sexual and reproductive health. These e-mails were sent before the FDA approved Plan B for nonprescription sale, and there is some evidence that publicity surrounding the controversy over the FDA’s decisions on Plan B has generally increased the American public’s awareness of EC. However, the questions being e-mailed to the Web site about 5 years later continue to manifest similar levels of general misinformation about sexual and reproductive health. It is difficult to know the sources of misinformation that feed these misconceptions, especially since we have very limited data about the e-mail authors. Nevertheless, a methodical search of the Internet and the medical literature suggests some of the ways in which popular health misconceptions are shaped by the social and political context of sexual and reproductive health in the United States.

Inadequate Sex Education

A majority of the Web site users (>70%) are based in the United States, where abstinence-only sex education has been funded by the federal government since Congress passed “welfare reform” legislation in 1996. Most schools that accept such funding prohibit teachers from talking about contraception except to report contraceptive failure rates, and abstinence-only curricula often includes misleading and incorrect information about pregnancy and disease risks.3 Poor sex education may partially account for questions that reveal a lack of basic understanding about pregnancy risks in nonpenetrative sexual acts and the protection afforded by different contraceptive methods.

Misinformation on the Internet

Studies of Internet users have shown that many people turn to the Internet for health information, particularly for sensitive or stigmatized topics such as sexual diseases, contraception, pregnancy, and abortion.4 Yet the reliability of health information online varies, making the Internet a source of common myths, misconceptions, and urban legends about sexual health.

Non—Evidence-Based Medicine and Medical Protocols

Ironically, the sources for some of these myths and misconceptions circulating on the Internet are medical science itself. For example, we have traced the origins of the belief about the pregnancy risk posed by pre-ejaculatory fluid to a 1966 Masters and Johnson textbook and the theory of implantation bleeding to a 1954 JAMA article.5,6 Each has often been repeated by both scholarly and popular sources, yet subsequent research has demonstrated that pre-ejaculatory fluid contains no motile sperm and there is no evidence that implantation causes vaginal bleeding.7,8
Dubious medical protocols may also fuel misconceptions about the time frame during which pregnancy occurs, when it can be detected, and the risks posed by EC to women and fetuses. For example, many emergency department protocols insist on administering pregnancy tests to sexual assault survivors before administering EC pills, even though pregnancy cannot be established during the time frame in which ECs are effective, and progestin-only EC pills pose no known health risk to women or to preexisting fetuses.9,10

back to top

Clinical Implications

It is fortunate that this Web site is available to women desperately seeking answers. There must be many more people out there with unanswered questions. This observation suggests 2 main clinical implications for health service professionals. First, there is a clear need and opportunity for patient education in clinical encounters. If clinicians listen attentively to patients for assumptions they may have about their health, they may find powerful opportunities to debunk misconceptions about the fundamentals of sexual and reproductive health. Second, hospitals, clinics, and clinicians must implement medical protocols grounded in evidence-based medicine, with the awareness that outdated protocols may perpetuate medical myths and misconceptions.

The authors report no actual or potential conflicts of interest in relation to this article.

back to top

L. L. Wynn, PhD, is Lecturer in Anthropology, Macquarie University, Sydney, Australia; Angel M. Foster, DPhil, MD, AM, is Senior Associate, Ibis Reproductive Health, Cambridge, MA; and James Trussell, PhD, is John Foster Dulles Professor in International Affairs and Director, Office of Population Research, Princeton University, NJ, and Visiting Professor, Hull York Medical School, Hull, UK.

References

1. Wynn LL, Foster AM, Trussell J. Can I get pregnant from oral sex? Sexual health misconceptions in e-mails to a reproductive health website. Contraception 2009;79(2): 91-97.
2. Trussell J. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year. In: Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D, eds. Contraceptive Technology. 19th rev ed. New York, NY: Ardent Media; 2007:759-760.
3. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: a review of U.S. policies and programs. J Adolesc Health. 2006; 38(1):72-81.
4. Rideout V. Generation Rx.com: how young people use the Internet for health information (a Kaiser Family Foundation survey). Kaiser Family Foundation, 2001. Available at: www.kff.org/entmedia/20011211a-index .cfm. Accessed August 24, 2009.
5. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown; 1966.
6. Speert H, Guttmacher A. Frequency and significance of bleeding in early pregnancy. JAMA. 1954;155(8): 712-715.
7. Zukerman Z, Weiss DB, Orvieto R. Does preejaculatory penile secretion originating from Cowper’s gland contain sperm? J Assist Reprod Genet. 2003;20(4):157-159.
8. Harville EW, Wilcox AJ, Baird DD, Weinberg CR. Vaginal bleeding in very early pregnancy. Hum Reprod. 2003; 18(9):1944-1947.
9. Harrison T. Availability of emergency contraception: a survey of hospital emergency department staff. Ann Emerg Med. 2005;46(2):105-110.
10. Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstet Gynecol. 1990;76(3 Pt 2): 552-557.

back to top