Gen Z Women Have Their Own Ideas About Contraception

Often citing concerns about side effects, Gen Z women (born between 1997 and 2012), increasingly are shunning evidence-based family planning and reproductive health counsel, turning instead to advice from social media influencers and fertility tracking apps — with mixed results — according to experts.

Federal data published in 2020, the most recent data currently available, reported that only about 14% of women in the United States used oral contraception. That was down by half from data collected in the United States in 2010.

One expert views the sea change as an emerging power struggle between women and medicine at large, the institution that has control over their fertility and body literacy.

Others are less worried about the dangers posed by social media and more about health data being stolen or subpoenaed, compromising their patients’ safety.

Influencers in the Mix

Among the many social media platforms, TikTok in particular attracts the most women in Gen Z, according to a recent Pew Research Center report. It found nearly 45% of platform users were women, the highest rate among any platform studied.

Last year, the Kaiser Family Foundation reported that 53% of Gen Z people surveyed in the United States reported they trust health information they consumed on TikTok. Nearly 60% of this cohort reported watching information about abortion on the platform, while 52% reported they had watched TikTok videos about birth control.

Zoe Pleasure, MPH, a doctoral candidate at the University of Washington, Seattle, and her colleagues are just beginning to analyze data from their study of how TikTok is used to discuss what she called the “perceived and experienced” side effects of hormonal contraceptive methods. The study is sponsored by the Society of Family Planning.

Among the investigators’ goals, Pleasure said in an interview, is to determine how side effects from hormonal contraceptive methods affect a woman’s decision-making about family planning. They also seek to learn what in social media might be useful in clinical practice, said Pleasure.

Evidence-Based vs First-Person Anecdotal Evidence

Over the past decade or so, there has been a raft of studies associating oral contraceptives, in particular, with higher rates of depression among women, as well as other poor health outcomes. However, in 2022, JAMA Network Open published an umbrella review of meta-analyses that concluded the majority of these studies were not based on high-quality evidence.

A meta-analysis on the mental health effects of oral contraception, also published in 2022, similarly found weak evidence, although investigators noted that the risk for depressive symptoms in adolescents using oral contraception should be kept in mind.

However, numerous TikTok influencers such as @broganperry and @amanda_pac contravene these studies. They report to their fans, numbering in the 10s of thousands or more, that they had a range of side effects that ended once they quit taking oral contraceptives.

This kind of social support should not be discounted, and not all sharing is misinformation, according to Pleasure.

“There are potential benefits to people sharing their contraceptive experiences online, such as supplementing what individuals might hear from their providers,” Pleasure said.

Unplanned Pregnancy Uptick

Results from another recent study suggest there is a knowledge gap for physicians to fill when it comes to properly using any kind of contraception.

Earlier this year, researchers in the United Kingdom found that across a 5-year span, there was an uptick in women seeking an abortion who reported they did not use any contraception. The study was published in BMJ Sexual & Reproductive Health.

The UK researchers also found an increase in the number of women who reported using fertility awareness methods and a decrease in use of prescription contraception.

The study compared data between 33,495 women who presented for an abortion in England and Wales from January to June 2018 and 55,055 women who presented for an abortion from January to June 2023. Investigators found that the use of hormonal contraception prescriptions fell from nearly 19% in 2018 to just over 11% in 2023. Use of long-acting reversible contraceptive implants fell from 3% to 0.6% in the period studied.

The investigators also found that the use of fertility awareness methods around the time of conception had increased from 0.4% in 2018 to 2.5% in 2023. The age of women using these methods fell from nearly 30 years to 27 years. Most salient was that the number of women who reported not using any form of contraception when they conceived rose from 56% in 2018 to 70% in 2023.

The study’s lead author, National Health Service researcher Rosie McNee, public health registrar, suggested the results point to a zeitgeist.

“Access to contraception during and following the pandemic is one aspect but also attitudes toward contraception are changing,” she said in an interview.

The study is relevant to clinical practice, according to McNee, in that it highlights the need to remove barriers to sexual and reproductive healthcare. This is “so that women can access timely, supportive, and evidenced-based reproductive healthcare,” she said.

‘All the Options’

One expert on family planning, Marguerite Duane, MD, does not believe all evidence-based options are in fact being presented to women of reproductive age.

That’s because doctors don’t know enough about them, she said.

“Even though fertility awareness is basic reproductive physiology, I didn’t learn it in medical school,” Duane told Medscape Medical News in an interview. “We learn aboutthe femalehormones, but we don’t learn that [a woman] can learn to observe external biomarkers that reflect the daily internal hormonal changes that are happening in her body, and that can serve as a fifth vital sign.”

The American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion in 2015 endorsing tracking the menstrual cycle as a vital sign, but only in adolescence. ACOG reaffirmed their stance in 2020.

Duane is a family medicine physician who created and teaches a fertility awareness class at Georgetown University School of Medicine in Washington, DC.

She salutes Gen Z. “They are absolutely pushing this. And I think doctors are going to feel the demand from the Gen Z women who want this information because they are tired of being gaslit,” Duane said.

Duane believes the current generation of women is demanding respect for themselves and their bodies, not control over them.

“Fertility is seen as a disease, right?” asked Duane. “For more than 50 years, women have been told that our reproductive system — which is biologically designed to allow us to reproduce — is a problem, and that it needs to be controlled with a drug, the Pill. No. We don’t need to suppress it. We need to understand it.”

“A woman can learn from a trained instructor how to chart her cycles, but the reality is the birth control industry is a billion dollar one,” she said.

Rhythm Method Is Outdated

Duane is the executive director and cofounder of FACTS about Fertility, an organization aimed at educating healthcare professionals about evidence-based fertility awareness methods. FACTS advisory council members have come from both Planned Parenthood and the Catholic Medical Association, according to Duane.

“Our goal is to work with anyone interested in educating medical professionals about the science supporting these methods,” she said.

One of FACTS’s primary areas of study is the standardization and refinement of fertility awareness–based methods (FABMs). A recent survey by the organization found that most physicians surveyed are uninformed about what Duane called “modern, evidence-based natural methods” such as the Billings method, which monitors cervical mucus. Some in the survey knew about the rhythm method, but Duane said that as revolutionary as it was when it was developed in the 1930s, things have advanced.

FABM Mania

Failure rates of FABMs, even when used correctly, can be up to 12%, according to the Guttmacher Institute. Used incorrectly, failure rates can be as high as 34%, they assert. By comparison, oral contraceptives have about a 0.3% failure rate when used correctly and an 8% failure rate when used incorrectly, all according to the Institute.

This failure rate has not deterred hundreds of millions of women around the globe from using it, as one study suggests. The researchers at Oxford University in the United Kingdom claimed that from April to December of 2021, fertility tracking apps such as Flo and Clue were downloaded around the world more than 200 million times and in 112 countries.

“Our findings reinforce emerging evidence that menstrual tracking apps are more popular in areas with limited access to reproductive health services and contraception,” the authors wrote.

In the United States, however, the American Medical Association is advocating for tougher standards around these apps. That’s thanks to a case prosecuted by the Biden administration in which a fertility tracking app developer lied to customers and disclosed their data to multiple third parties, including those in China.

App Users ‘Unconcerned’ Despite Risks

In May of last year, the Federal Trade Commission (FTC) released a study, performed by Duke University faculty, on the dangers of fertility apps. The authors warned that data collected by the apps could be sold without their knowledge or, in a post-Roe world, either seized by the government or turned over by app developers for use against women who terminate a pregnancy.

“The stakeholders who have access to the period-tracking apps’ collected data have the most impact on participants’ perceived privacy concerns, with government and law enforcement being the most concerning stakeholders,” the study authors wrote.

Data published in Contraception earlier this year found women are not as concerned about their privacy as the FTC suggests they should be. The study’s authors found that the use of fertility tracking apps by women in five states increased by half after the Dobbs decision.

“It doesn’t seem like people heeded the advice to stop using fertility trackers,” Emily Neiman, a clinical nursing instructor at The Ohio State University, Columbus, Ohio, and the study’s lead author, said in a media release.

Neiman said she believes some women use the apps not to track the best time to conceive but when they think it will be the best time for them to have unprotected sex.

“As providers and public health professionals, we could be doing a better job of educating around the reliability of the information they’re getting from these technologies to help people who are trying to prevent unwanted pregnancies,” Neiman said in the release.

Neiman suggested the rising popularity of these apps in a post-Roe world is a paradox.

“In a time when people should have very reliable contraception if they don’t want to be pregnant because of abortion restrictions, the push on social media seems to be for methods that are not as reliable because of the lack of understanding around what information the tech provides,” she said.

For Duane, the answer is less complicated.

“I tell women, ‘You’re smart, smarter than your smartphone. Don’t let your phone tell you when you’re fertile,’” Duane said. “Learn to observe your signs and learn how to interpret them with a trained instructor.”

None of the sources interviewed disclosed having conflicts of interest.