Efficacy as safety: Dominant cultural assumptions and the assessment of contraceptive risk

To reduce rates of unintended pregnancy, medical and public health associations endorse a contraceptive counseling model that ranks birth control methods by failure rate. This tiered model outlines all forms of birth control but recommends long-acting reversible contraceptives (LARC) to eliminate user error and increase continuation. Our critical discourse analysis of gynecology textbooks and medical recommendations examines how gendered and neoliberal ideas influence risk assessments underlying the tiered contraceptive counseling model. Specifically, we explore how embodied, lifestyle, and medical risks are constructed to prioritize contraceptive failure over adverse side effects and reproductive autonomy. We find that the tiered model's focus on contraceptive failure is justified by a discourse that speciously conflates distinct characteristics of pharmaceuticals: efficacy (ability to produce intended effect) and safety (lack of unintended adverse outcomes). Efficacy discourse, which filters all logic through the lens of intended effect, magnifies lifestyle and embodied risks over medical risks by constructing two biased risk assessments. The first risk assessment defines ovulation, menstruation, and pregnancy as hazardous (i.e., embodied risk); the second insinuates that cisgender women who do not engage in contraceptive self-management are burdensome to society (i.e., lifestyle risk). Combined, these assessments downplay side effects (i.e., medical risks), suggesting that LARC and other pharma-contraceptives are worth the risk to protect cisgender women from their fertile bodies and to guard society against unintended pregnancy. Through this process, ranking birth control methods by failure rates rather than by side effects or reproductive autonomy becomes logical as efficacy is equated with safety for cisgender women and society. Our analysis reveals how technoscientific solutions are promoted to address social problems, and how informed contraceptive choice is diminished when pharma-contraceptives are framed as the most logical option without cogent descriptions of their associated risks.