The Sexual Risk Avoidance Regime

On fertility-tracking apps and the return of abstinence education

These images, exclusive to the web edition of this essay, are taken from a brochure for the Pittsburgh Aids Task Force.

Passing by a local strip mall known, as if in confirmation of the longstanding fangless-ness of irony in the United States, as “Miracle Mile,” I’m sometimes compelled to pause. I’m at a light in my car, idling between the two major commercial and residential hubs in the rural area where I live, where I-91 and I-89 tangle at the Vermont-New Hampshire border, before they continue north and east, respectively. I’m usually pointed in the direction of Hanover, New Hampshire, and so, lazily riding the clutch as I’m occasionally wont to do, I’ll look right and find myself gazing at a sign that reads PREGNANCY CENTER. If I crane my neck a bit I can also make out the words VALLEY VAPE. Other businesses include: GT&R Auto, Dunkin’, Up All Night Entertainment.

I’m not an ancient person, but I’m not really all that young, either. It is, in theory, possible for me to become pregnant. However, when my eyes slip over PREGNANCY CENTER, I don’t feel interpolated. Of course, in theory, because I am female and because, again in theory, I have working ovaries, I’m among the sign’s intended audience. “Bring your pregnancy here, to this center,” the sign cajoles me and/or somebody. The center is located in a two-story structure with beige siding and a peaked asphalt roof. It’s in the middle of a series of slapdash buildings and parking lots, a place no one wants to linger. Soon I, too, am accelerating away, up a hill.

It’s possible, to be completely honest, that I was so careless of the sign’s bid for my attention—that I so rarely think about pregnancy or its “center[s]”—that I might never have noticed it at all. If you, like me, grew up in one of America’s larger cities or if you, like me until recently, have been spending a good portion of your adult life in one of them, maybe you don’t know what a “pregnancy center,” or a “pregnancy testing center,” to supply another iteration, is. Certainly, you know what a name like “Free Abortion Alternatives” or “Life Choice Ministries” implies. You get the message. You’ve read and heard about the various anti-abortion disinformation and intimidation tactics condoned not just by private groups and actors but state governments. Manhattan, New York, seems, as far as Google teaches me, not to have a readily locatable pregnancy center. Manhattan, Kansas, definitely has one. It’s right next to the Life Choice Ministries. (Free Abortion Alternatives is, meanwhile, located in Brooklyn.)

But to bring things full circle, even if you were not and have never been interpolated by a pregnancy center, there are other subtle messages out there. Among these are the ones riders on the New York City subway system are subject to. A common theme is the direct-to-customer disruptive app-product: the best, lightest, and most-made-of-recycled-materials shoes you’ll ever own or want to own; underwear that absorbs your period; pills for baldness; pills for your flaccid penis; chemical birth control. There are many I’m leaving out. The ads usually feature partial shots of mugging, pleased if embarrassed faces, or hands or feet. The backgrounds are fields of a single color. Objects are light and happy and minimalist, fonts jaunty. OkCupid, although it’s now been around long enough to seem like a “heritage brand” rather than a disruptor, was revitalized through a similar treatment, in which the expression/meme DTF was updated into a series of diverse f-word hobbies and practices (focusing on your chakras, feeling fabulous, firing up the kiln), practiced by diverse couples, again in colorful suits and environments, Jacques Tati on mescaline and minus the bureaucracy. There’s a lot to say about all this but I’ll attempt to limit myself to a couple of observations: Note the closeness/similarity/physical or conceptual continuity between the technology that enables the product and the product itself. It is often the case here that there is no product without the technology that either enables it or enables its distribution. In this sense, these products tend to “disrupt” other markets or means of distribution.

The terror did abate a bit—probably due to the fraction of autonomy I’d achieved.

The disruptive NYC subway-advertised app-product that has stuck with me of late and even caused most of the foregoing reflection is called “Natural Cycles.” I’ve attempted to pinpoint when it first appeared to me but as so often, ambient as my attention is in transit, most of my brain in my phone, I can’t remember. The advertising calls it “A Different Kind of Birth Control.” Natural Cycles is a phone app and thermometer. You pay nearly $100 for the two of them and then you use them to measure and track your body temperature, along with your menstrual cycle, in order to predict your fertility. In spring of 2019 one person posted an incredulous photo to Twitter (“Why is there an ad in the NYC subway for the 21st century take on the rhythm method?”); I was surprised, too, but for a different reason. Although Natural Cycles seems to walk the line for some people between hoax and homeopathic practice and was investigated in the U.K. after a number of people became pregnant while using it as directed, looking up at the advertisement I experienced a weird sense of recognition: Oh look, now they’re selling that thing I quietly do. I noticed myself noticing something shift for me, internally. I wondered, briefly, if the world was about to change.

An illustrated brochure explains to teens: "You're a sexual being" and "Sexuality doesn't mean sex."
Pittsburgh Aids Task Force

Life Hacked

There were a lot of things that it did not occur to me to notice that I was not noticing, when I was in high school. Among these was not the possibility of having sex. I, like everyone else, was noticing this. Sex was definitely there. But what I wasn’t noticing—and what “we,” by which I mean my classmates at a private high school in the Riverdale neighborhood of the Bronx, NYC, were not noticing—was the terror we associated with it. We did not know that our terror was there because we consumed a steady media diet: of baby tees and piercings, of muscled bodies drenched in Fahrenheit cologne. We had the images. It was some time after 1995 and we had seen Kids, an allegedly counter-cultural conte cruel. Sex could certainly shame you, but it might also cause you to die. For all of Kids’s gestures toward myth shattering, it mostly rehearsed simplistic (and very straight) ideas about masculinity, arguing that you should be afraid of your own sexuality: if you were female, because young men did not understand the concept of condoms and were entitled rapists; if you were male, because your unchecked aggression and misplaced need for parental love would cause you to manipulate, rape, and bash people’s heads in with your skateboard. Thus, we didn’t know we were terrified, because we thought terror was merely the correct relationship to have to any notion of sex. We had some idea of what safe sex was, but mostly we thought it was reasonable to assume you took your life into your own hands when you slept with somebody (which was something we did anyhow and often not as safely as we might have, had we been somewhat less frightened).

I like to think that we are all more aware of these politics now. And yet it astonishes me when I think back on the drama with which my childhood best friend’s contraction of an STI was treated, particularly when complications resulting from its mitigation landed her in the hospital for several days. Our parents communicated, and I was brought in to gaze upon her in her institutional bed. I think we must have been sixteen. This scene might, of course, given the existence of HPV vaccine, be less likely to occur today—along with the removal of polyps that led to blood loss. So, in spite of the fact that it wasn’t really the STI that had her in the hospital, but rather someone’s treatment of it, I was told, probably by my friend herself, that she could have died. I went home and consulted my copy of Our Bodies, Ourselves, which told me very little.

Another close friend had an early-term abortion and asked me to pick her up at the clinic. Although we were sober about it and the possibility of pain, I don’t remember there being anywhere near as much drama involved. I had been gearing myself up for drama, but instead we sat together for a little while and then went home. This must have had something to do with parents not being involved. But it’s also hazy in my memory—I may be forgetting that I was afraid, that we both were. Condoms were at once absolutely necessary and terrifying. The wisdom was they “did not feel good.” Things were a mess.

I mention this because I realize now what I must have been alerted to as an adolescent in sex-ed class—a part of my education of which I have absolutely zero memory, from who would have taught the class to what sorts of visual and/or discursive aids were employed—and which I would have personally reinforced through my reading of various manuals on human sexuality, sexual customs, and anatomy, which I read with demonic concentration, as if they were going to explain to me the meaning of life, which, in a sense, I guess they did. The thing I know I must have gleaned during this time was the fact of the female fertility cycle. I know I must have learned this somewhere. I mean, maybe I didn’t. But I’m pretty sure I did.

The thing was, I forgot to remember that the menstrual cycle occurs due to the rise and fall of hormones. This cycle results in the thickening of the lining of the uterus, and the growth of an egg (which is required for pregnancy). The egg is released from an ovary around day fourteen in the cycle; the thickened lining of the uterus provides nutrients to an embryo after implantation. If pregnancy does not occur, the lining is released in what is known as menstruation. P.S.: I took most of this paragraph from Wikipedia.

Fast forward seven or eight years. I’m twenty-five or so. I’m married and have just completed an MA. During the course of my MA, a time when I lived approximately 1,000 miles from home, far enough that I somehow managed to take my reproductive health into my own hands, I found a helpful gynecologist and started taking the pill, something I hoped would help with the terror I still felt in relation to sex. The terror did abate a little bit—probably due to the fraction of autonomy I’d achieved. The side effects, however, were noticeable: I do remember this, waking up and sitting in a chair by the window for several hours, weeping and, literally, gnashing my teeth. I privately termed these my “medieval abyss” moments. I didn’t think I was gaining too much weight but I do remember feeling mentally ill. I felt a kind of undercurrent to things, an ominous tug; all events had a slushy sentiment and I kept noticing my breasts.

I spoke to the gynecologist and she re-prescribed what was the lowest hormonal dosage then available. She used the verb “tolerate” to describe my interaction with the medication. Her phrase was something like, “if you can tolerate [this].” Because I had once been a good student and even a dutiful child, I tried.

Monitoring my cycles and body temperature was something I did with my phone, privately, or so I thought.

It took me something like two years of attempting to tolerate progestin and to tolerate having to put it into my body on a daily basis at the same time everyday (nearly impossible) to start talking about the problem with female friends. By this time, I was living with my then-spouse on the West Coast, even farther away from my parents. I was closer to Silicon Valley, too, but there were not yet any apps. Talking to one friend who had a sister who was close to her in age and had a mother who was honest with them, I learned and/or remembered: you can’t get pregnant all the time. I do recall my friend saying this to me. We were in her apartment in the Mission more than a decade ago and it was very simple, “Oh, but you can’t get pregnant all the time. Didn’t you know that?”

I guess I almost knew. Or I didn’t know well enough.

On her recommendation I went online and bought a book, Taking Charge of Your Fertility, that was mostly for women who were trying to get pregnant. I like to think of it as a proto “hack.” Although there was the predictable language about avoiding risky behavior and the need for a stable relationship if you wanted to try this out, there was indeed a short section about measuring one’s basal temperature and tracking it, along with other changes to one’s body, as a means of birth control. There were charts you could xerox and fill out. Surreptitiously, I xeroxed a large number of these at work. In the future, this could have been a scene that was rehearsed to comic ends on Girls, but for now it was just me fumbling around in what felt like an endless void. I’m trying to remember which parts of culture felt sympathetic to this predicament; I can’t come up with any.

I went off hormonal birth control, for some reason touting to those who would listen my financial savings. I was struggling with admitting that I had reached a chemical breaking point. As I came down from the hormones, it felt like the end of an unwanted trip. I lost weight I hadn’t noticed I had gained. Many persons and things ceased to be spectral and menacing. Mornings were bearable. Life felt more neutral. Although I did not give much thought to this at the time, it was clear that I had been on serious drugs. I was vaguely amazed to think—although, again, I did not really think much about it—that teenagers took these drugs, that their parents encouraged them. I considered some girls I had known who did, their steady boyfriends and expanded breasts. People also took them for their skin, to regulate periods, for reasons that went beyond my needs. I was just trying to keep my life in order—or, so I told myself. Thus, going off the pill felt vaguely illicit and maybe irresponsible, probably antisocial. I clumsily filled in my little charts and did not get pregnant, although sometimes I felt like I was crazy, or, failing that, infertile: you weren’t, so far as my education had given me to know, supposed to be able to do this.

I never took chemical birth control again. After Obama’s election, a sort of arbitrary marker, in a way, at parties I started hearing about IUDs. The guides I had read as a teenager had warned me against these devices with terrifying tales of medical error. People I knew had some stories, too, but in general everyone seemed to want something you could wear or that could be injected into you at intervals. Advertising in magazines and on television (both of which I now mostly consumed online) showed women receiving advice from doctors in sunny offices and then frolicking, often alone with a dog, having received their device or injection. They would not return to the doctor for a month or months. The daily pill was out. No one seemed to be on it. I revealed my own methods only to very close friends, for fear of being seen as either a gambler or a deluded person with non-working ovaries. I was private about it. Eventually, monitoring my cycles and body temperature was something I did with my phone, privately, or so I thought. I used an app, because there was an app for it. Then, there were multiple apps.

A woman puts a hand over the face of a man below the words "Sexual Abstinence - Choosing to wait"
Pittsburgh Aids Task Force

The Radical Center

I don’t mean, in writing this, to reveal myself as a basal-temperature truther. I’m happy that hormonal birth control exists. Of course, my “happiness” here probably has more to do with the separation from familial control, exigencies of marriage, and religious injunction that chemical means permits them a joy in the method itself, which is, as we all know, so far only administered to ovary-possessing bodies (i.e., there is no publicly available male hormonal birth control). This also isn’t a confession. I may be stuck in a certain (and certainly biased) first-person mode, but that has to do largely with my inability to explain my interest in these matters to you by way of statistics. Anyway, I am less interested, overall, in quantification of human behavior than in human forgetting, which is, to my mind, one of the most fascinating of all world-historical phenomena.

So, on the one hand, I can summon a feeling of surprise when I consider 1., descriptions I have read of the history of birth-control measures in the United States (eloquent 1771 man, protesting paternity suit: “I fucked her once, but I minded my pullbacks”), in which, until Second World War campaigns popularized condoms among members of the military, people depended on a wide array of non-industrially produced methods of family planning: withdrawal, ablutions, “pessaries,” abortions, et al.; 2., the place the country finds itself in now, with respect to birth control and the politics of its dissemination; in other words, who knows and has access and who doesn’t. With respect to 1., it is a frequently repeated statistic that in 1800 the average American white woman gave birth to seven children, in 1900 3.5. (In 2018, the average family had 1.9.) As usual, there are many ways of accounting for these shifts, but the proliferation of methods of birth control has to be among them. Yet, even considering this movement toward what seems like self-determination on the part of the people having and not having children, i.e., us, when I consider my own remarkable ignorance about human reproductive biology’s relevance to my actions, needs, and wishes, well into my mid-twenties if not beyond, I have to wonder about that apparent will to will, as a philosopher might put it. Which leads me to a secondary reflection: the forces that shaped my own education regarding reproductive health, such as it was, are for the most part still around today.

It’s worth pointing out that Ronald Reagan’s presidency is where an important component of the contemporary scene springs to life. In August of 1981, the Adolescent Family Life Act (AFLA), Title XX of the Public Service Health Act, was signed into law by the then-new president, as part of a massive act that reconciled the budget. Cosponsored by Republican senators Jeremiah Denton and Orrin Hatch, in spring of ’81, it reads, “Prohibits funds under this Act from being used for abortion related purposes, except for research concerning the consequences of abortion.” Nicknamed the “Chastity Act,” it ostensibly provided for significant funding for prevention, care, and research related to adolescent pregnancy, which included abstinence-based sex-ed, which is to say, a genre of sex-ed class in which students are told not to have sex and given no information about contraception. Funding already existed for research into teenage pregnancy and the prevention thereof: Title X of the Public Health Act and Titles V, XIX, and XX of the Social Security Act dated from the 1960s. Therefore, AFLA came into being as an alternative, a separate institution that openly promoted evangelical morality (abstinence and, if pregnancy occurred, adoption for teenaged mothers). It would be challenged by the ACLU on separation grounds in multiple cases including Bowen v. Kendrick, heard by the Supreme Court. Although the Court ruled in 1988 that AFLA did not violate constitutional division of church and state, programs brought about by the legislation did become subject to greater supervision.

Still, as the historian Janice Irvine writes, the reinforced “separation” of religious ideology and federal monies here was largely discursively enacted, in word not deed, further entrenching promotion of abstinence as a viable means of controlling teen fertility:

After Kendrick, the recognition of the need to conceal the promotion of explicit religious values led to secularizing strategies which have afforded these discourses on sexuality and young people enormous power on both the national and local levels. For example, major state support for the singular sexual morality of abstinence-only sex education came in the form of the welfare reform law of 1996. Spearheaded by a cohort of national pro-family, conservative organizations and research institutes—such as the Heritage Foundation, Concerned Women for America, the Christian Coalition, and the Eagle Forum—Section 510(b), Title V of the Social Security Act created a new entitlement program for abstinence-only education. . . . The law demonstrated the power of the Christian Right at the end of the century to legislate its own particular sexual value system.

There are all sorts of things one could say about the late-1990s president’s underlining of monogamy and marriage, his sick compromise, but I’ve already noted the pointlessness of ironic flourishes. Title V’s funding criteria are really quite disturbing and, to my mind, intrusive when viewed in the letter; they include: “teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children,” “teaches that abstinence from sexual activity is the only certain way to avoid out-of wedlock pregnancy, sexually transmitted diseases, and other associated health problems,” and, most totalitarian, “teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects.” Meanwhile, AFLA continued strong, receiving over $100 million in tax-based funding, including $29.8 million in the 2008 fiscal year alone. During this interval, in 2000, a third abstinence-education measure, Title XI, §1110 of the Social Security Act, was passed. Whereas previous funding schemes required state matching, Title XI allowed for direct grants to individual groups, including, amazingly, given Kendrick, faith-based organizations. Title XI had the same strict criteria regarding abstinence as Title V and is credited with the proliferation of pregnancy centers, pregnancy testing centers, or “crisis pregnancy centers,” as they might more ominously be called, which mimic the appearance and activities of clinics but actively discourage abortion. The Bush administration, predictably, continued to accelerate funding and even broadened federal guidelines regarding the definition of abstinence in 2006, so that the term included “any type of genital contact or sexual stimulation between two persons.” Although many states did not participate in these measures, due to the increasingly restrictive (and, in my opinion, bizarre) nature of the funding criteria, Title XI allowed money to flow to non-government actors whose “centers” proliferated and who seem, as far as I can tell, to have survived Barack Obama’s 2010 budget eliminating funding for abstinence-based programs.

State of Denial

Something else I had forgotten, or forgotten to remember, or forgotten to remember to notice is that for most of my life the official line on sex in the United States has been that it only exists for [white] heterosexual [Christian] people who are married and who will eventually be using the sex to procreate, thereby contributing to the ongoing glory of the human race. Elsewhere and otherwise, sex has, officially, been taught as a social disease. States’ rights muddy these matters a bit, and the directness of the Obama administration’s redress is startling, given that evangelical entitlements had been on the books for nearly thirty years. There is ideological memory there, infrastructure created with those hundreds of millions of dollars, a way of doing things. One imagines that the current administration need not cast about at length for plausible recipients to spend the $61 million it has made available in grants via the Teen Pregnancy Prevention Program (TPPP), which will now feature abstinence as a central strategy under the influence of such Trump-administration hires at the Department of Health and Human Services as Valerie Huber, formerly of Ascend, which bills itself as “the nation’s leader in the Sexual Risk Avoidance field.”

I suppose someone might be thinking about something like risk avoidance as they enter some piece of information into Clue, which seems to be the best of the menstrual-cycle tracking apps. Berlin-based Clue was created by a woman, Ida Tin, in 2013. It is relatively pared down, as such applications go, limiting itself to gently smiling or frowning face-options for describing the user’s mood and delicate drops of blood in various sizes one may select to indicate flow. It mostly eschews the patronizing feminine accents—hearts, flowers, alerts regarding opportune moments for “cuddl[ing]”—for which other tracking apps like Glow have been criticized. However, as other writers have noted, Clue is not simply an app for recording and predicting one’s period; it defaults to displaying a blue “FERTILE WINDOW” as a part of the schema depicting one’s cycle. The app is designed to inform the user about their risk of becoming, or their potential to become, pregnant. It can be used—is intended to be used—either as a form of birth control or as an aid in the creation of children. Indeed, the vast majority of menstrual-cycle tracking apps function in this manner: they can only represent a world in which one’s cycle exists as an indicator of fertility. Whether you see fertility as a problem or opportunity is up to you; all the same, you will be informed of it.

Whether you see fertility as a problem or opportunity is up to you; all the same, you will be informed of it.

It has occurred to me that, in the same way in which abstinence-based sex-ed is being rebranded in the Trump era using a misleading phrase I played upon a bit above, as “sexual risk avoidance,” and much as under previous administrations anti-abortion advocates staffed the non-medical offices deceptively termed “pregnancy centers,” so the terminology and visual languages associated with menstrual tracking apps create a world unto themselves, a plane of existence with values and desired outcomes. In some sort of utopia, we might imagine better-informed young people, with years of menstrual tracking under their belts, making improved and confident decisions about their reproductive health, via the accumulation of a series of simple repeated gestures, made in interaction with a phone. No need to clandestinely xerox a heavy book mostly about how to get pregnant while you are at work! But who am I kidding? If I had had access to Wikipedia and Google when I was fourteen, I might have seen that someone no less ancient than Saint Augustine had opined about female fertility cycles—and that top-tier humanist Montaigne had waxed eloquent regarding the value of the child-free life. Well, if I had ever left YouTube, I might have seen this, and if I had a smart phone that I was able to control and keep private, and if my practice of self-tracking inside the environment of an app full of politely pro-natalist imagery had not already convinced me that I should have my one point nine children at age thirty-seven, while continuing to work full time (all of the above being somewhat conditional).

So here is the less personal side of all this: I think we find ourselves at a crux or turning point with respect to reproductive politics, not merely because the Christian Right seems to have been funding itself for doling out meaningless platitudes and harmful denials of the reality of human sexuality to students ages twelve to eighteen, by way of the federal government and money accumulated through taxation for quite some time. In her book on motherhood Sheila Heti writes about her lack of urge to have children in various ways, at one point recounting a conversation between herself and another writer in which she tells the other writer that she “could see that it was being taken care of—motherhood. Other people were doing it, so it didn’t have to be done by me.” Perhaps it is personal of me not to find a thought like this comforting, but it also seems impersonal to find it discomforting, to feel ill at ease at this narrator’s notion because it seems to express a desire to disentangle oneself from a problem that one, as a human, cannot truly disentangle oneself from. When I think of people I know who are mothers, I think about how challenging this has been for them, that it has hardly been a matter of “tak[ing] care of motherhood,” but rather of surviving it, often by expanding it to include others: by asking others to help them “tak[e] care” of it alongside them, with gifts and loans of clothing, with help with meals, with emotional support and company, and so forth. Feminist scholar Laura Briggs has written about the harms of various forms of privatization of reproductive labor—and I think about the fertility app in this light, too, along with the essentially private space of the pregnancy center (so mysterious and closed off in the strip mall) and the essentially private, Christian discourse of abstinence.

Clue is always telling me that it is getting smarter. I mean this quite literally: When I enter information into it, a message appears on the screen of my phone, informing me, in turn, of the app’s increasing acumen. And although I want to like the world where tapping a screen everyday is enough to enable me and others who pay for smartphones and download apps and tap to take care of motherhood—taking care of it by knowing when we can and can’t get pregnant, behaving accordingly, according to Clue—I know it’s not enough. And I worry, speaking of reproduction, about whom these methods exclude or never take into account in the first place, as it seems like more and more young people are about to be denied access to free information about contraception and sex.

Lucy Ives is the author of the novels Impossible Views of the World and Loudermilk, or the Real Poet, or the Origin of the World.

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