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Personal Health

The Rise and Fall of the Diaphragm

Once the most popular birth control, diaphragms are disappearing. Why?

A few months ago, I went into a new OB/GYN’s office for an appointment. The nurse sat down with me to go over my information. She asked me what kind of birth control I was using.

“The diaphragm,” I said.

She looked up from her clipboard at that. “The diaphragm? They still make those?”

I laughed and assured her that of course they still make the diaphragm; it’s not going anywhere.

Except the nurse was right: Janssen Pharmaceuticals Inc.’s Ortho-All Flex, the most widely-used diaphragm on the U.S. market, had been discontinued three years earlier.

***

This was news to me, but it wasn’t news. Janssen quietly pulled the Ortho All-Flex off the market in December of 2013, leaving, at the time, only one diaphragm in the U.S. market. (That diaphragm, the Milex, was a different fit, and not all doctors were able or willing to prescribe it.)

The diaphragm, which in the earliest part of the 20th century was the most-used form of birth control among women in the U.S., was suddenly a lot more difficult to obtain.

I asked Janssen about the reason for the discontinuance. A spokesperson replied, in an email, that the diaphragm had been delisted because “comparable alternative products were available to women.” (A follow-up email, asking what the company meant by “alternatives,” went unanswered.) But for me, and for the tens of thousands of women who relied on the diaphragm even as it fell out of favor, the diaphragm has been a safe, effective form of birth control, one that doesn’t play havoc with hormones, and one that I was able to rely on without worrying about fighting for refills.

“I think it’s very unfortunate that Janssen has decided to stop manufacturing the Ortho All-Flex diaphragm,” says Dr. Vanessa Cullins, vice president of external medical affairs at Planned Parenthood Federation of America, in an interview. “I understand that it is a business decision because there are not a whole lot of women who are demanding access to the diaphragm, but the diaphragm is a very important form of contraception for women who don’t want to have a hormonal form of contraception, who don’t want to have something that is inserted inside their uterus, who don’t want to potentially move to permanent sterilization.”

There wasn’t a lot of coverage of the discontinuance; a handful of sites posted short articles about it. One of the most comprehensive pieces published at the time was posted on The Blog That Ate Manhattan, a site run by obstetrician-gynecologist Margaret Polaneczky, a professor and dean at Cornell University’s Weill Medical College.

Janssen’s decision is “a real shame,” she wrote in 2014, “because the diaphragm is an important contraceptive option for motivated women who can’t or don’t want to use hormones or IUDs.”

Maybe there are fewer such women these days, or maybe they’re just less motivated, but in any case diaphragm use had been on the downslide for a long time. When I reached out to Polaneczky for comment, she told me that in the past decade, she’s probably fit diaphragms for two or three patients every year.

“Diaphragms are often the method we turn to when all the others are off the table, either because the woman cannot or does not wants to take hormones or use the IUD, her partner refuses to wear a condom, and she is not ready for sterilization,” she says. “Rarely is it the first choice.”

***

Like many young women of my generation, my own birth control story began with condoms and progressed to the birth control pill. It never occurred to me to try anything else.

Society seemed to think I should be on the pill; pills were represented in all the media I’d ever seen as the birth control of choice. My friends took them. The guys I dated seemed to expect that I would be on them so they wouldn’t have to deal with the inconvenience of condoms. And as a working woman with insurance and a doctor, I figured I would always be able to walk into a pharmacy and pick up my prescription with no problem.

Then my job situation changed, and so did my insurance. Suddenly, refilling my birth control prescription every month began to look like an Amy Schumer skit. I became aware, as I fought every month for a refill, that if I wanted control of my contraception, I’d have to find another option.

What I found was the diaphragm.

I’d always discounted the diaphragm as being a ‘70s sex thing—like pornstaches, or the song “Afternoon Delight.” But when I started to look for alternative birth control methods after my debacle with the pill, it ended up being my savior. I wanted something that, like the pill, I controlled, and I wanted not to have to depend on insurance coverage for regular access to it. And I wanted something that was non-hormonal, so that if I decided to have a child, I didn’t have to wait months for my hormones to even out.

I couldn’t do the IUD; large fibroids that pulled my uterus out of its regular shape saw to that. So the only birth control method that ticked all the boxes for me was the diaphragm. My doctor at the time laughed when I told him I wanted to be fitted for one, but I didn’t care.

I never abandoned the diaphragm. Instead, I abandoned my uterus. In fact, as this article is being published, I’m on my way to the hospital for a hysterectomy. But for several years, the Ortho-All Flex was my go-to birth control. I was amazed that it would be discontinued.

Cullins, of Planned Parenthood, says that many women don’t know about contraceptives like the diaphragm (or its cousin, the cervical cap) because those birth control methods aren’t marketed—”not only from the standpoint of pharmaceutical marketing, but also in terms of the information that is given to women by their reproductive health-care providers.”

Plus, adds Polaneczky, “birth control choice is very driven by what one’s friends are experiencing.” If all of your friends are raving about the IUD, you’re much more likely to ask your doctor for one. And lately, not that many young women have been raving about the diaphragm.

If no one—companies, friends, or doctors—is talking about the diaphragm, women won’t know to ask about them. This is a problem the diaphragm has been running into for a long time. In fact, 100 years ago, it was illegal to even talk about this method of birth control.

Diaphragms, or pessaries as they were then called, have been around nearly as long as sex has. In ancient times, women inserted items like leaves and lemons (!) into the vagina, but the first recognizable diaphragm may have been a German device developed by Wilhelm Mensinga in the 1880s. It was the Ortho of its day, widely used in Europe and acknowledged by some free love experts as the best of its kind. A slightly different device, the poetically-named “womb veil,” had been introduced in the 1860s by a U.S. doctor.

But it was still not legal for women in the United States to actually own one of these devices. Thanks to the Comstock Law, passed in 1873, contraception was effectively illegal. The Comstock Law criminalized the shipment of contraceptives, and information about contraceptives, through the U.S. mail. The law also made it a misdemeanor to sell, give away, or even possess material that was considered obscene. Several states also passed obscenity laws that made it illegal to sell or possess contraceptives.

These laws made it illegal for anyone—including medical professionals—to teach others about birth control. Literature about contraception was illegal, and so was advertising it.

While birth control use by men received support from the U.S. government thanks to a spate of STDs during World War I, female birth control continued to face a struggle. (Most opponents believed that the fear of pregnancy was the only thing keeping women from promiscuity.)

Diaphragms were literally the catalyst for a change in these laws.

In 1936, Margaret Sanger, a nurse who had been indicted several times for writing and distributing information about birth control, arranged for a package of diaphragms from a Japanese doctor to be delivered to a doctor in the U.S. Sanger had long believed that the pessary was a woman’s best bet for birth control. “In my estimation, a well fitted pessary is the surest method of absolutely preventing conception,” she wrote in a 1914 pamphlet called “Family Limitation.” (You can see the 1917 edition here, complete with a stamp on the front which reads “RADICALISM.”)

Sanger’s package of diaphragms was seized, and the government filed a lawsuit: United States v. One Package of Japanese Pessaries. The court struck down a section of the Comstock Law; if a doctor sent it, it was no longer considered to be obscene. U.S. doctors could now order contraceptives to prescribe to patients. The federal ban had been lifted, but It would be decades before all of the knots in the state laws were ironed out; birth control was still illegal in some states, particularly for unmarried women.

Diaphragms became a popular birth control choice, gaining in popularity until 1960. In 1955, a U.S. National Fertility Survey reported that 25% of the 1,900 white married couples surveyed relied on the diaphragm. It was the same in 1960. By 1965, however, that number began to drop. The birth control pill had been introduced.

In 1982, 17% of women surveyed by the CDC used the diaphragm.That number fell to 15% by 1995, and 8.5% in 2000. By 2010, those numbers had dwindled further, according to Dr. Christine Dehlendorf, an advisor to the Bedsider program, run by the National Campaign to Prevent Teen and Unplanned Pregnancy.

“Data from the 2010 National Survey of Family Growth found that about 0.1% of women used the diaphragm, down from 0.3 percent in 2002,” says Dehlendorf, an associate professor in residence at University of California, San Francisco, in an email. “While 0.1% may not seem like a lot, this means that about 38,000 women were using this method.”

***

In the ‘30s, pessaries were some of the most effective birth control on the market. These days, the diaphragm’s efficacy is surpassed by the pill and the IUD. If a woman uses the diaphragm exactly as directed, with spermicide, leaving the diaphragm in for 6 to 8 hours after sex, she has a 94% chance of not becoming pregnant.That means six out of 100 women who use it perfectly will become pregnant. By contrast, says Polaneczky, if a couple uses both a condom and a diaphragm, they are almost 100% safe from an unwanted pregnancy.

This is not to say the diaphragm is a lot of fun to use. You’ve got to fill it up with spermicidal jelly, and then, well, get it in there. The Ortho has an arcing spring, meaning that the ring around the edge is a spring that you fold and then fit it in and it springs into place. (Not all diaphragms have these.)

When it works well, it works well. But it gets slippery with the gel on it and you can lose your grip when you’re putting it in and . . . look, there are some parts of your anatomy you don’t want to get snapped with an industrial-grade rubber band.

The whole operation is a little time-consuming, so spur-of-the-moment sex isn’t easy. Polaneczky says she encourages her patients to incorporate diaphragm insertion into lovemaking, but honestly, I never figured out a sexy way to do that.

There is another, more serious diaphragm risk: It doesn’t prevent HIV. In fact, says Polaneczky, because perfect diaphragm use requires a Nonoxynol-9 spermicidal gel, which can increase HIV transmission, diaphragms may increase the risk of infection.

***

The Ortho may be gone, but cervical barriers haven’t completely disappeared from the market yet.

The FemCap, a cervical cap, is available in the U.S., and now two diaphragms have stepped in to fill the void created by the departed All-Flex: the Milex, and the Caya, which like its ancestor, the Mensinga, is a German product. None of them are exactly the same as the Ortho, and not all doctors like the two new options.

“Choices are a bit limited as to the type of diaphragm,” says Polaneczky. About 15 years ago, she says, there were a range of options: a flat spring, which was light and easy to fold and use, good for women who’ve never given birth; an arcing spring, better for women who have had multiple pregnancies or births; and the all flex, which was good for anyone.

“Milex has two wide seal diaphragms—an arcing spring and an all flex, enough for pretty much anyone, but I miss the light flat spring for younger smaller women,” she says. “The big issue with the Milex is that the doctor has to order it for you, so you can’t just take a prescription to the drugstore.”

Unlike a traditional diaphragm, the Caya doesn’t come in several sizes. “Its advantage is that it is one-size and so doesn’t require fittings and re-fittings,” says Dehlendorf. “In fact, in Canada and many European countries women may buy Caya without a prescription.”

The Caya might come in one size, but that doesn’t mean it will work for everyone, according to Polaneczky, who has concerns about how it will fit some women who have given birth. “Caya is not ‘one size fits all,’ but ‘one size fits most.’ I would recommend my patients come in so I can check the fit before they entrust their family planning to the Caya,” she says.

The FemCap is a little different. Unlike the diaphragm, which blocks parts of the vagina as well, the cervical cap blocks only the cervix. FemCaps are smaller than diaphragms—they run from 22 to 33 mm (around an inch), while diaphragms come in sizes between 60 to 90 mm (2 to 3 inches).

Cullins recommends that women who are interested in a cap get fitted by their physician. “Most health-care providers are going to want to try to fit or determine which size of the FemCap is best, and you also want to be able to instruct the woman usually in office on how to place the FemCap,” she says.

For women who aren’t interested in diaphragms or cervical caps, there are other woman-controlled, non-hormonal contraceptives available. Those include the female condom, which is an over-the-counter barrier method but not easily found at a pharmacy (Cullins says you should be able to get one from Planned Parenthood), and spermicidal gels, creams, and vaginal films. Women who want a non-hormonal birth control method but are willing to go to the doctor instead of the drugstore may find that the IUD meets their needs.

All the doctors I spoke to for this piece emphasized that not every birth control method suits every woman, and none of them were thrilled about the discontinuance of the Ortho diaphragm, because it means one solid contraceptive is gone from the market. Still, all of them were realistic about the reason for its departure.

“Women know themselves,” says Polaneczky. “They make the choice that they think is right for them. And they are in general not choosing the diaphragm.”

Personally, the diaphragm served me well. It provided me with a family planning option that I’d be able to control no matter what. If I took a job that refused to cover birth control, I’d have my diaphragm. If birth control were again to become illegal somehow, I’d have my diaphragm. If we woke up to a zombie apocalypse, I’d have my diaphragm.

It liberated me from prescriptions. It allowed me take a break from birth control in order to have my son. I won’t miss the inconvenience of using it, but I’m grateful to have had this option. A range of options is, after all, what women need when it comes to birth control—and it’s always disappointing when one of those options disappears.

 

A.J. O’Connell is a journalist and author who lives in Connecticut with her husband, son, dog, and cat.

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