By Ginny Cassidy-Brinn
When Margaret Sanger coined the term in the early 1900s, “birth control” meant the diaphragm, a soft rubber dome that’s placed in the vagina to block sperm. In 1916, Sanger was arrested and jailed for telling women how to use a diaphragm. In 1936, after years of court battles, physician–prescribed birth control was legalized in the United States. Diaphragm use became widespread until the 1950s, when the Pill, the first hormonal contraceptive, began replacing the diaphragm. Intrauterine devices (IUDs) and various hormonal methods followed, and vaginal barriers slipped into oblivion.
During the 1970s and 1980s, however, young people sought a non-hormonal, female-controlled method that allowed them to experience their natural menstrual cycles. They became interested in old-fashioned methods their mothers might have used and—through word-of-mouth and feminist publications—vaginal barriers became popular again. Today, higher-tech methods have eclipsed vaginal barriers, but the method is being rediscovered by people who are dissatisfied by hormonal options or non-hormonal IUDs. This article gives an overview of vaginal barriers and their risks and benefits.
Benefits of Vaginal Barrier Methods
Unlike provider-controlled methods like the Pill, vaginal barriers are easy to stop and start. They’re immediately effective, with no waiting period before they prevent pregnancy, as with hormonal methods. Fifteen minutes after placing the barrier in your vagina, you’re protected. So, there’s no need to use the method unless you have sex in a way that could cause pregnancy. For those who don’t have penis in vagina (PIV) sex very often, a barrier method can be an excellent method.
You don’t have to go to a provider in order to stop using vaginal barriers, unlike IUDs. They have no lingering effects that might make it hard to get pregnant for a time after you stop using the method, which may be true with some hormonal methods (although the data isn’t clear). If you decide you want to get pregnant, you simply don’t use the barrier. One barrier method user commented, “We were talking for months about having a baby. It seemed like there would never be a right time. Then one night we just decided not to use the sponge, just go for it.”
Barrier methods’ effects are local to the vagina. They don’t introduce chemicals or objects into your uterus, like an IUD, or your bloodstream, like artificial hormones. For those who avoid unnatural dietary additives, non-hormonal barrier methods can be a logical next step. Barrier methods appeal to women who want to experience, affirm, or celebrate their natural hormonal cycles.
If your vaginal barrier is the right size and is inserted correctly, neither you nor your partner should feel it during PIV sex. Vaginal barriers don’t interfere with spontaneity, since they can be inserted one or more hours beforehand.
Barrier methods don’t cause heavy bleeding, mood changes, or any of the other effects that sometimes occur with hormonal contraception and IUDs. And, they don’t have any of hormonal contraception’s extremely rare but very serious side effects, like heart attack and stroke. “I wanted a hormone-free method, so I got the copper IUD. But I had so much pain and bleeding that I had it taken out and changed to the cervical cap,” said one user. “The cap is really convenient [and] without the pain.”
Using a Vaginal Barrier Method
Touching one’s genitals, an integral part of vaginal barrier method use, is one reason people decide against the method. Genital contact can also be an advantage to the method, however, because placing the barrier helps people learn about their bodies and take an active role in contraceptive use. One nurse practitioner suggests that menstrual cups’ popularity has lead to increased demand for vaginal barriers. “Now that menstrual cups are so popular, people are more comfortable with using a vaginal barrier. They are used to putting the menstrual cup in and feeling their cervix, which makes it easier to use a vaginal barrier.”
The first time you insert a vaginal barrier it may feel strange. But, most people learn quickly and, with practice, it becomes easy to push the barrier method towards the back part of your vagina and ensure it’s placed properly. “It was kind of awkward at first, but now I can put it in really easily, even in the dark in a sleeping bag,” said one diaphragm user. “It’s like learning to use a bicycle—once you learn it, you never forget.”
Types of Vaginal Barrier Methods
The table below describes the differences among the different vaginal barriers. You can get complete directions and information from your health care provider and the consumer instruction booklet.
Table: Method effectiveness
|Vaginal barrier||Description||Use for preventing pregnancy|
|Cervical Cap (FemCap)||Small, soft silicone cup||Put spermicide in the cap and place over your cervix. The cap gives 48 hours of protection. Add more spermicide in your vagina without removing the cap for repeated PIV sex.|
|Diaphragm (Caya or Milex)||Flexible, shallow dome made of silicone||Once you have put it in your vagina with spermicide you are protected for 2 hours. Add extra spermicide each time you have PIV sex.|
|Soft, loose-fitting silicone condom held in place inside your vagina by a flexible ring||Push the flexible, inner ring to the back of your vagina. The soft outer ring will cover the area around the opening of your vagina. As soon as you put it in, you are protected for 2 hours. Use a new condom each time you have PIV sex. Don’t use the male (or external) condom at the same time.|
|Contraceptive sponge||Small, soft, round sponge with a fabric loop for removal||Wet the sponge, fold it and put it deep in your vagina. It is effective immediately and gives 24 hours of protection. No need to add more for repeated PIV sex.|
|Spermicide-film||A small square of paper-thin film||Place the film in the back of your vagina and wait 15 minutes for it to melt. It gives 3 hours of protection. Add more film each time you have PIV sex. Using spermicide very frequently (an average of 3-5 times per day), could irritate your vagina and make you more susceptible to HIV.i|
Vaginal Barriers are Less Effective
Vaginal barriers don’t prevent pregnancy as reliably as hormonal methods or IUDs. If you use a vaginal barrier method correctly every time you have PIV sex, however, your personal effectiveness rate will increase. If you use the vaginal barrier and another method, effectiveness increases more. For example, some people use withdrawal in addition to their barrier method. Note that there’s very little research comparing different types of birth controls’ effectiveness, and research on vaginal barriers is particularly unsatisfactory.
Multi-use barrier methods work best with the addition of spermicide that slows down and kills sperm. Spermicide, which comes in the forms of cream, gel, foam, film, and suppository, can also be used alone as a barrier method. When using spermicide as a barrier, you can use an applicator to push it to the end of your vagina. Although it’s possible to develop vaginal irritation from the most common spermicide, nonoxynol 9, other less irritating, alternatives include ContraGel (not FDA-approved) and Phexxi.
Table: Number of pregnancies that would occur if 100 women used a vaginal barrier consistently and correctly for 1 year.
|METHOD||NUMBER OF PREGNANCIES PER 100 WOMEN, IN 1 YEAR OF USE|
|Diaphragmii iii||Milex diaphragm: 6
Caya diaphragm: 16
|Spongevi||If they have never had a vaginal birth: 9
If they have had a vaginal birth: 20
Before deciding to use a vaginal barrier, you might want to consider what you would do if the method failed and you became pregnant. Unfortunately, due to abortion stigmatization, very few health care providers consider this in discussing contraception with patients. For those who are comfortable parenting or having an abortion if they have an unexpected pregnancy, vaginal barriers’ lower effectiveness rates might be acceptable.
Getting a Barrier Method
The internal condom, the sponge and spermicide alone are all available over the counter. The diaphragm and cervical cap require a prescription. It is worth asking if your usual provider prescribes these methods. You can find a provider who will prescribe a barrier method by checking the manufacturer’s website for a provider directory.
Sadly, your health care provider could be an obstacle to getting a prescription vaginal barrier method. Most providers are taught to discourage patients from using these methods due to their lower effectiveness.viii ix However, they usually quote “typical use” effectiveness rates, which reflect statistics about large groups of users, many of whom didn’t use the method every time or used it incorrectly. This article quotes “perfect use” statistics, which reflect pregnancy rates of people who stated they used the method not only every time they had sex but also used it correctly, including adding spermicide as appropriate.
Women of color and low-income women may have a particularly difficult time accessing barrier methods. There is a commonly held idea that long-acting methods are a cure for poverty among women of color.x One study found that providers were more likely to recommend IUDs to low-income and Black women than other women.xi In another, Black women reported being pressured to choose IUDs, being discouraged from having them removed, and perceiving race to have influenced their providers’ recommendations.xii Ironically, another study showed that women of color tended to place a higher value than white women did on characteristics typical of barrier methods, such as being able to stop and start the method at any time; the method not affecting their menstrual periods, and not needing to use the method except when they were having sex.xiii In response to this situation, the NWHN and SisterSong developed a Statement of Principles about long-acting reversible contraceptives and coercion, which you can read here: https://nwhn.org/?s=LARC+coercion.xiv
There’s no perfect birth control method—they all have advantages and disadvantages. The Women’s Health Specialists’ website is an excellent source of unbiased information about all methods. Barrier methods aren’t for everyone. When making the very personal choice of contraceptive method, everyone needs to know about all of the different types of methods—including barrier methods. Providers should honor their patients’ values, needs, and preferences and assist them to choose the method that works best for them. For more information on effectively advocating for yourself, consult the NWHN’s article, “Communicating With Your Health Care Provider.”
Ginny Cassidy-Brinn is a nurse practitioner who has been providing reproductive health care for over 30 years. She is the Clinical Training Manager at Cardea.
i. Van Damme L, Ramjee G, Alary M, et al., “Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial,” The Lancet, 2002; 360(9338): 971–977. doi:10.1016/s0140-6736(02)11079-8.
ii. Perfect effectiveness of Caya diaphragm: Contraceptive Technology 21st Edition states, based on an extrapolation from a 6-month clinical trial, that the perfect use of the Caya diaphragm by 100 women for 1 year would result in 16 pregnancies. See: Trussell J, Aiken ARA, “Contraceptive Efficacy,” In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS… Kowal D (Eds.), Contraceptive Technology, 21st Edition, New York (NY): Ardent Media, 2018; and Report of clinical trial cited above: Schwartz JL, Weiner DH, Lai JJ, et al., “Contraceptive efficacy, safety, fit, and acceptability of a single-size diaphragm developed with end-user input,” Obstetrics & Gynecology, 2015; 125(4): 895–903. doi:10.1097/aog.0000000000000721
iii. In this article, I have largely used effectiveness numbers from Contraceptive Technology, 21st Edition. The text, written by leaders in the field, makes conclusions based on analysis of the best evidence. In the case of the diaphragm, I disagree with their decision to omit the best evidence on the effectiveness of the Milex diaphragm, which comes in different sizes and is fitted individually. The Milex diaphragm’s effectiveness is higher than the effectiveness of the one-size Caya diaphragm. Contraceptive Technology’s reasoning is that: “The latest estimate of the probability [when using the Milex] of pregnancy…is based on the 1995 NSFG; use of the diaphragm has virtually disappeared and would not reflect the experience of current users of Milex.” (Quotation from Trussell J, Aiken ARA, “Contraceptive Efficacy,” In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS… Kowal D (Eds.) Contraceptive Technology, 21st Edition, New York (NY): Ardent Media, 2018, p. 832.) In contrast, in evaluating the perfect effectiveness of the sponge, Contraceptive Technology’s 21st edition cites a 1993 study that also measured the perfect effectiveness of the diaphragm** and found that perfect use of the Milex diaphragm by 100 women for 1 year would result in 6 pregnancies. (See: Trussell J, Strickler J, Vaughan B, “Contraceptive efficacy of the diaphragm, the sponge, and the cervical cap,” Family Planning Perspectives, 1993; 25:1000-5, 135.) This calculation of 6 pregnancies per 100 women in 1 year was used in the previous (20thedition) of Contraceptive Technology. That figure is used in this article. (See Trussell J, “Contraceptive Efficacy,” In: Hatcher R A, Trussell J, Nelson AL, Cates W, Kowal D, Policar M (Eds.) Contraceptive Technology, 20th Edition, New York (NY): Ardent Media, 2011, p. 781.) Although the old-fashioned Milex is not as popular as it was in 1995, it is still available and is still fitted and used in the same way as it was in 1995. I have listed the effectiveness of the both the Milex diaphragm and the Caya diaphragm in this article.
iv. Trussel J, Aiken A, “Contraceptive Efficacy,” In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Kowal D … (Eds.), Contraceptive Technology, 21st Edition, New York (NY): Ardent Media, 2018.
v. Perfect use was based on a study measuring the comparative effectiveness of the FemCap® and the Ortho All-Flex® diaphragm. The 6 months of perfect use resulted in 11.1 pregnancies. Extrapolating from that figure, it would be expected that 1 year (13 cycles) would result in 24 pregnancies for 100 women using the FemCap® perfectly and consistently during this time. See: Mauck CK, Weiner DH, Creinin MD, et al., “FemCap with removal strap: ease of removal, safety and acceptability,” Contraception, 2006; 73(1):59–64. doi:10.1016/j.contraception.2005.06.074
vi. Trussel J, Aiken A, “Contraceptive Efficacy,” In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Kowal D … (Eds.), Contraceptive Technology, 21st Edition, New York (NY): Ardent Media, 2018.
vii. Trussel J, Aiken A, “Contraceptive Efficacy,” In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Kowal D … (Eds.), Contraceptive Technology, 21st Edition, New York (NY): Ardent Media, 2018.
viii. Gavin L, Moskosky S, Carter M, et al., “Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs,” MMWR Recomm Rep. 2014; 63(RR-04): 1-54.
ix. SisterSong and the National Women’s Health Network (NWHN), Long-Acting Reversible Contraception: Statement of Principles, Washington (DC): NWHN, 2016. Online: https://nwhn.org/?s=LARC+coercion
x. “Reducing Poverty by Cutting Unplanned Births, ” Health Affairs Blog, August 21, 2015.
xi. Dehlendorf C, Ruskin R, Grumbach K, et al., “Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status,” American Journal of Obstetrics and Gynecology, 2010; 203(4). doi: 10.1016/j.ajog.2010.05.009.
xii. Higgins JA, Kramer RD, Ryder KM, “Provider Bias in Long-Acting Reversible Contraception (LARC) Promotion and Removal: Perceptions of Young Adult Women,” American Journal of Public Health, 2016; 106(11): 1932–1937. doi:10.2105/ajph.2016.303393.
xiii. Jackson A, Karasek D, Dehlendorf C, et al., “Racial and ethnic differences in women’s preferences for features of contraceptive methods,” Contraception, 2016; 93(5): 406-411.
xiv. SisterSong and the National Women’s Health Network (NWHN), Long-Acting Reversible Contraception: Statement of Principles, Washington (DC): NWHN, 2016. Online: https://nwhn.org/?s=LARC+coercion
xv. Capilouto E, “Communicating with Your Health Care Provider,” Women’s Health Activist, 2016; 41(6): 6.