E102: The Emotional Domain of Family Planning

Kirtly: Okay. You want a child. You don't want a child. So you get out the spreadsheet, and you put in all the financial needs and relationship needs, family expectations, housing needs, educational hopes, and work requirements, all in your spreadsheet, and you figure out, "Child or no child?"

So you don't want a child right now, and you pick out the no child spreadsheet, and you put in all the methods and effectiveness and side effects and risks of all the contraceptive ways and pick out a method to stop your fertility, right?

Want the child? You pull up the spreadsheet for eggs and sperms and timing, right? Well, not exactly right.

In the 7 Domains of Family Planning, we're working on the emotional domain, and every one of those spreadsheets is splattered with emotions, and we're going to get to it.

I'm Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah, and I'm a reproductive endocrinologist. So I spent my professional time and my personal time with those spreadsheets with patients. And with me is Dr. Katie Ward, my co-host. She has a doctorate in nursing practice and a PhD in anthropology and a specialist in women's health. We met 35 years ago in a family planning clinic.

So, Katie, the decision spreadsheet, splattered with emotions. What's your take on that?

Katie: I love that. Have you been watching "Inside Out"?

Kirtly: Yes.

Katie: No, I love the image of a splattered spreadsheet. It captures something really important and something I was thinking about for this segment, that we tend to think of emotions as being sort of separate from decision-making, spreadsheets being rational and lead you to a decision, and emotions are things that kind of get in the way of reason.

I think I have less of a spreadsheet approach to making decisions and more of kind of a wobbly table, a three-legged stool sometimes missing a leg. You can stack all your rational reasons on one side, but one emotion, whether it's fear or love or hope or something else, can tip the whole thing over.

So what I was thinking about a lot was the emotional complexity of family planning decisions. We tend to think of these things as binary. You're either happy or you're sad, or you're excited or you're scared. And that's not really how humans experience life. You can have profound relief and profound sadness simultaneously. You can have hope and fear, joy and terror, and one doesn't cancel the other out. They're both true. That's okay, and that's our experience.

So, yeah, a spreadsheet maybe with a messy color wheel on top of it, or I was thinking of a game of Twister where your head is in the blue and your heart is in the red.

Kirtly: That's just so human. Thinking over the past with me and my patients going over the spreadsheets, not so much really. Sometimes I did draw them out on the sheet that goes over the table. I got my pen, and I drew it all out. But I know I didn't spend enough time with the emotions. I didn't ask for the color of the splatter on the spreadsheet. Is it fear and red, and joy and yellow, or hope and purple, or love and green?

The spreadsheets are very different, and different intensity. So if you're talking to a 15-year-old, which has bright colors, or a 40-year-old, which they're a little muted.

With us in the virtual Scope studio is Annabel Sheinberg. She is the director of The Turnaway Project, and she'll talk about that. The Turnaway Project combines groundbreaking research of The Turnaway Study with The Turnaway Play to engage people in a conversation about abortion that's based on stories and science.

She worked for Planned Parenthood of Utah for 15 years, serving as vice president of external affairs, and she worked for 3 years in education, organizational culture, leadership, policy, and advocacy.

She helped form and run groups of peer counselors. These are teens helping talk about contraception with other teens. And she formed groups of parents and children talking about sex, and she's going to help us talk about the emotional domain of family planning. Annabel, thanks for joining us.

So, Annabel, how did you get here? Did you go to college and sign up for the course that said, "I want to be a family planning expert"? Is that how you got here?

Annabel: Well, thanks for having me, Kirtly and Katie. It's a pleasure to spend time with you on a topic that I feel so deeply about.

How did I get here? I spent a lot of my early career working in child, youth, and family programs. And as a person, I was raised in the '70s really by parents who cared deeply about what had just happened in our country and who wanted to continue the work and really worked toward a world where women were fully human.

But I remember being the kid whose mother was in school making sure we lined up. We weren't lining up girls and boys because Title IX had just passed, and we needed to comply.

So that's part of how I got here, Kirtly. I really have this very strong gut love of women, and feeling about what women can do, and should be trusted to do in this world. I also have a strong desire for justice, and I think that this issue just fundamentally hits at the core of how we are respected as human beings and how we build our families and how we manage our relationships with other people, both intimate and work relationships. I mean, there's nothing that you can't connect this issue to, really, everything about it.

Kirtly: Well, I think so. On the teen spreadsheet with emotional splatters, how do teens react or how do they express their emotions about starting contraception or talking about sex? I mean, is it joy or anticipation or guilt or shame? What is it?

Annabel: I would say it's all of the above. I mean, just like all of us, teens have a broad range of who they are and how they feel in any moment. And it was always evident when teaching a class in sex ed or talking to a group of parents that each individual had a very different comfort level in just talking about this topic, mind you, or learning about the topic, sitting in a room where the topic is discussed.

There were students who were absolutely curious and eating it up and so grateful to get this information. You could tell they just couldn't wait to talk to the important people in their lives.

And there were some who would literally almost cover their eyes because they were just so uncomfortable with talking about contraception, sex, sexuality, all of the things.

And so that is who we are as people, and it's always interesting as the group leader to try to figure out what's the right level of information and how to deliver it to really make people feel as comfortable as possible when going through this kind of course.

How do teens feel? At some point in my career, I became familiar with this thing called a feelings wheel, and I thought, "Wow, this is super helpful." It names so many feelings, so many things that we experience. You can find one online, and I highly recommend taking a look at a feelings wheel to help you just even take a look at all of the things that we all go through when we're thinking about important things like contraception.

Teens feel in some cases empowered, in some cases uncertain, in some cases very grateful because maybe they have a very painful period and they want contraception to help manage that.

I guess my experience is that there are so many ways people walk through this world. And given the people that shaped them, they may have a lot of fear of contraception.

For some people, contraception was used to control their fertility by people who didn't empower them, right? And so they know that people like them were experimented on when contraceptive methods were developed, and that is a very different kind of relationship than somebody who is told, "Guess what? You get to be in charge of whether you want to become pregnant or not. And here is how you can do that."

So relationships with healthcare come into play and connections with your provider and ability to access that healthcare, and so many things.

Kirtly: Well, you talk about young women, sometimes many young women, go to control their period, and they start hormonal contraception. I'd say I, in my 40s, started hormonal contraception for really the first time to control my emotions, meaning I wasn't having rage, but I would get cranky. Before my periods, I would get cranky, and I needed to be 100% professional 100% of the time. And so I said, "Well, I'm just going to have my hormones be the same every day." And it worked great.

So there are emotional needs that are met by actually taking birth control and all those reasons.

Katie: Maybe more than some other people because I became a young mother, I think about what was happening for me as a teenager and how I was making decisions. And I think I was having those . . . You were talking about teens having different kinds of emotional experiences, and I was having different emotions all in one person, right?

So I think, for me, the guilt of using contraception was a little bit stronger than the guilt of having sex as a teenager. And so guilt was an emotion that I was kind of dealing with. Which one felt more wrong?

Based on my upbringing, there was this sort of . . . I could say, "I wasn't really planning to have sex. That just sort of happened," where the choice of using some kind of contraception made me really complicit in what I was doing. And that was a little bit too big of a burden for me to take on as an adolescent. So I was thinking about that a bit for my own life.

Certainly, as I raised my children, then I was much more like, "Here's all the stuff. Just use it." So I really tried to flip that script a lot.

Kirtly: It's not just the adolescent's emotions. It's the parents'. I remember I went off to college, and I never had sex and wasn't really planning on it. It wasn't on my spreadsheet. But my dad gave me some condoms and said, "If you get pregnant, you come home, and we will work this out." My mother, overhearing this, said, "If you get pregnant, don't ever walk in this door again."

Katie: Oh, man.

Kirtly: My parents had two completely different perspectives on what would happen if I got pregnant. Oh my goodness.

And I remember the emotional color of the room when I was talking with some adolescents who were going through very risky cancer. These are young women who had very risky cancers and were going to have bone marrow transplants. There were some very important things for us to talk about, women's health stuff, sex and infection, and future fertility.

I found much of the time that I had an immature adolescent, silent kid in the room with her mother. But when the mom was out of the room, up popped the most amazing mature kid who could very clearly articulate about this and her trials ahead. She was like a brand-new person when the mom went out of the room, and I said, "I love this girl." Before, it's like, "Oh, I don't want to see another teenager ever."

So, Annabel, your experience with parents and kids together, can you talk about that, the parents and kids together?

Annabel: I can. And first, I want to go back up to respond to something Katie said, if that's okay, and then segue into . . . Because I think those emotions of guilt and shame that go with choosing to be on a contraceptive method are very common, and they're very common throughout different ages.

We know that contraception is not supported by all faith communities, say, or peer communities. And that is only getting more complex now with the kinds of information people are accessing. So I think that it is really important to acknowledge the role that some of the shame and stigma can play when people are making decisions, especially teenagers.

To Kirtly, to your point where you got mixed messages from two parents, I think that is also very common, reflecting that parents don't often talk to each other about how they're going to handle this topic with their children.

So that is really true to form the way that you were talked to by two different people who cared and loved you about a topic that's really so important that it could disrupt your educational path as you left for college. Very interesting and very real. And so thanks for sharing both of those things.

I think what I saw with teenagers, starting in about 2016, and their parents, was really a different level of concern about contraception where people started to worry, "Will I be able to access this if I need it?" And we saw in 2016 a lot of people calling more out of an emotion of fear and panic and asking for IUDs because they knew they were a long-acting method.

And so facts are important. We know the different methods. We can talk to people about how they work. And then these other emotions come up, as you have said, that really drive people's decision-making. So contraception decision-making became quite a different conversation while I worked at Planned Parenthood during those years.

I just wanted to bring that into the room because I feel like we are the only developed country going backwards when it comes to access of contraception and the emotion that goes with that, living in a state where that is something that people worry about. And I think we need to acknowledge that fear, both on the parents' part and the young people's part.

But in terms of working with parents, what we would talk about a lot is to really try and go back to when you were that age. I mean, let's start out . . . you were 16 once, you were 20 once, you were 12 once, and not sure how you were going to get to be an adult or a parent. But start there. Start with some empathy.

And when you talk to them, think about, "When is a good time to talk? How do you want to approach it with your tone of voice and with your . . . Can you listen more than you talk?" Have you ever heard that acronym, WAIT? "Why Am I Talking?" Listen more than you're talking. And then how much do you actually want to say, and are they understanding? And so really think through how you might approach this topic.

Also, you're not the only person in their life, as the parent, they can have these conversations with. It's possible to schedule a visit with the healthcare provider, and if you do that, just like Kirtly said, give them a moment without you in there. Give them a moment where they really can be their true self.

I remember a teen who said . . . They were getting wheeled back for an ACL repair. They were in the hospital. Their mom was right there. It was the hallway. And just as they're going back for surgery, someone says, "Are you on birth control?" And they lied. They said, "No." And they were indignant that somebody asked them that right in front of their mom.

It was cool that they felt comfortable sharing the story with me, and I don't think it was going to put their life at risk, luckily. They might have managed it a little differently. But these are real things that happen to people all the time.

So giving them that moment with the healthcare provider is really important because healthcare providers speak about lots of issues, including STIs, right? So all these contraceptive methods aren't going to even protect the teen. They still might need that condom, like Kirtly's dad recommended. It's still important. And we need to remember those things. As parents, sometimes we excel in some areas and we omit some other details.

Kirtly: We're all amateurs.

Annabel: Yes. That's where we can really get help from people like aunties and grandparents, close friends. All those people can be helpful in talking to teenagers. It's just that comfort, that relationship, that timing, and the framing, because in the end of it, we frame it out of love and concern, we frame it out of empowerment, we frame it out of, "We trust your decision-making, and all methods have a failure rate. We're here for you to manage this part of your life, and we want it to be good. We want this to be a good part of life for you, your intimate relationships, your exploring your sexuality. And that's why we're doing this."

All of those things can help with the feelings part of the decision-making, and I think that really sets it up for success.

Kirtly: I always liked it when a mom trusted me enough, this is a mom who was my patient, to bring their daughter in and say, "I just don't think I can have 'the' conversation. It emotionally is just too hard for me. Would you do this? Talk to her." I thought it was a huge honor for mom to turn over her daughter. In my case, it was daughter. Because I'm a gynecologist, I didn't get the sons. I could have, but it would have been hard, I think, to have more guys, little guys, to talk about.

But when they brought them in and offered them, I thought, "Thank you. I want to honor you as the mom who wants to do right and have someone who isn't going to judge either the mom or the daughter." It was really a treat for me.

Katie: It's a nice compliment. That happens to me from time to time, too. Mothers say, "When should I start bringing my daughter?" And the other thing I hear in that is they have been happy with the care that I've been providing, and they want their daughter to get that same care. So that's a nice compliment, I think.

Kirtly: Yeah.

Annabel: One of the things I did not expect was parents of boys calling. Parents of teen boys who had a serious relationship happening would call and get referred to our education office at Planned Parenthood, and they wanted to know, "What kind of support can I give my son's partner? I'm really concerned. I want to make sure she has access to whatever method of birth control she wants or she's using the method correctly," or all of the things. And that was an interesting thing.

Then, of course, I have two boys, so I got to feel what those people were feeling much later and understood that sense of panic truly, because they saw how it could really derail both a happy and healthy relationship, but also the worry they have for their own child.

And that piece that it's not your child, but there are people you can refer this young person to talk to, and there are resources in the community. It's great that you feel comfortable enough to have those conversations.

Kirtly: Yeah. Well, let's talk about the emotional side of abortion. Admittedly, a huge topic. And whether by failure to prepare, not using your spreadsheet, or the method failing, not using a good enough method, or rape, or medical reasons, sometimes things don't go as planned.

Abortion happens to about 1 in 4, 25%, of U.S. women, and probably more than that. It used to be a third, somewhere between one quarter and one third of U.S. women will have had an abortion in their lifetime.

So, Annabel, maybe you can talk a little bit about The Turnaway Project, long-term emotions of women who've had an abortion and those who couldn't get one. And it's so individual. I mean, it's an emotional roller coaster when you're pregnant by choice and then when it's not.

Annabel: I think where I started is where you ended, Kirtly, which is the emotional impact of an unplanned pregnancy, regardless of someone's decision, is fairly intense. So all of a sudden, someone's trying to figure out, "How can I support the children I have? How can I navigate this unhealthy relationship with a partner? How can I access healthcare and decide what's my course of action?"

Depending on where you live in the United States, that's a very fraught situation to be in, and those decisions might involve traveling to get healthcare and might involve so many things.

And also, the really big health disparities in maternal health . . .

Kirtly: Oh my goodness, yes.

Annabel: . . . that make pregnancy itself a much more risky proposition for . . . We know maternal mortality for women of color is going up, black women especially. It's very different facing the decision to continue the pregnancy based on who you are and where you are. I guess that's a more succinct way to say that.

And starting there, I want to talk a little bit about The Turnaway Project and The Turnaway Study itself, which really had the main finding of people who are refused an abortion suffer far more negative and damaging life consequences than people who are able to receive one. And that is the main conclusion of The Turnaway Study.

So The Turnaway Study was conducted between 2008 and 2016 and just seems very relevant today. Researchers enrolled 500 women who were turned away at the clinic door for reasons such as being just past the legal limit or not having funds to pay for their abortion that day, and then 500 who got their wanted abortion.

What they found, looking at everything from credit scores, bankruptcies, economic well-being, relationship health with their partner, well-being of existing children and their development, and maternal health, it all turned out better, with rigorous follow-up over a five-year period for these two groups of women, and the women who received the wanted abortion.

I think, emotionally, we experience pregnancy differently, and The Turnaway Project did a great job of talking and really asking women a few times a year over a five-year period how they were navigating their lives post-abortion or post-abortion denial. And that has just been an incredible set of information for all of us to have.

Katie: Yeah. And then what you do is turned it into a play, which is the brilliant part. I mean, I think the thing that I see as a provider and a researcher . . . I'm familiar with this study. I've been watching it develop over the years they were working on it. And for me, as a scientist, a good research study is very much telling a story. In fact, I think about that when I have to write up my own research. "How do I tell this story?" But I've never thought of turning my research into a play.

And so I think that is very cool, of bringing what otherwise might sound to the non-researcher like something that's kind of boring, bringing out that data with humor and humanity and really bringing research to life in a way that people can hear it and listen to it, if you're just not compelled by p-values and things.

Annabel: Yeah, this whole idea of science plus stories, right? How do we underscore the science with the stories of the women who lived through these experiences?

There's also a book that Diana Foster, Dr. Foster, who was the principal investigator on the study. She's written a book about The Turnaway Study, which is a great read, but again, it's a long read, and it has a lot in it. The play is sort of this one-hour encapsulation.

It's one of the things that excited me about the work of The Turnaway Project, is engaging people through art and stories, and bringing them together for something other than a rally or a lecture or something that we frequently do in abortion rights and movement. This was really, for me, I thought, something different, and I wanted to be a part of it.

Katie: I mean, I feel like I confront this all the time in my clinic right now where social media is such a strong presence in people's lives. And so people will hear an influencer on social media talk about . . . Well, a thing that comes up a lot right now is pain with IUD insertion. All you need is to see one person telling a really compelling story on social media, and the fear that then my patients bring into the clinic about how much pain they're going to experience.

And there's sort of no amount of telling them what I know, both from my experience as a clinician and also from the research that I read and that I've conducted in my lifetime, that their fear might be unwarranted. You can't kind of combat that storytelling or convince people when it doesn't necessarily apply in their situation.

And so I think that this is a challenge for scientists right now, is to tell our stories in a compelling way.

Kirtly: And realizing that we're all struggling as humans to try to lead a life that's the best for our families and for ourselves.

There are many ways that family planning or the planning can go wrong in a pregnancy and end in a termination. And I remember weeping in my emotions here on how . . . This is me crying in the operating room, when we were doing a pregnancy termination for a young woman with a wanted and planned pregnancy who found that she had a very aggressive leukemia when she came for her first prenatal visit early in pregnancy. Without aggressive treatment and a bone marrow transplant, she would not survive the length of her pregnancy, and neither would her fetus.

And so she and her husband chose termination to save her life. I knew she was heartbroken and frightened, and I was so sad because the chemotherapy that would, and in fact did, save her life would leave her without any eggs for a future pregnancy. And it's just so complicated trying to do the right thing.

I've spent half of my clinical time with infertile women and their partners, and the spreadsheet for wanting a child is powerfully splattered with emotions, hope and sadness, anger and fear, the whole emotional palette.

And there were tears in the consultation room all the time, couples who had already had a child who had died of a terrible genetic disease who were fertile but didn't want to take the chance of another child suffering with that disease, and chose IVF with pre-implantation genetic diagnosis to choose a pre-implantation embryo that they could make with their own egg and sperm. We would test each embryo and pick out those that didn't carry the disease.

Emotions are so powerful in the fertility clinic that we had a psychologist. We had a clinical psychologist trained in reproductive psychology to help out our patients navigate the emotional terrain, because it was big. And we as doctors, MDs, weren't doing the right thing, so we got our PhD clinical psychologists to help us do it.

Of course, when two people are involved, they may have different emotions and hopes for pregnancy, which can lead to conflict, and the psychologist could help them come to common ground. So it's a lot going on.

And the couples who chose an adoption to make their family, with their hope and fear and joy. An adoption plan can fall through, just like a miscarriage of a baby that they already had in their hearts, but it wasn't in their arms yet.

And then there's the wanting-a-child spreadsheet. Then there are the potential grandparents who are hoping for a grandchild, and there's the person making the choices on the spreadsheet, of reason and choices that is colored by culture. "Everybody has a child. Your job is to give your mother a grandchild." And family expectations that go on several generations of emotions in this family planning thing.

Then there is the emotional wonder of a delivery room with the product of the spreadsheet, a family planning that's splattered by hopes and fears and joy as a child is handed to their parents, a healthy newborn baby.

So I'm going to wrap up here, and I just want to say that family planning is filled with emotions. As you all listening know, everyone in there has their own emotional palette of colors and intensity, but you know how you felt and you probably have people who are doing some of the same emotional stuff.

As a clinician, I learned over the years the most important thing is what they were most emotionally invested in and to listen and be empathetic. As humans, we experience empathy. It's who we are as humans. And if we develop right, we should be able to feel a little bit of how others are feeling so that we can at least hold their hands along their way. At least that's what we're hoping.

Katie: Yeah, it is one of the things that makes us human.

Kirtly: Yeah. And it's not just empathy for our own child, but our friends' children and our community's children and our community's families and the women who are trying to make these decisions, and men. We've been talking about women's health, but men struggle to make these decisions and hope for family too.

So thanks to Annabel. Thanks for joining us and helping us with her experience. And Katie, thank you, of course, for your wisdom.

For all of you who are listening, if you think it's the right thing to do, share this series of the 7 Domains of Family Planning with family or friends.

You can find us and all of our "7 Domains of Women's Health" topics wherever you get your podcasts, or on womens7.com. Thanks for joining us with all the colors of your family planning spreadsheet. Thank you.

Katie: Thank you.