From Medical Pariah to Feminist Icon: The Story of the IUD

The IUD is a clever little T-shaped object that does a really good job of babyproofing your uterus. It’s relatively safe, last up to 10 years, and is 20 times better at preventing pregnancy than birth control pills, the patch or the ring. Today the IUD, which stands for intrauterine device, has become so trendy that you can find it on necklaces and earrings on Etsy, and read upfront memoirs by women about their experiences. But it wasn’t always this way. 

In the 1960s and '70s, the device started hitting its stride as an icon of liberated feminism. But in the mid-'70s, disaster hit. For decades, the IUD was roundly shunned in the United States by women and doctors alike. Today it is by far the most-used reversible contraception method in the world, with 106 million women relying on it for long-term contraception. And yet it’s still relatively rare in the U.S., where nearly half of all pregnancies are still unintended.

That may be changing. Directly after President Trump took office, news outlets reported on the rush for long-acting birth control, speculating that the new urgency was fueled by fears that the administration would slash Obamacare requirements for insurers to cover intrauterine devices and other forms of contraception, as well as stop Medicaid reimbursements for Planned Parenthood. (Most forms of the IUD, it turns out, can outlast a presidential term.) Suddenly, it seemed that the IUD was destined to become a symbol of modern feminism once again.

To which longtime IUD-users say: Duh. What took you so long? Let’s go back to the beginning.

“Two Strands of Coarse Silkworm Gut”

In 1909, a German medical journal published a paper on a funny-sounding device meant to prevent pregnancy. The device, according to the article, consisted of “two strands of coarse silkworm gut … united by a thin bronze filament,” which were inserted into the uterus using a female bladder catheter (ouch!). The idea behind this and other early IUDs was that putting foreign objects in the uterus tended to spark an inflammatory response that made life tougher for sperm, says David Hubacher, an epidemiologist who studies contraception at FHI 360, a human development nonprofit.

Prior to this point, the main form of internal contraception was known as an “interuterine device,” a device made of metal or silkworm-and-glass that was originally used for "therapeutic purposes." This device had a major drawback: it crossed both the vagina and the uterus, thus connecting the uterus to the outside environment by way of the vagina. In a time when gonorrhea was more common and had no good cure, these devices resulted in a high rate of pelvic inflammatory disease. 

The 1909 paper’s title, “Ein Mittel zur Verhütung der Konzeption” (a means of preventing conception), was no doubt shocking to readers at the time, for whom birth control was a taboo topic, according to a contemporary medical journal. That might explain why, although it was “the first genuine IUD,” it seems not to have been widely used. It wasn't until 1928 that a German physician named Ernest Grafenberg developed a variation on the silkworm gut IUD, made of metal filaments shaped into a ring, which became more well-known.

Still, regulation was poor. As IUDs increased in popularity, so did reports of cases of pelvic inflammatory disease associated with them. By the late 1940s, only a miniscule number of American women were using European IUD technology, says Hubacher, who has written on the history of the device.

The IUD's first heyday dovetailed with the liberated 1960s and '70s. They got another bump when, in the 1970s, Senate hearings featuring safety concerns over the birth control pill pushed many women toward the IUD. Soon the little device had become, in the words of one doctor’s 1982 history of the IUD, the “unofficial status symbol for the ‘liberated woman.’ IUDs were worn as earrings even as bras were being burned.”

It seemed the IUD was finally destined to have its day. At one point in the '70s, nearly 10 percent of American women using contraception were choosing an IUD. But then, just as it had become the anti-pregnancy choice du jour among liberated women, one popular model turned out to be deadly. Enter: Dalkon Shield.

An American Tragedy

Today just the name "Dalkon Shield" evokes collective wincing among a certain generation. In the 1970s, this crab-shaped IUD model was beginning to be linked with reports major health problems including pelvic inflammatory disease, septic abortions, infertility and even death. In 1974, amid media reports, congressional hearings and falling sales, the device’s manufacturer suspended sales. By July 1975, there were 16 deaths linked to the device, according to the Chicago Tribune.

By 1987, the New York Times was reporting that “as many as 200,000 American women have testified that they were injured by the device and have filed claims against the A.H. Robins Company,” the one-time maker of Chapstick Lip Balm. (The Washington Post cited more than 300,000 victims.) The manufacturer filed for bankruptcy in 1985, and a $2.4 billion trust was established in the late ‘80s for women who’d been affected. The failure of Dalkon Shield would have consequences for decades to come.

Between 1982 and 1988, the use of IUDs and other long-acting reversible contraceptives in the U.S. declined significantly. That year, updated devices came out that met new FDA safety and manufacturing requirements, but the damage had been done. The shadow of the Dalkon Shield hung over the entire market, dissuading American women from even considering IUDs even as their popularity in Europe grew.

Mary Jane Minkin, a clinical professor of obstetrics, gynecology and reproductive sciences at Yale School of Medicine, says that in the 80s, when she discussed contraceptive options with her patients, IUDs were not even considered as a remote possibility. “There was no person who would have let me put one in,” she says.

In 1996, The Washington Post ran a story about a family planner from New Jersey working with IUD-using populations in Senegal, Nigeria and Kenya who herself had trouble finding an American physician willing to give her one. (At that time, only 1.4 percent of American women using birth control were using an IUD.) A year later, a Virginia physician trying to test a new IUD for market reported that he couldn’t give the device away for free.

The reasons for the Dalkon Shield’s problems are still a topic of debate. During the fallout of the device’s problems, researchers reported that a major problem with the device was the particular design of the Dalkon Shield’s tail string, which is used both to help women make sure the device is still in place, and to aid in its eventual removal. Unlike other IUDs at the time, the string on the Dalkon Shield was made not of one filament but of many tightly wound filaments.

According to expert testimony in legal cases and reporting from that time, the multifilament string acted as a wick, pulling “bacteria and sexually transmitted viruses into the wombs of Shield wearers,” as The New York Times put it in 1987.

But Hubacher and Minkin say it was never clear how much the device’s tail string was at fault. Rather, says Minkin, who was an expert witness on behalf of a trust later established to pay out women hurt by the device, the object’s pronged, crab-like shape made it difficult to insert. That, possibly combined with poor doctor training, meant that it probably wasn’t being placed correctly, she says. As a result, some women got pregnant while wearing the devices, leading to septic abortions and, in some cases, death.

She and Hubacher add that another potential danger for women was the fact that screening for pre-existing STIs like chlamydia and gonorrhea wasn’t as good in the 1970s as it is now. Inserting an IUD into a woman with an infection might have spread that infection, potentially leading to pelvic inflammatory disease, which can cause infertility. 

What's certain, however, is that the Dalkon Shield's failure rippled out to Americans' perceptions of all IUDs. After the controversy, all but one were pulled from the market by 1986. Even today, says Megan Kavanaugh, a senior research scientist at the Guttmacher Institute, some young women she interviews say their mothers have told them to avoid the devices.

 Contraception's Gold Standard

Over the last 15 years, cultural attitudes toward this maligned device have been warming. Ameican IUD use has been on the upward swing since the early 2000s, and several new brands have hit the market featuring names like Skyla, Kyleena and Liletta (apparently there’s a mandate that new IUDs sound like pop stars). In the years 2011 to 2013, around one in 10 American women aged 15 to 44 who relied on contraception used an IUD—a five-fold increase over the previous decade, according to data from the Centers for Disease Control.

“A safe IUD is the answer to all birth control prayers,” writes a woman on Huffington Post who put her two teenage daughters on the device. “I switched over a year ago from the pill to an IUD, and it has made a world of difference,” writes another, adding: "I am EXTREMELY forgetful, and it is how we ended up with my now-5-year-old!" A gynecologist who herself wears an IUD recently wrote about the advantages of using a form of birth control that “you’re supposed to forget.”

Kavanaugh attributes the change in great part to a recognition within the scientific community that modern IUDs are “extremely safe.” It helps, she adds, that a younger generation of women and doctors don’t have the strong negative associations as those who grew up during the time of the Dalkon Shield. The American College of Obstetricians and Gynecologists now recommends the IUD as the gold standard of birth control, calling them “safe and appropriate ... These contraceptives have the highest rates of satisfaction and continuation of all reversible contraceptives.”

These days there are two major types of IUDs: hormonal and copper. The copper IUD, physicians believe, is toxic to sperm, slowing and damaging the little wrigglers as they swim toward the egg like heat-seeking missiles. The hormonal IUD releases progestin—the synthetic version of the naturally-produced hormone estrogen, and the same hormone found in the pill—which makes cervical mucus thicker and more hostile to sperm. While the mechanisms are different, the result is the same: Never the twain shall meet.

Hubacher and Minkin attribute the safety of modern-day IUDs to a number of factors. First of all, screening for STIs is much better nowadays. In addition, because they use copper or hormones rather than merely plastic, modern-day IUDs are more effective at preventing pregnancy. (That means that IUD users are less likely to get pregnant, which can lead to medical issues like ectopic pregnancy.) Moreover, if the multifilament string was ever at fault, modern-day IUDs use single filament strings, eliminating that potential cause of infection.

Many physicians now back the IUD so much that it's become something of a cause to champion. Kavanaugh points to an organization in Washington, D.C. and a task force in New York City that promote IUD use and offer insertion training to medical professionals. IUD advertising has increased, and magazines like Cosmopolitan and Elle are running stories singing the praises of these tiny objects. Rates of IUD use have been growing across many demographic groups, says Kavanaugh, and the pace is especially rapid among young women. Now, a woman who becomes sexually active at 17 but doesn’t want a baby till she’s in her late 20s might be a good candidate for an IUD that lasts years.

Anecdotally, gynecologists say they’re seeing a major increase in demand. “About six months [ago], I was doing one to two IUD insertions a week and now I’m doing one to two a day. It's a huge increase," says Brandi Ring, an ob-gyn in Denver who’s part of a new generation of doctors and patients embracing the IUD. As of 2012, 10.3 percent of women who use contraception were using an IUD – slightly more than what it was before the Dalkon Shield fiasco. Of course, because the U.S. population has grown, that means “more women in the United States are using an IUD than ever before,” Hubacher says.

“I break it down for my patients in terms of how often they have to remember or think about their birth control,” says Ring. “I start with the pill, and I say: In the next year you will have to think about your birth control 365 times. For your IUD, you have to think about it twice: once to tell me you want it, and once when I put it in.” Even better, because the IUD gets inserted by the doctor and lasts for years, there’s little opportunity for user error. It has a “failure rate” of about one percent—compared to condoms, which have a 13 percent failure rate over the course of a year, or the pill, at 7 percent.

That said, the IUD isn’t perfect. Both forms can cause bleeding and cramping directly after insertion, and ParaGard (the copper version) is known in some cases to initially make periods heavier and cramping more intense. It is possible, while rare, that an IUD could perforate your uterus, particularly if you have never had children or have recently given birth; this serious risk usually happens during insertion. There is also small risk that your body will expel the device. (Check here for more common side effects for each type of IUD.)

The financial downside to IUDs is that women need to pay a chunk of change upfront, depending on insurance coverage. The price ranges: Right now, Obamacare generally covers the bulk of the cost of getting an IUD, sometimes leaving women with a few hundred dollars. Meanwhile, the cost of getting one without any insurance could be upwards of $1000 dollars, according to Kavanaugh. But over the long-term, the IUD ranks among the most cost-effective of contraceptives once you factor in things like the cost of unintended pregnancy.  

In the end, it's your body, your choice. But if you do go forth and get an IUD, know that the tiny device in your uterus comes with a long and tangled history.