PSYCHOLOGY © 2005 The Medicine Publishing Company Ltd 31 WOMEN’S HEALTH MEDICINE 2:5 There are now a wide range of possible contraceptives available for both men and women, yet the rate of unwanted pregnancies remains high and STDs are on the increase. Unprotected sex is therefore a common occurrence. Are women simply unaware of the possible outcomes of unprotected sex? Surely all that sex edu- cation needs to do is to improve their knowledge base and they would be rushing off to the GP or pharmacist for contraception at the first possible opportunity? And if knowledge is not enough, then shouldn't fear of either pregnancy or STDs be sufficient to motivate anyone to use contraception? Much sex education pro- vides knowledge about available contraception and describes the consequences of having unprotected sex, and unwanted pregnancy and STDs do generate fear. However, these factors alone do not seem to capture the complexity of the decision of whether or not to use contraception. This contribution will explore the psychology of why women do or do not use contraception and addresses how some of the barriers to use could be overrcome. The role of beliefs The pill requires a visit to the GP which could be embarrassing, it can cause weight gain and nausea but can be used outside of the sexual act. In contrast, condoms require only a quick visit to the pub machine and have no side effects, although they may be difficult to use. These differences can result in a range of beliefs which may influence whether or not women choose to use contraception. Such beliefs have been studied within health psychology research. For example, research shows that confidence in using condoms predicts condom use, whereas believing that condoms kill spontaneity or that carrying condoms is a sign of promiscuity may be a barrier to use. Similarly, whereas believing that the pill can be harmful may prevent its use, believing that it is easy to use may make the pill the contraception of choice. Other common beliefs that can influence behaviour are shown in Figure 1. For the risk of STDs some people may believe that a new part- ner would be low risk if ‘[s]he came from a nice family’ or had The psychology of contraception Jane Ogden Jane Ogden is Professor in Health Psychology at the University of Surrey, UK. She is involved in research on women's health, eating behaviour and doctor–patient communication and is author of four books and over 80 papers in health psychology. been ‘seen around’, and that the risk of AIDS ‘has been blown all out of proportion’. 1–3 A simple focus on knowledge and fear may not be enough, and from this perspective the use and non-use of contraception can be understood in terms of a range of beliefs that women hold about different contraceptives and their own personal risk of pregnancy or catching an STD. The impact of the situation Sex does not just occur for one person but is an interaction between people. The decision to use contraception is therefore influenced not only by individual beliefs but also by factors arising from the situation of sex itself. Some research has specifically addressed the impact of the situation by asking people to consider both the last time they did not use contraception and a time when they did. 4,5 This reflects a shift in emphasis from users or non-users to the use or non-use, which varies over time. Some of this research highlights the importance of an individual’s mood at the time of sex, which may be influenced by arousal, drugs or alcohol. Alcohol use in particular can be a problem for young women and research indicates that at such times, using contraception may seem like less of a priority. Other research has focused on the interaction itself. For example, women report that condom non-use is more likely to happen when their partners are less motivated to use condoms than they are, when they were not expecting to have sex or when neither they nor their partners discussed contraception. 4 Similarly, the use of emergency contraception has been related to a belief about the risk of pregnancy for that one incidence of sex and increased partner support over using the drug. 5 Contraception use is therefore not only a product of beliefs but also of factors that arise from the situation. Central to this is the emphasis on partner support and communication. Sex is an interaction and contracep- tion use often requires negotiation, although during sex ‘words are likely to be the most difficult things to exchange’. 6 The importance of negotiation As part of a large-scale study, women were interviewed about their sexual behaviour and many highlighted the problems involved in negotiating condom use. 6 For example, whereas some reported no difficulties in demanding safe sex; ‘if they don’t want to wear a condom then tough, go and find someone else’, many found the The coil is only for older women The female condom is intrusive The morning-after pill is a sign of being irresponsible The morning-after pill is morally wrong It is unlikely that I will get pregnant if I have unprotected sex as long as I know where I am in my cycle I didn’t get pregnant in the past when this happened so I thought it would be OK this time too Beliefs that can influence use or non-use of contraception 1