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RECOMMENDATIONS on Revising Papal Teaching Concerning the Ethical Use of Contraceptives submitted to the Pontifical Academy for Life by the Wijngaards Institute for Catholic Research – 3rd of August 2017

Note: These recommendations complement an interdisciplinary research report coordinated by the Wijngaards Institute, summarized in the Catholic Scholars’ Statement on the Ethics of Contraception (“the Statement”), signed by more than 160 Catholic academics with expertise in the relevant disciplines, and presented at a side-event to the September 2016 UN General Assembly, co-hosted by UNAIDS, UNFPA, UN Women (as part of the United Nations Inter-Agency Task Force on Religion and Development), the Wijngaards Institute for Catholic Research, the World Council of Churches – Ecumenical Advocacy Alliance, and Islamic Relief USA. See extracts in appendix; full text online at: http://www.wijngaardsinstitute.com/statement-on-contraceptives/.

EXECUTIVE SUMMARY AND RECOMMENDATIONS

  1. With regard to the use of barrier methods of birth control (e.g. condom) for prophylactic purposes (e.g. to minimise the probabilities of spreading AIDS and other STIs), the following points should be noted:
    • Humanae Vitae (HV) 15had already admitted the possibility of therapeutic interventions necessary to heal, even though they have a contraceptive effect.
    • In 2006 the Pontifical Council for Health Care Workers (now subsumed by the new Dicastery for Promoting Integral Human Development)commissioned an official research report collating the opinion of some moral theologians on the subject. Its conclusion was that barrier methods can be responsibly chosen when used for prophylactic purposes.
    • Since then, there have been several magisterial pronouncements which permit the prophylactic use of barrier methods such as condoms.
    • More recently still, in February 2016,in response to a question from a journalist about using “artificial” contraceptives to avoid getting pregnant during the Zika virus epidemic, Pope Francis stated: “Avoiding pregnancy is not an absolute evil”.

Hence the Statement, §14 offered the following Recommendation #1

With regard to the use of modern contraceptives as prophylactic.

In view of the magnitude of the HIV/AIDS epidemic, the fact that Catholic-run health care centers and schools constitute approximately 25% of the total worldwide, and that the topic has already been extensively researched, we recommend to the competent authorities in the Catholic Church that the following two steps be implemented as a matter of urgency:

The 2006 document by the Pontifical Council for the Pastoral Assistance to Health Care Workers which suggested that barrier methods of contraception can be morally legitimate when used by married Catholic couples for prophylactic purposes should be made public.

An official magisterial document should be published affirming that the use of non-abortifacient modern contraceptives for prophylactic purposes can be morally legitimate and even morally obligatory.

The statement could include an explicit provision allowing for the distribution of such modern contraceptives for prophylactic purposes by Catholic-run health care facilities, with the provision of adequate guidance.

  1. With regard to the use of modern non-abortifacient contraceptives, the following points should be noted:

2.1HV’s total ban on “artificial” contraceptives is groundless and mistaken. The biological grounds adduced for it are non-existent, the inferences it draws from supposed biological facts are mistaken, and the encyclical even contradicts itself on a key point (see “Notes on the Recommendations”, below).

Significantly, no other justification for a prohibition against “artificial” contraceptives has been found since HV, whether in the theological reflection or in official magisterial documents.

2.2 HV directly contradicts the Second Vatican Council’s Gaudium et Spes (GS). Some of HV’s key affirmations had been explicitly rejected as erroneous by the doctrinal commission charged with examining the proposed amendments to the final draft of the relevant paragraphs of GS on responsible parenthood.

2.3 HV directly contradicts the 1966 Final Report of the Pontifical Commission on Birth Control. Such Final Report offered suggestions on how to revise recent papal teaching prohibiting contraceptives, in light of the duty towards “responsible parenthood” (GS §48-51) and new understanding of the non-conceptive purposes of sexual intercourse in marriage. Many of those suggestions are still valid.

2.4 HV is not supported by the bible. The template texts on human sexuality – Gen 1:28, 2:18, 24, as well as the Song of Songs – affirms that the primary raison d’être, meaning and purpose of human sexuality is the fellowship and relationship between male and female, their union/communion of life and love (“one flesh”). In other words, the primary purpose or finality of human sexuality is affective or unitive.

Notably, procreation is not included in the core statements describing the raison d’être of sexuality (Gen. 2:18, 24). Instead, it is described separately and, significantly, as a blessing rather than a command.

The relevant passages of Genesis 1-2 describe human sexuality as good independently from the existence of a procreative finality in each and every act of sexual intercourse.

2.5 HV is revisable. This was explicitly stated in the official presentation of the encyclical to the press on 29 July 1968, the morning after its publication, by Mons. Ferdinando Lambruschini, who repeated twice that the encyclical was not infallible, and that its conclusions may be revised on the basis of new evidence.

2.6 The insistence that each and every act of sex must preserve a procreative finality is a profound misunderstanding of the meanings and purposes of human sexuality.

2.7 Given how central sexuality is to human nature, this mistake fundamentally weakens both the authority of the hierarchy in the eyes of Catholics and non-Catholic Christians, and the authority/appeal of Catholicism and Christianity in general in the eyes of non-Christians. It is a scandal to both ad intra (pastoral) and ad extra (evangelising) work, as well as to ecumenism.

2.8 HV’s central prohibition has been rejected by the church. The majority of Catholics reject it (the sensus fidelium). The same applies to non-Catholic Christians and, last but not least, the majority of people worldwide: this final fact is particularly relevant because the prohibition purports to be a norm of natural law, which applies universally and to all times, and whose reasonableness can be accessed to, and evaluated by, Christians and non-Christians alike.

2.9 The Catholic Church proposes two alternative solutions to family planning: 1) within marriage, FAMs relying exclusively on periodic abstinence (PA) during the fertile window; and 2) before marriage, “abstinence-only sex education,” to teach people to abstain from sex. Both solutions have been found to be ineffective and even counterproductive in typical use. Below is a summary of some of the most important reasons why that is the case.

2.10 FAMs relying exclusively on PA are not a viable alternative to modern contraceptives, for the following reasons:

  1. Their population level typical use failure rate (for those FAMs for which it is available) is relatively high, approximately 25%. That is, one in four women who want to avoid a pregnancy and use a “periodic abstinence” will still become pregnant within a year (compare this with the almost non-existent failure rate of the most effective modern contraceptives – e.g. the Long Acting Reversible Contraceptives – at <1%).
  2. Because PA has a very high typical use failure rate, and because between 40% to 50% of all unintended pregnancies worldwide are aborted, users of PA only contribute an estimated 16.7% of all abortions due to contraceptive failure despite being just less than 3% worldwide. Put differently: typical use of the only family planning method allowed by current papal teaching results in a disproportionate percentage of abortions in comparison with most other contraceptive methods.
  3. FAMs require abstinence between one third and half the length of the monthly cycle.
  4. FAMs are not suitable for the very large percentage of women who do not have regular monthly cycle. For example, even the relatively recent Standard Days Method/CycleBeads™, at times recommended by Catholic officials, is unsuitable to 40% to 50% of women due to their cycle not being “regular” enough for that method.
  5. Continuation rates of PA-based FAMs are very low. Again with regard to the SDM/CycleBeads™, for instance, “only 91 of 1,181 (7%) women admitted within the introduction studies and followed with quarterly interviews were still using the method on completion of year 3.”
  6. FAMs are generally marketed and used as fertility trackers, in order to know when to have protected sex (i.e. when to use other contraceptives such as condoms), rather than when to abstain.
  7. FAMs based on Periodic Abstinence (the only method allowed by current papal teaching) are only used by an estimated 3% of women who want to avoid a pregnancy.
  8. Worldwide, the vast majority of women (and men) in reproductive age cannot identify when a woman’s fertile period is, and that includes users of periodic abstinence methods who necessarily rely on identifying ovulation.

2.11 Similarly, “abstinence-only sex education” too has been proven to be less effective than its main competitor, namely “comprehensive sex education.” There is abundance evidence – in particular from the USA – that “comprehensive sex education” programs are more effective than so-called “abstinence-only sex education” programs in decreasing risk-taking, age of first sexual experience, promiscuity, unintended pregnancies, STIs rates, and abortions. Indeed, “Accidental pregnancies are mostly among users of traditional methods; substituting traditional method use with modern contraception could therefore reduce contraceptive failures by over 40%. Also, where less-effective family planning methods are commonly used, unplanned pregnancies and, consequently, abortions are likely to occur” (see Appendix).

2.12 The ongoing development of increasingly effective, affordable, and easy-to-use contraceptives (including Long-Acting Reversible Contraceptives, or LARCs) is accelerating the trend towards universal global coverage and uptake of modern contraceptives. FAMs cannot compete with the effectiveness and ease-of-use of the best modern contraceptives.

2.13 It is unrealistic to expect that people worldwide will gradually shift from using modern contraceptives to using instead PA-based methods. Some of the reasons for that prediction have been summarised above: people using periodic abstinence exclusively are estimated at a mere 3% worldwide. Likewise, knowledge of the ovulation period is also estimated at a similar number worldwide. Teaching people FAMs based exclusively on abstinence is demanding. Both uptake and continuation rates of such methods are very low. On the other hand, global coverage and uptake of increasingly effective, affordable, and easy-to-use contraceptives (including Long-Acting Reversible Contraceptives, or LARCs) has been increasing for years. Those methods do not depend on patient compliance, so their “typical use” failure rates are about the same as “perfect use” failure rates: less than 1% per year.

2.14 The papal ban on using “artificial” contraceptives applies to about one fourth of health care facilities worldwide, which are Catholic. For this reason, the current papal ban results in vast numbers of unintended pregnancies worldwide, primarily in the developing world, about half of which end up in abortion. A culture of life requires an ethics of contraceptives!

2.15 It is possible to revise HV while highlighting both the element of continuity (valid concerns and insights) with HV itself, and the elements of continuity with Tradition, not the least with GS §§48-51 and Amoris Laetitia.

In summary: the relevant evidence supports the conclusion that using modern contraceptives for family planning can be moral and commendable.

As noted, Mons. Ferdinando Lambruschini, when officially presenting HV on behalf of Paul VI shortly after its publication, explicitly said that a revision of its conclusions was possible if new findings came to light.

The argument can be made that those findings from evolutionary biology were not as well known in the sixties as they are now. The same can be said with regard to findings from the bible (see the “Notes on the Recommendations” below), social studies on the consequences of contraceptive use, etc., which shed much more light on the “natural” significance and finality of human sexuality. They can be presented as one of the basis for the revision.

Hence the Statement offered the following Recommendation #2:

An official independent commission should be urgently established by the competent ecclesiastical authority in order to re-examine the teaching of HV.

NOTES ON THE RECOMMENDATIONS

Introduction

In 2007, the late Cardinal Carlo Maria Martini said:

I am firmly convinced that the Church leadership can show us a better way than Humanae Vitae has managed to do. The Church will regain credibility and competence. Consider how John Paul II brought new life to the relationship between the Church and Judaism, and similarly between Church and science because he spoke the unforgettable words acknowledging wrong, words that have an effect today, centuries after the unjust judgments on Galileo or Darwin. In matters concerning life and love, there is no way we can wait so long. It is a sign of greatness and self-confidence if someone can acknowledge the mistakes and limited vision of their past.[1]Carlo Maria Martini and Georg Sporschill, Night Conversations with Cardinal Martini: The Relevance of the Church for Tomorrow (Paulist Press, 2013), 93-94.

In the same book-interview he also said: “Even if condoms were allowed for HIV-infected couples as a ‘lesser evil,’ that is probably not enough,” and that “In matters concerning life and love, there is no way we can wait so long” (i.e. centuries) before correcting a mistaken papal teaching.

Recommendation. A Clear Magisterial Statement is urgently needed affirming that so-called “barrier methods of birth control” can be used for prophylactic (preventative) purposes.

“[I]n mature HIV epidemics about 50% of HIV infections occur within marriage.”[2]John Cleland and Mohamed M. Ali, “Sexual Abstinence, Contraception, and Condom Use by Young African Women: A Secondary Analysis of Survey Data,” Lancet (London, England) 368, no. 9549 (November 18, 2006): 1788–93, doi:10.1016/S0140-6736(06)69738-9; referring to Stephane Hugonnet et al., “Incidence of HIV Infection in Stable Sexual Partnerships: A Retrospective Cohort Study of 1802 Couples in Mwanza Region, Tanzania.,” Journal of Acquired Immune Deficiency Syndromes (1999) 30, no. 1 (2002): 73–80; Maria Quigley et al., “Sexual Behaviour Patterns and Other Risk Factors for HIV Infection in Rural Tanzania: A Case–control Study,” Aids 11, no. 2 (1997): 237–248.

Before addressing the broader problem concerning the absolute prohibition against “artificial” contraceptives for family planning, it would make sense for the magisterium to first address the “easier” issue of the use of so-called “barrier methods” for prophylactic (as distinct from contraceptive) purposes.

This would arguably facilitate the reception of the conclusion of a future independent commission set up to examine the ethics of using modern contraceptives for family planning, and minimise possible worries from the conservative minority who would opposed any suggestion for change in that area.

Now, with regard to the issue of the use of barrier methods for prophylactic purposes, it is urgent to put out a clear magisterial statement unambiguously stating that such a use can be responsible and morally legitimate.

1) HV had already admitted the possibility of therapeutic interventions necessary to heal, even though they have a contraceptive effect:

“the Church does not consider at all illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result there from—provided such impediment is not directly intended for any motive whatsoever” (HV §15).

2) More recently, in 2006 the Pontifical Council for Health Care Workers (now subsumed by the new Dicastery for Promoting Integral Human Development) commissioned moral theologians to develop a lengthy report, which Cardinal Javier Barragán said at the time was more than 200 pages long. Its conclusion was, apparently, that barrier methods can be responsibly chosen when used for prophylactic purposes.

3) Since then, there have been several magisterial pronouncements which permit the prophylactic use of barrier methods such as condoms. First, in 2010 Pope Benedict XVI said so in his book interview Light of the World (the first ever papal pronouncement in favour of such use). This was officially clarified and confirmed as consonant with Catholic tradition by the CDF in its “Note on the Banalization of Sexuality”:

“Those who know themselves to be infected with HIV and who therefore run the risk of infecting others, apart from committing a sin against the sixth commandment are also committing a sin against the fifth commandment – because they are consciously putting the lives of others at risk through behaviour which has repercussions on public health. […] In this context […] it cannot be denied that anyone who uses a condom in order to diminish the risk posed to another person is intending to reduce the evil connected with his or her immmoral activity.

[T]hose involved in prostitution who are HIV positive and who seek to diminish the risk of contagion by the use of a condom may be taking the first step in respecting the life of another […]. This understanding is in full conformity with the moral theological tradition of the Church”[3]“Note on the Banalization of Sexuality – Regarding certain interpretations of Light of the Worldhttp://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20101221_luce-del-mondo_en.html

4) More recently still, in February 2016, in response to a question from a journalist about using “artificial” contraceptives to avoid getting pregnant during the Zika virus epidemic, Pope Francis stated: “Avoiding pregnancy is not an absolute evil,” and he went on to say: “In certain cases, as in this one, such as the one I mentioned of Blessed Paul VI [of Catholic nuns in Congo using the anovulant pill to avoid becoming pregnant in case of rape], it was clear”. Fr. Lombardi, the Pope’s spokesman at the time, confirmed to Vatican Radio that Pope Francis was indeed arguing for “the possibility of taking recourse to contraception or condoms in cases of emergency or special situations”.

Those latest affirmations by Pope Francis (and the clarification by Fr. Lombardi) are ground-breaking. They mean:

  • the pill and condoms can be used with the direct intention of avoiding conception. The point of attention is that this is different from, and broader than, the strictly “prophylactic” use of barrier methods in order to avoid a disease (such as would be the case with HIV/AIDS, as in Pope Benedict XVI’s condom remarks, above). The nuns in Congo were using “artificial” contraceptives not in order to avoid a disease, but rather with the direct intention of avoiding a pregnancy. Similarly, people in areas affected by the Zika epidemic who decide to use “artificial” contraceptives do so directly intending to avoid pregnancy (i.e. with a directly contraceptive intention), and not simply to avoid a disease;
  • Using the pill and condoms to avoid a pregnancy (as distinct from avoiding a disease, i.e. the prophylactic purpose!) could apply to other “cases of emergency or special situations” (Fr. Lombardi).

The above affirmations contradict HV: that encyclical famously affirms that any action which aims at hindering the procreative finality of sexual intercourse for the purpose of avoiding procreation is an “intrinsic evil,” i.e. immoral always and everywhere, regardless of the intention of the agent(s), the circumstances of the situation, and the consequences of the action (HV §14).

What is more significant, however, is that those affirmations did not have any influence in terms of changing the official policy within the Catholic institutions concerned: with few exceptions, Catholic charities, health clinics, hospitals, and schools worldwide, and especially in the developing world, continue their previous policy not to provide condoms or other barrier methods of birth control for prophylactic (as distinct from family planning) purposes. The Knights of Malta have been one of the latest victims of the lack of clear guidelines in that regard, with accusations that their efforts to distribute condoms to high-risk populations such as sex workers in Myanmar were against papal teaching.

Therefore, the teaching on the use of condoms as prophylactic expressed in the authoritative interventions mentioned above (and especially in the CDF own “Note on the Banalization of Sexuality”) needs now to be re-affirmed more clearly and unambiguously. A strong re-affirmation of the morality of using condoms or other barriers for prophylactic purposes in official magisterial documents (encyclicals, etc.) is urgent.

Can this can be done by working with other Vatican departments – i.e. the one on the Integral Human Development – to resurrect the 2006 report, and release appropriate guidelines for Catholic individuals and health care facilities?

The evidence of the considerable potential impact of such a clear policy is already there. In part, it is simply the general evidence of the contribution that condom use can make, together with abstinence and fidelity, to reducing HIV/AIDS transmission rates.

More specifically, the evidence is there thanks to the initiative of the late Boniface Lele, Catholic archbishop of Mombasa in Kenya, who – in an extraordinary breach with the then current papal and curial views – in 2005 allowed serodiscordant Catholic couples in his archdiocese to use condoms. This resulted in a statistically significant increase in condom use among the target audience only (serodiscordant Catholic couples), and a corresponding decrease of HIV/AIDS infections.[4]See J. Stroebel and A. Van Benthem, “The Power of the Church: The Role of Roman Catholic Teaching in the Transmission of HIV” (2012), http://pages.stern.nyu.edu/~jstroebe/research/pdf/PowerChurchRomanCatholicKenya.pdf (accessed on 06/02/2017): “the archbishop’s comments increased the probability of condom use at last sexual intercourse by 3.3 percentage points for married Catholics in Lele’s archdiocese. For the subgroup of those with condom access, the effect is 7.0 percentage points. These results are robust to a number of econometric specifications, statistically significant, and large relative to an average condom use rate of 13.2% for all respondents in the 2008-09 DHS.”

Hence the Statement recommends:

  • 14.2. An official magisterial document should be published affirming that the use of non-abortifacient modern contraceptives for prophylactic purposes can be morally legitimate and even morally obligatory.

The statement could include an explicit provision allowing for the distribution of such modern contraceptives for prophylactic purposes by Catholic-run health care facilities, with the provision of adequate guidance.

2. Recommendation. The Church should revise the teaching of HV prohibiting “artificial” contraceptives by stating that their responsible use in marriage can be moral and even commendable.

We can now move to the more delicate issue concerning the revision of the prohibition of using “artificial” contraceptives for family planning.

A revision is needed for several reasons:

  1. a) because HV’s argument is mistaken. A revision is thus required by fidelity to the truth (orthodoxy). These are the doctrinal reasons for a revision. They are explained concisely in the Statement §1-6, and complemented by the section “Fidelity to the Truth” below.
  2. b) because it causes negative consequences in the lives of millions of people, including unintended pregnancies and abortions. A revision is thus required by fidelity to the good (orthopraxis). These are the ethical reasons for a revision. They are explained concisely in the Statement 10, and complemented by the section “Fidelity to the Good” below, and by Appendix 2.
  3. c) because the vast majority of Catholics has rejected that teaching in their lives. The magisterium is here in a situation of schism from the body of the church. Healing that schism will strengthen the unity of the church. The majority of non-Catholics Christians have also rejected such a norm, which is therefore a scandal to ecumenism. Finally, that norm is supposed to be of natural law, and as such it should be capable of being understood and evaluated by all human beings regardless of their culture or religion, both now and throughout history. But the vast majority of people do not abide by that norm. That strongly signals that such a norm is mistaken.

A revision is therefore recommended as a step towards fidelity to the truth, as a step towards fidelity to the good, and as a step to strengthen communion and unity within the Catholic Church, and between the Catholic Church and other Christian churches.

2.1 Fidelity to the Truth – Revising HV’s Errors

One of HV’s mistakes that has been the most apparent, not only to experts but also to laypeople, was its famous contradiction between the following statements:

1) “sexual intercourse which is deliberately contraceptive [is] intrinsically wrong”;[5]Lat. “coniugalem actum, sua fecunditate ex industria destitutum, ideoque intrinsece inhonestum [est]” HV §14. and intrinsically wrong is also “any action which either in preparation of, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation—whether as an end or as a means” (HV §14, emphasis added).[6]Lat. “respuendus est actus, qui, cum coniugale commercium vel praevidetur vel efficitur vel ad suos naturales exitus ducit, id tamquam finem obtinendum aut viam adhibendam intendat, ut procreatio impediaturHV §14.

2) it is morally legitimate to use the rhythm method to have sexual intercourse with “the intention to avoid children and [the] wish to make sure that none will result” (HV §16).[7]Si infitiandum non est, coniuges in utroque casu mutua certaque consensione prolem ob probabiles rationes vitare velle, atque pro explorato habere liberos minime esse nasciturosHV §16.

The rhythm method limits sexual intercourse to the sterile periods in a woman’s monthly cycle with the intention of avoiding procreation. This is tantamount to act “in preparation of” sexual intercourse with the intention of deliberately preventing procreation. If doing the latter is always wrong, as HV §14 asserts, then rhythm or other FAM are always morally illegitimate when used to avoid procreation.

Conversely if, as HV §16 affirms, it is indeed morally legitimate to have sexual intercourse with a contraceptive intention (when using the rhythm method), then it cannot be correct to affirm:

  1. that “sexual intercourse which is deliberately contraceptive [is] intrinsically wrong”;
  2. that each and every act of sexual intercourse must always have a procreative finality and significance (HV12).[8]“This particular doctrine […] is based on the inseparable connection, established by God, which man on his own initiative may not break, between the unitive significance and the procreative significance which are both inherent to the marriage act” (HV §12).

Point b) is the famous “inseparability principle” at the heart of HV: it is among the statements contradicted by HV §16, which allows sexual intercourse with a contraceptive intention (when used within the context of the rhythm method). Using the rhythm method to have sexual intercourse with a contraceptive intention of avoiding children means deliberately choosing to separate the two “finalities” of sexual intercourse – i.e. union and procreation – which, according to HV §12, should never be separated.

Furthermore, HV affirms that “Sexual activity […] does not, moreover, cease to be legitimate even when, for reasons independent of their will, it is foreseen to be infertile.” (HV §11). The sentence appears to suggest that sexual activity ceases to be morally legitimate if wilfully timed so as to be infertile, e.g. when using any FAM.

In contrast, as noted, HV §16 also affirms that couples can of their own free will choose to have sexual intercourse when they can foresee it will be infertile. To choose to time sexual intercourse precisely to coincide with the period foreseen to be infertile is to do so wilfully:

couples who deliberately abstain from love-making during fertile periods but who make love at other times, do appear to be practicing contraception by another name. This is because not having sex at certain times is not just not doing anything, and so not doing anything wrong. As Gareth Moore points out, “They do not just not have intercourse; they actively avoid intercourse, as part of their plan to avoid children” (2001, p. 165). Their intentions are clear.[9]Adrian Thatcher, God, Sex, and Gender: An Introduction (Oxford: John Wiley & Sons, 2011), p. 219.

Not only is HV contradictory with regard to its central “inseparability principle”: but the latter is also based on a mistaken understanding of biology.

2.1.1. Humanae Vitae misunderstands the Biological Laws of Reproduction

HV’s argument is that because the biological “laws of conception” reveal that sexual intercourse has a “capacity to transmit life” (HV §13), each and every act of sexual intercourse has a “procreative significance” (HV §12) and “finality” (HV §3), and an “intrinsic relationship” (Lat. per se destinatus) to procreation (HV §11).[10]HV §13 rightly notes that to “impair[] the capacity to transmit life” of the act of sexual intercourse is to “depriv[e] it, even if only partially, of its meaning and purpose [or finality: Lat. “significationem et finem”].”

This misinterprets the biological evidence. The causal relationship between insemination and, on the other hand, fertilization, implantation, and ultimately procreation, is statistical, not necessary. No act of sexual intercourse has “per se” (i.e. in itself, by nature) an independent biological capacity for procreation. (If it were not so, every act of insemination would result in a conception). Rather, such a biological capacity is relative, i.e. dependent on the fulfilment of numerous other conditions. This fulfilment is statistical, not necessary.

Because no act of sexual intercourse has an independent capacity for procreation, it is erroneous to affirm – as HV does – that each and every act of sexual intercourse has, by nature, a procreative purpose or “finality.”

It is worthy of note that, as befits an argument which, as HV itself admitted, belongs to the (non-revealed) natural moral law, such an appeal to the biological facts of the created order of nature is the only argument supporting the papal doctrine prohibiting “artificial” contraceptives. Significantly, no other official justifications of HV’s prohibition has been provided in the years since 1968.

2.1.2. Humanae Vitae draws a Moral Obligation directly from the Biological Laws

From the above mentioned mistaken biological “fact” that each and every act of sexual intercourse has a procreative “finality” and “significance”, HV derived the moral obligation for human beings to never hinder them.

However, it is mistaken to derive a moral norm directly from biological laws. This is because our behavior, as rational agents, is not entirely determined by biology. Rather, biological laws are subsumed and controlled by our rationality and responsibility.

This is also evident in the area of human sexuality (please see section below, on the findings from evolutionary biology), so that it is impossible to derive the morality of means of family planning simply on the biology of the sexual intercourse. This was acknowledged by the famous par. 51 of Gaudium et Spes (GS) on family planning,[11]See the two “modi” or amendments referred to below, in the section “A Revision of HV Would Preserve Key Elements of Continuity with Traditional Teaching”. by the 1966 Final Report of the Pontifical Commission on Birth Control, and by many of the leading moral theologians before and after HV itself.

HV further justified the inference of a moral obligation from a supposed biological “fact” on the basis that it is God who established the biological laws expressing the procreative finality and significance of each and every act of sexual intercourse, and therefore to thwart them would be tantamount to go against God’s will.

This is deeply mistaken from the point of view of fundamental theology. According to mainstream Christian theology, unless one can prove an explicitly revealed absolute divine command never to interfere with the biological laws of the generative process – and scriptural exegesis has excluded the existence of such a divine command – one must assume no exceptions exist to the rule according to which human beings are understood as enjoying both the mandate and the responsibility to steward creation, “interfering” with it for theirs and creation’s mutual flourishing.

In this, the position of mainstream Christian theology coincides with the philosophical position which maintains the impossibility of deriving a moral obligation directly from a factual description, i.e. a judgment of value (about what morally ought to be) directly from a judgment of fact (about what is).

Therefore, the Statement notes:

  • 3.3. The affirmation that human beings may not interfere with the biological laws regulating human reproduction because they have been established by God is in contradiction with observational evidence on how human beings interact with the created order.

As agents of reason, human beings have a unique capacity to intentionally alter the schedule of probabilities inherent in the physical, chemical and biological laws of nature. This is a reality of daily life: for instance, any sort of medical intervention, from something as insignificant as taking pain-killers to something as consequential as performing cardiovascular surgery, affects probabilities – of healing, survival, death, etc.

Furthermore, the decision not to intervene in natural processes also affects those probabilities, just as choosing to intervene does.

The moral question is not whether to alter the schedule of probabilities within natural processes, but rather whether, when, and how doing so is conducive to human flourishing and the flourishing of all creation.

From the above perspective, Fertility Awareness Methods are also “unnatural” and “artificial,” as the Doctrinal Commission of Gaudium et spes noted in one of its reply to a proposed amendment (see section 2.1.5 below). In effect, people who use them time sexual intercourse outside the fertile window, in order to avoid procreation – an intentional, artificial separation of the “procreative” meaning which should be supposedly inseparable from the unitive meaning of each and every act of sexual intercourse.

FAMs are also “unnatural” in a second way: namely, in subjecting conjugal love to biological determinants. Since with FAMs sexual intercourse can take place only during days determined by the female cycle, it deprives a couple of the freedom in love-making. A spouse can come home after a long absence and the couple may be forced to abstain for days because they returned “at the wrong time” (more on this in section 5.3 below).

2.1.3. Humanae Vitae Is Contradicted by New Findings from Evolutionary Biology about the Non-Conceptive Purposes of Human Sexuality

The reason why moral norm with regard to contraception cannot be drawn directly from biology can be easily understood by looking at the evolutionary biology of human sexuality.

For most mammals, sexual intercourse is limited by biology to fulfil the function of genotype transmission or reproduction. Sexual activity is determined biologically by the reproductive hormones, which regulate its exercise and generally limit it to the female oestrus, a regularly occurring period of sexual receptivity and fertility in most female mammals (excluding humans).

It is distinctive of the evolutionary development of highly intelligent animal species that sexual intercourse moved away from an almost exclusive reproductive finality and related biological determinism on the reproductive hormones and the female oestrus. In particular, “Humans have the distinction of being comparatively free of hormonal determinism in our reproductive activities. Female fertility does not depend on limited periods of oestrus, and male sexual arousal does not require the perception of hormonal cues.”[12]Kelly Bulkeley, The Wondering Brain: Thinking about Religion With and Beyond Cognitive Neuroscience (2004), p. 60.

Rather, female sexual receptivity broke free of the hormonal determinism of the oestrus, and sexual intercourse acquired other meanings and ends than the mere transmission of the genotype, or reproduction: namely, sexual pleasure, pair-bonding, and many other purposes influencing socialization. This is particularly evident in the evolutionary development of primate sexuality: already in the great apes, and even more clearly in humans.[13]See a concise account in Adrian Thatcher, God, Sex, and Gender: An Introduction (John Wiley & Sons, 2011), https://books.google.co.uk/books?hl=en&lr=&id=gtF38d2YURcC&oi=fnd&pg=PR9&dq=God,+Sex+and+Gender:+An+Introduction&ots=LuMC59kqn-&sig=HI7R2rby2h0KOHd4bm2S2XBWAyI.

The advantages of retaining sexual receptivity at all times, including those when conception is not a physiological option, is obvious. Such a strategy clearly helps to maintain long-term relationships. It is an evolutionary device to maximize parental care of the young and provide sexual pleasure and comfort for the highly sexed human being.[14]Irina Pollard, “Fertility Awareness: The Ovulatory Method of Birth Control, Ageing Gametes and Congenital Malformation in Children,” in Bioscience Ethics (Cambridge, Mass.: Cambridge University Press, 2009), 90–105 (at 94).

The evolution of primate sexuality, and particularly the sexuality of human beings, shows a shift away from an exclusively reproductive function and related biological dependence on the reproductive hormones and the female oestrus, towards a sexuality more subsumed under the control of the brain and, consequently, responsive to rational agency.

In other words, “nature” itself shows that the sexuality of humans, differently from that of most other animals, is not simply determined biologically, i.e. regulated by the reproductive hormones. Rather, human sexuality and sexual intercourse are subsumed under the control of rational intentionality.

Such an integration of the reproductive hormones under the control of rational intentionality is precisely the distinctive “nature” of human sexuality in comparison with most non-human animals.

In this sense, what is “natural” for the sexual intercourse of human beings is what is in agreement with their rational faculties, rather than what follows blindly the patterns of the biological laws regulating reproduction. HV is accordingly mistaken to derive a moral obligation always to respect the supposedly natural procreative finality of each and every act of sexual intercourse.

Any appeal to the “nature” of sexual activity, the “natural finality” or telos of human sexuality cannot ignore the findings concerning the varied non-conceptive meanings and purposes of human sexuality, as highlighted by both evolutionary biology and sociological surveys. Those findings make it impossible to regard procreation as intrinsic to each and every act of sexual intercourse. Hence the Statement notes:

  • 8. The Bible identifies a variety of morally worthy non-conceptive motives for engaging in sexual intercourse. This is confirmed by evolutionary biology and modern sociological surveys, among other disciplines.

Those non-conceptive motives for sexual intercourse include pleasure, love, comfort, celebration and companionship. They are morally worthy even without the concurrent occurrence of either a “procreative significance” of the biological “laws of conception,” or the agents’ procreative intention.

The use of modern contraceptives can facilitate one or more of sexual intercourse’s non-conceptive meanings, as well as have additional morally worthy purposes – e.g. family planning, following the requirements of responsible parenthood (HV §10).

Therefore, the decision to use modern contraceptives can be taken for a variety of morally worthy motives, and so it can be ethical.

In summary: HV is reductionist and mistaken in deriving a moral obligation with regard to human sexual behaviour from the biology of human reproduction (which in any case it misunderstands at the factual level itself). Doing so ignores that the very distinctiveness of human sexuality and sexual intercourse is that they have “broken free” of the biological and hormonal determinism controlling the sexual behaviour of most other animals. It reduces human sexuality to a mere functionalist and utilitarian understanding, whereby each and every use of it must aim to biological reproduction. Instead, in human beings, because they are “rational” animals, the biological and hormonal “laws” have been subsumed under the higher control of human rationality and responsibility, which can and does routinely direct them for ends other than biological reproduction alone, such as affectivity, communion, commitment, and love.

C: The Duty/Responsibility towards “Responsible Parenthood” requires a corresponding Right of Freedom from Excess Fertility.

2.1.4. Humanae Vitaeem> is not supported by the Bible

HV affirms that each and every time people engage in sexual intercourse, they must preserve the procreative significance and finality which is said to be intrinsic to sexual intercourse itself.

However, this is contradicted by the seminal biblical texts directly addressing the meaning and purpose of sexuality: namely, Gen 2:18 and 24 (“It is not good for the man to be alone” and “That is why a man leaves his father and mother and is united to his wife, and they become one flesh”) and the Song of Songs.

Those two passages of Genesis highlight the “unitive” function (i.e. fellowship, relationship, affective union/communion in love) as the only raison d’être distinctive of human sexuality. In contrast, procreation is introduced only separately (Gen 1:28: “God blessed them and said to them [i.e. to man and woman], “Be fruitful and increase in number…”), and described merely as a blessing, rather than a command, and a blessing which is not distinctive of human beings but rather is given to all animals.[15]Richard M. Davidson, Flame of Yahweh: Sexuality in the Old Testament (Hendrickson Publishers Peabody, MA, 2007), pp. 49-50; Phyllis A. Bird, “‘Male and Female He Created Them’: Gen 1: 27b in the Context of the Priestly Account of Creation,” Harvard Theological Review 74, no. 02 (1981): 129–160. Thus Richard M. Davidson, one of the foremost experts on sexuality in the Old Testament, on Genesis 1:26-28 and 2:18, 24:

[S]exuality cannot be wholly subordinated to the intent to propagate children. Sexual differentiation has meaning apart from the procreative purpose. The procreative blessing is also pronounced upon the birds and fish on the fifth day (v. 22), but only humankind is made in the image of God. Genesis 1 emphasizes that the sexual distinction in humankind is created by God particularly for fellowship, for relationship, between male and female.

The complete absence of any reference to the propagation of children in Gen 2 highlights the significance of the unitive purpose of sexuality. This omission is not to deny the importance of procreation (as becomes apparent in later chapters of Scripture). But by the “full-stop” after “one flesh” in v. 24, sexuality is given independent meaning and value. It does not need to be justified only as a means to a superior end, that is, procreation. The interpretation given by some that husband and wife become one flesh in the flesh of their children is not warranted by the text.

Sexual love in the creation pattern is valued for its own sake. When viewed against parallel ANE [Ancient Near Eastern] creation stories, this biblical view of marriage also seems to be a polemical corrective to the prevailing ANE perspective represented, for example, by the Atrahasis Epic, which “links marriage and procreation closely as if to suggest that the primary function of marriage is procreation.” For the biblical narrator, by contrast, “the communitarian, affective function of marriage takes precedence over the procreative function of marriage.”[16]Davidson, Flame of Yahweh, emphases added.

Commenting on Davidson, David Instone-Brewer added:

The concept of “one flesh” implies a sexual unification separate from any connotation of childbearing, and linked with the “clinging” it implies a permanence in the relationship.[17]David Instone-Brewer, “Review Article: Richard M. Davidson’s Flame of Yahweh: A Theology of Sexuality in the Old Testament,” Andrews University Seminary Studies 46, no. 2 (2008): 6, emphasis added. Instone-Brewer also observes: “The HB [Hebrew Bible] portrays fertility as a gift to the creation and to humans, whereas the gods of surrounding cultures demanded cultic prostitution or priestly reenactments of divine sexual acts in order to maintain this fertility. Mesopotamian and Canaanite religions in particular demanded that the general population take part in cultic prostitution.”
Sexual differentiation has meaning apart from the procreative purpose […] [S]exuality is given independent meaning and value. […] Sexual love in the creation pattern is valued for its own sake.”

Interestingly, such an understanding was seemingly ground-breaking and counter-cultural for the times: other Ancient Near Eastern cultures regarded marriage in a much more reductionist and utilitarian way, i.e. as first and foremost for procreation. Ironically, by affirming that each and every act of sexual intercourse must always preserve the goal of reproduction, HV contradicts such a groundbreaking insight of the bible, and reverts to the same reductionist and utilitarian view of sexuality common among other Ancient Near Eastern cultures.

In summary: Genesis 1-2 affirms that the primary raison d’être, meaning and purpose of human sexuality is the affective or unitive one, i.e. the fellowship and relationship between male and female, the union/communion of love, affectivity, etc.

In contrast, procreation is not included in the core statements describing the raison d’être of sexuality (Gen. 2:18, 24). Instead, it is described separately, and as a blessing (rather than a command), a blessing moreover which is not exclusive or distinctive of humans, but is rather repeated to all other animals.

Accordingly, Genesis 1-2 does not regard procreation as a finality which needs to be present always, in each and every act of sexual intercourse. Genesis 1-2 describe human sexuality as good independently from the existence of a procreative finality in each and every act of sexual intercourse. Therefore, Genesis 1-2 contradicts what is in fact the central claim of HV.

Finally, it may be worth recalling that nowhere in the NT does Jesus or anybody else mention, never mind condemn, contraception, despite it being a well-known and widespread practice in the ancient world.

2.1.5. Humanae Vitae contradicts Vatican II

HV explicitly states that its treatment of the question was done “keeping foremost in Our Minds what was taught about this matter with the highest authority in Gaudium et Spes (GS), the pastoral constitution recently issued by the Second Vatican Council” (HV §7).

Despite that claim, HV’s key affirmation, namely the so-called “inseparability principle” that each and every act of sexual intercourse has by nature a “procreative significance and finality,” is in direct contradiction with what the so-called Mixed Commission said in explaining the meaning of GS §§48-51, on responsible parenthood.

Specifically, the commission rejected as erroneous several “modi” (or proposed “amendments”) to GS §§48-51, amendments that were later affirmed by HV, in contradiction with the commission.[18]The discussion of these amendments by the commission can be found in Acta Synodalia Sacrosancti Concilii Oecumenici Vaticani II. Vol. IV Pars VII Congregationes Generales CLXV-CLXVIII, Sessio Publica IX-X. (Vatican: Vatican Polyglot Press, 1978), henceforth Acta Synodalia, to which the page numbers of the extracts below refer. See also the analysis in John T. Noonan, “Contraception and the Council,” in The Catholic Case for Contraception. Leading Catholic Authorities Oppose Pope Paul’s Position on Birth Control, ed. Daniel Callahan (London: Macmillan, 1969), 3–18. Here they are:

  • The commission denied that each and every act of sexual intercourse is “per se apt [per se apti] for the generation of offspring.” The commission rejected this, stating “Not all acts tend to generation [ad generationem tendunt] (cf. sterility and the sterile times)” (modus 56 to par. 49).[19] Modus 56 to GS §49:

    d) Post: “uniuntur” (in lin. 32):

    – unus [Pater] proponit ut addatur: “in ordine ad generationem”;

    – 109 Patres petunt ut addatur: “ad prolis generationem per se apti”; […]

    1. – […] d) Nulla ex his tribus propositionibus videtur admittenda. Non omnes enim actus ad generationem tendunt (cf. sterilitas, tempus ageneseos) […].”

In contrast, while HV §11 did acknowledge that “new life is not the result of each and every act of sexual intercourse,” it still concluded that each and every act of sexual intercourse is “in itself oriented towards procreation” (“ad vitam humanam procreandam per se destinatus”), and has by nature a procreative “finality”.[20]In contrast, the 1966 Final Report had rightly observed that “the morality of sexual acts between married people […] does not […] depend upon the direct fecundity of each and every particular act. [It] depends upon the requirements of mutual love in all its aspects [and] is thus to be judged by the true exigencies of the nature of human sexuality.” Acta Synodalia, p. 491. This is an explicit contradiction of what the commission said – as well as of the biological reality.

  • The commission agreed that sexual intercourse among spouses is not just a biological act but a “human act” (as affirmed by GS48), in the sense that it is consensual, and that “conjugal life [and sexual intercourse] is integrally human and not merely biological” (“vita coniugalis […] integre humana et non tantum biologica [est]”).[21]See “modus” 15, amendments a), b), and e) to GS §48:

    “a) Quinque [Patres] postulant ut loco: “Ita actu humano“, dicatur: “Ita actu voluntatis legitime manifestato“, ut melius declaretur natura illius actus et ut attendatur ad formam requisitam. […]

    1. d) Unus Pater petit ut loco “actu humano“, dicatur “consensu humano, ne videatur agi de ipso actu coniugali.
    2. e) Decem vero Patres sequentem additionem rogant: “Ita actu humano, quo coniuges sese personaliter in vitae amoris communione tradunt atque accipiunt”, ut vita coniugalis ut integre humana et non tantum biologica appareat.
    […] [Replies of the Mixed Commission] R – a) In textu pastorali praecisio illa iuridica non requiritur. […]
    1. d) Clarum est vocabulum ad consensum referri.
    2. e) Hoc ex ipso contextu elucet.” Acta Synodalia, 476-77.

    This is important for the following crucial point:

  • The commission refused to say that “the generative faculty” is one of the “objective criteria” for determining the morality of the different means of birth control. It chose instead the words “taken from the nature of the person and his acts,” explaining the rejection of the amendment as follows: “by these words it is asserted that the acts are not to be judged according to a merely biological aspect, but as they relate to the human person integrally and adequately considered” (modus 104).[22] Modus 104 to GS 51:

    b) 13 Patres proponunt formulam: “criteriis ut exempli gratia in facultatibus generativis humanae naturae in eadem personae humanae dignitate fundatis.”

    1. c) Quinque petunt ut dicatur: “ex ipsa personae natura et dignitate desumptis”.
    […]
    1. f) Alius: “in eadem personae humanae dignitate atque iuxta naturam ipsorum”. […]
    2. – […] b) Additio videtur superflua, quia agitur de principio generali.
    3. c) et f): Elementa ex utraque hac propositione retinendo, proponitur ut loco: “in eadem personae dignitate fundatis“, dicatur: “ex personae eiusdemque actuum natura desumptis“; quibus verbis asseritur etiam actus diiudicandos esse non secundum aspectum merum biologicum, sed quatenus illi ad personam humanam integre et adaequate considerandam pertinent” (emphasis added). Acta Synodalia, pp. 501-502.

Yet, as noted, HV bases its central moral norm – the so called “inseparability principle” that each and every act of sexual intercourse must have a procreative finality (in addition to a “unitive” finality) – on precisely the “generative faculty” (“facultati vitae propagandaeHV §13) of the biological act.

HV §16 further insists that it is only interference with such a “generative faculty” that makes it possible to say that “artificial” contraceptives are prohibited (as they “obstruct the natural development of the generative process”), while the method of periodic continence is not.

  • The commission refused to explicitly condemn “onanism” and “contraceptive arts” [artes anticonceptionales]. That condemnation was in an amendment strongly proposed, twice, by Pope Paul VI, on 23rd and 26th November 1964, two weeks before the close of Vatican II, when the final draft of GS48-51 had already been discussed and no amendments asking for a change of the substance of the text should have been accepted anymore.

The commission rejected it. The reason, it noted, is that the expression “contraceptive arts” would include “the method of periodic continence, which often requires technical computations”.[23]See the response to the modus 5 to GS §51: “…non absque utilitate videtur hic mentionem facere de illicitis usibus contra generationem [i.e. “onanism” (onanismus) and “contraceptives” (anti-conceptio)]. Formula dicendi generalis praeferenda videtur locutionis: “artibus anticonceptionalibus“. Nam uterque ex his terminis tum apud scientificos hodiernos tum apud nonnullos alios coaetaneos quadam ambiguitate afficitur. Terminus enim: “artes“, apud easdem personas, rationem factibilium significat ideoque saltem ex obliquo quamdam technicam supponere videtur, ita ut, in hoc contextu, sese etiam extenderet ad sic dictam “methodum continentiae periodicae” (quae computationes saepe technicas requirit ut recte applicari possit), dum eadem personae saepe saepius distinctionem faciunt inter anticonceptionalia, contraceptiva et aconceptiva (ita ut ex damnatione anticonceptionalium non sequatur pro ipsis alia etiam esse improbata). Quibus omnibus perpensis, Commissio proponit ut scribatur: “insuper amor nuptialis saepius egoismo, hedonismo (de suppressione vocabuli: “erotico”: cf. Resp. ad Modum 6 sub c) et illicitis usibus contra generationem profanatur”. Acta Synodalia, pp. 473-74.

Also Noonan, ibid., p. 15: “In this final refusal to speak out on any contraceptive means, the Council refrained from judgment on any of them. It had stated in the introduction to the chapter on marriage that marriage today was profaned by “illicit practice against generation.” But “such practices” were not made precise […]. The Mixed Commission had rejected an effort to say ‘contraceptive arts’ at this point instead of ‘illicit practices.’ It did so for the pointed reason that ‘contraceptive arts’ could include ‘the method of periodic continence, which often requires technical computations’ (m. 51).” In other words, the commission said that the method of periodic continence would fall within the category of “contraceptive art” – HV §16 would use synonymous expressions[24]HV describes the means of contraception which it regards as illicit by using the noun “artificium” [ET “art”, “method”, “trick,” see §17 (“artificio”)], the adjective “artificiosus” [ET “artificial,” see §7 (“artificiosa”)] and adverb “artificiose” [ET “artificially,” see §16]. – so that any condemnation of the latter would have to include the method of periodic abstinence.

On this point too, HV contradicted the commission: as is well known, the encyclical famously yet erroneously distinguished between the method of periodic continence, which it regarded as “natural” and morally licit, and “artificial” contraceptives which it prohibited (see HV §§7, 16, and 17).

  • The commission refused to say that “conjugal love, independently from the procreative intention, does not justify conjugal acts.” Rather, it sharply replied: “this affirmation is not consonant with received doctrine.”[25]Modi generales” (proposed general amendments) 67 to GS §50 “De matrimonii fecunditate”: “Unus Pater petit ut totus numerus reficiatur et reducatur ad pauca principia doctrinae catholicae; alius ut clare dicatur amorem coniugalem, independenter ab intentione prolem procreandi, non iustificare actum coniugalem.
    1. – Prima propositio accipi non potest, quia esset contra normas; secunda affirmatio cum doctrina recepta non consonat.” Acta Synodalia, p. 492 (emphasis added).

In contrast, HV’s core affirmations are the following:

  1. each and every act of sexual intercourse need to have not just a “unitive” but also a “procreative” finality and significance (HV12);
  2. each and every act of sexual intercourse needs to maintain its intrinsic finality to procreation (HV11);[26]Lat. “…quilibet matrimonii usus ad vitam humanam procreandam per se destinatus permaneat.” HV §11.
  3. “sexual intercourse which is deliberately contraceptive [is] intrinsically wrong”[27]Lat. “coniugalem actum, sua fecunditate ex industria destitutum, ideoque intrinsece inhonestum [est]” HV §14. (HV14, contradicted by HV§16 on the method of periodic abstinence which can be moral even when used with a contraceptive intention).

Together, those three affirmations make clear that people engaging in sexual intercourse must never intentionally contracept and must always intentionally preserve the procreative finality intrinsic to sexual intercourse.

In other words, HV condemns sexual intercourse which is independent from the procreative intention. It thereby contradicts the conciliar commission. Although, as noted, HV later contradicts itself by allowing sexual intercourse with a contraceptive intention but only when using the method of periodic continence, and not when using “artificial” contraceptives.

HV’s contradictions of Gaudium et Spes as explained by the conciliar commission can usefully be acknowledged as justifying and indeed requiring a change of that encyclical.

2.2. HV contradicts the Common Human Experience

Historically, the reasons people have sex have been assumed to be few in number and simple in nature–to reproduce, to experience pleasure, or to relieve sexual tension. [However,] motives for engaging in sexual intercourse may be larger in number and psychologically complex in nature.[28]Cindy M. Meston and David M. Buss, “Why Humans Have Sex,” Archives of Sexual Behavior 36, no. 4 (July 3, 2007): 477–507.

Surveys have identified the following, among others: love and commitment, spiritual transcendence, kindness, stress reduction and relaxation, duty, conformity, experience seeking, self-esteem and self-confidence, social status, money, revenge, and so on.

Procreation is but one of the meanings and finalities of sexual intercourse. Biologically, in the human species the vast majority of acts of sexual intercourse does not have a procreative capacity, and therefore does not have a procreative finality. And there are no other grounds – whether in the bible, or indeed in the experience of people – to affirm that procreation need to be present as one of the finalities each and every time people engage in sexual intercourse.

I also quote an extract from the forthcoming interdisciplinary research report on which the Statement is based:

Not all motives [for sexual intercourse] will be always morally worthy. However, those which are indeed morally worthy can be affirmed and celebrated within marriage. Contraception can facilitate the other meanings of sexual activity, such as love, spousal bonding, play, comfort, celebration and companionship among others.

3. A Revision of HV Would Preserve Key Elements of Continuity with Traditional Teaching

Such a revision can be made better understood by highlighting both the ongoing validity of some of HV’s insights and concerns, and the continuity of the new conclusion with key elements of the Catholic tradition on marriage and sexuality.[29]As Charles Curran wrote shortly after the publication of HV: “To change the present teaching of the Church would be a case of development and not a direct contradiction. Gregory Baum has compared a development on the birth control issue with the development of the Church’s teaching on religious liberty.”

Good suggestions in this regard were already made in the 1966 Final Report of the Pontifical Commission on Birth Control. Most retain their validity to this day. Other elements of continuity:

– The call to “Responsible parenthood” (GS §51, HV §10);

– The acceptance that sexual intercourse can be undertaken with a contraceptive intention (HV §16 on the method of periodic abstinence, and several earlier pronouncements by Pius XII). As the 1966 Final Report of the Pontifical Commission on Birth Control noted:

“The notion of responsible parenthood which is implied in the notion of a prudent and generous regulation of conception, advanced in Vatican Council II, had already been prepared by Pius XII. The acceptance of a lawful application of the calculated sterile periods of the woman—that the application is legitimate presupposes right motives—makes a separation between the sexual act which is explicitly intended and its reproductive effect which is intentionally excluded.

The tradition has always rejected seeking this separation with a contraceptive intention for motives spoiled by egoism and hedonism, and such seeking can never be admitted. The true opposition is not to be sought between some material conformity to the physiological processes of nature and some artificial intervention. For it is natural to man to use his skill in order to put under human control what is given by physical nature. The opposition is really to be sought between one way of acting which is contraceptive and opposed to a prudent and generous fruitfulness, and another way which is, in an ordered relationship to responsible fruitfulness and which has a concern for education and all the essential, human and Christian values.

In such a conception the substance of tradition stands in continuity and is respected. The new elements which today are discerned in tradition under the influence of new knowledge and facts were found in it before; they were undifferentiated but not denied; so that the problem in today’s terms is new and has not been proposed before in this way. In light of the new data these elements are being explained and made more precise. The moral obligation of following fundamental norms and fostering all the essential values in a balanced fashion is strengthened and not weakened.”

– Opposition to the “Contraceptive mentality”: as already the 1966 Final Report noted,

“a willingness to raise a family with full acceptance of the various human and Christian responsibilities is altogether distinguished from a mentality and way of married life which in its totality is egotistically and irrationally opposed to fruitfulness. This truly “contraceptive” mentality and practice has been condemned by the traditional doctrine of the church and will always be condemned as gravely sinful”;

The rejection by GS §51 of two key affirmations later repeated in HV, namely that each and every act of sexual intercourse is in itself apt to procreate, and that the morality of sexual intercourse can be judged on the basis of the merely biological dimension.

– Continuity with Amoris Laetitia’s affirmation that “procreation and adoption are not the only ways of experiencing the fruitfulness of love”.[30]Pope Francis, Amoris Laetitia, §181 (p. 137), available at https://w2.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf.This refers to what is sometimes called “generativity” which, as is now accepted in Catholic theology, is more than mere biological reproduction. Family planning via modern contraceptives can facilitate non-biological “generativity”/“procreativity.” Women (and men) can and do decide to limit their families in order to devote themselves to other forms of service, thus expressing their “generativity” in a way which is non-biological but not necessarily less morally worthy. In this connection, there is evidence that women planning their families tend to have improved access to both educational and work opportunities, and contribute in many ways to the common good.

  • Continuity with Amoris Laetitia’s subtle revision of HV, according to which natural methods are no longer compulsory, but merely “to be promoted” (AL §222). That, and the emphasis on the fact that a couple must make decisions concerning family planning in conscience, suggests that using “artificial” contraceptives is no longer viewed as an “intrinsic evil.”[31]See the recent assessment by two French Jesuits in Grégoire Catta and Bruno Saintôt, “Fécondité : Le Discours Officiel de l’Église Évolue,” Revue Projet, July 4, 2017, http://www.revue-projet.com/articles/2017-07-catta-saintot_fecondite_le-discours-officiel-de-l-eglise-evolue/. Catta and Saintôt quote AL §222: “the use of methods based on the ‘laws of nature and the incidence of fertility’ (Humanae Vitae, 11) are to be promoted, since ‘these methods respect the bodies of the spouses, encourage tenderness between them and favour the education of an authentic freedom’ (Catechism of the Catholic Church, 2370).” They then go on to observe: “The regulation of births by the non-abortive pill can therefore, under certain conditions, also be compatible with respect for the body, tenderness, [and] genuine freedom. It is this relational quality that it is important to promote.”

  • New exegetical studies on the meaning and purpose of sexuality in the bible. The template texts, Gen 2:18 and 24 (“It is not good for the man to be alone” and “That is why a man leaves his father and mother and is united to his wife, and they become one flesh”) and the Song of Songs, highlights the “unitive” function (i.e. affective union/communion in love) as the only raison d’être truly distinctive of human sexuality. In contrast, procreation is introduced only separately (Gen 1:28), and described merely as a blessing, rather than a command, and a blessing which is not exclusive or distinctive of human beings but rather is given to all animals. See Davidson, Flame of Yahweh: Sexuality in the Old Testament, 2008, pp. 49-50.

– The legitimacy of using barrier methods for prophylactic purposes (HV §15, CDF, “Note on the Banalization of Sexuality,” 2010).

 

 

SECTION 2

4. Fidelity to the Good – Real Life Impact of Revising HV

As noted, while HV does contain some sound teachings – e.g. its argument that birth control is required by “responsible parenthood” – its key argument and conclusion are deeply flawed. Therefore, their revision is required firstly by fidelity to the truth.

But a revision is also required by fidelity to the good. This section is an attempt at quantifying the negative consequences that the current papal prohibition against “artificial” contraceptives is causing to millions of people, especially in the developing world.

Two points in this regard:

  • Worldwide, non-use of modern contraceptives have a disproportionate effect on the number of unintended pregnancies, about half of which end up in abortions. Allowing modern contraceptives for family planning would save lives. As a well known Catholic medical doctor once said, “A culture of life requires an ethics of contraceptives.”
  • Allowing modern contraceptives would heal the schism between magisterial teaching and Catholics’ belief and practice on this issue, thereby increasing the unity of the church.

What follows will expand on both affirmations. It must be reiterated, however, that the papal prohibition to use “artificial” contraceptives rests entirely on the validity of the “natural law” arguments above.

If using modern contraceptives for family planning does not go against nature and the created order, then it cannot be regarded as “intrinsically evil” (i.e. immoral regardless of the intention of the agents, the circumstances of their situation, and the consequences of that action).

Yet the worldwide papal ban on using contraceptives is not only erroneous (and so against the truth): it also causes many concrete negative consequences, first and foremost unintended pregnancies, approximately half of which end up in abortions.

What follows has put together the most relevant scientific evidence on some of the negative consequences of the current papal prohibition.

4.1 Contraceptives save Lives – A Culture of Life Requires an Ethics of Contraceptives[32]Amy O. Tsui, Raegan McDonald-Mosley, and Anne E. Burke, “Family Planning and the Burden of Unintended Pregnancies,” Epidemiologic Reviews 32, no. 1 (April 1, 2010): 152–74, doi:10.1093/epirev/mxq012: “Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy.”

Methodological preface: The effectiveness of a contraceptive method is evaluated not just in its “perfect use” efficacy, but also in its “typical use” effectiveness. It is particularly important that “typical use” be assessed at population level, because only then you reach an insight into real-world effectiveness of a given contraceptive method.

Summary:

The stakes are high: an ineffective family planning method – such as those based exclusively on “periodic abstinence” (the only ones approved by HV and current papal teaching) – increase recourse to abortion:

  1. An estimated 50% of unintended pregnancies worldwide end up in abortion, or approximately 85 million out of 215 million each year.
  2. “Periodic abstinence” methods – the only ones allowed by current papal teaching – have a significantly higher population level typical use failure rate (approximately 25%) than the most effective modern contraceptives. That is, one in four women trying to avoid pregnancy using periodic abstinence will still fall pregnant within a year.
  3. As a consequence, users of “periodic abstinence” methods
  4. a) account for a disproportionately high percentage of the unintended pregnancies worldwide
  5. b) account for a disproportionately high percentage of abortions following contraceptive failure

The more a contraceptive method is effective (as well as affordable, acceptable and easy-to-use), the more it prevents unintended pregnancies and abortions.

Conversely, the more a contraceptive method is ineffective – and “periodic abstinence” methods have among the worst population level typical-use effectiveness rate – the more it results in unintended pregnancies and, as a consequence, it increases recourse to abortion.[33]Cicely A. Marston and Kathryn Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?,” Contraception 93, no. 6 (June 1, 2016): 492–97, doi:10.1016/j.contraception.2016.01.006; Cicely Marston and Kathryn Church, “Response to Letters to the Editor from Irit Sinai ‘Standard Days Method Effectiveness: Opinion Disguised as Scientific Review’ and Kelsey Wright, Karen Hardee, and John Townsend ‘The Pitfalls of Using Selective Data to Represent the Effectiveness, Relevance and Utility of the Standard Days Method of Contraception,’” Contraception 94, no. 4 (October 1, 2016): 376–78, doi:10.1016/j.contraception.2016.06.003.

A culture of life urgently requires an ethics of contraceptives.

Evidence:

  • “Approximately 40 percent of [the 213 million] pregnancies worldwide, or 85 million pregnancies, were unintended in 2012”.[34]Gilda Sedgh, Susheela Singh, and Rubina Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends,” Studies in Family Planning 45, no. 3 (2014): 301–314.
  • Approximately 818 million sexually active reproductive-age women in the developing world are seeking to avoid a pregnancy as of 2008.[35]Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, “Contraceptive Technologies: Responding to Women’s Needs,” New York: Guttmacher Institute 201, no. 1 (2011), https://live.guttmacher.org/sites/default/files/report_pdf/contraceptive-technologies.pdf.
  • Of those 818 million women in the developing world who want to avoid a pregnancy, approximately one in four – i.e. an estimated 215 million, or 26% – are not using modern contraceptives.
  • Of those 215 million, approximately 75 million only use traditional methods (the remaining do not use any contraceptive at all). Traditional methods include those based on “periodic abstinence” (PA, the only category of methods allowed by current papal teaching), withdrawal, breastfeeding, lactational amenorrhea method or LAM, douching, and various folk methods).[36]Darroch, Sedgh and Ball (2011).
  • Most significantly for present purposes, in the developing world the relatively small minority of women using either traditional methods of contraception exclusively, or no contraceptives at all (around 26%, or 215 million women) accounts for the vast majority (82%) of unintended pregnancies: a disproportionate share of the total. That is, the 26% of women who do not use modern contraceptives account for an estimated 60 million out of a total of 72.6 million unintended pregnancies in the developing world.[37]Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.”Darroch, Sedgh, and Ball, “Contraceptive Technologies”: “The remaining [i.e. 18%] unintended pregnancies occurred among the 603 million women who were using a modern contraceptive and conceived because they had difficulty using their method consistently and correctly or because of method failure.”

    Susheela Singh and Jacqueline E. Darroch, “Adding It up: Costs and Benefits of Contraceptive Services,” Guttmacher Institute and UNFPA, 2012, http://www.who.int/entity/woman_child_accountability/ierg/reports/Guttmacher_AIU_2012_estimates.pdf?ua=1. use slightly different estimates, noted that in 2012 “Most – 63 million – of the 80 million unintended pregnancies in developing countries [occurred] among the 222 million women [not using] modern contraception,” i.e. among women who either did not use any contraceptive method, or only used traditional methods (including “periodic abstinence” methods). Women exclusively using traditional methods are an estimated 75 million in the developing world.

  • Traditional methods of contraception – including those based on PA – have lower typical-use (as distinct from “perfect-use”) effectiveness rates than the most effective modern contraceptive methods.[38]James Trussell, “Contraceptive Efficacy,” in Contraceptive Technology. Nineteenth Revised Edition, ed. Robert Anthony Hatcher et al., Nineteenth Revised Edition, vol. 18 (New York: Ardent Media, 2008), 747–826; comparison table available online at http://www.contraceptivetechnology.org/wp-content/uploads/2013/09/CTFailureTable.pdf.

With regard to PA methods specifically, their failure rate in typical (as distinct from perfect) use is estimated to be approximately 25% worldwide.[39]Interventions studies with newer Fertility Awareness Methods (e.g. the Standard Days Method and the Symptothermal Method) using periodic abstinence exclusively during the fertile period have shown improved efficacy rates, see an overview in Günter Freundl, Irving Sivin, and István Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception: IV. Natural Family Planning,” The European Journal of Contraception & Reproductive Health Care 15, no. 2 (April 1, 2010): 113–23, doi:10.3109/13625180903545302. However no randomized controlled trials have been carried out as yet to test their population level typical use effectiveness, including when used exclusively with periodic continence (as distinct from their use with protected intercourse during the fertile window), see David A. Grimes et al., “Fertility Awareness-Based Methods for Contraception: Systematic Review of Randomized Controlled Trials,” Contraception 72, no. 2 (2005): 85–90. The considerable problems concerning those new FAMs are addressed later in this report. A 2004 study of 15 low- and middle-income countries focusing specifically on those methods confirmed earlier estimates of approximately 25%, largely based on US data, by reporting a median typical-use failure rate of 23.6%.[40]“The analysis of PA failure and its consequences was restricted to married or cohabiting women. Data for three countries were omitted because they generated less than 100 episodes of PA use. After these restrictions, a total of 8387 PA-use episodes were available for this analysis. On the basis of single-decrement life-table procedures, the median 12-month probability of pregnancy for the 12 surveys was 23.6 per 100 episodes.” Yan Che, John G. Cleland, and Mohamed M. Ali, “Periodic Abstinence in Developing Countries: An Assessment of Failure Rates and Consequences,” Contraception 69, no. 1 (January 1, 2004): 15–21, doi:10.1016/j.contraception.2003.08.006. See also Chelsea B. Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data: Summary of a Detailed Report,” Contraception 94, no. 1 (July 1, 2016): 11–17, doi:10.1016/j.contraception.2016.03.011, quoted below; Diana Mansour, Pirjo Inki, and Kristina Gemzell-Danielsson, “Efficacy of Contraceptive Methods: A Review of the Literature,” The European Journal of Contraception & Reproductive Health Care 15, no. 1 (February 1, 2010): 4–16, doi:10.3109/13625180903427675. That means that, in typical use, almost one in four women using PA methods to avoid conception becomes pregnant within a year.

  • It was noted above that an estimated 40% of pregnancies worldwide are unintended as of 2012. Of these, a staggering 50% end up in abortion.[41]Gilda Sedgh et al., “Abortion Incidence between 1990 and 2014: Global, Regional, and Subregional Levels and Trends,” The Lancet 388, no. 10041 (2016): 258–267.
  • As a consequence, PA users a) account for a disproportionately high percentage of the unintended pregnancies worldwide; and b) account for a disproportionately high percentage of abortions following contraceptive failure. Specifically, the above mentioned 2004 study of 15 low- and middle-income countries found that, while the median value of women using PA in those countries was only 3.3% (compare the estimated global average of 2.6%),[42]United Nations, Department of Economic and Social Affairs, Population Division (2015). Trends in Contraceptive Use Worldwide 2015 (ST/ESA/SER.A/349), p. 50, available at http://www.un.org/en/development/desa/population/publications/pdf/family/trendsContraceptiveUse2015Report.pdf. the relatively high typical-use failure rate of 23.6% (median value) meant that “PA failures accounted for 28% of all contraceptive failures”, as well as “one-sixth [or 16.7%] of all abortions (or miscarriages) following contraceptive failure.”[43]The total number of miscarriages and abortions following failure of any contraceptive methods was 1386 (i.e. 25.2% of the total number of conceptions following contraceptive failure of all methods). Of these, 232 or 16.7% were due to contraceptive failure of PA users. See Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.” In other words, despite PA users being a relatively small percentage, they account for a disproportionate share of unintended pregnancies and abortions.

In summary: “despite the fact that [PA] is a relatively rarely used method [i]ts contribution to mistimed and unwanted births is […] considerable”.[44]Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries” (emphasis added). Moreover, “Most of the induced abortions in these countries are illegal and many present a serious health risk to the woman.” Other findings: “in these countries, PA failures accounted for 28% of all contraceptive failures, despite the fact that it is a relatively rarely used method. Its contribution to mistimed and unwanted births is thus considerable. […]

In this sample of countries, 25% of conceptions resulting from contraceptive failure ended in fetal loss. Induced abortions cannot be distinguished from miscarriages loss, but it is reasonable to assume that the majority were induced.”

Therefore “an ineffective family planning method may increase recourse to abortion.”[45]Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness”; Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries”; Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”

Conversely, using the most effective modern contraceptives is one of the factors to reduce the number of unintended pregnancies and, as a consequence, abortions.[46]Jeffrey F. Peipert et al., “Preventing Unintended Pregnancies by Providing No-Cost Contraception,” Obstetrics and Gynecology 120, no. 6 (December 2012): 1291–97; Natalia E. Birgisson et al., “Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review,” Journal of Women’s Health 24, no. 5 (March 31, 2015): 349–53, doi:10.1089/jwh.2015.5191.

The more a contraceptive method is effective, acceptable, affordable and easy-to-use, the greater its effect in preventing unintended pregnancies and, as a consequence, abortions.

Use of modern contraceptive methods with high typical-use effectiveness reduces unintended pregnancies and therefore abortions, i.e. it saves lives. In contrast, use of methods with lower typical-use effectiveness – such as those involving “periodic abstinence” – increase both the number of unintended pregnancies and the consequent recourse to abortions, thus causing a loss of life.

Therefore, a culture of life therefore requires an ethics of using contraceptives.

  • Improving modern contraceptive uptake can result in a considerable lowering of unintended pregnancies and abortion rates. Estimates are that if all 200 million women in the developing world who do not use a modern method of contraception were to do so, 54 million unintended pregnancies would be prevented (or almost two-thirds of the total). By the same token, an additional 21 million unplanned births and 26 million abortions (14 million of which would be unsafe), 6 million miscarriages, 70,000 maternal deaths and 500,000 infant deaths would be averted.[47]Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.” Also Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, “Contraceptive Technologies: Responding to Women’s Needs,” New York: Guttmacher Institute 201, no. 1 (2011), https://live.guttmacher.org/sites/default/files/report_pdf/contraceptive-technologies.pdf: “If all women who want to avoid unintended pregnancy were to use modern contraceptives, the number of unintended pregnancies in developing countries would decrease by 71%, from 75 million to 22 million annually. The impact on women, their families and their countries would be great: There would be 22 million fewer unplanned births and 25 million fewer induced abortions, which in turn would result in 15 million fewer unsafe abortions, 90,000 fewer maternal deaths and 390,000 fewer children who would lose their mothers.5 Moreover, because of the reductions in maternal mortality and morbidity, each year women would lose 12 million fewer healthy years of life.” P. D. Blumenthal, A. Voedisch, and K. Gemzell-Danielsson, “Strategies to Prevent Unintended Pregnancy: Increasing Use of Long-Acting Reversible Contraception,” Human Reproduction Update 17, no. 1 (January 1, 2011): 121–37, doi:10.1093/humupd/dmq026; James Trussell et al., “Burden of Unintended Pregnancy in the United States: Potential Savings with Increased Use of Long-Acting Reversible Contraception,” Contraception 87, no. 2 (February 1, 2013): 154–61, doi:10.1016/j.contraception.2012.07.016; Jennifer J. Frost, Laura Duberstein Lindberg, and Lawrence B. Finer, “Young Adults’ Contraceptive Knowledge, Norms and Attitudes: Associations with Risk Of Unintended Pregnancy,” Perspectives on Sexual and Reproductive Health 44, no. 2 (June 1, 2012): 107–16, doi:10.1363/4410712; Peipert et al., “Preventing Unintended Pregnancies by Providing No-Cost Contraception”; Birgisson et al., “Preventing Unintended Pregnancy.” Similarly, the evidence says that the best way to cut abortion rates does not seem to be making it illegal.
  • In evaluating those numbers, it is important to recall that non-use of modern contraceptives is not caused solely or even primarily by lack of access. Rather, the main motivations women worldwide have given for non-use of modern methods of contraception include “constraints on women’s decisionmaking abilities [and] provider bias”.[48]Gilda Sedgh and Rubina Hussain, “Reasons for Contraceptive Nonuse among Women Having Unmet Need for Contraception in Developing Countries,” Studies in Family Planning 45, no. 2 (2014): 151–169; Gilda Sedgh, Lori S. Ashoford, and Rubina Hussain, “Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method” (The Guttmacher Institute, 2016), http://repositorio.gire.org.mx/handle/123456789/2049. Martha Campbell, Nuriye Nalan Sahin-Hodoglugil, and Malcolm Potts, “Barriers to Fertility Regulation: A Review of the Literature,” Studies in Family Planning 37, no. 2 (2006): 87–98. The former include opposition to contraception because of cultural or religious norms and beliefs, whether of the woman herself, her partner, or other close person (e.g. relatives). The latter includes the prohibition on the part of many Catholic educational and health care facilities to inform about or make available modern contraceptive methods for family planning. A revision of HV would help the Catholic Church contribute powerfully to overcome all those issues.

The evidence provided above demonstrates that users of less efficient contraceptive methods based on “periodic abstinence” experience a disproportionate number of unintended pregnancies in comparison with users of more effective modern contraceptives, and that in turn a very high percentage (close to 50%) of those unintended pregnancies end up in abortion.

The numbers involved are in the millions. Those statistics are robust and cannot be ignored any longer. The data speak for themselves, and the defence of life itself demands an urgent change of policy from the Catholic Church.

The evidence provided above demonstrates the following direct causal relationships:

High Typical-Use Failure Rate of a Contraceptive Method => High Percentage of Unintended Pregnancies => High Percentage of Abortions

It also demonstrates that the population level typical use effectiveness of periodic abstinence methods is much lower than that of the most effective “artificial” contraceptives. As a consequence, users of periodic abstinence methods account for a disproportionate share not just of unwanted pregnancies but also of abortions.

Given the above, even those subscribing to the condemnation as morally wrong of the use of “artificial” contraceptives for family planning can accept the need to allow their usage if and when it lowers the number of abortions, on the basis of the principle of the lesser evil.

4.1.1 Use of Modern Contraceptives Prevents Natural Embryo Loss

There is another way in which modern contraceptives save lives: namely, by preventing natural early embryo loss.

“[H]umans are unique in the very high frequency of chromosome abnormalities and consequent early embryo wastage”:[49]Pollard, “Fertility Awareness: The Ovulatory Method of Birth Control, Ageing Gametes and Congenital Malformation in Children.” In the human species, even after insemination and conception, a very high percentage (approximately 50%) of zygotes are naturally discarded either before, during, or shortly after the process of implantation.

It has been estimated that this results in approximately 200 million early embryo losses worldwide a year.[50]Toby Ord, “The Scourge: Moral Implications of Natural Embryo Loss,” The American Journal of Bioethics 8, no. 7 (2008): 12–19; Toby Ord, “Response to Open Peer Commentaries on ‘The Scourge: Moral Implications of Natural Embryo Loss,’” The American Journal of Bioethics 8, no. 7 (2008): W1–W3.

Such a high percentage of “natural selection” occurs due to genetic abnormalities in the gametes, resulting in chromosomally unbalanced conceptions which fail to develop properly.

In addition, “the endometrium has the ability to recognize, respond to and eliminate implanting compromised embryos,” and therefore endometrial dysfunctions – such as “impaired differentiation of endometrial stromal cells into specialized decidual cells” – account for most of the non-chromosomal early embryo loss, i.e. the elimination of genetically viable embryos.[51]G. Teklenburg et al., “The Molecular Basis of Recurrent Pregnancy Loss: Impaired Natural Embryo Selection,” MHR: Basic Science of Reproductive Medicine 16, no. 12 (December 1, 2010): 886–95. Hence, “the natural in utero selection process […] eliminates 95% of chromosomally unbalanced conceptions”.[52]“Clinically recognized pregnancy loss [i.e. after a successful embryo implantation], is usually quoted as 15-20%. It is this clinical fraction of failed pregnancies that has been extensively studied cytogenetically and in which a chromosome abnormality rate of at least 50% has been established. This contrasts markedly with a 5% chromosome abnormality rate found in stillbirths, illustrating clearly the natural in utero selection process that eliminates 95% of chromosomally unbalanced conceptions. [I]t can be seen that 50-60% of developmental anomalies at birth are of unknown etiology while known causes can be assorted into chromosomal aberrations, mutant genes and environmental factors. Of the known categories, 20-25% are multifactorial inheritances.” See also Ibid.

The extent to which modern contraceptives prevent such a relatively high natural embryo loss depend on their effectiveness in preventing ovulation and/or fertilization. The more effective the method, the higher the prevention of natural early embryo loss.

Population-level typical-use effectiveness of the most effective modern contraceptives can be compared both 1) to non-use of any contraceptive, and 2) to population-level typical-use estimates (if available) of those Fertility Awareness Methods (FAMs) which are based exclusively on periodic abstinence, and thus exclude any use of “artificial” contraceptives during the fertile window.

1) In the first case, consider that modern contraceptives (especially LARCs) have a very high population level typical-use effectiveness because of their very high effectiveness in blocking ovulation and fertilization.

In contrast, “periodic abstinence” methods have a failure rate of approximately 25%. That number refers to verified clinical pregnancies (i.e. post-implantation): but if we were to include into the percentage of failures also the number of successful fertilizations, the number would be arguably higher.

In other words, typical use of “periodic abstinence” methods would result in a successful fertilization in a much higher number of cases than if using most modern contraceptives, especially LARCs.

This means that using “periodic abstinence” methods may contribute to natural early embryo loss to a much higher degree than using most modern contraceptives, especially LARCs.

FAMs may also increase the proportion of pregnancies occurring with “ageing” gametes and therefore may increase the rate of births with congenital malformations.

[WICR academics are in the process of examining current statistical estimates on the subject; an updated comparison of the natural embryo loss percentages using modern contraceptives and “periodic abstinence” methods will be sent to the Pontifical Academy for Life as soon as it is ready]

5. There are no viable alternatives to modern contraceptives for birth control

5.1. Abstinence is not an effective alternative to the use of modern contraceptives in order to reduce the number of unintended pregnancies and abortions

There are currently no alternatives to modern contraceptives in order to reduce the number of unintended pregnancies and consequent abortions.

The only alternative current papal teaching proposes is abstinence: to by achieved via 1) “abstinence-only sex education” before marriage, and 2) by using exclusively “periodic abstinence” methods of family planning within marriage.

Both policies have been proved largely ineffective. What follows summarises some of the key findings in that regard.

5.2. Abstinence-Only Sex Education

[1] No program of abstinence-only sex education is as effective in reducing unintended pregnancies and abortions as the so called “comprehensive” sex education programs, which do on the whole emphasise abstinence, but also provide guidance on the use of contraceptives for both family planning and prophylactic purposes.

This is the more so when there is access to affordable, effective, and easy-to-use modern contraceptives. In fact, the extensive evidence available on the vast majority of abstinence-only programs show little to no effect in delaying sexual debut, pregnancies, or STIs.[53]See bibliography in Appendix.

In contrast, “comprehensive” sex education, which complements an emphasis on abstinence and fidelity with information about how to use modern contraceptives for both family planning and prophylactic purposes, has been proved to lower STIs, unintended pregnancies, and abortions, not only in comparison with people who received no sex education whatsoever but also, more to the point, in comparison to people who had received abstinence-only sex education.

5.3. Fertility Awareness Methods (Natural Family Planning)

[2] Fertility Awareness Methods likewise present several major problems.

1) The most relevant for present purposes is that they are largely marketed and used simply as fertility trackers to more accurately target the use of barrier methods (generally condoms), rather than to abstain, during the fertile window.[54]See most recently Cicely Marston and Kathryn Church, “Response to Letters to the Editor from Irit Sinai ‘Standard Days Method Effectiveness: Opinion Disguised as Scientific Review’ and Kelsey Wright, Karen Hardee, and John Townsend ‘The Pitfalls of Using Selective Data to Represent the Effectiveness, Relevance and Utility of the Standard Days Method of Contraception’.,” Contraception, no. 10.1016/j.contraception.2016.06.003 (June 15, 2016), http://researchonline.lshtm.ac.uk/2572238/; Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”.

This is not likely to change even were all the other considerable current drawbacks of NFP methods to be resolved in the future. Among such current drawbacks, one can mention:

  • low typical-use effectiveness,
  • unsuitability to women with irregular cycles (the relatively recent Standard Days Method is unsuitable for up to 50% of women!),
  • low acceptability and continuation rates (this could be due to a mixture of low acceptability [the requirement to abstain to close to half the time each cycle is very demanding, particularly for young couples], low effectiveness, low ease of use, and relatively long training required);
  • low current uptake worldwide – arguably a result of the previous points, i.e. low acceptability, effectiveness, ease of use, and continuation rates.

The following points will expand on those drawbacks.

1) Fertility Awareness Methods of family planning (FAMs) based on “periodic abstinence” alone have a relatively low population-level typical-use effectiveness, that is they display a relatively high population level typical-use failure rate, approximately 25% for “periodic abstinence” based FAMs.[55]Grimes et al., “Fertility Awareness-Based Methods for Contraception.”James Trussell and Laurence Grummer-Strawn, “Contraceptive Failure of the Ovulation Method of Periodic Abstinence,” International Family Planning Perspectives, 1990, 5–28; Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.” In other words, one in four women using them who is trying to avoid a pregnancy will become pregnant within one year.

Low effectiveness is particularly important because “Of all the reasons why women choose particular contraceptives, method effectiveness ranks among the most important”.[56]James Trussell and K. Guthrie, “Choosing a Contraceptive: Efficacy, Safety, and Personal Considerations,” Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology. 19th Revised Ed. New York (NY): Ardent Media, Inc, 2007, 19–47; quoted in Willard Cates Jr, John Stanback, and Baker Maggwa, “Global Family Planning Metrics-Time for New Definitions?,” Contraception 90, no. 5 (2014): 472–475. As a FAM researcher recently put it: “traditional methods are both less effective and less often used than modern methods. Contraceptive efficacy is one of the most important aspects of method choice and promotion, and, with typical use, periodic abstinence and withdrawal (the two most commonly used traditional methods) are less effective than nearly all modern methods (Trussell 2004)” Clémentine Rossier and Jamaica Corker, “Contemporary Use of Traditional Contraception in Sub-Saharan Africa,” Population and Development Review, 2017, http://onlinelibrary.wiley.com/doi/10.1111/padr.12008/full.

One of the most comprehensive recent comparative studies of the effectiveness of the various contraceptive methods found that

modern contraceptive methods with the least room for user error generated the lowest median failure rates and the lowest variability in these rates. […] Withdrawal and periodic abstinence had the highest failure rates.[57]Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data.” Noteworthy is their comparison with previous findings on contraceptive effectiveness, and in particular Mohamed M. Ali, John Cleland, and Iqbal H. Shah, “Causes and Consequences of Contraceptive Discontinuation: Evidence from 60 Demographic and Health Surveys.,” 2012, http://www.popline.org/node/654966: “Our estimates for IUDs, injectables and oral contraceptive pills were similar to a recent large-scale analysis of contraceptive failure in DHS data by Ali et al. […]. For condoms, withdrawal and periodic abstinence, our estimates were somewhat lower, although estimates from Ali et al. for each of these methods were within the range of the 95% CIs around our estimates, suggesting no statistically significant differences. Comparing our results to estimates for the United States is more complicated. Our estimates were somewhat higher than U.S. estimates for implants (0.6 vs. 0.05) and IUDs (1.4 vs. 0.8), which are derived from clinical data. U.S. estimates for both of these methods fall within the 95% CIs for our estimates. On the other hand, our estimates were markedly lower than U.S. estimates for injectables (1.7 vs. 6), oral contraceptive pills (5.5 vs. 9), male condoms (5.4 vs. 18), withdrawal (13.4 vs. 22) and periodic abstinence (13.9 vs. 24), which are derived from 1995 and 2002 National Surveys of Family Growth and, notably, are corrected for abortion underreporting. […]

We are unable to estimate the impact that omission, misreporting and underreporting of contraceptive use episodes; reasons for discontinuation; and abortions resulting from contraceptive failure may have on failure rates, particularly since the level of underreporting may vary across surveys. Therefore, the estimates presented should be viewed as direct reflections of women’s reports, which are potentially affected by a number of biases.”

Indeed, “Implant users were 9 times less likely to report contraceptive failure than women using contraceptive pills and 23 times less likely than women using periodic abstinence.”[58]Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data.”

One of the things that renders more difficult an accurate assessment of typical-use effectiveness is that fact that FAMs are often used in conjunction with another contraceptive method (usually the male condom), rather than abstinence, during the fertile period.[59]See e.g. Günter Freundl, “European Multicenter Study of Natural Family Planning (1989-1995): Efficacy and Drop-Out,” Advances in Contraception 15, no. 1 (1999): 69–83, doi:10.1023/A:1006691730298., where rates of unintended pregnancy were reported separately for six different categories of behaviour during its practice ranging from “abstinence in the fertile time” and “genital contact or coitus interruptus in the fertile time” to “no documented sexual behaviour”. This point is discussed below.

On the other hand, the population level typical-use effectiveness – which is a key requirement for their universal viability – is still unproven.

Newer FAMs include the Standard Days Method (SDM), the Symptothermal Method (STM), and the Marquette Method (this latter using a hormonal fertility monitor, ClearBlue™).

Some of those newer FAMs – e.g. the SDM and STM– have observed a high typical-use efficacy (88% and 98% respectively) but – and this is the point of attention – only in intervention studies: no rigorous randomized controlled trial has been carried out on them.[60]Grimes et al., “Fertility Awareness-Based Methods for Contraception.” Likewise, Frank Herrmann’s subsequent reference study on the STM “was not a randomized controlled trial,” as the authors themselves acknowledged. They also commented that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Herrmann’s findings are further mitigated by a relatively low continuation rate: “the proportion [of participants] reaching one year was 509/831 (61.3%).”P. Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time: A Prospective Longitudinal Study,” Human Reproduction (Oxford, England) 22, no. 5 (May 2007): 1310–19, doi:10.1093/humrep/dem003.

It is noteworthy that Herrmann’s is the reference study on the effectiveness of STM, from a Catholic researcher sympathetic towards FAMs. No other randomized controlled trials on the typical-use effectiveness of the STM, SDM, or other FAMs exist as yet. “There are few randomized controlled studies of FABMs; existing randomized trials were judged to be of insufficient quality to draw any valid conclusions.” Stephen R. Pallone and George R. Bergus, “Fertility Awareness-Based Methods: Another Option for Family Planning,” The Journal of the American Board of Family Medicine 22, no. 2 (March 1, 2009): 147–57, doi:10.3122/jabfm.2009.02.080038. Again, “randomised trials comparing pregnancy rates of different FAB methods are absent, limiting evidence-based choice.”Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.” referring to Grimes et al., “Fertility Awareness-Based Methods for Contraception.” As Herrmann remarked, “The only randomized clinical trials on methods of NFP (Wade et al., 1981; Medina et al., 1980) are of limited use: they showed huge recruitment problems and retention as well as having a very strong selection bias (participants had to agree to expect quite high failure rates while attracted by free medical care at study entry), their results are therefore very questionable,” referring precisely to Grimes et al, op. cit.

The so-called Marquette Method has been found by its developed to be marred by its relatively low effectiveness even when used by couples in a developed country (the USA) after training. The method is so called because it has been researched, developed by Dr Richard Fehring at the Jesuit Marquette University. In 2009 Fehring observed “an increase in the number of unintended pregnancies that have occurred over the past twenty-three years through the Marquette University NFP programs.”Richard Fehring, “Efficacy and Efficiency in Natural Family Planning Services,” The Linacre Quarterly 76, no. 1 (February 1, 2009): 9–24, doi:10.1179/002436309803889377.

“The Billings Method cites an ideal effectiveness rate of 99.5 percent and typical use effectiveness of 98.5 percent based on a single study done in China (Qian et al. 2000; Xu et al. 1994). However other studies note a typical-use pregnancy rate of 22.5 percent and a significant gap between perfect and typical use (Trussell and Grummer-Strawn 1991). There have been no prospective studies done which have supported the effectiveness rates of the Chinese study within a different cultural context. While the Billings Method notes there are ‘four simple rules’ for its application, there is in reality multiple ‘meta-rules’ (the rules governing the four rules) and a range of nineteen different stickers and thirteen different symbols within the Billings Method (Smith and Smith 2014).” George Mulcaire-Jones et al., “Couple Beads: An Integrated Method of Natural Family Planning,” The Linacre Quarterly 83, no. 1 (February 2016): 69–82, doi:10.1080/00243639.2015.1133018.Also E. Faes, J. Van De Walle, and Y. Jacquemyn, “‘Fertility Awareness’ methoden: Oud Nieuws?,” Tijdschrift Voor Geneeskunde 72, no. 2–3 (2016): 88–95: “It is suggested that the symptothermal method, which is a combination of the temperature-based method and cervical secretion method, is most reliable, but there is a lack of randomized trials comparing methods and combinations.”

In summary, “Most of the reported data on the effectiveness of NFP is based on perfect use. The complexity and diligence required by many NFP methods make them unrealistic and untenable for many persons. With typical use, up to 25 percent of women using NFP will become pregnant within the first year.” Grant M. Greenberg et al., “Is Natural Family Planning a Highly Effective Method of Birth Control? No: Natural Family Planning Methods Are Overrated.,” American Family Physician 86, no. 10 (2012): Online. Consequently, there is no evidence that their high efficacy in intervention studies will translate into high typical-use effectiveness at population level.[61]Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”; Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness.”

In addition, even those newer FAMs suffer from very considerable drawbacks, as highlighted below.

2) Most FAMs (including one as relatively recent as the Standard Days Method/CycleBeads) require a relatively long period of abstinence, i.e. almost half the monthly cycle. (Of course, this applies only when abstinence rather than protected intercourse is chosen during the fertile period).

Thus, for the calendar methods “The duration of abstinence is 14 days, or about half of the cycle”; even newer FAMs fare only slightly better:“12 days of abstinence are required” by the SDM/CycleBeads developed in 1999.[62]Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.” Worse still, use of the TwoDay Method implies “some women will find only 12 safe days per cycle,” i.e. abstinence is required for the majority of days. The STM (double-check) “only” requires 7-10 days of abstinence per cycle, i.e. about a third of the monthly cycle: nevertheless, “[d]ouble checking provides more security in determining the fertile phase and may demand less, but sometimes more abstinence than earlier rules based on temperature alone.”[63]Ibid.

Requiring abstinence at a minimum of one third, and more commonly half of the time every month, means requiring a very significant change in sexual behaviour, especially for young couples.

This largely defeats the main morally commendable goal of modern contraceptives, namely that of facilitating the spontaneous expression of marital love. As it has been noted, “Modern contraceptive methods were invented so couples could act on natural impulses and desires with diminished risks of pregnancy. […] In this regard, modern methods must enable couples to have sexual intercourse at any mutually-desired time.”[64]David Hubacher and James Trussell, “A Definition of Modern Contraceptive Methods,” Contraception 92, no. 5 (2015): 420–421.

Abstinence FAMs by and large do not allow this for significant numbers of couples. Recent research from 55 countries (n=245,732 women) strongly suggests that use of FAMs decreases coital frequency, while use of modern contraceptives is associated with higher coital frequency.[65]“[O]ur results suggest that women with met need for contraception are having more frequent sex. If future research is able to establish a causal link from exogenous contraceptive availability to coital frequency, then findings like these would imply that reductions in unmet need could lead to increased sexual activity for couples worldwide.” The researchers also found that “It is notable that 72 percent of women who had unmet need [for modern contraception] had had sex in the last four weeks, compared with 89 percent of women using contraception. So there appear to be limits in couples’ commitment to embracing marital abstinence as a substitute for modern contraception.”

However, their data do not allow investigation of those women’s motivation for non-use: “It could be that some portion of the 72 percent of women with unmet need who had sex in the last four weeks only had sex once or only had sex when the risk of conception was low (i.e., unreported use of rhythm method), as opposed to the 89 percent of women using contraception who may have had sex more frequently and without regard to their monthly cycle. Unfortunately, the data do not allow investigation of these phenomena. It is also possible that women and couples who have infrequent sex are simply willing to accept a certain level of risk with regard to unintended pregnancy and choose to forego regular use of modern contraception given their limited exposure to sex. A recent study by Machiyama and Cleland (2014) provides evidence that reduced coital frequency is being deployed by women and couples in Ghana as an alternative to modern contraception. There is also the likelihood that some of these women do not fully appreciate the risk or cumulative risk of unintended pregnancy associated with repeated exposure to unprotected sex and thus are making a decision not to use contraception based on an incorrect perception of their risk. Further research is needed to understand these women’s motivation for non-use of modern contraception and how their contraceptive needs could best be met given their coital frequency.” Suzanne O. Bell and David Bishai, “Unmet Need and Sex: Investigating the Role of Coital Frequency in Fertility Control,” Studies in Family Planning 48, no. 1 (March 1, 2017): 39–53, doi:10.1111/sifp.12012 (emphasis added). In not a single country out of the 55 surveyed women who did not use contraception were having more sex than those who did.

Yet it is also well-known that a healthy sex life contributes to a healthy relationship and marriage. Modern contraceptives better allow a healthy sex life than methods requiring sexual abstinence for approximately half the time each cycle. As the lead authors of that recent study commented:

“Modern contraception presents an opportunity to reduce the risk of pregnancy without having to reduce sexual frequency, [Suzanne] Bell adds. Healthy sex lives are good for relationships but we often leave that out of conversations about the benefits of family planning,” she says. Adds [David] Bishai, the senior author: “For too long development specialists told policymakers that investing in family planning would create prosperity for the next generation. Now it’s time for a message focused on this generation. More family planning means more sex for married couples now.”[66]Johns Hopkins Bloomberg School of Public Health, “Better Access to Contraception Means More Sex for Married Couples,” ScienceDaily, January 26, 2016, www.sciencedaily.com/releases/2016/01/160126091436.htm.

That is arguably the reason why HV acknowledged that received papal teachings on contraception “can be observed only with the gravest difficulty, sometimes only by heroic effort” (HV §3).

It is arguably also the reason why FAMs (including the SDM/CycleBeads and the STM) are generally marketed as fertility tracker to know when to avoid unprotected intercourse, rather than to simply know when to abstain. This is indeed the way that many FAMs practitioners use them, namely to pinpoint when to use contraceptives (generally condoms).

Noteworthy in this regard is the fact that the two seminal studies about the efficacy of the STM and the SDM respectively include not only users abstaining during the fertile period, but also those using barrier methods.[67]Marcos Arévalo, Victoria Jennings, and Irit Sinai, “Efficacy of a New Method of Family Planning: The Standard Days Method,” Contraception 65, no. 5 (2002): 333–338; Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.” Indeed, the reference article with regard to the effectiveness of the STM, based on a 22-years European longitudinal study, found that the majority (509 out of 900 couples, or 56.5%) of participating couples had protected intercourse (i.e. used a barrier method) during the fertile window, with only 35.7% (322 out of 900) abstaining.[68]Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.” That category cannot be considered users of “Natural Family Planning” as required by the Catholic Church: rather, they can be described as “periodic users of condoms.”

This despite the majority of participants in that longitudinal study being likely more motivated than average to use that method, as admitted by the lead investigator, himself a Catholic and a promoter of the STM.[69]As noted elsewhere, Frank-Herrmann et al. noticed that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Ibid.

3) Generally speaking, FAMs are not suitable for women who have an irregular monthly cycle.[70]For instance, the marketing page for the STM (CycleBeads™) notes: “This family planning method is most effective for women with menstrual cycles that are regularly between 26 and 32 days long. […] Women with cycles outside this range should use a different method of family planning to prevent pregnancy.” https://www.cyclebeads.com/how-family-planning-method-helps-to-plan-pregnancy-or-prevent-pregnancy This is the case with all the recent methods mentioned above: the SDM, the STM, Marquette, TwoDays Method, and so on.

The STM, for example, was tested on women with a “Normal cycle lengths between 22 and 35 days”, with the warning that “20% of cycle lengths could be outside this range.”[71]Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.”

The SDM has an even worse eligibility pool: “At any given time, only 50–60 percent of women will meet the [SDM] requirements of cycle regularity and length”.[72]The Standard Days Method can only be used by women with known, regular cycle lengths of between twenty-six and thirty-two days (Arévalo, Jennings, and Sinai 2002). In the original study of the method, only 46 percent of women completed thirteen cycles of use. Of those who left the study, 28 percent did so because they had two cycles out of the accepted range of twenty-six to thirty-two days; and 9 percent left because they became pregnant (Arévalo, Jennings, and Sinai 2002). At any given time, only 50–60 percent of women will meet the requirements of cycle regularity and length (Institute for Reproductive Health 2014a). Furthermore the method cannot be reliably used in the transition from LAM to resumption of regular cycles, a critical time for child spacing (Arévalo, Jennings, and Sinai 2003). While the Standard Days Method has been vigorously promoted as a simple method for NFP use, even when taught with the option of barrier methods, only 91 of 1,181 (7%) women admitted within the introduction studies and followed with quarterly interviews were still using the method on completion of year 3 (Sinai, Lundgren, and Gribble 2012).” George Mulcaire-Jones et al., “Couple Beads: An Integrated Method of Natural Family Planning,” The Linacre Quarterly 83, no. 1 (February 2016): 69–82, doi:10.1080/00243639.2015.1133018, emphasis added; compare Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception”: the Standard Days Method “was designed for women whose cycles range, without exception, from 26 to 32 days.” When its other limitations are considered, it means that the SDM meets the “need of only a minority of women of reproductive age”.[73]Richard J. Fehring and Theresa Notare, Integrating Faith and Science Through Natural Family Planning (Marquette University Press, 2004); quoted in Mulcaire-Jones et al., “Couple Beads.”

Calendar methods other than the SDM fare even worse, in that they “should not be used if all cycles are shorter than 27 days”.[74]Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.”

4) Even newer FAMs are still relatively inaccurate in tracking the fertile window of women who have a regular cycle.

To accurately track the fertile window, it is necessary to be able to determine the time of ovulation approximately a week before it occurs. This is not easy to achieve. All FAMs rely on observation of the indirect, secondary effects of ovulation, such as changes in basal body temperature, cervical mucus, and/or the levels of estrogen and LH hormones.

Predicting the time of ovulation approximately a week before it occurs has an inherent margin of error. In order to be on the safe side, all FAMs tend to overestimate the duration of the biological fertile window. As a consequence, they require sexual abstinence for a longer period – almost half the time each cycle – than what would be required by the biological fertile window.[75]Rene Ecochard et al., “Self-Identification of the Clinical Fertile Window and the Ovulation Period,” Fertility and Sterility 103, no. 5 (2015): 1319–1325.

For example, “using the cervical mucus method over estimates the actual fertile phase by 5–6 days, and that is a very conservative estimate. [C]ervical-mucus monitoring is not as easy and maybe not as accurate as we had assumed.”[76]Fehring, “Efficacy and Efficiency in Natural Family Planning Services. ”Furthermore, Fehring added that “…the beginning of mucus clearly over-estimated the fertile phase. […] Anecdotally, we hear that women often find it frustrating to track mucus for days on end and not have a clear picture of their fertility.” More in general, Fehring admitted that

all of the current indicators of fertility utilized in methods of NFP are imperfect. All of them produce information in menstrual cycles that is hard to interpret. Most of these indicators overestimate the actual fertile phase.[77]Richard J. Fehring, “Grant Application: Randomized Comparison of Two Internet-Supported Natural Family Planning Methods,” 2013, http://epublications.marquette.edu/cgi/viewcontent.cgi?article=1009&context=data_nfp.

Because of the inherent uncertainty of predicting the ovulation time about a week in advance, it is unlikely that advances in fertility tracking (e.g. by using fertility monitors, as Fehring is advocating) will be able to significantly lessen the require to abstain for at least 10 days per monthly cycle (i.e. approximately one-third of the time).

And such a significant requirement will make it unlikely that FAMs will be used primarily to know when to abstain rather than simply as fertility trackers, to more accurately target contraceptive usage during the fertile window (please see also section 5.4 below).

5) Acceptability and continuation rates appear to be low. “NFP methods are not all that easy to provide or to use,” as even Dr Richard Fehring, a long-time researcher of NFP and the developer of the Marquette Method, recently observed.[78]“[P]roviding NFP services is complex, time consuming, and expensive. The training of health professionals to provide NFP services is also time consuming and expensive. Many NFP providers experience burn out providing the often intense NFP services. In the past twenty-three years, we have lost eight out of the fourteen health professionals who were trained for our NFP staff at Marquette [University]. The NFP methods we have been using are inefficient, and it often takes months to properly teach couples to the point that they are confident in their use. Finally, we have seen few changes in NFP in the past 30–50 years. What we call the “modern” methods of NFP were developed in the 1950s and 60s—40–50 years ago.”

With regard to the SDM/CycleBeads, for instance, “only 91 of 1,181 (7%) women admitted within the introduction studies and followed with quarterly interviews were still using the method on completion of year 3.”[79]Mulcaire-Jones et al., “Couple Beads.” Given that as well as the above mentioned fact that “At any given time, only 50–60 percent of women will meet the [SDM] requirements of cycle regularity and length,” the Standard Days Method meets the “need of only a minority of women of reproductive age.”[80]Ibid.

Another prominent researcher of FAMs observed that in developing countries “cost of teaching is an issue and […] continuation has a higher priority than efficacy”.[81]Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.”

Among other issues hindering adoption of FAMs is the fact that “partner cooperation in the use of periodic abstinence can be difficult to garner consistently […] where gender inequalities are pronounced.”[82]Clémentine Rossier, Leigh Senderowicz, and Abdramane Soura, “Do Natural Methods Count? Underreporting of Natural Contraception in Urban Burkina Faso,” Studies in Family Planning 45, no. 2 (June 1, 2014): 171–82, doi:10.1111/j.1728-4465.2014.00383.x. This is the more so because, as noted above, even the newer FAMs method, including the STD and STM, require abstinence for more than half the monthly cycle. Even a recent qualitative study sympathetic to FAMs reported that one African woman “found SDM harder to use than the injectables she had switched away from, because it required ‘a lot of self control on his side’.”[83]Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness”; citing C. Ujuju et al., “Religion, Culture and Male Involvement in the Use of the Standard Days Method: Evidence from Enugu and Katsina States of Nigeria,” International Nursing Review 58, no. 4 (2011): 484–490.

6) Low current uptake: “Worldwide FAB [Fertility Awareness Based] methods and withdrawal are used, respectively, by about 3.6% and 2.9% of all couples of reproductive age.”[84]“Worldwide use in 2007 of what the UN Population Division calls ‘rhythm’ or calendar methods is estimated to be 3.6% of all women, aged 15–49 who are married or in union. This estimate includes all methods in which periodic abstinence is required. Prevalence is higher in more developed countries (4.3%) than in less developed countries (3.4%) (Table 1). The UN estimates the prevalence of rhythm-related methods in Europe to have been 5.6% in 2007 (Table 1).” Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.” Specifically, in the USA, “[O]nly 0.2 percent of all U.S. women and 0.4 percent of all U.S. Catholic women between the ages of 15–44”[85]Richard Fehring, “Efficacy and Efficiency in Natural Family Planning Services,” The Linacre Quarterly 76, no. 1 (February 1, 2009): 9–24, doi:10.1179/002436309803889377; referring to Jennifer Ohlendorf and Richard J. Fehring, “The Influence of Religiosity on Contraceptive Use among Roman Catholic Women in the United States,” The Linacre Quarterly 74, no. 2 (2007): 6. use FAMs or, according to a more optimistic measure, “Only 1 to 3 percent of U.S. women use NFP for birth control”.[86]Crista B. Warniment and Kirsten Hansen, “Is Natural Family Planning a Highly Effective Method of Birth Control? Yes: Natural Family Planning Is Highly Effective and Fulfilling,” American Family Physician 86, no. 10 (2012): 1–2; Pallone and Bergus, “Fertility Awareness-Based Methods.”

In addition, “health professionals are reluctant to provide NFP services due to their inefficiency and poor efficacy. Only about 6–10 percent of physicians in the U.S. and Europe would consider prescribing them for birth-control purposes.”[87]Fehring, “Efficacy and Efficiency in Natural Family Planning Services.”

The relatively low uptake may be linked to those methods being relatively complex to use (i.e. they have low acceptability and continuation rates), requiring a relatively long period of abstinence (close to have the monthly cycle), and to them being only appropriate to women with regular cycle lengths (e.g. with regard to the relatively recent Standard Days Method “only 50–60 percent of women will meet the requirements of cycle regularity and length […]. Furthermore the method cannot be reliably used in the transition from LAM to resumption of regular cycles, a critical time for child spacing.”[88]Mulcaire-Jones et al., “Couple Beads.”

In summary, “The complexity and diligence required by many NFP methods make them unrealistic and untenable for many persons.”[89]Greenberg et al., “Is Natural Family Planning a Highly Effective Method of Birth Control?”

5.4. Are Future Improvements in FAMs’ Typical-Use Effectiveness, Acceptability, Ease of Use, and Cost Likely to Translate into Higher Uptake of Users “Periodic Abstinence” users?

Let us assume that in the future FAMs – perhaps complemented with hormonal fertility monitors linked to smartphones “apps”– will be capable of pinpointing the start and end of the fertile window with a very high degree of accuracy (despite the inherent difficulty of accurately predicting the time of ovulation approximately a week in advance).

Let us also posit that they may be able to do so for all women, including the many women who have an irregular hormonal profile and an irregular cycle, and who so far cannot effectively use many FAMs methods.

Let us further posit that pinpointing the time of ovulation a full week in advance of it happening will be much easier than is currently the case, where it generally requires a combination of regular calendar readings, temperature measurements, and cervical mucus assessments for maximum accuracy. Let us posit, for instance, that it could be done uniquely via a hand-held hormonal fertility monitor somehow capable of anticipating the time of ovulation by a full week with 100% accuracy.

Let us posit, finally, that such fertility monitors will overcome another considerable hurdle, namely affordability (the ClearBlue™ monitor used by the Marquette Method currently retails for $109.99USD, excluding the test sticks, at $39.20USD for 30), and that it will be able to be subsidised and accessible to everyone on the planet, including the poorest.

1) Still, even were FAMs and fertility monitors to become highly accurate, easy-to-use, and universally accessible for free, it is highly unlikely they will be used to know when to abstain from sex, rather than when to use barrier methods.

This is already the case: the most effective FAMs (i.e. the SDM and the STM) have been tested and marketed simply as methods for tracking the fertility cycle, and not as requiring periodic abstinence. Users are told to avoid unprotected sexual intercourse during the fertile period, either by abstaining or by using modern contraceptives (often condoms).

Indeed, even the Georgetown University-based Standard Days Method (CycleBeads™), available through UNFPA to international NGOs, markets it for “women who keep track of their cycle days and do not have unprotected intercourse on Days 8 through 19 of their cycles” (emphasis added).[90]https://www.cyclebeads.com/research (accessed 05/07/2017), referring to the seminal article Marcos Arévalo, Victoria Jennings, and Irit Sinai, “Efficacy of a New Method of Family Planning: The Standard Days Method,” Contraception 65, no. 5 (2002): 333–38; but see observations in Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness.” On the official website of SDM/CycleBeads™, it is explained that

If a woman wants to prevent pregnancy using this family planning method, then she should avoid intercourse or use a back-up birth control method such as condoms during her fertile days (days 8-19).[91]https://www.cyclebeads.com/how-family-planning-method-helps-to-plan-pregnancy-or-prevent-pregnancy (accessed 05/07/2017). Same applies to the Symptothermal Method. One of its guides notes: “With the STM, during the fertile days, men have to learn to either observe some days of sexual abstinence (appreciated by many women), or to use a condom.” R. Harri Wettstein and Christine Bourgeois, The Complete Symptothermal Guide. Ecological Birth Control & Pregnancy Achievement, p. 17.

Similarly, the two seminal studies about the efficacy of the STM and the SDM respectively include not only users abstaining during the fertile period, but also those using barrier methods.[92]Marcos Arévalo, Victoria Jennings, and Irit Sinai, “Efficacy of a New Method of Family Planning: The Standard Days Method,” Contraception 65, no. 5 (2002): 333–338; Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.” Indeed, the reference article with regard to the effectiveness of the Symptothermal Method, based on a 22-years European longitudinal study, found that the majority (509 out of 900 couples, or 56.5%) of participating couples had protected intercourse (i.e. used a barrier method) during the fertile window, with only 35.7% (322 out of 900) abstaining.[93]Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.” Only “in more than a third [of the cycles analysed] the STM was used with abstinence during the fertile time.” This despite the majority of participants in that longitudinal study being likely more motivated than average to use that method, as observed by the lead investigator, himself a Catholic and a promoter of the STM.[94]As noted elsewhere, Frank-Herrmann et al. reflected that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Ibid.

2) One of the main reasons why it is highly unlikely FAMs will be used to know when to abstain from sex, rather than when to use barrier methods, is that to abstain every month during the fertile window requires a significant change in sexual behaviour. The evidence is that such a change is rejected in the vast majority of cases.

Interventions to change sexual behaviour have consisted in providing adequate sex education. A considerable amount of evidence from the USA suggests that “abstinence-only” sex education curricula are not effective in changing sexual behaviour.[95]“[C]ouples with fertility awareness knowledge are more likely to use condoms more consistently in the fertile time. Most cited NFP studies do not report the quantity of additional barrier method use, yet we have learnt from the European study that it exists to a certain extent within all communities that use NFP methods.” Ibid.Significantly, the vast majority of such programs has not been effective in changing sexual behaviour in comparison to “comprehensive” sex education, where often an emphasis on abstinence is complemented with information on modern contraceptives. Specifically, a meta-analysis of 98 interventions (51,240 participants) from 67 studies concluded that

interventions were successful at reducing the frequency of sexual behavior when (1) they were implemented with adolescents who were institutionalized, (2) had no focus on abstinence as a goal, (3) had greater numbers of intervention sessions, and (4) had control conditions with non-HIV content (eg, general health promotion); the latter predictor narrowly missed conventional statistical significance. On average, interventions did not succeed when the intervention focused on abstinence….[96]Blair T. Johnson et al., “Interventions to Reduce Sexual Risk for Human Immunodeficiency Virus in Adolescents: A Meta-Analysis of Trials, 1985-2008,” Archives of Pediatrics & Adolescent Medicine 165, no. 1 (January 3, 2011): 77–84, doi:10.1001/archpediatrics.2010.251, emphasis added. See also e.g. Laura Duberstein Lindberg and Isaac Maddow-Zimet, “Consequences of Sex Education on Teen and Young Adult Sexual Behaviors and Outcomes,” Journal of Adolescent Health 51, no. 4 (October 1, 2012): 332–38, doi:10.1016/j.jadohealth.2011.12.028.

The same results have been found again and again elsewhere in the world.[97]Pascaline Dupas, “Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya,” American Economic Journal: Applied Economics 3, no. 1 (January 1, 2011): 1–34, doi:10.1257/app.3.1.1: “Providing information on the relative risk of HIV infection by partner’s age led to a 28 percent decrease in teen pregnancy, an objective proxy for the incidence of unprotected sex. […] In contrast, the official abstinence-only HIV curriculum had no impact on teen pregnancy.” Again, “Many sub-Saharan African countries have incorporated HIV/ AIDS education in their school curriculum, but the great majority of those curricula are limited to risk avoidance information; they aim at completely eliminating pre-marital sex by promoting abstinence until marriage. They omit to provide risk reduction information, for example that condom use reduces the risk of HIV transmission.” “Using data from a randomized field experiment involving 328 primary schools, this paper compares the effects of providing abstinence-only versus detailed HIV risk information on teenage sexual behavior.” However, “The results suggest that the teacher training on the national HIV/AIDS curriculum had no effect on the likelihood that teenage girls started childbearing within a year, suggesting no reduction in risky behavior. In contrast, the relative risk information led to a 28 percent decrease in the likelihood that girls started childbearing within a year, suggesting an important decrease in the incidence of unprotected sex among those girls […].

These results suggest that the behavioral choices of teenagers are not responsive to risk avoidance messages, but are responsive to information on the relative riskiness of potential partners. Overall, the relative risk information led to an increase in reported sexual activity, but to a decrease in unsafe sex. This suggests that teenage sexual behavior is more elastic on the margin of what type of sex to engage in—the choice of partner and the choice of protection level—than on the margin of whether to engage in sex or not. These results suggest that, in the fight against HIV, risk reduction messages might be more effective than risk avoidance messages.” Interestingly, “Prior evidence on the effectiveness of sexual health education in Africa is almost nonexistent.”

See also John S. Santelli, Ilene S. Speizer, and Zoe R. Edelstein, “Abstinence Promotion under PEPFAR: The Shifting Focus of HIV Prevention for Youth,” Global Public Health 8, no. 1 (2013): 1–12: “Abstinence-until-marriage (AUM) – strongly supported by religious conservatives in the USA – became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President’s Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.” Also, Virginia A. Fonner et al., “School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis,” PLOS ONE 9, no. 3 (March 4, 2014): e89692, doi:10.1371/journal.pone.0089692: “Importantly, no individual study included in meta-analysis, including abstinence-only, abstinence-plus, and comprehensive school-based sex education interventions, found detrimental effects of school-based sex education on increased risky sexual behavior. This finding is notable given that some argue programs including information on abstinence and safe sex strategies give mixed messages to students and may promote sexual activity [91].

Comprehensive school-based sex education comprised the majority of interventions included in this review despite extensive attempts to identify abstinence-only and abstinence-plus interventions.Given PEPFAR’s past emphasis on abstinence-only and abstinence-plus interventions [4], it is surprising to find so few peer reviewed evaluations of this strategy that met our inclusion criteria. The uneven distribution in comprehensive versus abstinence-only or abstinence-plus interventions made it difficult to compare the effectiveness of these intervention types. Additionally, many abstinence-only or abstinence-plus interventions measured outcomes related to HIV-knowledge but did not include outcomes related to sexual risk behavior, such as condom use or number of sexual partners, thus rendering comparisons to comprehensive sex education unfeasible. These findings are similar to those of parallel systematic reviews and meta-analyses comparing the effectiveness of comprehensive sex education and abstinence-only interventions, which found that although comprehensive sex education interventions were effective at reducing high-risk sexual behavior, no conclusion could be drawn from interventions emphasizing abstinence due to the small number of eligible studies and inconsistent findings [10]” (emphases added).

It has also been argued that denying accurate information with regard to contraceptives in many abstinence-only sex education programs violates fundamental human rights guaranteed by international law, and specifically the rights “to information, to education, to be free of arbitrary and unjust discrimination, and to health, among other rights — because silence or misinformation on condom effectiveness not only violates speech and information rights but also denies young people a means through which they could protect their right to health.” Alice M. Miller and Rebecca A. Schleifer, “Through the Looking Glass: Abstinence-Only-until-Marriage Programs and Their Impact on Adolescent Human Rights,” Sexuality Research & Social Policy 5, no. 3 (September 1, 2008): 28, doi:10.1525/srsp.2008.5.3.28; also Rebecca Schleifer and Joanne Csete, “Ignorance Only: HIV/AIDS, Human Rights, and Federally Funded Abstinence-Only Programs in the United States. Texas: A Case Study,” Human Rights Watch 14, no. 5 (2002), http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/2800. More evidence is provided in Appendix 2.

In light of that evidence, even were FAMs requiring periodic abstinence to be promoted worldwide and coupled with an abstinence-only sex-education course of suitable length, they would be highly unlikely to bring to a widespread change of sexual behaviour.

Quite simply, the reason why such a change in sexual behaviour is unlikely is that it would run against the experiences and insights of the vast majority of people all over the world, namely:

  • that sexual intercourse has many more meanings and purposes than reproduction alone, and that each and every act of sexual intercourse need not be open to procreation;[98]See Statement, §8:

    “The Bible identifies a variety of morally worthy non-conceptive motives for engaging in sexual intercourse. This is confirmed by evolutionary biology and modern sociological surveys, among other disciplines.

    Those non-conceptive motives for sexual intercourse include pleasure, love, comfort, celebration and companionship. They are morally worthy even without the concurrent occurrence of either a ‘procreative significance’ of the biological ‘laws of conception,’ or the agents’ procreative intention.

    The use of modern contraceptives can facilitate one or more of sexual intercourse’s non-conceptive meanings, as well as have additional morally worthy purposes – e.g. family planning, following the requirements of responsible parenthood (HV §10).

    Therefore, the decision to use modern contraceptives can be taken for a variety of morally worthy motives, and so it can be ethical.”

  • that “responsible parenthood” is a moral duty, and it requires family planning (in this, people agree with the Catholic position);
  • that family planning via modern contraceptives is no more “artificial” (and no less “natural”) than contraceptive methods based on periodic abstinence during the fertile window;
  • that both categories of technical means for family planning, when used with the same intention of avoiding procreation – and with all other things being equal – are morally equivalent.

It is arguably for those reasons that the vast majority of people across the world do not perceive using modern contraceptives to be always immoral when used for family planning. As a consequence, regardless of how accurate, easy-to-use, and affordable FAMs will become, it is highly unlikely that people will ever be convinced of the need “periodically abstain” rather than using modern contraceptives during the fertile window simply because of a supposed moral duty to always preserve procreation as the intrinsic finality of each and every act of sexual intercourse, and because modern contraceptives would be supposedly “artificial” and “against nature”, while Fertility Awareness Methods would not.

Finally, in this connection, it should be recalled that FAMs are also “unnatural” or “artificial” in two ways. First, because they artificially time sexual intercourse so as to intentionally avoid procreation. As mentioned earlier, that was the very reason why the Doctrinal Commission rejected an amendment to explicitly condemn the “contraceptive arts” because such an expression would include “the method of periodic continence, which often requires technical computations,” and which previous popes had already accepted.

Secondly, FAMs are artificial and unnatural because they submit the supremely human act of conjugal love to biological determinants. Since with NFP intercourse can take place only during days determined by the female cycle, it deprives a couple of the freedom in love-making. A couple can be reunited after a long absence and yet they may be forced to abstain for two weeks because they were reunited “at the wrong time”. As recent research shows, use of FAMs decreases coital frequency, while use of modern contraceptives is associated with higher coital frequency. Hence modern contraceptives better allow the “natural” expression sexual love than methods which artificially and unnaturally constrain such an expression to the biological determinism of the female menstrual cycle and so require sexual abstinence for approximately half the time each cycle.

6) The ongoing development and increased worldwide availability of more effective, easy-to-use, and affordable contraceptives is another factor that will hamper usage of Fertility Awareness Methods to abstain, rather than have protected intercourse, during the fertile window.

Among the recent developments, noteworthy is the rapid rise of Long-Acting Reversible Contraceptives (LARCs, which include injections, intrauterine devices [IUDs] and subdermal hormonal implants). LARCs are the most effective reversible methods of contraception because they do not depend on patient compliance. So their “typical use” failure rates, at less than 1% per year, are about the same as “perfect use” failure rates.

Another significant change is the ongoing development of new male contraceptives, both hormonal and mechanical (the latter represented for instance by Vasalgel/RISUG [“Reversible Inhibition of Sperm Under Guidance”]).[99]See a selected list at https://www.malecontraceptive.org/prospective/. Also: “At present, male controlled methods include condoms and vasectomy. These are not optimal or generally acceptable because of the high user failure rate with condoms and the difficult reversibility of vasectomy. In spite of the shortcomings, one third of couples using contraception worldwide relies on a male method. These observations would suggest that if new contraceptives for men were available, many couples worldwide would use them.”

In the strategy to reduce unintended pregnancies and abortions, the current recommendation – shared by USAID and UNFPA – is to “use more effective contraceptive methods, without increasing total contraceptive prevalence rate,” by encouraging the following changes:

  • All traditional method users switch to a short-term modern method.
  • Women using contraception for birth spacing switch to a short-term modern method, and women using contraception for limiting births switch to a long-acting modern method.
  • All non-long-acting and permanent method users switch to a reversible long-acting method of contraception.
  • All spacers [i.e. women who want to delay a new pregnancy, in order to space their children] switch to a long-acting method, while all limiters [i.e. women who do not want to have any more children] switch to a permanent method.[100]Sarah EK Bradley, Trevor Croft, and Shea Oscar Rutstein, “The Impact of Contraceptive Failure on Unintended Births and Induced Abortions: Estimates and Strategies for Reduction,” DHS Analytical Studies (ICF Macro for USAID, 2011), http://iussp.org/sites/default/files/event_call_for_papers/Contraceptive%20Failure%20Unintended%20Births%20-%20Bradley%20Croft%20Rutstein%20-%20IUSSP%202013.pdf.

As it has been observed, modern contraceptives are there to allow the free expression of sexual love whenever mutually desired. The above strategies would allow doing so in a much better way than periodic abstinence.

In summary, it is certainly useful to increase knowledge of the monthly fertility cycle across the world. FAMs are ways of tracking the monthly fertility cycle. Their use should therefore be encouraged.[101]Even so, it is important to remember that “Among users with correct knowledge of the timing of ovulation, reported failure was 12% lower than among those with incorrect or no knowledge. [T]his is a surprisingly weak link, which suggests that factors other than the wife’s knowledge of the correct time to abstain from intercourse are important. For instance, husband’s compliance may well be crucial. This key result provides only a modest justification for increasing efforts to disseminate basic information about sexual and reproductive physiology, including facts about the menstrual cycle. It is unlikely that more than a minority of couples who try PA consult health staff prior to use and thus any restriction of information to health institutions would have little impact. Therefore, informational activities would need to be multi-sectoral, including in-school curricula, electronic and print media.” Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.” However, it is highly likely that the increased knowledge of the monthly fertility window will be used in order to more accurately target the use of barrier methods of contraceptives, rather than to abstain, for the reasons highlighted earlier.

5.5. Some concluding considerations on FAMs.

6. Potential Impact of the Catholic Church’s Change of Policy

Of the women in developing countries who do not use modern contraceptives, close to one in four say that they do not use modern contraceptives because they or others close to them oppose them. That is generally due to cultural or religious objections against them.[102]https://www.guttmacher.org/news-release/2016/new-study-examines-why-women-developing-countries-who-wish-avoid-pregnancy-do-not. The evidence suggests that the role of the Catholic Church in this regard is not insignificant.[103]Johannes Stroebel and Arthur Van Benthem, “The Power of the Church-The Role of Roman Catholic Teaching in the Transmission of HIV,” Available at SSRN 2018071, 2012, http://pages.stern.nyu.edu/~jstroebe/research/pdf/PowerChurchRomanCatholicKenya.pdf.

Because of the extent of the Catholic Church’s health provision, those negative consequences have a worldwide impact:

  • Approximately one-fourth of health care facilities worldwide are Catholic and therefore cannot, by statute, offer even non-abortifacient contraceptives for the purpose of family planning.[104]See e.g. Catholic Bishops Conference of the Philippines, “Moral Norms for Catholic Hospitals and Catholics in Health Services” (1973), http://cbcponline.net/v2/?p=188 (accessed on 20/10/2016).

In the developing world they are often the only providers of health care for large sections of the population. Anybody relying on them cannot ordinarily access other reproductive health services.

  • What Catholic Church officials say on the issue significantly influences the sexual behavior and reproductive choices of many Catholics in the developing world.

This is both because of the trust and authority they enjoy as spiritual leaders, and because of their power to shape the concrete policies of Catholic health care facilities.

Catholic hospitals and individuals cannot in theory provide contraceptives for family planning. Some still do, but have to do so secretly.

As a consequence, millions of poor people are denied access to modern non-abortifacient family planning services because of the current official stance of the Catholic Church.

A case in point is the very public “condom scandal” that rocked the Knights of Malta. Their charity arm, Malteser International, was forced to change its policy of distributing condoms to sex workers in some developing countries because management felt it was against current papal teaching and Vatican directives.

The same happens regularly at the individual level. A case in point is the charity work by Fr. Heinz Kulüke, since 2012 superior general of the SVD missionaries. Fr. Kulüke had been helping the poor in and around Cebu since 1986 and, on an almost nightly basis he distributed condoms to women and girls involved in prostitution in the Barangay Kamagayan, a red light slum area of Cebu City.[105]Interview with Father Heinz Kulüke, Cebu City, Philippines (December 11, 2005), as reported in The Protection Project, International Child Sex Tourism. Scope of the Problem and Comparative Case Studies (Washington, D.C.: Johns Hopkins University, Paul H. Nitze School of Advanced International Studies, 2007), pp. 150-51, retrieved from http://www.protectionproject.org/wp-content/uploads/2010/09/JHU_Report.pdf. But he had to do so without any institutional support from the Catholic Church. Quite the contrary in fact: in 2010, charges were brought against him to the local bishop alleging that he was distributing condoms, and that that was against church teaching. He survived the attack, and went on to be elected Superior General of the SVD order.

The point of attention of those two well known cases is that unless the Catholic prohibition on using contraceptives for both prophylactic and family planning purposes is officially abandoned, Catholic individuals and institutions will continue being hampered in what they can do publicly, with very severe consequences for millions of people.

7. A Revision of HV would be received well by the vast majority of Catholics

It would boost, rather than damage, the moral authority of the magisterium in the eyes of the vast majority of people, whether Catholics, non-Catholic Christians, and non-Christians in general.

Only a small minority of Catholics would be upset, namely very conservative Catholics who accept and practice HV’s conclusions (recall the worldwide usage of periodic abstinence methods is less than 3%, and it is unknown which percentage of that figure are Catholic users who use FAMs to obey HV).

To attempt and preserve the status quo, for fear of the conservative minority, is the “safer” option only apparently: in reality it will continue the alienation of Catholics from the Church, and will not stop the issue from resurfacing in the media regularly. The magisterium’s authority will continue to suffer from it, especially with regard to what it says about sexual morality.

To minimise the shock to the conservative minority, a few things can be done.

First, act with regard to the prophylactic use of condoms. That will in itself get rid of the perceived absoluteness of HV’s prohibition, and prepare the ground for further advances.

Second, set up an independent study commission, to show that any conclusion has the backing of the relevant experts (including the experience of laypeople).

It is important that the selection of the commission members be impartial, based exclusively on their relevant expertise.

Third, emphasise the positive effects of using contraceptives. They were ignored by HV §17, which only focused on presumed negative effects (sexual promiscuity, mistreatment of women, etc.).

Fourth, liaise with the wider theological community worldwide to present any future revision to the media, and to help explain it to them. The Wijngaards Institute is happy to offer its support in that regard.

 

 

 

Appendix 1. Can Abstinence-Only Sex Ed be a Solution Instead?

Public statements by popes and bishops in the past twenty years or so show a significant shift in the arguments used to justify the prohibition against “artificial” contraceptives. HV was clear that “artificial” contraceptives are “intrinsically evil” because they go against nature.

Now, however, this argument is largely passed under silence; instead, the argument which is often repeated is the following:

1) access to contraception increases risk-taking and promiscuity by “enabl[ing] sexual encounters and relationships that would not have happened without it”;

2) Modern contraceptives can fail: their failure rate in the real world, due to incorrect or inconsistent use, is significant;

3) The sexual promiscuity enabled by modern contraceptives, and their real failure rate, is what causes both unintended pregnancies and STIs (e.g. HIV, Zika, etc);

4) The only solution is abstinence: complete abstinence before marriage, and periodic abstinence within marriage.

In summary: modern contraceptives increase a risky sexual behaviour, can fail, and so they increase both the number of unintended pregnancies and the spread of STIs.

In other words, there has been a shift in the arguments used by the hierarchy, and particularly the last two popes, to defend the absolute prohibition of “artificial” contraceptives. Nowadays, in public speeches and interviews, references to the affirmation that “artificial” contraceptives are “intrinsically evil” because against nature are generally avoided. Instead, that prohibition is now supported mostly by arguing that 1) modern contraceptives enable riskier sexual behaviour than would otherwise be possible without them, 2) that they have a relatively high failure rate, and, as a consequence of those two points, 3) that they increase transmission of STIs, unwanted pregnancies, abortions etc.; and the conclusion is drawn that the only solution is abstinence.

These arguments are unfounded and deserved a detailed reply.

[1] Does access to contraception increase risk-taking and promiscuity?

The evidence does not support this hypothesis. The USA provide an ideal testing ground for the first hypothesis, because for decades it has run extensively two types of sex education curricula — so-called “comprehensive” programs that promote abstinence but also teach about contraceptives (also known as “Risk Reduction” programs), and programs that promote only abstinence, many of which cast contraceptive use in a negative light, if it is included at all (also known as “Risk Avoidance” programs).

The amount of evidence available is impressive. A number of large studies have shown that the programs which are proven to positively change teen behaviour belong to the “Risk Reduction” comprehensive category – a positive change which results in a significantly lower percentage of both unintended pregnancies and abortions. In contrast, the vast majority of risk-avoidance, “abstinence only” programs have not been shown to lower unintended pregnancies or abortions in comparison to control groups which were not taught any sex education at all. Below are some of the key studies:

Teaching about contraception [is] not associated with increased risk of adolescent sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education.[106]Pamela K. Kohler, Lisa E. Manhart, and William E. Lafferty, “Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy,” Journal of Adolescent Health 42, no. 4 (2008): 344–351.K. Underhill, D. Operario, and P. Montgomery, “Abstinence-Only Programs for HIV Infection Prevention in High-Income Countries,” The Cochrane Database of Systematic Reviews, no. 4 (October 17, 2007): CD005421, doi:10.1002/14651858.CD005421.pub2. “Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective, but generalizability may be limited to US youth. Should funding continue, additional resources could support rigorous evaluations with behavioral or biological outcomes. More trials comparing abstinence-only and abstinence-plus interventions are needed.”

In fact,

Study results [a meta analysis of “56 studies that assessed the impact of such [sex ed] curricula (8 that evaluated 9 abstinence programs and 48 that evaluated comprehensive programs) on adolescents’ sexual behaviour”] indicated that most abstinence programs did not delay initiation of sex and only 3 of 9 had any significant positive effects on any sexual behavior. In contrast, about two thirds of comprehensive programs showed strong evidence that they positively affected young people’s sexual behavior, including both delaying initiation of sex and increasing condom and contraceptive use among important groups of youth. Based on this review, abstinence programs have little evidence to warrant their widespread replication; conversely, strong evidence suggests that some comprehensive programs should be disseminated widely.[107]Highly cited study Douglas B. Kirby, “The Impact of Abstinence and Comprehensive Sex and STD/HIV Education Programs on Adolescent Sexual Behavior,” Sexuality Research & Social Policy 5, no. 3 (September 1, 2008): 18, doi:10.1525/srsp.2008.5.3.18. Prof. Douglas Bernard Kirby was one of the world’s leading experts on school and community programs to reduce sexual risk taking, and dedicated his career to promoting sexual and reproductive health among young people through his writing, teaching, and research. . He authored over 150 articles, chapters and monographs on these programs, and frequently spoke nationally and internationally on his work. He served as a scientific adviser to the CDC, USAID, WHO, UNFPA, UNESCO, and the National Campaign to Prevent Teen and Unplanned Pregnancy.

Again, there is no evidence that availability of Emergency Contraception results in an increased sexual risk behaviour. “[A] substantial body of research demonstrates that there is no relationship between availability of EC [Emergency Contraception] and increased sexual risk behaviour.”[108]“Though emergency contraception (EC) is only intended for occasional use, concerns have been raised that increasing access to EC (e.g., by making it available without prescription over-the-counter) would lead to increased sexual risk-taking. For example, if EC was easily accessible, would women use contraception less regularly, more readily engage in casual sex, or be at increased risk of contracting STIs? There is no scientific evidence to substantiate these concerns. To the contrary, a substantial body of research demonstrates that there is no relationship between availability of EC and increased sexual risk behaviour.” DC Weiss et al., “Does Emergency Contraception Promote Sexual Risk-Taking?” (Bixby Center for Global Reproductive Health, 2008), https://bixbycenter.ucsf.edu/sites/bixbycenter.ucsf.edu/files/DoesECPromoteSexRiskTaking_2008.pdf.

A meta-analysis of 98 interventions (51,240 participants) from 67 studies concluded that

interventions were successful at reducing the frequency of sexual behavior when (1) they were implemented with adolescents who were institutionalized, (2) had no focus on abstinence as a goal, (3) had greater numbers of intervention sessions, and (4) had control conditions with non-HIV content (eg, general health promotion); the latter predictor narrowly missed conventional statistical significance. On average, interventions did not succeed when the intervention focused on abstinence and when control groups included HIV-related content (eg, in diluted form).[109]Blair T. Johnson et al., “Interventions to Reduce Sexual Risk for Human Immunodeficiency Virus in Adolescents: A Meta-Analysis of Trials, 1985-2008,” Archives of Pediatrics & Adolescent Medicine 165, no. 1 (January 3, 2011): 77–84, doi:10.1001/archpediatrics.2010.251, my emphasis. See also e.g. Lindberg and Maddow-Zimet, “Consequences of Sex Education on Teen and Young Adult Sexual Behaviors and Outcomes.”

The same results have been found again and again elsewhere in the world.[110]Pascaline Dupas, “Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya,” American Economic Journal: Applied Economics 3, no. 1 (January 1, 2011): 1–34, doi:10.1257/app.3.1.1: “Providing information on the relative risk of HIV infection by partner’s age led to a 28 percent decrease in teen pregnancy, an objective proxy for the incidence of unprotected sex. […] In contrast, the official abstinence-only HIV curriculum had no impact on teen pregnancy.” Again, “Many sub-Saharan African countries have incorporated HIV/ AIDS education in their school curriculum, but the great majority of those curricula are limited to risk avoidance information; they aim at completely eliminating pre-marital sex by promoting abstinence until marriage. They omit to provide risk reduction information, for example that condom use reduces the risk of HIV transmission.” “Using data from a randomized field experiment involving 328 primary schools, this paper compares the effects of providing abstinence-only versus detailed HIV risk information on teenage sexual behavior.” However, “The results suggest that the teacher training on the national HIV/AIDS curriculum had no effect on the likelihood that teenage girls started childbearing within a year, suggesting no reduction in risky behavior. In contrast, the relative risk information led to a 28 percent decrease in the likelihood that girls started childbearing within a year, suggesting an important decrease in the incidence of unprotected sex among those girls […].

These results suggest that the behavioral choices of teenagers are not responsive to risk avoidance messages, but are responsive to information on the relative riskiness of potential partners. Overall, the relative risk information led to an increase in reported sexual activity, but to a decrease in unsafe sex. This suggests that teenage sexual behavior is more elastic on the margin of what type of sex to engage in—the choice of partner and the choice of protection level—than on the margin of whether to engage in sex or not. These results suggest that, in the fight against HIV, risk reduction messages might be more effective than risk avoidance messages.” Interestingly, “Prior evidence on the effectiveness of sexual health education in Africa is almost nonexistent.”

See also John S. Santelli, Ilene S. Speizer, and Zoe R. Edelstein, “Abstinence Promotion under PEPFAR: The Shifting Focus of HIV Prevention for Youth,” Global Public Health 8, no. 1 (2013): 1–12: “Abstinence-until-marriage (AUM) – strongly supported by religious conservatives in the USA – became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President’s Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.” Also, Virginia A. Fonner et al., “School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis,” PLOS ONE 9, no. 3 (March 4, 2014): e89692, doi:10.1371/journal.pone.0089692: “Importantly, no individual study included in meta-analysis, including abstinence-only, abstinence-plus, and comprehensive school-based sex education interventions, found detrimental effects of school-based sex education on increased risky sexual behavior. This finding is notable given that some argue programs including information on abstinence and safe sex strategies give mixed messages to students and may promote sexual activity [91].

Comprehensive school-based sex education comprised the majority of interventions included in this review despite extensive attempts to identify abstinence-only and abstinence-plus interventions.Given PEPFAR’s past emphasis on abstinence-only and abstinence-plus interventions [4], it is surprising to find so few peer reviewed evaluations of this strategy that met our inclusion criteria. The uneven distribution in comprehensive versus abstinence-only or abstinence-plus interventions made it difficult to compare the effectiveness of these intervention types. Additionally, many abstinence-only or abstinence-plus interventions measured outcomes related to HIV-knowledge but did not include outcomes related to sexual risk behavior, such as condom use or number of sexual partners, thus rendering comparisons to comprehensive sex education unfeasible. These findings are similar to those of parallel systematic reviews and meta-analyses comparing the effectiveness of comprehensive sex education and abstinence-only interventions, which found that although comprehensive sex education interventions were effective at reducing high-risk sexual behavior, no conclusion could be drawn from interventions emphasizing abstinence due to the small number of eligible studies and inconsistent findings [10]” (emphases added).

It has also been argued that denying accurate information with regard to contraceptives in many abstinence-only sex education programs interfere with fundamental human rights guaranteed by international law. See e.g. “Ignorance Only : HIV/AIDS, Human Rights, and Federally Funded Abstinence-Only Programs in the United States : Texas : A Case Study. :: Georgetown Law Library,” accessed March 2, 2017, http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/2800. Also Miller and Schleifer, “Through the Looking Glass.”

[S]tudy after study dispute the effectiveness of abstinence-only education for reducing teen pregnancy, delaying the onset of sexual activity, and promoting safer sex practices among youth (March & Fields, 2014). Opponents of abstinence education argue that the rights of young people are violated in respect to reliable sexual health information and resources, free of coercion. […] Earlier, Santelli et al. (2006) conducted a review of abstinence and abstinence-only education showing that it was ineffective in delaying sexual activity. In addition, these programs can have a negative impact on the knowledge and well-being of young people, particularly LGBTIQ and other marginalized youth. Schalet (2011) argues for the recognition of diversity and for comprehensive sexuality education.[111]James J. Ponzetti Jr, ed., Evidence-Based Approaches to Sexuality Education: A Global Perspective (Routledge, 2015).

Does the Percentage of Unintended Pregnancies and STIs Increase More with Access to Modern Contraceptives?

Where free modern contraceptives are available, unwanted pregnancies and abortions have gone consistently down.

A 2003 landmark study, “Relationships Between Contraception and Abortion: A Review of the Evidence,” found that:

After fertility levels stabilized in several of the countries that had shown simultaneous rises in contraception and abortion, contraceptive use continued to increase and abortion rates fell. […] Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly.[112]Cicely Marston and John Cleland, “Relationships between Contraception and Abortion: A Review of the Evidence,” International Family Planning Perspectives, 2003, 6–13. An update to this seminal research is being prepared, and will be sent to the Pontifical Academy for Life as soon as it is ready.

Those findings have been confirmed in several regions of the world. In the USA, for example,

A study [of 9,256 women and adolescents in the St. Louis area between 2007 and 2011] by investigators at Washington University [School of Medicine in St. Louis] reports that providing birth control to women at no cost substantially reduces unplanned pregnancies and cuts abortion rates by a range of 62 to 78 percent compared to the national rate [in the USA].[113]“Access to Free Birth Control Reduces Abortion Rates,” Washington University School of Medicine in St. Louis, October 12, 2012, https://medicine.wustl.edu/news/access-to-free-birth-control-reduces-abortion-rates/. See also the website of that research project, called the “Contraceptive CHOICE Project,” at http://choiceproject.wustl.edu/, and Sue Ricketts, Greta Klingler, and Renee Schwalberg, “Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women,” Perspectives on Sexual and Reproductive Health 46, no. 3 (September 1, 2014): 125–32, doi:10.1363/46e1714.

Modern contraceptives can fail, but the best methods (e.g. IUD, etc) are almost 100% effective, and the current global trend is towards long-acting, reversible, contraceptives (LARCs) which are highly effective, with a <1% failure rate over 5 years of use. They are the most effective reversible methods of contraception because they do not depend on patient compliance. So their typical use failure rates are about the same as perfect use failure rates.

In contrast, FAMs require a very high users’ compliance – a compliance HV itself described as “heroic” and as requiring “ascesis” (HV §§3 and 21) – have a population level typical-use failure rate (estimated 25%) much higher than said LARCs, as well as other best-in-class modern contraceptives. Worldwide, that means that approximately one in four women using traditional methods will conceive in any given year despite trying to avoid a new pregnancy.

  • It has been estimated that approximately 40 percent of pregnancies worldwide are unintended – the result of non-use of contraception, ineffective contraceptive use or method failure.[114]Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.”
  • Accidental pregnancies are mostly among users of traditional methods; substituting traditional method use with modern contraception could therefore reduce contraceptive failures by over 40%. Also, where less-effective family planning methods are commonly used, unplanned pregnancies and, consequently, abortions are likely to occur”;[115]Elisabeth Ahman and Iqbal Shah, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, 6th edition (Geneva: World Health Organization, 2011), http://apps.who.int/iris/bitstream/10665/44529/1/9789241501118_eng.pdf.
  • “An increase in contraceptive prevalence and in the use of effective contraceptive methods reduces the incidence of abortion. This is empirically supported by data from developed countries.”[116]World Health Organization, “Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality in 2008 (6th Edition),” 2011, http://apps.who.int/iris/handle/10665/44529.
  • Abortion prevalence is higher where the unmet need for family planning is high, contraceptive prevalence is low, and less-effective contraceptive methods prevail.[117]Ibid. The report continues: “Reports from Uganda and Pakistan describe the contraception-abortion paradox. “Increasingly, abortion, which remains illegal in Uganda, is becoming an important method of fertility regulation. Out of the 5.3 million sexually active female population of Uganda, only 23% (18% modern) are currently using contraception, implying that 4.2 million are sexually active but are not using contraception. Lack of contraceptive use contributes to unwanted or mistimed pregnancies, which are in turn linked to unsafe abortion, and consequent maternal mortality and morbidity.” From Pakistan, Sathar reports on stagnating fertility levels ‘High unmet need for contraception and the proportion of births that are unplanned confirm that a large fraction of currently married women in Pakistan are at risk of an unwanted pregnancy and potentially of undergoing an abortion.’”
  • “a study of 12 developing countries show[s] that in those countries the shift to modern method use could reduce induced abortion levels by some 30% on average; and a shift from using traditional to modern methods can, on average, reduce abortion by over 20%. This suggests that the best option for reducing numbers of abortions is expanded family planning counselling and services to encourage use of modern contraceptive methods.”[118]Ibid.

The evidence is that by far the most effective way to lower unintended pregnancies and abortions is by providing access to effective modern contraceptives.

References   [ + ]

1. Carlo Maria Martini and Georg Sporschill, Night Conversations with Cardinal Martini: The Relevance of the Church for Tomorrow (Paulist Press, 2013), 93-94.
2. John Cleland and Mohamed M. Ali, “Sexual Abstinence, Contraception, and Condom Use by Young African Women: A Secondary Analysis of Survey Data,” Lancet (London, England) 368, no. 9549 (November 18, 2006): 1788–93, doi:10.1016/S0140-6736(06)69738-9; referring to Stephane Hugonnet et al., “Incidence of HIV Infection in Stable Sexual Partnerships: A Retrospective Cohort Study of 1802 Couples in Mwanza Region, Tanzania.,” Journal of Acquired Immune Deficiency Syndromes (1999) 30, no. 1 (2002): 73–80; Maria Quigley et al., “Sexual Behaviour Patterns and Other Risk Factors for HIV Infection in Rural Tanzania: A Case–control Study,” Aids 11, no. 2 (1997): 237–248.
3. “Note on the Banalization of Sexuality – Regarding certain interpretations of Light of the Worldhttp://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20101221_luce-del-mondo_en.html
4. See J. Stroebel and A. Van Benthem, “The Power of the Church: The Role of Roman Catholic Teaching in the Transmission of HIV” (2012), http://pages.stern.nyu.edu/~jstroebe/research/pdf/PowerChurchRomanCatholicKenya.pdf (accessed on 06/02/2017): “the archbishop’s comments increased the probability of condom use at last sexual intercourse by 3.3 percentage points for married Catholics in Lele’s archdiocese. For the subgroup of those with condom access, the effect is 7.0 percentage points. These results are robust to a number of econometric specifications, statistically significant, and large relative to an average condom use rate of 13.2% for all respondents in the 2008-09 DHS.”
5, 27. Lat. “coniugalem actum, sua fecunditate ex industria destitutum, ideoque intrinsece inhonestum [est]” HV §14.
6. Lat. “respuendus est actus, qui, cum coniugale commercium vel praevidetur vel efficitur vel ad suos naturales exitus ducit, id tamquam finem obtinendum aut viam adhibendam intendat, ut procreatio impediaturHV §14.
7. Si infitiandum non est, coniuges in utroque casu mutua certaque consensione prolem ob probabiles rationes vitare velle, atque pro explorato habere liberos minime esse nasciturosHV §16.
8. “This particular doctrine […] is based on the inseparable connection, established by God, which man on his own initiative may not break, between the unitive significance and the procreative significance which are both inherent to the marriage act” (HV §12).
9. Adrian Thatcher, God, Sex, and Gender: An Introduction (Oxford: John Wiley & Sons, 2011), p. 219.
10. HV §13 rightly notes that to “impair[] the capacity to transmit life” of the act of sexual intercourse is to “depriv[e] it, even if only partially, of its meaning and purpose [or finality: Lat. “significationem et finem”].”
11. See the two “modi” or amendments referred to below, in the section “A Revision of HV Would Preserve Key Elements of Continuity with Traditional Teaching”.
12. Kelly Bulkeley, The Wondering Brain: Thinking about Religion With and Beyond Cognitive Neuroscience (2004), p. 60.
13. See a concise account in Adrian Thatcher, God, Sex, and Gender: An Introduction (John Wiley & Sons, 2011), https://books.google.co.uk/books?hl=en&lr=&id=gtF38d2YURcC&oi=fnd&pg=PR9&dq=God,+Sex+and+Gender:+An+Introduction&ots=LuMC59kqn-&sig=HI7R2rby2h0KOHd4bm2S2XBWAyI.
14. Irina Pollard, “Fertility Awareness: The Ovulatory Method of Birth Control, Ageing Gametes and Congenital Malformation in Children,” in Bioscience Ethics (Cambridge, Mass.: Cambridge University Press, 2009), 90–105 (at 94).
15. Richard M. Davidson, Flame of Yahweh: Sexuality in the Old Testament (Hendrickson Publishers Peabody, MA, 2007), pp. 49-50; Phyllis A. Bird, “‘Male and Female He Created Them’: Gen 1: 27b in the Context of the Priestly Account of Creation,” Harvard Theological Review 74, no. 02 (1981): 129–160.
16. Davidson, Flame of Yahweh, emphases added.
17. David Instone-Brewer, “Review Article: Richard M. Davidson’s Flame of Yahweh: A Theology of Sexuality in the Old Testament,” Andrews University Seminary Studies 46, no. 2 (2008): 6, emphasis added. Instone-Brewer also observes: “The HB [Hebrew Bible] portrays fertility as a gift to the creation and to humans, whereas the gods of surrounding cultures demanded cultic prostitution or priestly reenactments of divine sexual acts in order to maintain this fertility. Mesopotamian and Canaanite religions in particular demanded that the general population take part in cultic prostitution.”
18. The discussion of these amendments by the commission can be found in Acta Synodalia Sacrosancti Concilii Oecumenici Vaticani II. Vol. IV Pars VII Congregationes Generales CLXV-CLXVIII, Sessio Publica IX-X. (Vatican: Vatican Polyglot Press, 1978), henceforth Acta Synodalia, to which the page numbers of the extracts below refer. See also the analysis in John T. Noonan, “Contraception and the Council,” in The Catholic Case for Contraception. Leading Catholic Authorities Oppose Pope Paul’s Position on Birth Control, ed. Daniel Callahan (London: Macmillan, 1969), 3–18.
19. Modus 56 to GS §49:

d) Post: “uniuntur” (in lin. 32):

– unus [Pater] proponit ut addatur: “in ordine ad generationem”;

– 109 Patres petunt ut addatur: “ad prolis generationem per se apti”; […]

  1. – […] d) Nulla ex his tribus propositionibus videtur admittenda. Non omnes enim actus ad generationem tendunt (cf. sterilitas, tempus ageneseos) […].”

20. In contrast, the 1966 Final Report had rightly observed that “the morality of sexual acts between married people […] does not […] depend upon the direct fecundity of each and every particular act. [It] depends upon the requirements of mutual love in all its aspects [and] is thus to be judged by the true exigencies of the nature of human sexuality.” Acta Synodalia, p. 491.
21. See “modus” 15, amendments a), b), and e) to GS §48:

“a) Quinque [Patres] postulant ut loco: “Ita actu humano“, dicatur: “Ita actu voluntatis legitime manifestato“, ut melius declaretur natura illius actus et ut attendatur ad formam requisitam. […]

  1. d) Unus Pater petit ut loco “actu humano“, dicatur “consensu humano, ne videatur agi de ipso actu coniugali.
  2. e) Decem vero Patres sequentem additionem rogant: “Ita actu humano, quo coniuges sese personaliter in vitae amoris communione tradunt atque accipiunt”, ut vita coniugalis ut integre humana et non tantum biologica appareat.
[…] [Replies of the Mixed Commission] R – a) In textu pastorali praecisio illa iuridica non requiritur. […]
  1. d) Clarum est vocabulum ad consensum referri.
  2. e) Hoc ex ipso contextu elucet.” Acta Synodalia, 476-77.

22. Modus 104 to GS 51:

b) 13 Patres proponunt formulam: “criteriis ut exempli gratia in facultatibus generativis humanae naturae in eadem personae humanae dignitate fundatis.”

  1. c) Quinque petunt ut dicatur: “ex ipsa personae natura et dignitate desumptis”.
[…]
  1. f) Alius: “in eadem personae humanae dignitate atque iuxta naturam ipsorum”. […]
  2. – […] b) Additio videtur superflua, quia agitur de principio generali.
  3. c) et f): Elementa ex utraque hac propositione retinendo, proponitur ut loco: “in eadem personae dignitate fundatis“, dicatur: “ex personae eiusdemque actuum natura desumptis“; quibus verbis asseritur etiam actus diiudicandos esse non secundum aspectum merum biologicum, sed quatenus illi ad personam humanam integre et adaequate considerandam pertinent” (emphasis added). Acta Synodalia, pp. 501-502.

23. See the response to the modus 5 to GS §51: “…non absque utilitate videtur hic mentionem facere de illicitis usibus contra generationem [i.e. “onanism” (onanismus) and “contraceptives” (anti-conceptio)]. Formula dicendi generalis praeferenda videtur locutionis: “artibus anticonceptionalibus“. Nam uterque ex his terminis tum apud scientificos hodiernos tum apud nonnullos alios coaetaneos quadam ambiguitate afficitur. Terminus enim: “artes“, apud easdem personas, rationem factibilium significat ideoque saltem ex obliquo quamdam technicam supponere videtur, ita ut, in hoc contextu, sese etiam extenderet ad sic dictam “methodum continentiae periodicae” (quae computationes saepe technicas requirit ut recte applicari possit), dum eadem personae saepe saepius distinctionem faciunt inter anticonceptionalia, contraceptiva et aconceptiva (ita ut ex damnatione anticonceptionalium non sequatur pro ipsis alia etiam esse improbata). Quibus omnibus perpensis, Commissio proponit ut scribatur: “insuper amor nuptialis saepius egoismo, hedonismo (de suppressione vocabuli: “erotico”: cf. Resp. ad Modum 6 sub c) et illicitis usibus contra generationem profanatur”. Acta Synodalia, pp. 473-74.

Also Noonan, ibid., p. 15: “In this final refusal to speak out on any contraceptive means, the Council refrained from judgment on any of them. It had stated in the introduction to the chapter on marriage that marriage today was profaned by “illicit practice against generation.” But “such practices” were not made precise […]. The Mixed Commission had rejected an effort to say ‘contraceptive arts’ at this point instead of ‘illicit practices.’ It did so for the pointed reason that ‘contraceptive arts’ could include ‘the method of periodic continence, which often requires technical computations’ (m. 51).”

24. HV describes the means of contraception which it regards as illicit by using the noun “artificium” [ET “art”, “method”, “trick,” see §17 (“artificio”)], the adjective “artificiosus” [ET “artificial,” see §7 (“artificiosa”)] and adverb “artificiose” [ET “artificially,” see §16].
25. Modi generales” (proposed general amendments) 67 to GS §50 “De matrimonii fecunditate”: “Unus Pater petit ut totus numerus reficiatur et reducatur ad pauca principia doctrinae catholicae; alius ut clare dicatur amorem coniugalem, independenter ab intentione prolem procreandi, non iustificare actum coniugalem.
  1. – Prima propositio accipi non potest, quia esset contra normas; secunda affirmatio cum doctrina recepta non consonat.” Acta Synodalia, p. 492 (emphasis added).

26. Lat. “…quilibet matrimonii usus ad vitam humanam procreandam per se destinatus permaneat.” HV §11.
28. Cindy M. Meston and David M. Buss, “Why Humans Have Sex,” Archives of Sexual Behavior 36, no. 4 (July 3, 2007): 477–507.
29. As Charles Curran wrote shortly after the publication of HV: “To change the present teaching of the Church would be a case of development and not a direct contradiction. Gregory Baum has compared a development on the birth control issue with the development of the Church’s teaching on religious liberty.”
30. Pope Francis, Amoris Laetitia, §181 (p. 137), available at https://w2.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf.
31. See the recent assessment by two French Jesuits in Grégoire Catta and Bruno Saintôt, “Fécondité : Le Discours Officiel de l’Église Évolue,” Revue Projet, July 4, 2017, http://www.revue-projet.com/articles/2017-07-catta-saintot_fecondite_le-discours-officiel-de-l-eglise-evolue/. Catta and Saintôt quote AL §222: “the use of methods based on the ‘laws of nature and the incidence of fertility’ (Humanae Vitae, 11) are to be promoted, since ‘these methods respect the bodies of the spouses, encourage tenderness between them and favour the education of an authentic freedom’ (Catechism of the Catholic Church, 2370).” They then go on to observe: “The regulation of births by the non-abortive pill can therefore, under certain conditions, also be compatible with respect for the body, tenderness, [and] genuine freedom. It is this relational quality that it is important to promote.”
32. Amy O. Tsui, Raegan McDonald-Mosley, and Anne E. Burke, “Family Planning and the Burden of Unintended Pregnancies,” Epidemiologic Reviews 32, no. 1 (April 1, 2010): 152–74, doi:10.1093/epirev/mxq012: “Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy.”
33. Cicely A. Marston and Kathryn Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?,” Contraception 93, no. 6 (June 1, 2016): 492–97, doi:10.1016/j.contraception.2016.01.006; Cicely Marston and Kathryn Church, “Response to Letters to the Editor from Irit Sinai ‘Standard Days Method Effectiveness: Opinion Disguised as Scientific Review’ and Kelsey Wright, Karen Hardee, and John Townsend ‘The Pitfalls of Using Selective Data to Represent the Effectiveness, Relevance and Utility of the Standard Days Method of Contraception,’” Contraception 94, no. 4 (October 1, 2016): 376–78, doi:10.1016/j.contraception.2016.06.003.
34. Gilda Sedgh, Susheela Singh, and Rubina Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends,” Studies in Family Planning 45, no. 3 (2014): 301–314.
35. Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, “Contraceptive Technologies: Responding to Women’s Needs,” New York: Guttmacher Institute 201, no. 1 (2011), https://live.guttmacher.org/sites/default/files/report_pdf/contraceptive-technologies.pdf.
36. Darroch, Sedgh and Ball (2011).
37. Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.”Darroch, Sedgh, and Ball, “Contraceptive Technologies”: “The remaining [i.e. 18%] unintended pregnancies occurred among the 603 million women who were using a modern contraceptive and conceived because they had difficulty using their method consistently and correctly or because of method failure.”

Susheela Singh and Jacqueline E. Darroch, “Adding It up: Costs and Benefits of Contraceptive Services,” Guttmacher Institute and UNFPA, 2012, http://www.who.int/entity/woman_child_accountability/ierg/reports/Guttmacher_AIU_2012_estimates.pdf?ua=1. use slightly different estimates, noted that in 2012 “Most – 63 million – of the 80 million unintended pregnancies in developing countries [occurred] among the 222 million women [not using] modern contraception,” i.e. among women who either did not use any contraceptive method, or only used traditional methods (including “periodic abstinence” methods). Women exclusively using traditional methods are an estimated 75 million in the developing world.

38. James Trussell, “Contraceptive Efficacy,” in Contraceptive Technology. Nineteenth Revised Edition, ed. Robert Anthony Hatcher et al., Nineteenth Revised Edition, vol. 18 (New York: Ardent Media, 2008), 747–826; comparison table available online at http://www.contraceptivetechnology.org/wp-content/uploads/2013/09/CTFailureTable.pdf.
39. Interventions studies with newer Fertility Awareness Methods (e.g. the Standard Days Method and the Symptothermal Method) using periodic abstinence exclusively during the fertile period have shown improved efficacy rates, see an overview in Günter Freundl, Irving Sivin, and István Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception: IV. Natural Family Planning,” The European Journal of Contraception & Reproductive Health Care 15, no. 2 (April 1, 2010): 113–23, doi:10.3109/13625180903545302. However no randomized controlled trials have been carried out as yet to test their population level typical use effectiveness, including when used exclusively with periodic continence (as distinct from their use with protected intercourse during the fertile window), see David A. Grimes et al., “Fertility Awareness-Based Methods for Contraception: Systematic Review of Randomized Controlled Trials,” Contraception 72, no. 2 (2005): 85–90. The considerable problems concerning those new FAMs are addressed later in this report.
40. “The analysis of PA failure and its consequences was restricted to married or cohabiting women. Data for three countries were omitted because they generated less than 100 episodes of PA use. After these restrictions, a total of 8387 PA-use episodes were available for this analysis. On the basis of single-decrement life-table procedures, the median 12-month probability of pregnancy for the 12 surveys was 23.6 per 100 episodes.” Yan Che, John G. Cleland, and Mohamed M. Ali, “Periodic Abstinence in Developing Countries: An Assessment of Failure Rates and Consequences,” Contraception 69, no. 1 (January 1, 2004): 15–21, doi:10.1016/j.contraception.2003.08.006. See also Chelsea B. Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data: Summary of a Detailed Report,” Contraception 94, no. 1 (July 1, 2016): 11–17, doi:10.1016/j.contraception.2016.03.011, quoted below; Diana Mansour, Pirjo Inki, and Kristina Gemzell-Danielsson, “Efficacy of Contraceptive Methods: A Review of the Literature,” The European Journal of Contraception & Reproductive Health Care 15, no. 1 (February 1, 2010): 4–16, doi:10.3109/13625180903427675.
41. Gilda Sedgh et al., “Abortion Incidence between 1990 and 2014: Global, Regional, and Subregional Levels and Trends,” The Lancet 388, no. 10041 (2016): 258–267.
42. United Nations, Department of Economic and Social Affairs, Population Division (2015). Trends in Contraceptive Use Worldwide 2015 (ST/ESA/SER.A/349), p. 50, available at http://www.un.org/en/development/desa/population/publications/pdf/family/trendsContraceptiveUse2015Report.pdf.
43. The total number of miscarriages and abortions following failure of any contraceptive methods was 1386 (i.e. 25.2% of the total number of conceptions following contraceptive failure of all methods). Of these, 232 or 16.7% were due to contraceptive failure of PA users. See Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.”
44. Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries” (emphasis added). Moreover, “Most of the induced abortions in these countries are illegal and many present a serious health risk to the woman.” Other findings: “in these countries, PA failures accounted for 28% of all contraceptive failures, despite the fact that it is a relatively rarely used method. Its contribution to mistimed and unwanted births is thus considerable. […]

In this sample of countries, 25% of conceptions resulting from contraceptive failure ended in fetal loss. Induced abortions cannot be distinguished from miscarriages loss, but it is reasonable to assume that the majority were induced.”

45. Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness”; Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries”; Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”
46. Jeffrey F. Peipert et al., “Preventing Unintended Pregnancies by Providing No-Cost Contraception,” Obstetrics and Gynecology 120, no. 6 (December 2012): 1291–97; Natalia E. Birgisson et al., “Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review,” Journal of Women’s Health 24, no. 5 (March 31, 2015): 349–53, doi:10.1089/jwh.2015.5191.
47. Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.” Also Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, “Contraceptive Technologies: Responding to Women’s Needs,” New York: Guttmacher Institute 201, no. 1 (2011), https://live.guttmacher.org/sites/default/files/report_pdf/contraceptive-technologies.pdf: “If all women who want to avoid unintended pregnancy were to use modern contraceptives, the number of unintended pregnancies in developing countries would decrease by 71%, from 75 million to 22 million annually. The impact on women, their families and their countries would be great: There would be 22 million fewer unplanned births and 25 million fewer induced abortions, which in turn would result in 15 million fewer unsafe abortions, 90,000 fewer maternal deaths and 390,000 fewer children who would lose their mothers.5 Moreover, because of the reductions in maternal mortality and morbidity, each year women would lose 12 million fewer healthy years of life.” P. D. Blumenthal, A. Voedisch, and K. Gemzell-Danielsson, “Strategies to Prevent Unintended Pregnancy: Increasing Use of Long-Acting Reversible Contraception,” Human Reproduction Update 17, no. 1 (January 1, 2011): 121–37, doi:10.1093/humupd/dmq026; James Trussell et al., “Burden of Unintended Pregnancy in the United States: Potential Savings with Increased Use of Long-Acting Reversible Contraception,” Contraception 87, no. 2 (February 1, 2013): 154–61, doi:10.1016/j.contraception.2012.07.016; Jennifer J. Frost, Laura Duberstein Lindberg, and Lawrence B. Finer, “Young Adults’ Contraceptive Knowledge, Norms and Attitudes: Associations with Risk Of Unintended Pregnancy,” Perspectives on Sexual and Reproductive Health 44, no. 2 (June 1, 2012): 107–16, doi:10.1363/4410712; Peipert et al., “Preventing Unintended Pregnancies by Providing No-Cost Contraception”; Birgisson et al., “Preventing Unintended Pregnancy.” Similarly, the evidence says that the best way to cut abortion rates does not seem to be making it illegal.
48. Gilda Sedgh and Rubina Hussain, “Reasons for Contraceptive Nonuse among Women Having Unmet Need for Contraception in Developing Countries,” Studies in Family Planning 45, no. 2 (2014): 151–169; Gilda Sedgh, Lori S. Ashoford, and Rubina Hussain, “Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method” (The Guttmacher Institute, 2016), http://repositorio.gire.org.mx/handle/123456789/2049. Martha Campbell, Nuriye Nalan Sahin-Hodoglugil, and Malcolm Potts, “Barriers to Fertility Regulation: A Review of the Literature,” Studies in Family Planning 37, no. 2 (2006): 87–98.
49. Pollard, “Fertility Awareness: The Ovulatory Method of Birth Control, Ageing Gametes and Congenital Malformation in Children.”
50. Toby Ord, “The Scourge: Moral Implications of Natural Embryo Loss,” The American Journal of Bioethics 8, no. 7 (2008): 12–19; Toby Ord, “Response to Open Peer Commentaries on ‘The Scourge: Moral Implications of Natural Embryo Loss,’” The American Journal of Bioethics 8, no. 7 (2008): W1–W3.
51. G. Teklenburg et al., “The Molecular Basis of Recurrent Pregnancy Loss: Impaired Natural Embryo Selection,” MHR: Basic Science of Reproductive Medicine 16, no. 12 (December 1, 2010): 886–95.
52. “Clinically recognized pregnancy loss [i.e. after a successful embryo implantation], is usually quoted as 15-20%. It is this clinical fraction of failed pregnancies that has been extensively studied cytogenetically and in which a chromosome abnormality rate of at least 50% has been established. This contrasts markedly with a 5% chromosome abnormality rate found in stillbirths, illustrating clearly the natural in utero selection process that eliminates 95% of chromosomally unbalanced conceptions. [I]t can be seen that 50-60% of developmental anomalies at birth are of unknown etiology while known causes can be assorted into chromosomal aberrations, mutant genes and environmental factors. Of the known categories, 20-25% are multifactorial inheritances.” See also Ibid.
53. See bibliography in Appendix.
54. See most recently Cicely Marston and Kathryn Church, “Response to Letters to the Editor from Irit Sinai ‘Standard Days Method Effectiveness: Opinion Disguised as Scientific Review’ and Kelsey Wright, Karen Hardee, and John Townsend ‘The Pitfalls of Using Selective Data to Represent the Effectiveness, Relevance and Utility of the Standard Days Method of Contraception’.,” Contraception, no. 10.1016/j.contraception.2016.06.003 (June 15, 2016), http://researchonline.lshtm.ac.uk/2572238/; Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”.
55. Grimes et al., “Fertility Awareness-Based Methods for Contraception.”James Trussell and Laurence Grummer-Strawn, “Contraceptive Failure of the Ovulation Method of Periodic Abstinence,” International Family Planning Perspectives, 1990, 5–28; Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.”
56. James Trussell and K. Guthrie, “Choosing a Contraceptive: Efficacy, Safety, and Personal Considerations,” Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology. 19th Revised Ed. New York (NY): Ardent Media, Inc, 2007, 19–47; quoted in Willard Cates Jr, John Stanback, and Baker Maggwa, “Global Family Planning Metrics-Time for New Definitions?,” Contraception 90, no. 5 (2014): 472–475. As a FAM researcher recently put it: “traditional methods are both less effective and less often used than modern methods. Contraceptive efficacy is one of the most important aspects of method choice and promotion, and, with typical use, periodic abstinence and withdrawal (the two most commonly used traditional methods) are less effective than nearly all modern methods (Trussell 2004)” Clémentine Rossier and Jamaica Corker, “Contemporary Use of Traditional Contraception in Sub-Saharan Africa,” Population and Development Review, 2017, http://onlinelibrary.wiley.com/doi/10.1111/padr.12008/full.
57. Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data.” Noteworthy is their comparison with previous findings on contraceptive effectiveness, and in particular Mohamed M. Ali, John Cleland, and Iqbal H. Shah, “Causes and Consequences of Contraceptive Discontinuation: Evidence from 60 Demographic and Health Surveys.,” 2012, http://www.popline.org/node/654966: “Our estimates for IUDs, injectables and oral contraceptive pills were similar to a recent large-scale analysis of contraceptive failure in DHS data by Ali et al. […]. For condoms, withdrawal and periodic abstinence, our estimates were somewhat lower, although estimates from Ali et al. for each of these methods were within the range of the 95% CIs around our estimates, suggesting no statistically significant differences. Comparing our results to estimates for the United States is more complicated. Our estimates were somewhat higher than U.S. estimates for implants (0.6 vs. 0.05) and IUDs (1.4 vs. 0.8), which are derived from clinical data. U.S. estimates for both of these methods fall within the 95% CIs for our estimates. On the other hand, our estimates were markedly lower than U.S. estimates for injectables (1.7 vs. 6), oral contraceptive pills (5.5 vs. 9), male condoms (5.4 vs. 18), withdrawal (13.4 vs. 22) and periodic abstinence (13.9 vs. 24), which are derived from 1995 and 2002 National Surveys of Family Growth and, notably, are corrected for abortion underreporting. […]

We are unable to estimate the impact that omission, misreporting and underreporting of contraceptive use episodes; reasons for discontinuation; and abortions resulting from contraceptive failure may have on failure rates, particularly since the level of underreporting may vary across surveys. Therefore, the estimates presented should be viewed as direct reflections of women’s reports, which are potentially affected by a number of biases.”

58. Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data.”
59. See e.g. Günter Freundl, “European Multicenter Study of Natural Family Planning (1989-1995): Efficacy and Drop-Out,” Advances in Contraception 15, no. 1 (1999): 69–83, doi:10.1023/A:1006691730298., where rates of unintended pregnancy were reported separately for six different categories of behaviour during its practice ranging from “abstinence in the fertile time” and “genital contact or coitus interruptus in the fertile time” to “no documented sexual behaviour”.
60. Grimes et al., “Fertility Awareness-Based Methods for Contraception.” Likewise, Frank Herrmann’s subsequent reference study on the STM “was not a randomized controlled trial,” as the authors themselves acknowledged. They also commented that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Herrmann’s findings are further mitigated by a relatively low continuation rate: “the proportion [of participants] reaching one year was 509/831 (61.3%).”P. Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time: A Prospective Longitudinal Study,” Human Reproduction (Oxford, England) 22, no. 5 (May 2007): 1310–19, doi:10.1093/humrep/dem003.

It is noteworthy that Herrmann’s is the reference study on the effectiveness of STM, from a Catholic researcher sympathetic towards FAMs. No other randomized controlled trials on the typical-use effectiveness of the STM, SDM, or other FAMs exist as yet. “There are few randomized controlled studies of FABMs; existing randomized trials were judged to be of insufficient quality to draw any valid conclusions.” Stephen R. Pallone and George R. Bergus, “Fertility Awareness-Based Methods: Another Option for Family Planning,” The Journal of the American Board of Family Medicine 22, no. 2 (March 1, 2009): 147–57, doi:10.3122/jabfm.2009.02.080038. Again, “randomised trials comparing pregnancy rates of different FAB methods are absent, limiting evidence-based choice.”Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.” referring to Grimes et al., “Fertility Awareness-Based Methods for Contraception.” As Herrmann remarked, “The only randomized clinical trials on methods of NFP (Wade et al., 1981; Medina et al., 1980) are of limited use: they showed huge recruitment problems and retention as well as having a very strong selection bias (participants had to agree to expect quite high failure rates while attracted by free medical care at study entry), their results are therefore very questionable,” referring precisely to Grimes et al, op. cit.

The so-called Marquette Method has been found by its developed to be marred by its relatively low effectiveness even when used by couples in a developed country (the USA) after training. The method is so called because it has been researched, developed by Dr Richard Fehring at the Jesuit Marquette University. In 2009 Fehring observed “an increase in the number of unintended pregnancies that have occurred over the past twenty-three years through the Marquette University NFP programs.”Richard Fehring, “Efficacy and Efficiency in Natural Family Planning Services,” The Linacre Quarterly 76, no. 1 (February 1, 2009): 9–24, doi:10.1179/002436309803889377.

“The Billings Method cites an ideal effectiveness rate of 99.5 percent and typical use effectiveness of 98.5 percent based on a single study done in China (Qian et al. 2000; Xu et al. 1994). However other studies note a typical-use pregnancy rate of 22.5 percent and a significant gap between perfect and typical use (Trussell and Grummer-Strawn 1991). There have been no prospective studies done which have supported the effectiveness rates of the Chinese study within a different cultural context. While the Billings Method notes there are ‘four simple rules’ for its application, there is in reality multiple ‘meta-rules’ (the rules governing the four rules) and a range of nineteen different stickers and thirteen different symbols within the Billings Method (Smith and Smith 2014).” George Mulcaire-Jones et al., “Couple Beads: An Integrated Method of Natural Family Planning,” The Linacre Quarterly 83, no. 1 (February 2016): 69–82, doi:10.1080/00243639.2015.1133018.Also E. Faes, J. Van De Walle, and Y. Jacquemyn, “‘Fertility Awareness’ methoden: Oud Nieuws?,” Tijdschrift Voor Geneeskunde 72, no. 2–3 (2016): 88–95: “It is suggested that the symptothermal method, which is a combination of the temperature-based method and cervical secretion method, is most reliable, but there is a lack of randomized trials comparing methods and combinations.”

In summary, “Most of the reported data on the effectiveness of NFP is based on perfect use. The complexity and diligence required by many NFP methods make them unrealistic and untenable for many persons. With typical use, up to 25 percent of women using NFP will become pregnant within the first year.” Grant M. Greenberg et al., “Is Natural Family Planning a Highly Effective Method of Birth Control? No: Natural Family Planning Methods Are Overrated.,” American Family Physician 86, no. 10 (2012): Online.

61. Marston and Church, “Does the Evidence Support Global Promotion of the Calendar-Based Standard Days Method® of Contraception?”; Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness.”
62, 74. Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.”
63, 80, 118. Ibid.
64. David Hubacher and James Trussell, “A Definition of Modern Contraceptive Methods,” Contraception 92, no. 5 (2015): 420–421.
65. “[O]ur results suggest that women with met need for contraception are having more frequent sex. If future research is able to establish a causal link from exogenous contraceptive availability to coital frequency, then findings like these would imply that reductions in unmet need could lead to increased sexual activity for couples worldwide.” The researchers also found that “It is notable that 72 percent of women who had unmet need [for modern contraception] had had sex in the last four weeks, compared with 89 percent of women using contraception. So there appear to be limits in couples’ commitment to embracing marital abstinence as a substitute for modern contraception.”

However, their data do not allow investigation of those women’s motivation for non-use: “It could be that some portion of the 72 percent of women with unmet need who had sex in the last four weeks only had sex once or only had sex when the risk of conception was low (i.e., unreported use of rhythm method), as opposed to the 89 percent of women using contraception who may have had sex more frequently and without regard to their monthly cycle. Unfortunately, the data do not allow investigation of these phenomena. It is also possible that women and couples who have infrequent sex are simply willing to accept a certain level of risk with regard to unintended pregnancy and choose to forego regular use of modern contraception given their limited exposure to sex. A recent study by Machiyama and Cleland (2014) provides evidence that reduced coital frequency is being deployed by women and couples in Ghana as an alternative to modern contraception. There is also the likelihood that some of these women do not fully appreciate the risk or cumulative risk of unintended pregnancy associated with repeated exposure to unprotected sex and thus are making a decision not to use contraception based on an incorrect perception of their risk. Further research is needed to understand these women’s motivation for non-use of modern contraception and how their contraceptive needs could best be met given their coital frequency.” Suzanne O. Bell and David Bishai, “Unmet Need and Sex: Investigating the Role of Coital Frequency in Fertility Control,” Studies in Family Planning 48, no. 1 (March 1, 2017): 39–53, doi:10.1111/sifp.12012 (emphasis added).

66. Johns Hopkins Bloomberg School of Public Health, “Better Access to Contraception Means More Sex for Married Couples,” ScienceDaily, January 26, 2016, www.sciencedaily.com/releases/2016/01/160126091436.htm.
67, 92. Marcos Arévalo, Victoria Jennings, and Irit Sinai, “Efficacy of a New Method of Family Planning: The Standard Days Method,” Contraception 65, no. 5 (2002): 333–338; Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.”
68, 71, 81, 93. Frank-Herrmann et al., “The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour during the Fertile Time.”
69. As noted elsewhere, Frank-Herrmann et al. noticed that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Ibid.
70. For instance, the marketing page for the STM (CycleBeads™) notes: “This family planning method is most effective for women with menstrual cycles that are regularly between 26 and 32 days long. […] Women with cycles outside this range should use a different method of family planning to prevent pregnancy.” https://www.cyclebeads.com/how-family-planning-method-helps-to-plan-pregnancy-or-prevent-pregnancy
72. The Standard Days Method can only be used by women with known, regular cycle lengths of between twenty-six and thirty-two days (Arévalo, Jennings, and Sinai 2002). In the original study of the method, only 46 percent of women completed thirteen cycles of use. Of those who left the study, 28 percent did so because they had two cycles out of the accepted range of twenty-six to thirty-two days; and 9 percent left because they became pregnant (Arévalo, Jennings, and Sinai 2002). At any given time, only 50–60 percent of women will meet the requirements of cycle regularity and length (Institute for Reproductive Health 2014a). Furthermore the method cannot be reliably used in the transition from LAM to resumption of regular cycles, a critical time for child spacing (Arévalo, Jennings, and Sinai 2003). While the Standard Days Method has been vigorously promoted as a simple method for NFP use, even when taught with the option of barrier methods, only 91 of 1,181 (7%) women admitted within the introduction studies and followed with quarterly interviews were still using the method on completion of year 3 (Sinai, Lundgren, and Gribble 2012).” George Mulcaire-Jones et al., “Couple Beads: An Integrated Method of Natural Family Planning,” The Linacre Quarterly 83, no. 1 (February 2016): 69–82, doi:10.1080/00243639.2015.1133018, emphasis added; compare Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception”: the Standard Days Method “was designed for women whose cycles range, without exception, from 26 to 32 days.”
73. Richard J. Fehring and Theresa Notare, Integrating Faith and Science Through Natural Family Planning (Marquette University Press, 2004); quoted in Mulcaire-Jones et al., “Couple Beads.”
75. Rene Ecochard et al., “Self-Identification of the Clinical Fertile Window and the Ovulation Period,” Fertility and Sterility 103, no. 5 (2015): 1319–1325.
76. Fehring, “Efficacy and Efficiency in Natural Family Planning Services. ”Furthermore, Fehring added that “…the beginning of mucus clearly over-estimated the fertile phase. […] Anecdotally, we hear that women often find it frustrating to track mucus for days on end and not have a clear picture of their fertility.”
77. Richard J. Fehring, “Grant Application: Randomized Comparison of Two Internet-Supported Natural Family Planning Methods,” 2013, http://epublications.marquette.edu/cgi/viewcontent.cgi?article=1009&context=data_nfp.
78. “[P]roviding NFP services is complex, time consuming, and expensive. The training of health professionals to provide NFP services is also time consuming and expensive. Many NFP providers experience burn out providing the often intense NFP services. In the past twenty-three years, we have lost eight out of the fourteen health professionals who were trained for our NFP staff at Marquette [University]. The NFP methods we have been using are inefficient, and it often takes months to properly teach couples to the point that they are confident in their use. Finally, we have seen few changes in NFP in the past 30–50 years. What we call the “modern” methods of NFP were developed in the 1950s and 60s—40–50 years ago.”
79, 88. Mulcaire-Jones et al., “Couple Beads.”
82. Clémentine Rossier, Leigh Senderowicz, and Abdramane Soura, “Do Natural Methods Count? Underreporting of Natural Contraception in Urban Burkina Faso,” Studies in Family Planning 45, no. 2 (June 1, 2014): 171–82, doi:10.1111/j.1728-4465.2014.00383.x.
83. Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness”; citing C. Ujuju et al., “Religion, Culture and Male Involvement in the Use of the Standard Days Method: Evidence from Enugu and Katsina States of Nigeria,” International Nursing Review 58, no. 4 (2011): 484–490.
84. “Worldwide use in 2007 of what the UN Population Division calls ‘rhythm’ or calendar methods is estimated to be 3.6% of all women, aged 15–49 who are married or in union. This estimate includes all methods in which periodic abstinence is required. Prevalence is higher in more developed countries (4.3%) than in less developed countries (3.4%) (Table 1). The UN estimates the prevalence of rhythm-related methods in Europe to have been 5.6% in 2007 (Table 1).” Freundl, Sivin, and Batár, “State-of-the-Art of Non-Hormonal Methods of Contraception.”
85. Richard Fehring, “Efficacy and Efficiency in Natural Family Planning Services,” The Linacre Quarterly 76, no. 1 (February 1, 2009): 9–24, doi:10.1179/002436309803889377; referring to Jennifer Ohlendorf and Richard J. Fehring, “The Influence of Religiosity on Contraceptive Use among Roman Catholic Women in the United States,” The Linacre Quarterly 74, no. 2 (2007): 6.
86. Crista B. Warniment and Kirsten Hansen, “Is Natural Family Planning a Highly Effective Method of Birth Control? Yes: Natural Family Planning Is Highly Effective and Fulfilling,” American Family Physician 86, no. 10 (2012): 1–2; Pallone and Bergus, “Fertility Awareness-Based Methods.”
87. Fehring, “Efficacy and Efficiency in Natural Family Planning Services.”
89. Greenberg et al., “Is Natural Family Planning a Highly Effective Method of Birth Control?”
90. https://www.cyclebeads.com/research (accessed 05/07/2017), referring to the seminal article Marcos Arévalo, Victoria Jennings, and Irit Sinai, “Efficacy of a New Method of Family Planning: The Standard Days Method,” Contraception 65, no. 5 (2002): 333–38; but see observations in Marston and Church, “Response to Letters to the Editor from Irit Sinai “Standard Days Method Effectiveness.”
91. https://www.cyclebeads.com/how-family-planning-method-helps-to-plan-pregnancy-or-prevent-pregnancy (accessed 05/07/2017). Same applies to the Symptothermal Method. One of its guides notes: “With the STM, during the fertile days, men have to learn to either observe some days of sexual abstinence (appreciated by many women), or to use a condom.” R. Harri Wettstein and Christine Bourgeois, The Complete Symptothermal Guide. Ecological Birth Control & Pregnancy Achievement, p. 17.
94. As noted elsewhere, Frank-Herrmann et al. reflected that “The markedly high use-effectiveness rates of our data may partly be explained by the motivation of those couples and their teachers who agreed to participate.” Ibid.
95. “[C]ouples with fertility awareness knowledge are more likely to use condoms more consistently in the fertile time. Most cited NFP studies do not report the quantity of additional barrier method use, yet we have learnt from the European study that it exists to a certain extent within all communities that use NFP methods.” Ibid.
96. Blair T. Johnson et al., “Interventions to Reduce Sexual Risk for Human Immunodeficiency Virus in Adolescents: A Meta-Analysis of Trials, 1985-2008,” Archives of Pediatrics & Adolescent Medicine 165, no. 1 (January 3, 2011): 77–84, doi:10.1001/archpediatrics.2010.251, emphasis added. See also e.g. Laura Duberstein Lindberg and Isaac Maddow-Zimet, “Consequences of Sex Education on Teen and Young Adult Sexual Behaviors and Outcomes,” Journal of Adolescent Health 51, no. 4 (October 1, 2012): 332–38, doi:10.1016/j.jadohealth.2011.12.028.
97. Pascaline Dupas, “Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya,” American Economic Journal: Applied Economics 3, no. 1 (January 1, 2011): 1–34, doi:10.1257/app.3.1.1: “Providing information on the relative risk of HIV infection by partner’s age led to a 28 percent decrease in teen pregnancy, an objective proxy for the incidence of unprotected sex. […] In contrast, the official abstinence-only HIV curriculum had no impact on teen pregnancy.” Again, “Many sub-Saharan African countries have incorporated HIV/ AIDS education in their school curriculum, but the great majority of those curricula are limited to risk avoidance information; they aim at completely eliminating pre-marital sex by promoting abstinence until marriage. They omit to provide risk reduction information, for example that condom use reduces the risk of HIV transmission.” “Using data from a randomized field experiment involving 328 primary schools, this paper compares the effects of providing abstinence-only versus detailed HIV risk information on teenage sexual behavior.” However, “The results suggest that the teacher training on the national HIV/AIDS curriculum had no effect on the likelihood that teenage girls started childbearing within a year, suggesting no reduction in risky behavior. In contrast, the relative risk information led to a 28 percent decrease in the likelihood that girls started childbearing within a year, suggesting an important decrease in the incidence of unprotected sex among those girls […].

These results suggest that the behavioral choices of teenagers are not responsive to risk avoidance messages, but are responsive to information on the relative riskiness of potential partners. Overall, the relative risk information led to an increase in reported sexual activity, but to a decrease in unsafe sex. This suggests that teenage sexual behavior is more elastic on the margin of what type of sex to engage in—the choice of partner and the choice of protection level—than on the margin of whether to engage in sex or not. These results suggest that, in the fight against HIV, risk reduction messages might be more effective than risk avoidance messages.” Interestingly, “Prior evidence on the effectiveness of sexual health education in Africa is almost nonexistent.”

See also John S. Santelli, Ilene S. Speizer, and Zoe R. Edelstein, “Abstinence Promotion under PEPFAR: The Shifting Focus of HIV Prevention for Youth,” Global Public Health 8, no. 1 (2013): 1–12: “Abstinence-until-marriage (AUM) – strongly supported by religious conservatives in the USA – became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President’s Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.” Also, Virginia A. Fonner et al., “School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis,” PLOS ONE 9, no. 3 (March 4, 2014): e89692, doi:10.1371/journal.pone.0089692: “Importantly, no individual study included in meta-analysis, including abstinence-only, abstinence-plus, and comprehensive school-based sex education interventions, found detrimental effects of school-based sex education on increased risky sexual behavior. This finding is notable given that some argue programs including information on abstinence and safe sex strategies give mixed messages to students and may promote sexual activity [91].

Comprehensive school-based sex education comprised the majority of interventions included in this review despite extensive attempts to identify abstinence-only and abstinence-plus interventions.Given PEPFAR’s past emphasis on abstinence-only and abstinence-plus interventions [4], it is surprising to find so few peer reviewed evaluations of this strategy that met our inclusion criteria. The uneven distribution in comprehensive versus abstinence-only or abstinence-plus interventions made it difficult to compare the effectiveness of these intervention types. Additionally, many abstinence-only or abstinence-plus interventions measured outcomes related to HIV-knowledge but did not include outcomes related to sexual risk behavior, such as condom use or number of sexual partners, thus rendering comparisons to comprehensive sex education unfeasible. These findings are similar to those of parallel systematic reviews and meta-analyses comparing the effectiveness of comprehensive sex education and abstinence-only interventions, which found that although comprehensive sex education interventions were effective at reducing high-risk sexual behavior, no conclusion could be drawn from interventions emphasizing abstinence due to the small number of eligible studies and inconsistent findings [10]” (emphases added).

It has also been argued that denying accurate information with regard to contraceptives in many abstinence-only sex education programs violates fundamental human rights guaranteed by international law, and specifically the rights “to information, to education, to be free of arbitrary and unjust discrimination, and to health, among other rights — because silence or misinformation on condom effectiveness not only violates speech and information rights but also denies young people a means through which they could protect their right to health.” Alice M. Miller and Rebecca A. Schleifer, “Through the Looking Glass: Abstinence-Only-until-Marriage Programs and Their Impact on Adolescent Human Rights,” Sexuality Research & Social Policy 5, no. 3 (September 1, 2008): 28, doi:10.1525/srsp.2008.5.3.28; also Rebecca Schleifer and Joanne Csete, “Ignorance Only: HIV/AIDS, Human Rights, and Federally Funded Abstinence-Only Programs in the United States. Texas: A Case Study,” Human Rights Watch 14, no. 5 (2002), http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/2800.

98. See Statement, §8:

“The Bible identifies a variety of morally worthy non-conceptive motives for engaging in sexual intercourse. This is confirmed by evolutionary biology and modern sociological surveys, among other disciplines.

Those non-conceptive motives for sexual intercourse include pleasure, love, comfort, celebration and companionship. They are morally worthy even without the concurrent occurrence of either a ‘procreative significance’ of the biological ‘laws of conception,’ or the agents’ procreative intention.

The use of modern contraceptives can facilitate one or more of sexual intercourse’s non-conceptive meanings, as well as have additional morally worthy purposes – e.g. family planning, following the requirements of responsible parenthood (HV §10).

Therefore, the decision to use modern contraceptives can be taken for a variety of morally worthy motives, and so it can be ethical.”

99. See a selected list at https://www.malecontraceptive.org/prospective/. Also: “At present, male controlled methods include condoms and vasectomy. These are not optimal or generally acceptable because of the high user failure rate with condoms and the difficult reversibility of vasectomy. In spite of the shortcomings, one third of couples using contraception worldwide relies on a male method. These observations would suggest that if new contraceptives for men were available, many couples worldwide would use them.”
100. Sarah EK Bradley, Trevor Croft, and Shea Oscar Rutstein, “The Impact of Contraceptive Failure on Unintended Births and Induced Abortions: Estimates and Strategies for Reduction,” DHS Analytical Studies (ICF Macro for USAID, 2011), http://iussp.org/sites/default/files/event_call_for_papers/Contraceptive%20Failure%20Unintended%20Births%20-%20Bradley%20Croft%20Rutstein%20-%20IUSSP%202013.pdf.
101. Even so, it is important to remember that “Among users with correct knowledge of the timing of ovulation, reported failure was 12% lower than among those with incorrect or no knowledge. [T]his is a surprisingly weak link, which suggests that factors other than the wife’s knowledge of the correct time to abstain from intercourse are important. For instance, husband’s compliance may well be crucial. This key result provides only a modest justification for increasing efforts to disseminate basic information about sexual and reproductive physiology, including facts about the menstrual cycle. It is unlikely that more than a minority of couples who try PA consult health staff prior to use and thus any restriction of information to health institutions would have little impact. Therefore, informational activities would need to be multi-sectoral, including in-school curricula, electronic and print media.” Che, Cleland, and Ali, “Periodic Abstinence in Developing Countries.”
102. https://www.guttmacher.org/news-release/2016/new-study-examines-why-women-developing-countries-who-wish-avoid-pregnancy-do-not.
103. Johannes Stroebel and Arthur Van Benthem, “The Power of the Church-The Role of Roman Catholic Teaching in the Transmission of HIV,” Available at SSRN 2018071, 2012, http://pages.stern.nyu.edu/~jstroebe/research/pdf/PowerChurchRomanCatholicKenya.pdf.
104. See e.g. Catholic Bishops Conference of the Philippines, “Moral Norms for Catholic Hospitals and Catholics in Health Services” (1973), http://cbcponline.net/v2/?p=188 (accessed on 20/10/2016).
105. Interview with Father Heinz Kulüke, Cebu City, Philippines (December 11, 2005), as reported in The Protection Project, International Child Sex Tourism. Scope of the Problem and Comparative Case Studies (Washington, D.C.: Johns Hopkins University, Paul H. Nitze School of Advanced International Studies, 2007), pp. 150-51, retrieved from http://www.protectionproject.org/wp-content/uploads/2010/09/JHU_Report.pdf.
106. Pamela K. Kohler, Lisa E. Manhart, and William E. Lafferty, “Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy,” Journal of Adolescent Health 42, no. 4 (2008): 344–351.K. Underhill, D. Operario, and P. Montgomery, “Abstinence-Only Programs for HIV Infection Prevention in High-Income Countries,” The Cochrane Database of Systematic Reviews, no. 4 (October 17, 2007): CD005421, doi:10.1002/14651858.CD005421.pub2. “Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective, but generalizability may be limited to US youth. Should funding continue, additional resources could support rigorous evaluations with behavioral or biological outcomes. More trials comparing abstinence-only and abstinence-plus interventions are needed.”
107. Highly cited study Douglas B. Kirby, “The Impact of Abstinence and Comprehensive Sex and STD/HIV Education Programs on Adolescent Sexual Behavior,” Sexuality Research & Social Policy 5, no. 3 (September 1, 2008): 18, doi:10.1525/srsp.2008.5.3.18. Prof. Douglas Bernard Kirby was one of the world’s leading experts on school and community programs to reduce sexual risk taking, and dedicated his career to promoting sexual and reproductive health among young people through his writing, teaching, and research. . He authored over 150 articles, chapters and monographs on these programs, and frequently spoke nationally and internationally on his work. He served as a scientific adviser to the CDC, USAID, WHO, UNFPA, UNESCO, and the National Campaign to Prevent Teen and Unplanned Pregnancy.
108. “Though emergency contraception (EC) is only intended for occasional use, concerns have been raised that increasing access to EC (e.g., by making it available without prescription over-the-counter) would lead to increased sexual risk-taking. For example, if EC was easily accessible, would women use contraception less regularly, more readily engage in casual sex, or be at increased risk of contracting STIs? There is no scientific evidence to substantiate these concerns. To the contrary, a substantial body of research demonstrates that there is no relationship between availability of EC and increased sexual risk behaviour.” DC Weiss et al., “Does Emergency Contraception Promote Sexual Risk-Taking?” (Bixby Center for Global Reproductive Health, 2008), https://bixbycenter.ucsf.edu/sites/bixbycenter.ucsf.edu/files/DoesECPromoteSexRiskTaking_2008.pdf.
109. Blair T. Johnson et al., “Interventions to Reduce Sexual Risk for Human Immunodeficiency Virus in Adolescents: A Meta-Analysis of Trials, 1985-2008,” Archives of Pediatrics & Adolescent Medicine 165, no. 1 (January 3, 2011): 77–84, doi:10.1001/archpediatrics.2010.251, my emphasis. See also e.g. Lindberg and Maddow-Zimet, “Consequences of Sex Education on Teen and Young Adult Sexual Behaviors and Outcomes.”
110. Pascaline Dupas, “Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya,” American Economic Journal: Applied Economics 3, no. 1 (January 1, 2011): 1–34, doi:10.1257/app.3.1.1: “Providing information on the relative risk of HIV infection by partner’s age led to a 28 percent decrease in teen pregnancy, an objective proxy for the incidence of unprotected sex. […] In contrast, the official abstinence-only HIV curriculum had no impact on teen pregnancy.” Again, “Many sub-Saharan African countries have incorporated HIV/ AIDS education in their school curriculum, but the great majority of those curricula are limited to risk avoidance information; they aim at completely eliminating pre-marital sex by promoting abstinence until marriage. They omit to provide risk reduction information, for example that condom use reduces the risk of HIV transmission.” “Using data from a randomized field experiment involving 328 primary schools, this paper compares the effects of providing abstinence-only versus detailed HIV risk information on teenage sexual behavior.” However, “The results suggest that the teacher training on the national HIV/AIDS curriculum had no effect on the likelihood that teenage girls started childbearing within a year, suggesting no reduction in risky behavior. In contrast, the relative risk information led to a 28 percent decrease in the likelihood that girls started childbearing within a year, suggesting an important decrease in the incidence of unprotected sex among those girls […].

These results suggest that the behavioral choices of teenagers are not responsive to risk avoidance messages, but are responsive to information on the relative riskiness of potential partners. Overall, the relative risk information led to an increase in reported sexual activity, but to a decrease in unsafe sex. This suggests that teenage sexual behavior is more elastic on the margin of what type of sex to engage in—the choice of partner and the choice of protection level—than on the margin of whether to engage in sex or not. These results suggest that, in the fight against HIV, risk reduction messages might be more effective than risk avoidance messages.” Interestingly, “Prior evidence on the effectiveness of sexual health education in Africa is almost nonexistent.”

See also John S. Santelli, Ilene S. Speizer, and Zoe R. Edelstein, “Abstinence Promotion under PEPFAR: The Shifting Focus of HIV Prevention for Youth,” Global Public Health 8, no. 1 (2013): 1–12: “Abstinence-until-marriage (AUM) – strongly supported by religious conservatives in the USA – became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President’s Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.” Also, Virginia A. Fonner et al., “School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis,” PLOS ONE 9, no. 3 (March 4, 2014): e89692, doi:10.1371/journal.pone.0089692: “Importantly, no individual study included in meta-analysis, including abstinence-only, abstinence-plus, and comprehensive school-based sex education interventions, found detrimental effects of school-based sex education on increased risky sexual behavior. This finding is notable given that some argue programs including information on abstinence and safe sex strategies give mixed messages to students and may promote sexual activity [91].

Comprehensive school-based sex education comprised the majority of interventions included in this review despite extensive attempts to identify abstinence-only and abstinence-plus interventions.Given PEPFAR’s past emphasis on abstinence-only and abstinence-plus interventions [4], it is surprising to find so few peer reviewed evaluations of this strategy that met our inclusion criteria. The uneven distribution in comprehensive versus abstinence-only or abstinence-plus interventions made it difficult to compare the effectiveness of these intervention types. Additionally, many abstinence-only or abstinence-plus interventions measured outcomes related to HIV-knowledge but did not include outcomes related to sexual risk behavior, such as condom use or number of sexual partners, thus rendering comparisons to comprehensive sex education unfeasible. These findings are similar to those of parallel systematic reviews and meta-analyses comparing the effectiveness of comprehensive sex education and abstinence-only interventions, which found that although comprehensive sex education interventions were effective at reducing high-risk sexual behavior, no conclusion could be drawn from interventions emphasizing abstinence due to the small number of eligible studies and inconsistent findings [10]” (emphases added).

It has also been argued that denying accurate information with regard to contraceptives in many abstinence-only sex education programs interfere with fundamental human rights guaranteed by international law. See e.g. “Ignorance Only : HIV/AIDS, Human Rights, and Federally Funded Abstinence-Only Programs in the United States : Texas : A Case Study. :: Georgetown Law Library,” accessed March 2, 2017, http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/2800. Also Miller and Schleifer, “Through the Looking Glass.”

111. James J. Ponzetti Jr, ed., Evidence-Based Approaches to Sexuality Education: A Global Perspective (Routledge, 2015).
112. Cicely Marston and John Cleland, “Relationships between Contraception and Abortion: A Review of the Evidence,” International Family Planning Perspectives, 2003, 6–13. An update to this seminal research is being prepared, and will be sent to the Pontifical Academy for Life as soon as it is ready.
113. “Access to Free Birth Control Reduces Abortion Rates,” Washington University School of Medicine in St. Louis, October 12, 2012, https://medicine.wustl.edu/news/access-to-free-birth-control-reduces-abortion-rates/. See also the website of that research project, called the “Contraceptive CHOICE Project,” at http://choiceproject.wustl.edu/, and Sue Ricketts, Greta Klingler, and Renee Schwalberg, “Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women,” Perspectives on Sexual and Reproductive Health 46, no. 3 (September 1, 2014): 125–32, doi:10.1363/46e1714.
114. Sedgh, Singh, and Hussain, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.”
115. Elisabeth Ahman and Iqbal Shah, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, 6th edition (Geneva: World Health Organization, 2011), http://apps.who.int/iris/bitstream/10665/44529/1/9789241501118_eng.pdf.
116. World Health Organization, “Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality in 2008 (6th Edition),” 2011, http://apps.who.int/iris/handle/10665/44529.
117. Ibid. The report continues: “Reports from Uganda and Pakistan describe the contraception-abortion paradox. “Increasingly, abortion, which remains illegal in Uganda, is becoming an important method of fertility regulation. Out of the 5.3 million sexually active female population of Uganda, only 23% (18% modern) are currently using contraception, implying that 4.2 million are sexually active but are not using contraception. Lack of contraceptive use contributes to unwanted or mistimed pregnancies, which are in turn linked to unsafe abortion, and consequent maternal mortality and morbidity.” From Pakistan, Sathar reports on stagnating fertility levels ‘High unmet need for contraception and the proportion of births that are unplanned confirm that a large fraction of currently married women in Pakistan are at risk of an unwanted pregnancy and potentially of undergoing an abortion.’”