Sex, of course

Joseph B. Stanford1.
Published in First Things 97 (November 1999): 28-33.
Copyright (c) Firts Things 1999.
English translation: Charlie Paternina and Jokin de Irala.

School When I started my programs of study at the University of Minnesota Medical School in 1984, I did not know that 15 years later, as a family physician, I would be fully dedicated to promote understanding human sexuality and procreation from a point of view that is completely at odds with the most widely held views and widespread practices of our contemporary culture.

I have found that medicine is steeped in positions toward sexuality and fertility that are incompatible with Christian values about marriage and procreation. These positions reflect and perpetuate the recreational approach to sexuality found in our secular culture.

Based on personal experiences, experiences with patients, my own research and the research and programs of study of others, I am convinced that there is a spiritually authentic and scientifically correct approach to sexuality and human procreation that is sorely lacking in today's medicine, but which is essential to recover for authentic respect for human life in our culture.

Perhaps, my first direct meeting with the secular doctrine of sexuality in medicine was a university seminar on "rethinking attitudes toward human sexuality." Part of this course included several hours of aggressive pornographic films, used to "broaden" students' perspectives on human sexuality.

While deciding whether to attend this seminar, I prayed and took advice from my church leaders. This stance has helped me stay on my path on fundamental issues ever since. Along with other colleagues at class, I decided not to take part in seminar, and wrote a article about my stance on sexuality and how it would affect the care I would give to patients who had different positions than mine.

This helped me clarify my ideas about how I could be consistent with my beliefs about the sacredness of human sexuality and the value of chastity, while providing compassionate care to patients who may not have these ideas. I began to learn how to treat all patients with full human respect, including those who made choices I considered immoral.

In pharmacology classes at School of Medicine, we were taught that hormonal contraception ("the pill" and other methods), which does not always prevent ovulation, alters the endometrium in such a way as to reduce the probability of implantation in the womb of newly formed human lives. A small group of us in the classes decided that we would not prescribe hormonal contraceptives. Those who made this commitment were a Catholic, a Baptist and myself, a Latter-day Saint (Mormon). I'm not sure about my colleagues, but I have been faithful to my decision throughout my medical training and my internship , and this has opened the way for me to give my patients many things that I would not otherwise have been able to offer.

The potential of hormonal contraception to act after conception offers an interesting contrast to modern medicine. Although it is recognised in most gynaecological and pharmacological literature, most gynaecologists ignore it, nor does the written information that patients receive about contraception echo it. The evidence that hormonal contraception works in this way is not final, but it suggests it. Patients should be informed about all of this topic as a basic principle: women and their husbands need to have the best medical information available to be able to make family planning decisions that are in line with their own values and moral conscience agreement .

I was learning that the pill could act as an abortifacient, and this was the beginning of my questioning the value of contraceptives. During the spanish medical residency program in family medicine, I avoided doing tubal ligations or vasectomies because the official Latter-day Saint statutes strongly reject these procedures. In the end, I realised that fertility is part of health, not a disease, and that there is something fundamentally contradictory about operations that seek to prevent healthy bodily function.

With time and experience with my patients, I began to think that any form of contraception had harmful effects on marriages and even pre-marital relationships, although not everyone recognised this. More and more, I became certain that sexuality and fertility are linked at the most fundamental level both physically and spiritually. I began to see more clearly what can happen when men try to undo this connection.

Sexual union in marriage should be a perfect gift from each spouse to the other, and when fertility (even in potential) is deliberately excluded from this gift, I am convinced that something valuable is lost. The husband may begin to see his wife as an object of sexual pleasure that must always be available for his own satisfaction. This tendency takes force in the prevailing view of sexuality in our society, which idealises unlimited eroticisation and sexual satisfaction, but free (at least theoretically) from any possibility of pregnancy. Sterilisation and hormonal contraceptives especially feed this common and highly distorted male perspective (also adopted by many women).

Couples can easily lose sight of why they made the decision to avoid pregnancy, and not try topic for months or even years, having sex in a way that is far removed from even the idea of procreation.

There are also side effects of a greater or lesser nature with every contraceptive. In a couple of years, I came to the conclusion that I would not in conscience prescribe contraceptives of any subject (abortifacients or not), because I felt that, in a way, all contraception is detrimental to marriage and the health of the spouses.

I would not have been able to make this decision about prescribing contraceptives if I had not simultaneously learned about family planning in an effective, scientifically correct and spiritually healthy way. There are easy and accurate ways to monitor and interpret the signs of fertility in a woman's body. Couples can learn to use these fertility signs to plan conception by having sex during fertile periods, or to space pregnancies by abstaining from sex during these periods.

The basic signs of fertility are:

changes in vaginal secretions during ovulation periods, which correspond to secretions from the uterine cervix that allow sperm to survive and move around.

an increase in basal body temperature, which is a sign that ovulation has taken place.

With proper preparation, these signs can be interpreted reliably, regardless of the calendar, and regardless of whether a woman's cycles are regular or not. In fact, these physiological phenomena of human fertility have applications beyond a simple method of family planning "naturally", i.e. without contraception. However, since the term "natural family planning" (NFP) has been widely used to describe the basic knowledge of the fertility and infertility cycles of a woman's body, in addition to its application to spacing pregnancies, we will address in this paper all the applications of knowing these phenomena.

Three modern NFP methods are supported by a comprehensive set of scientific data :

the symptothermal method, based on observations of vaginal secretion and basal body temperature, sometimes combined with other symptoms

the ovulation method, also known as the Billings Ovulation Method, by Drs. John and Evelyn Billings, based solely on observations of vaginal discharge

the model Creighton, an adaptation of the ovulation method that standardised protocols for using and teaching it, developed at Creighton University.

Each of these methods has a solid foundation of medical evidence programs of study that demonstrates high effectiveness in preventing pregnancy.

Couples who have a serious need to space or avoid pregnancies can do so reliably using NFP. Many couples face these situations at some time during their marriage. If there were no effective alternative to contraception (other than total abstinence), this would be a difficult status.

The periodic abstinence used in NFP to avoid pregnancy may be a challenge, sometimes difficult, but it brings marriages together, as both partners put the needs of the other (and of the marriage) ahead of their own needs. It takes faith to use NFP: if not faith in God, at least faith in the strength of marriage, and in the good omen and ability of each spouse to yield to an NFP discipline for the common good of their marriage and family.

This faith is more than compensated for: there is a profound "courtship-honeymoon" effect among couples who use NFP, even after years of marriage. Abstinence from contact genitalia during the fertile period evokes a sense of periodic "courtship", after which the couple enjoys a "honeymoon" that enhances the joy and appreciation of sexual union.

Research suggests that the frequency of sexual intercourse among couples using NFP is similar to that of most married couples using contraception, but is distributed differently. I have known couples during my years of medical internship who routinely engage in sex on a daily basis, but who do not experience the satisfaction of their "sex life" to the depth that NFP couples do. In other words, NFP improves marriages in a way that contraception does not.

In my opinion, couples using NFP gain the following benefits:

husbands have a deeper appreciation of fertility as a gift from God rather than a biological phenomenon to be manipulated or an evil to be avoided

Generally, they consciously and quickly achieve pregnancies when they choose to (surprise pregnancies are very rare among couples using NFP).

rethink their fertility choices on a regular and ongoing basis.

in their intimate relationship, each spouse sends an implicit and powerful message: "I accept you completely, including your fertility".

learn to take and exercise responsibility for their fertility together

learn that periods of abstinence from contact genitalia can make a relationship stronger.

Most people who start using NFP do not do so because they expect to experience the relationship and spiritual benefits described above. Research suggests that, at first, most are primarily interested in the health benefits: the absence of side effects and the knowledge normal functioning of the body. Others start using NFP because of a religious commitment. Regardless of why people start using NFP, research has shown that, compared to other family planning methods, a relatively high proportion of users continue to use it. And after a few months of use, most of them tell you that they have noticed some of the benefits we have just talked about in their relationship.

The fundamental difference between NFP and contraception becomes clearer when couples using NFP to avoid pregnancy are trying to conceive a new life. For couples using contraception, the choice to conceive usually means cutting contraception (or using it in a disparate and inconsistent way) and "taking a gamble" or "seeing what happens". Although some couples using NFP may occasionally use these expressions, their experience is qualitatively different. In contrast to couples using contraception, they know full well that conception is likely to occur, even if they are not deliberately planning to do so. Moreover, they know about fertility, with the benefits and responsibilities it entails. All this is beyond the reach of the couple who rely on contraception for family planning.

This knowledge has the potential to make the couple discover the divine power of procreation. Contrary to contraception, NFP does not lead to the desire to have as few offspring issue as possible. Quite the contrary. While enabling couples to reliably avoid pregnancy, it also encourages couples to have as many children as they can reasonably care for. From a Christian perspective, this is an advantage of NFP that no other family planning method shares. NFP is, by its very nature, open to life.

I do not mean to say that married couples who use contraception must necessarily have family or marital problems. I know many wonderful couples who are open to life, fully committed to their family, and yet use contraception. But I am convinced that most of these couples would use NFP if they had the opportunity to understand it and the blessings it brings.

There are two other dimensions of NFP that I can only briefly mention, but which are of equal importance for their value in spacing pregnancies. The first is the great hope that NFP offers to couples facing infertility. NFP is the beginning of an approach to infertility that is based on the regeneration of the natural - God-given - processes of human reproduction for healthy functioning. This is in radical contrast to most of today's technologically advanced infertility efforts, which treat human life as an object to be scientifically manipulated rather than a sacred reality. Many couples and many doctors use in vitro fertilisation and other such procedures because of their desire for fertility, only to find themselves facing unsuspected moral dilemmas such as what to do with cryopreserved embryos. The "natural procreation" approach to infertility, which may even incorporate sophisticated medical and surgical techniques as long as they are used to refund normal fertility physiology, is based on respect for the processes of human procreation and for human life in its earliest stages.

The precise data on the effectiveness of natural procreation approaches (which receive little funding for research, currently) have yet to be interpreted, but the available data convince me that this approach will prove at least as effective as those currently being used to medically treat infertility. (The high school Paul VI for the Study of Human Reproduction, in Omaha, Nebraska, is leading the development on the "natural procreative technology" option for infertility). This application of NFP will probably be the first thing to enter the reproductive medicine welter. Even so, it will meet with a firm civil service examination from those who invest heavily in the current system of medical infertility treatment.

Another essential contribution of NFP is the potential it offers for women's gynaecological and reproductive health. Knowing when and if a woman is ovulating, and when and if her reproductive system is functioning normally, is of great value for the diagnosis and treatment of conditions that are related to the reproductive system, such as premenstrual syndrome, irregular bleeding, endometriosis and ovarian cysts.

By far the most common way that doctors treat all of these conditions - with varying success in controlling symptoms - is to prescribe women birth control pills or other hormonal treatments that suppress the normal functioning of the reproductive system. In contrast, NFP offers the possibility of developing medical treatments that will restore the normal functioning of the reproductive system. What's more, NFP financial aid helps women to better understand their bodies, allowing them to know exactly what the medical treatment consists of. In my years of medical internship , I have seen a qualitative difference when treating women with these problems who use (or are beginning to use) NFP to understand their cycles, and those who do not. Research will increase the potential of this option in the future.

Just as current methods are good at identifying fertile periods in the menstrual cycle, I am convinced that in the future we will develop more comprehensive and effective practices. There are some couples who still have substantial difficulties in learning and interpreting their fertility signs. However, I have found that when couples who have these difficulties receive the best possible medical and moral support, they usually stay with their choice to use NFP, and are able to overcome difficult times with a strong marriage.

Less than 1% of couples in the US use modern NFP. Why aren't more using it? Among the causes are lack of knowledge, lack of access at various levels, a culture saturated with contraception, and intrinsic trust issues. In addition, there is a minority who perceive NFP as "natural contraception" and reject it as contraception.

In a culture where, statistically, it is very unlikely that anyone knows anyone who uses NFP, it is difficult to get adequate information about topic, let alone social support for using it. Effective use of NFP requires adequate instruction by a specialised trainer. The issue of available NFP teachers varies geographically, but is still very limited in most places. Insurance companies do not cover medical expenses for couples using NFP-related health services, although it is striking that they do cover medical expenses for contraception and sterilisation, although this is slowly changing.

Doctors and health professionals are very uninformed (or misinformed) about modern NFP, and usually do not even discuss the option with patients. I first learned about NFP not through my classes, but through a series of elective evening classes organised by medical students to cover topics that were not in the curriculum of our School medical school. Most Schools medical schools and Education medical programmes lack adequate and accurate information on NFP.

internship Contraception has become so integrated into the medical internship that it is difficult for those students or doctors who choose not to prescribe it to be allowed to fill in their Education, and in the field of obstetrics and gynaecology it is almost impossible. I do not attribute this to any conspiracy, but to the cultural acceptance and promotion of contraception over the last 30 years.

In this regard, one should not underestimate the influence and role of pharmaceutical companies in the widely accepted internship of contraceptive prescribing by health professionals, as they are perhaps the only source of non-state funding for continuing medical study and professional obstetrics and gynaecology conference and congresses.

However, the lack of NFP use is not because most women and couples are satisfied with modern contraceptive methods. Few women really enjoy the physical experience of taking the pill or other hormonal contraceptives and their typical and atypical side effects. I have not found any woman who really enjoys having to wear a diaphragm, nor any man who prefers to wear a condom when having sex. Research has shown that many women and men are looking for something better.

I do not attempt to judge others (especially my patients) when they choose to use contraceptives. Their choices about their reproductive potential are between them and God, and it is their right and responsibility to determine for themselves what to do with their fertility. In conversations with my patients, I make an effort to maintain balance by discussing my medical advice about different contraceptive methods.

At the same time, without judgement, I try to convey to my patients (to the extent that they want to hear) why I believe there is a healthy and effective alternative that is in complete harmony with their fertility and with their dignity as human persons, as children of God. I make it clear to them what I can and cannot do with my own conscience, and that they will have to go elsewhere if they choose an option in which I cannot participate. Almost all my patients understand this. Those who choose to no longer be prescribed contraceptives almost always return to me for the remainder of their medical care.

I have found that about a quarter of my patients who have not used NFP choose it after a conversation with me about it. (Many patients visit me because they are looking for a doctor to help them with their initial choice to use NFP). In addition to many family doctors, there is a growing issue of obstetrics and gynaecology professionals who have made the decision to prescribe only NFP for spacing pregnancies, treating infertility, and almost all other aspects of reproductive health. I am very much involved in work which is run by the American Academy of Natural Family Planning, a committed organisation dedicated to service and research within a framework of work of total respect for life and procreation. I have served as director of the committee for Science and research, and recently as president. That I am one of the few non-Catholic members of the organisation has not hindered my deep friendship and purpose commonality with these health professionals.

It is possible for a couple to use NFP inappropriately, to selfishly limit their family, but I think this is much less likely to happen with NFP than with the use of artificial methods of contraception.

Of course, I am familiar with the Catholic perspective on these issues. I have read and re-read Humanae Vitae, the 1968 encyclical of Pope Paul VI. Although there are some theological points on which I disagree, I fully agree with the fundamental vision of human sexuality and family life that the encyclical defines in a beautiful way. I believe that the ideas in the encyclical can only come from divine inspiration. Similarly, although I do not agree with agreement with all the points described by Pope John Paul II in Evangelium Vitae, meeting this vision of the battle between the Culture of Life and the culture of Death is very enlightening.

The strongest resistance to NFP will probably remain concentrated among those who believe that population control is the most critical topic of our time, because they warn - quite rightly - that NFP is not as "reliable" as many methods of contraception from the perspective of encouraging people not to have children. As I have said, NFP's first steps into the great stream of medicine will probably come at first for its potential to help couples with infertility.

In the end, I hope to see the majority of US health professionals accepting NFP as an option that should be available for all women and couples. Even those who are into contraception and against abortion could support this additional "option".

There is a growing issue of health professionals who promote the benefits of NFP, although they see NFP as basically one among many other methods of contraception, whatever their advantages. Many of these promote a version of fertility awareness that encourages the use of barrier methods of contraception (or other variations such as oral sex) during fertile periods - a version that retains some of the health benefits of NFP but loses its spiritual benefits.

The ultimate value of NFP will be found by those who bring sexuality and faith together. They will find that NFP differs fundamentally from contraception in that it cooperates with the divine gift of fertility, rather than seeking to suppress or destroy it, and that cooperating with the divine gift of fertility brings spiritual blessings as well as medical benefits. NFP restores the connection between sex and procreation, enhances marriage and financial aid to the virtue of chastity. financial aid spouses to see each other as persons and creators of persons properly, for it is in procreation that people perceive their dignity as children made in the image of their Father.