Sex, Naturally 

When I entered medical school at the University of Minnesota in 1984 I did not know that fifteen years later, as an academic family physician, I would be fully committed to promoting an understanding of human sexuality and procreation radically at odds with the prevailing views and practices of our contemporary culture. I have found that medicine is permeated with attitudes toward sexuality and fertility that are incompatible with Christian values of the sanctity of life, marriage, and procreation, attitudes that both reflect and perpetuate the recreational approach to sexuality found in our secular culture. Based on personal experience, experience with patients, my own research, and the research and wisdom of others, I am persuaded that there is a spiritually authentic and scientifically sound approach to human sexuality and procreation that is largely lacking in medicine today, but that is essential to restoring full respect for human life in our culture.

Perhaps my first direct encounter with secular doctrine on sexuality in medicine was a required weekend "human sexuality attitude reassessment" seminar. Part of that course included several hours of hard-core pornographic films, used to "broaden" students' perspectives on human sexuality. In considering whether I should attend this seminar, I prayed and counseled with my church leaders, an approach that has helped me steer through many issues since that time. Along with a few other classmates, I opted out of that weekend seminar by writing a paper on my personal attitudes on human sexuality and how they would affect the care I would give patients who had attitudes different from mine. This helped me clarify my thoughts on how I could be true to my belief in the sacredness of human sexuality and the value of chastity while providing compassionate care to patients who may not have such beliefs. I began to learn how to treat all patients with full human respect, including those who make choices that I consider to be immoral. 

During pharmacology class in medical school we were taught that hormonal contraception ("the pill," and other forms), 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 life. A small group of us in the medical school class decided that because of this, we would not prescribe hormonal contraceptives. Those that made this commitment included a Catholic, a Baptist (both women), and myself, a Latter-day Saint (LDS). I don't know for sure about my classmates, but I have stuck with that decision throughout my training and practice, and it has opened the way for me to give much to my patients that otherwise I might never have been able to offer.

The potential of hormonal contraception to act after conception offers an interesting study in contrasts in modern medicine. Despite being acknowledged in most standard gynecologic and pharmacologic texts, it is unknown to most physicians, and is ignored in almost all literature on contraception that patients receive. The evidence that hormonal contraception acts in this way is not definitive, but it is strongly suggestive. Patients should be told of it under the principle of informed consent. Women and their husbands need to have the best available medical information in order to make decisions about family planning that are in accord with their own values and moral conscience.

Learning that the pill could act as an abortifacient was the beginning of my questioning the value of contraceptives. During my residency training in family medicine, I avoided doing tubal ligations or vasectomies because of official statements by LDS church leaders strongly discouraging these procedures. I came to recognize that fertility is a part of health, not a disease, and that there is something fundamentally contradictory about doing a surgery to impede a healthy function of the body. Over time and experience with patients, I began to think that any form of contraception had detrimental effects on marriages and even nonmarital relationships, although not everyone recognized them. Based on a growing understanding 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 man tries to undo this connection.

Sexual union in marriage ought to be a complete giving of each spouse to the other, and when fertility (or potential fertility) is deliberately excluded from that giving I am convinced that something valuable is lost. A husband will sometimes begin to see his wife as an object of sexual pleasure who should always be available for gratification. This tendency is reinforced by the dominant perspective on sexuality in our society, which idealizes unlimited sexual titillation and gratification freed (at least theoretically) from any consideration of pregnancy. Sterilization and hormonal contraceptives especially feed into this prevalent and highly distorted male perspective (which is also adopted by many women). Couples can also easily lose sight of why they have made a decision to avoid pregnancy and then not discuss the issue for months or even years, developing an approach to their sexual relationship largely divorced from even the thought of procreation. There are also medical side effects of greater or lesser nature with every contraceptive. Within a couple of years, I came to the decision that I could not in conscience prescribe contraceptives of any sort (whether or not they are abortifacient), because I felt that on at least some level, all contraception is detrimental to marriage and to the health of the spouses. 

I would not have been able to make a decision not to prescribe contraception had I not simultaneously learned of an effective, scientifically sound, and spiritually healthy approach for family planning. There are simple, accurate ways to monitor and interpret the signs of fertility in a woman's body. Couples can learn to use these signs of fertility to plan conception by intercourse during the fertile time, or to space births by genital abstinence during the fertile time.

The primary fertility signs are: 1) the changes in vaginal discharge around the time of ovulation that correspond to the secretions from the uterine cervix that allow the sperm to survive and move about, and 2) the rise in basal body temperature, which is a marker that ovulation has occurred. With proper instruction, these signs can be reliably interpreted independent of the calendar, regardless of whether a woman's cycles are regular or irregular. In fact, these basic physiologic phenomena of human fertility have applications that go far beyond being simply a method of family planning "naturally," i.e., without contraceptives. Nevertheless, because the term "natural family planning" (NFP) has been widely used to describe the basic understanding of the cycles of fertility and infertility of a woman's body, in addition to its application for spacing pregnancies, in this essay I will refer to all applications of this knowledge under that rubric.

Three modern methods of NFP are supported by a strong body of scientific data: 1) the sympto-thermal method, based on observations of vaginal discharge and basal body temperature, sometimes combined with other symptoms; 2) the ovulation method, also know as the Billings ovulation method after Drs. John and Evelyn Billings, based solely on observations of vaginal discharge; and 3) the Creighton Model System, an adaptation of the ovulation method with standardized protocols for use and teaching, developed at Creighton University. Each of these methods has a strong base of medical studies demonstrating high effectiveness in avoiding pregnancy.

Couples who have a serious need to space pregnancies or to avoid pregnancy altogether can reliably do so by using NFP. Many (perhaps most) couples face such situations during some seasons in their marriage. If there were no effective alternative to contraception (other than complete abstinence) to avoid conception, this would seem a hard bind indeed. 

The periodic abstinence used in NFP to avoid pregnancy can be challenging, even at times very difficult, but it strengthens marriages as both spouses put the needs of the other-and their marriage-ahead of their own needs. It takes faith to use NFP: if not faith in God, then at least faith in the strength of one's marital relationship and in the good will and ability of each spouse to yield to the gentle discipline of NFP for the common good of their marriage and family. 

This faith is well rewarded: there is a strong "courtship/honeymoon" effect among NFP users, even after years of marriage. Abstinence from genital contact during the fertile phase evokes a sense of periodic "courtship," after which the couple enjoys a periodic "honeymoon" that increases the appreciation and enjoyment of the sexual union. Available research suggests that the overall frequency of intercourse among married couples using NFP is about the same as among most married couples using contraception, but that it is distributed differently. I have known couples in my practice using contraception who routinely have daily intercourse, but these couples do not have anywhere near as satisfying a "sex life" as those couples I see who use NFP. Simply put, NFP enhances marriages in a way that the use of contraception does not. 

I find that the following benefits come to those couples who use NFP: 1) they come to a deeper appreciation of fertility as a gift from God rather than a biological phenomenon to be manipulated or a curse to be avoided; 2) they are usually able to consciously and rapidly achieve pregnancy when they so choose ("surprise" pregnancies are rare for NFP users); 3) they reevaluate their choices about fertility on an ongoing basis; 4) in their intimate relationship, each spouse sends to the other the implicit and powerful message: "I accept all of you, including your fertility"; 5) they learn to assume and to exercise joint responsibility for decisions about their fertility; 6) they learn that times of abstinence from genital contact can strengthen their relationship. 

Most people who start to use NFP do not do so because they expect to experience the benefits to their relationship and spirituality that I have just described. Research suggests that a majority are initially interested primarily for the health benefits-the absence of medical side effects and the insight into the normal functioning of the body. Others begin use of NFP because of a prior religious commitment. Regardless of the reason for beginning use of NFP, most research has shown that, compared to other family planning methods, a relatively high proportion of users continue to use it. And after some months of use, most users will tell you that they have noticed some of the benefits to their relationships that I have described.

The fundamental distinction between NFP and contraception becomes clearer when couples who are using NFP to avoid pregnancy try to conceive. For couples who are contracepting, choosing to conceive usually means discontinuing the contraceptive (or using it erratically and inconsistently) and "taking chances" or "seeing what happens." While some users of NFP may occasionally employ this language, their experience is qualitatively different. Unlike most contracepting couples, they know very well when they are likely to conceive, whether or not they are deliberately "planning" to do so. They have a level of understanding about fertility, with its attendant privileges and responsibilities, that is simply unavailable to the couple that relies on contraception for family planning.

This understanding has the potential to profoundly inform the couple's appreciation of the divine power of procreation. Unlike contraception, NFP does not encourage the minimization of the number of offspring. Quite the contrary. While NFP does enable couples with serious considerations to avoid pregnancy reliably, it also encourages couples to have as many children as they can reasonably care for. Seen from a Christian perspective, this is a distinct advantage of NFP that is shared by no other family planning method. NFP is by its very nature open to life.

I do not mean to imply that married couples who use contraception will necessarily have marital or family problems. I know many wonderful couples who are very open to life, are completely committed to their families, and yet also use contraception. Yet I remain convinced that many of these couples would switch to NFP if they had the opportunity to really understand it and the additional blessings it bestows. 

There are two other dimensions of NFP that I can only briefly touch on here, but that are of equal importance to its value to space births. The first is the strong hope that NFP offers couples who struggle with infertility. NFP is the foundation for an approach to infertility that is based on restoring the natural, God-given processes of human reproduction to their healthy functioning. This stands in radical contrast to most of the high-tech efforts in infertility today, which treat human life as an object to be manipulated scientifically rather than as a sacred reality. Many couples and physicians come to rely on in vitro fertilization and related procedures because of their laudable desire for fertility, only to find themselves facing unexpected moral dilemmas such as what to do with cryo-preserved embryos. The "natural procreative" approach to infertility, which can even incorporate sophisticated medical and surgical techniques as long as they are used to restore the normal physiology of fertility, is based on a respect for the processes of human procreation and for human life at its earliest stages.

Rigorous data on the effectiveness of the natural procreative approach (which receives virtually no research funding at present) have yet to be compiled, but I am persuaded by available data that it will prove to be at least as effective as the present medical approaches to infertility. (The Pope Paul VI Institute for the Study of Human Reproduction in Omaha, Nebraska, is leading the way in developing the "natural procreative technology" approach to infertility.) This application of NFP will probably be the first to break into the mainstream of reproductive medicine. Even so, it will encounter stiff opposition from those who are invested in the currently prevailing system for medically treating infertility.

Another essential contribution of NFP is the superior approach it offers to women's gynecologic and reproductive health. A knowledge of when and whether a woman is ovulating, and when and whether her reproductive system is functioning normally, is of great value in diagnosing and treating conditions that relate to the reproductive system, such as premenstrual syndrome, irregular vaginal bleeding, endometriosis, and ovarian cysts. By far the most common way that physicians currently treat all of these common conditions, with variable success in controlling symptoms, is by placing women on birth control pills or other hormonal treatments that suppress the normal functioning of the reproductive system. In contrast, NFP offers the prospect of developing medical treatments that will restore normal functioning of the reproductive system. Further, NFP helps women understand their bodies more thoroughly, allowing them to participate as equal partners in any medical treatment. In my own practice, I see a qualitative difference in treating women for any of these conditions who are using (or who begin to use) NFP to understand their cycles, and those who do not. Research will develop a much greater realization of the potential of this approach in the future. 

As good as current methods are for identifying the time of fertility during the menstrual cycle, I believe that we will develop more complete and effective approaches in the future. A few couples still have substantial difficulties learning to interpret their fertility signals. However, I have found that when couples that encounter these difficulties are given the best possible medical and moral support, they usually stick with their choice to use NFP, and are able to come through such difficult times with a stronger marriage for it.

Less than 1 percent of all couples in the U.S. use modern NFP. Why not more? The issues include lack of understanding, lack of access on multiple levels, a culture that is saturated in contraception, and intrinsic issues of trust. In addition, there is a minority who perceive NFP as "natural contraception" and who therefore reject it along with contraception. 

In a culture where one is statistically unlikely to know anyone who uses modern NFP, it is hard to get accurate information about it, much less social support for using it. Effective use of NFP requires adequate instruction, which needs to be provided by a trained teacher. The number of NFP teachers available varies geographically, but is still very limited in most places. Insurance companies do not reimburse couples for professional health services related to NFP to the extent that they do for contraception or sterilization, though this is slowly changing. Physicians and health professionals are widely uninformed (or misinformed) about modern NFP, and usually they do not even discuss the option with patients. I first learned about NFP not through my classes, but through an optional noontime lecture series organized by medical students to cover items not addressed in our medical school curriculum. Most medical schools and continuing medical education programs lack adequate and accurate information about NFP.

Contraception has become such an integral part of medical practice that it is difficult for those medical students or physicians who decide not to prescribe it to be allowed to complete their training, and in the field of obstetrics and gynecology it is almost impossible. I do not attribute this to any conspiracy, but to the cultural acceptance and promotion of contraception of the past nearly thirty years. In this regard, one should not underestimate the influence and role of pharmaceutical companies in the widespread prescription of contraception by health professionals, since they are perhaps the single greatest source of funding for continuing medical education and professional journals in obstetrics and gynecology.

At any rate, the lack of use of NFP is not because most women or couples are intrinsically satisfied with modern contraceptive methods. Relatively few women really enjoy the physical experience of being on the pill or other hormonal contraceptives, with their assorted side effects, common and uncommon. I have not met any women who really enjoy having to put in a diaphragm, nor men who would prefer to put on a condom in order to have intercourse. Research has demonstrated that many women and men are looking for something better.

I do not presume in any way to judge others (particularly my patients) when they choose to use contraceptives. Their choices about their reproductive potential are between themselves and God, and it is their right and responsibility to determine for themselves what they will do about their fertility. In discussions with patients, I strive to be balanced in discussing my medical assessments of various contraceptive methods. At the same time, in a nonjudgmental way, I try to convey to patients, to the degree that they are ready to hear it, why I think that there is a healthy and effective alternative that is in full harmony with their fertility and with who they are as human persons, as children of God. I clearly let them know what I can and cannot do within my own conscience, and that they will need to go elsewhere if they choose an option in which I cannot participate. Almost all of my patients are quite understanding of this. Those who do end up choosing to use prescription contraception nearly always return to me for the rest of their medical care. I have found that approximately one-fourth of my patients who did not previously use NFP choose to do so after having a detailed discussion with me. (On the other hand, many of my patients come to me because they are seeking a physician who will support their prior choice to use NFP.)

In addition to many family physicians, there is a growing number of obstetrician-gynecologists who have made the decision to prescribe only NFP for birth spacing, infertility, and most or all remaining aspects of reproductive health. I have become very involved in the work of the American Academy of Natural Family Planning, an organization committed to professional service and research within a moral framework of full respect for life and procreation. I have served as chairman of the science and research committee, and recently as president. The fact that I am one of few non-Catholic members of that organization has not hindered my deep friendship and common purpose with these faithful health professionals.

I am often asked by my Catholic friends about the stance of the Church of Jesus Christ of Latter-day Saints on contraception. There are very few recent statements from LDS church authorities explicitly on the subject of contraception, but statements by church leaders have made very clear the following relevant doctrinal points: 1) Human life is sacred from the moment of conception. 2) Chastity is of central importance both outside and inside marriage. 3) Marriage is a cornerstone of God's plan for humankind. 4) There is a divinely mandated and inseparable link between sexuality and procreation. 5) The body is a sacred gift from God and a central part of the purpose for our earthly life. 6) The body is the temple of the Holy Spirit. 7) It is vitally important that we do nothing that would harm or injure the health or normal function of the body. 8) In this mortal life we need to search out, learn, and live by the laws that govern our earthly lives. 9) The first commandment given to married couples to multiply and replenish the earth is still valid. 10) Children are "an heritage of the Lord," the Lord's blessings to a married couple. 11) Family life is where the greatest blessings of life are found. 12) Each husband must be respectful of his wife's health and well-being. 13) Parents must carefully seek divine inspiration to plan for and care for their families. 14) Self-control and mutual respect are vitally important components of the marriage relationship.

A recent proclamation on the family by the First Presidency and Council of the Twelve Apostles of the Church states:

The first commandment that God gave to Adam and Eve pertained to their potential for parenthood as husband and wife. We declare that God's commandment for his children to multiply and replenish the earth remains in force. We further declare that God has commanded that the sacred powers of procreation are to be employed only between man and woman, lawfully wedded as husband and wife. We declare the means by which mortal life is created to be divinely appointed. We affirm the sanctity of life and its importance in God's eternal plan.

Of course I have become quite familiar with Catholic perspectives on these issues. I have read and reread Humanae Vitae, the 1968 encyclical of Pope Paul VI. Although there are some theological points in it with which I disagree, I find myself in complete agreement with the fundamental vision of human sexuality and family life that it beautifully sets forth. I believe that the insights of that encyclical could only have come from divine inspiration. Similarly, though I cannot agree with every detailed point of Pope John Paul II's Evangelium Vitae, I find his vision of the battle between the Culture of Life and the Culture of Death very illuminating. 

The strongest resistance to NFP will probably remain concentrated among those who believe that population control is the most critical issue of our time, because they correctly sense that NFP is not as "reliable" as many methods of contraception from the perspective of encouraging people not to have children. As I have noted, the deepest inroads for NFP into mainstream medicine will probably come initially from its potential to help couples with infertility. Eventually, I hope to see the majority of health professionals in the United States come to accept NFP as an option that should be available to all women and couples. Even those who are committed to contraception and countenance abortion could support this additional "choice." There are an increasing number of health professionals who promote the health benefits of NFP while still seeing NFP as essentially one of many methods of contraception, whatever its advantages might be. 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 the fertile time-a version that maintains some health benefits of NFP but loses its spiritual benefits. 

The ultimate value of NFP will be found by those who approach sexuality in faith. They will come to realize 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 supports the virtue of chastity. It helps spouses see each other as persons and creators of persons-appropriately enough, because it is in procreation that people become most aware of their status as children made in the image of their Father.

Joseph B. Stanford, M.D., is Assistant Professor of Family and Preventive Medicine at the University of Utah and was until recently President of the American Academy of Natural Family Planning. Parts of this essay are adapted from an essay that appeared in Physicians Healed (One More Soul).