Yes, FEMM is biased, but Fertility Awareness isn’t: In response to “Revealed: women's fertility app is funded by anti-abortion campaigners”
A few days ago, The Guardian called out the FEMM fertility app and organization for receiving funding from anti-abortion campaigners. The article also pointed out FEMM’s criticism of birth control and used outdated and questionable statistics to support an assertion that fertility awareness is not reliable. While some of these claims are well-founded, we shouldn’t allow fertility awareness to be painted with such a broad brush. The author suggests that fertility awareness works against women’s rights by using a hidden agenda to strip them of their choices, but that couldn’t be further from the truth.
The article from The Guardian exposes some very valid concerns about conflicts of interest in reproductive health, but then carefully selects facts that support their claim, while ignoring others. The writer oversimplifies the issues, and in doing so, is actually being subversive. Fertility, birth control, and abortion are complex, multi-faceted issues. It should be up to each individual to decide what is best for them, and it’s not helpful to be swayed by misleading, incomplete information as we make these important decisions.
True informed consent is the foundation of my practice. Providing people with real, accurate, unbiased, research-based facts is the only way to help others lead their healthiest lives. Because of this deeply held belief, I feel compelled to shed light on all that The Guardian’s article selectively omitted in order to bolster their argument. Whether you are considering FEMM teacher training, looking for help learning fertility awareness, or share a concern for body literacy and reproductive justice, you deserve to know the facts.
The Truth about Fertility Awareness
Fertility Awareness Based Methods (FABMs) are a group of non-hormonal contraception practices that involve teaching a menstruator how to observe fertility signs (like cervical mucus, basal body temperature, and cervical position). Once a user understands how to interpret their fertility signs, they can follow a set of rules around when sex is likely or unlikely to result in a pregnancy.
These methods are growing in popularity, most likely because they allow people to avoid medical intervention and unpleasant side-effects of birth control. Using fertility awareness puts you in the driver’s seat of your own health and reproductive goals. It can be a very empowering experience to take control of your fertility, and it aids people in becoming more comfortable in their bodies. In these ways, fertility awareness works outside of the patriarchy, big pharma, and medical insurance companies to put the power in the hands of individuals.
Fertility Awareness Based Methods of contraception are evidence-based and can be highly effective. There are many different FABMs, and each has its own set of rules and efficacy rate. While the most effective of FABMs is the Sympto-thermal Method (99.6% effective when used perfectly or 98.2% with typical use), there are some FABMs that are less effective at preventing pregnancy (1). The Rhythm Method for example, relies on predictions of fertility based on previous cycles. With a perfect use efficacy of 95.2 % and a typical use success rate of 88.8%, this is not a very effective method (and some might even argue that it’s not a true FABM at all) (2).
Unfortunately, most fertility apps are based on the Rhythm Method, which degrades the reputation of FABMs. When all methods get lumped into one group, the average efficacy rate can make all FABMs seem less effective. The Guardian’s report cited outdated efficacy rates from the Center of Disease Control (CDC) in which there was no differentiation between failure rates of different FABMs. The CDC recently updated their efficacy listing of FABMs, now citing a failure rate of 2-23%, depending on the method (3).
Problems with FEMM
I completed my Fertility Awareness Educator certification through Fertility Education and Medical Management (FEMM), but I won’t teach their method. On the FEMM website, you can read about the non-profit’s mission of empowering women to make informed choices about their bodies and health through education and medical support. Although this mission isn’t inclusive enough to perfectly match my ideals, I felt it was similar enough to my own goals and a valid training program. I researched the organization and didn’t find any red flags. I had heard praise from many FEMM-trained educators about the quality and rigor of the program. And while it’s true that the FEMM teacher training is full of quality, accurate information, there are also several discrepancies and exclusionary tactics within the program- and even more importantly, the organization- that are problematic.
Most of the research cited in FEMM is peer- reviewed, quality information. That means on a foundational level, FEMM is using science to teach how hormones affect our bodies, as well as how to identify and interpret some fertility signs. In terms of biology, anatomy, and physiology of the menstrual cycle, FEMM is spot-on. I learned SO much (especially in terms of cervical mucus). But there was a subtle bias in the information presented, and in a time full of bias against uterus-owners, it seems prudent to call them out.
1.“Predicted” Efficacy is Not Actual Efficacy
Regardless of the fact that FEMM has not yet conducted or participated in efficacy studies, they do list an efficacy rate in their presentations. It is unconscionable to present an efficacy rate for a method that hasn’t been studied.
FEMM has been careful to not list their efficacy in many places (like their website). In the FEMM Family Planning presentation, the efficacy rate presented makes it look like FEMM is 88-97% effective when charting cervical fluid only and 92-98% effective when charting cervical fluid and LH. When I asked my instructor where I could find the complete study, she told me that these numbers are the typical and perfect use numbers for other Fertility Awareness Based Methods that are based on the same rules and principles as FEMM.
Contraception failure rates are a big deal! FEMM’s representation of the efficacy rate is intentionally misleading and damaging to the women they claim to serve.
2. Conflict of Interest
In a statement to Catholic News Agency, FEMM founder Anna Halpine said “We think that this knowledge is basic women's health literacy, and we think every woman has the right to know how her body works, in order to make an informed choice about how she wants to manage her fertility” (4).
With a mission like that, we need to talk about the elephant in the room. FEMM’s founder, board of directors, and funding all have strong ties to Catholic and anti-abortion organizations. That’s not to say reproductive health programs can’t ever be based on ideology, but rather that organizations should be very transparent about those connections. FEMM’s subtle ideology (discouraging all other methods of contraception and safe sex practices, as well as not including LGBT and non-binary people in instruction for this method) is harmful and deceptive.
Anna Halpine, FEMM founder, also founded the World Youth Alliance, an anti-abortion youth activism group. The World Youth Alliance has provided funding to FEMM. The Guardian’s report included lots of other funding ties that I was unable to find on my own, but which should be taken seriously.
There may also be some conflict of interest in the Medical Management aspect of FEMM.
If FEMM is so new that there have been no efficacy studies, we should also be skeptical of the validity of the Medical Protocols created and implemented for FEMM Health. There is virtually no information about this on their website or in any of their teacher training materials.
FEMM trusts the Reproductive Health Research Institute (RHRI) to run their Medical Management program. In the article from The Guardian, the credentials of the doctors involved with RHRI are questioned. The report from The Guardian also indicated a concerning connection between FEMM, RHRI, and the World Youth Alliance. According to Jessica Glenza, reporter for The Guardian, “The institute is registered at the same New York City address as the Femm Foundation and another anti-abortion organization called World Youth Alliance. When the Guardian tried to call RHRI, a receptionist answered the phone as the World Youth Alliance” (5).
If the Reproductive Health Research Institute, where people receive treatment for fertility and reproductive needs, is connected in any way to an anti-abortion group, they should be very transparent about their agenda.
3. Opposition to barrier methods and safe sex practices
In the FEMM teacher training program, FEMM states that condom use can inhibit a person’s ability to distinguish between different types of cervical fluid, and should therefore be discouraged. While it is known that lubricants and spermicide can make observation more complicated, it’s hard to understand why using a condom would make cervical mucus observation less confusing than having semen in the vaginal canal. When I asked the FEMM instructor for clarification she told me that in her opinion risk of infection is more important than the risk of an unclear observation, implying that it’s better to use a condom when necessary, but that condom use doesn’t really fit in with FEMM. In my practice, it’s a bad idea to dissuade anyone from using condoms under any circumstances. I urged the instructor to revisit this suggestion, as it is not evidence-based, and could be harmful.
4.FEMM is not for everyone
Let me preface this one by saying that there is no single birth control or fertility awareness method that works for everyone. We all have different bodies, needs, and priorities in terms of reproductive health. According to their mission, FEMM is for all women, regardless or race or age. In reality, FEMM is for cis gender, monogomos women in heteronormative relationships.
Fertility awareness should be accessible for all people. FEMM excludes menstruators by only using gendered language in all of their materials. In an effort to make FEMM more inclusive, I offered to send them resources and to edit materials. My communication was ignored.
There is another red flag here. Apparently FEMM (a Catholic organization primarily run by white people) has an interest in providing education in rural Africa, which looks suspiciously like white saviorism. I’ve been unable to find much information about this, aside from one promotional video posted on the FEMM website. It appears that FEMM partnered with Doctor’s Health Initiative, a private non-profit based in Nigeria. Not surprisingly, the twitter account for Doctor’s Health Initiative shows several statements about God as well as photos of smiling participants at anti-abortion rallies.
5. Claims not based in science
FEMM advises against becoming too familiar with your own anatomy. While many FABMs encourage regular checks of cervical position, FEMM asserts that internal cervix and cervical mucus checks create a higher risk of infection. While it makes sense that any time the cervix is touched, there is a risk of infection, I’ve been unable to find any studies that support this claim. My larger concern about discouraging self-cervical checks is that it disconnects us from our bodies. Does FEMM have such little faith in users to wash their hands? It shows just another attempt to decide what is best for menstruators rather than giving people information about risk, and then encouraging them to make informed choices.
One of my initial main concerns about FEMM is that their method is based on cervical mucus, with application for optional LH testing. It is well-known that LH testing is not a reliable measure of or predictor of ovulation. LH testing can only confirm that the hormone LH is present. The presence of LH alone does not ensure ovulation will occur. It is possible to get a positive LH test and not ovulate. It’s also possible to get a negative result due to “missing” the LH surge. FEMM estimates that LH tests are effective in predicting ovulation only about 80% of the time. This leads me to question the validity of using it as the only secondary measure. There are other signs of fertility that are far more accurate and objective (like basal body temperature, which can’t predict ovulation, but can confirm it). If FEMM’s goal is really to help users avoid or achieve pregnancy, their trust in LH test over other, more accurate fertility signs does not make sense.
FEMM makes two claims in their education program for which I have found no supporting studies. They claim: birth control use causes premature cervical aging and birth control use during adolescence causes delayed maturation of cervix (making the cervix more vulnerable to disease). These two claims suggest to users that hormonal birth control is dangerous. While there are several studies that show hormonal birth control can cause nutrient depletion (6), decreased size and vascularity of the clitoris (7), increased risk for depression (8), and some cancers (9), it’s important to note that there is currently no scientific study linking birth control to damage of the cervix.
The article by The Guardian criticized FEMM for their statements against birth control, but in doing so, failed to look at the big picture. The pill has revolutionized what it means to be a woman. Hormonal birth control has helped so many people to live full, happy, rich lives without fear of unwanted pregnancy. But it’s far from perfect. In fact, most people who use hormonal birth control suffer from side effects. According to one study from the Center for Disease Control and National Health Statistics, 47% of people discontinued use of a birth control method due to adverse side effects (compared with only 9.3% who discontinued use of a non-hormonal method due to adverse side effects). To present birth control as a perfect solution is a disservice to uterus-owners.
So what?
When many of these issues became obvious to me (within three weeks of the start of my program), I contacted the FEMM teacher training instructor. She ignored my repeated attempts to contact her. The organization also ignored my repeated requests to be added to the FEMM Teacher’s Facebook Group. Ultimately, I chose to continue my training because I felt that I needed to participate in the full program to be able to identify biases, inaccuracies, and be taken seriously by the organization. My hope was to urge FEMM to make some positive changes to their program in order to create a more accurate and inclusive program. Unfortunately, my attempts to start conversations with my FEMM teacher and in the FEMM Facebook group were ignored.
My hope is that this explanation helps menstruators make an informed decision about which organizations, educators, and apps they support. I’d also be very grateful if the FEMM organization was interested in hearing ideas about improving their program.
Sometimes, it feels like our world is divided against itself- if you’re one thing, you’re against another. But in the reproductive health world, that just isn’t true. You can be pro- fertility awareness and pro- birth control and pro- choice. To have real informed consent, we have to be exposed to multiple perspectives. Most importantly, we have to call out people who push their agendas in a subversive way if our goal is true empowerment.
Bibliography
Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention: A Systematic Review. Peragallo Urrutia, Rachel MD, MS; Polis, Chelsea B. PhD; Jensen, Elizabeth T. PhD; Greene, Margaret E. PhD; Kennedy, Emily MA; Stanford, Joseph B. MD, MSPH [Review] Obstetrics & Gynecology. 132(3):591-604, September 2018.
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. “Contraception | Reproductive Health | CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Dec. 2018, www.cdc.gov/reproductivehealth/contraception/index.htm.
Rezac, Mary. “FEMM Fertility App CEO Says Women Have the Right to Understand Their Bodies.” Catholic News Agency, Catholic News Agency, 31 May 2019, www.catholicnewsagency.com/news/femm-fertility-app-ceo-says-women-have-the-right-to-understand-their-bodies-66482.
Glenza, Jessica. “Revealed: Women's Fertility App Is Funded by Anti-Abortion Campaigners.” The Guardian, Guardian News and Media, 30 May 2019, www.theguardian.com/world/2019/may/30/revealed-womens-fertility-app-is-funded-by-anti-abortion-campaigners.
Dante, G., Vaiarelli, A., & Facchinetti, F. (2014). Vitamin and mineral needs during the oral contraceptive therapy : a systematic review.
Clitoral Vascularization and Sexual Behavior in Young Patients Treated with Drospirenone–Ethinyl Estradiol or Contraceptive Vaginal Ring: A Prospective, Randomized, Pilot Study Battaglia, Cesare et al. The Journal of Sexual Medicine, Volume 11, Issue 2, 471 - 480
Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry. 2016;73(11):1154–1162. doi:10.1001/jamapsychiatry.2016.2387
“Oral Contraceptives and Cancer Risk.” National Cancer Institute, www.cancer.gov/about-cancer/causes-prevention/risk/hormones/oral-contraceptives-fact-sheet.
Center for Disease Control and Prevention, National Health Statistics,Contraceptive Methods Women Have Ever Used: United States, 1982 – 2010, February 2013