Talk:Comparison of birth control methods

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[edit] Scope of article

Is this page intended only to show effectiveness of various methods? Or is it envisioned to expand to compare other things such as side effects, convenience, etc.? Lyrl Talk Contrib 01:29, 17 July 2006 (UTC)

I've no idea. Certainly original wording was of being a comaprison of risks, yet in fact only shows failure rates.
  • In favour of more info would be that it becomes a quick ready-comprison chart (difficult to do if having to read through lots of separate full articles). But it needs to be brief, else will never fit on a page. Perhaps just using summarised info as currently found in the BirthControl infobox templates ? This articles title is about "comparison", not "relative contraceptive effectiveness rates".
  • Against - It will end up duplicating info included already in each article (via the infobox template and the rest of the article's description). Unless extraordinary care is taken, the necessary crude summarisation (eg for COCP risks "DVTs") is so brief as to be lacking in balance (eg when the DVT scare came out about 3rd generation COCPs having higher rates of DVTs of 25-20 per 100,000 - those who immediately stopped, against media advice, and subsequently became pregnant through other-methods failures were at even higher risk rates of DVT of 60 in 100,000) - yet fuller explanations may end up getting too long to fit onto a single table in this page.

As the article/table stands at the moment, it would be a candidate for merger suggestion with Pearl index... David Ruben Talk 02:18, 17 July 2006 (UTC)

I have several concerns on the article in its current state.
  • It only discusses Pearl Index method for calculating pregnancy rates. While a majority of studies use Pearl Index, many studies use life table rates that do not have some of the problems PI does.
  • It makes birth control recommendations (via the color-coding).
    • An encyclopedia should not give medical advice.
    • The recommendations do not take into account individual characteristics (e.g. a person who can remember to use condoms at every act of intercourse, but can't remember to take a pill daily, could have a lower actual failure rate with condoms vs. pill - even though the perfect use rate of the pill is lower than that of condoms).
  • It groups together a number of only very loosely related methods under Natural Family Planning. Observational and lactational methods should be broken apart from the Rhythm Method.
I also share David's concerns on duplicate information and summaries not giving the topic a good coverage. However, there did seem to be support for an article similar to this in the following discussing: Talk:Birth control#Effectiveness of birth control section Lyrl Talk Contribs 22:16, 18 July 2006 (UTC)

May I suggest a comparison of the cost of the various methods? —Preceding unsigned comment added by 124.104.22.78 (talk • contribs) 01:15, 15 June 2007

In general, I think that's a good idea, but I'm not sure from what perspective to start such a section - retail cost, wholesale cost, cost to the user (which may be subsidized)? Lyrl Talk C 12:16, 16 June 2007 (UTC)

[edit] Lea's shield

I have serious doubts about the failure rates associated with Lea's shield. I've read the FDA Summary of Safety and Effectiveness (http://www.fda.gov/cdrh/pdf/P010043b.pdf) and they talk about 9% and 14% rates (with and without spermicide). In fact, the low indexes I have found are at http://www.contraceptiononline.org/contrareport/article01.cfm?art=210, and they talk about 4 and 6%, but correcting the statistics because of a supposed bias associated with few nulliparous users. Anyway, it seems that till now the data is scarce, so if we choose to say 4% I would add a note about low sample used. --213.194.135.44 15:21, 5 August 2006 (UTC)saragc

[edit] Delete for now?

There seems to be very little interest in working on this page. I propose deleting it for now and concentrating on improving the birth control article. When that article has sufficient information to need a spin-off, I think we could re-create a much better version of this page. Lyrl Talk Contribs 01:33, 25 July 2006 (UTC)

No - I really like the list for allowing comparison of effectiveness rates and banding into highj/medium/low effectiveness rates (agree "not recomended" is poor phrasing in an encyclopedia), just not sure if article title correctly reflects the current content (vs perhaps Comparison of birth control effeciveness or better Birth control (effectiveness)) or whether table should be expanded to meet full meaning of article title (i.e. other comparisons than just effectiveness - various approaches as previously discussed but no consensus on). Likewise table as it currently stands best here or in Pearl index article. If we can get a few more editors to suggest where we go from here than perhaps can tag article, vote/consensus and make a change. But work-in-progress, even if goal not entirely clear is not a reason for deletion; well perhaps it is if one is a deletionist, but I'm more a weak inclusionist :-) David Ruben Talk 02:06, 25 July 2006 (UTC)

Comment - I'm the original author of the page, so I won't take a stance here :-) . I'd just like to clarify that I compiled it simply because I wished to see an overview of birth control methods by using some information from the "fact boxes" on most of the birth control method articles here as a base. That way, I figured me and others could avoid navigating through dozens of articles if just being on the look after basic facts and references. I now understand the problem with heavily summarizing the subject, but if it helps to include other measures for efficiencies and other important properties, I'm all for including such here. My intended scope was anyway just that; a side-by-side overview of the "fact" boxes on most of the birth control articles. If another article covers such a summary, I admit this may not fill much use. If not, I believe it does, but feel free to vote it away if you feel like. ;-) I'd hope for people to do consider fixing it up if merely finding it to be lacking, though. I am in no way an expert on sexuality matters, so maybe I had no clear view of what's important, and you do. -- Northgrove 21:31, 9 August 2006 (UTC)

One more thing, the Pearl Index used was simply chosen because it seemed to be most prevalent and easiest to find agreeing figures on from various sites, as well as being formerly documented well on Wikipedia. I applied no thought to the PI itself and its accuracy when using it. -- Northgrove 21:40, 9 August 2006 (UTC)

Merge - I would suggest merging it with Birth Control. Also, I think that maybe it's ok to stick with colors and ranges, but not with labels "high/low", because I think that is quite subjective, isn't it? It strikes me as odd to have withdrawal as a low risk method, together with condoms, for instance. And I would suggest also to use the same source for all the failure rates of the different methods, for instance the ones given by FDA. In this way, it doesn't matter so much the accuracy of the data, because you can always make a comparison between them. If we use different sources, this can be seriously distorted. 81.32.8.78 20:10, 12 August 2006 (UTC)saragc

i vote for a merge with pearl index, as it's stubby and this article is only a comparison of effectiveness of different forms of birth control. i think there is no way to concisely summarize the comparative risks of bc in tables/boxes in an informative way. all the risks are too complicated, too enmeshed in controversy and opinionated risk-benefit calculations. plus, the categories bear comparison to each other, and then methods within categories bear comparison to each other--bc doesn't lend itself to a handy pocket guide/simple comparisons or decisions, i don't think... Cindery 22:13, 6 September 2006 (UTC)

[edit] Effectiveness calculation

The stats are presented as "chance of getting pregnant in a year". As well as being dependant on the method, this obviously depends on how many times you have sex during the year. Is there a standard assumed in these stats? Any allowance for variance of frequency around the menstrual cycle? It would be nice to be able to say, if you have sex once, using method X, at point Y in the cycle, the chance of pregnancy is 1 in n. The small amount of info about "Effectiveness calculation" suggests the stats are not that precise and simply based on a sample of couples in a marriage-like relationship who reported back at the end of the year. I might hazard a guess that such couples average 2 or 3 times a week. Clearly, your mileage will vary if you're at it twice a day, or twice a year for that matter. However, sociologically, the numbers for a per-copulation rate would be so small people could be misled into thinking them negligible. Suppose a method has a 10% annual failure, based on say 120 copulations per annum. Some arithmetic leads me to a per-copulation failure rate of under 1-in-a-thousand. A lot more people would take those odds. jnestorius(talk) 07:55, 27 January 2007 (UTC)

Pregnancy rates based on where a woman is in her menstrual cycle are discussed at fertility awareness. During the least fertile portions of the menstrual cycle, couples could go twice a day or more and have a less than 1% chance of pregnancy per year. On the most fertile day, a single act of intercourse results in pregnancy about 2/3 of the time. This is a huge variation in fertility. Combined with the fact that most women do not track their fertility signals, I believe that makes any "sex per year" stats completely useless for birth control purposes. I think we're stuck with the "couples reporting back at the end of the year" method (though note actual studies typically have followup at least monthly). Lyrl Talk C 15:50, 27 January 2007 (UTC)

[edit] Failure rates involving another statistic (sex frequency) is confusing

The failure rates reported here don't take sex frequency into account. They are based on how many women (in real life) become pregnant during a year, when using certain forms of contraception. They therefore don't represent absolute truths about the chance of getting pregnant. Instead, these failure rates indicate the chance of getting pregnant during 'typical use', compared to all the women in the studies that were taken into consideration. If your sex life resembles the 'typical sex life' of these women, your chance of getting pregnant during one year's use of a particular method will be the same as reported here.

NB Recent Dutch research showed about 60% of people in a steady relationship had sex once a week or less. 'Typical use' is therefore probably not based on 120 occurrences of intercourse. Not in the Netherlands anyway... —The preceding unsigned comment was added by 193.67.185.234 (talk) 16:06, 23 February 2007 (UTC).


Agreed, and changed the title (it seemed more like a response then a statement.) This is very confusing because although this article assumes there is some constant number, unusually feisty people or even people that don't know much about other relations might not know the real chances for them. Also, a side-effect of not knowing the exact statistic is the sex frequency of these groups could be differant, which means this entire article could be off. Simplifying it to per experience, or a solid number close to to experiences per year, or at least letting everyone know what that number is so they can figure it out for themselves. MikedaSnipe 03:41, 2 May 2007 (UTC)
During the least fertile portions of the menstrual cycle, couples could go twice a day or more and have a less than 1% chance of pregnancy per year. On the most fertile day, a single act of intercourse results in pregnancy about 2/3 of the time. (See fertility awareness) This is a huge variation in fertility. Combined with the fact that most women do not track their fertility signals, I believe that makes any "sex per year" stats completely useless for birth control purposes. Lyrl Talk C 00:45, 4 May 2007 (UTC)

[edit] Very confused by table sorting

If you go to this section, with the table, and you look at the fourth column titled Perfect-use failure rate (%), and you click on the button underneath the word "failure" that sorts the methods, we see that there are two different sorting methods and four different displays (with each of the two methods displayed from top to bottom or vice versa, for four displays in total). Just watch for where Lea's shield is sorted and you will see what I mean; either all the methods are sorted by color with Lea's shield at the opposite end (top or bottom), or with it integrated and the colors sorted slightly differently. I am very confused by this and would appreciate it if someone could explain. Better would be if someone would write an explanation and include it in the article.

Also, could someone explain the default sort, before any buttons are pressed? Thanks! Joie de Vivre T 12:35, 16 June 2007 (UTC)

[edit] Local availability

A user had recently noted that the Prentif cervical cap is not available in the United States. This is true. The contraceptives Jadelle and Lunelle are also not available in the United States, and there are many countries where the ring and the patch, for example, are not available. I do not believe there is enough room in the table to provide availability data on every contraceptive for every country, or even for five or six "world regions". There is also not a good reason to provide information for the United States without providing information for other parts of the world, so I have removed the note about U.S. availability. The topic of availability can be covered in the individual articles. LyrlTalk C 14:09, 13 April 2008 (UTC)

Seems reasonable, it was getting cumbersome as you note. In a similar vein - I note there has been a trend of late to put brand names on the contraceptives. (Today sponge, Prentif cap) Don't think that is such a good move, unless there are wide differences in effectiveness of different brands (in which case should list separately). Rather than getting tied up in details of different brands, think more useful to focus on comparison of the techniques in general, e.g. use (typical values for sponge, rather than any particular one). (Using specific brands moves it closer to advertising.) I don't think there is a particular problem with noting example brands in parenthesis, like Mirena or Coper T to help clarify the item, but using the brand as the front part of the item title seems less desirable. Zodon (talk) 18:14, 13 April 2008 (UTC)
The other brands have not been tested as well. Additionally, Contraceptive Technology, the source of most of the numbers in the table, only lists brands available in the United States. Today is the only brand of contraceptive sponge marketed in the U.S., so the Contraceptive Technology listing for "contraceptive sponge" cites only a study of the Today brand. This confusing U.S.-centric labeling of the table meant that specifying the brand in the table got overlooked. The contraceptive sponge article cites studies of the other brands; I don't have access to the full text of these studies and am unsure of judging how authoritative they are. It's nice to be able to cite a authoritative secondary source who judged the study's results reliable before including them here.
Similarly to the sponge, the 18th edition of Contraceptive Technology listed effectiveness the only brand available in the U.S. (Prentif) under "cervical cap". The U.S. distributor of Prentif went out of business in 2005, so the brand is no longer available in the U.S. - and not listed in the 19th edition of Contraceptive Technology. FemCap is now available in the U.S., and Oves in Europes, but there is currently a dispute over the content of the cervical cap article and no effectiveness rates are listed. Apparently the study of FemCap was not judged authoritative by Contraceptive Technology: they did not include it in their 19th edition, published just last year. For other brands of cap available in Europe - Dumas and Vimule - no effectiveness studies have ever been done. LyrlTalk C 19:41, 13 April 2008 (UTC)

[edit] Propose change initial sort/coloring to typical use

For most users of these methods, the typical use information is more relevant than the ideal use. So it doesn't make much sense to emphasize the ideal use characteristics at the expense of the typical use ones in the table. This is particularly evident in the current sorting of such methods as IUD and female sterilization. Because of small differences in ideal use effectiveness, they are listed after several methods which in practical use have 10 times their failure rate. For practical purposes, ordering and coloring by typical use would make more sense. e.g. something on the order of

  • green = typical use failure rate less than 1%
  • yellow = up to 10%
  • orange = up to 20%
  • pink = 21%+

(Or perhaps add another color, so green = <1%, unspecified color = 1-9, yellow = 10-20 (basically the 15-16 clump), orange = 21-30, pink = 30+) Zodon (talk) 09:14, 20 April 2008 (UTC)

Is there a way to color for both numbers? One color in the typical column and one in the perfect use column (the names might have to be left white in such a setup)? I don't have an opinion on the initial sort criteria, but I do think both numbers are useful.One person may be unable to remember to take a pill at the same time every day, but have no trouble remembering to use a barrier method at each act of intercourse; such a person might be interested in the typical use information for the pill and the consistent use information for a barrier method.
I'm not sure about us making the judgment that one number or the other is more relevant for "most users". Unfortunately the initial sort forces that judgment to be made, but it would be nice if the coloration system at least could be more neutral. LyrlTalk C 22:06, 20 April 2008 (UTC)
Y Done I've coloured Typical & Perfect use values separately (this edit) as per key currently in table (up to 1%, up to 5%, up to 10% and over 10%). Of course not having a single colour for a method means teh method name & type should nolonger be coloured. The previous hidden values needed to be shown greyed out (either no Perfect use value so copy the Typical use for sake of having some value to sort, or in FA, no Typical use value, so value used was that in article. David Ruben Talk 23:11, 20 April 2008 (UTC)
I've then split off into purple values over 20% and then rearranged the order the table is initially shown with (i.e. by Typical values) - partly because of the above points but also from copyediting decision that Typical-values are the left-hand (ie first) of the two columns of values and so takes visual presidence. Items with same Typical-values are then sorted by Perfect-use values and finally alphabetically. David Ruben Talk 23:33, 20 April 2008 (UTC)
Neat - this way works even better than what I had in mind. Thanks. Zodon (talk) 05:48, 22 April 2008 (UTC)
Ditto to Zodon: nice job, thank you, David. LyrlTalk C 21:35, 22 April 2008 (UTC)
I changed all the colors so that they would be a reverse spectrum from blue to red (rather than the way they were previously: green, yellow, orange, red, purple). I also added grey for "no data" and thistle (purple) for "see footnote" (when the sources conflict, or any other reason a clear answer cannot be given). Whistling42 (talk) 02:11, 25 April 2008 (UTC)

[edit] Sortable table provides one round of correct sorting, another of incorrect sorting

Try this: visit the comparison table, and click the button to sort by "perfect use" rates, once. Only once. See the two "no data" items at the top, there? OK, now click it again: what's happening is that it is being sorted in a different way. I don't know the name for it, but if you look at the very top of the block of blue items in "perfect use", and start moving your eyes up line by line, you will see it go from 2 to to 20 to 26. Clearly it is being sorted in a way that make mathematical sense, but is useless for this comparison. Is there a way to make the sortable table not do this? (I asked over at Help talk:Sorting as well.) Thanks! Whistling42 (talk) 02:44, 25 April 2008 (UTC)

It worked with this version - but adding in text of "no data" (rather than previous imperfect copied data with caveats) seems to have broken sort system. Also even on 1st click, the "no data" entries come to top of list which is unlikely. Personally I'ld suggest going back to previous "all cells have a number" :-) David Ruben Talk 03:51, 25 April 2008 (UTC)
But for those three cells, there is either no data (and thus no number), or there is a wide range of data (and thus no clear choice on which number to use). Feel free to check out Help talk:Sorting (section) for a suggestion which I didn't quite understand. Whistling42 (talk) 03:57, 25 April 2008 (UTC)

This problem has been solved, thanks to EncMstr. (Thanks!) Whistling42 (talk) 18:22, 25 April 2008 (UTC)

[edit] Sorting order

I put the fertility awareness item back to sorting with the Contraceptive Tech typical use effectiveness. Now that adding other text won't mess up the sort order, no reason we can't use an authoritative comparative review source (where available) for sort order, while also noting ranges of values. Zodon (talk) 17:13, 25 April 2008 (UTC)

I reverted this change: "no data" means "there is no data", not "we're going to list it here, because we can deduce that it is at least this effective". The "sort" button for typical-use values is right there, if someone wants to see that value, they can. The value you proposed putting under "Perfect use" is not accurate. This could easily confuse readers (who may not bother to read the footnote).
There is a very wide range of values for the typical-use effectiveness rate for fertility awareness: the sources range from less than 1% to over 25%. That range nearly spans the entire range of efficacy for all methods, from the most effective to the least. It doesn't "mess up the sort order" to leave one item out of one sort range; it is clearly marked with a different color. When the available research produces such conflicting results, the article should clearly reflect that. Whistling42 (talk) 18:20, 25 April 2008 (UTC)
Note that Contraceptive Technology is considered by many to be "The most authoritative source we know for comparing the effectiveness of various methods of birth control" [1]. All but one study of fertility awareness was available when the latest edition was published; the authors reviewed the studies and found them to not meet "modern standards of design, execution, and analysis". The source used by Cont Tech (the CDC's National Survey of Family Growth) has its own problems, so the fertility awareness article goes into more detail. But Hatcher et al believe the NSFG number is more reliable than the studies, and they are the authority. In an overview article such as this I think it may be best to just cite Cont Tech and use their number, leaving caveats to the individual articles (see Depo-Provera as another example of where the Cont Tech typical effectiveness may not tell the whole story). LyrlTalk C 12:55, 26 April 2008 (UTC)
I think that if there are any situations where CT does not tell the whole story, this chart should reflect that in some way, whether with a footnote, a separate color, instructions to read the footnote instead of giving a number, a combination of two or all three. Whistling42 (talk) 12:03, 27 April 2008 (UTC)
Why was the addition of Trusell to the sources giving 25% failure rate removed from note 5?
Some of the sources given in note 5 do not say what note 5 says they do. For instance, Shao-Zhen Qian, et al. does not say what the failure rate is in typical use. The use they studied includes: having to pass a test about the method to be accepted into the study, having a trainer continuously working with and monitoring the couple, and monthly review sessions with the researchers. Nowhere is it indicated that support of this level is available to the typical user, either in China or worldwide.
Similar levels of support would ensure almost perfect use for methods like DMPA, CIC, patch or ring (which require monthly or less frequent action), and would undoubtedly improve success in other methods that require user actions. To make a meaningful comparison between method effectiveness they must be provided similar levels of support, and corrections made for special support that is not uniformly available. If some method receives special support for typical users, that should also be noted.
The broad range indicated in note 5 appears to be in part the difference between typical use and near-perfect use. (It is not clear that the figures reflect typical use.) As with any method who's effectiveness depends on user actions, it is possible to get better than typical results. That is one of the messages of typical use vs. perfect use. So far, I still favor use of Contraceptive Technology. If you wish to reject Contraceptive Technology and their definition of typical use, please suggest an alternative definition for typical use and indicate why it is superior (with sources, of course). Thanks. Zodon (talk) 04:57, 27 April 2008 (UTC)
As far as support, women who learn in a classroom will almost always have a followup visit a month later included in their teacher's fee; in some organizations (such as the Couple to Couple League) the teaching fee includes unlimited followup for one year after the class. So I don't know that PMID 17314078 (I believe the only study published after the 2007 edition of Contraceptive Technology was released) presents a completely unrealistic typical failure rate. Unfortunately, that study was done in Germany. Compared to populations of other countries, Germans seem to experience a significantly lower typical failure rate with all methods of birth control. So I also wouldn't want to present that study as applicable to the entire world.
For fertility awareness in this article, I would like to see the chart use the Contraceptive Technology number, with a brief footnote such as David had made in this diff. LyrlTalk C 13:29, 27 April 2008 (UTC)

[edit] 4 May revert

DavidRuben added the 25% number to the fertility awareness line with a short footnote, and both Zodon and I have expressed support for that format. Why this number was removed from the article I'm not sure.

I have also de-integrated the references for effectiveness from the references for the remainder of the article; both the integration and the large number of calls to the Contraceptive Technology citation made the information more difficult to navigate.

Lastly, I have removed the specific methods of fertility awareness for which we do not have effectiveness data; a blank line in a table is of no use to readers. LyrlTalk C 20:44, 4 May 2008 (UTC)

[edit] User dependence

Some of the material in User Dependence section doesn't make sense. It seems to imply that barrier methods are more user dependent than hormonal methods, and that therefore the spread between typical and perfect use effectiveness is larger.

However, looking at the data it isn't clear that that is true. E.g. for hormonal contraceptives with daily to monthly action required the spread is about 8% (typical is 26x the perfect use). For the condom the typical is only 7x the perfect use (though admittedly the absolute difference is 13%), however several of the other barrier methods show even less spread (diaphragm or cap about 8% absolute difference, 2x relative difference).

Seems like things may be a little more complicated than the section suggests. Perhaps a reference or two, or some revision is in order. Zodon (talk) 10:27, 23 May 2008 (UTC)

There also seems to be some overlap between the user dependence and the ease of use sections. Perhaps some of the material should be merged? Zodon (talk) 02:26, 24 May 2008 (UTC)

A merge sounds good. I've looked around a little for sources: this one seems to just classify methods as "user-independent" and "user-dependent", without the middle category currently described in this article. Although this source expresses a belief that lower frequency of required actions will increase user compliance, it only talks about hormonal methods (pill vs. ring or patch vs. shot). A rewrite to conform to sources would probably shorten that section, making it a good candidate for merging. LyrlTalk C 02:44, 24 May 2008 (UTC)

[edit] Proper use of female condom?

I'm confused by this edit. It's not immediately obvious to me what the requirements for proper use of a female condom during intercourse are that distinguishes it from diaphragms, caps, and sponges. LyrlTalk C 02:47, 24 May 2008 (UTC)

The difference that I had in mind was that with the other methods (diaphragm, cap, sponge), no particular user action is required during intercourse. Once you have the method properly inserted the only other action/preparation needed is possibly adding spermicide. However with the female condom, care must be taken that the penis is inserted inside the condom. When I asked a family planning physician about why is the female condom less effective than the male condom, she said that one of the reasons is that sometimes the penis gets misdirected outside the condom. (I have no citation for that, but that is what gave me the idea for the change.)
So the others female barrier methods are sort of insert and forget, the female condom requires action/care during intercourse to use it properly. I hope that makes it clearer what I was trying to say. Sorry it wasn't clear, I will try to think how to clarify the text, or if you have suggestions how to make it clearer. Zodon (talk) 06:16, 25 May 2008 (UTC)
The above is also why in the table entry for Female condom I added "+ penile covering" to delivery, and had changed the User action column to "During sex," and set it to sort with the male condom.
I didn't see your revision of the table putting the female condom back to before sex until today. (i.e. I was unaware of it when I made the edit you asked about above, didn't mean to work at cross purposes.) I understand why saying "Before sex" seems natural, and saying "During sex" is unexpected. But after thinking about it, it seemed that the level of interruption/care/etc. required for the female condom is more similar to the male condom (both require some care during sex) than it is to the diaphragm, etc. It seemed worth making that distinction in the table. (So there is some care required during sex, but not as much as with withdrawal.)
I had considered something like "Before and during sex," but thought that would be even more confusing; "During insertion," was ambiguous (it meant insertion of penis, but could be confused with insertion of female condom). I haven't come up with a compact phrasing that I though was great, open to ideas.
I tried putting it back to During sex and adding a footnote to explain the unexpected value. Does that help any? Zodon (talk) 07:30, 25 May 2008 (UTC)
The penis can also go on the wrong side of the diaphragm; more likely in certain positions and if the diaphragm isn't a good fit, although a few couples have anatomy that makes this particular failure mode likely even with good fit and careful insertion of the penis. Sponges (and sometimes caps) can become displaced over several hours; if one was not inserted immediately before intercourse some practitioners recommend checking to make sure the device is placed correctly before penetration occurs.
So while I can see a note about taking care during initiation of intercourse (penetration?), I'm currently not convinced the female condom is unique in this regard. LyrlTalk C 12:01, 25 May 2008 (UTC)
The context of the items in question is ease of use/user dependence/when is user action required. One disadvantage sometimes mentioned for the male condom is that putting them on interrupts sex, so requiring user actions during sex may be regarded differently than requiring actions before sex ease of use standpoint. Therefore it seems reasonable to distinguish those methods that require action during intercourse from those that don't. Admittedly, how much action is required may also be significant, but I don't have references for that, and any evaluation of that nature would require citations, or be WP:OR.
Here is an example of use instructions for the female condom which say that part of proper use is during intercourse: Engender Health - Female Condom Instructions "Once you begin to engage in intercourse, you may have to guide the penis into the female condom." (Presumably this would be after the stage where a male condom would have been applied.)
The instructions that I am familiar with for use of the diaphragm, sponge and cap are all along the lines of insert device (w/ spermicide, etc.) before intercourse. Add extra spermicide and check position before (or between) intercourses. Remove it so long after intercourse. The instructions in the wikipedia articles for these methods are along these lines, and a brief search didn't turn up anything much different. Is there some user action that is routinely recommended during intercourse? If so, then I agree we should update the items here to indicate that action is required during intercourse. We should probably also update the articles about the individual methods as well.
If for the other methods this is a possible failure mode, but it is not under direct user control, then it seems a different thing from the female condom - where it is under user control and preventing it is part of the regular instructions for use. Zodon (talk) 05:44, 27 May 2008 (UTC)
The position a couple chooses for intercourse is something they can control. While there are sources that talk about the diaphragm not working for "some sexual positions, penis sizes, and thrusting angles and techniques"[2] or advise "If you change positions, you may want to check to see that the diaphragm is still covering the cervix" [3], you are correct that these are not nearly as prevalent as the "guide" recommendation in female condom instructions. But, many or most couples have to guide the penis in to begin intercourse when not using a female condom [4], [5].
So, two things: first, I'm not convinced the guiding bit of FC use is anything other than par for the course for most couples having intercourse. Second, stopping to verify the correct position of a diaphragm or cap seems like it would "interrupt" more than incorporating guidance into an act of intercourse. Such an evaluation could not be put into the article without sources, but we don't have a source that explicitly says diaphragms are less bother than female condoms, either, which is what the current formatting of the table implies.
For the "ease of use" section I've tried to reword it to prevent the confusion I mentioned when starting this discussion. LyrlTalk C 16:30, 27 May 2008 (UTC)
Any thoughts on my comments above? Also, any thoughts on the level of detail for use instructions in this article? It strikes me as unsymmetrical to explain that the FC must be removed before standing up, but to not mention that the male condom needs to be held onto when disengaging for the same reason (preventing slippage that could lead to semen in the vagina). LyrlTalk C 11:52, 28 May 2008 (UTC)
The part about needing to remove FC before standing was along the lines of part of why it is different from the other female barriers (which must be left in for some time after sex). It also occurred to me (after I logged off) that mentioning the need to withdraw promptly after sex and hold onto the male condom would make sense as an ease of use matter.
As far as thoughts on your comments of 27 May, I am still thinking about them. It still seems to me that the female condom has some fundamental usability differences from the other "female barrier methods," (not necessarily better or worse, just different) and I am not yet persuaded that the differences are insignificant. I need some time to read the references you posted and check some articles on female barrier method use/failure/user reactions to see if they lent more clarity to my thoughts. Zodon (talk) 22:51, 28 May 2008 (UTC)

[edit] User action and sorting

After thinking about the discussion on female condom usage, I'm leaning toward grouping all barriers and withdrawal together for user action in the table. While the different methods require different actions, which actions are more or less difficult or bothersome is going to vary from user to user. I haven't come across any good discussions of typical or most common attitudes on these actions, so any judgments on sorting order made by editors would be bordering on original research. Just saying they all require action for every act of intercourse (not specifying timing of action) gets around this issue. Not having to have footnotes explaining the sorting order also simplifies the table.

A related issue is the description of user action for LAM and fertility awareness. The current description for LAM says "every 4-6 hours", but that's a minimum. The actual guideline is "on demand", which for infants is commonly every two hours or less. The current description for fertility awareness says "daily", which I think is meant to imply once per day, but charting can require action several times a day. Taking a temperature in the morning, then using the thermometer's memory to recall the temp and record it before bed, for instance. With mucus observation, it's recommended to be aware of sensation throughout the day, and in addition look at one's toilet paper after every act of urination: that's probably at least four times a day for most people, plus again the recording. When I originally wrote the "ease of use" section, I was using "daily" in the sense of "at least once per day", not the current sense of "exactly once per day".

I think for both the text in the "ease of use" section, and the sorting order in the table, it would be nice to treat LAM and FA consistently. Either list them both as "daily" (in the sense of "at least once per day"), or specify for both of them a higher frequency ("on demand, min. every 4-6 hrs" for LAM and "observation throughout day" or something similar for FA?) LyrlTalk C 03:21, 1 June 2008 (UTC)

I based the sort order in the column on time - how frequent for the items that require regular action, how close to sex for the other items. (So withdrawal closer to culmination of sex, then condoms, then the methods that could be inserted before and removed after sex.) So while it was inspired by the ease of use sections, the order was based on something that was more objective (time). ("When" could be regarded as implicitly included in the title.) I agree, without some data wouldn't go into trying to order by difficulty/intrusiveness the various items are. (Since male condoms are frequently commented on as interrupting sex, felt confident putting them in separate category from cap/etc. Was debating having 2 groups - "during sex" and "before/after sex")
When I read something that says daily, I assume mean basically once per day. So I was a bit surprised when I read in the LAM article that it requires action every 4-6 hrs. Hence the change. Probably good to update it with the typical frequency rather than the minimal (I based change on what I found in the Wikipedia article on LAM). Wasn't aware that FA also requires multiple actions/day. I think important for clarity to differentiate methods that require actions once/day vs those requiring attention every few hours. (e.g. big ease of use/compliance difference having to take a pill once a day vs. doing it 4x/day. Sure you get a reminder with LAM, but need to know what getting into. Don't necessarily need to specify exactly how frequent the action is in each case in table, a category for multiple times/day would suffice.) So think should keep differentiation between pill and (presumably) calendar methods that really are once/day action and ones that require more frequent action.
I still favor differentiating methods that require action "during sex" from those that just require before/after (assuming there are any of the latter). But until I do some more reading, lumping them together is okay. However I am a little unsure about the phrasing "Every act of intercourse." If a couple has sex multiple times in succession, do all of those methods require action for each time? (I know condoms (m & f), withdrawal and spermicide do, but do the sponge/diaphragm/caps all require actions for each time?) Zodon (talk) 08:01, 1 June 2008 (UTC)
While cap/etc. can be inserted before sex, many couples prefer to insert during foreplay, at the same point a male condom would be put on. I like the idea of distinguishing potential differences, but I think the variety of ways to use these methods makes it too complicated to reduce to table format.
With diaphragms, it is recommended to add additional spermicide into the vagina before every 2nd, 3rd, etc. act of intercourse. Sponges and caps do not require additional action, but I'm afraid trying to distinguish them would make the table so much more wordy it would interfere with readability.
I think once/day is a good representation for calendar methods, but perhaps symptoms-based fertility awareness and LAM could both say "throughout day"? LyrlTalk C 13:56, 1 June 2008 (UTC)
Femcap should be inserted at least 15 minutes before any sexual arousal (Contraceptive Tech.). So some methods need action before sex. But moot since not differentiating in the table at this point.
In my comment above about the current phrasing - wasn't thinking of trying to distinguish the methods, wanted to seeing if we could come up with a phrasing that more neatly cover the variety of methods in the group. (Some require action before, some during, some several hours after, some at each act, some just before/after whole series.)
"Throughout day" sounds reasonable phrasing for the table entry on LAM & fertility awareness. Zodon (talk) 19:09, 1 June 2008 (UTC)