Beyond Superstition: How IUDs Moved

Nana Abuelsoud's picture. Illustrations of tiny trees with envelops on them is at the bottom of the image. Text on the image reads, "Beyond Superstition: How IUDs Moved" "Nana Abuelsoud, Egypt"

If I ever decide to celebrate Halloween, I’ll stick it on my cheek — that small device, unfamiliar to many — to evoke its magical powers of moving upward with a fluidity unseen by others. The IUD is a medically tested device with proven efficiency, but still, I’ve long had an inexplicable fear of it. Its reputation has improved in recent years, but the IUD is still surrounded by myth and superstition. As one strand of the myth goes, “it can wander up to the heart and the brain.” There are a few other rumors about it, of varying details but equal horror. Where does this bad reputation come from? 

In 1974, after two unplanned pregnancies, Loretta decided to insert a type of IUD called the Dalkon Shield. For six months, Loretta suffered from severe pain. Her doctor attributed the infection causing the pain to her sexual relations with American soldiers returning from Vietnam. Loretta did not correct his false, racist assumption, and she could not turn to another doctor because healthcare arrangements available to her were so limited. 

After sticking to the doctor’s prescription and lying to herself, Loretta could not withstand the pain anymore. On the eve of another consultation, she lost consciousness at home and woke up in the hospital to find out that doctors had performed a hysterectomy. She would no longer be able to plan a pregnancy after completing her studies, as she had wished. Loretta managed to pull her medical file and headed to another doctor. He confirmed that the Dalkon Shield could have been removed when her pain intensified. Thousands of women other than Loretta paid the price of racist and misogynist doctor biases, and suffered from fatigue, fainting and pain caused by the Dalkon Shield, with many similarly losing the ability to conceive or living unforeseen complications.

Since first appearing on the market in 1971, Dalkon Shield’s promotional campaigns in the United States and Puerto Rico relied on it being a better alternative to oral contraceptive pills, which cause blood clotting and increase the risk of cancer. After three years of widespread use in the US and abroad, Dalkon Shield led to severe uterine inflammation and miscarriages in thousands of women. It sold more than 3.5 million units in the US before it was pulled from the market under government pressure in 1974, with a total of 18 deaths due to its complications and 400,000 legal cases against its distributor, A.H. Robins. When losses reached their peak, Planned Parenthood stopped using Dalkon Shield throughout the US.

Feminist movements in the US and abroad pushed the judiciary to extend the class-action seeking damages for Dalkon Shield’s victims beyond the United States.

Some subsequent analysis attributed the reasons behind human losses to the absence of a binding protocol that would oblige healthcare providers to routinely test for STIs before and after inserting the IUD, a practice which has since become mandatory. Additionally, it was not subject to oversight from the US Food and Drug Administration (FDA). It was considered a device, not a medication, and the FDA’s guidelines at the time only applied to drugs and their distribution. Damages caused by Dalkon Shield led to substantive changes that expanded the FDA’s jurisdiction over managing contraceptives in 1976 and negatively impacted the range of contraceptives available in the United States for decades. Following the Dalkon Shield catastrophe, IUDs did not reemerge in American markets until 1984. Even after they had been made safer, American women across generations stayed away from IUDs

The birth of Dalkon Shield

Before his name became locally and globally associated with the medical establishment’s hubris and its abuses of women in the US and abroad, Hugh Davis was also abhorred in lecture halls, according to his son . Davis was a well-known figure in women’s health and family planning at Johns Hopkins University and headed several medical delegations to countries in South America due to his expertise in contraception and sterilization. Upon returning from an occupational residency in Denmark, he engaged with the public’s concern over population growth in the United States. Just like his colleagues, Davis’s scientific obsessions included finding a solution to address the failures of contraceptive pills and population growth. During his repeated attempts to mold a contraceptive device, he met an electrical engineer by the name of Irwin Lerner who was enthusiastic about marketing new products having just opened a factory of his own. And so, Dalkon Shield was born. Davis rushed the new product’s research and scrambled to publish incomplete study results praising it in medical journals in just one year without naming himself as its inventor, or mentioning his share in projected profits once it goes to market. Investigations later revealed that the study’s conclusions were weak as its evidence was based on a small sample over an extremely short time frame. The 1971 launch of Dalkon Shield in global markets coincided with the release of a book Davis penned for physicians, which contributed to increasing the new IUD’s sales and, by extension, his personal profits. After six months of Davis utilizing his scientific authority to promote the new product, A.H. Robins bought the new IUD, while maintaining its inventor’s annual profit share for the following three years.

Some writings tried to break down the name “Dalkon” to form the names of the men behind it: A “d” for Davis, an “l” for Lerner and a “k” for Lerner’s lawyer Robert Cohn — and it is said that the “shield” is inspired by a police shield. Looking at its shape on feminist printouts, I see the metaphor and I am filled with resentment. In some literature, it is referred to as the “spider-shaped IUD” on account of the two side prongs that hold it place. The string, which distinguished Dalkon Shield and helped market it as an easy device to insert, hold in place and remove, was like a cable formed of coiled wires. But the space between the wires created a path for bacteria to travel from the vagina to the uterus. Compared to other types of contraceptives, the US Centers for Disease Control and Prevention (CDC) concluded that women who use spider-shaped IUDs are more vulnerable to pelvic inflammatory diseases compared to women who use different types of IUDs.

A snippet of “Triple Jeopardy” (June, 1974)

Litigation

The distributing company A.H. Robins drowned in settling class-action lawsuits and filed for bankruptcy in 1985. The company’s leadership decided to dispose of the returned Dalkon Shield devices. 

The controversy around the Shield was completely missing from feminist and research statements specialized in interpreting reproductive trends and behavior in Arabic, even though there was no proof that it was no longer being used or that victims had been compensated for damages. 

Meanwhile, the United States Agency for International Development (USAID)’s family planning programs had extended its roots east and south, or in more historically accurate terms, had expanded to the “third world.” A.H. Robins’ director of global public relations pitched it to USAID as the ideal product for controlling population growth and family planning around the world, with bulk discounts up to 48 percent. In 1972, the director of USAID’s Office of Population Reimert T. Ravenholt, the godfather of the Demographic and Health Survey, enthusiastically approved the A.H. Robins offer. 

Ravenholt had long been obsessed with population growth in the third world and worked tirelessly to curb it. USAID obtained 700,000 units of Dalkon Shield, just over half of which went to the International Planned Parenthood Federation, while the rest was distributed among Pathfinder International, the Population Council and international aid for family planning. Unsterilized devices were shipped to the third world in actual shoe boxes. The distributor relied on the fact that countries benefiting from the aid’s generosity would sterilize it before use. Nevertheless, the company provided only one instruction manual per 1,000 units in English, Spanish and French, and only one applicator for every 10 units of Dalkon Shield. There are no complete databases that could be relied on to follow the international path of Dalkon Shield. There are scattered reports among international organizations and governmental authorities, but no specific numbers illustrate the limits of its deadly impact in the countries to which it was sent, such as Tunisia, Kenya, Indonesia, Nigeria, Brazil and Mexico. In other countries, such as Egypt, the databases are completely missing. 

Feminist movements in the US and abroad pushed the judiciary to extend the class-action seeking damages for Dalkon Shield’s victims beyond the United States. After altercations and a long wait to settle damages for Dalkon Shield’s victims, an Australian feminist spoke to the court about her frustration with the long litigation process and blamed the delay on some victims in other countries being unaware of their right to litigate. In a final attempt to get the job done and retire, the judge hearing the lawsuit appointed a lawyer to contact victims outside the US, to add their cases to the class-action. A deadline to file lawsuits was set on April 30, 1986.

A snippet of the April/May 1986 issue of “Up and Coming

On the other side of the distribution network, some governments in the Arabic-speaking region refused to authorize the campaign inviting women to participate in lawsuits against A.H. Robins, or distribute informational materials about contraceptives, including Lebanon, Egypt, Saudi Arabia, Iraq, Jordan, Kuwait, Syria and Bahrain. The Egyptian government did not respond to the claimants committee’s proposal to hold a press conference in Arabic in Cairo. In fact, it threatened those in charge about addressing contraceptives in public. An international advertising agency encouraged women to file lawsuits against the distributing company. Some governments — in Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Saudi Arabia and Syria — rejected its proposal to broadcast any messages about the Dalkon Shield. They attributed their decision to “religious and cultural reasons.”

To use the power of physicians to convince women of best contraceptive practices since the shared goal — at least, in theory — is providing health services that respond to women’s reproductive needs.

Why Dalkon Shield now?

The Dalkon Shield catastrophe was not the only time that faulty contraceptives made their way to us from abroad. Depo Provera, an injectable contraceptive, which was shipped to the third world before the spider-shaped IUD’s wounds had healed. Even though the FDA refused to approve Depo Provera as a contraceptive in the US in 1978, it noted in its decision the differing benefit and risk consideration among countries. The FDA said that there is no problem in non-Americans benefiting from contraceptives that are not allowed in the US. In less diplomatic words and crude terms, USAID’s advisory committee’s justifications leaned on the assumption that Depo Provera’s benefits outweigh its risks for women in the third world

Dalkon Shield’s echoes were still being heard all over Cairo’s 1994 International Conference on Population and Development, including in statements from Loretta Ross on reproductive justice. Not much time had passed. But I was struck by the fact that the controversy around the Shield was completely missing from feminist and research statements specialized in interpreting reproductive trends and behavior in Arabic, even though there was no proof that it was no longer being used or that victims had been compensated for damages. 

This is an attempt to uncover the history behind a feeling of unease, of distrust and even superstition that lingers around the IUD, and to contribute to a body of knowledge that starts here, where we are.

In a hurried search for anything written in Arabic about the Dalkon Shield, I only found writing by men using the catastrophe as an example of the damage international development and American aid cause to women and society through family planning programs. I could not find Nawal al-Saadawi’s rejections of Dalkon Shield in Egypt, which were mentioned by Dr. Amal Abdel Hadi in an interview from winter 2020.

I used to ridicule fears passed down through generations of women, because they are scientifically incorrect and inapplicable according to my limited knowledge of the history that formed these myths. In one phase of my career, I was convinced of the tactical importance of synthesizing physicians’ authority and women’s needs to achieve their reproductive rights. That is to say, to use the power of physicians to convince women of best contraceptive practices since the shared goal — at least, in theory — is providing health services that respond to women’s reproductive needs. My attempts failed rather dramatically.

I came to this research by way of curiosity about the panic over population growth in Egypt. That panic isn’t new here or — USAID has been spreading its fears about population growth since the 1960s. This piece isn’t intended as a critique of USAID’s policies towards women in the global south, nor do I want to contribute to a discourse that undermines women’s rights to access birth control from any provider. These are two sides of the same coin. This is an attempt to uncover the history behind a feeling of unease, of distrust and even superstition that lingers around the IUD, and to contribute to a body of knowledge that starts here, where we are. The IUD surely does not glide through the body to settle over the heart or inside the brain. But I’ve learned that there is always truth to the myth.

Sources Referred:  Vancouver Women’s Health Soc. v.A. H. Robins, United States Court Of Appeals, Fourth Circuit (June 1987)

BY NANA ABUELSOUD

This article was originally written in Arabic and published on Mada Masr.