Self-Esteem and Use of Contraceptives

Four of the five studies investigating the association between selfesteem and contraceptive use report similar findings: low self-esteem is associated with less frequent or less sustained use of contraceptives. As shown in Table 4.2, the effect is sometimes apparent only for males, or only for females, or only under certain conditions. Always, however, when an effect is present, it is in the same direction. No study demonstrates a link between low self-esteem and effective use of contraceptives.

Two Canadian studies, one by Herold, Goodwin, and Lero (1979) and the other by Hornick, Doran, and Crawford (1979), investigated self-esteem in relation to contraceptive use by females. The sample and the measure in the former study were the same as those used in Herold and Goodwin's (1979) study investigating predictors of sexual attitudes. Females with high self-esteem expressed more positive attitudes toward using birth control pills, were more likely to have used effective contraception at last intercourse, and were more consistent in their use of birth control than were females with low self-esteem. When two groups of "extremes" were compared (sixty-eight users of birth control pills who were renewing their pill prescriptions, and seventy-nine subjects who had never used the pill or an IUD and had come for pregnancy testing), the self-esteem scores of the effective contraceptors were significantly higher than those of the ineffective contraceptors. The researchers conclude that self-esteem influences both attitudes toward and the actual use of contraceptives. They suggest that women who have a low sense of self-esteem may fail to use effective contraceptive methods,

first, because the necessary planning would require acknowledging their intention to engage in sexual behavior and, second, because they would be concerned about negative reactions to their use of contraception.

These data on self-esteem and contraceptive use are open, however, to the alternative explanation that adolescents who have not used contraceptives and who believe they may be pregnant may have low self-esteem for precisely that reason. In a follow-up report, Herold and Samson (1980) attempted to address this issue by analyzing the differences between 48 females who had not yet had intercourse and had come to a clinic to obtain birth control and 183 women who were already sexually experienced at the time they visited a birth control clinic. The young women who obtained birth control before initiating sexual activity were older at the time of first intercourse (17.4 years old, as opposed to 16

years old) and had higher educational aspirations than the sexually experienced women. Unfortunately, no statistical tests were reported, and the measure of self-esteem was not mentioned.

The Hornick, Doran, and Crawford (1979) study of contraceptive use among sexually active adolescents was based on responses from 144 female and 100 male high school and university students in south-central Ontario. (No other sample characteristics were given.) Contraception included the high-risk methods of withdrawal and rhythm, as well as the low-risk methods of the birth control pill and the IUD. The average age of the high school females was 17; the average age for males was 16.9. The mean age of the university students was greater, 19.3 years for females and 20.1 years for males. Because only some of the respondents were adolescents and the data were analyzed for the combined sample, we can draw only limited generalizations about adolescents from this study. Nonetheless, the subject's age did not emerge as a "best predictor" of contraceptive use for either males or females, and the results are consistent with those of Herold, Goodwin, and Lero (1979). Along with a number of other variables, high self-esteem, as measured by the Coopersmith Self-Esteem Inventory, was associated with greater contraceptive use by females; this was not the case for males.

Ager, Shea, and Agronow (1982) studied 143 clients of a Planned Parenthood teen clinic for eighteen months, from the time the clients first came to the clinic to obtain contraceptives. All the subjects were female, 79 percent were black, and most lived in Detroit. Their ages ranged from thirteen to seventeen; the median age was 16.1 years at the start of the study. Continuance or discontinuance of contraception was charted over time, and reasons for discontinuance were investigated. The most frequent reasons given for discontinuing use of the birth control pill were experiencing side effects (42 percent) and fearing side effects (17 percent). Eleven percent indicated that the distance to the clinic or its eventual closing contributed to their decision to discontinue contraception. Self-esteem, as measured by the Coopersmith Inventory, did not differentiate those who continued and those who discontinued using birth control pills.

When the risk-taking behavior of the adolescents was identified, however, those with low reported self-esteem or a high inclination to take risks were significantly more likely to discontinue using the pill upon experiencing side effects than were those with high self-esteem and a low risk-taking personality. That is, the impact of side effects on

behavior depended on the adolescent's personal characteristics. If she had high self-esteem and was a low risk-taker, she continued using the pill despite the side effects. From these data, we may infer that although many factors influence an adolescent's decision to discontinue using a "more effective" method of birth control, having high self-esteem, perhaps in combination with other characteristics, may influence her to persevere in using such a method, despite the difficulties.

In the studies described above, high self-esteem was associated with some measure of contraceptive use for females. Only one of these studies included both males and females in the sample and, again, the association between self-esteem and contraception was apparent only for females.

This was not the case in the only other study to report results for both male and female adolescents (Cvetkovich and Grote 1980). The characteristics of the sample and the self-esteem measure have been described earlier. In this study, contraceptive use was defined as the frequency with which some effective form of contraception had been used by either partner during intercourse in the previous three months. For white males only, more effective contraceptors reported higher self-esteem and did not relegate the responsibility for birth control to their female partners. They also disagreed with items implying that it was sometimes all right to chance a pregnancy.

Only Rogel and Zuehlke's (1982) study of contraceptive behavior in adolescence failed to find an association between contraceptive use and self-esteem. The 120 females who participated in the study ranged in age from twelve to nineteen, were predominantly black (98 percent), and were recruited from three clinics at the Michael Reese Hospital in Chicago in 1979. The majority of the girls were sexually active, and 75 percent either were or had been pregnant at the time of the study. The median age of first pregnancy was 15.6 years, with 81 percent of the pregnancies occurring by age seventeen. Self-esteem, measured by the Rosenberg Self-Esteem Scale, tended to be unusually high for the entire sample: 46 percent scored high on the scale (30 or higher on a scale that ranges from a low of 10 to a high of 40), and no one scored below 25. The high level and narrow range of self-esteem scores may explain why self-esteem failed to distinguish those who began contraception early from those who began late and from those who never used birth control.

The range of self-esteem scores does not explain why self-esteem should have been so unusually high in this group of adolescents. It may

have been the result, as Kaplan (1975) argues, of the sexual activity and the heterosexual relationships with which that activity is associated. The researchers suggest that girls may use sexual activity as a means of attaining intimacy and closeness with a valued person outside the family; they point out that most of the girls had infrequent sex with only one sexual partner, whom they had known for more than a year. Participation in the relationship may have bolstered self-esteem, resulting in a surprisingly high level of self-esteem in the sample and in the process obscuring any association that might have existed initially between low self-esteem and failure to use contraception. This interpretation, although speculative, is consistent with Kaplan's prediction that measures of self-esteem obtained after deviant behavior has been adopted may be the result rather than the cause of that behavior.

In sum, there is evidence linking high self-esteem to more effective use of contraception among sexually active adolescents. Because none of the studies controlled entirely for the possibility that pregnancy or guilt associated with not using contraception might account for the lower self-esteem reported by the less effective users, any causal inference must be tentative. Moreover, in the research available to date, high self-esteem has been associated with effective contraception primarily for white adolescents, thereby limiting the applicability of these findings to other groups. Nevertheless, there is sufficient correlational evidence to further consider a possible causal link between self-esteem and contraceptive use.