Whatever Happened to the Diaphragm?

I recently discovered that buying a diaphragm in Canada is harder than buying illegal drugs. Perhaps you think this is inaccurate. And it is, so let me rephrase: It is much harder to buy a diaphragm in Canada than illegal drugs.

Or perhaps, since it is so obscure, you don’t know what a diaphragm is. This was the case for one pharmacy worker I spoke to on the phone when I called hoping to find one that’s sold over the counter. “What’s it for—periods?” they asked. Another thought it was a type of IUD.

The diaphragm is an internal contraception device that a person inserts into their vagina and over their cervix to prevent pregnancy. It is non-hormonal, reusable over many moons and fully within the control of the person looking to prevent pregnancy. Further, it doesn’t leave people relying on insurance each month, as they do with the pill, or feeling like they’re in an Amy Schumer skit, as A.J. O’Connell writes, every time they have to re-up their prescription.

While the pill is still one of the most common methods of contraception (along with condoms and the withdrawal method) in Canada, fewer women are taking it: There was an 11% decrease in prescriptions for the pill between 2011 and 2015, which means more people are relying on other methods. So in a time when many are looking to divest themselves of hormonal birth control—and when many are concerned about limited access to abortion services—one would think the use of a method like the diaphragm would be on the upswing.

On the contrary, the diaphragm is next to obsolete. In fact, when I go to my local sexual-health clinic in Saint John, N.B., I’m told that it’s no longer available in Canada. Nurse practitioner Shelley Gautreau, who works in women’s health in New Brunswick, tells me that more and more patients are looking for non-hormonal birth-control options or, at least, options with lower doses. Usually, she recommends the IUD—either the hormone-free copper option or the low-hormone one—because diaphragms, she says, are “an old technology, and they are hard to fit.”

However, I decide not to take “no” for an answer. I keep researching and find that Clinique des femmes de l’Outaouais, in Gatineau, Que., according to its website, offers diaphragm fittings. I am determined, people, and not above driving to another province for this mission. But when I call to make an appointment for a fitting, the nurse who picks up the phone says, “We don’t do that here, no.”

Are diaphragms a thing of the past?

When I think of diaphragms, I think of that time on Sex and the City when Carrie’s gets stuck in her vagina and Samantha has to roll up her sleeves and retrieve it. Then there’s that episode of Seinfeld when Elaine unwittingly embarrasses Jerry’s date—who is a virgin—with one of her characteristically cavalier descriptions of her sexual escapades. She was talking to a guy, she tells them, when she threw her purse on the sofa and out flew her diaphragm! “So I carry around my diaphragm. Who doesn’t?!” she exclaims.

Consequently, as a teen, I thought diaphragms were what cool women used for birth control once they were good and far away from their parents and squarely in control of their own affairs. As I got older, though, none of my friends ever talked about diaphragms—everyone used condoms or the pill (if any contraception at all). The nurse practitioner at my local sexual health clinic said I was the first patient to ask for one in her 14 years of practice, and my local pharmacist told me she hadn’t filled a script for a diaphragm since she started her career in 2001.

There’s a bit of a self-fulfilling prophecy behind the diaphragm’s scarcity: It is generally regarded as outdated, and therefore there’s little focus placed on it in medical-school teaching. This means word often doesn’t get out to patients that it’s a viable option.

But that’s not the only reason many people choose other forms of birth control—the diaphragm comes with some downsides. It has a higher failure rate than other forms of contraception: With perfect use every time, it’s 94% effective. (That stat goes down to 88% when human error is factored in.) Also, notes Halifax-based Dr. Joyce Curtis, some planning is required because it has to be inserted well before you have sex because spermicidal gel, which is typically paired with a diaphragm to ensure maximum efficiency, takes anywhere from 10 minutes to half an hour to work (depending on which one you use; be sure to check the label). Further, she warns, it doesn’t protect against STIs.

A diaphragm can also take time to get used to: It needs to be folded, inserted and placed in the right spot. On top of all that, those looking to use the traditional diaphragm need to get their vagina measured by a healthcare professional to be sure they can get the right size, which is nobody’s idea of a good time.

But, all of that said, it is a good and effective option if you’re tracking your cycle, using the withdrawal method and want a backup during the time of month when you’re most at risk for pregnancy.

What has been gaining in popularity in recent years is the IUD. It’s 99% effective, and it’s the option many doctors choose to protect themselves against unwanted pregnancy. Newer models with lower hormone doses are being unveiled all the time, it seems, promising few side effects and lighter periods. This is not ideal for those looking to avoid hormones completely, though, and the copper IUD, while hormone-free, is not for everyone: For some people (Hi!), it induces longer periods with unearthly levels of cramping and relentless swamps of blood.

So, how do you actually get a diaphragm then?

Dr. Curtis is the only doctor I can find in the maritimes who seems able to discuss diaphragms and measure patients for them. So I book an appointment and drive the four hours to Halifax so I can get fitted—but it turns out that isn’t necessary anymore. She explains that the “older style” comes in six different sizes, and the vagina has to be measured and fitted with the right one. There is a design flaw, too. The ring-shaped device will block off the cervix in theory, but its structure isn’t quite right: It’s shaped like a cylinder, but the vagina isn’t perfectly cylindrical. Enter the Caya diaphragm, which is oval-shaped but flatter on the bottom, like a little boat, and fits over the cervix on the vast majority of people. You pinch it to insert it, kind of like a menstrual cup. It seems easy enough, and the best part? I can just go to any pharmacy and fill my prescription without getting fitted.

At least, in theory I can. The Caya, which is manufactured in Germany, was supposed to be available in Canada. But for the first six months I actively tried to get one, it wasn’t. Nobody seemed to know why it wasn’t being stocked or why the availability date kept getting deferred. I called the distributor, the supplier, retailers and Health Canada looking for answers, all to no avail. I thought pharmacies might have more info, but for months they kept giving me different availability dates.

Finally, though—finally!—after months of researching and running around and years of begging healthcare professionals to hook me up with a hormone-free method of contraception that would both allow me to neatly sidestep anything implanting itself in my uterus and not leave me bawling on the floor googling how to end it all, I get my hands on a small white paper bag that contains the coveted device.

When I pull the Caya out of its (frankly excessive) packaging, I’m impressed: It comes in a little white carrying case that looks like it was designed by Steve Jobs. And inside is my pale-violet saviour. It feels and even kind of looks like the nipple of a baby bottle, and it’s made of medical-grade silicone and nylon.

To my surprise, it’s actually quite straightforward to insert and remove. It takes a few awkward minutes in the bathroom wondering what the hell I’m doing and whether I should go back to “a silent prayer” being my contraception method of choice, but it doesn’t take long to get the hang of it. There’s a small tab that you can pull on to remove it, and overall it’s a more intuitive product than you’d think.

As for its efficacy? Well, it’s been over a month, and I’m still happily not pregnant. In the past, I’ve tried the pill, the copper IUD, condoms and the plain old withdrawal method, and my diaphragm gives me more peace of mind than any of those. I’ll continue to use it, coupled, of course, with spermicide—and maybe the odd prayer thrown in for good measure.