2015 - Issue Three

Allowing the Body to Speak: The Power of Fertility Education

Hanna Klaus Download Article

St. John Paul II had it right.

When John Paul II began his pontificate one of his first tasks was to address the harm which the rejection of Humanae Vitae had caused. He responded with his catechesis on the Theology of the Body. As a phenomenologist he knew the importance of experience in forming judgments, attitudes and character. While his role as pope limited his direct teaching to speaking and writing, he encouraged experiential learning of the signs of the body’s fertility by natural family planners and teachers of youth. In this he followed Pope Paul VI who encouraged physicians to find effective methods for the regulation of births which were consistent with Church teaching (Humanae Vitae, 27). When seven of us―Margaret McGauley, Mary Fran Reid, Merrilee Underhill, Ann O’Donnell, Sisters Ursula Fagan MMS, Natalie Elder, CM, and I―began the Aware Center in St. Louis, Missouri in 1973 to teach the Billings Ovulation Method, our theological “underpinnings” were minimal, but we knew that fertility was not a disease and did not need to be isolated from the body to achieve marital harmony. We began with women/couples “where they were.” Most who sought a natural method came from a combination of obedience to Church teaching and a dislike or fear of the pill which had been available since the mid 1960’s.

Because we learned that our clients were coming to the class for such a variety of motives, we invited them to a group meeting to explore and discuss their reasons for seeking to learn the Ovulation Method. The majority of reasons were ecological and religious, but many women also expressed fear of failure of the method, or fear of a negative effect on their spousal relationship. Women who feared that the method would fail were often uncertain about their observations or how they interpreted them, or about their husband’s responses to being told that they were now fertile and needed to abstain if they did not want to have another child. We were able to relieve their uncertainty in follow-up sessions during which we reviewed the women’s charting and either affirmed or corrected it. Most women required no more than two additional meetings, while one woman came monthly for one year. With the women’s consent we made copies of their charts that included notations of the days of intercourse, and analyzed the outcomes.

At the end of our first year, the young director of St. Louis University’s Data Center reported that “all the women who became pregnant had intercourse.” I thanked him but added that the only couple about which this was in doubt was not included in our series. (This was prior to Louise Brown, the first IVF baby.) Our youthful helper did not understand, but was happy to reanalyze the data set to find out when in the cycle the conceptions occurred and to correlate the outcomes with the couple’s desire to achieve or avoid conception. We found that the women who learned the method correctly and followed it consistently had no pregnancies while those who misunderstood or “took chances” conceived. Larger studies later found that unplanned pregnancies due to a failure of the method were indeed few, ranging from 0‒2%, while user-related pregnancies varied depending upon how much a couple wanted to avoid an unplanned pregnancy: 0.52% in a large study in China to 12‒14% in Kenya, Korea and USA.

Women’s fears that husbands would not cooperate were dispelled when husbands learned to understand their combined fertility as a couple. Most women who anticipated difficulties had made untested assumptions. One young wife told the group that she had assumed that her husband would be angry if she refused intercourse because she was in her fertile phase and they had not planned to have another child. She was pleasantly surprised that he was more than happy to cooperate with her; all he needed was an explanation. Another woman was afraid that her husband would ridicule her for talking about mucus at all. Once the husband understood, he became a partner in decision making, much to his wife’s relief. Unfortunately there were, and are, men who, rather than admit their ignorance, belittle their wives. Teaching the husbands first, as during a cursillo,and inviting them to teach or bring their wives to class has proved to be proactive to ensure couple cooperation. Learning to understand and value their combined fertility changed many aspects of the marital dynamics.

Not long after helping to introduce the Billings Method in several Midwestern cities, Sister Joan Devane―a fellow Medical Mission Sister who was the Medical Secretary of the Kenyan (Catholic) Episcopal Conference―was in St. Louis on furlough, and saw the work we were doing. She obtained support from Misereor (the German Catholic Bishops’ Organization for Development Cooperation) and invited me to introduce the method in Kenya. The Billings method resonated with the Kenyan and other sub-Saharan women because it confirmed what their grandmothers had taught them. The method caught on so well that a formal evaluation was begun by CORAT-AFRICA and KEC, funded by USAID via the Johns Hopkins University School of Public Health. There were four sections to the entire program, and I was the “overseas consultant” to the Billings section. We were able to evaluate the effects of the Billings method in the special program in the parish of Nyahururu, Kenya. Leaders of 63 of the parish centers had been trained to teach the method. Couples who enrolled were pleased with their success.[1]

But we also wondered what intentional use of the Billings Method did to the couples’ relationship. We invited Dr. Violet Kimani, an anthropologist at the University of Nairobi, herself a Kikuyu, to interview a sample of couples. She and a team of Kikuyu medical students interviewed Billings method users to learn their views about the use of the method. The most significant change was the women’s view of the role of sexual intercourse in marriage. Prior to the program the most important function of coitus was to have children. A year later, it was the sharing of love. Not coincidentally, the women’s lives had significantly changed. The Kikuyu tribe is highly patriarchal, but after a year of Billings method use the women were sharing in all the domestic decisions: where to send the children to school, how to spend the money, etc. While most couples had indeed achieved their family planning goals, the most important achievement of the Billings method was not so much successful child spacing, but raising the status of the wife to one of full equality with her husband. This came about without external input: when a man learns to respect his wife’s body, he learns to respect her person, since, as John Paul II said “the body is a sign of the person.”

The Kikuyu men of Nyahururu were proud of their mastery of the practice of natural family planning, as were others who had been taught in the program. One Turkhana husband told us, “I used to be afraid to sleep in the same hut with my wife unless we wanted another baby. Now I can sleep in the same bed with her.” That’s power!

During the second meeting of Billings teachers in Melbourne, Australia in 1978, Dr. John Billings asked me to concentrate on teenagers, as there was considerable increase in premarital sex, contraceptive use and abortion since the advent of the pill. In 1980 the U.S. teen pregnancy rate was 12/1000. With support from the Joseph P. Kennedy Jr. Foundation we began a research project to teach fertility awareness to girls 15‒17 years of age. We identified the sites, and did not invite participants until we had met with their parents and explained our project. As parents are the primary educators of their children in all matters including sexuality, parental permission was, and is, a legal and moral entry requirement. The church and the school can assist in this task with the permission of the parents.[2] More recently some states in the US and UK have chosen to provide contraception and abortion to minors without obtaining parental permission but we do not follow this practice. The parent meeting is important not only to win the parents’ consent, but to clear up misunderstandings. We often encounter parents who fear that if their children learn to identify their fertile times that they will want to make use of the times of infertility to have sexual relations. Thankfully, our behavioral outcomes show that this is not the case. Many parents are using, or have used, contraception. It is not our place to challenge them, but to remind them that parents always want better things for their children than they had. So we hoped that if their child wanted to enter Teen STAR, that they would consent. Most women are not enamored of the pill; they just did not know there were workable alternatives.

I had written an outline for our teachers, but Mary Lou Bryant, an experienced teacher in Louisville, Kentucky changed it to make it appropriate for the needs of young girls. After explaining the program and getting consent from the girls and their parents, she began the first class by asking the girls if they wanted “to talk woman talk.” They did. They were very curious. And the very first question they asked was “what’s that stuff that comes out?” The girls were invited to record their observations of their cervical mucus and learned where it came from and what caused it. We went on to teach the girls about the different hormones which dominate the different cycle phases and their effects on emotions. The girls spoke about relationships, commitment, life styles, goals and ethical frameworks and had individual interviews to discuss their observations and their activities. Generally the girls needed to observe three cycles before they felt confident. One of the things which made them confident was learning that the time from ovulation, as indicated by the last day the mucus was slippery, clear and stringy, was followed by the same number of days until the next menstrual period. Knowing exactly when to expect the period was a huge victory. Now their bodies were speaking to them and the girls understood what they were saying. As a result they expressed increased self-confidence, began to resist peer pressure and made their own decisions. Their mothers reported this at the second parent meeting three months later. Girls reported all sorts of benefits from knowing their cycles. One of two sisters who were in the class told Mrs. Bryant “when my sister and I have a fight, I just say ‘Go get your chart’ and when I see that she is close to her period I just say, ‘Forget about it, we’ll talk later.’”

Our pilot group included 200 girls in seven U.S. cities. Twenty were already sexually involved when they began the program. Half stopped activity, three girls began activity: two experimented once each, one wanted to become pregnant and succeeded. The couple left school four months prior to graduation and had a big wedding, proving that free will still operates. The pregnancy rate for our group was 0.52/1000 which compared favorably with the rate for the general population. We named the program Teen STAR. Star stands for Sexuality Teaching in the context of Adult Responsibility.

Several of the mothers asked that we have a similar program for their sons, and Rev. Donald Heet O.S.F.S. crafted the Teen STAR curriculum for young men. It is necessary to have men teach the boys, as they need to learn not only reproductive physiology but self-possession, which is better caught than taught. We monitor behavioral outcomes not only through follow-up but with anonymous exit questionnaires. The boys’ behavior parallels the girls. Most of the teens we encounter have not begun sexual activity, and do not begin during the program. Roughly half of those already active stop.We found this to be true in USA, Chile, France, Poland, Ethiopia and Uganda. Because we had been able to show that Teen STAR supported premarital abstinence we were funded as an AIDS prevention program in Ethiopia and Uganda. Besides the thankfully excellent behavioral outcomes, the program opened up communication between teens and their parents about sexual behaviors, a topic which had been discouraged by the taboos of their culture. At one meeting in Assela in Ethiopia one of the fathers told of the change Teen STAR had effected in his son: the boy used to go to bars in the evening instead of doing his homework but now was bringing his friends home and getting the homework done. Then the father said “I am the government education officer for this district and have 22 schools and I want Teen STAR in all of them.” In time, the teachers were trained by the trainers of Teen STAR Ethiopia. The 2 and 3 year post-program behavioral outcomes from Ethiopia and Uganda showed similar outcomes as the earlier studies―excellent support for primary and secondary abstinence[3]―giving us some assurance that what we taught the young men had resonated with them and influenced their decisions later in life. Actually, 25% of our group had stopped intercourse more than 6 months ago, another 25% had stopped more than a year earlier.

Longer effects are known only anecdotally. One teacher attended an alumni meeting of the school where she had taught freshmen boys Teen STAR more than ten years earlier. The physiologic part of the course was taught by a male teacher, but she had conducted the rest of the curriculum. Several wives of the alumni thanked her for what their husbands had learned in Teen STAR―a gratifying testimonial to long term effectiveness.

Clearly the experience of the signs and effects of fertility help to possess one’s sexuality in a way that purely “head knowledge” cannot achieve. Gaudium et spes, 22 teaches that Christ “reveals man to himself.” In taking a human body, Christ gave the body a dignity it did not possess before. As explained in Laborem Exercens, the body is the sign, the quasi-sacrament of the person. Perhaps an additional reason Our Lord became man, beyond redeeming us, was to teach us that our bodies also have their own truth which must be respected and not manipulated to fulfill desires which contradict it.

[1] Labbok, M., Klaus, H., and Perez, A., „Efficacy studies in NFP: Issues and management implications illustrated with data from five studies,” Amer J Obstet Gynec (December 1991, 165:6): 2048‑2051.

[2] Cf. Educational Guidance in Human Love, Sacred Congregation for Education, 1983.

[3] The Center for Disease Control defines “primary abstinence” as never having had intercourse, and “secondary abstinence” as not having had intercourse within the last three months.

Hanna Klaus is a Medical Mission Sister who served 7 years in Pakistan as an obstetrician gynecologist. On returning to the US she taught in the gynecology departments of Washington and St. Louis University Medical schools, St. Louis Missouri , then at the George Washington University in Washington D.C. She began to teach and research the Billings Ovulation Method in 1973 and cofounded the Teen STAR program in 1980. Currently the International Teen STAR Association has programs in 30 countries.