The NURJ

Condoms had been the only birth control method Evelina Serfioti considered using in high school. “I think many people consider birth control to be dangerous for your health in Greece, and they don’t trust it,” said the 19-year-old Athens native. “I think people just don’t know about their options.” 

Growing up in Greece, Serfioti said that sex education in her high school was “nonexistent,” and that no one discussed birth control pills, intrauterine devices (IUDs), rings, patches, or anything other than condoms. 

Serfioti now studies biology at the University of Crete. She says if not for her major, she would not have learned about different birth control methods. 

“Most other students don’t know about birth control, whether it’s good or whether it’s bad for your health,” Serfioti said. “There is not much conversation going around.” 

Serfioti isn’t the only one noticing the low use of modern birth control methods in Greece. Professor Efthymios Deligeoroglou, Director of Obstetrics and Gynaecology at the Clinic of Athens Medical School, said at a 2017 conference that young people in Greece use interrupted intercourse and male condoms at much higher rates than other contraceptive methods. 

Recent data suggest that both hormonal birth control methods and long-acting reversible contraceptives (LARCs) such as IUDs are still used at low rates in Greece. A 2019 report by the United Nations showed that 5.7% of women of reproductive age in Greece use the pill, compared to the 15.8% average across Southern Europe. In comparison, Spain, Italy, and Portugal all have at least double or triple the rates of pill use compared to Greece. The same report shows Greece to be below the Southern Europe average for injectables, implants, and IUDs. 

This low use of contraceptives has an impact, especially on young unmarried women and adolescents. In 2013, a study by the European Parliament reported that Greece has one of the highest numbers of abortions in the European Union. However, this figure refers only to abortions taking place in national hospitals, as many go unrecorded. In 2017, 150,000 abortions took place in Greece, a fifth of them for girls under 16. In comparison, 862,320 abortions were performed in the US that year, a country with approximately 30 times the population of Greece.

In other countries, increased contraceptive use has caused a decline in unplanned pregnancies, and consequently, fewer abortions. In 2016, the Guttmacher Institute reported that in the U.S., “abortion decline between 2008 and 2011 was driven by a steep drop in unintended pregnancy, 

which in turn is most plausibly explained by more and better contraceptive use.” Furthermore, a 2017 Guttmacher report found abortion rates in Eastern Europe decreased because the use of “effective contraceptives increased dramatically.” 

Greece’s birth control patterns stand out among neighboring countries. When examining the experiences of young college-aged women in Greece and contextualizing them using interviews from women’s health advocates and government officials, it becomes clear that even in a developed country in the modern era, women have limited options in terms of birth control. With one of the highest abortion rates in Europe, compounded by relatively low use of modern contraceptive methods, Greece serves as a case study for what happens when women do not have access to the full spectrum of birth control methods, not because of physical barriers, but rather because of the society in which they live. Several factors contribute to Greece’s low use of modern contraceptive methods, including the education system, culture, and doctor-patient conversations around birth control. 

CURRENT CONTRACEPTIVE USE 

Condoms are the preferred method of contraception in Greece. For women of reproductive age (15-49 ) in Greece, the UN estimates in their 2019 Contraceptive Use by Method data booklet, that 29.4% of Greek women use condoms as their contraceptive method, above average for Southern Europe. 

Young people in Greece show an even stronger preference for condoms compared to the broader population. In a study done in 2009, 102 female graduating medical students completed an anonymous questionnaire. Results showed 45.1% of students were using condoms as their only contraceptive method and 16.7% were not using any contraceptive method. 

Withdrawal or interrupted intercourse is also popular in Greece, and is estimated by the UN’s 2019 data booklet to be used by 10.9% of women of reproductive age. According to the US Center for Disease Control, withdrawal has a 22% failure rate with typical use, while condoms have a failure rate of 18%. Hormonal methods and LARCs, which all have less than 10% failure rates, are used at low rates in Greece. 

EDUCATION

One of the key factors behind Greece’s low use of birth control methods outside of condoms is presumed to be the general lack of sex education in the school curriculum. 

In a 2010 report, “Exploring Primary School Sex Education in Greece: Policies and Praxis,” Margarita Gerouki, a researcher at the University of Helsinki and Greek native, noted the use of abortion as a contraceptive method. Abortions in Greece were double the number of living births at the time. People in Greece “have generally erroneous knowledge about contraception and other sexual related issues,” Gerouki wrote. “To a great extent, [researchers] attribute the gaps in knowledge, as well as particular behaviours (such as unprotected sex) … to the absence of systematic, structured, school-based sex education.” 

In her report, Gerouki comments on contemporary announcements from the Ministry of Education that sex education would be introduced in the elementary sector beginning in the 2009–2010 school year. Ten years later, the Ministry has yet to fulfill this promise. 

“There is no state education and health education starting from the young ages,” said Professor George Pierrakos from the University of West Attica Social Policy Division. The European Board and College of Obstetrics and Gynaecology said in a 2019 position statement on sex education that “sexual and relationship education should be part of educational curriculum in early teenage years. The young people should be provided with evidence based education to reduce the risks of untimed pregnancies and sexually transmitted infections.” 

“I don’t know anyone who’s had sex education classes,” said 20-year-old Athens native, Argiro Varzakakou.“If we had sex education classes it would definitely be different.” 

Serfioti said that when she was taught sex education in her private high school, it was confined to a short lesson plan that did not cover all necessary material. “During our [high school] biology class, our teacher, for one lesson, told us about protection,” she said. “Basically she told us how to use a condom, but nothing more.” 

Education on contraceptive methods is not just lacking among women. With condoms being the primary form of birth control, both women and men need accurate information about proper use. 

“The male population has very, very low knowledge on birth control,” Pierrakos said. “So the men here in Greece, do not believe, for example, in the use of condoms. It’s another thing that has to do with health education starting from school age.”

Many young people in Greece are impacted by the lack of knowledge around condom use, and would benefit from having the topic covered more comprehensively in schools. “They just don’t understand why they should,” Varzakakou said. “I actually know many girls who don’t really care either. I think the amount of girls and boys I’ve met who don’t really recognize why they should be wearing it is the same.” 

COMMUNITY AND CULTURE 

Alternative forms of contraceptives could protect couples from unplanned pregnancies, however the myths around other birth control options contribute to an overall lower use.

“People know very little about birth control pills,” said 19-year-old Athens resident Serfioti, adding that there is a significant amount of misinformation around oral contraceptives circulating in Greece, including the idea that they cause lasting health problems. 

Varzakakou has noted a similar sentiment regarding oral contraceptives. “Generally it’s advertised as something that puts a strain on your body,” she said. “So, not many girls choose it.” 

Both girls said an increased effort by schools to educate teenagers on safe sex would provide much needed clarification. 

“We don’t hear anything from school,” Serfioti said. “And the only source of information is your family. And many families don’t even talk about birth control or ways you can protect yourself.” 

Cultural and social factors in Greece also contribute to women’s birth control choices. 

“With contraceptive use, it’s a very social thing,” said Dr. Erin Pearson,  a women’s health professor at Johns Hopkins University’s School of Public Health and advisor at Ipas, an organization that provides reproductive health services to women internationally. “If you look across demographic and health surveys from different countries, you’ll see that there’s almost always a really dominant form of contraception that is popular in a country. People kind of do what their neighbors and friends do. It’s a very social phenomenon.” Thus, when young women become sexually active they are more likely to choose that option because they are influenced by those around them. 

By that same logic, when very few women in a community use a certain type of birth control, other women are less likely to hear about it, perceive it as safe and healthy, and use it.

“I don’t know a lot of girls my age taking birth control [pills],” said Melina Chalkia, a 19-year-old Athens native. “I know one girl that’s taking birth control. But for other reasons, like hormonal reasons. And there were a lot of side effects. I know that it was emotionally a lot. She was like, crying, with mood swings a lot. Apart from that, I don’t know anyone else.” 

Chalkia added that she believes that her peers use condoms because they see it as easier to access compared to other methods, and they don’t want to deal with side effects. 

Maria Tegopoulou, another 19-year-old from Athens, said that like Chalkia, she didn’t know anyone taking birth control pills to prevent pregnancy, and that those who took pills used them primarily for hormone regulation. 

According to Dr. Pearson from Ipas, it’s not just a lack of knowledge and sexual education that leads women away from certain methods of birth control. It is also due to the way women understand different methods based on the use they see around them and the reputation methods have within communities.

“Even if you know everything about an IUD, but you’ve had a friend or a neighbor who had a bad experience or had something happen to them, that they attribute to the IUD, you know, that can still spread like wildfire in communities,” Pearson said. “Some of it is more like a PR campaign. You need more positive stories about contraception out there and not just the negative stuff being shared.” 

In the absence of in-school sex education, young women are limited in who they can talk to about their birth control decisions. “In many Greek families, conversations like that don’t take place,” Serfioti said. “They don’t talk about things like sex. They are more conservative.” 

Social norms play a large role in outlining what is acceptable for women in terms of birth control, explains Dr. Julia Behrman, a professor of sociology at Northwestern University. “I think the question of what is culturally appropriate matters a lot for who’s using birth control, that  interacts with social norms as far as what’s acceptable or what’s normal, or how much power women have in relationships to negotiate things like contraceptive use.” 

DOCTOR-PATIENT INTERACTIONS 

Aside from the lack of adequate education on the topic and generally negative cultural view concerning hormonal birth control, a woman’s gynecologist plays a key role in her final decision to use birth control. 

When Varzakakou asked her doctor about potentially going on birth control, she said the response was less than encouraging. Most women in Greece consider birth control pills as something that generally does more harm than good, she said, and her doctor further solidified these beliefs. “The one I’ve heard the most is that it messes up your hormones because when you take it, basically everything stops functioning,” Varzakakou said. “That’s what my doctor said to me, my gynecologist, when I asked her. That it just messes with your body quite a lot.” 

In order to be prescribed birth control, Varzakakou’s doctor recommended she get blood work and testing done to match her with a form of oral contraceptive. Other women reported being told to see an endocrinologist before getting a prescription. Varzakakou ultimately decided against birth control. 

“Not because of the side effects,” she said. “It was mainly because of boredom, to be honest. Because I didn’t want to go and do those tests, I never really decided to take the pill.” 

Dr. George Daskalakis, an associate professor of Obstetrics, Gynecologists and Fetomaternal Medicine at the National and Kapodistrian University of Athens, wrote in an email that he will often recommend testing to his patients prior to prescribing birth control. 

“I ask them about their personal or family history of thrombosis or any other medical problems,” he said. “I usually prescribe hepatic [liver] and coagulation tests and I also offer them (if they want) thrombophilia testing. After having completed the initial tests the women can start.” 

Nowhere in the EBCOG (European Board and College of Obstetrics and Gynaecology) Standards of Care for gynecology does it say that gynecologists should require testing for blood clots, liver enzymes, or thrombogenic mutations prior to prescription. 

The organization states that “all services should provide counselling on evidence-based efficacy, advantages and disadvantages of the available methods of hormonal, non-hormonal, including long acting and permanent contraception as well as on sexual health,” as well as, “provide balanced and detailed educational materials regarding the different methods.” 

Additionally, research has shown that blood work is typically not necessary and not entirely accurate when prescribing birth control pills. Dr. Donna Hagberg, a gynecologist that practices in Greenwich, Connecticut in the U.S, said that she can almost always prescribe birth control based on a discussion with a patient. 

“Most of the time I can just listen to the patient and hear what their menstrual history is and what their cycles are like,” Hagberg said. “If they’re bleeding heavy or light, if they’ve got a lot of cramping or not, and help to gear them toward what I think might be the appropriate option for them.” 

Furthermore, all three types of tests named by Dr. Daskalakis are categorized by the US Center for Disease Control as “Class C” examinations, meaning that each test “does not contribute substantially to safe and effective use of the contraceptive method.” While doing extra testing before prescribing birth control is not harmful to patients, it sends a message that the contraception can cause health problems, potentially deterring women from choosing it. 

Ultimately, the young women in Greece that were interviewed were discouraged by their education, culture, and doctors from using hormonal contraception. 

The barriers to accessing this full spectrum of options for women in Greece might be more subtle than the obvious financial or physical availability barriers faced by women in other countries, but they are barriers nonetheless. When women do not have access to methods of birth control that work for them, they are more likely to experience unplanned pregnancy. 

“I definitely think that birth control works better than just using protection,” Chalkia said. “It’s just easier to use protection than get birth control.”