REVIEW

A Biopsychosocial Model for the Counseling of Hormonal

Contraceptives: A Review of the Psychological, Relational, Sexual,
and Cultural Elements Involved in the Choice of Contraceptive Method
Filippo Maria Nimbi, PhD, PsyD,1,2 Roberta Rossi, PsyD,2 Francesca Tripodi, PsyD,2
Kevan Wylie, MD, FRCP, FECSM,3 and Chiara Simonelli, AP, PsyD2,4

ABSTRACT

Introduction: Hormonal contraceptives are among the most popular contraceptives used by women worldwide.
Long-term adherence may vary significantly among users because of fear of side effects, unhealthy habits, and lack
of knowledge, despite their proven effectiveness.
Aim: To analyze the psychological, relational, sexual, and cultural factors associated with choice and use of
hormonal contraceptives. We highlight the importance of a biopsychosocial approach to contraceptive
counseling.
Methods: A systematic literature review was conducted in September 2018.
Main Outcome Measures: 99 articles published in Google Scholar, Web of Science, Scopus, EBSCO, and the
Cochrane Library about counseling to hormonal contraception and related biopsychosocial factors were reviewed.
Results: In the current work, we have analyzed a broad range of factors involved in the contraceptive choice
among psychological, relational, sexual, and cultural spheres under the umbrella of the biopsychosocial model.
The literature has highlighted that counseling provided by a specialized health care professional may help women
in selecting a contraceptive method that best suits their personal needs and lifestyles, maximizing compliance and
well-being.
Conclusion: The importance of psychological, relational, sexual and cultural aspects involved in the selection of
a contraceptive should be acknowledged by health care professionals and addressed during individualized
counseling to ensure that the option selected and offered is tailored to the personal preferences, lifestyle, and
practices of each woman. Nimbi FM, Rossi R, Tripodi F, et al. A Biopsychosocial Model for the Counseling
of Hormonal Contraceptives: A Review of the Psychological, Relational, Sexual, and Cultural Elements
Involved in the Choice of Contraceptive Method. Sex Med Rev 2019;XX:XXXeXXX.
Copyright
2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key words: Contraception; Hormonal Contraceptives; Counseling; Women’s Health; Biopsychosocial Model

INTRODUCTION discuss patient sexuality openly and nonjudgmentally.1 Ac-

Sexual and reproductive health are fundamental human cording to the World Health Organization2 and the United
rights strongly influencing the quality of life for women. Both Nations,3 the improvement of contraceptive use is a key factor
are enhanced by ease of access to sex education, public for increasing women’s health worldwide. Current innovations
services, and specialist health care professionals (HCPs) able to in hormonal contraceptives (HC) beyond the oral “pill” (eg,
rings, implants, patches, injections, medicated intrauterine
system) give greater choices to women and their partners.
Received January 22, 2019. Accepted June 19, 2019.
1
Worldwide in 2017,4 63% of women were using
1 contra-
Department of Dynamic and Clinical Psychology, Sapienza University of
ceptive, with most (92%) using HC, condoms, intrauterine
Rome, Rome, Italy;
2 devices, vaginal barriers, sterilization, and emergency contra-
Institute of Clinical Sexology, Rome, Italy;
3
ception. Contraceptive use was >70% in Europe, the Carib-
Sexual Medicine, University of Sheffield, Sheffield, United Kingdom;
4
bean, and Northern and Latin America, whereas it was <25%
Department of Dynamic and Clinical Psychology, Sapienza University of
Rome, Rome, Italy
in Western and Middle Africa. Although women in wealthier
countries generally have access to a wider range of HC,
Copyright ª 2019, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. combined oral contraceptives (COC) remain the most popular
https://doi.org/10.1016/j.sxmr.2019.06.005 method in Europe and the United States.5

Sex Med Rev 2019;-:1e10 1

2 Nimbi et al
Knowledge of methods of contraception remains limited for
many women. Awareness and current usage are higher for COC
and male condoms, whereas knowledge of other methods varied
largely among countries, depending on accessibility and cultural
factors.6 A study7 showed that women in 2007 preferred to
consult their physician for information concerning benefits of
HC but usually talked with friends and relatives about risks and
side effects. With the advent of the internet, this tendency may
change radically, with women able to search for information
regarding sexual health matters, although there is an associated
risk of consulting unreliable sources.
Women using contraceptives may report several related issues
leading to poorer adherence and unsatisfactory sexual experi-
ences. A change of contraception method is very frequent,
because the needs of a woman may change for a variety of
reasons. Changes to life circumstances and concerns about side
effects are among the most common reasons for poor compliance
with HC.6 It is essential that the HCP provides individualized
counseling to ensure that the contraceptive options proposed are
tailored to the personal preferences, lifestyle, and practices of
each woman7,8 and address any associated psychological, rela-
tional, sexual, and cultural issues.9,10
With the increasing acceptance of the biopsychosocial model
(BPS) as a key approach for both research and clinical practice in
sexual and reproductive health, politics and practice are in turn
adapting to greater holistic care. For centuries, illness had focused
within a biomedical model with the mechanistic view of the
human body and physiopathology11 Engel12,13 introduced the
concept of “complexity” in healthcare, introducing the BPS
model as a general approach in which health and illness were the
consequence of an interplay of biological (physiology and pa-
thology), psychological (thoughts, emotions, and behaviors), and
social (relational, socioeconomic, environmental, and cultural)
factors.14 Thus, the BPS approach rejects the unimodal pro-
cedures (eg, exclusive biomedical therapies or psychosocial
treatments) in favor of comprehensive treatments.15
During the assessment of a sexual problem, the clinician
should explore predisposing, precipitating, and perpetuating
factors through medical, sexual, and psychosocial history taking;
undertake (or arrange for a) physical examination and laboratory
investigation (when indicated); and offer counseling to the pa-
tient (and their partner) evaluating specific requirements,
emotional circumstances, and motivation.16 The goal is the re-
establishment of the patient’s health status, where possible, and
the improvement of personal satisfaction and quality of life
recognizing a complex system of interplaying variables may be
involved.17 Knowledge and competence, as outcomes of good
training and professional expertise, should lead to a greater
flexibility to tailor treatments to patients.18 To deliver scientific
information in a non-judgmental way, the practitioner needs to
acknowledge possible discomfort in discussing sexual health,
sexual attitudes and practice. In this regard, sexologic training
programs must attend to possible curriculum limitations and
individual and cultural prejudices on sexuality.19e21 In addition,
several economic, commercial and political issues are considered,
including accessibility to services (especially if supplied in private
practice), recognition of sexual healthcare providers, and national
and international accreditation of training standards. The BPS
approach may be more expensive and take longer than unimodal
procedures, but improved outcomes are reported for patients.22
The aim of this review is to analyze the psychological, rela-
tional, sexual, and cultural factors associated with HC choice and
use, highlighting the importance of a BPS approach to the
implementation of contraceptive counseling using the “5 Ws and
How” paradigm.
METHODS
This review is based on the results of a bibliographic research
of relevant articles published in Google Scholar, Web of Science,
Scopus, EBSCO, and Cochrane Library. Main keywords used,
including asterisk, were “Hormonal Contracept*,”
“Biopsychosocial” AND “Contracept*,” and “Contracept*”
AND “Counseling*.” Additional research included the words
“Psychologic*,” “Cultural*,” “Sexual*,” and “Relational*.”
Results were reviewed as reported in Figure 1. Articles were all
published in English, with particular regard for guidelines, meta-
analyses, systematic reviews, randomized controlled trials, and
original research. Attention was paid to articles discussing BPS
factors associated with contraceptive counseling, choice, and
adherence to HC. Articles were full-text accessible and, when not
directly available, requested from authors by mail. Article refer-
ences were reviewed to identify additional articles. A total of 99
relevant articles and books were included in this review.
RESULTS
The critical analysis of the literature showed an increasing
number of studies on BPS factors associated with contraceptive
choice and use in the last years. Whereas a detailed review of
biological factors is out with the scope of this work, the use of
HC has been associated with a variety of biological side effects,
which are important deterrents for women making choices about
their health. New-generation HC are still associated with nega-
tive beliefs related to first-generation HC therapies. A study on
COCs23 reported that the estimated risks were very low (venous
thromboembolism, arterial thrombosis, and some types of can-
cer) compared with non-users, but, given the large number of
women taking COCs, this may represent a substantial number of
women. However, COCs also offer some additional health
benefits: their use is associated with a considerable decrease in
menstrual bleeding, dysmenorrhea, hirsutism, acne vulgaris, and
reduced risk of ovarian, endometrial, and colorectal cancer.
Whereas the use of HC has been associated with a variety of
biological side effects, the psychological, relational, sexual, and
cultural impact has received comparatively scant attention.
Women using HC are more likely to report higher rates of
Sex Med Rev 2019;-:1e10
Biopsychosocial Hormonal Contraceptive Counseling
Figure 1. PRISMA Flow Diagram. Figure 1 is available in color online at www.smr.jsexmed.org.
depression, reduced sexual functioning, and higher interest in
short-term sexual relationships compared with naturally-cycling
women.24 In this complex scenario, gender and sexual
stereotypes may have an important confounding effect on data
interpretation.25
To be clear for the reader, the studies presented here show
mostly associations between phenomena rather than actual causal
effects. This should be considered to give the relevant signifi-
cance to data and their interpretation.26,27 Many factors come
into play when relationships are involved, and further studies are
needed to better explain how use of HC are associated with the
biopsychosocial variables.
Psychological Factors
The effects of HC on mental health are inconsistent in the
literature. Starting HC may lead to an increased risk of depres-
sion over a short time frame, particularly in adolescents.28 In a
study of 1,311 women,29 77% had previously used HC, and, of
these women, 51% reported
1 mood-related side effect,
particularly women who were single. Other studies reported no
difference or improvement in mood state with the use of HC. A
longitudinal survey noted that HC users did not significantly
differ from naturally-cycling women, but women who used HC
reported fewer mood-shifts between depression and joy in the
midluteal period and fewer ruminating thoughts during all
Sex Med Rev 2019;-:1e10
3
phases.30 A Finnish survey on 3,223 women confirmed that HC
were well tolerated among women aged 18e53, with few note-
worthy outcomes on mental health.31 Some studies highlighted
how HC may exacerbate existing psychological problems. A
double-blind randomized clinical trial of 202 participants re-
ported that women with ongoing or previous mood, anxiety, or
eating disorders or risky alcohol use had higher risk of COC-
induced mood symptoms.32 Moreover, women with depression
and stress symptoms were usually at higher risk for contraceptive
failures and dropout.33 On the basis of these retrospective
findings, HCPs should consider women’s psychological and
emotional status during counseling for contraceptive decision-
making and management. Overall, the influence of HC on
mental health appears to be modest and generally favorable. The
length of contraceptive use is associated with beneficial effects on
mood, and this might be important to share with women.31
Moreover, women with existing psychological problems may
be good candidates for long-acting reversible methods, which are
effective and with fewer related mental side effects.33
Relational Factors
Numerous studies report that women using HC differ in their
mate preferences from women who have regular cycles, but these
results are controversial.34e36 When a woman either begins or
ceases the HC, she may experience some modifications within
4 Nimbi et al
her relationship and mate preferences.37 A regression analysis
reported that the higher the dose of the synthetic estrogen
contained within a COC, the higher was the level of objectifi-
cation of other women (a tendency to attribute appearance-
related body features rather than competence-related).38 In a
Czech sample, among women who had engaged in non-
monogamous sexual behavior, HC users reported fewer 1-night
affairs than non-users and tended to have fewer partners in
general. HC users also showed more frequent dyadic intercourse
than non-users, potentially indicating higher commitment to
their current relationship.39 Interactive relationship dynamics
(such as commitment and sexual decision-making) are very
important elements to predict contraceptive use. Depending on
the decision of the couple about whether to have a baby in the
future, “long-acting hormonal methods” or “no contraceptive at
all” were shown as the preferred methods above the others.24
Both estrogen and progestin prescriptions for women could
moderate the association between faithfulness, loyalty, or both of
the woman to her partner, as well as frequency of sexual inter-
course. As progestin levels increase and estradiol levels diminish,
faithfulness or loyalty and frequency of intercourse usually
increases. This result may support the evidence that HC has the
same effect of natural hormones.40 A study on university stu-
dents in a relationship found an increase in jealousy at the time
of starting or stopping HC compared with regular and long-
standing use.37 Some women with inconsistent HC use
reported less relational satisfaction and higher jealousy scores
compared with congruent users.41
Sexual Factors
Negative effects of HC on sexual function can be reported by
women and may represent a strong deterrent for ongoing
adherence. An Egyptian study42 of progestin-only contraceptives
reported a significant general impairment in sexuality for desire,
arousal, lubrication, and orgasm. Moreover, injectable solutions
were associated with worse sexual side effects than oral medica-
tions. In the previously cited research on 1,311 women,29 38%
reported
1 sexual side effect. Moreover, women who com-
plained of sexual side effects were also more likely than others to
complain of mood and physical side effects. The most frequently
reported sexual symptom is a decrease in sexual desire. In a group
of 3,740 women,43 27% reported a decrease in sexual drive
attributed to HC use, compared with only 12% of women using
hormone-free contraception. Pastor et al44 reported that libido
was decreased only with oral medications containing 15 mg
ethinylestradiol but not in COCs with 20e35 mg. Experiencing
reduced desire seems to be a strong predictor for changing or
discontinuing contraceptive method. New molecules show
promising results on preserving sexual drive.45 Contraceptives
may affect women’s sexuality in both positive (increasing intra-
partner satisfaction and number of sexual intercourses) and
negative ways (sexual desire, lubrication, and orgasm). Appro-
priately trained HCPs in sexology, sexual medicine, or both and
offering contraceptive counseling are well placed to promote a
better sexual well-being and a more user-friendly contraceptive
practice.17,29,46
Cultural Factors
Sexual behavior and contraceptive methods are impacted by
cultural messages about gender and sexuality too often related to
stereotypes and double standards. Data from interviews with 88
women47 reported an emphasis on concerns with regard to
weight gain and mood volatility ascribed to HC use. These
negative beliefs are strictly connected with the female stereotype
(eg, female passivity, emphasis on body attractiveness and beauty,
uncontrollable and irrational bipolar emotional-switches during
menstruation). Many women report prioritizing male pleasure in
their sexual encounters and giving less importance to their own
sexual desire, wishes, or interests,48 resulting in a choice that may
be uncomfortable for both partners because it has not been
negotiated within the couple.
Data on 1,017 sexually active Hispanic women between ages
16e24 highlighted how women embracing Western culture or
with higher educational levels were more familiar with the use of
long-acting reversible HC.49 Factors including relationship, race,
class, economic status, and gender roles may create a difficult
scenario, especially for marginalized young women and their
partners, who have no possibility to discuss contraceptive man-
agement. This may result in poor sexual health and higher rates
of unintended pregnancies.50
Cultural factors have a serious impact on HC adherence,
because side effects are imbued with social meanings that may
challenge women’s goals to prevent pregnancy.47 HCPs require
knowledge and understanding of cultures and religions to pro-
vide contraception counseling to all women, including migrants.
It is important to be aware that women have different and per-
sonal values regarding reproductive and sexual health that need
to be respected. The challenge for HCPs is to understand and to
be curious about every woman’s perspective.51,52
IMPORTANCE OF CONTRACEPTIVE COUNSELING
A huge amount of literature agrees on a key point: the need of
an appropriate counseling for women’s contraception. What is
not clear is how it should be addressed. We introduce the “5 W’s
and How” paradigm.
Why Offer Contraceptive Counseling? Because It Is
Effective
Many studies have demonstrated the efficacy of counseling vs
information leaflets, asking friends or nothing. After the increase
of opportunities for contraceptive counseling in London, the
number of unplanned pregnancies decreased from 64% in 1993
to 53% in 2010, and the use of COCs considerably reduced
toward the adoption of other methods.53 In the “CHOICE
study”,54 the wider European research on contraceptive methods
and counseling, 18,787 women underwent a counseling
Sex Med Rev 2019;-:1e10
Biopsychosocial Hormonal Contraceptive Counseling
experience for contraceptive purposes with gynecologists. After
the intervention, 47% of participants selected a different HC
method, with a significant increase of patch and ring use. Nearly
all women who were undecided about a contraceptive method
selected 1 after the counseling. Participants selected the pill for
reasons like “ease of use,” “convenience,” and “regular menstrual
bleeding,” whereas “daily use” and “forget to take it” were the
main adverse points.5 Many articles5,54e60 report consistently
that after contraceptive counseling women increasingly opt for
patches, injections and rings rather than the pill. Moreover,
counseling is helpful for the women who are undecided about
their contraceptive practice by allowing them to make a more
conscious choice for their health.
Who Should Give the Counseling? All HCPs When
Appropriately Trained
There is no specific supportive evidence about the type of
HCP who should offer contraceptive counseling to women.
Some studies reported the preference for gynecologists and
midwives,54,61,62 whereas another reported for general prac-
titioners.63 Based on the country regulations on contraceptive
delivery, other HCPs can legitimately offer the counseling
process. Canadian collaborative agreements in family planning
allow for nurses, in conjunction with pharmacists, to provide
counseling programs and to prescribe HC to healthy women
of reproductive age for a 6-month period.64 In Canada,
pharmacists are often the front-line HCPs for women seeking
emergency contraception.65 However, physicians are the
HCPs with the greatest influence on women’s choice.6 The
key point for effective contraceptive counseling is the HCP’s
educational path: knowledge and competence, as outcomes of
good training and professional expertise, should lead to
greater flexibility to tailor treatments to each woman. To
deliver scientific information in a non-judgmental manner,
the practitioner needs to recognize their individual discomfort
in discussing sexual health, sexual attitudes, and practice. In
this regard, sexology and sexual medicine training programs
may overcome existing curriculum limitations, as well as
attending to any personal and cultural prejudices on
sexuality.10,17
Although we are not able to determine the quality of all sexual
training offered to HCPs, the certified national and international
courses, such as The ESSM School of Sexual Medicine, could be
a good example of comprehensive BPS training in this field.66
Moreover, some European scientific societies such as the Euro-
pean Society for Sexual Medicine (ESSM) and the European
Federation of Sexology are advancing opportunities in the
recognition of the HCPs curricula with a specialization in sexual
health with 2 current European certifications: the Fellow of the
European Committee on Sexual Medicine” for physicians and
the European Federation of Sexology/ESSMeCertified Psycho-
sexologist with Mark of Excellence for psychologists, psychia-
trists, and physicians with additional psychotherapy training.67,68
Sex Med Rev 2019;-:1e10
5
When and Where Should the Counseling Be Given?
More Often and at Different Life Stages in Clinical
Settings
There are many potentially appropriate and inappropriate
moments to talk about contraception. Current practice is to
provide contraceptive counseling during routine consultations
within a clinical setting.63 These are usually reported as useful
and effective by many women, yet the poor rates of adherence for
longer-term contraceptive use remains challenging. A study69
highlighted how women were more confident and more
adherent to their choice when counseling was repeated after 2
months. This provides the opportunity for women to talk about
adverse events related to HC use (physical side effects, psycho-
logical, relational, and sexual outcomes) and to better adjust use
where necessary. Intensive counseling after abortion usually has
similar effects to routine counseling during control visits in terms
of HC adherence.70,71 Delivering contraceptive counseling when
women ask for abortion is often experienced as complex by
HCPs, and this may not be the best moment for contraceptive
counseling given distractions from issues of loss and emotional
distress. Regardless, improvement of skills and knowledge to
prevent repeated unwanted pregnancies is necessary, with con-
traceptive counseling more appropriate during the follow-up
visits and may represent the best choice for this cohort of
women.72 Other studies have suggested that individual coun-
seling in the third trimester of pregnancy would effectively in-
crease postpartum contraceptive use.73 Antenatal contraceptive
counseling, delivered by trained midwives, is achievable and
highly suitable to women.74 This is an excellent opportunity to
talk about sexuality and contraception use in the upcoming
postnatal period. Decisions about further pregnancies require
discussion and renegotiation by the couple. In general, both
partners should be involved in the decision process of contra-
ceptive practice impacting on both motivation for use and
increasing adherence.75 Nevertheless, the final decision should
always be made by the woman.
What Should Be Included in the Counseling and
How Should It Be Addressed? Methods and Tools
Are Listed
In Europe and globally, there are reported many deficiencies
and gaps in terms of contraceptive counseling and care. These
include the following:76
 A lack of tailored communication combining the individual
woman needs, her BPS circumstances, and her background
with the counsellor;
 A lack of time for taking a sexual and reproductive health
history;
 A lack of knowledge about contraceptive methods;
 A lack of training in contraception on the side of the providers;
 Insufficient support on guidelines and use of safe prescribing.
Effective contraceptive counseling implies an open and
sensitive discussion of feelings, requirements, and topics
6 Nimbi et al
related to sexuality. Improving communication skills and
understanding women’s requirements are the baseline level to
counseling.77 Many women experienced being pressured by
their HCPs to make a contraceptive choice that they did not
feel was right for them, thus, losing control of their life and
decision-making about their health.78 Approaches to enhance
women’s experiences of contraceptive counseling include
working together to develop a close trusting relationship and
taking the opportunity of a shared decision-making method
by eliciting and responding to women’s preferences.79 Both
parties are involved in a negotiation of information in which
the HCP is the sensitive provider of detail and advice
focusing on the individual circumstances of the woman. The
dialogue should be balanced between giving general contra-
ceptive information (methods, practices, side effects, risks,
etc) and connecting with the individual emotional needs of
the woman.80
Regarding the counseling approach, some models are
reported in the literature, with good results such as the
information-motivation-behavioral skills model81,82 and the
health belief model83 these models are similar by stating
that information and motivation are not enough to elicit
healthier behaviors. Self-efficacy, the individual’s belief in
their ability to achieve goals, is central in both models, and
it is a key point of the counseling experience. However,
these models fail in giving a holistic understanding of the
health and the process of care. The BPS model,16 stressing
the importance of a holistic integrated approach, has suc-
cessfully been applied to contraceptive care.76 Moreover, the
literature offers many specific guidelines or studies exploring
contraceptive counseling in specific health conditions,
highlighting specific needs and issues for sickle cell dis-
ease,53 multiple sclerosis,84 severe and persistent mental
illness,85 cancer,86 rheumatoid arthritis,87 polycystic ovary
syndrome,88 peripartum cardiomyopathy,89 and
90
endometriosis.
The main topics of contraceptive counseling could be
summarized as “efficacy of various methods” and “side effects
and associated health risks”.91 Women express interest in
receiving information about all the contraceptive options.92
Before proposing any contraceptive, the HCP should
explore the main risk factors for various methods including
age, obesity, smoking, hypertension, dyslipidemia, glucose
intolerance including diabetes, thrombophilia, and venous
thromboembolism.88 Themes that need to be discussed
include efficacy, side effects, and other issues, including cyclic
bleeding. Although women held a broad view that menstru-
ation may be an inconvenience, they also ascribe positive
values to regular bleeding as an intrinsic part of being a
woman and a signifier of the non-pregnancy state.93,94
It is very important that any contraceptive counseling includes
specific questions with regard to sexual health. The counsellor
should explore sexual intercourse techniques, sexual
relationships, preferred practices, sexual function (including any
problems of sexual desire, arousal and orgasm, or the presence of
painful intercourse) before offering contraception. These are very
important parameters for a baseline sexual history that the HCP
may use to evaluate any subsequent side effects such as changes
in sexual libido. At this stage, the use of a short questionnaire on
sexual functioning such as the Female Sexual Function Index95
or the Sexual Complaints Screener96 are strongly recommended.
HCPs could use adjunctive materials to strengthen the
counseling message or to improve the adherence to the selected
method. Literature offers a wide range of possibilities from
questionnaires to explore women views, leaflets including online
facilities and support groups. Questionnaires such as the vali-
dated “Contraception: HeLping for wOmen’s choice”97 can
shorter the process of initial screening about adverse health
conditions and women’s needs and preferences influencing the
contraceptive choice. The use of comprehensive leaflets can be of
great help during counseling.56,60 They should be brief, clear and
with useful pictures. Counseling materials provided by the gy-
necologist seem to be an appropriate communication channel,
but it should be borne in mind that the leaflets do not substitute
for HCP-woman communication but can reinforce the messages
and advice provided by the HCP.61 To maintain and improve
adherence, a combination of intensive counseling followed by
multiple contact opportunities and reminders (using mail,
telephone calls, and text messages) may be helpful in continuing
to motivate women and to allow for regular feedback.98 Less
common in daily practice, but potentially useful, could be the
formation of peer-group networks within public health ser-
vices.62 Other approaches evaluated in the literature includes the
implementation of computerized counseling, which shows
promising results.99
CONCLUSIONS
Contraceptive counseling is a key element for safer and
effective prevention of unintended pregnancies and to improve
adherence to HC. Many women change their mind after
contraceptive counseling and select another method from the 1
they initially chose. Further studies are needed on the HCP-
woman relationship, to increase the efficacy of counseling, and
to decrease dropout and inconsistent use. Contraception
knowledge is the basis for HCPs’ involvement in the counseling
process, but it should be integrated with more specific skills.
According to this review, the importance of psychological, rela-
tional, sexual, and cultural aspects involved in the counseling
should be recognized among HCPs. Future research should
explore, according to the BPS model, whether and how these
topics are addressed in consultation and to provide data on
appropriate and favorable training programs for contraceptive
counseling. Regarding our field of expertise, specific training
about sexology and sexual medicine for HCPs is strongly
recommended to offer best practice to women. HCPs should
Sex Med Rev 2019;-:1e10
Biopsychosocial Hormonal Contraceptive Counseling
review their personal attitudes to provide counseling that is free
from prejudice and personal values. Informing, educating, and
empowering women and couples to choose the best suitable
method in their specific and unique situation and building a
trustful relationship would improve the quality of sexual,
relational, and general health for women.
Corresponding Author: Filippo Maria Nimbi, PhD, PsyD,
Institute of Clinical Sexology, Via Savoia 78, 00198, Rome,
Italy. Tel: þ393405006643; E-mail: filipponimbi@hotmail.it
Conflicts of Interest: The authors report no conflicts of interest.
Funding: None
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Filippo Maria Nimbi; Roberta Rossi
(b) Acquisition of Data
Filippo Maria Nimbi
(c) Analysis and Interpretation of Data
Filippo Maria Nimbi; Roberta Rossi; Francesca Tripodi; Kevan
Wylie; Chiara Simonelli
Category 2
(a) Drafting the Article
Filippo Maria Nimbi
(b) Revising It for Intellectual Content
Roberta Rossi; Francesca Tripodi; Kevan Wylie; Chiara Simonelli
Category 3
(a) Final Approval of the Completed Article
Filippo Maria Nimbi; Roberta Rossi; Francesca Tripodi; Kevan
Wylie; Chiara Simonelli
REFERENCES
1. WAS e World Association for Sexual health. Declaration of
Sexual Rights; 2013. Available at : http://www.worldsexology.
org/wp-content/uploads/2013/08/declaration_of_sexual_rights_
sep03_2014.pdf. Accessed September 25, 2018.
2. WHO - World Health Organization. MDG 5: Improve maternal
health, New York. United Nations; 2015. Available at: http://www.
who.int/topics/millennium_development_goals/maternal_health/
en/. Accessed September 25, 2018.
3. UNDP - United Nations Development. Mål 5: Förbättra
mödrahälsa. Fortfarande dör 800 kvinnor om dagen i sam-
band med graviditet eller förlossning. Stockholm: United
Nations; 2014. Available at: http://www.millenniemalen.nu/
minskamodradodligheten-med-tre-fjardedelar/. Accessed
September 25, 2018.
4. WHO - World Health Organization. World family planning high-
lights. New York: United Nations; 2018. Available at: http://www.
un.org/en/development/desa/population/publications/pdf/family/
WFP2017_Highlights.pdf. Accessed September 26, 2018.
5. Egarter C, Tirri BF, Bitzer J, et al. Women’s perceptions and
reasons for choosing the pill, patch, or ring in the CHOICE
Sex Med Rev 2019;-:1e10
7
study: A cross-sectional survey of contraceptive method se-
lection after counselling. BMC Women’s Health 2013;13:9.
6. Johnson S, Pion C, Jennings V. Current methods and attitudes
of women towards contraception in Europe and America.
Reproductive Health 2013;10:7.
7. Tiihonen M, Heikkinen AM, Leppänen HM, et al. Information
sources used by women in Finland who use hormonal contra-
ceptives. Pharm World Sci 2010;32:66.
8. Hooper DJ. Attitudes, awareness, compliance and preferences
among hormonal contraception users. Clin Drug Invest 2010;
30:749-763.
9. Elaut E. Why a biopsychosocial approach is needed when
studying the sexual effects of hormonal contraception. Eur J
Contracep Reproduct Health Care 2017;22:156-158.
10. Tripodi F, Nimbi FM, Fabrizi A, et al. L’approccio integrato in
sessuologia Teoria e prassi clinica. Psicobiettivo 2016;2:
52-71.
11. Lane RD. Is it possible to bridge the Biopsychosocial and
Biomedical models? BioPsychoSocial Med 2014;8:3.
12. Engel GL. The need for a new medical model: A challenge for
biomedicine. Science 1977;196:129-136.
13. Engel GL. From biomedical to biopsychosocial. Being scientific
in the human domain. Psychosomatics 1997;38:
521-528.
14. Berry MD, Berry PD. Contemporary treatment of sexual
dysfunction: Reexamining the biopsychosocial model. J Sex
Med 2013;10:2627-2643.
15. Jannini EA, McCabe MP, Salonia A, et al. Controversies in
sexual medicine: Organic vs. psychogenic? The Manichean
diagnosis in sexual medicine. J Sex Med 2010;7:1726-1733.
16. Hatzichristou D, Kirana PS, Banner L, et al. Diagnosing sexual
dysfunction in men and women: Sexual history taking and the
role of symptom scales and questionnaires. J Sex Med 2016;
13:1166-1182.
17. Simonelli C, Fabrizi A, Rossi R, et al. Clinical sexology: An in-
tegrated approach between the psychosomatic and the
somatopsychic. Sexologies 2010;19:3-7.
18. Althof SE. It was the best of times; It was the worst of times.
J Sex Marital Ther 2007;33:399-403.
19. Parish SA, Rubio-Aurioles E. Education in sexual medicine:
Proceedings from the international consultation in sexual
medicine; 2009. J Sex Med 2010;7:3305-3314.
20. Athanadiasis L, Papatharitou S, Salpiggidis G, et al. Educating
physicians to treat erectile dysfunction patients: Development
and evaluation of a course on communication and manage-
ment strategies. J Sex Med 2006;3:47-55.
21. Tsimitsiou Z, Hatzimouratidis K, Nakopoulou E, et al. Predictors
of physicians’ involvement in addressing sexual health issues.
J Sex Med 2006;3:583-588.
22. Goldstein I. Sexual medicine reflects the light of knowledge.
J Sex Med 2012;9:2733-2735.
23. Brynhildsen J. Combined hormonal contraceptives: Prescribing
patterns, compliance, and benefits versus risks. Therapeutic
Adv Drug Safety 2014;5:201-213.
8 Nimbi et al
24. Harvey SM, Oakley LP, Washburn I, et al. Contraceptive method
choice among young adults: Influence of individual and rela-
tionship factors. J Sex Res 2018;55:1106-1115.
25. Welling LL. Psychobehavioral effects of hormonal contraceptive
use. Evolutionary Psychol 2013;11:718-742.
26. Nimbi FM, Tripodi F, Rossi R, et al. Testing a conceptual model
for men’s sexual desire referring to automatic thoughts,
emotions, sexual function, and sexism. J Sex Med 2018;
15:1518-1526.
27. Nimbi FM, Tripodi F, Rossi R, et al. Which psychosocial variables
affect drive the most? Analysis of sexual desire in a group of
Italian men. Int J Impot Res doi: 10.1038/s41443-018-0105-8.
E-pub ahead of print.
28. Ross RA, Kaiser UB. Reproductive endocrinology: The
emotional cost of contraception. Nat Rev Endocrinol
2017;13:7.
29. Wiebe ER, Brotto LA, MacKay J. Characteristics of women who
experience mood and sexual side effects with use of hormonal
contraception. J Obst Gynaecol Can 2011;33:1234-1240.
30. Hamstra DA, de Kloet ER, de Rover M, et al. Oral contracep-
tives positively affect mood in healthy PMS-free women: A
longitudinal study. Journal of Psychosomatic Research 2017;
103:119-126.
31. Toffol E, Heikinheimo O, Koponen P, et al. Hormonal contra-
ception and mental health: Results of a population-based
study. Hum Reprod 2011;26:3085-3093.
32. Bengtsdotter H, Lundin C, Gemzell Danielsson K, et al.
Ongoing or previous mental disorders predispose to adverse
mood reporting during combined oral contraceptive use. Eur J
Contracept Reprod Health Care 2018;23:45-51.
33. Hall KS, Moreau C, Trussell J, et al. Young women’s consistency
of contraceptive use—Does depression or stress matter?
Contraception 2013;88:641-649.
34. Flegr J, Kroupa S, Nekola O, et al. The effects of the phase of
the menstrual cycle, hormonal contraception, pregnancy, and
the marital and the parenthood status on partner preferences.
PeerJ Preprints 2018;6:e26958v1.
35. Gildersleeve K, Haselton MG, Fales MR. Do women’s mate
preferences change across the ovulatory cycle? A meta-
analytic review. Psychol Bull 2014;140:1205.
36. Cobey KD, Little AC, Roberts SC. Hormonal effects on
women’s facial masculinity preferences: The influence of
pregnancy, post-partum, and hormonal contraceptive use. Biol
Psychol 2015;104:35-40.
37. Cobey KD, Roberts SC, Buunk AP. Hormonal contraceptive
congruency: Implications for relationship jealousy. Personality
Individual Diff 2013;55:569-573.
38. Piccoli V, Cobey KD, Carnaghi A. Hormonal contraceptive use
and the objectification of women and men. Personality Indi-
vidual Diff 2014;66:44-47.
39. Klapilová K, Cobey KD, Wells T, et al. Current hormonal con-
traceptive use predicts female extra-pair and dyadic sexual
behavior: Evidence based on Czech National Survey data.
Evolutionary Psychol 2014;12:36-52.
40. Grøntvedt TV, Grebe NM, Kennair LEO, et al. Estrogenic and
progestogenic effects of hormonal contraceptives in relation to
sexual behavior: Insights into extended sexuality. Evolution
Human Behav 2017;38:283-292.
41. Jern P, Kärnä A, Hujanen J, et al. A high-powered replication
study finds no effect of starting or stopping hormonal con-
traceptive use on relationship quality. Evolution Human Behav
2018;39:373-379.
42. Hassanin AM, El-Halwagy AM, Ismail NN, et al. A study of the
impact of the commonly used female contraceptive methods in
Egypt on female sexual function. J Sex Marital Ther 2018;7:1-
8.
43. Malmborg A, Persson E, Brynhildsen J, et al. Hormonal
contraception and sexual desire: A questionnaire-based study
of young Swedish women. Eur J Contracept Reprod Health
Care 2016;21:158-167.
44. Pastor Z, Holla K, Chmel R. The influence of combined oral
contraceptives on female sexual desire: A systematic review.
Eur J Contracept Reprod Health Care 2013;18:27-43.
45. Caruso S, Cianci S, Cariola M, et al. Improvement of low sexual
desire due to antiandrogenic combined oral contraceptives af-
ter switching to an oral contraceptive containing 17 b-estradiol.
J Womens Health 2017;26:728-734.
46. Higgins JA, Smith NK. The sexual acceptability of contracep-
tion: Reviewing the literature and building a new concept. J Sex
Res 2016;53:417-456.
47. Littlejohn KE. “It’s those pills that are ruining me”: Gender and
the social meanings of hormonal contraceptive side effects.
Gender Society 2013;27:843-863.
48. Kelly M, Inoue K, Barratt A, et al. Performing (heterosexual)
femininity: Female agency and role in sexual life and contra-
ceptive use—A qualitative study in Australia. Culture Health
Sex 2017;19:240-255.
49. Roncancio AM, Ward KK, Berenson AB. The use of effective
contraception among young Hispanic women: the role of
acculturation. J Pediatr Adolesc Gynecol 2012;25:35-38.
50. Fefferman AM, Upadhyay UD. Hybrid masculinity and young
men’s circumscribed engagement in contraceptive manage-
ment. Gender Soc 2018;32:371-394.
51. Atallah S, Johnson-Agbakwu C, Rosenbaum T, et al. Ethical
and sociocultural aspects of sexual function and dysfunction in
both sexes. J Sex Med 2016;13:591-606.
52. Kolak M, Jensen C, Johansson M. Midwives’ experiences of
providing contraception counselling to immigrant women. Sex
Reprod Healthc 2017;12:100-106.
53. Eissa AA, Tuck SM, Rantell K, et al. Trends in family planning
and counselling for women with sickle cell disease in the UK
over two decades. J Fam Plann Reprod Health Care 2015;
41:96-101.
54. Bitzer J, Gemzell-Danielsson K, Roumen F, et al. The CHOICE
study: Effect of counselling on the selection of combined
hormonal contraceptive methods in 11 countries. Eur J Con-
tracept Reprod Health Care 2012;17:65-78.
55. Gemzell-Danielsson K, Thunell L, Lindeberg M, et al. Compre-
hensive counseling about combined hormonal contraceptives
changes the choice of contraceptive methods: results of the
Sex Med Rev 2019;-:1e10
Biopsychosocial Hormonal Contraceptive Counseling
CHOICE program in Sweden. Acta Obstet Gynecol Scand
2011;90:869-877.
56. Costa ARR, Palma F, Sá JL, et al. Impact of a women’s
counselling programme on combined hormonal contraception
in Portugal—The IMAGINE Study. Eur J Contracept Reprod
Health Care 2011;16:409-417.
57. Machado RB, Pompei LM, Giribela A, et al. Impact of stan-
dardized information provided by gynecologists on women’s
choice of combined hormonal contraception. Gynecol Endo-
crinol 2013;29:855-858.
58. Merki-Feld GS, Gruber IM. Intention to use a combined con-
traceptive method and decision after counselling in Switzer-
land—Swiss data from the European CHOICE study. Eur J
Contracept Reprod Health Care 2012;17:119-127.
59. Gambera A, Corda F, Papa R, et al. Observational, prospective,
multicentre study to evaluate the effects of counselling on the
choice of combined hormonal contraceptives in Italy—the ECOS
(Educational COunselling effectS) study. BMC Womens Health
2015;15:69.
60. Merckx M, Donders GG, Grandjean P, et al. Does structured
counselling influence combined hormonal contraceptive
choice? Eur J Contracept Reprod Health Care 2011;16:
418-429.
61. Vogt C, Schaefer M. Disparities in knowledge and interest
about benefits and risks of combined oral contraceptives. Eur J
Contracept Reprod Health Care 2011;16:183-193.
62. Loeber OE, Muntinga ME. Contraceptive counselling for
women with multiple unintended pregnancies: The abortion
client’s perspective. Eur J Contracept Reprod Health Care
2017;22:94-101.
63. Kazerooni R, Takizawa A, Vu K. Predictors of adherence to
hormonal contraceptives in a female veteran population.
Contraception 2014;89:292-298.
64. Guilbert ER, Morin D, Guilbert AC, et al. Task-shifting in the
delivery of hormonal contraceptive methods: Validation of a
questionnaire and preliminary results. Int J Nurs Pract 2011;
17:315-321.
65. Wong K, Hum S, McCarthy L, et al. Beyond Plan B: A quali-
tative study of Canadian pharmacists’ emergency contracep-
tion counselling practices. J Obstet Gynaecol Can 2017;
39:1021-1027.
66. Lowenstein L, Reisman Y, Tripodi F, et al. Oxford School of
Sexual Medicine: How are we doing? J Sex Med 2015;12:
59-65.
67. Lowenstein L, Tripodi F, Reisman Y, et al. EFS/ESSM-certified
psychosexologist with mark of excellence. J Sex Med 2014;
11:2141-2142.
68. Reisman Y, Eardley I, Porst H, et al. New developments in
education and training in sexual medicine. J Sex Med 2013;
10:918-923.
69. Akintomide H, Rank KM, Brima N, et al. Counselling to include
tailored use of combined oral contraception in clinical practice:
An evaluation. BMJ Sex Reprod Health 2017;44:37-42.
70. Modesto W, Bahamondes MV, Bahamondes L. A randomized
clinical trial of the effect of intensive versus non-intensive
counselling on discontinuation rates due to bleeding
Sex Med Rev 2019;-:1e10
9
disturbances of three long-acting reversible contraceptives.
Human Reprod 2014;29:1393-1399.
71. Caruso S, Cianci S, Vitale SG, et al. Sexual function and quality
of life of women adopting the levonorgestrel-releasing intra-
uterine system (LNG-IUS 13.5 mg) after abortion for unin-
tended pregnancy. Eur J Contracept Reprod Health Care
2018;23:24-31.
72. Kilander H, Salomonsson B, Thor J, et al. Contraceptive
counselling of women seeking abortion—A qualitative interview
study of health professionals’ experiences. Eur J Contracept
Reprod Health Care 2017;22:3-10.
73. Akman M, Tüzün S, Uzuner A, et al. The influence of prenatal
counselling on postpartum contraceptive choice. J Int Med Res
2010;38:1243-1249.
74. Cameron ST, Craig A, Sim J, et al. Feasibility and acceptability
of introducing routine antenatal contraceptive counselling and
provision of contraception after delivery: The APPLES pilot
evaluation. BJOG 2017;124:2009 e2015.
75. Lete I, Lobo P, Nappi RE, et al. Male perception about the
inconveniences associated with monthly bleeding for their
partner—An international survey. Eur J Contracept Reprod
Health Care 2018;23:1-11.
76. Bitzer J, Marin V, Lira J. Contraceptive counselling and care: A
personalized interactive approach. Eur J Contracept Reprod
Health Care 2017;22:418-423.
77. Bombas T, Costa AR, Palma F, et al. Knowledge-attitude-
practice survey among Portuguese gynaecologists regarding
combined hormonal contraceptives methods. Eur J Contracept
Reprod Health Care 2012;17:128-134.
78. Waller R, Tholander M, Nilsson D. “You will have these ones!’:
Six women’s experiences of being pressured to make a con-
traceptive choice that did not feel right. Soc Sci 2017;6:114.
79. Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling:
Best practices to ensure quality communication and enable
effective contraceptive use. Clin Obstet Gynecol 2014;57:659.
80. Rivano Eckerdal J. Information sources at play: The apparatus
of knowledge production in contraceptive counselling.
J Documentation 2012;68:278-298.
81. Fisher JD, Fisher WA. Theoretical approaches to individual-level
change in HIV risk behavior, In Handbook of HIV prevention.
Boston: Springer; 2000. p. 3-55.
82. Fullerton T, Rye BJ, Meaney GJ, et al. Condom and hormonal
contraceptive use by young women: An information-
motivation-behavioral skills assessment. Can J Behav Sci
2013;45:196.
83. Hall KS. The health belief model can guide modern contra-
ceptive behavior research and practice. J Midwifery Womens
Health 2012;57:74-81.
84. Houtchens MK, Zapata LB, Curtis KM, et al. Contraception for
women with multiple sclerosis: Guidance for healthcare pro-
viders. Multiple Scler J 2017;23:757-764.
85. Macaluso M, Zackula R, Bowman C, et al. Residents perceive
limited education on family planning and contraception for
patients with severe and persistent mental illness. Academic
Psychiatr 2018;42:189-196.
10
86. Britton LE. Unintended pregnancy: A systematic review of
contraception use and counseling in women with cancer. Clin J
Oncol Nurs 2017;21:189-196.
87. Østensen M. Contraception and pregnancy counselling in
rheumatoid arthritis. Curr Opin Rheumatol 2014;26:
302-307.
88. Yildiz BO. Approach to the patient: Contraception in women
with polycystic ovary syndrome. J Clin Endocrinol Metab
2015;100:794-802.
89. Rosman L, Salmoirago-Blotcher E, Wuensch KL, et al.
Contraception and reproductive counseling in women with
peripartum cardiomyopathy. Contraception 2017;96:36-40.
90. Yong PJ. Deep dyspareunia in endometriosis: a proposed
framework based on pain mechanisms and genito-pelvic pain
penetration disorder. Sex Med Rev 2017;5:495-507.
91. Wyatt KD, Anderson RT, Creedon D, et al. Women’s values in
contraceptive choice: A systematic review of relevant attributes
included in decision aids. BMC Womens Health 2014;14:28.
92. Merki-Feld GS, Caetano C, Porz TC, et al. Are there unmet
needs in contraceptive counselling and choice? Findings of the
European TANCO Study. Eur J Contracept Reprod Health
Care 2018;23:183-193.
93. Merki-Feld GS, Breitschmid N, Seifert B, et al. A survey on
Swiss women’s preferred menstrual/withdrawal bleeding
pattern over different phases of reproductive life and with use
Nimbi et al
of hormonal contraception. Eur J Contracept Reprod Health
Care 2014;19:266-275.
94. Newton VL, Hoggart L. Hormonal contraception and regulation
of menstruation: a study of young women’s attitudes towards
“having a period. J Fam Plann Reprod Health Care 2014;
41:210-215.
95. Rosen C, Brown J, Heiman S, et al. The Female Sexual Function
Index (FSFI): A multidimensional self-report instrument for the
assessment of female sexual function. J Sex Marital Ther
2000;26:191-208.
96. Hatzichristou D, Rosen RC, Derogatis LR, et al. Recommen-
dations for the clinical evaluation of men and women with
sexual dysfunction. J Sex Med 2010;7(Pt. 2):337-348.
97. Jamin CG, Häusler G, Lobo Abascal P, et al. Development and
conceptual validation of a questionnaire to help contraceptive
choice: CHLOE (Contraception: HeLping for wOmen’s choicE).
Eur J Contracept Reprod Health Care 2017;22:286-290.
98. Halpern V, Lopez LM, Grimes DA, et al. Strategies to improve
adherence and acceptability of hormonal methods of
contraception. Cochrane Database Syst Rev 2013;
26(10):CD004317.
99. Schwarz EB, Burch EJ, Parisi SM, et al. Computer-assisted
provision of hormonal contraception in acute care settings.
Contraception 2013;87:242-250.
Sex Med Rev 2019;-:1e10