Making a More Modern Diaphragm

How the new, very purple “Caya” is trying to make an old-fashioned birth-control option relevant again

A line of diaphragms is run through a compression test to check for durability at PATH. (Elaine Thompson / AP)

Contraception is not a toy, but the Caya, a new, one-size-fits-most diaphragm, looks like something Polly Pocket might be into: It’s lilac, squishy, and comes in its own little case. The look is part of its appeal. It’s an attempt to break down the stigma that diaphragms are your grandma’s birth control and to make them relevant again.

There was a time when diaphragms, putty-colored cups used to cover the cervix, were the most frequently prescribed form of birth control. They were a sexual standard for half a decade. In the ‘40s, a third of American married couples were using them, but they fell out of favor when hormonal birth-control methods became reliable and inexpensive.

Now, clinics can buy some IUDs for around $50 and most women can get the pill for free through their health insurance. But some women could benefit from another option. If a woman doesn’t want to, or can’t, use hormonal birth control, the next most popular option is a condom. If that, too, is unappealing, or if her partner won’t wear a condom, a diaphragm can fill that need for nonhormonal, female-controlled birth control. Which is why PATH, a Seattle-based global health non-profit, developed Caya.

The diaphragm, as a concept, has been around for a long time. In ancient Egypt, women would put sea sponges or a hollowed-out lemon half into their vaginas to stop sperm from getting into their cervixes.

In 1839, Charles Goodyear figured out how to vulcanize rubber, which led to the development of rubber-based contraceptives including the condom and the horrific-sounding first stab at a diaphragm called a “wife’s protector,” which had an external eight-inch metal handle to help with removal. In 1882, a German doctor, Wilhelm Mensinga, patented a rubber-covered metal watch spring attached to a flexible dome that fit over the cervix—what we now think of as a diaphragm.

It took a while to get to the United States. In 1916, Margaret Sanger, who coined the phrase “birth control” and founded Planned Parenthood, opened the first birth-control clinic in the U.S., and distributed diaphragms she’d illegally imported from Europe. Sanger worked as a nurse in a poor neighborhood clinic and after seeing women die from unplanned pregnancies and back alley abortions, became a champion for contraceptives. She claimed to have fitted 488 women for diaphragms in the 10 days her clinic was open before the New York police raided it, arrested her, and shut it down. She was charged with violating the Comstock Act of 1873, a law that banned the trade and circulation of “Obscene Literature and Articles of Immoral Use.” Sanger went to jail for a month, but she appealed her conviction and eventually won. In 1918, an amendment to the act allowed doctors to prescribe birth control for medical reasons, and in 1938 a judge lifted the ban on contraceptives entirely.

For 40 years after Sanger snuck them into the U.S., diaphragms were the most widespread form of contraception, but when the pill was approved by the Food and Drug Administration in 1960, they slowly started to slide off the radar.

It only declined further as time went on. “I think when highly effective IUDs became available in the ‘80s, people started looking at the diaphragm, which had been around for hundreds of years, and it seemed old fashioned and passé,” says Maggie Kilbourne-Brook, the program officer at PATH, who was in charge of developing Caya. “You go to family-planning clinics now and they’re not even on the posters anymore.”

Vanessa Cullins, the vice president of external medical affairs for Planned Parenthood, says that she thinks diaphragms are a decent option because they’re simple, long lasting, and you can stop and start using them whenever you want. But she says they don’t get many women asking for them anymore—which she chocks up to drug-company marketing—and that Planned Parenthood tends to encourage IUDs and implants, because they’re harder for the user to screw up.

To show how they’d direct patients, Cullins pointed me to MyMethod, their digital tool for helping women choose birth control. You answer questions about your health and sexual activity and it spits out what it thinks might work for you. I tried it a few times, changing my answers about things like my health history and my schedule to see what kinds of options it would come up with. It steered me toward an IUD, and then the pull-out method, before it told me I should think about a diaphragm.

That’s what drove Kilbourne-Brook and her team to develop a new diaphragm—they wanted to provide a diaphragm women might actually choose to use. There were still gaps in the system. A 2012 study from the Guttmacher Institute found that 24 percent of women in the developing world who wanted an option for birth control weren’t using any form, because nothing met their needs. Women in developing countries were requesting non-hormonal methods that they could stop or start easily, and which could be used discreetly without a partner knowing. Kilbourne-Brook says that when they started doing research they saw some of these same needs in developed countries.

Part of the problem is that most readily available methods, from the ring to the pill, are hormonal. For the majority of women that’s not a huge problem, but some medical conditions, like cervical cancer, hepatitis, or blood clots, make them off-limits, and some women just don’t like the way they feel when they take hormones.

Kilbourne-Brook says they saw a need, albeit small, for an alternative. So, the question became: How to modernize a medical device that hadn’t been updated in 50 years? And then how to break the stigma that diaphragms are birth control for grandmas?

A makeover didn’t hurt. When Kilbourne-Brook pulls out the nine different sizes of diaphragms that a clinic would typically stock and sets the set next to a Caya, the old ones look a bit like shriveled pantyhose. They’re fleshy looking and saggy, while the Caya, in its plasticky purpleness, looks like a Barbie accessory.

That’s intentional. PATH spent 20 years trying to make the Caya both anatomically friendly and visually appealing. The idea to design a new diaphragm started in 1994, at the United Nations’s International Conference on Population and Development, to address the need for contraception in low-resource areas, where women might not be able access time-sensitive pills or IUDs, or might not want their partners to know they were using birth control. PATH, which does a lot of work on global family planning, spearheaded the project with funding from USAID and help organizing the trials from the Contraception Research and Development (CONRAD), research group.

Their goal was to make a diaphragm that was less awkward for the user and easier for health-care providers, who struggled with stocking nine different sizes of diaphragms, and spending the time to fit women for them. When they conducted surveys, Kilbourne-Brock said they heard stories about diaphragms flying across the room as women tried to insert them, or first-timers freaking out when they tried to find their cervix. “If you have a bad first time you’re not going to come back,” she says. “It was discouraging.”

They worked through six different iterations before they settled on the version currently being sold. The wanted the rim to be firm enough to stay in place, but not so firm that it sprung up and thwacked you in the insides while you were inserting it. The older models, with their stiff, watch-spring rims, would often snap open painfully when they were deployed. They worked with vaginal anatomists to size it so it would fit almost every woman and sit over the cervix instead of spanning the whole vagina. So it’s smaller, and one-size fits all. They thinned out the silicone membrane to make it easy to fold.

The final result has indents on the side, for grip, and a bubble on the front that’s easy to grab when a woman takes it out. The rim is contoured and made of squishy nylon instead of metal. Focus groups around the world reported finding the purple color appealing.

Martin Kessel, who distributes the Caya in Europe, surveyed the women who bought it, and found that most of them had no previous experience with diaphragms. They were predominantly pill-users who were looking for a different method.

Because of the European Union’s regulatory standards, Kessel was able to license and distribute Caya in Europe and the Middle East most easily. So starting in 2013, they launched it in those regions first, and are slowly rolling it out in other countries as they clear regulation. Because of the FDA’s stringency it’s been available since late this June in the U.S., and it’s only available with a prescription. Bob Patane, the founder of HPSRx, the American distributor, says their biggest struggle has been getting pharmacies on board, and making it easy for women to find. He says health-care providers have expressed interest, but that they’re not sure what their patients will think. “They remind us there is only a small subset of the contraceptive users that will be interested,” he says. “But they are also quick to point out that this subset does seems to be growing as more and more women are concerned about hormonal contraception and looking for alternatives.”

“This isn’t just the introduction of another diaphragm,” Kilbourne-Brook says. “It’s reintroducing a whole generation to a method they haven’t seen, it’s not part of their culture.”