We celebrate the 40th anniversary of the introduction of the oral contraceptive pill in a world considerably different from the one we knew four decades ago. How much of the change we have experienced can be traced, directly or indirectly, to the pill? Since this method first became available in 1960, many articles have been written about its impact on society. Like other publications, Family Planning Perspectives has periodically examined the pill's influence on women's roles and on the separation of reproduction from sexuality. As we begin a new century, however, we believe it is valuable to take a look at several other issues that have—despite their importance—received less attention.
The experts we asked to address these topics seem to agree that the pill has played a complex role in how we think, communicate and interact. Indeed, they may raise at least as many questions as they answer. Have oral contraceptives allowed women freedom from the risk of pregnancy, only to subject them to a physician's rigid ideas of how they should take them? Has the pill given women more control over contraception, only to burden them with responsibilities they would prefer to share with their partners? Has it encouraged women who grew up with the pill to talk about contraception and sex with their daughters, only to find that their daughters want them to believe they are taking the pill to alleviate painful menstrual cramps? Is the pill a way for black women to gain bodily autonomy, or a tool used by white society to limit black fertility? Did we think the pill had liberated us from the hated condom, only to find that we now need both? Given the dearth of new methods on the horizon, it is likely that we will struggle with these and other questions far into the 21st century.
The essays in this forum were solicited, developed and edited by Frances A. Althaus, senior editor of Family Planning Perspectives.
In the 1960s and 1970s, oral contraceptives were new. Some observers argued that the pill ushered in the sexual revolution by freeing women from the worry that sexual intercourse would inevitably lead to pregnancy. Indeed, trends in rates of sexual activity among adolescents over the years suggest that there really have been changes in sexual behavior: In 1970, fewer than 50% of 19-year-olds had experienced intercourse, while by 1985, more than 50% of 17-year-olds were sexually experienced.1
In the 1960s and 1970s, most young women did not tell their mothers that they were sexually active or that they were taking oral contraceptives. They were introduced to responsibility about reproductive issues through visits to family planning clinics, and most of those visits were made alone or with a girlfriend, not with their mother. Many of the clinicians who provided contraceptive services for adolescents in that era were aware that assurances of confidentiality were of paramount importance to many teenagers.2
The teenagers of the 1960s and 1970s have now reached middle age; many have adolescent children. Has the pill made a difference in how we relate to our daughters (and sons)? Has the pill made a difference in our beliefs about family communication? I believe that it has. About 80% of women born since 1945 have taken oral contraceptives.3 They grew up with the pill. They took it for granted. They assumed that their sexual lives could be separated from their decisions about parenting and conception. And so do their daughters. But their own mothers did not have the same confidence that they could control their reproductive lives as successfully. This change, occurring over two generations, is attributable to oral contraceptives.
Today's mothers know that their daughters can receive oral contraceptives without parental involvement, much as they themselves did. But because they know this, many of them have made decisions about how they want to parent, based on their own experiences as adolescents. They have decided that they want to do a better job of communicating with their children about healthy sexuality than their parents did with them. They talk about many things that their parents left undiscussed—contraception, STDs, HIV, homosexuality and oral sex. Not that these conversations are easy. They talk about these things with their children in part because they feel that they are too important to ignore, but also because the times in which they live have made it dangerous not to. They talk about these things because they can't ignore the availability of oral contraceptives, nor would they want to. As parents, they know that they need to talk about oral contraceptives as an option for their daughters. For some of today's mothers, the pill changed life for the better (fewer menstrual cramps, predictable periods and reliable contraception), while for others it caused uncomfortable or even frightening side effects.
As a consequence of this knowledge, many mothers of adolescents help their daughters obtain medical and gynecologic care; they often make the appointments and accompany their daughters to see a clinician who will provide appropriate health education and preventive guidance. The clinicians who provide care for today's adolescents recognize the importance of confidentiality, but also understand that adolescents grow up within the context of a family.
In my practice, I see many adolescents; I see most of them with their mothers. As I have grown as a clinician, I have come to recognize the importance of fostering healthy communication between mothers and daughters. When I see a new patient, I allow time to talk with the mother and daughter together, to speak with each privately, and then to meet again together. This process allows an adolescent to keep whatever information she chooses confidential, but allows the sharing of information and health concerns.
When I talk about oral contraceptives, I feel that it is most helpful if both mother and daughter can hear about the risks, benefits and potential side effects. Of course, many daughters today still choose not to tell their mothers of their need for contraception. They may instead request that oral contraceptives be described to their mothers as therapy for cramps, irregular periods or heavy bleeding. In addition, many older adolescents come for gynecologic visits alone. But I encourage them to try to talk with their mothers. I do believe that this is easier today than in years past, in part because so many of today's mothers have themselves taken the pill, and because the pill has evolved from a revolutionary new pharmacologic development into an assumption of modern life and health.
Most mothers of adolescents know or will soon come to know the essential fact of parenting—that they are preparing their children to make decisions for themselves. While they would like to protect them from making foolish, dangerous or inappropriate choices, they can only provide them with the information, support and encouragement to make smart and healthy choices.
But most mothers of adolescents today recognize that knowledge is power. They want to provide knowledge about contraceptive options to their daughters. They want them to know that they can effectively protect themselves from unintended pregnancies, but that sexually transmissible infections are a potentially problematic, morbid or even life-threatening possibility. They want them to be safe—from pregnancy, from infections and from emotional hurt; they want to protect them from an intimate relationship that is premature, exploitive, unequal or ill-advised. They would like for them to postpone having intercourse until they are cognitively, socially, emotionally and developmentally mature enough to make responsible choices. And mothers and daughters today do talk about these issues—and I believe that is so because oral contraceptives helped to set the stage, shaped the mothers' own behaviors and helped them think about how they would like to have been parented.
The pill becomes the focus of many mother-daughter discussions relating to adolescent growth and development, achievement of independence, individuation and responsible choices. That is a good thing; these issues need to be addressed.
In general, the interactions that I observe between today's mothers and adolescents seem healthier than those of a generation ago. The fact that women can successfully postpone childbearing until they actively choose to parent is an assumption of modern life. I believe that this assumption has and is shaping today's families, and that the pill played and is playing a major role in the transformation of relationships between mothers and daughters.