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.
Approval of the oral contraceptive pill for marketing in the United States 40 years ago was the culmination of a long search for a way to give women reliable control over their own fertility. The goal of finding a means for women, on their own, to prevent pregnancy reflected the burden many women had borne for centuries when their wishes about when and how many children to have were overridden or ignored by their male partners.
The introduction of the pill (along with that of the IUD and easier methods of contraceptive sterilization) during the 1960s changed the link between sexuality and contraception and altered the balance of male-female involvement in contraceptive use. Before the pill became available, contraception meant almost exclusively a method used at the time of intercourse (such as the condom, the diaphragm and withdrawal) or related to the timing of intercourse (periodic abstinence). The only contraceptive option not related to intercourse, sterilization, was little used.
For the most part, methods of contraception available before the pill usually implied the involvement, or at least the knowledge, of both the woman and the man at or around the time of intercourse. With the advent of the pill, the realm of contraception became increasingly a female arena. In 1995, female methods accounted for 63% of all contraceptive use reported by women aged 15-44.1 The change over the past four decades came primarily at the expense of joint use, with the proportion relying on some form of periodic abstinence dropping sharply; a smaller decline occurred in the proportion of women relying on their partner to use a method.
And, to a large extent, contraceptive use—especially use of female methods—has become disengaged from intercourse. In 1995, 94% of women using contraceptives themselves were using coitus-independent methods, primarily the pill and tubal ligation. Because the only coitus-independent method available to men is vasectomy, 68% of men practicing contraception were using the condom or withdrawal.
The availability of an array of highly effective female methods that are independent of intercourse, and therefore largely outside the control and even the knowledge of a woman's male partner, is a great achievement. Nevertheless, this accomplishment has drawbacks as well as benefits. As women gained more control of contraception, men were distanced from method choice and use. Some men have undoubtedly been glad to leave this responsibility to women. Others, it is probably fair to say, have been excluded by women who see fertility control as their sole prerogative. The heavy reliance on methods independent from intercourse has meant that sexual partners do not need to alter their behavior around intercourse or even discuss contraception in the context of sexuality.
These changes have pluses and minuses on an interpersonal level. They also have implications for our reactions to the HIV and STD crises, for gender roles related to sexuality and reproduction, and for our readiness to take advantage of potential new contraceptive methods for men.
The methods that most men and women prefer to use for prevention of pregnancy—those that women control and that don't have to be used at the time of intercourse—are ineffective against sexually transmitted diseases (STDs). Prevention of STDs, including HIV, depends on partners' openness to discussions of their sexual and infection risk status and on use of the male condom, the only proven method of protection for those at risk of infection. Although condom use has risen, a minority of couples—even those in which one or both partners have other sexual relationships—use condoms. Has the availability of the pill and other coitus-independent methods been a factor in today's low levels of condom use? In separating contraception from sexuality, they lowered the likelihood that people would gain competence and comfort talking about sex and developing skills for integrating method use into intercourse.
Forty years after the pill was acclaimed as a way for women to take control over their bodies and their reproductive lives, increasing attention is being focused on acknowledging and expanding men's involvement in reproductive and contraceptive decisions and behavior. People have been somewhat stymied, however, by the need to define desirable parameters for men's contraceptive involvement. Besides their actual use of condoms, vasectomy or withdrawal, what role can men play in contraception? If a couple relies on a female method, men can provide support that ranges from helping to pay for method costs and picking up supplies to offering empathy for women experiencing uncomfortable side effects. Will there be greater balance when men also have more method options?
After such a long period when almost all contraceptive method advances were for women's methods, systemic methods for men have moved into clinical trials. While much remains to be done, there is reason to expect that within the next decade men too will be able to select a reversible method of contraception that is not linked to intercourse. Will we be ready? The benefit of experience with women's methods has both raised the demands for safety and prior testing for side effects and, hopefully, lowered expectations that a new method will be "perfect"and suitable for everyone throughout their reproductive lives.
But the field of male contraceptive development has been plagued by questions of whether men will be willing to use systemic methods, and whether women will trust their contraceptive protection to a male method that they cannot verify is being used. These are realistic questions, given our lack of experience with male methods, and given differences in the effects of unintended pregnancy on women and men. The impact of unintended pregnancy on men has been heightened by efforts to enforce financial support of any children they have, especially when men cannot override a woman's decision to carry a pregnancy to term.
Even though the focus of pregnancy prevention over the past four decades has been almost exclusively on women, it is clear that some men are willing to assume responsibility for contraception and that some women are comfortable with that arrangement. Male methods now account for 38% of all reversible contraceptive use, and 28% of reproductive-age women who use contraceptive sterilization rely on their partner's vasectomy.2 However, it is questionable how many women would be willing to rely on men's use of a systemic, undetectable method, except in the context of a long-term, committed relationship.
Facing ongoing challenges related to contraception and sexual relationships even 40 years after the introduction of the pill does not negate the important differences this breakthrough has made for women's—and men's—lives. But the context has changed, and new challenges have arisen. Some are the negative challenges of HIV and other STDs—that women and men become more capable and willing to deal openly with sexuality and to integrate condom use into intercourse. Others are more positive—men's interest in becoming more involved in sharing contraceptive responsibility and the potential availability of systemic methods for men.