>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.

Forty years after the contraceptive revolution brought about by the pill, there is still a demonstrable unmet need for more effective contraception, part of which will—we hope—be met by better contraceptives. More is required than the usual call for better services and improved sexual health education and counseling to use existing methods better.

For years, the very name "pill" has been synonymous with contraception. This has maintained ignorance of any alternatives beyond condoms and sterilization. However, the supremacy of the pill is now being challenged. For a start, in a world in which sexually transmitted infections (STIs) are rife, it cannot be relied on for safer sex. In addition, public confidence in oral contraceptives has been shaken by periodic reports that pill use may increase the risk of such serious health problems as breast and cervical cancer and cardiovascular disease.

A good example was the "mother of all UK pill scares" brought about in October 1995 by a letter sent individually to every doctor by the Committee on the Safety of Medicines (the UK equivalent of the U.S. Food and Drug Administration). This communication was intended to advise physicians of a very small absolute increased risk of venous thromboembolism related to use of pills containing either desogestrel or gestodene (two third-generation progestogens) instead of levonorgestrel or norethindrone. But the manner of the announcement led the UK media and general public to perceive it as a serious problem affecting all types of oral contraceptives. The major independent provider of legal abortions reported an 11% increase between December 1995 and February 1996, and 61% of the women involved said they had failed to finish their current course of pills.1

A third problem is one expressed well by the following anecdote:

When he was creating Adam, God informed him that he had two pieces of good news for him and one piece
of bad news. He continued, "The first good news is that I am going to create for you an organ called the brain. With this gift of mine, you will be able to think and to learn, and if you use it well you will be a good steward, caring for all the other amazing creatures I have made."

"Thank you very much," said Adam. "What's the other good news?"

"Well," said God, "I have given you another organ: the penis. With it, you will be able to give your wife Eve much pleasure, and receive the same back from her. And with my help, children will be conceived through this organ, so that you will be fruitful and multiply."

"Thank you for that second gift," replied Adam. "But what's the bad news?"

"You will never be able to use both organs at the same time," God said.

This little story encapsulates why the oral contraceptive, well though it has served us, is unlikely to retain its preeminence to the end of this new century. In the anecdote, this disjunction between the brain and genitalia is a feature of the man, Adam—rightly, as it certainly seems to affect men more strongly than women. The vast majority of men in almost every country, from their teenage years on, do have the information that penis-in-vagina equates to a real risk of conception and, outside of monogamy, of a sexually transmitted infection. But, they too often do not apply that knowledge to their "second organ"—in the proper use of condoms, for example—especially when their "first organ" is under the influence of alcohol or other drugs.

Although the disjunction between knowledge and behavior appears to be most acute for men, it also affects women's use of contraceptives. With the pill, there is at least the advantage that nothing has to be done to prevent pregnancy in the heat of the sexual moment. Yet there are many obstacles to good compliance.2 Not only do women have to remember to take a tablet at more or less the same time every day, but in any new relationship those who have stopped using the pill during a period of sexual inactivity must also restart in time.

The observation that so many unintended conceptions occur at the start and finish of relationships implies that many women also fail to meet the challenge to use their brain and their sexual organs at the same time.

A better future model would be a reversible method with a different "default mode" than the pill. That is, instead of requiring repeated decisions to avoid conception, such a method would require only one such decision when the user was sure he or she wanted to remain child-free for a number of years. (In principle, the method could be for use by either sex.) After acting on that decision, individuals would be free of all contraceptive responsibility and nothing else would need to be done until they were good and ready for conception. Until then, the method would have the ideal default state—contraception—unlike the pill, whose default state is conception!

Contraceptive utopia is inhabited by perfect users of perfect methods. The methods are free of side effects, are 100% effective, protect against STIs and are completely user-friendly in the manner just described. Implants, IUDs and the new levonorgestrel-releasing intrauterine system for women are current methods that point the way forward. Unlike the pill and the condom, they do have the correct default state; however, none are free of side effects (especially irregular bleeding), nor are they protective against STIs. They are not therefore usually methods of first choice for teenagers.

Thus, we particularly need more methods that are both usable by adolescents and completely forgettable once instituted. Without a crystal ball, it is difficult to predict what these methods will be: Innovative compounds such as antiprogestins and new slow-release technologies will be necessary.3 But they are most likely to be implantables of one kind or another, ideally with instant user-reversibility. Until we develop methods with all the advantages of the pill but without its inappropriate default state and lack of STI protection, it is unlikely to become obsolete. We can only hope that, sometime during this century, all societies will at last have access to and learn to use improved, completely forgettable contraceptive methods perfectly, so making side effects, unplanned pregnancies and STIs dimly remembered problems of the past.