The Period of Choice

Early last year, I found myself sitting around a table of women comparing battle stories. We often end up here, strung out after a long week (or increasingly a long decade), recounting like war journalists our recent medical histories. The conflict in question—our own reproductive systems—is as unresolved as any we see or hear about happening out in the wider world today.

Each one of us at one point in our lives has taken oral contraceptives, and for a range of reasons: including dysmenorrhoea, an irregular menstrual cycle, to assist with potential PCOS symptoms, or in my case as part of my hormone replacement therapy as a trans woman (an affair that heavily relies on hormonal medication produced for other purposes). We often ask each other why this isn’t easier.

When I returned home that night, I started to research the history of oral contraception and contextualise what easier might mean in the worlds of drug research and diagnosis. Almost immediately, I stumbled across the first comprehensive study¹ ever published about the mental quality of life of patients on birth control, a drug that has existed and been prescribed for over 50 years. It had been published the previous week.

The knowledge contained in the report—that hormonal contraceptives can have a significant impact on the wellbeing of those taking them—is not new, but it has largely fallen on deaf ears for decades. For the population that seeks access to hormonal contraception, side effects are not simply seen as routine, but are routinely overlooked and undervalued by parents, teachers, doctors, friends and partners. Despite many of these side effects being seen as commonplace, little has been done to look into either how common they are or how they are caused.

Despite the existence of other more effective methods of contraception and long-acting reversible contraception being recommended by international health groups, to this day the oral pill remains the most popular form of birth control for doctors and their patients in Australia² and America³ This is often in spite of the lack of clear information about the very real risks of unplanned pregnancy and adverse health effects. Oral contraceptives primarily undergo trials on their effectiveness at preventing conception, which—while of obvious importance—indicates the lack of study required before a drug can be deemed ‘safe’ and not simply ‘effective’. As I recall the countless stories I’ve heard of how these pills have caused affliction and disrupted lives, I can’t help but see an incongruity in contraception being presented as an unshackling of all womankind.

Very little remains known as fact, and it seems fair to argue that the ‘least worst’ option hardly achieves any suitable yardstick of liberation. Every month I weigh up the positive and negative outcomes of my own current concoction of hormonal medication, each slight adjustment bringing a new range of benefits and symptoms. Even the most supportive doctors struggle in the face of insufficient research, and we are simply left to bluster our way around a system with only a modicum more sympathy than it has answers, our bodies directly bearing the brunt of this deficit of knowledge.

What some see as the most important invention of the twentieth century,⁴ the oral contraceptive has shifted the paradigm of how we make reproductive choices as a society—and in the process has become so pivotal it’s known simply as ‘the pill’. Often cited as an equaliser, a tool of empowerment, or the means of sexual and societal revolution, the world we live in is undeniably different as a result of these medications. Nonetheless, we must ask ourselves whether oral contraceptives truly represent equality. Choice exists only when the options provided to us are able to be fully understood—both their benefits to us, and their risks.

Despite our many shared tables, there’s an unfinished conversation lingering uncomfortably in the margins of ‘choice feminism’, regarding whom the word ‘choice’ entails. The ability to make choices in this area is inextricably intertwined with factors of identity, and the public discourse is spoken in especially hushed voices whenever disability, race, or more controversial contraceptive techniques are on the table. The current climate of research contextualises this slightly, but to better understand where we stand now, we must look to the history of this world-altering drug.

 

*

 

Having completed animal research in the 40s and 50s which showed that administered progesterone inhibited ovulation, biologist Gregory Pincus sought to push his work further, seeing himself as ahead of the curve on a highly important and lucrative branch of drug development. Despite a political climate in which research into contraception was often illegal, he started human trials of a drug containing oestradiol (estrogen) and progesterone—and the oral contraceptive pill was born.

The first large-scale trial was conducted in Rio Piédras, Puerto Rico on over 200 women, many of whom were illiterate. They received ‘little information about the safety of the product they were given, as … no one thought that it might be necessary to provide such information’⁵ and the side effects they experienced were downplayed in the published research. Many subjects were not told that they were participating in a study, not given adequate follow-up treatment when complications arose, and were prescribed a dose many times higher than the recommended safe dose today.

On the back of these women, Enovid 10 (containing the same high dose) was brought onto the U.S. market. It was first submitted for FDA approval as a treatment for menstrual disorders and infertility (approved in 1957), and then for use specifically as an oral contraceptive (approved in 1960). Despite never being marketed specifically for contraceptive use, the modern period of the pill began to take off. Elizabeth Siegel Watkins writes:

[It] dramatically altered the contraceptive landscape for women during its first decades. In 1955, … twenty-seven percent [of American women] reported using a condom most recently, and 25% reported using a diaphragm. Ten years later … 27% of American women reported use of the Pill, 18% used condoms, and just 10% relied on a diaphragm.⁶

Regardless of the sudden surge in popularity, it remained a highly untested drug. The first published case of a blood clot and pulmonary embolism in a patient taking Enovid—a direct result of the estrogen dose—appeared in November 1961, a whole four years after it was approved. In response to this and the similar plight of many others, Barbara Seaman published the book The Doctors’ Case Against The Pill in 1970, making public the stories of women across the U.S. and bringing awareness to side effects and complications that had previously only existed behind the privacy of doctors’ curtains.

After being brought to the attention of Wisconsin senator Gaylord Wilson, a series of hearings into the drug were arranged that year. Given no time to voice their concerns, the feminist activists who were attending the proceedings interrupted to ask why patients weren’t better informed, why no research had gone into a male contraceptive pill, and as protestor Alice Wolfson noted, why it had been ‘literally handed out like candy.” She decried the use of patients as test subjects, stating on the record:

It must be admitted that women make superb guinea pigs. They don’t cost anything, they feed themselves, they clean their own cages, pay for their own pills, and remunerate the clinical observer. We will no longer tolerate intimidation by white-coated gods antiseptically directing our lives.⁷

In spite of industry condemnation, these outcries instigated changes in the manufacturing and regulation of contraceptive pills, including dramatically dropping hormone doses, and the requirement that from 1972 information outlining potential risks must be included in the drug’s packaging. 1972 also brought the first inclusion of an oral contraceptive pill on Australia’s Pharmaceutical Benefits Scheme—making us the second country to do so, though it was solely for married women. While researching, I find myself surprised over and over again at what is shown, what is passively hidden, and what is expressly concealed. When the pill is celebrated today, we are often asked to view history through a rosy aperture, forgetting the more sordid details left out of the glossy promotional pamphlets. It is important for us to recognise the powerlessness and pain of those have been harmed on the path to making the pill what it has become today.

 

*

 

Despite the clamour of the pill’s twentieth century conception, reproductive medicine has existed in a multitude of forms since antiquity, and has typically rested in the hands of the women using it. Through administering preparations of highly in-demand plants, these medical women were able to provide a range of contraceptives and abortifacients easily and as required.

This great body of knowledge continued to be passed down through generations of women for centuries, across continents, and despite the odds. Healers and midwives carried histories of care. This shifted in the twelfth century when the construction of medical knowledge was transformed from a communal practice to a controlled discipline. The practice of midwifery was removed from local practitioners by university-qualified physicians, and from women to men. Within several centuries, the ancient continuation of midwifery and herbal knowledge was broken, and in its place a great distrust of folk medicine arose.

This chain has carried on to the present day, with the bodies of knowledge that women had historically held for themselves and their communities being qualified and quantified, and the women themselves losing autonomy over their bodies. In the mid-nineteenth century Dr. J. Marion Sims, the man charged with founding modern gynaecology, perfected his methods on Anarcha, Betsy, and Lucy, who were slaves and women of colour. Sims operated upon them dozens of times without anaesthetic, but then struggled to perform the same operations upon white women, as none of them were able to endure the pain.⁸

The blatant bigotry within this field continued well beyond Sims. In her 1998 book, Dorothy Roberts devotes a whole chapter to the relationship between contraceptives and eugenics, entitled ‘The Dark Side of Birth Control’. She writes:

The spread of contraceptives to American women hinged partly on its appeal to eugenics bent on curtailing the birthrates of the ‘unfit’, including Negroes. For several decades, peaking in the 1970s, government-sponsored family planning programs not only encouraged Black women to use birth control but also coerced them into being sterilized.⁹

It cannot be understated how intrinsically the invention of oral contraceptives is linked to eugenics, the carrot of chemical population control being successfully dangled before a white, middle-class public. This not only proved a successful distraction from the popular early twentieth-century narrative that contraceptives were for the morally moribund, but tapped into heightened fears of the time. Barratt examines this history through the lens of how it is told today, or more precisely how it isn’t—many modern histories glossing over or omitting altogether the population control aspect of the conversation:

[In] the 1950s and 1960s … there was little distinction made between the ‘liberating’ use of contraception, and the coercive use of contraception, and even the most ardent feminist supporters of birth control considered population control and individual reproductive control to be equally important.¹⁰

For Australia, the twentieth-century fear of population explosion was predominantly aimed at Asia, and the expedited introduction of the pill has ties to this panic. National reproductive policy was resultantly shaped by international prejudice. In addition to this, there was also hope that by providing access to the pill for developing nations, birth rates would slow. This idea is backed by the fact that much of the non-western world is able to purchase oral contraceptives over the counter to this day.

There is no doubt that the advent of modern contraception has provided more choices than ever for how we care for and regulate our bodies, but it becomes more and more apparent that this entrancing paradigm of ‘choice’ has risen out of a history fraught with hierarchical structures that abused and devalued those without power.

 

*

 

By 1995, 40% of women using contraception reported on the Australian census that the oral pill was their method of choice. Despite a shifting culture around contraceptives and sex over the years, little has changed in terms of the make-up of the medication itself. A tablet containing a formulated dose of either progesterone or a combination of progesterone and estrogen is taken daily or according to a cyclical schedule as prescribed by a doctor or specialist, as many readers will know intimately. Verma Liao & Dollin’s December 2012 paper ‘Half a century of the oral contraceptive pill’ notes that ‘much appears to have changed in half a century, but not a lot really has’. The authors point out that even though there are a range of new contraceptive medications and devices available in the new millennium, just as before, the burden of implementation and cost falls almost universally on the party who is physically able to get pregnant.

It’s not like contraceptives aimed at men haven’t been developed. A 2016 study into ‘A safe and effective reversible method of male contraception’¹¹ took on 320 participants and concluded that the study regimen yielded near-complete and reversible spermatogenesis suppression. Nonetheless, it came at the cost of a high frequency of moderate mood disorders, which ruled it out from being made available to the public any time in the near future. When this news broke, a range of media outlets mocked the fact that a contraceptive medication could be deemed unsuitable because it causes mood swings and cramping, citing it as a failure of the men involved in the study to toughen up. Others, however, noted that the rightful scrutiny afforded to the risks of such a product had not been applied to its counterpart.

The side effects of the pill are something that we experience daily, that we worry about, that we talk about with our friends, and yet so little research into them has been undertaken. Meanwhile, our own knowledge of our bodies is all too often dismissed by health professionals who ‘know better’. The first time a friend of mine was told by a doctor that their ‘period was not meant to be incapacitatingly painful’, they immediately posted about it online with relief, but also with anger that for all their life doctors had advised otherwise. The average delay between the onset of symptoms of endometriosis (often called the ‘invisible illness’) and definite diagnosis is six to ten years,¹² and people often go far longer—sometimes their whole lives—being told their pain is normal.

Even ability to make choices about our bodies starts to falter as soon as we enquire into any contraceptive options that aren’t temporary. Inevitably shared around tables of friends are stories of those of us who’ve sought voluntary tubal ligations, only to be turned away because a future partner of ours might want children, or simply because doctors think we will change our mind. A friend recently had one performed, and even as we last spoke of it remained incredulous that it had been granted at all.

Facing these limitations of institutionalised medicine, it is not surprising that people have sought their own avenues of empowerment. In truth, people have been finding answers and making decisions on their own for as long as has been necessary. The internet has made this process far more accessible, but groups have gathered throughout modern history to forge paths reminiscent of the ley lines set by ancient healers. Communities have formed around present and past users of medications, in support of reproductive conditions that have seen little light, funding, or oversight, and in general assistance of those seeking sexual health education.

The recently started wiki gynopedia.org¹³ provides a crowd-sourced guide to accessing reproductive health services and understanding local legal frameworks around the world, but still seems to predominantly be aimed at western travellers rather than local communities themselves. At the other end of the speculum, there is the Catalan collective Gynepunk, who aims to ‘decolonize the female body’ by providing open-source gynecological lab tools for self-analysis.¹⁴ They’ve also renamed the Skene gland (originally named after nineteenth century gynecologist Alexander Skene) after Anarcha, one of the slave women operated on by J. Marion Sims. This honours her pivotal place in the history of modern reproductive medicine and serves to counteract the historical patriarchal control over women’s bodies.

Even outside of organised groups, forums and social media have allowed for the creation of networks of information, awareness and action, with many people having their symptoms and ailments being heard as valid for the first time by peers after a lifetime of being disregarded by medical professionals. Armed with new-found knowledge and the support of these communities, people have been able to fight more clearly to have their symptoms taken seriously and their lives made better.

Despite this modern movement of self-knowledge, the authority over contraceptive medicine and the bodies that stand in need of it remains with academics and pharmaceutical corporations, existing in the spaces created all those centuries ago by men of medicine in their institutions. Since the very beginning of the pill’s existence, questions have been asked of its efficacy and safety, with few of them hearing adequate answers. Meanwhile, the list of bodies left in the wake of research and a lack of informative consent remains predominantly unnamed and unknown.

 

*

 

For many of us, it starts with this moment—realising that we have a modicum of control over the choice we’re told we are afforded. But this opportunity doesn’t come for everyone. The structural power of creating and controlling these substances still lies outside our hands, ensconced in boardrooms and political cabinets that would barely pass the Bechdel test. When we look at the thorough audit of ‘male contraceptives’ and compare it to the history of medicines that we are actively taking today, there’s a clear discrepancy. The difference lies not simply in the greater restrictions placed on modern medical research, but in the gender of the majority of users, and the systematic ways choice is afforded to them.

It would not be unfair to say at this point that the modern construction of choice provided by the pill is as much an application of marketing as of liberation. For white, able-bodied women with some economic means, oral contraceptives do enable an ability to make personal decisions about reproductive health. But it hardly remains radical—this ability having always been the precise goal of the mainstream modern contraceptive movement.

It’s estimated that over one hundred million people are currently using oral contraceptives, and despite a history often both ignoble and unspoken, it remains a drug of extraordinary importance. People all over the world use the pill for a range of reasons, not least of all providing an unprecedented level of access to family planning. It nevertheless continues to be important to not march forwards blindly under the mantle of liberation simply because we as individuals have found working solutions. When starting to research for this piece, I was vaguely aware that the pill’s history had sordid elements, but their depth had eluded me entirely. Knowing this history is just one step toward better contextualising what liberation means for us today, but they are steps not trodden often enough.

The ideological wall between the metaphoric licence to bodily autonomy and the literal licence to practice medicine remains towering and guarded. But as we shine light on this past, share ever-less clandestine details online, fight for positive change and even just laugh around tables of friends, we’re learning how to kick out those walls one brick at a time—as if it even was a choice in the first place.

Liz is a writer, sexual health nerd and photographer who has had their work featured in Kill Your Darlings, Crikey, Archer, Junkee, and Overland. She can be found on @lizduckchong, co-hosting @letsdoitpodcast, or catching trains around Sydney’s inner west. 

1. Zethraeus, N., Dreber, A., Ranehill, E., Blomberg, L., Labrie, F., von Schoultz, B., … Hirschberg, A. L. (2017). A first-choice combined oral contraceptive influences general well-being in healthy women: a double-blind, randomized, placebo-controlled trial. Fertility and Sterility. https://doi.org/10.1016/j.fertnstert.2017.02.120
2. http://www.abs.gov.au/AUSSTATS/abs@.nsf/2f762f95845417aeca25706c00834efa/e50a5b60e048fc07ca2570ec001909fb!OpenDocument
3. https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states#1
4. http://www.economist.com/node/347484
5. Liao, P. V., & Dollin, J. (2012). Half a century of the oral contraceptive pill: historical review and view to the future. Canadian Family Physician Médecin de Famille Canadien, 58(12), 757–60. Retrieved from http://www.cfp.ca/content/58/12/e757.full
6. Watkins, E. S. (2012). How Pill became a lifestyle drug: The pharmaceutical industry and birth control in the United States since 1960. American Journal of Public Health, 102(8), 1462–1472. https://doi.org/10.2105/AJPH.2012.300706
7. Gazit, C., & Steward, D. (2003). The Pill. PBS American Experience.
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1376165/
9. Roberts, D. (1997). Killing The Black Body. Pantheon Books.
10. Barratt, ‘Ill-conceived History: An Analysis of the Fiftieth Anniversary of the Pill’ 2012
11. Hermann M. Behre, et. al ‘Efficacy and Safety of an Injectable Combination Hormonal Contraceptive for Men’ 2016
12. https://www.acog.org/about_acog/news_room/~/media/newsroom/millionwomanmarchendometriosisfactsheet.pdf
13. Gynopedia. (n.d.). Retrieved from https://gynopedia.org/Welcome_to_Gynopedia
14. Chardronnet, E. (2015). GynePunk, the cyborg witches of DIY gynecology. Makery. Retrieved from http://www.makery.info/en/2015/06/30/gynepunk-les-sorcieres-cyborg-de-la-gynecologie-diy/