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4
Values and
Contraceptive Development
The contraceptive development process cannot be adequately understood by
focusing only on the potential gain in effectiveness or safety of a new method or
on the profits a manufacturer projects for a new product. It is also important to
understand the attitudes and values that influence the perception of individuals
and groups regarding contraceptive practice and the need for new methods, as
well as their desire for certain levels of risk, convenience, and cost and their
willingness to support efforts to develop new contraceptives.
This chapter provides a sketch of some of the many facets of American values
related to contraception and human reproduction. Although the committee did
not attempt a comprehensive treatment, these issues are important and merit
attention. One reason that we have not provided more detail is that the information
needed for complete analysis of the history and sociology of American attitudes
toward the control of human reproduction and their likely impact on contraceptive
development is not available. Although there is a sizable scientific literature
examining knowledge about, attitudes toward, and the practice of contraception,
almost no research has been done on public opinion regarding contraceptive
development. Thus, we cannot present a full-blown examination of this complex
topic. Despite the shortcomings in available information, it is important to
illustrate the range of attitudes and values related to contraceptive development
that exist in the United States and to discuss the value conflicts that almost
certainly have affected the development of new contraceptives. These conflicts,
and the differences in attitudes on which they are based, are part of the full range
of factors that influence contraceptive development in the United States.
41
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42 DEVELOPING NEW CO=~CE~~ES
ROOTS OF AMERICAN VALUES ON CONTRACEPTION
In comparison with some cultures, American attitudes toward reproduction
and contraceptive use appear remarkably conservative; compared with other
societies, we seem permissive and sexually liberated. Moreover, when examining
the likely effects of values, attitudes, and beliefs on contraceptive development, it
is not clear whose values are most decisive-those of pharmaceutical industry
executives, those of the likely users of a new method, those of militant opponents
of a potential new method, or those of some larger and less-well-def~ned public. It
is also not clear how to evaluate the importance of the historical context in which
these attitudes exist. Positive public attitudes may have encouraged support for
contraceptive research and development at one time, but these attitudes may have
changed partly in response to other changes, such as the legalization of abortion or
the advent of AIDS, and interest in new methods may have increased or decreased.
Historical Perspectives
The history of fertility control has been marked by occasional efforts to
promote contraceptive use as a means of ensuring a certain numerical balance or
even the superiority of a particular group. Before World War II, for example,
there was a concern about maintaining racial homogeneity in the United States, a
factor that influenced some of those who promoted family planning and who
drafted America's immigration laws (Reed, 1978~. Some leaders in the black
community have worried about what they termed the genocide inherent in white
promotion and black acceptance of federally subsidized family planning services
(Littlewood, 1977~. Given the links between the eugenics movement and the birth
control movement, it is not surprising that some in the black community have
argued that government-supported, organized family planning programs were
racier In the 1960s, considerable controversy erupted when family planning
centers were located in black communities, because some people thought these
programs were designed specifically for minority communities Joffe, 1986~.
Indeed, there is evidence that family planning clinics in small counties in the
South were located in black areas, regardless of other measures of the need for
such services (Billy, 1979~. Despite the suspicion with which family planning
was regarded in minority communities, minority women have used family planning
services to meet their individual desires to prevent pregnancies and births. But
there are people who feel uneasy about government support for fertility control
and for contraceptive development. Moreover, for some Americans there is the
added influence of deeply held cultural or religious values that cause them to
question the appropriateness of efforts to influence reproductive choices or to
help people control fertility.
While hostility to contraception exists in the United States, recent decades
have witnessed a growing acceptance of the idea that fertility should be controlled
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VALUES AND CONTRACEPTIVE DEVELOPMENT 43
and substantial increases in contraceptive practice to enhance individual and
social welfare. Only modest differences exist in rates of practice among various
economic, religious, and racial groups. Opposition to family planning appears to
be limited to a tiny minority of Americans, almost all of whom oppose abortion,
sterilization, or modern methods of contraception for religious reasons. Despite
the widespread practice of modem contraception and the overall favorable attitudes
toward fertility control, there is no broad public demand for the development of
new contraceptives. Resistance to the notion of separating sex from reproduction,
which may have slowed the development of some contraceptives in the past
(Potts, 1988), has been replaced with concern about the safety and appropriateness
of different means of fertility control as a principal attitudinal barrier to development
efforts. Changing attitudes toward sex, women, work, and the family have
become increasingly important determinants of the nation's orientation toward
fertility control, and these attitudes may now be more favorable to contraceptive
development than in the past. If the economic importance of women in the work
force continues to increase and is expressed in terms of greater political activity,
their preferences for particular contraceptive products may become a more
important factor in contraceptive development efforts and public pressure for new
products.
Religious Perspectives
Current American attitudes toward contraception and human reproduction are
often rooted in beliefs and values molded by the nation's dominant religious
traditions. It is useful to briefly note the highlights of what those traditions have
had to say about contraceptive practice. Although the desire to control fertility
and the existence of contraceptive devices date to primitive times (Noonan,
1965), contraceptive use has often been a controversial practice for believers of
all sorts. The societal disapproval that was manifested in religious prohibitions
has often been incorporated into secular law. Both the religious and secular
restrictions were, in turn, influenced by society's attitudes toward the role of
women, marriage, and the family (Gordon, 1976~.
In the Orthodox Jewish tradition, sexuality is considered a natural function of
human beings that satisfies values other than procreation (Bleich, 1981~. But,
although it is viewed as a natural function, sexuality was historically not permitted
unfettered expression, because "Eriecognition and sanctification of the multiple
values inherent in the sexual act do not bestow the right to thwart its procreative
role" (Bleich, 1981:55~. Orthodox tradition does not permit contraceptive use
unless "pregnancy represents a health hazard to the mother or child, or when
previous children have been born defective" (Kertzer, 1978:58~. In contrast,
Reform and Conservative Judaism have supported a more liberal position on
contraceptive practice. The Central Conference of American Rabbis (Reform)
approved the use of contraceptives for economic, social, and health reasons in
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44 DEVELOPING NEW CO==CE~~ES
1930 and were joined in this position in 1935 by the Conservative Rabbinical
Assembly (Kertzer, 1978~. The Orthodox tradition appears to have little influence
on the contraceptive behavior of most American Jews or on their support for the
development of new contraceptive technology. Sample surveys consistently find
Jews to be among the most liberal group in the United States with respect to
attitudes toward contraception and abortion Jacqueline D. Forrest, unpublished
tabulations of the 1982 National Survey of Family Growth).
Like its contemporary Roman counterpart, the early Christian church was
generally opposed to contraception. It valued an ascetic ideal that favored
celibacy. Later, the church was much influenced by the Stoics and others who
believed that 1egiumate sexual activity was distinguished by its procreative purpose
(Noonan, 1965~. This view was strongly reinforced by Saint Augustine, who also
found the value of marriage in its procreative purpose. Thus, efforts to Frustrate
procreation by contraception were generally condemned.
The Roman Catholic church has in general continued to adhere to these early
Christian traditions. Although the church sanctioned intercourse for mamed
couples for whom reproduction was not possible, its teaching consistently asserted
the goodness of procreation and remained opposed to contraception. In 1930,
Pope Pius XI's encyclical Casii Connubii affixed that the goal of marriage was
procreation and condemned all contraceptive use except periodic abstinence or
rhythm. Despite the fact that a papal commission appointed after Vatican II to
review the church's position on family planning recommended that married
couples be allowed to use contraceptives, in 1968 Pope Paul VI reaffirmed the
church's disapproval of what Catholics refer to as artificial birth control (Murphy,
1981~. The Catholic church's formal opposition to any method of contraception
except periodic abstinence has remained unchanged over the last two decades.
The Catholic church's prohibition of all contraceptives but periodic abstinence
(or the rhythm method) has not generally been observed by Catholics in the
United States. Overall levels of contraceptive practice are very similar among
Catholics and non-Catholics in the United States (Goldscheider and Mosher
1988~. There is no reason to think that Catholics in general would be more
opposed to the development of new methods than members of other religious
groups.
Protestant churches were generally in agreement with the Catholic church in
opposing birth control until 1930. Dunng that year, the Lambeth Conference of
the Church of England recognized abstinence and permitted the use of
contraceptives when abstinence was not possible. In 1931 the Committee on
Marriage and Home of the Federal Council of Churches in the United States also
permitted the use of contraceptives in some circumstances. Their position has
been generally followed by all Protestant churches in the United States with the
exception of the Lutheran church and certain fundamentalist churches (Murphy,
1981~. With few exceptions, most Protestant denominations now permit
contraceptive use, at least in some circumstances, and there are no data to suggest
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VALUES AND CONTRACEPTIVE DEVE~PME ~45
that American Protestantism is a significant impediment to faster contraceptive
development.
While these religious traditions may not significantly influence individual
contraceptive practice, they may play a role in people's willingness to publicly
support contraceptive development. Contraceptive use is largely a private matter,
and private behavior may diverge from publicly held positions. People shaped by
certain religious traditions or living in communities influenced by those traditions
may be reluctant to advocate openly and strongly the development of better means
of preventing births, even if they are using contraception themselves. The climate
of hostility created by certain religiously motivated opponents of different
contraceptive methods is cited by some people as an element in pharmaceutical
industry decisions not to support contraceptive development, but it is impossible
to establish how important such opposition has really been.
Legal Perspectives
The impact of religion on contraceptive practice and attitudes toward the
development of new methods may be difficult to specify, but the importance of
the American legal system is clear and, like other aspects of the society, it too was
influenced by the religious orientations of Americans. By the nineteenth century,
laws began to regulate contraceptive use in the United States. Early attempts by
the state to control contraceptive use took the form of restricting distribution of
products or information about them by equating such information with obscenity.
The primary example of this strategy was the Comstock Act, a federal statute
enacted in 1873, which prohibited the mailing of "obscene or crime-inciting
matter." Passage of this statute and the many state statutes that were modeled on
it was rooted in religious objections to contraception. In addition to popular moral
and ideologically based opposition to contraception, some people believed that
the increasing use of contraceptives would contribute to a decline in the birth rate,
which was already well under way in the nineteenth century but which still
worried those who associated rapid population growth with American prosperity
(Dealer, 1980~.
The first significant break in the legal prohibition of contraceptive use came in
1936, when a federal court of appeals ruled that the Comstock Act did not prohibit
the distribution of contraceptives by physicians. However, state statutes modeled
on the Comstock Act were not affected by the decision. Although access to
contraception increased, especially for those able to pay for services from a
physician, it was not until 1965 in Griswold v. Connecticut (431 U.S. 687 [19651)
that a state statute modeled after the federal Comstock Act was successfully
challenged. Although the justices in Griswold differed in their rationale for
striking down the statute, the case is regarded as a landmark in the establishment
of a constitutionally protected right to privacy, which has continued to be especially
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46 DEVELOPING NEW CO=RACE~IVES
significant in reproductive rights cases. Subsequent cases have further established
the importance of autonomy and choice in the area of contraceptive use.
Read in light of subsequent cases, the teaching of Griswold is that the
Constitution protects individual decisions in matters of childbearing from unjustified
intrusion by the state. Although the Constitution protects the rights of individuals
to have access to contraceptives, legal controversy remains. The extent to which
parents have a legal role in reproductive decisions by their minor children and the
extent to which religiously affiliated institutions involved in family planning
activities may be supported by the federal government have been especially
controversial.
CONTEMPORARY VALUE CONFLICTS:
STERILIZATION AND ABORTION
No other aspects of contraceptive development and use have been as
controversial, or as hotly debated by those with different religious and legal
orientations, as sterilization and abortion. Americanst attitudes and values about
these methods of fertility control highlight the problems that development of new
methods poses for some people. Historically, concern about preventing births
focused on contraception because, although sterilization and abortion were
practiced, it was not until the early twentieth century that medically safe means of
sterilization and abortion were developed (Mohr, 1978~. Once safe procedures
became available, these methods were used with greater frequency. For very
different reasons, they became more controversial than other means of controlling
fertility.
The early association of sterilization with the eugenics movement largely
accounts for persistent mistrust among some populations toward those who advocate
its use (Reed, 19781. Indiana enacted the first state law authorizing mandatory
sterilization of certain persons in 1907. It is estimated that 70,000 persons have
been compulsorily sterilized in Indiana and other states since then. As of 1985, 17
states had legislation authorizing sterilization of certain persons (Areen, 1985~.
One such statute was reviewed by the Supreme Court in Buck v. Bell (274 U.S.
200 [19271~. In an opinion written by Justice Oliver Wendell Holmes, Jr., the
Court upheld the constitutionality of a Virginia law that permitted mandatory
sterilization of"mental detectives." Justice Holmes reasoned:
It is better for all He world, if instead of waiting to execute degenerate offspring for
crime, or to let Rem starve for their imbecility, society can prevent those who are
manifestly unfit from continuing Weir kind. Lee principle Cat sustained compulsory
vaccination is broad enough to cover cutting die Fallopian tubes. Three generations
of imbeciles are enough.
The Supreme Court has never overruled Buck, although its significance has
been undermined by subsequent decisions such as Skinner v. Oklahoma (316 U.S.
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VALUES AND CONTRACEPTIVE DEVELOPME ~47
365 [19421), in which the Supreme Court held that Jack Skinner, a convicted
criminal, was not required to undergo mandatory sterilization as provided by
Oklahoma law. The law, which was concerned with the inheritability of criminal
tendencies, allowed for the imprisonment and sterilization of any person convicted
of a felony more than twice.
Abuses associated with sterilization have not been confined to actions of states
in connection with the mentally disabled or criminals. In 1973 it was learned that
federal funds had been used in Alabama to sterilize the Relf sisters, black minors
ages 12 and 14, without their consent or the consent of their parents (Areen,
1985~. As a result of successful litigation, federal regulations were changed and
now provide that federal funds cannot be used to sterilize minors under 21 or
mentally incompetent persons. Despite the fact that male and female sterilization
together constitutes the most widely used method of fertility control among
married couples in the United States, and despite the fact that many courts have
tightened the standards that must be met before a retarded child or adult can be
sterilized, in minority communities particularly, the abuses associated with
sterilization have helped foster distrust of many promoters of contraceptive services,
even though there has been no apparent impact on the levels of contraceptive
practice, including sterilization (Weisbord, 1975~.
Changing technology has also influenced the public's view of different
contraceptive options. The development of highly effective long-term methods
may also help to narrow the perceived difference between sterilization and other
forms of contraception. Today it is possible to reverse surgical sterilization,
although the procedures for doing so are complex and expensive and have a
relatively low success rate. Highly effective long-term methods of contraception,
such as NORPLANT@, are claimed by some to be, in effect, sterilization, although
pregnancy rates among those discontinuing these methods to become pregnant are
similar to those observed following discontinuation of other methods. Moreover,
the highly effective long-term (but temporary) contraceptives currently under
development may replace surgical sterilization as the preferred method of
preventing births in certain populations, such as mentally disabled persons.
Without doubt, abortion is the most controversial method of preventing births.
Because little was known about pregnancy or development of the fetus, no laws
governed abortion in the United States until the late nineteenth century. American
common law adhered to principles concerning the fetus inherited from English
common law (Luker, 1984b). Abortion was not a crime prior to the point at which
the women felt the fetus move and, even after this quickening, abortion was not
considered the murder of a person. By the end of the nineteenth century,
however, every state had passed legislation severely restricting abortion. It was
not until the mid-twentieth century Rat widespread efforts to liberalize these
restrictive laws began.
The movement toward less restrictive abortion laws reached its peak in the
1973 decision of the Supreme Court in Roe v. Wade (410 U.S. 113 [19731~. In
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48 DEVELOPING NEW CONCEIVES
Roe, the Court declared unconstitutional a Texas abortion statute that prohibited
abortion except to save the life of the mother. The Court reasoned that the right of
privacy includes the decision of a woman whether to terminate her pregnancy.
Under Roe, the woman's privacy right is not absolute, however; it is subject to
state interests in maternal health and the potential life of the fetus. The interest in
health becomes compelling at the end of the fast trimester of pregnancy, and the
interest in potential life becomes compelling at the point at which the fetus
becomes viable. Even after viability, a woman can obtain an abortion in some
circumstances because a state is able to legislate to protect the fetus and prohibit
abortion only if an abortion were not necessary to preserve the life and health of
the mother. In Roe the Court also declared that the fetus is not a person within the
meaning of the Fourteenth Amendment, and it refused to decide the question of
when life begins. The Roe decision has been affirmed in subsequent decisions
(Glendon, 1987), but one recent decision (Webster v. Reproductive Health Services,
109 S. Ct. 3040 [19891) suggests that far-reaching changes may occur, particularly
with respect to state-mandated restrictions on access to abortion.
Although abortion remains a subject of enormous controversy in the United
States, data from public opinion polls indicate that a substantial number of
Americans, more than 85 percent in some surveys, approve of abortion in some
circumstances; approval is highest when a women's health is in jeopardy (Ross)
and Sitaraman, 1988~. Furthermore, these attitudes have changed very little since
the mid-1970s. Citing data from a variety of polls, Lamanna concludes (1984:4)
that the data on people's attitudes toward abortion have a basic tripartite pattern
that is consistent across researchers and time periods. Approximately 20 percent
of Americans would forbid abortion under any circumstances except to save the
mother's life. About 25 percent support the position as defined in Roe v. Wade.
Everyone else is in between, approving of abortion in some circumstances, but not
in others. In general, Lamanna observes, the American people support abortion
for hard reasons, such as risk to a mother's life, risk to her physical health, the risk
of a genetically defective child, and pregnancy resulting from rape or incest, but
oppose it for soft reasons, such as being unmarried or a teenager, not being able to
support a child, or simply not wanting a child.
Support for abortion also depends on when during pregnancy an abortion is
performed (Glendon, 1987~. Although public opinion polls suggest the presence
of a broad middle group that might be characterized as reluctantly pro-choice,
their numbers have not been felt in public debates and discussions of abortion;
those who hold views at either end of the spectrum of opinion have set the tone for
abortion discussions. The distaste many people feel toward abortion and the
increased visibility of those who oppose it may have served as disincentives in the
contraceptive development process.
Attitudes toward abortion do not exist in isolation. Attitudes toward abortion
and contraception are often linked: some who are opposed to abortion also have
attitudes about women, work, and the family Mat are threatened by the easy
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VALUES AND CO=RACEPTIVE DEVELOPME ~49
availability and widespread use of contraception to control childbearing. Studies
undertaken by Luker (1984b) and Joffe (1986) underscore the fact that, because
pro-life and pro-choice advocates disagree about a host of issues related to
women, work, sex, and family, they are often at odds not only on the question of
abortion, but also on the subject of contraception.
The controversy associated with abortion has spilled over recently into
discussions of the morality of new fertility control methods, such as RU486.
This controversy may have become aggravated because scientific advances have
blurred the clear distinctions that once were seen to mark the boundaries between
stages of human development and, therefore, between contraception and abortion.
The action of some new methods, such as RU486, which can be used very early
in pregnancy before implantation occurs, makes them particularly controversial
and, therefore, has reduced the number of organizations and scientists willing to
become involved in their development.
The Link Between Contraceptive Development and Abortion
In addition to the link between attitudes about abortion and contraception,
there is another interface between contraceptive development and abortion. Often
women seeking abortion have experienced a contraceptive failure or have
discontinued contraception because of perceived risks or unacceptable side effects
or because they were in the process of considering other contraceptive options,
including sterilization. The high prevalence of sterilization in the United States is
due in part to the experience of contraceptive failure and in part to the limited
acceptability and often low effectiveness of other contraceptive options available
to older women. Studies in less developed countries suggest that similar
relationships exist among contraceptive development, the demand for sterilization,
and abortion, although in many countries the lack of safe abortion services or of
easy access to a range of contraceptive choices compounds people's problems.
The extent to which abortion is available may also affect a woman's choice and
use of contraception. If abortion is safe, legal and readily available, a woman
might choose a safer but less effective contraceptive method. Conversely, if
abortion is not readily available, a woman might select a more efficacious but also
riskier contraceptive. The interdependence between abortion and contraception is
such that the development of a safe and highly effective contraceptive could
significantly reduce the frequency of abortion. One recent study indicates that as
many as half of all unintended pregnancies resulting in abortion were the result of
contraceptive failure (Henshaw and Silverman, 1988~.
The link between contraception and abortion is also important because the
mechanisms of action of different contraceptives have, in the minds of some
people, clouded the differences between contraception and abortion. For those
who believe that life begins at the moment of conception, any method that acts
after that point is unacceptable. Although this is a metaphysical and religious
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50 DEVELOPING NEW coNTRAcEPrivEs
issue and not a scientific one, it is worth noting that most scientists think conception
is best represented as a process and the precise points at which it is initiated and at
which it is completed are matters of definition. It is difficult to maintain that
fertilization per se can produce a unique genetic identity or individual. The
phenomenon of identical twiMing, for example, may occur several days after
fertilization. Implantation does not occur until the sixth or seventh postPertilization
day, when there is contact with the bed of the uterus (endometnum) and further
exchange thereafter between the mother and the recently formed conceptus.
Prevention of pregnancy during the interval between fertilization and onset of
the first menstrual period, euphemistically referred to as interception, raises a new
array of medical and ethical concerns. For many people, the critical point in
human development is implantation rather than fertilization. In this view,
implantation is crucial because it marks the point at which we know with empirical
certainty that a new human entity with a unique genetic identity exists. Moreover,
pregnancy cannot routinely be diagnosed before implantation. As a consequence,
a woman cannot determine with certainty that she is pregnant until after
implantation. Those who see implantation as the decisive stage believe that an
intervention that acts during the period between fertilization and implantation
resembles a contraceptive rather than an abortifacient because the interruption
takes place before a pregnancy can be confirmed.
New technology used in the treatment of infertility has focused attention on the
interval between fertilization and implantation, and a great deal of new information
has been obtained recently from studies of in vitro fertilization (IVF). The Ethics
Committee of the American Fertility Society refers to the first 14 days after
conception as the "preembryonic stage" (American Fertility Society, 1986~. It is
generally agreed by those examining the ethical issues posed by IVF that, from
the completion of normal fertilization, the conceptus is entitled to increased
"respect," compared with other cells in the human body. Most nonreligious
bodies, however, stop short of a firm definition as to when meaningful human life
begins. Nevertheless, these developments serve to heighten the concern of those
who oppose fertility control from the very earliest stages of fertilization that new
methods of contraception could act after fertilization. This, coupled with the
interdiction of some religious groups against almost all forms of modern
contraception, provides a continuous source of potential conflict and controversy,
the net result of which is probably to discourage bow public and private investment
in new contraceptive development.
RU-486
A new generation of compounds has recently appeared that are capable of
interfering with the production of progesterone, the hormone essential for
pregnancy. Two of these have been shown to be effective abortifacients (Nieman
et al., 1987; Crooij et al., 1988~. Other agents, which have been introduced for
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VALUES AND CONTRACEPTIVE DEVELOPMENT
51
purposes unrelated to contraception, also cause early pregnancy loss. The
potentially most important of these compounds from the contraceptive point of
view is RU486. When RU486 is used in combination with prostaglandins
(agents that cause uterine contractionsy, pregnancy termination before the 45th
day of pregnancy is successful in 95 percent of the cases ~Jlmann and DuBois,
1986~. Use of RU~86 would reduce the need for surgical termination of pregnancy.
The publicity surrounding RU486 has focused renewed attention on the ways
that different contraceptives work. For some, RU486 is entirely acceptable. For
others, it is potentially acceptable if it is used before there is recognized evidence
of pregnancy in the form of a missed menstrual period. For still others, the fact
that RU486 might act after the completion of the fertilization process makes it
completely unacceptable.
Discussions of the ethical aspects of the development and use of RU486 and
similar agents are compounded by the fact that such drugs may also have potentially
important noncontraceptive applications. Introduction of RU486 for any purpose
in the United States probably would be difficult because of widespread concern
among medical scientists and pharmaceutical company executives about a
conservative backlash against them, including the risk of economic boycott of
manufacturers and distributors. A lack of strong public support has added to this
climate of uncertainty and has resulted in a lack of research in the United States on
RU486 and other methods that, in some cases, are in their final stages of
development abroad.
WOMEN'S PERSPECTIVES ON REPRODUCTION
AND SOCIAL ROLES
Women have an obvious interest in controlling fertility because only they can
become pregnant and give birth. Women must be concerned with the timing and
spacing of births and, indeed, the decision to have children in ways that men may
avoid. Women are more affected by pregnancy and childrearing than men and, as
a consequence, their ability to pursue different options in life are often sharply
circumscribed. To the extent that women can control reproduction, and thereby
increase their ability to engage in activities unrelated to childbearing, they can
move to equalize responsibilities with men for home and children (Petchesky,
1984~.
The interrelationship between the perceived social benefits of a certain
demographic balance and women's desire to control fertility has been particularly
important in the twentieth century. Concern about the falling birth rate and the
trend toward smaller families in the United States, evident in the beginning of the
century, caused Theodore Roosevelt to brand women who avoided having children
as "criminalEs] against the race . . . the object of contemptuous abhorrence by
healthy people" (Gordon, 1976: 136~. Many people feared that members of the
Yankee stock would be overwhelmed numerically and hence politically by
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52 DEVELOPING NEW CO=RACE~IVES
immigrants, nonwhites, and the poor, all of whom had higher birth rates. Some
people also viewed fertility control as a rebellion against women's primary duty
of motherhood (Reed, 1978~. Some women age with these concerns, but
others objected either because they thought that fertility control was an issue of
self-determination, or because they sought the expanded options for women that
smaller families or childlessness might permit (Gordon, 1976~.
The controversy generated by the low growth rates of native whites and by race
suicide beliefs was brief-it was largely over by 191~but its effects are important
to an understanding of contemporary attitudes toward contraceptive development
and use. The controversy freed some feminists to argue explicitly for contraception
as a means of giving women freedom to control their lives. And the controversy
exposed splits among women that have had enduring significance.
From 1942, when the Birth Control Federation of America changed its name to
the Planned Parenthood Federation of America, to the 1960s, birth control was
explicitly identified with the family. The success of this orientation helped to
bring about the involvement of women in birth control issues in the 1960s. What
was missing in the evolution of the birth control movement in the United States
was an approach explicitly oriented to individual women's rights and health
concerns. Despite the involvement of the medical profession in all aspects of
contraceptive development and practice, many women felt that their health concerns
were ignored or at least downplayed.
The medical orientation of most contraceptive services has reinforced the view
among some women that adequate account has not been taken of their social and
economic concerns. In the United States today, women generally receive
contraceptives from private physicians or medically oriented family planning
clinics. Although almost all family planning specialists argue that the ideal
method of contraception would be one that would be safely available over the
counter and without the need for any medical supervision, most currently available
modem methods involve some risk and therefore require varying degrees of
medical supervision. Thus, for example, pelvic examinations are needed prior to
the insertion of an IUD or the fitting of a diaphragm. Proper utilization of the pill
is dependent on knowledge and understanding of a woman's medical history.
An expanded understanding of the factors that should be taken into account in
contraceptive development what is being called "the user perspective" (Bruce,
1987) would involve considerations well beyond a narrow focus on technical
efficacy. From the standpoint of a woman seeking to avoid pregnancy, it is the
method that fails when she errs in its use, when the method is flawed or too
expensive, or when its risks, side effects, mode of administration, or use make it
unacceptable to her or her partner. In short, a method fails because it does not
meet a woman's basic needs, which include the need to maintain her health, life-
style, and well-being and perhaps the need to keep her options open about future
childbearing (Petchesky, 1984~.
Many women who want to control their fertility desire to do so in a context that
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VALUES AND CONTRACEPTIVE DEVELOPMENT 53
permits sharing the responsibility with men. Thus, they support the development
of male contraceptives because they wish to equalize the burden of contraceptive
practice. At the same time, however, there is appreciation that for many women
reliance on men to prevent birth is not feasible (Petchesky, 1984~.
The 1960s and 1970s saw the emergence of birth control as a key concern of
the women's movement. Yet the involvement of the women's movement has not
resulted in overwhelming support for the development of new contraceptives. In
part this is the case because contemporary feminism has paid more attention to
keeping abortion legal and accessible than to the development of new
contraceptives. Moreover, the feminist health movement has often been critical
of the family planning establishment and of specific contraceptives, including
Depo-Provera, the IUD, and the pill aoffe, 1986~. This critique has often
overshadowed concurrent feminist pleas for improved contraceptives. Even
though there may be a common understanding that preventing births has special
significance for women, their views are influenced by a variety of factors including
race, religion, social class, education, and labor force participation. The women's
movement has not subordinated this diversity to a single vision of what is best for
women simply as women.
CONCLUSION
A large number of factors influence the nation's commitment to contraceptive
development and the willingness of public and private organizations to invest in
the field. The links between contraceptive development and abortion have enlarged
the impact of groups opposing abortion on contraceptive research and development.
These groups may influence a congressional decision to fund research or override
industry's inclination to develop and market new contraceptive products.
Low fertility in Westem industrialized nations, together with the perception
that only women are affected, has contributed to the lack of public interest and
political support for contraceptive development. The priority given to contraceptive
development has been low because of more pressing demands for funding. Even
the Planned Parenthood Federation and other family planning organizations have
assigned contraceptive development a lower priority than other needs they perceive
to be more immediate.
Despite religious opposition by some people and a history of minority group
concerns about suspected abuses, recent decades have demonstrated a much
greater demand in the United States for safe and effective contraceptive technology.
These demands are based on a now-widespread view that the ability to regulate
childbearing is a basic human right and is of primary importance to people's
health and well-being. Nevertheless, the search for new and better contraceptives
is hampered by a weak commitment to reproductive research and contraceptive
development on the part of Congress, private foundations, and the pharmaceutical
industry. Although millions of people may value the development of new
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54 DEVELOPING NEW CO=RACE"~ES
contraceptives highly, these values have not influenced the federal government's
contraceptive development program nor that of private industry. Given the
importance of developing safer, more effective, more acceptable or more convenient
contraceptives, it is surprising that the growing positive attitudes toward
development have not been reflected in greater public support of policies and
programs to enhance the likelihood that new methods will be developed.
In the 1960s and early 1970s, many women who might have supported the
development of new contraceptive methods were concerned about the goals of
those advocating government subsidized birth control, about the role and influence
of the medical profession in contraceptive development and provision, and about
the lack of concern for the users' perspective. Nonetheless, for all women, safer
and more effective methods of preventing births, which take account of women's
social and economic conditions and their changing life-styles, are critically
important. Alliances among scientists, clinicians, and women are probably more
possible today than at any time in the past. The likelihood that support for
contraceptive development will increase may be dependent on whether these
alliances can be formed and sustained.
Representative terms from entire chapter:
family planning
