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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.