booknotes: america and the pill

Footnote-mining Bodies of Knowledge and The Morning After brought me to Elaine Tyler May's America and the Pill: A History of Promise, Peril, and Liberation (Basic Books, 2010).  May is an historian of mid-twentieth century America family life whose previous work includes a history of childlessness in "the promised land" and the family in Cold War America. Her parents were also, incidentally, involved in the development and early clinical trials of the birth control pill, so her personal history is also intertwined with the story she seeks to tell about Americans and the introduction of hormonal contraceptive pills from the 1950s to the present.

America and the Pill is a highly readable, solidly-researched history of the development, distribution, and use of the birth control pill in America since the fifties. In seven brief chapters (I read the book in an afternoon) May describes the development and testing of the pill, its promotion by politicians and thought leaders interested in population-control, its use by married couples, the pill's role in the sexual revolution, the search for hormonal contraceptives for men, "questioning authority," and public use and perception of the pill today.

Clearly written as an introductory overview, this history begs for further elaboration on a number of points -- for example, the complicated relationship between individual use of birth control and national and international attempts to limit population growth. I would also be interested in a further exploration of how perceptions and use of the pill as a method of birth control relates to concerns about the spread of sexually-transmitted infections. For example, can we see a significant shift in what populations use the pill vs. the condom before and after the advent of AIDS/HIV?

I would also like to see further elaboration on the discourse concerning libido and hormonal birth control, since concerns over low libido remain a primary barrier to developing a male birth control pill, while women's persistent reporting of side-effects of the pill, including lowering of libido, have been glossed over as psychosomatic or unimportant when compared to the goal of limiting population growth. May offers an interesting historical perspective on this issue:

Although today's pill may not suppress libido more than the original oral contraceptive did, women today may well experience the effect of the pill differently. For many in the first generation of pill users, the intense fear of pregnancy diminished women's libido to such an extent that when they went on the pill and that fear disappeared, their sexual pleasure was increased considerably. Today there is no longer the terror of facing an illegal abortion, a ruined reputation, banishment to a home for unwed mothers, or a hasty marriage. ... With so many contraceptive options available to women today, some are unwilling to compromise their sexual pleasure of the convenience of the pill (149). 

While women's sexual pleasure is here understood in tension with their desire to manage their fertility, men's sexual pleasure (even their gender identity) is situated in their ability to procreate -- with no corresponding desire to limit family size. May quotes one medical doctor who in 1970 wrote in the Boston Globe that "generally speaking, a man equates his ability to impregnate a woman with masculinity. And all too often the loss of such ability really deflates his ego" (99). Presumably, many individual men in the 60s and 70s desired to take measures to ensure their partners did not get pregnant -- but while medical personnel and the public at large understood the fear of pregnancy and/or the desire to limit or space pregnancies as a legitimate concern for women, it appears they did not assume the same for men.

I felt at points that May was deliberately writing for a lay audience (that is, an audience of non-historians, or those unfamiliar with the history of twentieth-century medicine). For example, when she describes the clinical trials of the birth control pills which were undertaken without informed consent on populations such as mental patients and prisoners, she is at pains to point out that such trials were standard operating procedure until well into the 1980s when such violations of bodily autonomy and ethical mismanagement became the subject of public debate and regulation. At times, May's efforts to contextualize the clinical trials spills over into what feels like a bit too much post-facto justification. For example, when writing about the trials conducted in rural Puerto Rico in the mid-50s she writes,

The developers of the pill were particularly concerned about its safety. They put in place elaborate precautions to monitor the health of the women who took part in the trials, such as frequent medical exams and lab tests. Study participants in impoverished areas received medical attention vastly superior to what was normally available to them. ... By the standards of the day, the studies were scrupulously conducted (31).

While all of these statements may be factually accurate (and I have no reason to suspect they are not), these passages feel a little too much as if May is trying to forestall protests about how these trials were conducted, protests which -- while not undermining the data collected -- would certainly be legitimate. What sort of pressure were poverty-stricken Puerto Rican women under to participate in the trials, for example, if the healthcare they received as a result was "vastly superior to what was normally available"? Obviously, it's important to understand these medical protocols in the historical context in which they happened, but it feels a little like May is trying to preempt discussion of ethical implications.

These passing editorial moments aside, May has written a great introduction to the historical context of the birth control pill that will be an enjoyable -- and historically robust -- read for anyone interested in the topic of women's and sexual/reproductive health, history of medicine, history of the family, and related fields.

booknotes: the morning after

After reading Bodies of Knowledge by Wendy Kline back in March, I decided to follow up one history of women and medicine with another: Heather Munro Prescott's The Morning After: A History of Emergency Contraception in the United States (Rutgers University Press, 2011). Part of the Critical Issues in Health and Medicine series, edited by Rima D. Apple (University of Wisconsin-Madison) and Janet Golden (Rutgers), The Morning After focuses on the development of pharmacological postcoital contraception beginning in the mid-twentieth-century, the ad hoc off-label distribution of contraceptives in emergency situations, and finally the process by which a dedicated emergency contraceptive pill was approved by the FDA for production and marketing. Her narrative ends in the recent past, when emergency contraception was approved for over-the-counter sale to those over the age of seventeen.

Prescott's history is a fairly straightforward narrative which, while valuable in its own way, could have benefited from more analysis and a stronger historical argument. One of the interesting changes Prescott observes over time is in the attitude of feminist/women's health advocates. During the 1970s and 80s were incredibly skeptical (due to a number of high-profile drug failures) about the FDA's interest in, and ability to, ensure the safety of contraceptives and other women's health-related pharmaceuticals. By the 1990s, feminist rhetoric had shifted from safety to one of women's agency: access to emergency contraception became something women had the right to access, once they had been fully and meaningfully informed about their options. This shift from the authority of medical professionals to the authority of women to control their own reproductive capacity is something that I would have liked to see developed further, with particular focus on how it re-formed the politics around emergency contraception.

The other aspect the history of emergency contraception in the U.S. that is touched upon in The Morning After but largely passed over is the shift within the religious right from being fairly neutral about birth control and family planning mid-century (with the exception of the Catholic church) to actually conflating the pharmaceutical birth control options with abortion. Not just in that the two are morally equivalent, but that taking birth control pills (including postcoital birth control) causes you to abort. While medically inaccurate this  blurring of the boundary between what is pre-pregnancy birth control and what is abortion expands the backlash on women's reproductive agency exponentially. Birth control advocates can no longer gain allies among anti-abortion activists by arguing (as they did throughout the twentieth century) that the birth control pill will lower the abortion rate by preventing undesired or mis-timed pregnancies. Because "birth control" as become synonymous with "abortion" in many anti-abortion circles. This is a rhetorical shift with on-the-ground consequences, and emergency contraception had no small part to play in this tug-of-war over women's lives. I would have liked to see this particular chapter in the history of EC given a little more time.

Overall, The Morning After is a solid history of a specific type of contraceptive technology, and one which I am glad to have read, as both an historian of feminism, gender, and sexuality, and as someone who tries to stay current in the world of reproductive justice activism.