Read the next episode: “Who Gets To Be Perfect?“
Read the previous episode: “Your Brain Is Your Phone“
When I was growing up in the U.S. in the 2000s, the decision to go on the pill felt as natural as the decision to have sex. It didn’t feel politically revolutionary, as it might have for my parents and grandparents. Nor did it feel like the fantastic biohack that it is, hindering one of the body’s key functions: reproduction.
Instead, like bra-shopping or using tampons, taking the pill to prevent pregnancy was presented to us as a step intrinsic to teenage girlhood (unless we were “saving ourselves”). We didn’t question it. Most of us didn’t think about the side effects until we were experiencing them.
There is something essential in the language we use about women’s contraceptives–”the pill,” “the coil,” “the implant”–as though these devices are incorporated into our bodies as easily as internal organs: “the heart,” “the brain,” “the liver.” If any woman who has an IUD or implant counts as a cyborg–and they surely do have, in the words of the scientists who coined the term, “physical abilities extended beyond normal human limitations by mechanical elements built into the body”–then that applies to roughly five million women in the United States, and to one in seven women aged 15″”49 worldwide. Include every form of contraceptive and that figure rises to nearly 50 percent.
In Donna Haraway’s 1984 A Cyborg Manifesto, the feminist technologist writes that, “the boundary between science fiction and social reality is an optical illusion.” When it comes to women’s bodies, the illusion is strong: we’ve been trained to see reproductive technologies as a natural extension of women’s biology.
But when you talk about the possibility of men taking similar steps to alter their reproductive function, the conversation–and its tone–changes completely. Take RISUG, or “reversible inhibition of sperm under guidance,” a contraceptive for men that’s been in development for decades. It works like this: a polymer gel is injected into the vas deferens, which renders sperm ineffective by reversing its positive electrical charge, rupturing each sperm’s cell membrane as it passes. Another injection breaks down the gel, so that patients become fertile once again.
282 couples in India have been using the drug for decades, with a 99 percent success rate. But many mainstream publications refer to the drug as “sketchy” or “like drain-o,” even while claiming to support male contraceptives in theory. The headline that the British tabloid Metro chose for a report about RISUG is typical of how seriously it’s taken by much of the media: “Contraceptives for men are finally here”¦but it involves an injection in your balls”.
These flippant dismissals of a promising drug betray deeper beliefs about male and female bodies: the scrotum is sacrosanct, while the uterus is an open biological playground. After all, an injection into the testicles is on par with the implantation of an IUD into the uterus, which many women rank among their most painful experiences. The uterus might seem permeable because of how it changes during pregnancy and childbirth, but that doesn’t mean that a woman’s body can tolerate any kind of invasive technology.
In fact, the history of female contraceptives tells us quite the opposite. The Dalkon Shield is a case in point. The IUD, which looked like a cross between a sea creature and a circular saw, made it further than RISUG ever has. Of the 2.5 million women in the 1970s who had it implanted, as many as 200,000 claimed to have been injured by it through infection, and 18 died. Thousands of women had to receive emergency hysterectomies, while the manufacturer went bankrupt settling lawsuits totaling billions of dollars. More recently, a permanent form of contraceptive implant called Essure, intended as a simpler alternative to female sterilization, has led to 9,000 removals by hysterectomy–a procedure much more invasive than the sterilizations would have been.
As medical historian Nelly Oudshoorn argues in The Male Pill, the field of gynecology was invented because late-19th-century scientists believed that women’s bodies were more innately linked to sex and reproduction than men’s, and as a result, research focused on how women would bear the burden of reproductive control. These attitudes remain today: for example, even though vasectomies and condoms are simpler, cheaper, and safer, female sterilization is much more common around the world. But when contraception goes wrong, it doesn’t just affect women: it can create divisions in relationships along with physical trauma, as explored in this episode of Reveal.
When Dr. Sujoy Guha began to test RISUG on human subjects in the late 1980s, he knew the drug would affect both subjects and their partners, and he wanted the research process to reflect that. He also wanted subjects to be aware of all possible risks, which is why he found only five people for the initial trial–three of whom, like him, worked at the All India Institute of Medical Sciences in Delhi.
But RISUG worked. “So thereafter we invited the subjects who had been injected, along with their wives, to meet prospective volunteers and their wives. We have a joint meeting,” Guha told me over the phone. Today, he says, he has to turn people away because too many are requesting to participate. Despite the decades Guha has been testing it–and despite the success of those trials–RISUG still isn’t available to the general public.
While RISUG has been in perpetual trial mode, women around India have been dying from botched sterilization surgeries, motivated by government quotes and incentives. In Chhattisgarh in 2014, local government health officials offered money to women who already had children to be voluntarily sterilized in overcrowded, undersupplied “camps.” One surgeon, Dr. R. K. Gupta, was paid by the number of sterilizations he could perform over short time periods. In under six hours, he operated on 83 different women; 13 of them died, and Gupta was arrested. He had previously received an award from the Indian health minster for sterilizing more than 50,000 women throughout his career, and claimed to have a personal record of 300 women in a single day.
His speedy operations on these women, so different from Guha’s, are an extreme example of an attitude doctors and scientists have displayed toward poor women of color throughout recent history–and especially since they began to interfere with women’s reproductive systems.
The global reproductive health complex has two targets. There are the individual consumers, often in higher-income countries, marketed to as “empowered women” who make careful decisions about their fertility. Their choices allow them to pursue their sexual desires and long-term life goals, free from the burden of unwanted pregnancy. These women can help drug companies turn a profit.
Then there are populations that need to be controlled. While nearly half of women worldwide use some form of contraception, the numbers within continents and countries vary hugely–from two-thirds of women in Europe, to only a third in Africa. Contraceptive programs in lower-income parts of the world often focus on incentivizing women to stop having children, and, in particular, invasive IUD implanting programs or sterilizations are prioritized over short-term, optional methods like the pill.
Both of these archetypes–the impoverished woman whose uterus needs disciplining, and the self-sufficient women in need of empowerment–were central to the origin story of the birth control pill. Margaret Sanger, considered the pioneer of birth control, supported both causes, simultaneously advocating for population control among poor women of color in U.S. territories and abroad, and for empowerment among educated American women like herself.
In the mid-1950s, Katherine McCormick, a wealthy heiress who took on Sanger’s cause, went on a mission to find what she called a “cage of ovulating females” to test the birth control pill on. The idea would become her legacy. Dr. Edris Rice-Wray, another American who McCormick had enlisted to supervise the trials, found “just the place”–a housing project near San Juan, in the U.S. territory of Puerto Rico.
The location was attractive to McCormick’s team–which included male Drs. Gregory Pincus and John Rock, who would later become famous as the public faces of the pill in popular culture–for a few reasons. While contraception and sterilization were illegal in the mainland United States, sterilization had been legal in Puerto Rico since Law 116 was passed in 1937. It was directly inspired by the so-called “Model Eugenical Sterilization Law” written by eugenicist Harry Laughlin in 1922–a blueprint for how U.S. states could enact their own programs for sterilizing the mentally ill and “the socially inadequate.”
Law 116 would not be repealed until 1960, but for researchers in the 1950s, it meant that they would escape liability if their experiments accidentally rendered test subjects permanently infertile. A housing project in Rio Piedras, a suburb of San Juan, would also provide the “cage” McCormick wanted. High demand for subsidized housing also meant that the test subjects would be unlikely to leave before the study ended, for fear of not being able to find alternative housing.
Based on Rice-Wray’s description of the recruitment process, it appears that the women did not know that they were participating in a medical experiment:
“The social worker would say “‘I’m from the Family Planning Association’–like the Cancer Society or the infantile-paralysis campaign, so they could relate it to something they considered decent, you know. Then they said “‘We’re very much interested in parents having the right to have the number of children they want to have when they want them. We have a pill that a woman can take twenty days a month and she doesn’t get pregnant.’ Well, they just couldn’t get hold of it fast enough.”
When the women began to experience side effects like nausea and headaches, Pincus told a journalist that they “happen because women expect them to happen.” Still, the team decided to test whether the side effects were psychosomatic by giving some women a placebo–but they didn’t inform them, putting them at risk of becoming pregnant when they thought they couldn’t.
The women in Rio Piedras also dealt with unforeseen dangers. During the trials, two women developed heart-related complications, and one of them died. Today we know that the pill can cause potentially deadly blood-clotting problems, so it seems plausible that the death was linked to the trial. We will never know for sure, because she was not examined.
On top of all this, there was a mistake in one of the key components of the formula that contraceptive pills–one that remains to this day. The “combined oral contraceptive” pill contains synthetic estrogen and progestin–the hormones convince the body that it’s already pregnant, so it doesn’t continue to ovulate. But the presence of synthetic estrogen in the trial pills was actually an error; traces of the synthetic hormone had contaminated the pills in the factory. Pincus and Rock only realized that the estrogen helped prevent pregnancy after withdrawing the pills that contained it.
Despite all these false starts–and despite the fact that Rice-Wray herself believed the pill’s side effects made it unacceptable–Enovid, the first oral contraceptive for women, was on the market two years after the trials were completed. The male doctors on the team, Pincus and Rock, overrode Rice-Wray’s recommendation against it. But the side effects indeed proved unacceptable to many consumers once it was on the market–there were over 100 side-effect-related lawsuits in the first few years it was on sale. Women’s health advocates have since pushed for contraception with lower doses of hormones, and the medication has slowly improved over the years.
This slow and often painful process is reflective of the divide between the “impoverished women” and “empowered women” who have set out the path for female birth control. While both have suffered due to insufficient testing and dismissal of side effects, educated women with resources were more likely to have chosen birth control without coercion–and were able to advocate for themselves when they found its effects unacceptable.
As the 20th century progressed, the men who would control women’s reproductive destinies were not concerned with individual women’s fates. Around the world, governments, in collaboration with organizations like the UN and the Population Council, have attempted to place the onus of “poverty reduction” on poor women’s fertility.
Alan Guttmacher, the second president of Planned Parenthood and vice president of the American Eugenics Society, articulated this division in a speech to the first International Conference of the IUD in 1962:
“The reason the restraint of population growth in [the developing world] is moving so slowly is the fact that the methods we offer [condoms and the pill] are Western methods. Our methods are largely birth control for the individual, not for a nation.”
In her book The Global Biopolitics of the IUD, Chikako Takeshita describes the IUD as “a machine part that efficiently controls the uterus.” It does seem that the IUD’s initial proponents thought of it this way. As Takeshita puts it, Guttmacher and others hoping to get IUDs to “the masses” were uninterested in individual women, and whether it was sufficiently effective or safe to improve their lives. They just wanted overall population numbers to go down. (And these early IUDs were not nearly as reliable in preventing pregnancy as those available today.)
Those attitudes were echoed by governments hoping to reduce their populations. In India, women were offered financial incentives to have IUDs implanted for decades–similar to the incentives they now receive for sterilization–but their individual well-being wasn’t a factor in the government’s decision-making, and follow-up care was poor, as detailed in criticism by organizations like Human Rights Watch. Asoka Mehta, India’s planning minister in the 1960s, justified the program by describing the fight against population growth was a “war.” He said, “as in all wars, we cannot be choosy, someone will get hurt.” In the 1970s, American politicians used similar language while promoting family planning. In a Senate hearing, Republican Senator Bob Dole said contraceptive technology was an “important weapon in the struggle to achieve some control over our ability to multiply ourselves into chaos.”
“Contraception at some point had been thought of as relatively uncontroversial,” says Adam Sonfield, senior policy manager at the Guttmacher Institute. “Back in the 1970s, when the Title X National Family Planning program was created, that was done with overwhelming bipartisan support.” Sonfield says politicians were unified by a common cause: the desire to prevent unplanned pregnancies, which also meant preventing abortions.
But when women’s contraception becomes an issue of individual choice and not population control, the terms of the game change. In recent years women’s right to contraception–not just abortion–has come to the fore as a controversial issue. Sonfield says that one important catalyst was the Women’s Preventative Services mandate in the Affordable Care Act, which granted women, as individuals, the contraceptive method of their choice, free of cost.
RISUG falls outside both the twin narratives of of population control and women’s empowerment. So far, large pharmaceutical companies in the U.S. have not tried to test it for the American market. This could be a financially motivated–since the drug only requires one injection to take effect and another to be reversed, potential profits are limited. Male contraceptives would also require a new marketing strategy. It’s tricky to sell birth control to men as “empowerment” when they already hold the power in most areas of life. Some women even worry that they could lose their autonomy by giving men the reins in the contraceptive realm.
Male birth control advocates have instead tried appealing to “caring men” who want to help their partners by taking on the burden of contraception. The problem with that to Laury Oaks, a sociologist at UC Santa Barbara, is that pharmaceutical companies fear there are too few such men. “[Instead] it could be a men’s rights argument, right?” he says. “Make sure you never get yourself in a position where somebody’s gonna claim you are the father.”
I talked to some men who do want male birth control–some had even donated money to the cause–and it’s true that feminism wasn’t necessarily their primary motivation. Instead, a lot of new gender clichés came into their thinking. Byron Pepper, a 28-year-old college student in Michigan, says he believes he should be allowed control because he is “half of the equation to make a baby,” and that access to RISUG (which has been licensed to the US non-profit Parsemus Foundation, which is now developing and planning to test its own version under the name “Vasalgel” for the American market) would be a way to avoid “the baby trap” from women who are “less than upstanding.” Miracle Diala of Illinois told me that his male friends wanted the technology “for no other reason than to ditch the condom,” adding, “a perfect PR slogan would be “‘you’ve got two choices: 10″”15 years of birth control, or 18 years of child support.'”
Providing men with RISUG injections might be an effective tool for “population control”–or to use a more contemporary, benevolent phrase, “poverty reduction”–but organizations with this goal also have a history of gearing themselves toward women. The Bill and Melinda Gates Foundation website on family planning reflects change from the time when people like Guttmacher talked about birth control for “the masses.” The focus now is on giving women the “voluntary” option to obtain “high quality” contraceptives–a seemingly conscious contrast from coercive government contraceptive programs that landed women with poor-quality IUDs. (Editor’s note: The Bill and Melinda Gates Foundation is a primary funder of How We Get To Next.)
The goals of poverty reduction and empowerment are coming together, but organizations like the Gates Foundation are still far more focused on women’s responsibility than men. It invested more than $147.9 million in women’s contraceptives in 2015, compared to only $600,000 for “testing the feasibility” of “disruptive and high risk approaches” to male contraceptives.
For male contraception to become a big part of global reproductive control efforts, we might need to shift our thinking away from the gender divide altogether.
There are a lot of reasons individuals and couples use specific contraceptives–and it often has little to do with what is safest and most reliable. What’s available to you depends on a host of factors, from biological sex to income to race to whether you live in the global south.
But many of these divides are becoming blurrier. In the U.S., women are increasingly gravitating towards what are known as “long-acting reversible contraceptives” like IUDs, partly for the same reason they’re popular in the global south–they’re reliable if you cannot be certain you’ll have regular access to a gynecologist. Threats to the Affordable Care Act and cuts to women’s health care in the U.S. have meant that many women have lost or fear losing regular treatment, while childbirth has become more dangerous. And they are finding often-risky ways around formal medical treatment, like removing IUDs on their own and thus avoiding a potentially expensive doctor’s visit. In Texas, women’s healthcare access is so limited that some women are inducing their own abortions or traveling to Mexico to get them.
Largely-neglected male contraceptive research offers a way to retrieve an opportunity lost in the path to female contraceptive technology–the chance to use these body-altering tools as a way to break away from the prison of traditional gender roles, rather than reinforcing their walls.
The ability to block pregnancy could, too, have been framed as a gender hack, a way of breaking down barriers. But instead we’ve simply updated these traditional boundaries to include female contraception. For those in favor of birth control, women are responsible for the labor of maintaining their chosen family structure by controlling their fertility–men are not to be trusted with such responsibilities. For those who oppose birth control, it’s an excuse to zero in women’s bodies and find every tiny part that could be construed as within the government’s–or God’s–control.
Last year, a lot of people were disappointed when a male hormonal contraceptive trial was abruptly halted due to unpleasant side effects. Despite my desire for a viable male contraceptive, I don’t want men who decide to shoulder the physical burdens of birth control to endure the same suffering women did when their side effects were ignored.
Laury Oaks agrees. “Equal opportunity suffering is not the goal,” she says. Instead, she wonders, “How can we have reproductive sexual and reproductive issues combined with the contraceptive technology issues to work for everyone?” A lot of experts think that it is a mistake to even attempt a hormonal approach on men–that it’s seductive to try to repeat the history of something that’s worked, even if it doesn’t actually work that well.
RISUG may or may not be truly viable, but I hope we get the chance to find out. I would be lying if I said this drug didn’t excite me just as much for its symbolic power as its biological power. It would be a break from medicines developed in the U.S., tested on poor brown women to be marketed to rich white women; a break from hormonal contraceptives with histories rooted in eugenics. That would really be radical.
Read the next episode: “Who Gets To Be Perfect?“
Read the previous episode: “Your Brain Is Your Phone“
How We Get To Next was a magazine that explored the future of science, technology, and culture from 2014 to 2019. The Human Machine is an eight-part series that interrogates the increasingly blurred lines between humans and machines.
