In Our Control (44 page)

Not everyone thought male contraceptives would improve female lives. Feminists also articulated concerns that female power could be reduced if men took control of pregnancy prevention. Some voiced anxieties that after decades of fighting to get women moved to the center of public health agendas, men were back in the spotlight. Might shifting contraceptive
priorities to men, who already in general enjoyed a higher standard of health care, simply siphon specialized resources from women? In international contexts, activists argued that contraception provided a small measure of power to those women who still lived in more traditional patriarchal environments.

This bold emerging global health agenda both helped and hurt prospects for male birth control. It helped in that it again revived dying institutional interest in the possibility of male methods, particularly at the Population Council and WHO. It hurt in that this redefinition of goals, at both Cairo and Beijing, marked the moment at which such institutions’ financial backing of contraception began to decline. A cynic might point out that as soon as reproducing women in the abstract were removed as a cultural threat, and women in particular were championed and empowered as reproductive actors, cultural urgency to provide family planning fell away.

Hope for the male pill surged again in the late 1990s, when pharmaceutical firms finally got involved with research on male methods. Two European companies, Schering and Organon, were the first to launch research programs, with a small number of American firms, including Wyeth, sticking their toes reluctantly in the water. This change of heart for drugmakers is attributable, at least in part, to the blockbuster success of the anti-impotence drug Viagra, which changed the way that industry thought about drugs and male sexuality.
¹⁸
Its runaway success indicated the presence of untapped markets, and for a fleeting moment, drugmakers thought birth control might become hugely profitable. In 1996, an article in the British medical journal the
Lancet
noted that “after 30 years of research, the prospects for a new male contraceptive are at last looking good,”
¹⁹
and they estimated that a drug would hit the market within five to seven years. When Nelly Oudshoorn published
The Male Pill
in 2003, prospects for the availability of a male option were excellent. A few hormonal variations had entered later clinical trial phases, and pharmaceutical companies seemed—at last—to be on board.

And then it all went wrong again. In a 2008 article in the journal
Contraception
, Michael J. K. Harper chronicles the retreat of drug companies from contraceptive research and development in general, and research on men in particular.
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First, the two major industry players in male birth
control, Schering and Organon, became the same company when Schering acquired Organon. Then Schering designed a massive merger with drug giant Merck. The American companies, Wyeth (now part of Pfizer) and Johnson & Johnson, both left the birth control development business for the most part. Today, only one large European firm and two American companies, including Teva, continue to develop new birth control options. This, coupled with the serious problems in the global economy, has put the future of male birth control technology, even after all these years, in serious doubt.

Birds, Bees, and Pharmaceuticals: Changing Old Ideas about Men and Women to Make a New Drug

As I have said, some of the biggest obstacles to the development of male methods are mental ones; drug companies, media outlets, and scientists all continue to insist on a set of outdated ideas about men, women, and birth control that have been reiterated—although not substantiated—for fifty years. When you say something often enough, most people will accept that it is true.

One of the greatest surprises to me during the process of writing this book has been how many men have asked me, upon finding out about my project, when a good option for them is coming. “I would be all about it,” one twenty-seven-year-old told me. “It would be nice to have a feeling of control about that part of my life. And also responsibility; I feel bad always putting that on my girlfriend.” Another newlywed in his early thirties told me that after getting married, his wife had used the Pill. Soon, though, her frequent migraines led them to ditch OCs. Today they use the fertility awareness method, but he wishes there were more choices available to him.

Doctors and social scientists working on male birth control have gone to great efforts to dispel notions about male unwillingness to embrace pharmaceutical options. Nearly every piece of research on male contraception feels the need to initiate reports by reiterating two important points: first, that men want and would use male birth control and second, that their partners would support such drugs and would trust their partners to use them successfully.

One such study, conducted by Edinburgh-based scientist Richard Anderson and colleagues, notes that among men in Scotland, Shanghai, Hong Kong, and Capetown, 44 to 83 percent said that they would welcome a male pill.
²¹
Anderson also found that men were more likely to be open to trying a contraceptive if their partners encouraged them to do so. A related study found even more support among women for the drug, with 71 percent saying it would be a good idea and only 2 percent expressing concern that their partners weren’t up to the job.
²²

Stereotypes about the willingness of men to be primary contraceptive actors are particularly pernicious when applied to men in the developing world. Surveys have been conducted to disprove stereotypes about men in developing nations, particularly the notion that they are generally opposed to birth control and want to have lots of babies. In fact, with the notable exception of Sub-Saharan Africa, research shows that men in the non-Western world desire families similar in size to their American counterparts, an average of two to three children.
²³
Researchers found that the greatest limitation on men taking a more active role in contraception is a lack of available options.
²⁴
A 2002 survey of men in Argentina, Brazil, France, Germany, Indonesia, Mexico, Spain, Sweden, and the United States found that 55 percent of respondents said they would be willing to try a hormonal contraceptive,
²⁵
although specific acceptance rates varied by country between 21 and 71 percent.

Of course, as Jacqueline E. Darroch points out, men’s responses to potential technologies in the abstract may be different than what they would be if a drug were actually to hit the shelves: “It is very difficult to predict ultimate levels of interest and use of new methods until they are actually introduced.”
²⁶
This might be particularly true if, after a few months or years, a nasty side effect were to emerge.

The strangest part of the cultural insistence that men wouldn’t be willing to take responsibility for pregnancy prevention is that until the advent of the female pill, that is exactly what they had been doing. Indeed, in 1955, condom use and withdrawal—two male-dependant methods—accounted for 32 percent of total contraceptive use in the United States, and 21 percent used periodic abstinence to limit births.
²⁷
While we can breathe a sigh of relief that more options are now available, it is interesting that with a history of substantial male involvement, we have become
convinced that men want nothing to do with mediating the consequences of sex.

Today male involvement is on the decline, despite the rise of HIV/AIDS, which gave condoms a new relevance and prevalence on the world stage as well as increasing their overall use.
²⁸
The percentage of total contraception for which men are responsible has dropped from 37 percent in 1987
²⁹
to 25 percent in 2005.
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Men cannot necessarily be blamed for this: the last time science offered them an improvement in their options that was truly novel and fully reversible was when the vulcanization of rubber facilitated better condoms in the middle of the nineteenth century.

In a certain way, the AIDS crisis and concerns about sexually transmitted infection have created more than one generation of young men who know that they will use condoms for at least part of their sexual lives. This expectation of involvement provides a good opportunity for changing the balance of the contraceptive burden. If young men are used to taking responsibility for pregnancy prevention through condom use, a transition to injections or pills would seem more natural than for the generations of men who fell, sexually speaking, between the Pill and the advent of HIV/AIDS.

It is conceivable that men protected from pregnancy might worry less about STIs and neglect using barriers for disease prevention. This would put countless people at risk and potentially create problems for partners who felt pressure to engage in sex without protection. With every technological innovation we must be careful not to abandon the wisdom and strengths of former methods in our enthusiasm for new ones.

The first oral contraceptives were offered only to “married” women in the hopes of avoiding a cultural backlash. The first male options were tested only on men in “committed relationships,” however dubiously this is defined. In this case the concern is not over morals, but sexual health and informed consent. Early trials of hormonal methods insisted on condom use because of ethical concerns for women. Women would ultimately reap the benefits of a male pill while their partners endured the risks, but during the trial phase, women are the ones at risk of pregnancy if the drugs don’t work.

Nelly Oudshoorn points out that the weight we give to side effects and
risks varies based on the power and social status of the person facing risk. When it comes to contraception, for better or for worse, science and industry seem to be much more concerned about the potential hazards of drugs for men than they are about comparable drugs for women. For example, there is deep concern over sexual side effects experienced by men in trials of hormonal drugs. While curtailed libido is indeed disturbing, the problem has always been a commonly reported side effect of the female pill. In one case this side effect has been a major factor in keeping potential drugs off the market, and in the other, it is merely a small-type footnote in a patient-package insert. The medical community simply does not consider the loss of sexual desire in women to be as serious a consequence as it is in men. Because stereotypical ideas about sexuality imagine sex drive to be a fundamental part of male identity and less important to females, the problem is given different weight in these two populations.

Some argue that greater weight is given to problems with male pills because of the history of safety issues with female drugs. While it would be deeply encouraging to imagine that science has “learned the lesson” of hormonal contraception in the 1960s—namely, that aggressive marketing and a lack of informed consent are undesirable—problems with other drugs reveal that the matter isn’t a simple historical progression to better, more ethical medicine. A look at the course of hormone therapy and estrogen therapy in the 1990s shows that pharmaceutical firms were willing to very aggressively market hormone drugs to healthy populations of women even after serious concerns about the risk of cardiovascular disease and cancer in connection with these drugs had been raised in previous decades. When the issue of testosterone therapy for aging men was raised, many scientists were quick to dismiss the idea, noting, like G. D. Searle’s doctor in the 1960s, how dangerous such drugs might be; among other problems, doctors noted that the risks of testosterone replacement therapy included cancer and increased risk of heart disease.
³¹

Side effects in a male pill are harder for doctors and drugmakers to justify because men don’t face the potential health problems that women do if a pregnancy results. Their risk/benefit analysis is skewed. If a new male method is ever going to be put on the market, Oudshoorn theorizes, then side effects in men can and should be weighed against the health difficulties alleviated in women. Thinking this way requires, to some extent, that
birth control be taken out of the doctor’s office and placed back in the context of sexuality. If contraception is somehow inherently relational, then it makes sense that two people, not one, should be considered when discussing the benefits and drawbacks of a method. A failure to change this thinking will mean ultimately that no male drug will ever be safe enough. As Oudshoorn writes, “The aim of clinical testing of male hormonal contraceptives has culminated in a quest for zero risk.”
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But as women have learned through experience, every drug and method carries potential problems. Without a certain willingness to endure and address side effects, these essential tools in contraceptive health would never have become available.

Of Tails and Targets: The Male Reproductive System and Contraceptive Options

The male reproductive system, much like the female, relies on a series of chemical reactions among the brain, pituitary gland, and reproductive organs. Remember that female reproductive cycles actually begin not in the pelvis, but in the brain. Men work the same way. Hormonal male contraception functions by manipulating gonadotropins, chemicals that trigger a hormonal chain of events that culminates in sperm production. Like women, men make follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When these chemicals are suppressed in men, sperm counts either seriously decline or disappear.

Because a typical ejaculation contains 100 to 200 million sperm, and men can ejaculate multiple times a day, it is surprising to realize that the journey of a sperm cell from its genesis in the testicle to its exit through the external urethral orifice at the tip of the penis can take about seventy-four days—over two months. This journey starts in the tightly packed cells of the testicle, where coiled tubes house the growing sperm. In between the sperm cells are other cells that produce testosterone. FSH causes the sperm to grow, and LH stimulates testosterone production. The inside of the testicle is carefully protected by the body from outside toxins and dangerous changes in external temperature. This very effective protection system makes this stage of sperm growth hard to disrupt through nonhormonal means.