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BIOETHICS

Autonomous Contraception

Science, Sociology, and the Potential of a Male Pill

circular container of birth control pills with male symbol on it SOURCE: iStockphoto, SP A recent discovery might open the door to an effective male contraceptive drug, a technology that could have been developed decades ago, were it not for social factors that enable women but not men to effectively regulate their fertility outside of sexual activity and without their partner’s participation or knowledge.

Researchers at Oxford University recently discovered that a genetic defect with the PLC zeta protein in sperm leads to infertility in men because proper functioning of this protein is needed to allow fertilization. This discovery is not only important to men suffering from this type of infertility; it also presents the possibility that researchers could develop a male contraceptive that would inactivate the PLC zeta protein, and that would probably have fewer unpalatable side effects than other male contraceptives under research.

Before comparing this potential male contraceptive to others, it is first important to justify the need for male contraception. The dearth of male contraceptives, especially long-acting, reversible contraceptives, referred to as LARCs, contributes to an unjust arrangement in which women bear the majority of the social, economic, and health-related burdens associated with contraception. Today, there are eleven female contraceptive methods but only two male methods: condoms and vasectomy.[1] Women alone contracept 67.3 percent of the time. If we include shared methods as well as male condom use, which women often negotiate, then women are involved in almost 91 percent of all contraceptive use. Men, in contrast, only participate in contraceptive use one third of the time.[2] Moreover, men’s involvement with contraception is usually limited to casual sex, not long-term monogamous relationships where couples tend to prefer LARCs.

In short, men’s autonomy is enhanced by their freedom from contraceptive responsibility.

The high cost of contraception can affect women’s ability to use contraception, their choice of contraception, and their overall economic situation. The one in five women of reproductive potential who are uninsured have to pay out of pocket for contraception, and, not surprisingly, they are 30 percent less likely to report using prescription contraceptives than women with health insurance. Even having insurance does not obviate financial concerns. Copayments can be high and often add up quickly. Additionally, many insurance companies do not cover contraception. As a result, women pay 68 percent more out of pocket for their routine reproductive health care than men of the same age.[3]

In addition to the economic burdens of contraception, women also suffer from the negative side effects associated with contraception. The side effects of female contraceptives are generally more serious than for male contraceptives in part because there are no hormonal methods for men, and such methods typically carry more risks. Specifically, the side effects of female hormonal contraceptives can include cardiovascular complications, depression, hepatic adenomas, pathologic weight gain, and possible bone loss.[4] The two available male forms of contraception also carry fewer risks than their corresponding female contraceptives, female barrier methods and tubal ligation, respectively. Some dismiss women’s side effects as “minor”; however, to the women who experience them, they often are far from benign. Women most commonly discontinue contraceptives due to side effects[5] and most forms of contraception have discontinuation rates approaching 50 percent after one year of use.[6]

Not being responsible for some or all of these economic, health-related, and other burdens is a significant boon for men. Men typically do not have to dedicate time and energy to contraceptive care, pay out of pocket for the usually expensive and sometimes frequent (often monthly, or at least four times a year) supply of contraceptives, acquire the knowledge about contraception and reproduction needed to effectively contracept, deal with the medicalization of one’s reproductive health, endure the bodily invasion of contraception, suffer the health-related side effects and the mental stress of being responsible for contraception, and face the social repercussions of their contraceptive decisions (such as whether to use a particular contraceptive or to switch contraceptives), and the moral reproach for contraceptive failures. Women who contracept have to devote and sacrifice many aspects of themselves and what they value: their body, health (physical and mental), time, money, etc. These contraceptive burdens and sacrifices limit people’s freedoms. Since men are frequently not responsible for contraception, they are absolved from these burdens and thus their freedom is not infringed upon. In short, men’s autonomy is enhanced by their freedom from contraceptive responsibility.

At the same time, however, men’s autonomy is also diminished by the fact that they are usually not responsible for contraception. For many men, neither of the two currently available male contraceptives is well-suited for their contraceptive needs: they want a long-acting, reversible contraceptive. The lack of such options forces many men in monogamous relationships to rely on their partners to contracept. Even when men choose to use the condom, given its high failure rate of 16 percent for typical use, they are still not able to regulate their reproduction as effectively as women, for many female hormonal methods and IUDs have failure rates under three percent.[7] To further decrease the probability of pregnancy, some couples use both the male condom and a female method. But even if men contracept, they are often dependent on women to also use contraception if they want to use a method with a high success rate (and they are not yet ready for sterilization).

This dependence on women reduces men’s reproductive autonomy. Men have to trust that their partners are correctly and consistently using contraception. If a pregnancy does occur—either unintended by both partners or when the woman decides to stop contracepting without telling her partner—men have no recourse. Men cannot mandate that women get an abortion. Regardless of the circumstances under which the pregnancy transpired, men are still held socially and financially responsible for any children they father. In some ways it seems unfair to hold men responsible for children they did not want when they are ill equipped to prevent pregnancy.

What men need in order to successfully control their reproduction is the one type of contraceptive they are missing (and that women currently have), LARCs. Indeed, the development of male LARCs would enhance men’s reproductive autonomy by enabling them to do what women have been doing since the advent of the female pill: effectively regulate their fertility outside of all sexual activity and without their partner’s participation or knowledge. Scientists have been working on developing male contraception for the last 40 years and keep saying that these contraceptives are just around the corner. So why are there still no male LARCs?

First, dominant understandings of women’s and men’s bodies have played a role. Some scientists claim that it is more difficult to create male contraceptives because men’s bodies are more complex than women’s: women release one egg a month, while men produce millions of sperm a day; women’s fertility is limited to a handful of days each month, whereas men are consistently fertile.[8] At play in these comparisons are implicit and sexist assumptions about the mind/body dichotomy: women’s bodies are more simplistic and closer to nature, while men’s bodies are more advanced and farther from nature. While some scientists still insist that women’s bodies are more controllable and better suited for medical intervention, especially reproductive intervention, other scientists assert that men’s bodies are more easily manipulated and that “if scientists had simply followed nature, they would have developed male contraceptives rather than female methods.”[9] Regardless of the relative ease of developing female or male contraceptives, other factors have contributed to the dearth of male contraceptives. Notably, it was not until the 1970s—50 years after scientists starting researching “modern” female contraceptives—that scientists began researching new types of male contraceptives.[10] Previously, scientists’ work on male contraceptives was limited to improving the condom.[11] Because the female reproductive system has been studied for so much longer, more is known about it and consequently there are more female contraceptives and developing female contraceptives is not as difficult.

Second, much more money is allocated to female contraceptive research. The distribution of research and development money in the 1990s was as follows: 60 percent to high-tech female methods, 3 percent to female barrier methods, spermicides, and natural fertility control methods, 7 percent to male methods, and 30 percent to multiple methods, though mostly for women.[12] Researchers who would like to study male contraception often cannot due to a lack of funding. For example, Richard Anderson, a professor of clinical reproductive science at Edinburgh University, says that “most of the work [on male contraception] has been initiated by university investigators and the World Health Organisation. There has so far not been a lot of money from corporate companies.”[13] Despite positive findings on a male contraceptive pill, Anderson has not been able to conduct trials because no pharmaceutical company will financially support them.[14] The main reason pharmaceutical companies decline to fund male contraceptive research is that they do not think male contraceptives will be lucrative. While nonprofit organizations also research contraception, they typically lack the resources to do on a large scale. The World Health Organization had been one of the more visible and active nonprofit organizations working on male contraceptives, but today they focus entirely on female contraception because they see it as the key to helping women in developing countries.[15]

Third, many do not think there is a market for male contraception because they doubt both the women will trust men to contracept and that men will be interested in using contraception. Yet this reasoning is based on gender ideologies, not fact, and so it is not surprising that empirical evidence shows the opposite conclusions. For example, while mass media articles in the English speaking-world assert women will not trust men (including their partners) with contraception,[16] an international study reveals that only 2 percent of women would not trust their partner to contracept. A gender ideology relating to why men would not be interested in male contraception is that men do not want to participate in private-realm responsibilities like reproduction because they are women’s work. However, empirical studies show that 55 percent of men would be willing to use contraception.[17] Therefore, the data suggest that if those men had access to a long-lasting contraceptive, their female partners would have reason trust they were using it.

Another gender ideology that has inhibited the development of male contraception is that men are not willing to suffer side effects that “minimize” their masculinity. Many of the hormonal male contraceptives currently under research, such as gels, patches, implants, and injections, depend upon testosterone to induce sterility. While most men do not mind increased muscle weight gain, many are troubled by other side effects of testosterone like acne, mood swings, and temporary shrinking of the testes.[18] Additionally, some men are concerned about the effect hormones will have on their libido and their future fertility.[19] A non-hormonal male contraceptive pill currently under research avoids these unpalatable side effects and works by preventing ejaculation. Although the lack of an ejaculation does not affect the quality of orgasm, urologist Harry Fisch claims this side effect will preclude many men from considering this contraceptive: “I don’t think a lot of men are going to take this … The ejaculate coming forward is a significant part of a man’s sexuality.”[20]

A potential male contraceptive based on a genetic defect with the PLC zeta protein would sidestep the aforementioned negative side effects, thereby making it more acceptable to men. This is not to say, however, that this potential contraceptive would not also have problematic side effects. Moreover, a contraceptive that mimics this defect is still in its infancy. Although developing more male contraceptives will make it easier for men to contracept, it is unlikely that men will start contracepting at the same rates women do without any changes in dominant ideas about contraceptive responsibility. The mere existence of a particular technology is not enough to change our current contraceptive arrangement. Permanent contraceptives provides a strong example of this fact.

Unlike the case of reversible contraceptives, permanent contraceptives are equally available for women and men. Both have one option available to them: tubal ligation for women and vasectomy for men. This equality of options might lead one might expect similar rates of tubal ligation and vasectomy. Yet, tubal ligation is practically three times more common in the United States. Worldwide, the same pattern stands. In fact, only two countries, Britain and the Netherlands, have vasectomy rates that are equivalent to tubal ligation rates.[21] These differing rates cannot be attributed to availability of technology nor to the procedures themselves, as vasectomies are quicker, easier, safer, and cheaper than tubal ligations. The alignment of femininity with contraceptive responsibility explains, at least in part, why tubal ligation is much more popular. Before we can expect any male contraceptive to be widely accepted—no matter how objectively attractive it may be—we must first work on changing social norms so that men, as well as women, are expected to assume reproductive responsibility.

Lisa Campo-Engelstein, Ph.D. is a senior research fellow in medical humanities at the Feinberg School of Medicine, Northwestern University and a member of the Oncofertility Consortium.

Endnotes

[1] The eleven female-only contraceptive methods are sterilization (tubal ligation); barrier methods (the diaphragm, the sponge, the cervical cap, and the female condom); hormonal LARCs (the pill, the patch, injectables, implants, the vaginal ring, and a progestin-releasing IUD); and a non-hormonal LARC, other types of IUDs. The two male-only contraceptive methods are vasectomy and the male condom. The two shared methods are withdrawal and the rhythm method.

[2] The Alan Guttmacher Institute. 2008. Facts on contraceptive use. January. http://www.guttmacher.org/pubs/fb_contr_use.html. Accessed June 20, 2008.

[3] Knudson, Lara M. 2006. Reproductive rights in a global context: South Africa, Uganda, Peru, Denmark, United States, Vietnam, Jordan. Nashville: Vanderbilt University Press, 115.

[4] Hatcher, Robert A., James Trussell, Felicia H. Stewart, Anita L. Nelson, Willard Cates Jr., Felicia Guest, and Deborah Kowal. 2004. Contraceptive technology. 18th Revised Edition. New York: Ardent Media, Inc, 241.

[5] Nass, Sharyl J., and Jerome F. Strauss III, editors. 2004. New frontiers in contraceptive research: A blueprint for action. Washington, D.C.: The National Academies Press, 119.

[6] Nass and Strauss, 125-6

[7] Hatcher, foreword.

[8] For more examples, see Knight, James W., and Joan C. Callahan. 1989. Preventing birth: Contemporary methods and related moral controversies. Salt Lake City: University of Utah Press, 12.

[9] Oudshoorn, Nelly. 2003. The male pill: A biography of a technology in the making. Durham,

N.C.: Duke University Press, 46.

[10] Public Broadcasting Station (PBS). Timeline: The Pill. http://www.pbs.org/wgbh/amex/pill/timeline/index.html. Accessed July 21, 2008.

[11] Oudshoorn, 19.

[12] Yanoshik, Kim, and Judy Norsigian. 1992. Contraception, control, and choice: International perspectives. In Healing technology: Feminist perspectives, ed. Kathryn Strother Ratcliff. Ann Arbor: University of Michigan Press, 70.

[13] Quoted in Moss, Lyndsay. 2007. Hopes for male pill hit by lack of cash. The Scotsman, July 2, 12.

[14] Moss, 12

[15] Oudshoorn 192-3; Dow, Steve. 2005. No pill for him just yet. Sydney Morning Herald, September 29, 6

[16] See for example: Christman, Jennifer. 2006. What’s in a dame? Would he even take the Pill, if he could? Little Rock: Arkansas Democrat-Gazaette. November 7; Levenson, Ellie. 2006. A single dose of a new male contraceptive pill promises “instant” protection from pregnancy and no lasting effects. The Guardian, November 28: 17; Richard & Judy. 2006. Rely on a man to take the pill? Surely they have got to be joking. The Express, December 2: 21.

[17] Glasier, A.F., R. Anakwe, D. Everington, C.W. Martin, Z. van der Spuy, L. Cheng, P.C. Ho, and R.A. Anderson. 2000. Would women trust their partners to use a male pill? Human Reproduction 15 (3): 646-649.

[18] Nuzzo, Regina. 2006. Beyond condoms: Years in the making, male hormonal contraceptives may finally be on track. Los Angeles Times October 16, F3.

[19] Godson and Bourke. Bourke, Fionnuala. 2006. Boys may be offered male pill. Sunday Mercury, May 7, 20.

[20] Macrae, Fiona. 2006. The instant male pill; Scientists unveil contraceptive a man can take before          sex…while hours later his fertility returns to normal. London: Daily Mail. November 27. Fisch quoted in Traister, Rebecca. 2006. Men and the pill. Salon.com December 1.

[21] Ringheim, Karin. 1996. Whither methods for men? Emerging gender issues in contraception. Reproductive Health Matters No. 7 (May), 88, footnote.

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