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Contraception: How Far Are We From Gender Equality?

by Malek Chouchane, PhD | January 8, 2020

The Female Body as the Intervention Object

Birth control refers to the use of devices, medications, surgical procedures, and sexual behaviors to prevent pregnancies. Most of the discussion regarding birth control has centered around the female body in part because the female body has been traditionally considered to be the intervention object for reproductive matters. In fact, the Kahun gynecological papyrus crafted in Egypt documents how humans were discussing conditions of the womb as early as 1800 BCE. Despite the enduring interest in the female reproductive body, women possessed little to no control over their fertility for several centuries. Education and access to birth control pills was almost nonexistent until the 20th century.

Not until the mid 1950s did technological advancements enable gynecologists to offer oral hormonal contraceptives. In the 1960s, the American biologist Gregory Pincus collaborated with the two pharmaceutical companies Syntex and Searle to produce the first oral contraceptive pills specifically for women. Due to its success, research and development of new contraceptive agents boomed and attracted major American and European pharmaceutical companies to this new area of drug development. The success of these oral contraceptives also played a fundamental role in revolutionizing attitudes towards sex, relationships and women’s rights. One of the most widely circulated magazines, The Saturday Evening Post, noted just how transformative the birth control pill was:

“It may, in fact, be the most popular pill since aspirin. It is certainly relieving bigger headaches—both family and global. And all at a cost of about $1.75 for a month’s supply. The pill is big business, produced by seven firms, advertised in the medical journals in two- and three-page spreads with lace-and-roses borders and sold in “feminine and fashionable” dispensers. Some resemble powder compacts, others, telephone dials, marked off to help the woman keep track of the days she should take them” (January 15, 1966, The Saturday Evening Post).       

Admittedly, there were several obstacles for this industry to overcome. Reports started to emerge about the health risks of oral contraceptives. Some even suggested that the pills might be associated with an increased risk of developing cancer and cardiovascular issues. Other reports have indicated that the pills might have undesirable side effects such as headaches, nausea, etc. Liability suits threatened their widespread production. The FDA also developed more stringent rules and procedural regulations for their production that led to higher costs of development.

Nevertheless, the new freedom, responsibilities, and power with which these pills endowed women helped spur their development and use. Recent figures by the United Nations show that more women than ever use family planning. Projections for global population growth and increased education about sexual health stand to make female contraception the most reliable tool for containing global population. In the United States alone, around 10 million women each month use the contraceptive pill. This current and projected usage explains why the contraceptive market is expected to reach over $30B by 2025.

A Male Pill?

In the 1970s, feminist groups began to mobilize and question the assumption that the female body should serve as the primary intervention object for birth control. Should women be largely responsible for pregnancy prevention in an era where gender equality is being demanded more than ever? A 2015 United Nations report found that over half of married women used a pill for birth control while only eight percent relied on their husband to use a condom. Several surveys also indicate that men are willing to use male contraceptives if available.

Recently, a number of organizations and startups have launched attempts to develop novel male contraceptives. Drs. Ronald Swerdloff and Christina Wang of the Lundquist Institute and Dr. Stephanie Page at the University of Washington have helped oversee clinical studies funded by the National Institutes of Health (NIH) for two new male contraceptives. The first study involves a daily administered pill containing dimethandrolone undecanoate (DMAU), which works to suppress the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Ideally, DMAU-mediated suppression of FSH and LH should decrease testosterone levels without causing many of the adverse symptoms commonly associated with low testosterone. The second clinical trial involves a topically administered gel that enters a man’s body through his skin and subsequently releases hormones to suppress the production of sperm and ultimately lowers sperm counts in the ejaculate. The gel supposedly reduces the production of sperm without impacting the male user’s testosterone levels or ability to produce sperm at a later date. Dr. Wang noted that “the gel would be useful for couples in stable relationships.” The Lundquist Institute and the University of Washington are studying how individuals from different countries and genetic backgrounds respond to treatment and ascertain the effectiveness of the gel as a contraceptive. Underlying genetic differences can shape factors such as the time required to sufficiently reduce sperm count, ultimately determining the optimal regimen to use such contraceptives. However, data regarding the impact of ethnicity and race on male contraceptive efficacy are limited as trials to date have been too small to rigorously examine such potential differences.

While these contraceptives attempt to prevent pregnancies by altering male hormones, some men would prefer to use contraceptives that do not affect their hormones. As a result, other groups are working to develop non-hormonal alternatives. YourChoice Therapeutics, a startup based in Berkeley, CA, is not only working on different non-hormonal targets that can prevent hyperactivation of spermatozoids and be used as unisex contraceptives, but also on a lubricant contraceptive for women. The startup is led by a team of UC Berkeley researchers, including two experts in sperm physiology and sperm-egg interactions. It has raised over $500,000 in funding, including a $150,000 check from Y Combinator. CEO Akash Bakshi emphasized that YourChoice is “encouraging the on-demand contraceptive.” Why would a man use their product? Bakshi said their product will be “very efficient.” He added that there is increasing “demand for more effective methods” and pointed out how “using a condom is less enjoyable.” Bakshi said that YourChoice plans to have a contraceptive ready to market by 2025 and that it will reach men and women globally. While these non-hormonal methods have the potential to avoid issues associated with hormonal methods, Dr. Page duly noted that “we should be careful to say that there will not be side effects. No drug has no side effects.” Thus, a significant number of safety studies – first in animals and ultimately in humans – must be performed before these products reach the market regardless of whether these novel contraceptives involve hormonal or non-hormonal methods.

There are still many questions to be addressed before we witness widespread adoption of a male contraceptive pill or gel. How much will the pill cost? How accessible will the pill be? Will physician approval be required? When will one of pharmaceutical giants attempt to develop a male pill? How will companies convince men to use these novel contraceptives over condoms? Are hormonal methods riskier than non-hormonal strategies? These male pills should also be considered in the context of larger cultural shifts underway in the United States that have sought to fight for gender equality, social justice, and women’s empowerment. Movements like MeToo and Time’s Up represent dramatic shifts in the social constructions of gender and gender relationships. Whether such broader forces shape the contraceptive market remains to be determined.

Malek Chouchane, PhD is a Postdoctoral Scholar at the University of California, San Francisco.