Harvard Book Store; WGBH Forum Network; Laura Eldridge: Contraceptive Choices for Women

So this evening on behalf of Harvard bookstore I'm pleased to welcome Laura Eldridge for discussion of her new book in our control the complete guide to contraceptive choices for women in this new authoritative guide to Laura Eldridge explores the knobbly of birth control methods alongside an analysis of the political historical and cultural context and their use in the 21st century. Eldridge revalue its the pale in the light of its recent 50 year anniversary and also presents issues of environmental concerns to international laws surrounding birth control. In our control successfully seeks to encourage women and men to broaden the conversation around contraceptive use. The feminist review calls the book straightforward non-judgmental and honest. And Elizabeth kissing in a Miss magazine blog has this to say. Just book quote This is women's health activism at its best. Feminism isn't just about choices. It's about having access to information and resources to make informed authentic choices. And it is only possible when reliable and comprehensive information is widely available. And such as Mr. Eldrick his book. Laura Eldridge is a women's health writer and activist. She

began working with the founder of the women's health movement Barbara seaman when she was studying at Barnard College alongside in our control mistletoe is also the author of the no nonsense guide to menopause and the coeditor of body politic Dispatches from the women's health revolution. We're so thrilled that Laura is here with us in Cambridge in the cueball. So much for being here with us. Please join me now in welcoming Laura Eldritch. Thank thank you so much. I'm absolutely thrilled to be here and to be back in Cambridge where my brother lives. So I've had the privilege of being here a few times. So I want to first start by talking a little bit about how he came to write this book. There are really two answers to that question of why I decided to write the book. The actual idea for the project emerged in March of 2000 and in February in less than a month before my friend mentor boss and eventually co-author Barbara seaman had passed away suddenly after a very short battle with lung cancer but a very long

battle for women's health. Barbara was tireless and funny and courageous and she had sort of been a warrior for women's health for many decades. In 1969 she was a young journalist writing for Bride magazine Ladies Home Journal and a couple of other women's magazines. She began receiving letters as you do from readers and a number of these letters disturbed her. Many of them had to do with using the birth control pill which at that point was still a relatively new thing in American life. After a few years of this of sort of hearing stories talking to doctors writing on the subject Barbara decided she needed to do something to raise awareness about some of the health concerns associated with the pill which of course at that point was a very different drug than the one that we have today. What Barbara did the thing that turned her into a full fledged activist was to write a book that was published in 1969 called the doctor's case against the pill. Barbara's book prompted congressional hearings sponsored by a senator named Gaylord Nelson.

At that time the second wave womens movement was sort of just gaining steam and there were a lot of grassroots women's organizations cropping up all over the country and one of those groups was D.C. Women's Liberation which was a group that was sort of headed up by a young woman named Alice Wolfson who came up in the anti-war and the civil rights movement and have been trained in activist strategies and had done and the group had done a lot of activism around the D.C. area. They decided to attend the PIL hearings not intending to stage any kind of activism but rather just intending to kind of gather information when they got there and they started listening to doctors and scientists testify. They realize that no patients no women in fact were were being allowed to take the stand Barbara seaman herself who helped Senator Nelson design the hearings was not taking the stand and they started to get angrier and angrier and they started to shout out questions such as Why are women being used as guinea pigs and why is there no pill for men. These two why should they end at that point of course they were encouraged to leave the hearing room.

But they caught the attention of the media and they made the national news and it brought a real awareness around the country to the issues that were being discussed at that point. These two important different and connected pieces of health activism Barbara's book and Alice Wolfson and the D.C. women's liberation protest became essential and foundational pieces of the women's health movement and eventually these two women actually went on with other women to found the National Women's Health Network and sort of broaden out the work they were doing with the pope to so many other women's health issues being critical of the pill at that moment was a very complicated thing. The second way of women's movement was just getting going just gaining momentum. The pope was a new thing in American life. And many people and indeed many feminists felt that to be critical of it was a bad thing for women because it. It gave strength to the voices of those arguing more broadly against contraceptive access and it's easy today to understand those anxieties. Right now we face challenges to contraceptive access on so many fronts from abstinence

only education policies to efforts to reduce funding for contraception under Medicaid in Title 10 clinics and on college campuses to so-called conscience clauses that make it easier for providers to refuse services. And of course institutional problems and we'll talk more about that later but what happened at FDA with bringing Plan B over the counter and in light of so many challenges it can be very easy to say let's not worry about this stuff you know let's focus on the main event worry about these other things. Barbara Alice Wolfson and many others understood that ensuring that contraception was was safe was as and as important as ensuring that it was a it was available when Barbara was writing about the birth control pill. She was writing about a dangerous drug. Today when I write about the pill I have the privilege of writing critically about a drug that while not perfect is safe. This change didn't happen because Barbara and Alice Wilson kept their mouth shut or because countless women were too afraid of losing contraceptive access to speak up and share their experiences. The change happened specifically because of a healthy

thriving culture of feminism that was both publicly and privately in conversation about the pill and other contraceptive methods. I worked with Barbara for about nine years. She was my boss she was my coworker and she was my friend and when I lost her it was two years before the 50th anniversary of the birth control pill. And one year before the 40th anniversary of her landmark book. Before her death she had been talking to Dan Simon Seven Stories Press about updating doctor's case against the pill sort of looking at the issues that are hot today and saying what's going on right now. After her passing I was meeting with Teresa Noll our editor on an anthology that we were doing for Seven Stories Press. We got to talking about tax case about Barbara's legacy and about Eventually our own contraceptive frustrations. We discussed the idea of redoing our updating docs case but at the end of the conversation we decided that the best way to honor her memory was to do an entirely new book. Our goal in this book was in part to re

center the contraceptive conversation which we felt had narrowed down sort of restrictively to the pill and condoms. And we thought why not take the anniversary of the Pill as a moment to look at the pill today to say what is the same what has changed. And then to move outward and to look at everything that's out there contraceptive Lih speaking. So the other reason I wanted to do the book was more personal. I myself was on the pill for about 10 years. I broke up with the pill when I was 27. I first went on the pill when I was 18. Like so many young people I was going off to. I had been in a relationship for a while and was thinking about having sex and I was going off to college and I didn't want to take any chances. Being a young person at that point I didn't walk up to my doctor and say Can I have a prescription although I probably could have. I could have you know said that I wanted it for my skin or for any number of other things but instead I did what all kids in Salt Lake City at that point who wanted birth control did I went to this mall Planned Parenthood about two blocks from my small Catholic high school. And I knew this was the thing to do because this was the thing that girls

talked about in the cafeteria over french fries and sort of we knew that this was the smart thing to do. Kids went there because it was cheap because it and employed the Don't Ask Don't Tell policy and I knew people who went for all kinds of services including things like concern for basic health things like pap smears and things they were too embarrassed to ask their doctor for another context. The first time I went on the pill not much happened. I would go on and off the drug for the next 10 years each time experiencing more side effects when I did. In 1999 I met Barbara seaman as part of an internship for a women's studies class. I fancied myself a serious feminist and I jumped at the trends to work with an author who a friend had explained to me had been an active member of the second wave womens movement. You can imagine my surprise when on my first day of work I came to understand what doctors case against the pill was about and I was about to learn that while and there is no there is no denying that the pill has revolutionized American women's lives and indeed the lives of women around the world that this is a long story and it's a complicated story and it's one

that's that's worth getting into and learning. So even as I continue to work with Barbara I stayed on the pill the last time I went on the pill I was 24 and things that had been small problems in the past became big problems I started to have really crazy mood swings so my doctor changed my pill. I continued having mood swings but then started having breakthrough bleeding. My doctor changed my pill. This continued with different symptoms over time and eventually I ended up trying five different brands and if you count the generic as a unique brand then six different brands. A lot of people have said to me you know you worked with my regime and you were going to decide that you didn't like the pill. I don't think a person tries six different brands because they don't want to be the right thing for them I really did. And I wish that it had been you. My my it so my last straw finally came when I stopped having a period entirely and a lot of people might like that but I didn't I found it very stressful and

worried that I was pregnant all the time. And I finally went into my doctor and I said enough is enough. I want to try something else. Let me say from the beginning I don't share my own story to scare women off the pill. That is not at all my goal I believe in fact that most women who take the pill the majority of women have little to no side effects and have good experiences and I would never tell a friend who is happy on the pill to get off of it. Our birth control choices are private and we as individuals dictate the factors safety efficacy expense ease of use degree of sexual interference and so on that are important to each of us. When it comes to contraception and to sexual have health there is no magic bullet. There is nothing that works equally well for everyone but this is not the cultural message that we receive to be informed consumers to truly exercise our freedom of choice we must sort of trust ourselves and to build that trust. You have to understand how our birth control works and in our bodies to research all the options that are available and to take into account the complicated

sometimes difficult history of how different birth control is came to exist as they do today. When women fought for the right to legally use birth control in the 20th century they sought contraceptive access as the answer to women's social problems. Secondly feminists made the right to abortion and birth control central goals of their activism and this is why many feminists in the 1970s didn't want to hear that the birth control pill was unsafe because it meant facing was a really difficult truth that simply accessing the drug was not something that enhance women's power. Of course at this point after so many decades of experience. We've learned that gaining reproductive rights is not a simple answer to the bigger issues of reproductive justice and of course health justice for all women and all people. In American history reproduction has always been a place where racial inequality has been institutionalized where the control of women by men has been constantly reaffirmed and we are middle class and wealthy women have been valued over poor women putting women in control of reproduction means addressing many social issues building reproductive freedom including

the ability to make contraceptive decisions means given women not the many cultural forces around them and people in positions of power around them. The ultimate right to make choices about pregnancy. Limiting contraceptive knowledge is dangerous a form of coercion as preventing physical access to methods. Young women today sit at the epicenter of many cultural battles and their access to knowledge about their birth control options is often foreclosed by those arguing that abstinence not having sex is the only valid way of preventing pregnancy for young adults. Programs insisting on abstinence only education have been getting huge amounts of political and financial support for close to three decades in the United States and abroad. Besides seeking to prevent young people from becoming educated about contraceptive health these programs promote religious values in public schools declined to address the needs of students with their first sexual identities and insist on dangerous essential list ideas about women and gender. Simply put they instruct young people that gender is destiny. In addition laws and policies that insist

on parental consent detain certain types of health care and threaten to limit confidentiality for young women violate the rights of young women and create a dangerous double standard. Women even young women should be given respect and knowledge and resources to make their own decisions. Women in the 21st century have the best birth control in history. They can use methods that promise to work more than 99 percent of the time. And yet since the hormonal innovations of the 1950s and 60s little has changed on the contraceptive landscape. And I'll speak a little bit later about some of the alternative distribution methods things like the patch and the ring that in some ways are are new but in other ways are sort of really building on the technology that came earlier. In many ways female consumers can't win when it comes to birth control innovation. If we insist on safety it discourages pharmaceutical firms from advancing new and potentially dangerous methods and then you know they're worried about lawsuits if we embrace innovation it often means taking big safety risks and accepting that we may not get all the information from companies with a financial

stake in promoting potentially lucrative new products. Understanding the ways that protecting consumer safety has related to birth control innovation. It is an important step in asking the question of why after half a century and countless scientific advances there aren't really any truly new methods of pregnancy prevention really. I mean on the level of the pill since the pill and the obvious gender inequities within birth control are also really important to explore. Why is it that other than condoms vasectomy and pulling out all methods of contraception involve women's bodies. In what ways has scientific innovation or sexism in medicine prevented the development of male options and to what extent do women fail to involve male partners in these choices. There are no easy answers to this question will talk a little bit more about that in a minute. It's a really really complicated question. Looking at birth control through these many lenses isn't easy. It means asking questions that often breed more questions and I have been learning

this firsthand traveling with this book in the past month. My perspective on some of these things continues to shift as I have conversations with women about their experience as I talk to doctors along the way who say oh I worked on this topic. This is tough stuff. So I want to briefly talk about some of the content in the chapters. Again with the caveat that each one of these issues is really complicated and I can't do it justice but if I leave anything out ask me about it. So of course this is the 50th anniversary of the pill. So the past few weeks it's been very difficult to open up a newspaper without seeing a story. Talking about the pill the pill was the brainchild of Margaret Sanger Sanger was sort of a very complicated figure for women she's at one time the heroine of the women's health movement who sort of are not them until the moment of the birth control movement who basically legalized birth control after the Comstock laws and brought a social acceptability to it with a speed that

probably wouldn't have happened without her tireless crusading. She also is somebody who by the end of her career had started to invest or at least give lip service to many really disturbing eugenicist kind of ideas. Any time you look at Sanger there's no simple answer she's a really difficult figure. Sam was dreaming of the birth control pill. Even back when she was opening her first illegal clinics in Brooklyn New York. It would be many decades before she would be able to see it go any further. It happened when she met two people who she was able to bring together at an advantageous moment one of those people was Gregory Pincus Pincus. I think I believe had been here at Harvard had done some really revolutionary work with rabbit embryos stuff that was really ahead of its time and he was characterized as a mad scientist he lost his teaching position and opened up an independent lab in Massachusetts. So here she had a man who she believed had the scientific know how to make this happen. Around the same time an old friend of hers a woman named Katherine Dexter McCormick approached her about

getting into the birth control business. McCormick was the wife of schizophrenia and she had nursed him for many years and had put most of his considerable fortune into research on schizophrenia when he died. She decided to redirect those funds to things that were more that were closer to her own heart namely birth control. Sanger had been hoping to get a hold of some of McCormick's money for a long time. So when it happened she said all right Gregory. Katherine and the rest is history. The pill was always a product that was a woman's product as well as a men's product. I think there was a line at one point that said you know the pill was a male product imposed on female bodies but of course I think a really brief look at this shows that that's not true there was of course Sanger and McCormick but there were also women in Pincus as labs in Massachusetts there was rice Ray and other female physicians and doctors in Puerto Rico conducting the early trials. So this was always something that women were a part of making. When I went to write on

the pill I went back to Barbara seaman's 969 book again the pill today were the pills today because of course there are so many different kinds of pills. But most fall into the category of you know being a combined oral contraceptive which is estrogen and progestin or progesterone only pill which is newer and it's something we're still continuing to learn about. But these are pills that have. About a tenth of the hormones that the original 1969 I sorry one hundred sixty An av it had. So that's a big difference. There are a lot of good news on the pill. I think the most the most prominent of which is the good news about ovarian cancer and the fact that using the pill lowers the risk for that that illness. When it comes to side effects I think they can be divided into two categories. There's there's one life this sort of potentially life ending and life disrupting life ending is something that really doesn't happen much anymore. This is a very very rare outcome. This is the kind of thing that Barbara first became tremendously

concerned about when she started getting letters saying I had a blood clot. I had a pulmonary embolism. These things don't happen much anymore. They do still happen. I had a childhood friend who had a stroke and her parents were very surprised when her column a trained neurosurgeon told them that they believe that it was in part because of her pill use but this for most women unless you have a history of blood clotting or some sort of preexisting cardiovascular risk factor and family history that concerns you. This is. Not something that bears on your decision to take or not take the pill today because this is so so very rare when it comes to life disrupting and here I'm talking about things like changes in mood changes in libido and sexuality metabolic changes things like that. This is where you get into things that women very frequently and have for many years very frequently voiced that they believe there are connections between changes in their body and taking the pill. There's not consistent clinical evidence in a lot of cases to to back that up.

I've now spoken to hundreds of women over the course of this process maybe more people sharing their stories and I believe that there are groups of women who experience these things as I said. The majority you know do very well but I do believe there are groups of women who have these struggles. Why wouldn't it be something that shows up in a clinical setting I think is an interesting question I spoke to a doctor and scientist in England named Cynthia Graham and she's been working for many years on sexuality and the pill and she said she outlined a number of sort of structural problems with a lot of the better trials looking for these things. For example like she said a lot of them were performed on long term pill users. So it was sort of self-selecting to begin with women who have had trouble in the pill and gotten off were never included in the in the trials to begin with. And she outlined a number of things like that. What Cynthia Graham is trying to do and I think this is the way that we need to think is to say how can we test this differently design studies differently so that we can try to plan for which the group of women the smaller group of women who may be more vulnerable to

these problems and use that information to make the pill better to make patient information better and to sort of put this thing in the service of women. So I think that's absolutely the right way rather than saying you know this is good this is bad there's so much that's polemical out there rather to say how can we take what we have which is good and make it better. Alternative distribution method so when I talking about this I'm talking about the patch the shot an implant will ring even the eye US which is a type of IUD that has a hormonal component Mirena. It can be very easy to feel that birth control is changed totally in the past 10 years because every year there's a new one of these devices and of course it's valuable to realize that these things are all hormonal birth control. They use the same technologies that were developed in you know early to mid part of the 20th century. Now of course they do have unique benefits and they do have unique risks in terms of

benefits of course I've talked to many young women who like you know that some of these methods can. You don't have to think about them every day. In most cases it's something that you only have to think about once a week or once a month or every two months depending or with the U.S. once every 10 years depending which method you select. So it has a lot of advantages that way I spoke to one woman who shared her story of taking the pill and having three unplanned pregnancies and switching to the ring and having that be something that was able to make a change because she just couldn't remember to take it regularly. These things also have unique risks and those of course because these things are new or continue to emerge. And we'll see only with time and experience what they are and why why they exist. The earliest alternative distribution methods were Norplant and Depo-Provera depo was actually developed first in the 1980s by a Brazilian doctor who speak again in a minute Doctor who wrote a book called Is menstruation obsolete. But Norplant was the first to hit the

American market within a week of hitting the American market. The Philadelphia Inquirer published an article claiming that Norplant maybe was the solution to poverty and then it went to step further and said maybe it's the solution to black poverty. It became very clear that a very disturbing history that we have in the United States of trying to use birth control in coercive ways in communities of low income women and low income women of color was not past us. In addition to the very understandable outrage that surrounded the Philadelphia Inquirer article there were also a lot of legislators who went home and started drafting proposals to try to use Norplant in coercive ways for example to make it a condition of receiving welfare benefits having it inserted. This sort of thing going on in less official ways it went on in ways where doctors were trained how to put the devices in but not how to take them out or programs were created to make it cheap to get it put in but not to provide financial resources for having it removed. None of the none of the program's

legal programs went into place mostly because of really fantastic activism on the part of women's health activists advocates. But it was a cautionary tale so this coupled with bad safety information that started coming back about pain on site. Other kinds of problems led to the swift pulling of Norplant from the market. Now I don't think I didn't think at the time and I don't think now that Norplant was a great a great device. But at the same time I think when something gets pulled and there are fewer choices that women are sort of the ones who lose I think the better thing and the norm. And I think their plan is an example of how things could have gone differently. What could have been different if they had taken the time to get proper safety studies if they had dealt with some of the some of the political stuff surrounding the drug. If they had made sure for example that doctors were better trained this could have been a different story but instead it became a cautionary tale and it sent drug makers running even faster away from contraceptive R&D which they have always been tentative about in the first place.

Today much more prominent are things like the ring which I heard from a lot of young women that they like the patch in the rain are sort of a story that go together. The patch hit the market. It had its moment in the sun with the media and then very quickly stories about blood clots started arising. Studies were performed. There were two two slightly larger ones one funded in part by the drug maker. The study that was not funded by the drug maker concluded that there were more blood clots and the one funded by the maker concluded that there were not. They updated that study a few years later to say yes yes there were there were more. The ring has similar anecdotal reports of blood clotting but it doesn't have the the trials behind it so it remains something where that's it's more anecdotal than something that's been shown. The question then I guess becomes with these devices which as I said obviously have a lot of benefits for a lot of women and as I've also said I'm not in favor of just you know being too quick to just pull something but. So with these two things Why might there be more blood

clots. Part of this might have to do with the way that the hormones is taken into the body for example. The thought with the patch was that actually it would make hormone exposure lower but in fact it was higher so it didn't work exactly the way that people who made it expected. Or it could be the type of progestin that's in it. Both the things you third generation progestins which there have been studies now for about 10 years saying that third generation progestins have slightly higher blood clotting rates then older protest and two from Year Two studies from Europe last summer sort of backing up again what's now an increasing body of research on that subject. So what the cause is remains to be seen but it I guess goes to is another sort of chapter in that story of saying this new thing that has unique advantages but we're still kind of finding out what the problems are and of course we saw the same thing with the pope Rivera and bone loss even something that had been on the market a long time where there was still this relatively unanticipated consequence with it of young women losing bone that was not necessarily regained although that point is controversial some doctors think that it is

readily regained. So when it comes to non hormonal contraception. There's not a lot. Well actually there are two different stories I guess is the better way to put it when it comes to female barriers they're disappearing. So something like the diaphragm something like the cervical cap and even something like the female condom which is a slightly different story. I asked the question in the book Why has the diaphragm disappeared. Certainly the diaphragm has a lower efficacy than hormonal birth control which is a fact. That is not in dispute. But I think that the story of its disappearance is more complicated than that. I think in part Of course it has been. Unfavorably compared with pharmaceutical alternatives trying to position themselves from a marketing standpoint as something young hip cool you know. This is the new and they position themselves against something like a diaphragm saying all of this is 1950s this is old this is messy This is not sex positive all of these sorts of things. I think that it's important because while most women in the United States the majority of women

never use something like a diaphragm in the United States even before the pill it was never the majority of women but there was always a group of women that it worked well for. And I think with all of these contraceptives you find that there is a group of women that it works well for. And what happens when they fall out of use for multiple reasons is what's happened with the cervical cap which is no longer available in the traditional form that your doctor would fit is available something called the fem cap which is a preferred device comes in three sizes but just think about how different all women are physically in shape in size and everything and you can see why a perfect device might not have the same kind of efficacy as something that was fit in a more precise way. So I think that's the importance of keeping these things around so that for the women that they are the best option they're available and they're available in the best way. The female condom has been redesigned recently. When I spoke to him and I did not get tremendously great feedback about the female condom but hopefully maybe that will change with this new redesign it's become sleeker to different material it's now made with a

synthetic rubber which conducts heat better and should have a more natural feel than the polyurethane that the older one was made out of. So that's a hopeful story. We'll see what happens. It's one of those things that's always been more in the media than it's been in most women's lives. And the question I think for a lot of women's and women's health activists who see this as something with so many different kinds of benefits is to say how do you change that perception of it or change the design of the things so that it's actually better. As diaphragms and female barriers are on the decline the IUD is a star on the rise right now. Right now the major the big public health organizations the Guttmacher Institute Planned Parenthood some of these big organizations are really saying let's look again. A lot of people are asking why don't American women choose the IUD. And I think there's one answer to that question I think the answer is the kind of shield which was a very popular idea in the 1970s. In the 1970s FTA at that point lacked the ability to regulate devices

so if I had the right you know manufacturing resources I could make an IUD you could make an IUD. It was the Wild West. Why you do that was made was the shield it was made by a doctor in part by a doctor named Hugh Davis Dr. Davis concealed his involvement in creating the shield and he concealed his financial interest in it. What he did was he went around sort of raising awareness of the dangers of the pill and saying if you don't like this try this. And it became a real cautionary tale of the dangers of saying this method is terrible everything else must be better let's which clearly is not better and many women found that out the hard way through infection infertility and some women even died. Today it's a different story FDA as I said now does regulate these things we say but really in America we have one eye you do you we have para guard Mirena which is another type of. It's more accurately and in the uterine system because it has a hormonal component.

So it's a hybrid device. The jury is still out on paregoric on the one hand I've spoken to women who've had both kinds of experiences and on the one hand people are very cautiously optimistic saying this is a really good thing this is a great option for women even young women for many years doctors wouldn't put put these in young women because of the legacy of the Alpine shield. But you also have some cautious voices. Cindy Pearson at the National Men's Health Network said to me you know we want to withhold judgment because we still think there is a slight increase risk of infection with this. So I think time and many more women using device will will give us these answers it would be nice if it didn't have to be that way. But we'll see what happens. Sterilization a strange thing to realize about sterilization actually is that you if you combine male and female it's the number one method of birth control in the United States. If you don't combine male and female it's the pill. But I think we don't think of it that way because we think of it as something that the choice of couples who completed their families whatever that means.

So I think you know that's changing slightly these days with more couples opting to live childfree and making choices like that and there have been innovations within sterilization something like Escher which is a different and alternative to tubal ligation and again with anything new. We'll have to wait and see on the safety we won't have the answers but there is innovation going on. I wrote a chapter in the book on fertility awareness method. I hadn't really heard anything about fertility awareness method before I wrote this book. I almost as an afterthought I said let me look into it if it's something I'll do a chapter. I didn't realize that this was going to be one of the most controversial parts of the book to discuss this. Fertility awareness is a type of quote unquote natural birth control I don't like to use the word natural because I think it's more confusing than instructive but what I mean is that it doesn't involve a device or a pill. So fertility awareness involves monitoring the signs within the body things like body temperature throughout the menstrual cycle cervical fluids

cervical position things like this charging them and trying to figure out when the body obviously is and you can use this in a number of ways. Well if you're trying to figure out when you have you know you're using it for probably for pregnancy prevention or for pregnancy encouraged you know for conception which actually more women do. It has of course other benefits not the least of which is that it gives women a really interesting way to learn about their menstrual cycles and in fact their menstrual health and to trouble shoot for various kinds of gynecological problems and it becomes a real resource for that. Even if you know like me you look at it and you say I'm not ready to use this for birth control but I think the thing that impressed me the most about this is that there's a really passionate feminist community that wants to raise awareness about about this methodology which for a lot of years women's health people have been really cautious of in part because it seems along with other types of natural birth control like a counter based method something like the rhythm method to be the province of people who are interested in

for clothes and other kinds of contraceptive access. So I think that's one of the big reasons why it's been really hard for feminists and women's health people to get up and say let's talk about this. I don't want to romanticize this. This has really high user failure as a contraceptive method. I spoke to a lot of people who had unplanned pregnancies I've spoken to people who are happy and who have not. I heard both stories. I don't think it's so dangerous though that we can't talk about it if we don't romanticize it. I think we can have a conversation and in fact I think it's important because I don't know that we can Alliance build with the people who have the knowledge about training in this method right now so I think it's really important to build a secular feminist base of knowledge about this so that we can provide this information and this training to women who want to use this. I talk a lot about menstruation in this book because I think menstruation is where a lot of women sort of bad attitudes about various parts of their bodies get go and we are getting messages about our peers and we are so young. An interesting case study in the way that this has

worked has been the rise of menstrual suppression drugs so hormonal birth control designed to prevent withdrawal bleeding. Most most traditional birth control pills have several weeks of hormones followed by a week of sugar pills are just not taking any pills. When the hormones that your body's been taking suddenly are withdrawn you have a bleed that was really the brainchild of John Rock one of the other men besides Pincus who built the pill and he was a devout Catholic and he really believed that he could construct the pill in a way that would would be acceptable to the Catholic Church that would seem natural enough that the Catholic Church could accept it. And he realized that if women weren't having periods there was nothing that seemed natural about it to the church for the church. And since then a lot of people you know women for many years have have skipped periods by simply continuously taking the hormones rather than taking the sugar pills in the past 10 years we've seen a number of dedicated drugs come on the market. The most widely known I think I there's season now in season eek where you have four periods a year and

Vibro which seeks to eliminate periods entirely. These drugs have a lot of potential to help certain groups of women. Women for example with certain gynecological problems with something like endometriosis that makes men that makes menstruation excessively painful. Women who just have really bad periods you know there are a lot of women who could benefit from this drug. The problem there are a lot of problems though but among them are that these drugs have been sold using some of the worst messages about menstruation in particular and women's bodies in general and that's really unfortunate because they get I think these are things that could be really useful. There are two conflicting messages with the menstrual suppression drugs. One is that periods aren't natural that that women you know would have been constantly gestating and lactating so they would have had regular menstruation and periods our product of like sort of lazy post-industrial society and that sort of thing. Anytime I see cavewoman I get worried I don't think she ever comes out for good reasons I don't think it's ever to encourage women to like have more choices in

the world. The other message about these drugs and you can decide for yourself if you think these two messages can be reconciled is that is that they are a triumph of science that now allows us to go beyond our natural bodies that all of these messy human things can be overcome because of this fantastic new product. I think that it's really interesting in terms of identifying the way that contraception especially hormonal contraceptives in certain countries that the devices are being replenished as lifestyle drugs by drug makers. So when you watch these ads these young women are hip they're cool they have lower East Side apartments and in the rocker boyfriends the coolest new iPhone and they have x pill. And in this context the pope becomes divorced from what it does and becomes another consumable. But I think that it's something that you see particularly with menstrual suppression drugs but more generally with other types of birth control it becomes a place where you need to separate you know health effects from idiology and marketing. And it it's not always easy

in general I don't think that there are negative health effects with these drugs beyond what you see with the regular pillow though of course there are questions that won't be answered for a while. The biggest thing seems to be unscheduled bleeding ironically which is that when women take these drugs rather than having a planned withdrawal bleed they have intermittent bleeding that they don't know when it will come. This is something that decreases with use over time but doesn't go away for a lot of women so it's something to take into account. Emergency contraception has now been over-the-counter for several years. This was not a sure this was a long long fight. 1998 was the first time that a dedicated emergency contraception pill came on the market. This is the type of birth control that can be taken after sex. In 2003 the maker of Plan B which is the most well-known dedicated emergency contraceptive went to FDA and said we want to take our product over the counter. The science was there. All the scientists said. The moment is here let's do it. You know we've looked at

this this isn't going to endanger women increasing access is going to be a help in terms of for example maybe helping to lower rates of teen pregnancy things like that. Everyone thought this was a done deal and then it didn't happen. Then they got an approval letter. It became very clear with a couple more years that politics was trumping science at FDA and people within the Bush administration were bringing pressure to bear in certain ways to prevent this from happening. Susan Wood who is a tremendous women's health activist at FDA for many years. Watch this happen and eventually ended up walking out on her job as a way to underscore the institutional problems that were allowing politics to beat science. Finally in 2006 it was approved but only for women 18 and up. Something that changed with the New York court decision a couple years later. The whole incident though became the latest chapter in what has become an increasingly successful battle to curtail contraceptive access. I think it was also emergency

contraception becomes instructive in other ways. And then I think you see certain conservative groups using the drug to redefine. In fact when a pregnancy occurs you know if the old the old fight over. Reproductive Choice was that you know well is it a life or not this was an effort to say well let's redefine when pregnancy happens most scientific death definitions of pregnancy hold that a pregnancy begins when a fertilized egg implants in the uterus and body makes pregnancy hormones increasingly you stop people using E C which was mentally a great vehicle for this because of course you take it after sex and we live with this idea that you know you live with the consequences of sex you can have unprotected sex and the next day say all right you know what I didn't I don't want to get pregnant let me take something so we have something psychologically that says after sex abortifacient before sex birth control E C is in fact contraception meaning it's something that works before

a pregnancy occurs. It's in fact progestin whereas medication abortion is anti-protest And so in fact they're opposite things in a way. But because of the fact that taken after sex it was a very powerful way to say no this is an abortifacient. And then to tie the notion of an abortifacient to a drug that could prevent the changes the uterine environment in a way that makes it less hospitable to implantation. If we follow that line of logic and we say that anything that works that way is an abortifacient that includes the pill that includes Ru DS that includes breast feeding. This includes a lot of things. So I think this is a really dangerous slippery slope that we see emerging right now in this conversation. So another question that you see brought up for me was the question of if the regular pill should now come over the counter. We've had a few years of experience and it's let us think about the particular safety and health risks obviously taking the pill is more complicated. You do it consistently over eight years. Obviously I'm somebody who believes that

you know the safety concerns of the pill are something we should be honest about. I also believe that it should come over the counter because I think in this case access has become the issue that trumps studies show in fact that women do as well or better than their doctors when given a self screening step to screen with for potential problems and I just think you know again this is a very complicated question but maybe the moment has come. What's what's difficult there are a few different things there is actually just an editorial in The New York Times about this someone arguing that it's time for it to happen. What's difficult is that so many Poles are me too drugs that means they used approval studies from older drugs. So if one of them goes over-the-counter all the drugs that use those studies have to go as well. So this becomes a problem if women want to get the pill covered by their insurance once it's over-the-counter you got to pay for it and that could be really expensive. One option is to bring progesterone only pills over the counter and leave combined pills on prescription. This is this is not simple either because of course

it has a potential to class that just because it's a newer pops or newer We have less safety data and the women who needed to rely on over-the-counter access for example maybe teenagers would be dealing with a drug that we had less safety information about. But I think at the very least the discussion about U.S. opens up these questions and keep your eye on emergency contraception because of course there's a new emergency contraceptive that just got approved. It's going to be even more controversial than Plan B because. In terms of they might change the uterine environment even more then than the traditional drugs we don't know we're still getting some of these answers but it's going to be very controversial. So look out for it. The male pill is always five to 10 years away at any given moment I am used used to going to parties and having people come up to me and say oh isn't this great I heard on the news it's finally happening and I don't want to be the person who sort of says well maybe not. Gregory Pincus when he was making the original pill he dreamed of a male pill as well. And in a day when ethical true ethical standards and trials were lower he tested an early version of his birth

control pill on male mental patients in Massachusetts. So there was always this hope that it could work for men too. Why it hasn't happened is a very complicated question and there are a lot of answers. Some of the problems have been scientific that we don't have the same catalog of steroids. So it's hard to define for example a hormone that would last in the body that could be used in an implant form. So when they test a lot of the hormonal alternatives today you have men going in once a week or twice a week to receive injections which is not obviously sustainable unlike a real world context. Some of the problems are structural The drug companies have not been interested in getting involved for many reasons. Obviously lawsuits are always on the list but also the. Reception that men wouldn't use these drugs that men aren't interested in them and that women wouldn't trust them to use it. I've heard these opinions voiced a lot since I've been on tour with this book but I believe we have to overcome these kind of ideas if we're ever going to get a product made. Obviously when we do it's going to have health and safety problems as well and I don't you know women

live with that and I don't wish it on men but I still think it's something where I would like to see men in one way or another more involved with with this decision making process in this conversation. The problem like I said has been so so without drug company money it's very hard to bring a drug all the way through trials. What's happened is that the World Health Organization has done a lot of the research and big international health organizations have done a lot of the research. This is become both a good thing and a bad thing it's had some real innovation in terms of how you can do perform studies not only all over the world with different labs and it's had some problems for example one method that was tested in China and had a 98 percent efficacy and then was tested on Asian men in Scotland and the efficacy dropped to about 65 percent so there's huge ethnic variation and racial variation with some of these drugs and an international organization doing the testing obviously then faces unique challenges in terms of moving these things along.

So yeah that's the things that are closest to happening are hormonal alternatives non-hormonal things are further away. In the 1980s it hit the news that there was finally it was going to happen and it was a drug called Gossip all that was doing developed in China and it was going to be a non-hormonal male contraceptive option. Gossip all came from the cotton plant. They noticed in certain rural regions of China that in times of famine people would eat a cotton byproduct and that the men would start to be sterile. They were this for then they found that the cotton plant has this nifty self defense mechanism that it causes to Realty in anything that eats it. So for a moment it looked like it was going to happen as it turned out it was not reversible. So it was in fact a type of sterilization not a type of reversible contraception. And the story has replayed itself over the years with a couple of different non-hormonal botanicals. I think with non hormonal male birth control though you see people thinking really so far outside the box and I think there is something valuable about that process anyway sort of thinking where

can we come into the reproductive cycle to stop so for example should we can we create something that causes the tails on the sperm not to work. Or you know in different ways these things are really far away they're science fiction still. But what it shows is the type of creativity that we've become very accustomed to not having. For a lot of different reasons. Finally I wrote a chapter on environmental effects of contraception I thought it was important to do it because it seems like an issue that's really coming up. I want to say from the beginning that when we talk about for example finding ethanol asteroidal in water or in the environment in different ways it is not alone. It is alongside massive amounts of agricultural estrogens industrial estrogens like chemicals that are used to harden and soften plastic phyto estrogens and from beauty products. We're sort of in a chemical soup. The pill is a piece of this puzzle but you can't single women and the pill out so it becomes something where I think on the one hand I just I received an email two weeks ago that the American Life League is mounting a protest about you know arguing

that the pill kills the environment. Once again women are singled out and the pill is singled out and this is just not. This is neither accurate nor address. On the other hand I think we need to be in conversation about these issues and about the role you know that the pill does play in this problem. And what we can do of course again like I said with the trials earlier is we can start to do proactive things that don't involve women giving up the pill for example developing better water filtration things like that. You know thinking creatively also of course condoms which you know until we find another way to prevent sexually transmitted infection. I think you know condoms have increasing only increasing relevance in our lives. And that's the way it should be. But I think I wish that we had better ways to dispose of them that were more environmentally friendly and I think that's a conversation that we can have about better ways to do that. So often I shop now and take some questions but thank you so much. I think I would say a couple of things obviously it's incredibly popular Like I said

male and female sterilisation being at the top of the list for Americans still in terms of their contraceptive options. There is still innovation in terms of creating better procedures I saw heard about one the other day. But yeah it's it's out there. I guess what I would say is that for many years I during the writing of this book I spoke to a lot of couples I spoke to a lot of young men who had chosen to have the Second Muse who didn't want children and who had really struggled to find doctors who would perform them. And obviously I think that's really wrong. I understand why doctors are reluctant to do it but I think again at the end of the day nobody else should be making your contraceptive decisions for you and if that's the right method for you then you know you shouldn't have doctors saying oh come back to me in 30 years you know you don't know what you want. So I mean I think we're on the same page for sure. It seems really strange to me I to be in the position of answering this question because I think I've been I've been sort of criticized for being too critical of the pill throughout the process of bringing this book along. And what I

want to be is honest about it to say I mean I think first of all a lot of people feel it's dangerous. A lot of people think it's like a huge health benefit and a boon. I think the answer is somewhere in the middle. I think some women have really bad experiences with the pill. We know this and like I said my friend was one of them who had a stroke. These things are still out there. But a lot of women do well. I think there will always be health questions with the pill because of the types of research that we can do on it. What we can't do is leg massive long term randomized double blind clinical trial for a lot of obvious reasons you can't control big pill trials. There are people who do little ones and they have all the women use other methods of contraception. But obviously you know you can ask thousands and thousands of women to stay on the birth control pill for 15 years of their life for 20 years of their life in the way that they did with hormone therapy with the Women's Health Initiative. So I think there are some things that are going to stay open questions. I think also there are questions that we're

not asking for example about the benefits of the menstrual cycle and about things that get shut down when you take the pill. I think these are questions worth asking and I try to hit on that in the book and a lot of the stuff you're talking about in terms of female bodies and medicalizing female bodies I touch on in the menstruation chapter in that portion of the book because I absolutely think you're right. And it's something that we can't come to this discussion without acknowledging the history of and thinking of the ways that we still live with those challenges for sure not hormonal birth control that was definitely something I saw that well some women go back to the pill many of you know I mean obviously many do but I also saw higher incidence for example of IUD use things that were somehow a middle ground between sterilization and totally reversible birth control. Yeah although in some context for example like right after childbirth there are certain methods that are better at that time like I think protests and only pills birth control pills have been used although there are some questions about that with safety so yeah Mirena is an IUD so in some ways it

works using the in the ways that are you do which I should say from the beginning we're not entirely sure how they work. It has something to do with causing a low level of inflammation that makes it unlikely that you'll have a pregnancy with Moran that you add to that progestin that's released slowly in the body over time and lessens how much is released over time. But it's something that because of that is maybe closer to something like Norplant or JDL or imply it is more like a contraceptive insert then then even something like Depakote which is a shot that obviously takes time to wear off but it doesn't last for 10 years like Miranda or Miranda shorter for 5 years like Marina. I think I mean I don't know specifically I'm not being from the area but what I'll say is that I feel very strongly about providing contraceptive education to children. Look I think it's been a real a really damaging thing when you look at the United States and you say why are teen pregnancy rate so high part of that is material access is actually having the devices. But part of that also is

educational and it's making sure that people have information so they can make choices. And that's not something that in this country has been an easy thing and will not be. I think most studies show to want to add most studies show that people who are provided with really good comprehensive sexual education are less likely to have problems that doesn't encourage more sexual activity is always sort of the line on it that that's been shown in most of the studies to be inaccurate. So well it's one of those things I think when for example my mentor Barbara seaman was thinking about the advent of this that what a great thing people can make their own decisions they'll put it out there. One of the things she wanted with the original pill was a patient package insert which at that time there was one your doctor would give you a packet of pills and say Take these and that was it that was the end of your question to want like well should I expect you know my skin to get better or my hair to fall out or whatever you didn't ask those kind of questions. So I think that all this will be great. Now now all that information will be there on the television I think we've all seen that it's a

double edged sword on the one hand you have you know things where it's like made cars you know bleeding sterile incontinence you know. But then on the other hand it makes it look really sexy. So it's complicated. I don't think there's an easy answer. I'm not really for banning it but I think I mean for me I don't know when you hear this sort of laundry list of side effects I think for me the bigger problems and this was something I dealt with much more in my first book come in with the relationships between drug companies medical journals and doctors because I think in a lot of cases the big decision making factor for people becomes what does my doctor say or what did you know what did the media what did my local news station say which of course has everything to do with what The Journal said and they take their stories from there so I think that's a piece of it to making sure that doctors aren't salesman for drugs. I think you. Thank you. Thank you.