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Birth control is the control of fertility, or the prevention of pregnancy, through one of several methods. Another common name for birth control is contraception, because that is precisely what the various birth control methods do; they prevent the viable sperm and egg from uniting to form a fertilized embryo. Though discussing birth control is no longer likely to lead to an arrest, as it did in the days of birth control pioneer Margaret Sanger, public debates remain. Some debates address which methods of birth control are the most effective at attaining one’s reproductive goals, while others address whether insurance benefits should include the cost of birth control, the likely long- and short-term effects of their use, how to increase the use of birth control among sexually active young people, and questions over why there are still so many more methods that focus on women’s fertility compared with those that focus on men’s fertility.
Birth Control in Nineteenth-Century America
The nineteenth century witnessed major demographic and cultural changes in the United States, as the nation transformed from an agricultural society into an urban and industrialized society. As the need for many children to help on the farm began to disappear, American women had progressively fewer children. Fertility rates fell from an average of 7.04 children per woman in 1800 to an average of 3.56 per woman in 1900.
At the same time, conceptions about family, the quality of life, and motherhood were also changing. The working class desired fertility regulation out of economic necessity; reducing the number of children was the most obvious way to survive economically. The roles and responsibilities of middle-class women in the household were undergoing a transformation. Upper-class women, meanwhile, were supposed to demonstrate their husbands’ affluence by their visibility in society and charitable acts. Limiting family size gave wealthier women more free time to devote to their new role. By the 1870s, the fledgling feminist movement had given rise to a voluntary motherhood movement. Elizabeth Cady Stanton, who lobbied for women’s suffrage, also lectured women on family planning.
Although no organized birth control movement existed in nineteenth-century America, both men and women clearly practiced contraception and abortion. Midwives had knowledge of herbal abortifacients, and some women had access to recipes in cookbooks and diaries for herbal compounds intended to control fertility. In 1831, two influential books disseminated contraception information to a larger audience: Dr. Charles Knowlton’s The Private Companion of Young Married People contained medical information about birth control and a discussion of the importance of practicing family planning; Robert Dale Owens’s Moral Physiology likewise discussed contraception frankly.
Public discussion of family planning was less and less the social taboo it once had been. By the mid-nineteenth century, information about contraception was widely available in books and pamphlets sold at newsstands, bookstores, or stationers or by mail order. Advertisements for contraceptive services and “disguised” advertisements for abortion services regularly appeared in newspapers.
Several birth control techniques became available. Condoms, which had existed in one form or another since the sixteenth century, were now readily accessible. Although the original inventor of the condom remains unknown, the Italian anatomist Gabriel Fallopius (1523–1562) was the first to popularize it. Fallopius studied venereal diseases and discovered the connection between condom use and disease prevention. Condoms were intended to reduce the likelihood of contracting a venereal disease and were commonly used in prostitution circles.
Early versions of the condom (also called a sheath) were made out of animal intestines or fish bladders and imported from Europe. Consequently, they were expensive and most people did not use them. In the 1850s, vulcanized rubber was created, which substantially reduced the cost of condoms and led to mass production of the prophylactic device. Even though the condom was associated with prostitution, the decline in price made it a popular birth control device among married couples. By the 1860s, latex rubber condoms were sold in barbershops and other places where men congregated.
Other methods not linked to prostitution were also preferred, including douching, using vaginal sponges and cervical caps, and inserting lard or oil into the vagina. In fact, by the 1850s a popular book entitled The People’s Lighthouse of Medicine and Science of Reproduction and Reproductive Control explicitly recommended the use of condoms, douche powders, the rhythm method, and vaginal sponges. Many forms of birth control could be purchased through mail-order houses, wholesale drug supply houses, pharmacies, and dry goods and rubber vendors. Periodic abstinence and the rhythm method were practiced, but neither was very effective as a contraceptive technique. Because most people believed that ovulation occurred during a woman’s menstrual cycle or shortly before it, the rhythm method was highly unreliable.
Men practiced two other forms of contraception—coitus reservatus (withholding ejaculation) and coitus interruptus (withdrawing the penis before ejaculation, also called the “withdrawal technique”). Physicians, who claimed the withdrawal method caused nervousness, a hardening of the woman’s uterus, and impotence, discouraged coitus interruptus, as did many manuals published for married couples. Nevertheless, coitus interruptus remained one of the most frequently practiced birth control methods in nineteenth-century America.
Finally, abortion was used for family planning. At the time, no distinction was made between contraception and abortion—both were widely regarded as forms of birth control. In the nineteenth century there was little regulation of abortion practices. Guidelines were inherited from English common law, which generally held that an abortion prior to quickening (the point in a pregnancy when a woman can feel the fetus move) was at worst a misdemeanor. Prosecuting violations of this law was difficult and generally received little support from authorities. In short, abortion was a prevalent and largely tolerated practice throughout the 1800s.
Prohibition of Birth Control
Despite the visibility and widespread use of contraception, certain segments of the population did not agree with current practices. The “social purity” movement surfaced and gained political support in the late 1800s. Involved in numerous issues (reestablishing traditional morals and values, promoting temperance, advocating Sunday closing laws, and limiting prostitution), the movement also had an active committee dedicated to the suppression of vice. The committee was composed primarily of ministers and physicians who lobbied the government to take a role in restricting personal behavior they considered obscene.
The suppression of vice committee teamed up with physicians interested in restricting abortion services for safety and economic reasons. Together, these reformers supported the federal Act for the Suppression of Trade in and Circulation of Obscene Literature and Articles of Immoral Use, commonly referred to as the Comstock Act (after the bill’s sponsor, Anthony Comstock). The Comstock Act, in 1873, prohibited the trade of obscene literature, which included materials discussing birth control or abortion. The legislation prohibited the possession, sale, or mailing of contraception, marking the first U.S. federal involvement in birth control practices.
After the Comstock Act, several follow-up measures—referred to as the Comstock laws—were passed, and several states enacted even tighter restrictions. Over the next decade, the courts upheld the Comstock Act and even strengthened it by convicting individuals who were indirectly connected to the transmission of birth control information or devices. The dissemination of birth control information and devices would remain illegal for the next hundred years.
Rise of the Birth Control Movement
By the 1900s, the public’s access to birth control information had been severely curtailed. Even the medical community had to remove any reference to birth control from its books to avoid prosecution. Part of the hostility toward birth control stemmed from racist beliefs and ideologies. Throughout this period there were many overtly racist genetic explanations for purported black inferiority as well as many “cultural” explanations. In the early 1900s, the so-called “culture of poverty thesis” came to be embraced by many elites in American society. According to this theory, poverty is passed down from generation to generation. Elitists argued that African-American culture emphasized laziness, ignorance, lack of morality, alcoholism, unemployment, and permissive sexual behavior, all of which was learned and transmitted to succeeding generations. Racist elites were alarmed, therefore, that white middle-class families were having fewer children while fertility rates among African Americans, immigrants, and the poor remained high.
Many prominent figures in society feared a shortage of “valuable” citizens in the future and warned of an impending “race suicide.” People discouraged family planning for white, middle-class families and encouraged them to have large families. President Theodore Roosevelt, among many others, publicly condemned smaller families.
Despite the call for larger families among the middle-class population, little changed. Fertility rates remained low and stable for the middle class and high for the poor. Urbanization and industrialization contributed to new social problems that were particularly acute among the poor. Social observers began to recognize that poor people tended to have larger families even though they did not have the financial capacity to meet their children’s needs. Indeed, the high fertility rate among immigrants and the poor was singled out as a major contributing factor to the miserable living conditions they endured.
Political conditions were beginning to change, however, bringing some relief to the poorer segments of society. Surfacing in the first two decades of the twentieth century, the Progressive Party began lobbying for social and economic changes. Advocates for the poor and uneducated pointed out the disparity between the upper and lower classes with respect to birth control, prenatal care, infant mortality, and maternal mortality. Growing out of Progressive Party concerns, Congress passed the Sheppard-Towner Maternity and Infancy Protection Act in 1921. This act provided for the first federally funded program to administer health care, but it was insufficiently funded and unable to offer women financial aid or medical care. Moreover, it had no provision for family-planning education, which was illegal at the time.
Many reformers denounced the Sheppard-Towner Act because it did little to ease the suffering of the poor. Poor people lacked knowledge of birth control and often relied on ineffective and dangerous techniques. Many women turned to illegal abortions, frequently resulting in medical complications and death. By the 1950s, doctors observed that the only significant cause of maternal mortality resulted from unsafe abortion practices.
Birth control advocates attempted to publicize the need for reform. In 1910, Emma Goldman and Benjamin Reitman distributed a four-page pamphlet entitled Why and How the Poor Should Not Have Many Children. The pamphlet described and recommended the use of condoms, cervical caps, diaphragms, and devices a person could make using common household supplies (suppositories, douches, and cotton balls dipped in Vaseline).
Around this time, the most influential reform advocate started to emerge. Margaret Louise Higgins was born in 1879; her mother (Anne Higgins) had eleven children and Margaret was number six. Anne Higgins died at the age of 50, and Margaret attributed her mother’s early death partly to the excessive childbearing she had endured. Determined to have a different fate, Margaret enlisted the support of her older sisters, who helped her attend college and nursing school. A few months shy of graduation, Margaret met and married the architect William Sanger. The couple had three children and moved to a suburb of New York City, only to move back to Manhattan a few years later.
In 1912, Margaret Sanger began working at Lillian Wald’s Visiting Nurses’ Association in New York, where she was further exposed to the conditions of the poor. Sanger was appalled at the lack of contraception education available to poor women. She believed that poor women could achieve economic, social, and health liberation by reducing family size. Sanger dedicated her life to challenging the Comstock Act and legalizing contraception.
Sanger, who coined the term “birth control,” began to publish a radical feminist journal, The Woman Rebel, in 1914. By disseminating information about birth control, the journal violated the law. Three issues were confiscated and, after publication of the ninth issue, Sanger was arrested for violating the obscenity law. To avoid prosecution, Sanger fled to Europe where she received training on contraception practices and published a pamphlet, Family Limitation, that explicitly described how to use contraception. Sanger asked her family and friends to distribute the pamphlet while she was in Europe.
In 1915, Sanger’s husband, William Sanger was arrested and jailed for thirty days for distributing a copy of Family Limitation. Sanger returned from Europe to face her own trial. When the government dropped the charges, she embarked on a national tour promoting the use of birth control. Sanger was arrested in several cities, which attracted heavy media attention to the cause of birth control reform.
Concluding the tour in 1916, Sanger returned to New York City and opened the first birth control clinic, in Brooklyn. The facility was raided and shut down after nine days of operation; Sanger and her staff were arrested. She was convicted and spent the next 30 days in jail, again attracting media attention. The publicity generated more support for birth control reform, and Sanger began to receive hefty financial donations. She founded the American Birth Control League (ABCL) in 1921 and began publishing its monthly journal, the Birth Control Review (BCR). The ABCL called for changes in the law prohibiting the distribution and use of contraception.
Sanger appealed her conviction in the New York State appellate court. Although the conviction was upheld, the court made an exception for physicians who were disseminating contraception for medical purposes. This created a loophole in the law that allowed Sanger to establish a legal physician-run birth control clinic. The Birth Control Clinical Research Bureau, established in 1923, run by female doctors and social workers, became a model for future birth control clinics. The bureau also became a center for critical research examining the efficacy of various forms of contraception.
Despite the growing success of Sanger’s reform efforts, public and political opposition was still prevalent. Many in society were not ready to embrace her radical ideas, such as supporting individual rights and eliminating governmental influence over women’s private lives. The rhetoric in the BCR put many people off; the publication frequently criticized the government, describing members of the judicial system as lifeless, antiquated relics of the past who were 50 years behind in their beliefs. The majority of society also resisted Sanger’s tactics. She advocated the use of civil disobedience and challenged reformers to break the Comstock laws. In the end, most Americans shied from publicly embracing family planning because it involved sex and sexuality—two topics that were not openly discussed in early twentieth-century American society.
Politically, Sanger ran into several obstacles. Many politicians and political organizations mirrored the public’s unease with the topic of birth control. In 1919 the Supreme Court refused to hear an appeal to Sanger’s 1917 conviction, preventing the Comstock laws from being legally challenged or overturned. A short time later, two major women’s political organizations rejected Sanger’s plea for birth control reform. The League of Women Voters would not include birth control reform on their 1920 agenda, and organizers at the National Woman’s Party convention of 1921 blocked the issue from even being introduced on the convention floor.
Sanger also had difficulty gaining public support from doctors. In 1921 she sponsored the first American Birth Control Conference in New York. Several rooms were rented to run birth control clinics, but the conference ended up being canceled because the doctor hired to run the clinic backed out. Several years later, Sanger still met with the same resistance when she approached both the League of Women Voters and the National Woman’s Party.
Growing frustrated with the slow progress of reform, Sanger turned her efforts to public education and outreach. She believed that the only way to make progress was to gain widespread public support for birth control reform. Sanger began to solicit support from doctors, social workers, and the left-wing faction of the eugenics movement. Although Sanger had always advocated birth control as a way to liberate women from the burden of uncontrolled fertility, her alliance with the eugenics movement steered her to increasingly justify birth control for preventing genetically transmitted physical or mental defects, and she even advocated sterilization for mentally impaired individuals. Sanger’s use of eugenics rhetoric as well as her association with this movement would forever taint her reputation.
Birth Control and Eugenics
The eugenics movement was grounded in racist ideology and supported birth control reform for racially motivated purposes. Borrowing from Charles Darwin’s theory of evolution, eugenicists argued that only the strongest members of society should procreate. They defined the fittest members of society as white and middle or upper middle class. Eugenicists encouraged these segments of the population to have many children to “improve” the nation’s gene pool. At the same time, eugenicists wanted to prevent poor people, who were disproportionately African American and immigrants, from having children. They also openly advocated sterilization of people they believed were unfit for society, such those deemed feebleminded or epileptic.
In 1907, Indiana enacted the first compulsory sterilization law in the country. By 1932, 26 other states had enacted laws that permitted coercive sterilization for individuals the government deemed unfit. Stemming from this movement, between 1929 and 1941 more than 2,000 eugenic sterilizations were performed in the United States each year. More than 70,000 of these were involuntary; the majority of victims were women being punished for out-of-wedlock pregnancy or perceived promiscuity.
American eugenicists also supported sterilization laws overseas. On January 1, 1934, a Nazi sterilization law modeled on legislation implemented in California went into effect. Initially designed to authorize the government to sterilize unfit members of society (those deemed feebleminded), it eventually became associated with the Nazi Holocaust. By 1940, eugenics had been exposed as bad science, motivated by racism. The movement was shamed by its support of the Nazi sterilization laws that were the legal foundation for the murder of millions of Jews.
A Changing Climate
Despite public and political resistance to reform, the birth control movement continued to make progress. The first significant victory came in 1936 with the ruling in U.S. v. One Package. In that decision, the U.S. Court of Appeals determined that medically prescribing contraception to save a person’s life or promote a person’s well-being was not illegal under the Comstock Act. The court argued that if the creators of the Comstock Act had known (60 years earlier) the dangers associated with pregnancy and the benefits of contraception, they would not have considered all forms of birth control obscene. The court effectively allowed physicians to import, sell, and distribute contraception to their married clients. Following this ruling, the American Medical Association Committee on Contraception revoked its 1936 statement condemning birth control and organizations that sponsored it, and tentatively endorsed birth control practices.
By 1937 public opinion had shifted dramatically. National surveys revealed that 71 percent of the adult population supported contraception, and 70 percent believed that legal reform was necessary. By 1938, even though they could not legally advertise their services, 374 birth control clinics were operating in America. Moreover, there was a shortage of available contraception for married women, especially diaphragms and cervical caps. Those women who were able to purchase a diaphragm (through either a physician or pharmacy) often ended up with the wrong size. Diaphragm usage had other problems: the device was only 80 percent effective after a year of use, it required planning, it was difficult to clean in homes without running water, and women who were uncomfortable with their bodies had difficulty inserting it.
Importantly, poor women, who needed birth control the most, continued to have limited access to birth control education and contraceptive devices. Even with its limitations, using a diaphragm was the most effective method available at the time, but it had to be medically prescribed, and poor women were less likely to have a private physician. Responding to this situation, the U.S. surgeon general in 1942 approved federal funding for birth control through the maternal and child health funds. First Lady Eleanor Roosevelt also publicly supported birth control reform and was influential in many of the family planning decisions of the time.
Open political support led to some important changes, particularly for poor women. In 1958, the municipal hospitals in New York City changed their birth control policy, allowing their doctors to prescribe birth control. Significantly, many other municipalities looked to the New York Board of Hospitals to set medical standards and soon adopted similar policies. This change expanded access to contraception for poor women, who were much more likely to seek treatment at a public hospital than from a private physician.
In the 1960s, the government launched its War on Poverty program, which recognized that poor women continued to have unequal access to contraceptive services. Congress mandated federal funding for birth control services for the poor between 1965 and 1970. Finally, the remaining legal barriers to contraception were removed in 1965 and 1972. In Griswold v. Connecticut (1965), the U.S. Supreme Court invalidated Connecticut’s anticontraception statute, ruling that married couples and single people have a constitutional right to privacy and therefore can use birth control without government intervention. Subsequently, ten states liberalized their laws and began funding birth control services. Not until 1972, however, could married or single people in all 50 states legally obtain birth control. In Eisenstadt v. Baird (1972), the Supreme Court overturned a Massachusetts law designed specifically to prohibit single people’s access to birth control information or supplies.
Immediately following the legalization of birth control, the Office of Economic Opportunity (OEO) awarded $8,000 to a project in Corpus Christi, Texas, to provide contraception services. This was the first federal grant directly allocated for family planning services in the United States. In the following two years, the OEO spent approximately $5 million for such services, and over the next few years federal legislation attached family planning provisions to several other programs.
Family planning advocates achieved a major victory in 1970 when Congress passed Title X of the Public Health Service Act, the Family Planning Services and Population Research Act. Title X was created to provide voluntary family planning services to anyone desiring them. Importantly, Title X was specifically intended to aid indigent people. Although other funding exists, Title X would eventually dwarf all other federal funding sources for family planning, providing these services to approximately 6.5 million people by the late 1990s.
The Great Revolution
With legal barriers removed, birth control services could be obtained by anyone regardless of marital status. However, a major problem continued to exist—the lack of efficient, reliable, and affordable birth control techniques. Researchers rapidly began to develop cheaper, more effective forms of contraception. In 1957, Gregory Pincus and John Rock developed the birth control pill at the Worcester Foundation for Experimental Biology. By 1960, the U.S. Food and Drug Administration approved oral steroid pills for contraception. Although illegal at the time of its development, the pill was America’s greatest contribution to birth control choices and currently remains the most significant advancement in contraceptive technologies.
The pill is an oral birth control treatment that prevents pregnancy by controlling ovulation. Since its invention, the pill has undergone some important changes. Initially, it contained an unnecessarily high dosage of steroids. In one of the first pills introduced on the market in 1960, one tablet contained the same amount of progestogen found in an entire month’s supply of pills today, and five times as much estrogen as the pills now on the market.
Over time, researchers have refined the pill’s formula and discovered important effects unrelated to pregnancy prevention, such as a link between pill use and cardiovascular disease. Women who take birth control pills have an increased risk of heart disease, stroke, and venous thrombosis. The risk is drastically higher for women who are over the age of 35, take high-dosage pills (containing 50 mcg of estrogen), and smoke cigarettes. Conversely, the pill has been shown to have a protective effect against ovarian and endometrial cancers. Researchers are also investigating a possible adverse link between pill use and breast cancer, which is currently unclear. Despite the potential side effects, an estimated 26.9 percent of American women rely on the pill for pregnancy prevention. It is the most effective reversible technique available, with a pregnancy prevention rate of 99.9 percent if used consistently and correctly.
American women have other choices for contraception, in addition to the pill; however, their choices (and access to birth control) seriously lag behind those available to women in other industrialized countries. Many of the contraceptive methods available have also developed poor reputations or have significant shortcomings. Consequently, sterilization is the most popular form of birth control in America. As of 1998, approximately 27.7 percent of women in the United States used tubal sterilization for contraception.
The intrauterine device (IUD) was invented in the nineteenth century; however, its popularity in America has fluctuated over the years. The devices became available in the United States in the 1960s but fell into disrepute in the 1970s following the deaths of several women who used the Dalkon Shield IUD. This poorly designed device caused death and serious injury from pelvic infections in many women. More than 4,000 legal cases were filed against the manufacturer. As the IUD became linked with death and injury in America, its use was substantially reduced. Today, only 6 percent of women over the age of 40 use an IUD, compared to 23 percent of French women in the same age category.
Aside from the pill, sterilization, and the IUD, most available forms of contraception (diaphragms, cervical cap, spermicides, and condoms) have been around for many years, several dating back centuries. The sponge, implants, and injectable contraceptives are notable exceptions; however, they are not commonly used. The three devices combined are used by only approximately 5 percent of women in the United States.
Toward the end of the twentieth century, the emergence of HIV/AIDS reestablished the condom’s importance because it reduced disease transmission in addition to its contraceptive function. Recognizing the rapid spread of the disease, the government issued guidelines for developing educational curricula on AIDS transmission and prevention. Currently, the condom (when used consistently, correctly, and particularly in conjunction with a spermicide) is the only contraception device that offers any protection against sexually transmitted diseases.
Challenges in the Twenty-First Century
Since many Americans want only one or two children, a woman spends about three-quarters of her reproductive life avoiding conception. Compared to other industrialized countries, America has higher rates of unintended pregnancy and abortion. Every year in the United States, half of all pregnancies are unintended. The teenage pregnancy rate in the United States is also considerably higher (83.6 pregnancies per 1,000 women aged 15 to 19) than those of France (20.2 per 1,000 women), Sweden (25 per 1,000 women), Canada (45.7 per 1,000 women), and Great Britain (46.7 per 1,000 women). Providing women with adequate choices and funding for birth control services remains a challenge for birth control reformers in the United States.
Since the introduction of the pill, birth control technology has not advanced significantly, and the few advances that have been made are often unavailable for American women. In fact, at the end of the twentieth century, fewer birth control devices were available to American women than in the 1970s. The National Institute of Health spends only about 10 cents per capita annually on contraceptive development and research. Inadequate education on birth control options continues to plague modern American society, and contributes to high failure rates for contraception practices.
Historically, poor people have had the most difficulty obtaining birth control and this pattern is still prevalent today. Publicly funded family planning services serve about 6.5 million women a year, helping them avoid 1.3 million unintended pregnancies a year, but they fall short of offering all women, regardless of financial background, the ability to regulate their fertility. Throughout the 1980s and into the new century, family planning has continued to be tied to prevailing political sentiment.
Clinics have faced increased scrutiny as the debate over abortion has become more salient over the years. Planned Parenthood, founded by Margaret Sanger in 1916, is the largest organization in the world dedicated to providing voluntary family planning services to any person desiring its services. The organization’s philosophy on reproductive rights includes supporting access to contraception and abortion services. Because Planned Parenthood receives federal funding, it has frequently been the target of political and legal battles over its support of legalized abortion. A vocal minority of political leaders and citizens have portrayed birth control clinics as promoters of teenage sexual activity and abortion.
Conflict between abortion supporters and opponents over federal funding for family planning clinics has resulted in real losses for the clinics. Title X of the Public Service Act is the only federal program currently designated for the sole purpose of providing contraceptive services, and in 1999 it received 60 percent less funding than it did 20 years earlier (adjusted for inflation). Since the vast majority of women who receive services at publicly funded clinics are poor, they are disproportionately affected by changes in funding for clinics. The obstacles to family planning remain acute for poor people and a major challenge for the birth control movement in the twenty-first century.
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