This Podcast Will Kill You - Ep 60 Giving birth to "The Pill"

Episode Date: October 13, 2020

Well, TPWKY listeners, it has been a heck of a year, and it’s not even over yet! But one thing has come to an end: our third season. Given the profound implications these next couple of months will have on the future of health and security in the United States, for our season finale we chose to cover a topic that’s near and dear to our hearts and minds: birth control. Have you ever thought to yourself, “I know this IUD/patch/pill prevents pregnancy, but how exactly does it do that?” or “How on earth did someone come up with this pill and then get it legalized?” If so, you’re in luck. In this episode, we walk through the basics of how the most common hormonal contraceptives work and then journey through the history of the various birth control movements in the United States. Finally, we wrap up with some of the latest developments in birth control technology (male hormonal contraceptives, anyone?) as well as the major legal decisions impacting access to birth control.We want to thank all of you fantastic listeners who have been with us through this wild year. You have made it all worth it! And fear not - we’ll be back with season 4 before you know it. Make sure to subscribe so you don’t miss the first episode drop of the next season! See omnystudio.com/listener for privacy information.

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Terms and conditions apply. Visit blueapron.com slash terms for more information. I'm Amanda Knox, and in the new podcast, Doubt, the case of Lucy Letby, we unpack the story of an unimaginable tragedy that gripped the UK in 2023. But what if we didn't get the whole story? Evidence has been made to fit. The moment you look at the whole picture, the case collapsed. What if the truth was disguised by a story we chose to book?

Oh, my God, I think she might be innocent. Listen to Doubt, the case of Lucy Letby, on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. This is Special Agent Regal, Special Agent Bradley Hall. In 2018, the FBI took down a ring of spies working for China's Ministry of State Security, one of the most mysterious intelligence agencies in the world. The Sixth Bureau podcast is a story of the inner workings of the MSS and how one man's ambition and mistakes opened its fault of secrets. Listen to the Sixth Bureau on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. My name is Aaron Welsh, and I am co-host of this podcast Will Kill You.

I have been taking some form of birth control since I was 18 years old, so 15 years now. And I've tried the various ones. I've tried, you know, the combination oral contraceptive. I've done maneuvering and I currently have a hormonal IUD. I started taking birth control because, well, it was a combination of things. One was my periods were so bad that I was like laid out in my house for two days at least every month just in horrible pain, couldn't leave. And also because I didn't want to get pregnant. And the, as soon as I started taking the oral contraceptive, I, it was like night and day. Like my, the pains were so much less. My periods almost disappeared. It was like I was so, so grateful to be able to just like function normally is what it felt like. And I've been really fortunate in that I haven't had very many problems. And all these various forms have continued to do the trick for me. So, you know, I don't want to get pregnant. And the birth control that I have taken has been very effective in that way. And so I'm, I'm really, grateful for, you know, for having access to birth control and continued access to birth control.

And I hope that it stays that way. My name is Aaron Alman Updike and I am the other co-host of this podcast Will Kill You. And I first started birth control when I was 20, which was about 12 years ago. And I started exclusively to try and prevent getting pregnant. It was very effective. I started on like a combination oral pill. I never had any real issues with it. I tried, I think I had to increase my dose like once.

And then I did have one very stressful year where my insurance got wonky and I wasn't able to get access to birth control. And that was very stressful because I very much didn't want to become pregnant. But I was able to get back on until I decided a few years ago to start trying to get pregnant. So I'm really grateful that I was able to make that decision when it was right for me and my partner and our family. And then after I had my baby, I got the copper IUD, which is a non-hormonal option of contraception. And that's been really great for me too. One year in and I'm still not pregnant, so that's nice. Yeah, I also am just really grateful. I had, you know, only one year when I

wanted and needed access to birth control and I didn't have it and that was a really really stressful year. So I can't imagine like never having access to it how different my life could have been. Hi. I'm Aaron Welsh again. I'm Aaron Owen Updike one more time. And this is this podcast will kill you. Those were our birth control stories. It was a strange feeling to be in the firsthand account chair. I don't know if I liked it. Let's not do it again. Deal. Okay.

So welcome everyone to our 60th episode. Our 60th episode, it's unbelievable that we've made it this far, I feel. And sadly, we have to note it is our season finale. So this is the last episode of season three. Not all sad. That's also, it's exciting, too. Like, woohoo! Yeah, yeah, it's exciting.

Like I can't, I look back and I'm like, syphilis was a year ago. How, wow. It just feels like a lifetime. Yeah. Yeah. Hey, that's funny. We started with syphilis and we're ending with birth control. I know.

I like it. So this wasn't the episode that we had planned for our season finale. We had planned a very, very different episode. Yes. But in light of recent events, especially the passing of Justice Ruth Bader Ginsburg, and the impact that that's inevitably going to have on reproductive rights in the United States, we decided to focus this episode on birth control. We decided that we wanted to honor the incredible amount of work that the notorious RBG did during her time on the Supreme Court. And so, yeah, we're really excited for this

episode. I mean, we had been planning on doing something like this in the future. Eventually. Yeah, but now seem like as good a time as any, if not the most important time. But speaking of time, before we jump into the episode, it is, in fact, quarantini time. It is. You are absolutely correct about that. You are exactly right about that. What are we drinking this week? We're drinking notorious. That's right. In honor of notorious.

R.B.G. Erin, what is in Notorious? Well, of course, in order to properly honor RBG, it's a wine cooler. Or wine spritzer? I don't know what you call it. What's the fancy term for it? We aren't using, what is it, Opus 1 or something? Is her particular brand of wine?

We can't afford that. So just use whatever wine you can afford. Yes. And we will post the recipe for Notorious as well. as our non-alcoholic placebo rita. Oh, that's going to be another fun one to make a non-alcoholic wine. We'll post those recipes on our website. This podcast will kill you.com as well as on all of our social media channels, which you can find links to through our website as well. Yep. Well, Erin, do we have more business? Oh, actually, I don't know why I asked you. I have a couple

pieces of business. Oh, okay. This was more of just like a couple of things that a bunch of people had reached out to us about, so the first part is in relation to our herpes episode. And, you know, in the episode, I had asked about stigma against genital herpes in other countries and whether it existed. And multiple people reached out to us from a bunch of different countries and said, no, no one even thinks about it here. Like, it's not a second thought. And that if there is any stigma, it seems to be lifted from American TV shows or movies that, like, either joke about it or make fun of it or call it out or something like that. So, wow.

There you go. Cool. And then, I mean, it is, it is great that there's like no stigma in other countries. So let's just, let's be more like that. And then the other thing is that our last episode was thalidomide. And apparently there's a major storyline or plotline on Call the Midwife about thalidomide. And Aaron, you and I watched like so much of that. but I guess we stopped before. Yeah, we must not have made it that far, but dang, I can't believe we missed that. I know, I know.

So I'm going to have to start watching that again. It's on Netflix. It's a fun show. Okay. Anyway. All right. Well, then, is that all? Shall we dive in?

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and the search for accountability in a sea of lies. Listen to Love Trapped on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts. Aaron, you already said that we're excited to talk about this, but I have to just say, talking about birth control, it's one of the things that makes me most excited. And it's one of the things that I look forward to the most in becoming a doctor is getting to talk about birth control with future patients. Like, I love reproductive health counseling. Okay. I know this about you, Aaron, and I love it about you. I'm so excited. I think my breath is going to be like shaky, so I need to just calm. down. It does like, I think it was us having to do the first-hand accounts, but I feel like this is our

first time podcasting or something. Yeah. It feels that way. I'm nervous. Okay. But before I can start talking about birth control, I want to back up because we have to kind of talk about the menstrual cycle and some general basic anatomy before we can talk about how birth control affects your body. Okay. I love it. Foundations. Foundations. Okay. Okay, I'm going to start off really basic here because a lot of people with a uterus don't really know their own anatomy since it's internal. So in general, in people with a uterus, we have two ovaries and then fallopian tubes, which are what kind of collect the eggs. That's connected to the uterus itself. The inside lining of that uterus is called the endometrium.

And then the bottom of the uterus is called the cervix. I feel like that's an important one. And then you have the vaginal canal and then the outside world. Okay? The outside world. Does that work? All right. So then let's talk about the menstrual cycle because this is the thing that happens about every month or so in most people who have a uterus.

We're going to go over the specific phases and hormones that are involved in a second. But the cycle essentially begins. It ends weirdly with the start of menstruation, so the start of like vaginal bleeding. Isn't that weird that that's where we start it? I mean, it's just arbitrary, right? It's totally arbitrary. That's just where we start it. And then it ends with the kind of resumption of menstruation, like the next cycle,

or with implantation of a blastocyst, which would then be called pregnancy. So, at the beginning, day one of your menstrual cycle, you're bleeding probably. And at this point in time, almost all of the hormone levels in your body are pretty low. And there are a complex series of feedback loops between three organs or parts of organs. The hypothalamus in your brain, the pituitary, which is also in your brain, and then your ovaries themselves. and all three of these release hormones that result in the endometrial lining, so the lining of your uterus, proliferating and expanding, and then follicles in your ovaries maturing and then eventually egg release, right, ovulation.

So if day one is the start of menstruation, that will usually last anywhere from two to seven days, And then the process of follicle maturation. So basically eggs getting ready to be released in your ovary is happening at this time. So your brain is releasing two hormones, F-S-H and L-H, that are causing that follicle to mature. This phase is called the follicular phase. Get it? Okay. Follicle.

Okay. And through this time period, your estrogen levels are slowly rising. So they start off kind of low and then they slowly start to rise. Around day 14, but this can vary from like 12 to 20 days, estrogen levels will surge and that causes another hormone LH to surge. And those two hormones surging is what triggers ovulation. Okay. And then after ovulation, the egg is released from those ovaries.

It has to travel down the fallopian tube. and now you're in the next phase or the ludial phase of your menstrual cycle. And what's happening during this phase is that where the egg was released from in your ovary develops into what's called the corpus luteum, and this secretes yet another hormone progesterone. And so now it's also going to be secreting estrogen, but progesterone is going to rise much more than it has up to this point in the cycle. So now you have steadily high progesterone and estrogen. This is going to prevent any further eggs from maturing. It's going to stabilize the lining of your uterus, that endometrium, so that if that egg is fertilized, it can implant

in the endometrial lining and a pregnancy can take place. If that egg is not fertilized, then after 14 days that corpus luteum degenerates essentially, progesterone. drops and the menstrual cycle starts over, aka you bleed from your vagina. Okay, so can I start with the questions? Yes. Instead of asking how, even though I really want to ask how, like these things work on a molecular and like a larger, I guess, level, can you tell me why we have a menstrual cycle? Oh, Erin.

I'm so glad that you asked that. question. Because some animals don't. Like, rabbits will ovulate only after, like, only after copulation. Erin, not only do some animals don't. The vast majority of other animals do not menstruate. Right. Oh, you just, if you think I'm excited about birth control, you should not have asked me this

question. Let me tell you all about it. So, okay, that process that I said of building up the endometrial lining, okay, that process where it gets thickened, the blood supply increased. is that is called decidualization. Okay, that's what that process is called, building up the thickening of that lining in preparation for implantation of an embryo. In humans and a couple of other primate species, four species of bats, one species of spiny mouse and the elephant shrew, this process happens spontaneously. So the question is not,

why do we menstruate? We menstruate because spontaneously every month our uterus is like, hey, got to build up this real thick lining, got to get things ready before there's an egg that's been released, before there's an embryo that's been created. Like, we do that for no reason, just ready to get it ready. And we don't know exactly why that happens. But that is what then leads to menstruation. Yeah. Isn't that fascinating? We don't know. Well, that's what I mean. Like, why does this, why does this buildup happen? Like, why is it like, oh, let's get ready. Let's expend all of this, like, energy and stuff into creating this lining. And then we shed it. We don't even resort it. Like a lot of other species that have estrus cycles, they'll resorb that lining if implantation doesn't happen. It's a really, really good question. Some of the evolutionary hypotheses have to do with, like, how deeply the placenta invades into our endometrium. So having like an extra thick lining. can help prevent more invasive placentation. Okay. But it's not entirely clear.

We have right now just hypotheses. We don't have solid answers to that question. Okay. But it is all triggered by those specific hormones, right? So it's all hormonally driven. And that whole cycle of menstruation can last anywhere from like 25 to 35 days. And one thing that I think is important about that is that variation in length, occurs in the follicular phase, so that first phase when the follicle is developing, not during

the ludial phase. So the period from ovulation to menstruation is almost always right about 14 days, maybe 12 to 15. It's a much narrower window. Okay. That's how a normal menstrual cycle pretty much functions. I'm not going to touch on all the different ways that that can go wonky. There's a lot. but how do oral contraceptive pills, the pill, interact with this cycle? And how do they prevent pregnancy? Oh, so fun. So the oral contraceptive pill, the pill that most people are familiar with, is a combination pill that includes both estrogen and progesterone.

Okay? And there's a lot of different forms of synthetic progesterone. Ignore them all for now. both of these in combination are then going to be present when you take this pill at higher levels than they would be during a normal follicular phase of your cycle. So what they do is by the constant presence of a higher level of especially progesterone, you inhibit ovulation from ever occurring. Right.

Because ovulation depends on a source. surge of estrogen, so a rapid increase in estrogen, which triggers a rapid increase in LH. By having relatively higher levels of progesterone and estrogen, your body never sees that surge and therefore never ovulates. Isn't that incredible? I mean, I guess, like, simplicity may not be the right word, but, like, simplicity may not be the right word, but like it does seem beautifully like obvious. Yeah.

I mean, relatively. Yeah. Yeah. And I'm simplifying this cycle, but, you know, that's fine. Well, but I know. I just mean like the way, the mechanism of action of the birth control pill. Yes. And it's just like, oh, we are going to just use this trick that already exists.

Like this is just something that the body already does and we're just going to kind of lean into it a bit more. Right. Yeah. And so in these combined oral contraceptive pills, it's really the progestin, the progesterone that's most effective at inhibiting ovulation. The addition of estrogen does help to ensure that ovulation doesn't occur, but it also helps to stabilize that endometrium in a way that can prevent irregular bleeding, so like breakthrough bleeding. And so it helps to regulate menstrual cycles because you can have. have like this constant level of estrogen and then you take it away for a certain number of days and then boom, you're going to shed that lining. And so that's kind of the most in the United States, that's the most commonly used form of contraception is the combined OCP. Now, these pills also do a few other things that become more important in other forms of contraception. The presence of

progesterone helps to thicken the cervical mucus. So remember, the cervix is the bottom portion of the uterus. It's the top of the vaginal canal. So that's the entryway for sperm to get in to the uterus. So by thickening the mucus that's present there, it makes it really, really difficult for sperm to actually get into the uterine cavity. And if sperm can't get in, then fertilization can't take place. Now, if you, Aaron, you said you've used the NUVA ring before. Have you ever used the patch? No, I haven't used the patch. I thought about it for a bit, but no. the NUVA ring and the patch are basically the same as combination oral contraceptives. They're estrogen and progesterone.

So they work the same way. Now, there are a lot of other forms that I'll go through just really quickly because I don't want to like spend thousands of years even though I absolutely could. We should do a mini series. Yeah. So you mentioned Aaron progesterone only pills. And those still exist today. It's often called the mini pill, which I think is silly because I think it's.

the same size pill. I mean, I assume so, yeah. But it's only progesterone instead of progestin and estrogen. Now, a question is, why would you want this as an option? Well, it turns out that even though estrogen is great in a lot of ways and does make cycles more regular in things, estrogen of these two hormones is associated with higher risk of complications, especially a higher risk of blood clots. Now, a caveat is that the increased risk of blood clot by taking oral combined contraception is far less than the increase in risk of blood clot that you get by becoming pregnant. Like, right, way, way less. Okay. Well, so that's why blood clots kind of like came to the mind first when people were looking at

potential side effects because they were like, oh, if this essentially mimics pregnancy in a way, then what are some of the things that we see during pregnancy, do we see that during this pill? Exactly, right. So there is a small increase in risk of blood clots with combination contraception. So the NUVA ring, the patch, and the pill. Again, it's much less than the risk of pregnancy. But for some people, actually myself included, I started having migraines with aura. So I am now and future contraindicated from combination therapy. But there are a lot of other options that don't include estrogen. And they are just as effective. Okay. So the mini pill is just progestin. It usually is lower doses than the amount of progestin in combination pills, which I think is interesting.

So although they do help to inhibit ovulation, they do so a little less consistently than combination pills do. but they do a wonderful job of drastically changing the cervical mucus. Oh, okay. In a hospital environment? Exactly. So that the sperm are really unable to penetrate the cervix and make it into the uterus. Okay. Even if sperm are able to get through this really thick, sticky cervical mucus,

their motility is absolutely ruined. so that even if they make it into the uterus, like they're never going to be able to fertilize an egg, even if you happen to ovulate. That's really cool. Yeah. One downside with progestin-only pills, because we always have to talk about downsides, is that it's a narrow window of effectiveness compared to estrogen-containing pills. Right.

So like the exact hour is really important, okay, that you take the pill. Right. So with a combination pill, like you need to take it every day, but if you don't, take it at the exact same time every day, that's okay. With progestin pills, they really are effective for about 23 hours. So you need to take it at the same time every day. So that can be a lot harder to remember. And are you going to later talk about like what effective means, like proper use and effectiveness and blah, blah, blah, break those things down in all different forms of contraception? Oh yeah, Erin. Absolutely. Okay, perfect. Okay. So there's like,

kind of three other forms of contraception I want to touch on really briefly, and then we'll go through the effectiveness of all these types, okay? Excellent. So the next one is called Deepo Prevara. That's probably a brand name, and I wish I would have said the generic, but whatever. This is a long-acting, injectable form of progestin, progesterone. So it does exactly the same things that the progestin-only pills do. It's better at inhibiting ovulation than progestin only pills. So Deepo shots are really good at blocking ovulation so you're not going to ovulate. They're really great at changing the cervical mucus so that sperm can't get in. And Deepo Prevara also remember that estrogen in the combined pill helps to stabilize the lining of the uterus

so that you don't have breakthrough bleeding and you have like that kind of a thing. With Deepo-Pravera and a lot of the progestin-only contraceptives, it diminishes the proliferation of that uterus so that you're just not building up a lining to begin with. Yeah. The only downside with the Depot prevera is that unlike pretty much every other form of contraception, fertility takes longer to increase back to baseline after you stop using it. And that's because it's so long acting. So it inhibits ovulation for a lot longer than the 12 to 13 weeks in which you should get your shots regularly. Okay. Gotcha. Okay. And then we have my favorite, but these are all great options. And those are the long acting reversible contraceptions, larks. There's two kinds. There's the IUD,

and there's the implant. Okay? Gotcha. You know this already, Aaron. I know this. So the I UD is a little T-shaped plastic device that is inserted through the cervix into the uterus. There are several different brands on the market right now. Erin, we have two different brands in our bodies. We do. Some of them contain progestin. So again, just progesterone, which is going to act to thicken your cervical mucus, inhibit sperm motility, not let them get in.

It's going to thin the lining of the uterus. These ones can also help to suppress ovulation. These ones in the U.S. are approved for either three or five years. So you put it in and then three or five years go by. You don't have to think about your birth control. What? Yeah. It's like a slow cooker.

Set it and forget it. And then there's the implant, which in the U.S. is like the neck splenon. I think it's the only one we have. It's the same exact thing. It's a little piece of plastic. It's just shaped like a rod and it goes right underneath the skin of your arm. It works literally the exact same way. It releases progestin over time.

It does all the same things to your cervix. Mm-hmm. And then finally, there's the copper IUD, which is the only non-hormonal form of birth control that I've talked about thus far. And that is a plastic T-shaped little thing, but it's covered in coils of copper wire. I don't know who thought of this.

It's incredible. But copper ions happen to cause inflammatory changes, in the lining of your uterus, the endometrium, that have spermacidal activity. So it kills the sperm if they make it into the uterus. And if that's not enough, if not all sperm die, these ions also block the activation of enzymes in the heads of sperm that are necessary for fertilization to take place. It blew my mind that just like a little bit of copper can do all that. little bit of copper.

Blue my mind. Yeah, it's really incredible. So because the copper IUD doesn't have these hormonal effects, it's not going to have a big effect on your cervical mucus. It doesn't have an effect on your ovulation cycles. It doesn't have an effect on you building up an endometrial lining because it's not interfering with your hormones whatsoever. So the biggest downside for a lot of people with copper IUDs is that because you have

this kind of constant inflammation in your uterus, it can lead to you. to more bleeding. So if you already have really heavy periods, some people don't like the copper IUD because then they have heavier periods potentially. Right. Okay, I want to sum it up a little bit, and then we'll talk about the effectiveness of all these different ones, okay? Yeah. And actually, I want to post this really great graphic that's from reproductive access.org that has all these different forms of contraception and their effectiveness with typical use. So in summary, we have the pills as well as the NUVA ring and the patch. With perfect use, those options are actually like 98, 99% effective. They're super effective. That's amazing. Well, I mean, perfect use though. Perfect use.

Okay. So with typical use, they're about 90 to 93% effective. So that's still pretty dang good, especially if you compare that to the condom, which with typical use is about 85 to 87. percent effective. Mm-hmm. So you're getting an additional, you know, three to six percentage points of effectiveness, which is pretty great. Important boost, yeah. Yep.

Now, the Depot Pravera, so the shot, is about 96% effective with typical use. Again, we're reaching over 98, 99 with perfect use. So that's if you got it exactly on time every time. The Larks, so IUDs, next plan on. These are over 99% effective. Wow. They are equivalent to a tubal ligation. So having your tubes tied in forms of effectiveness. And they are reversible and don't require surgery. And in the case of the implant, it doesn't even require a pelvic exam. Huh. And another thing that I want to really point out and highlight here is that every one of these birth control options that I mentioned are. contraceptives. So they are preventing pregnancy from ever happening. These do not serve as abortive fashions, which means they do not prevent implantation. You can still get pregnant even with an IUD in place. Okay? Right. And there is a lot of misinformation out there right now,

especially about IUDs saying that they kill embryos, which is not true. No. So an abortifacient is something that we can use to induce an abortion, so terminate a pregnancy after the point of implantation. Right. Implantation in the wall of the uterus is the scientific and the legal definition of the start of pregnancy. Right.

So the egg has been released and fertilized. implants. In implants. Exactly. IUDs do not block implantation, period. Which is why you can still, in theory, though it's very rare, get pregnant while using an IUD, while having an IUD in place. All of the IUDs block fertilization from taking place. Right. And so it's, you're right, just preventing the sperm from ever meeting. Exactly. That's what all of these contraceptive options are. doing. Whether they do that by preventing ovulation, so there's no egg there, whether they do that by

by changing the cervical mucus in a way that makes it impossible for sperm to penetrate the uterus, or whether they do it by changing the environment of the uterus such that the sperm can then, they basically either die or are so adversely affected that they're unable to fertilize the egg. Okay, gotcha. Okay. I think, yeah, I think that's a really important point to make. It is. And clarify. It is. And that is also true for the last form of contraception I haven't touched on, and that is emergency contraception. So this is essentially just a pill that is a high dose of progesterone. It's 58 to 94% effective. That's a huge range. And the reason is because it functions to block ovulation.

So if you have already ovulated by the time you take that contraception, it's not going to be effective. It has no effect on fertilization and no effect on implantation, which is so important because there was so much misinformation about this out there. And that's why the emergency contraceptive pills, that by the way, legally should be available over the counter to anyone over, I think age 3,000. 13 in the United States without a prescription, male or female, by the way. They are most effective if they're taken as soon after an unprotected sexual encounter as possible, right? Right. Rather than like having to get signed parental permission or prescription from the doctor or whatever else. Yeah, exactly. Yeah. So that's it, Aaron. That is contraception and how it works. Does that answer your questions? Do you have more?

I mean, yeah, I probably have more in there, but I'm just processing now. Do you want to hear about the history of birth control? Yes, I do. How did we come up with it? How long have we even had access to it? I don't know the answer to that question. Okay. Let's take a quick break first.

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It'll cause so much harm at every single level of the British establishment of this is wrong. Listen to Doubt, the case of Lucy Lettby. Let me be on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. The history of birth control or reproductive control is massive, as you might expect, like absolutely massive and enormously complicated. And the motivation behind the fight for reproductive rights hasn't always been the same, and nor have its opponents always had their same justifications. So what I want to do, my goal for this section,

is to try to understand how we got to where we are today by examining some of the past struggles for reproductive rights, particularly in terms of birth control, and then focusing more narrowly on the development of the hormonal birth control pill. Awesome. And a quick caveat, before I begin, there are a million different ways to tell this story, but no one wants to sit here for a million years. And so I'm going to focus primarily on the U.S. for birth control history. And I would love to talk about the global history of each and every contraceptive, but nobody wants an episode that long.

Nobody. Okay. So I think there's this common misconception that birth control methods emerged out of the 20th century as a result of an increase in scientific technology and a loosening of the puritanical morals that had shaped many of our earlier policies and laws. But not so. Really? Not so. Not so. In fact, up until the 1950s, the most common methods of birth control had been with us for hundreds, if not thousands of years. Is it like pulling out? Well, okay, that is one of them. But there are other ones too, vaginal sponges, condoms, withdrawal methods, diaphragms, even like early forms of IUDs had all been in use, like, since the ancient world.

Oh, also fertility tracking is another effective method. Exactly. Although it took a really long time for that to like emerge in medicine because doctors never wanted to study women's periods because they were yucky. They're so yucky. Bloody you. There's a famous quote by Heinlein, Robert Heinlein, which is that every generation thinks it invented sex. Each generation is totally mistaken. And I think the same could be said for birth control. And I think the other thing that's really important is that the sheer virul. variety of all these different methods and the ingenuity, the creativity that went into making them shows just how important birth control has always been to humans.

Yeah. Birth control was not invented by the scientists and doctors of the 20th century. It was tested and practiced by women who passed their knowledge of folk medicine from generation to generation. Early in human history, when humans lived primarily in small nomadic groups, family size was really important because it was much easier to feed and pack up and move a small family compared to a large one. And so it's not surprising that these groups regularly practiced various forms of contraception and abortion. And then with the agricultural revolution, one of our favorite themes

to discuss on the podcast, larger family sizes were not only more possible to support, but they were even economically advantageous because more people then could work the land. Yeah. And then combined with the high infant mortality due to the increase in infectious diseases that the agricultural revolution brought on, this led to many of these agricultural societies producing ideologies that banned birth control entirely. Wow. Isn't that interesting? I never really thought about it that way. Absolutely fascinating. Yeah.

And horrifying. And horrifying. In the last 500 years or so, the growth of cities and industrialization meant that in many places, large families no longer held the same economic advantage as they had in early farming societies. Children started to cost more than they contributed, which I know is like a horrible, like it sounds like a very horrible way to look at it, but this is just sort of like sociologically sort of the trend in what happened. Also, they're very expensive. Children are expensive. They're very expensive. And this shift, this, you know, the increase in cost of children is reflected in a slow decline of the.

birth rate, particularly in urbanized areas. But this drop in the birth rate did not correspond to a loosening of those ideological standards. If anything, things became even stricter during the Victorian era, which sharply defined how proper women should behave. Then there were moralistic policies, such as the Comstock law enacted in 1873, which forbade sending obscene matter through U.S. male, including but not limited to birth control devices or even information about birth control. What? Side note. And I know that like this episode is long and I should probably just cut this, but I really wanted to tell you that the namesake of the law, Anthony Comstock, as a teenager,

masturbated so obsessively that he thought he might be driven to suicide by it. And he blamed it on the magazines and postcards, the sexy magazines and postcards. And so he made it his life's mission to prevent their. distribution. Oh my God. Just because he couldn't stop masturbating? Yeah. Well, and was probably told that it was wrong to masturbate. Yes. Right. And like, it's immoral and blah, blah, blah. Right. That is so, ugh, awful. I know. But these types of policies like the Comstock law, they weren't just a relic of the times. They were a response to a growing rebellion against this type of thought. And they were fighting a losing battle.

So the roots of the modern birth control movement really began in voluntary motherhood, which is a concept and movement that originated out of the woman's suffrage movement of the late 19th century. And at its outset, it opposed all methods of birth control devices. Behavior and restraint were the only approved proper methods. But this movement also dared to suggest that women could be sexual subjects rather than objects, that women were capable of sexual desire for pleasure itself, not just to become pregnant. At the heart of it, the voluntary motherhood movement was about a woman's right to say no, to refuse her husband, her wifely duty.

And this movement, I know, I know. And this movement was preceded by an already existing drop in birth rates in the U.S. So in the late 1700s, American women had on average eight live births, 100, yeah. Oh, I'm sorry, my face just like, oh, no. It's a lot, that's a lot of pregnancies to go through. I'm squeezing my vagina. 100 years later, that number was three.

It was down to three. Wow. So what can explain this? It's not restraint. The answer is birth control. It's contraception, it's abortion. And sure, some methods or devices were improved during that time, but it was not really about a lack of technology, but rather a suppression of that technology. Nevertheless, people found a way around that.

For instance, euphemistic advertisements that warned Portuguese female pills not to be used during pregnancy, for they will cause miscarriage. Or stimulates menstruation when late or irregular. Those were hidden messages to those in the know. Yep. Okay, so rolling into the 1900s, morality ruled over medicine, at least in the U.S. Physicians saw themselves as guardians over the sexual purity of their patients. Gross. Absolutely disgusting.

I am infuriated. Mm-hmm. I mean, yep. That sentence, Erin, is one of the most gross. Is it worse than the female organism? I don't know if it's worse than the female organism. but it's up there. It might be worse.

Oh, my gosh. Okay. Well, and this inflated self-importance of theirs led them to make decisions for their patients not just based on medical reasoning, but also morals. A break from the dominant stance on birth control is bad came in 1912 from the President of the American Medical Association, Abraham Jacobi. He advocated for a campaign for industrial health. access to birth control, and requiring STI testing before marriage, which is problematic.

Very. There had been growing support for birth control throughout the U.S., including from the medical community, but the fact that the president of this moral, respected institution was calling for the separation of sex from reproduction, was both sort of this culmination of decades of debate, as well as a revitalization of the birth control movement, or what would become the birth control movement. Okay. People were also simply talking about sex more. Freud's concept that sex was good and repression was bad had reached the U.S.

and had led people to question their assumptions about sex. And a new set of beliefs, unfortunately housed in the objective terminology of biology, began to take hold. Uh-oh. Eugenics. Oh, yeah. Yeah. Yeah. Real quick, just in case people haven't heard of eugenics or have heard of it, but don't

know what it is. It has really old roots, but the modern eugenics movement began around the late 1800s and was a set of beliefs or policies which stated that people can be classified as having either superior or inferior genetics, like just incredibly subjectively, and that those deemed inferior should not be allowed to reproduce. Right. If it sounds like Nazi talk, it's because it is. It is. Nazis got many of their ideas from U.S. eugenics policy. Cool. Eugenics became popular when it did because with the incredible advancements in medical science and technology, people were living much longer. And the global population had greatly expanded.

And so this led to a lot of fears and talk of overpopulation and discussion about what to do with it. Okay. Back to birth control. Eugenics had a complicated relationship with birth control. It was pro in some cases and anti and others. Essentially, who should be able to use birth control was a concern of the whole society and not for an individual to decide. Oh, dear God. Uh-huh. So Teddy Roosevelt was a huge eugenicist and very anti-birth control.

Great. He said that smaller families were a sign of moral disease and that women who avoided having children were criminal against the race, the object of contemptuous abhorrence. by healthy people. I have, Aaron, I have so many feelings right now. I honestly can't deal with them. I know. Just sit back, let it wash all over you, and then take a nap. Oh, God.

Well, it's going to get worse. I know. It always does with you. It always does. Race suicide, quote unquote, became a, a talking point and a passion of his for the next five or so years. Which race was the one committing suicide wasn't specified, but it's pretty implied that Roosevelt and others wanted wealthy, educated white people to have more children and poorer people,

especially people of color, to have fewer. This is eugenics. Falling birth rates, particularly among the wealthier and more educated, was attributable to birth control because the most effective methods were the most expensive and required seeing a doctor. And so women using birth control were specifically condemned as selfish or displaying unladylike ambition, denying their true purpose in life, which was motherhood. I know, rage noises. But this didn't result in the proponents of the birth control movement championing it as an inherent right of women to have agencies over their own bodies, nor were they shamed into giving

it up. Rather, this resulted in an unfortunate alliance between the birth control movement and the eugenics movement. Oh, no. Yeah. Oh, yes. God. The answer to quote race suicide, they said, was greater access to birth control by the poorer classes. This provided a more palatable reason for people, particularly people in power, to support birth control, rather than, hey, women like sex too and may not want to be continuously pregnant, but honestly, it's none of your business, so I'm going to do what I want to do. That was not the reason.

That was not what they wanted to hear. Right. They wanted to hear, here's a solution to the problem that you see. And it's important to note that the eugenics movement in the early 1900s in the U.S. was not some fringe group.

It was also global. Like, a lot of countries had eugenics movements. Oh, yeah. It was huge, and it greatly impacted policy. For instance, by 1915, 13 states had compulsory sterilization laws. By 1932, 27 states had them. I mean, Erin, this just sounds like you're talking about 2020, quite honestly. Like, it doesn't sound any different, and I'm getting really...

Oh, absolutely. I mean, like, forced or coer sterilizations have been happening for as long as the first person was able to figure out how to remove... sterilize. Yeah, to figure out how to sterilize. And these policies were by no means limited to the U.S. There were plenty of international organizations seeking to reduce birth rates in other countries, particularly developing ones. During this time, the rise of eugenics, the birth control movement gained an outspoken leader. Enter Margaret Sanger. Growing up, Sanger had been taught to speak her mind, and when she moved to New York City after finishing nursing school, she met people whose radical ideas, at least radical during the time, would completely change her life. In particular, the socialist

leader Eugene Debs and the famous feminist Emma Goldman, who became her mentor and from whom she would learn so much more about the voluntary motherhood movement. As a nurse in New York City, Sanger spent much of her time serving poverty-stricken regions where there was a lot of overcrowding, there were high rates of infectious disease, and like, no one was getting adequate nutrition. And one experience in particular made a huge impact on Sanger. There was a woman named Sadi, who had been told by her doctor that she shouldn't get pregnant again because she would likely die. And so as a solution, her doctor recommended that she sleep on the roof so her husband wouldn't bother her. Sadie got pregnant because who's going to sleep on a roof for your whole life?

and then died after an abortion attempt. Jesus. This death was a pivotal moment for Sanger. She vowed that she would do whatever she could to ensure that women had the right to contraception. The next year, in 1913, she began writing a series of educational articles about sex and reproduction titled What Every Girl Should Know.

Of course, the Comstock Act prevented the distribution of many of these articles and Sanger was arrested for her involvement. But instead of showing up to court, she skipped town, went to Europe for a couple years, where her radical education continued. And her time there also led to her narrowing her focus on contraceptives rather than women's liberation overall, which is sort of at the beginning she was much more about equality in the workplace and equal rights. And then she was persuaded to just focus on contraception. In the books I read for this, Sanger is described as being kind of in the right place at the right time. She was a huge fighter. She was very outspoken, but this fight, the fight for access to contraceptives,

seemed to be simply waiting for a leader to head the charge. Sanger coined the term birth control in 1915, and in 1916, she opened the first birth control clinic in Brooklyn. Wow. there, she and her sister and a team of nurses handed out condoms and what were essentially early diaphragms. And the clinic was under constant threat of closure because it was illegal and it did get closed a few times, but Sanger wasn't discouraged easily. And for a few years, she continued the operation of her birth control clinics and the grassroots movement to increase awareness of birth control. But beginning in the 1920s, she began to form some powerful allies with physicians, politicians, and eugenicists.

Oh, gosh. Sanger is painted alternatively as being a eugenicist herself or just someone who saw the value in this powerful alliance. Based on her own writings, I'm inclined to believe the former. She had written that certain people should be sterilized and that criminals, illiterate, sex workers, and drug addicts should be separated from the rest of society. Oh, dear.

Mm-hmm. Throughout the 1920s and 30s, the birth control movement gained a lot of momentum. More clinics were opened and more people got behind the idea that perhaps women should have some control over their family size. The Great Depression also played a role in this. Women were increasingly seeking out employment to help support their family, and for many of them, this meant moving out of the home and into big cities, becoming financially independent. The idea of, hey, maybe I don't want kids right. now and that's okay was becoming more and more common. And during this time, eugenics fell out of favor in the U.S. as it rose to prominence in Nazi Germany. It was replaced or maybe just repackaged

as population control with both international and national programs offering incentives for those willing to have an IUD put in or to be sterilized and finder's fees for those who could find someone willing to have either procedure done. But generally speaking, at least privately, people were finding that they didn't need as much of a justification for birth control for themselves. World War II and then the threat of nuclear holocaust during the Cold War lent a sort of, you know, get it while a getting's good vibe to the times. And Alfred Kinsey's titillating research began making headlines and got people talking even more about sex, even though his findings were super flawed and biased, but they were a crucial step forward in chipping away some of the

shame associated with sex in the U.S. And during these decades, Sanger was still hard at work on her goal of making birth control accessible to women. The first clinic from 1916 had grown into many more across the country, organized first as the American Birth Control League, which later became the Birth Control Federation of America, which then changed its name to the Planned Parenthood Federation of America and in 1942. Huh.

There you go. Wow. Though Planned Parenthood began as a place where contraceptives or info about contraceptives could be obtained, it gradually turned into a medical facility that provided much, much more. Counseling, family planning, medical procedures, etc. And by making contraception more accessible, it basically paved the way for the feminist movement of the 1960s, which is kind of, I also think it's ironic because at the beginning they would only provide contraceptives to married women.

Married. Mm-hmm. Yeah. But this brings me to one of the biggest developments in birth control history and the main focus of this episode, the birth control pill. The pill. Erin, you talked a bit about different classifications of birth control based on how they work. But there's another way that you could group them.

Which person in a sexual relationship was responsible for its use? Oh, yeah. And whether using it is obvious to the other person or if its use could be concealed if necessary. Oh, my gosh. Yeah. Huh? Mm-hmm. A magic bullet contraceptive had been dreamt about by Margaret Sanger for decades, something 100% effective with minimal side effects that could be easily obtainable, affordable, and allowed a woman to be completely in control of her body. She had also listed the help of a philanthropist and feminist named Catherine McCormick, who graduated from MIT in 1904 with a biology degree, the second woman ever, I think, to graduate from MIT.

And McCormick would essentially fund the entire creation of the pill. Wow. Basically all from her. Wow. Sanger had approached researchers to try to realize her dream, but she was repeatedly turned down because it was disreputable work. disreputable. That is, until she met Gregory Pinkus in winter 1950. Pinkus was a bit of, I don't know if iconoclast is the right word.

He was a brilliant scientist with a bad reputation. His work on in vitro fertilization in rabbits had led to him being compared to Victor Frankenstein. And basically any reputable research institution refused to hire him. So he started his own research. Center. Like you do. The Worcester Foundation for Experimental Biology. After his meeting with Sanger, he realized that creating a birth control pill could not only get him the scientific respect he felt he deserved, but it would also earn him fame for tackling what he felt was a pressing global issue overpopulation. He readily agreed to look into the possibility of a birth control

pill, and he even knew where to start. Back in 1937, a few researchers from the University of Pennsylvania had published a paper titled The Effect of Progesterine and Progesterone on ovulation in the Rabbit, which described how progesterone injections could prevent ovulation. Pinkus and another researcher at the lab named M.C. Chang set out by first repeating the experiment described in the paper. Things went as expected, so then they started to play around a bit. What if a progesterone pellet was lodged under the skin of the rabbit? And does this also work in rats who ovulate spontaneously, like humans, as opposed to rabbits who ovulate after copulation.

Yes, it does indeed. All told, things were looking very promising for Pinkus and Chang. The next step was simply to test out the procedure on humans. So Pinkus teamed up with a doctor who specialized in infertility named John Rock. Together, they sought out dozens of women seeking help for difficulty in conceiving. They didn't tell them about the study that they were to be a part of, which was not required by U.S. law at the time. nor did they ask for any kind of consent, nor did they pay the women.

Oh, my God. They just told them to take pills, take their temperature daily, collect their urine, and take some vaginal smears. So they took women who were actively wanting to become pregnant and having difficulty, and they made it to make sure that they were not going to become pregnant. So it was, they were told that the pills that they were taking would prevent them from becoming pregnant, but what it might do afterwards was regulate their ovulation such that they're likelihood of getting pregnant is increased following the end of the study. Some tiny relief.

Yeah, yeah. Oh, well, okay. Scratch that relief because they also went to asylums to bump up their studies. Cool, cool, yep, yep, yep, yep, sounds about right. Mm-hmm, mm-hmm, like lots of them. And it was just not, no one was informed outside of like the head of the asylum. Of course. Cool.

Yeah. Cool. Cool. And so Pinkus loaded up these women with extremely. high doses of progesterone. So I don't think you mentioned that like what a pill is consistent. But this is between 250 and 300 milligrams daily. That's, and that's a lot. What is, what's like a pill today? They vary a lot depending on the synthetic progesterone used, but it's like, I don't know, one maybe, two depending on the, on the type. Yep. Yeah. Yeah. Yeah. Um, yeah.

Of the 60 women who were enrolled in the study without their knowledge, about half dropped out due to the demanding requirements or because the side effects were just too much. Yeah. The results of the study were mixed, so four women became pregnant after it was over, suggesting that it might help people who have difficulty in conceiving. But about 15% of the participants continued to ovulate during the study, which was too high to be an effective method of contraception in Pinkus's eyes. More research needed to be done to bring down that number to make it more effective, but where were they going to get the sample sizes that they needed to do these studies? Oh, some more terrible, Aaron. For Pinkas, the answer was Puerto Rico.

So Puerto Rico had already been subjected to extensive medicalized torture from the U.S. in the post-World War II years. Thousands upon thousands upon thousands of sterilizations were performed, both with and without consent. It was, in fact, like, one of the most common procedures after a delivery was sterilization. Probably without ever consent. Yeah. So it was, like, the most common form of birth control, essentially. Of, like, yeah. Oh, well, you had a baby.

You're done. Clip, clip. Yeah. I mean, and these were, like, these were policies implemented by the U.S. And there was, like, it was an active program to try to. Oh, yeah. Yeah. But it wasn't just an annoying amount of urine collecting that the women would have to face in their

preliminary study, only five of the 70 women involved reported no side effects. The rest experienced things ranging from breast soreness, change in pigment or size of nipples, nausea, vomiting, vaginal discharge, increased or decreased libidos, lactation, etc. These are all pregnancy complications. Shocker. No one involved in the research seemed to really care about these side effects. So he proceeded with the studies, also beginning to experiment with synthetic progestins, which were more powerful than natural progesterone and worked better than progesterone when taken orally. But despite the initial promising results of the pill, Pancis was still facing difficulties in retaining people in the study. So he decided to change things up a bit. Maybe instead of just like keeping people

in the dark and not telling them anything about what they are involved with, what if we actually recruit women who want to try out a contraceptive pill. What a concept. What if we try informed consent? Is that the conclusion he came to? Yeah. And it turned out that that was like a way to get people involved. People were like, oh yeah, actually I am interested in this and not having to be sterilized after I give birth. Jesus. But still, the participants experienced unpleasant or severe side effects, which caused many to drop out. And even though Pinkus was convinced that the side effects were mostly in the women's heads. They were severe enough to be costing him a good sample size.

So he started to play around with combinations. So first he added an antacid or changed the dose, but it didn't really make a difference. And then he and Chang made a discovery. The progestin that the company, the pharmaceutical company, Cyril, had provided, was actually contaminated by a small amount of estrogen. And it had just slipped under the cracks. So that must be causing the side of it. effects, right? So then when he gave women the pure progestin, nausea and breakthrough bleeding became

even worse. Okay, so let's add a little bit of that estrogen back in. Too much, and there'd be breast tenderness and nausea, too little, and you're back to breakthrough bleeding. Eventually, he found a sweet spot. They were back on track to getting this pill to market. Cyril, the company that had produced the synthetic progestin, applied for FDA approval to market this birth control pill that they were calling enavid, but not for contraception, for infertility and menstrual irregularities. Interesting. Mm-hmm. And in July 1957, the first packs of enavid or anovid, I'm not really sure, were prescribed

to women for those purposes, but also for whatever the doctor wanted to give them for. Yeah, I mean, that's how it. Label use. Yeah. That's how it works. And so that included contraception. Mm-hmm. In 1958, there were still 17 states in the U.S. that had laws banning the sale distribution or advertisement of any kind of contraception.

In Massachusetts, where the pill was developed, it was a felony to sell or prescribe or hand out or provide information about contraceptives. What? Uh-huh. Oh, my gracious. But things were changing. And part of that change was not just the early signs of the sexual revolution, which I talked a little bit about in the herpes episode. it was politicians realizing that their voters wanted access to birth control. It was also corporations like Cyril realizing how much profit they could make through the legal sale of contraceptives.

It was an untapped market. And socially, what had in previous decades been a moral majority had decreased to a small but vocal minority, largely made up of the Catholic Church. When articles published in popular magazines such as time or life highlighted the drug, there wasn't the roaring backlash that they had expected to accompany this news. They merely presented this drug as almost a welcome innovation. Of course, these articles barely mentioned the side effects or long-term safety, but following their publication, there was a rush for the pill. So by 1959, which is when Enovid or Enovid is on the market only as a treatment for infertility or irregular periods,

an estimated 500,000 women were taking the drug. Wow. So word had gotten out. Yeah. Though there may not have been a lot of outcry directly on the pill's release, there was still plenty of debate about contraception in politics. Some advocated for funds to be used in international aid programs to supply contraception, which, of course, smacks of eugenics, particularly because in one proposal, for instance,

the reasoning was that otherwise we face, quote, communist political and economic domination. Oh, my God. But gross. Meanwhile, the pill was up for approval at the FDA, not for its sale, which it already had, but to be able to advertise for it as a contraceptive pill, as a birth control pill. This was a totally different process and a very new one, because rather than the pill being used to treat a condition, it was being taken by healthy people. And so its safety standards were totally different. The FDA agent handling their application took his time with it, a la Francis Kelsey. he wanted to know whether there was an elevated risk of cancer or blood clots associated with long-term use.

And so he decided to send out a questionnaire to 61 doctors that had experienced prescribing the drug. Ultimately, even though some doctors said, I don't think it's ready, I think there are too many side effects. The decision that most doctors came to was that the pill had far fewer side effects and was much safer than an unwanted pregnancy. Than any pregnancy. Than any pregnancy. actually an unwanted pregnancy. Right. Or an unplanned pregnancy.

And also, the FDA was not there to decide whether a drug should be approved or rejected based on moral, religious, or political grounds. Their job was simply to decide whether it did what it was supposed to do and whether it was safe while it was doing it. And so, for this, Anavid was approved as the first oral contraceptive on May 9, 1960. Wow. its use grew steadily, and within a few years, it was not known as Enavid, but just the pill, which with that simple name, highlighting just how incredibly important it had become. Yeah.

Like, the pill. The pill. I mean, everyone knows when you say the pill. Yeah. Yeah. By 1965, so five years after its release as a contraceptive, an estimated 6.5 million American women were using it. And lower dose pills became available and more affordable. The pill didn't start a movement, but it surely played a role.

Women were able to have greater agency over their own bodies than they ever had before. They were free to pursue a greater variety of career opportunities, and they were also free to not do those things. The pill simply gave them the choice. In 1970, women made up 10% of first-year law students and 4% of first-year business students. In 1980, those numbers jumped up to 36% and 28%. Wow. In large part, a lot of people reason is because of the pill. Yeah.

And also overall, like, the second wave feminist movement. But okay, a quick note about the timing of our episodes, I just wanted to say, in 1959, to the same year that the birth control pill was up for approval to be advertised as a contraception, philidamide was also up for approval. and it made me think about whether the birth control pill would have been approved so quickly if it had happened a year after thalidomide, for instance. Very interesting. Yeah. Also, a listener commented on one of our Instagram posts that she's doing a thesis in which she talks about how apparently in the Soviet Union during this time they tried to recreate the birth control pill there, but they didn't put enough resources into its development. And so there were some horrible side effects associated with it. And a lot of women confused that birth control pill with thalidomide.

And so they assumed that they were the same. And so the use of hormonal birth control pill really dropped. And abortion became the main form of birth control. Oh, wow. So she's still writing the thesis, but she said she's going to send it to us when she's done. Oh, my gosh. I'll be so interested to read that. I know.

Okay. So despite wrapping up here, despite the open arms with which many people welcome the birth control pill, It did not stop being controversial. Long-term health risks such as blood clots, heart attacks, strokes, and cancer were found to be associated with the high doses of estrogen in early versions of the pill. And people advocated for safer doses and pointed out that these side effects would never have been deemed acceptable in a version of male birth control. Oh, we can talk more about that if you want later. Oh, good. Oh, good. And then there was the enormously racist practices that emerged from the development of family planning clinics in predominantly black.

neighborhoods. For instance, incentivizing these long-acting reversible contraceptive implants or shots or the IUDs. So a lot of those were preferentially given to black women than they were to white women. Later analysis showed that there was disproportionate prescription of those forms of birth control pill between black people and white people or people of color and white people. you know like that's and that's not even to mention the forced sterilization of thousands upon thousands of black and Native American women. Yes. And then there's some more bad news. So like the Dalcon Shield IUD scandal in which many women were hospitalized or died due to infections related to that IUD. And it was pulled from the market, the Dalcon Shield was pulled from the market much, much like way too long after it should have been. And this led to enormous decline in other IUDs as well out of fear of lawsuits and out of fear of the women who were like, well, if I put this in here, am I going to like, is this going to hurt me? But throughout the 1970s, there were some positive developments. In 1972, the Supreme Court legalizes birth control for unmarried people. Loretta Lins, I know, Loretta Lins song, The Pill,

is released in 1975. And sterilization procedures become strict. requiring informed consent and awaiting period. Oh, do they? Except in 2020 if you're in Georgia at a nice detention facility? At least, okay. Nowadays, it's illegal. Then it wouldn't have been. Right. Yeah. Which is so depressing.

I mean, it's depressing. It's layers of depressing upon depressing upon rage and nihilism. Since the release of the first birth control pill, there has been overall incredible progress made both in terms of technology like better IUDs and emergency contraceptives, as well as in social perspectives on the right to access contraceptives. The birth control movement became more about the individual rights of a woman to have agency over her body rather than a tool for eugenics or population control. That's not to say that those perspectives are gone, nor should the origin story of the birth control movement be forgotten. But even more important to remember or pay attention

to is the justifications that people use to restrict access to birth control. Yes. Only when birth control became a representation of women's liberation and a woman's right to decide for herself what to do with her life and was no longer a justification for racist population control programs, did the outcry against it begin to grow. I think there's a very unusual timing there. Birth control doesn't go against nature. We have been practicing it for thousands upon thousands of years. Hormonal birth control pills mimic what our bodies do during pregnancy. Why not a

similar outcry against condoms? If there was a male birth control pill, would there be as much debate over whether it was natural or moral? I highly doubt it. Restriction of reproductive rights isn't about what's natural or healthy. It's about control. It's about putting people in boxes narrowly defined by those in charge. This pushback against reproductive rights has picked up a terrifying amount of momentum in these past few years. Erin, why don't you bring us up to speed on birth control today? Okay. I think I'm going to need a quick break first.

Same, same. Touch briefly on male contraception, if you like, just to kind of get started. Yeah, I'm very curious about this. Yeah, there are currently two forms of contraception available that target males, and that is the condom. and a vasectomy. That's it. Cool.

Condoms, I mentioned briefly earlier. They're about 87% effective with typical use. The biggest benefit of condoms is that they protect against other STIs as well, which the vast majority of other contraception options don't. So that's a real huge benefit of condoms. Right. Important thing to remember also. Yes, definitely.

Vesectomy, it's very effective. but it's a little bit invasive. And for the most part, at this point, at least it's not reversible, at least not reliably so. Okay. So there's not like the snip, snip, snip, snip, snip, snap, from the office. Yeah, not quite. There has been a lot of research to try and develop like gels, injectable gels that would then be able to be reversible. Like you inject a gel that causes occlusion of the vast deference, which is where the sperm would exit,

and then be able to inject something else to, like, dissolve that, essentially. But they're not, like, on the market at this point or anything. There aren't a lot of non-hormonal male contraceptive options that have really been under that advanced level of clinical investigation, so not large-scale studies of those yet. They're mostly in animals models. Okay. Now, hormonal male contraception methods, including androgen. so testosterone administration with or without the addition of a progestin in various forms.

So like short acting injectables, long acting injectables, little subcutaneous implants, kind of like Nexplanon, as well as pill forms, have all been studied. They are in fact very effective. However, what's the holdup? Yeah. They have the risk of certain side effects. There was actually, I think, one of the largest studies of this, and I will link to a review article that kind of updates all of the research on male contraception.

That's from 2019, so it's a really comprehensive up-to-date article. But in 2008 to 2012, there was a really long-term phase two clinical trial of an injectable combination of testosterone and progestin. So a four-year study that was found to be very effective, and 74% of male participants and 80% of their female partners said that they were satisfied or very satisfied with their birth control method, so this injectable, and 85% and 88% respectively said that they would use this method of contraception if it was available. Now, the side effect profile included weight gain, changes in libido, either increase, or decreased, an increase in acne, an increased risk of hypertension, so high blood pressure,

and increases in abnormal liver function tests, as well as a slight increase in moderate to severe depression. Now, one thing to point out is that those are essentially exactly the same side effects as female targeted combination oral contraceptive pills. Okay? Another thing to point out is that in this study, only 6% of participants discontinued the study due to these side effects. Which is a far cry from, at least in the early years of birth control studies, like 50% or more. Yeah, yeah. But especially because of the increase of moderate to severe depression, this study was ended a bit early and it was not approved. Now, one big difference that I do have to mention is that in females, because contraceptives are actively preventing pregnancy, and pregnancy itself is an extremely risky state of being, not just during pregnancy, but childbirth and postpartum.

There are so many increased risk that increases your risk of hypertension, preeclampsia, stroke, gosh, You can die by hemorrhage. There are so many ways that you can die, blood clots, everything, right? So in preventing pregnancy, you have a bit more risk that you might be willing to take before you exceed the benefit, if that makes sense. So your risk-benefit profile is different when you are targeting females preventing pregnancy versus preventing males from getting somebody pregnant because they're not directly affected by pregnancy. That's interesting. Yeah, I hadn't really considered that. Right. I think that that's really important to keep in mind. But in terms of what people want, males are very interested in contraceptive methods that they would be able to take, like overwhelmingly.

Yeah. So I think that that's important too. Okay. So that's that. Globally, IUDs are by far the most common method of contraception, reversible female contraception in the globe. Over 168 million people worldwide use an IUD. as their form of contraception. In the U.S., that's not the case. Combination oral contraception is the most common by far. And for a really long time, like you mentioned, especially after those lawsuits in the 80s, IUDs got a really bad rap in the United States. But in the last few years,

the rates of long-acting reversible contraception use has been steadily increasing. So in 2008, the overall LARC use was about 6%. And in 2014, that had increased to 14%, which is really incredible. Because again, these are much more effective forms of contraception. Mm-hmm. Okay. And over roughly that same time period, so from 2008 to 2011, when we saw this increase in long-acting

reversible contraception use, that is the same time period, that is the time period. the first time in recent decades that the unintended pregnancy rate actually declined. Really? In 2011, it had declined to 45% from 51% in 2008. Huh. And 2011 is the most recent data I could find on this. So that also means that 45% of pregnancies in this country are unintended. which either means unwanted or wanted later, like not wanted right now.

That is a higher number than I thought. Uh-huh. And 40% of unintended pregnancies end in abortion in this country. So in 2014, the availability of family planning services, including contraceptive coverage, helped to avoid over 2 million unintended pregnancies that would have occurred without access to contraceptive coverage. Additionally, public funding for contraception in 2010 resulted in $10.5 billion of cost savings. That's nearly $6 of savings per dollar spent on contraceptive coverage. And if you take into account additional family planning services like STI screenings, HIV screening, cervical cancer

screenings. It's like $13 billion of saving by investing in family planning services. Wow. Yeah. Contraceptive use is linked to increases in educational attainment and wage earning. And coverage of this contraception, like by insurance companies, saves women over a billion dollars a year in out-of-pocket spending. That's a lot of money. Yeah. Yeah. Yeah. And so even though we've seen some improvements in terms of the uptake of long-acting, reversible contraceptive use, and in 2011 a reduction in the rate of unplanned pregnancies, reproductive rights in this country are not just on the ballot they're being actively stripped away. Oh, yes.

In 2010 is when Obama signed the Affordable Care Act, which requires, coverage of preventable health services and screenings like STI screenings and cervical cancer screening. And then the next year, it also required that employers and insurers provided women with coverage at no cost for all FDA-approved contraception, all of those ones that we talked about. So the first time that this law was challenged, it went up to the Supreme Court in 2014. You probably remember everyone, Hobby Lobby case. Oh, God. Okay. In that case, the Supreme Court ruled in favor of Hobby Lobby in a five to four decision,

saying that in a family-owned company with particular religious beliefs, they could deny coverage of their employees contraception. Then in 2018, Trump issued an even broader ruling saying that almost any organization, including non-profits, private companies, non-governmental institutions, anyone who claims a religious or moral objection to birth control is not required to provide it to their employees. And here's what I think is really important. Two things.

First of all, under the original ACA, the original Affordable Care Act, religious entities like churches or mosques were already exempt from having to provide contraceptive coverage. So religiously affiliated non-profit institutions like universities, hospitals, and charities were not exempt, but under the original ACA, they could issue a formal request for exemption to the government or their insurance provider so that it would be the insurance company itself that would have to front the cost and cover the contraceptives for employees. Okay. So like a religious university or hospital wouldn't have to pay for its employees to have

birth control, but those employees could still be covered directly from the insurance provider. But somehow that was considered unacceptable. And so this new Trump ruling insisted that these organizations had the right based on religious or moral grounds to completely deny access to contraceptive coverage for their employees.

And in July of this year, the Supreme Court ruled essentially in favor and punted it back to lower courts of this extremely broad-based restriction. There were only two voices in dissent. And guess what?

They were both women. Shocking. The late Justice the late Justice Ruth Bader Ginsburg and justice Sonia Sotomayor. And what's very frustrating is not, I think, just that this happened, but also that these companies were allowed to cite blatantly untrue statements as their reasoning for objecting to birth control, not only claiming that birth control itself is against their particular religious beliefs,

but claiming that the forms of birth control they were objecting to, are capable of destroying embryos and causing abortions, which is simply not true. How is that allowed? I truly don't know, Erin. Again, there has been extensive research on this and nothing to support the idea that emergency contraceptives, oral contraceptive pills, hormonal IUDs, or implants ever act as an abortive fashioned. and the only circumstances under which copper IUDs may is if they are used in the context of emergency contraception,

and even then they act to prevent implantation, which is the scientific and legal definition of the start of pregnancy. So yeah, not only are contraceptives not acting as abortive fashions, but access to contraceptive coverage reduces the rate. of abortions. All of these rulings, all of the quote-unquote logic just reveals one thing that it's only ever been about control over people's bodies. Yeah. Period. Because the thing is that allowing people to choose when and if to have children and this doesn't get enough coverage, but how far apart to space their pregnancies, which is really important. Right. And. And, and. And, you know, what form of contraception they want to use. Allowing people to have these options, it has benefits for moms, it has benefits for babies,

it has benefits for families, it has helped to further women's equality, educational attainment, wage earning. It results in better pregnancy and neonatal outcomes, and again, it reduces abortion rates. So there truly is no reason. to hinder or block access to safe and effective comprehensive. Comprehensive, that means all the options that are available, contraceptive coverage. So one of the things that we hoped to do in this episode was to provide you all with information about how these birth control options work,

because I think that it's hard to know that information sometimes, you know? Mm-hmm. So because I know you care, about the people in your life that can benefit from access to contraceptives and comprehensive reproductive health care. I think the most important thing that we all need to do is please vote. Vote. This is a long episode to ask you to vote.

It's the most important thing right now is to vote. Anyways, that's all I got, Aaron. I mean, we got a lot, Erin. Mm-hmm. We sure do. Oh. You want to do sources? Man.

Yes, I do have a couple of sources. So I read a couple of books. One is the moral property of women, a history of birth control politics in America by Linda Gordon. And that has gone through several revisions and iterations. And I read the one from 2002. And then by Jonathan Eig, I think it's Eig, the birth of the people. pill how four pioneers reinvented sex and launched a revolution. That's from 2016. And then finally, the Our Bodies Ourselves.org website has a brief history, a brief timeline of birth control. And so I

extracted, especially some of the later points from there. Awesome. I have a number of articles about the mechanism of action of contraception, as well as that review article on developments in male contraception, which was from 2019, and also on the Gutmacher Institute website, that is an organization that does a lot of research on reproductive rights, and they have some great stats. So I have a link to a couple of their articles as well. You can find all of our sources from this episode and every single one of our episodes from all three seasons. That's 60 episodes on our website, this podcast will kill you.com. Thank you to Bloodmobile for providing the music for this episode and all of our 60 episodes.

And thank you to you, listeners. This has been a fun three seasons. We will be coming back with season four in a few weeks. We don't have a particular date. So make sure that you're subscribed so that you don't miss it when we drop the new season. Absolutely. Well, until next season, wash your hands. You filthy animals?

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