Living without the Pill
At 3 a.m., Dr. Fred Fallis awoke to what he thought was a crank call—a gruff, scratchy voice panting at the other end of the phone. But it turned out to be something more ominous—the contorted voice of his 20-year-old daughter, Betty Joan, desperately gasping for air. She had wakened in a feverish sweat with pains in her chest and back and she was barely able to breathe. Dr. Fallis quickly picked her up and delivered her to the emergency ward of Toronto General Hospital. It was the beginning of a long and painful ordeal that saw Betty Joan hospitalized for 2V2 months. Diagnosis: pulmonary embolism, or blood clots in the lungs. Probable cause: the Pill.
Three years later, Betty Joan Fallis has made a complete recovery, but she will never go back on the Pill. Stories such as hers, while rare, have led millions of North American women to turn their backs on the birth control method that was once hailed as their liberator.
Pill sales in the United States, where statistics are available, have dropped by more than 25 per cent since their heyday in the early 1970s. Across Canada, clinics and doctors report a similar disenchantment. Once the most widely used contraceptive in Canada, the Pill is losing ground to the old “barrier methods”—condoms, diaphragms and the almost-extinct cervical cap—which stop sperm with a physical barrier in the vagina rather than by altering the body’s delicate internal workings.
The search for alternatives is intensifying rapidly. An estimated 45 to 55 per cent of couples practising birth control now use the condom (compared to 30 to 35 per cent 10 years ago), making it almost certainly the most widely used method in Canada. Sales of diaphragms, which almost disappeared from the contraceptive market in the late ’60s, have climbed about 15 per cent annually in the past five years. Demand for diaphragms became so great last summer that Calgary actually ran out of them for six weeks. And the cervical cap is making such a successful return
that a Toronto clinic will no longer put £ names on the waiting list for fittings. 2 “A lot of women feel that the most readi< ly available methods of birth control g just aren’t that safe,” concludes Mon-treal birth control counsellor Clara Valz verde. “Women really feel up against § the wall.”
The flight from the Pill is certain to have far-reaching consequences. Ironically, it may give women more control over sex. While the Pill gave women the biological option to have sex more freely and frequently, ultimately it may not have liberated them as much as is conventionally believed. In many cases its use put women under great pressure to have sex—even when they didn’t want to—simply because it was safe and convenient.
Now, as women move back to the barrier methods, which involve planning, motivation and greater risk, they may be regaining their right to say no. Connie Clement, an editor of the women’s health magazine Healthsharing, also suggests that barrier methods may make women more selective, more
demanding sexually and less likely to accept “routine 10-minute sex after the hockey game.”
The changes for men are also dramatic. They are finding themselves abruptly drawn back into the birth control equation. And that can be a shock to males who for the past 20 years simply have not had to worry—or even think about—birth control. The new, more co-operative approach to birth control may enhance some relationships but introduce tensions into others if men are not keen to accept their new responsibilities.
But as couples move into the post-Pill era, they are finding a surprising lack of good contraceptive alternatives. The growing interest in the barrier methods has not been shared by doctors, drug companies and government agencies that determine which methods will be developed and promoted. Virtually no research money has gone into enhancing these methods, even though technological breakthroughs in the past 30 years have made dramatic improvements feasible. Instead, massive amounts of research and development money have been, and continue to be, channelled into other hormonal contraceptives and devices placed inside the womb. As a result, more than a decade after comprehensive British studies es-
tablished the health dangers of the Pill, the barrier methods remain virtually unchanged from what they were 40 or 50 years ago. “At the rate of research now, it will be at least another 40 years before there’s much new,” says Dr. Pierre Blais of the federal government’s Bureau of Medical Devices. “The barrier methods are definitely on the back burner.”
The Pill first came onto the North
As women move back to the barrier methods, they may become more selective and more demanding sexually
American market 21 years ago, quietly overturning a basic biological rule that had made sex throughout human history a riskier venture for women than for men. Birth control had been practised for centuries—everything from 17th-century condoms made of fish membranes to home-made potions of dried beaver testicles brewed by 19thcentury New Brunswick Indian women. But the Pill was the first to deliver virtually fail-proof guarantees.
However, the dream of a no-stringsattached answer to the birth control dilemma turned out to be just that—a dream. Studies began to link the Pill to a string of serious medical conditions previously almost unheard of in healthy young women—strokes, heart attacks, thrombophlebitis, liver tumors. A bizarre range of other problems also emerged—vomiting, migraines, depression, bleeding gums, dark brown blotches on the face, even hair growth on the chest. Nancy Poole, a 30-year-old drug addiction counsellor in Toronto, developed a patch of heavy, dark hair on her chest shortly after she started taking oral contraceptives at the age of 20. The problem still persists 10 years after she stopped taking the Pill. Some women actually found that the Pill reduced their interest in sex. “I was taking pills so I could be sexually active,” recalls 33-year-old Lorna Zaback of Vancouver. “But I stopped wanting to have sex. It was ridiculous. I used to stand on the street and scream.”
As stories of damaging side effects grew in number, the Pill became another victim of the public’s growing suspicion of chemicals and unnatural products that alter the body’s chemistry. The new lower-dose pills—the industry’s attempt to improve its prodI uct—tamper less with the body’s inter-
nal workings than those sold in the Pill’s heyday. But even in low doses, the hormones in the Pill end up affecting just about every organ and tissue in the body. Long-term use is “like throwing a sledgehammer into the system,” says outspoken Toronto physician Dr. Gerald Green. Because the Pill affects so much of the body, Green thinks it is nearly impossible to develop an oral contraceptive without side effects.
The same reasoning applies to the much-vaunted, long-awaited male pill. It is still being developed but, like the female Pill, it affects many systems in the body. Men have become particularly concerned by reports that side effects include a reduction in sex drive. Says Dr. Albert Parlow, an endocrinologist at the Pituitary Hormones Centre in Torrance, Calif.: “Under no circumstances would I allow my hormones to be molested by a preparation that has wide-ranging effects beyond the specific one of inhibiting spermatogenesis.”
The general wariness of all “interfering products” has also led to a move away from the IUD (intrauterine device).
After the first alarming reports about the Pill, women turned to the IUD as the logical alternative only to find it had a long, if not widely known, history of problems of its own. Inserted inside the womb, the IUD can cause serious internal infections, sometimes resulting in sterility.
Still, despite growing public reaction against the Pill and the IUD, government funding continues to be concentrated heavily on hormonal and chemical birth control methods. Out of a total of $155 million spent worldwide on all aspects of reproductive and contraceptive research in 1979, less than $1 million—a meagre two per cent—went toward the barrier methods. The vast majority of funds were spent instead on research and development of female hormonal contraceptives: improved
pills, subdermal implants, injectables, intranasal sprays and anti-pregnancy vaccines. The World Health Organization’s most recent summary of contraceptive research lists dozens of such projects, as well as research into improved IUDs, but does not even mention barrier methods. Dr. Bruce Schearer, a biochemist who heads New York city’s Population Resource Centre, says the bias can be explained partly by the fact that the scientists doing the research
have been trained in biology and medicine. “They have had little to do with synthetic materials and the development of devices,” he explains.
For its part, the pharmaceutical industry, which profited heavily from the expanding Pill markets in the ’60s, has been reluctant to make the necessary investments to improve the barrier methods. That is probably because any improved product would only have the effect of further undercutting the stilllucrative Pill markets. Despite the dramatic drop in the number of Pill prescriptions filled in 1980 compared to
1976, revenues from U.S. Pill sales rose from $186 million to $320 million because of price increases in the same period. In Canada, oral contraceptives are now a $50-million-a-year business, one of the biggest-selling drugs. As New York pharmaceutical industry analyst Richard Stover puts it, “The dollars are growing nicely.”
With so little money going into barrier method research, it is not surprising that there have been few advances since the turn of the century. “Here we are with the space shuttle going on, and birth control is back in the Dark Ages,” complains Sue Yvonne, a counsellor at Toronto’s Hassle Free Clinic. The idea has persisted that the simple barrier methods are about as good as they could be. “How much can you improve on a shoelace?” asks Percy Skuy, president of Ortho Pharmaceutical (Canada) Ltd., the largest contraceptive manufacturer in the country. To which contraceptive expert Schearer replies, “Quite a lot.”
The condom is a good example. It has been made out of latex rubber since the late 19th century, even though synthetic polymers developed in aerospace and plastics research in the 1940s and ’50s
would make a far more satisfactory product. Schearer says a synthetic condom would be thinner but stronger and would actually transmit a woman’s body heat and moisture. (Sperm, however, would not be able to escape, since it is made of larger molecules.) Similar to products now produced for burns and skin grafts, a synthetic condom would feel more like another layer of skin. “The difference in sensation would be dramatic,” says Schearer. But although Ortho’s sister company in the United States has held patents for a synthetic condom since the 1960s, the company has not yet brought one onto the market. Skuy says research is continuing but he cannot estimate when one might be introduced.
Dominated by large multinational firms, the contraceptive industry has shown itself slow to improve barrier methods unless prodded by a dynamic new competitor. The only significant ingnovations in condoms ycame about in the mid5l970s because a maver°ick German company, I Amor Gummiwaren, Isuddenly broke into a ^market that for years I had been controlled alSmost entirely by three large multinationals— Ortho, London Rubber Company and U.S.-based Arkwell.
Amor Gummiwaren merely replaced the lubricant that manufacturers put on condoms with spermicide, so that the awkward condom-plus-spermicide method could be reduced to a simple one-step procedure. The new product cornered a large part of the German market almost immediately. London Rubber quickly followed suit with its own version, which became the number 1 seller in Britain within a year and a half.
A spermicidal condom should be available in Canada shortly, after its approval was held up by Canadian authorities for about four years. A small Quebec importing house tried to introduce the German model to Canada back in 1977 but gave up after waiting nearly three years for government approval. Julius Schmid, a division of London Rubber, applied to import its spermicidal condom into Canada more than a year ago, and a go-ahead was given only late last week. “Never in our wildest imagination did we expect it to take this long,” says Murray Black, president of Julius Schmid in Canada. What perplexed Black is that the same condom and spermicide already had been sold
separately for years on the Canadian market. The ministry of health and welfare refuses to divulge details of the case but says it is waiting to receive more information from the company.
It has also been left to a small firm to attempt to bring a similar concept onto the Canadian market—a vaginal sponge barrier combined with spermicide. VLI Incorporated of Costa Mesa, Calif., applied to the Canadian government last January for authorization to market its “contraceptive pillow.” But judging from past experience, it could be years before a decision is made.
Another radical invention—the custom-made cervical cap—will likely also be brought to the public by a maverick drug company. The notion first appeared in medical literature almost a century ago and has been technologically feasible since the 1950s.
Based on dental technology used to take moulds of teeth, Robert Goepp, a Chicago dentist, and Uwe Freese, a Chicago gynecologist, developed a method for taking a mould of the cervix so that a cap could fit the woman exactly, allowing greater protection
against pregnancy. The Goepp-Freese cap also includes a one-way valve—allowing bodily secretions to flow out but preventing sperm from flowing in—so the cap could be left in place for weeks, months, possibly even years. Since it would provide an airtight seal, spermicide would be unnecessary. The cap is still in the testing stage, but Goepp and Freese have found an enthusiastic distributor, Chicago entrepreneur Paul Moriarty, who has set up a firm to market the product.
Ironically, the birth control boom of the 1960s and ’70s not only passed the barrier methods by but had the effect of almost eliminating some of them. As a result, a woman now has a range of dozens of birth control pills to choose from, but her choice in the barrier methods is fairly limited-more limited, probably, than her mother’s or grandmother’s was. Birth control was never advertised in those days, but any woman who knew what to ask the druggist could usu-
ally find a wide selection of barrier devices. The diaphragm, previously available in three models to suit different body structures, is now only available in two. The one that has disappeared had a less rigid steel rim—one of the major complaints from users of the surviving diaphragm. “Putting one in can be like playing with a Frisbee,” says Montreal’s Valverde of the modern diaphragm.
The cervical cap has fared even worse. A thimble-like device considered by many to be more desirable than the
diaphragm, the cap has remained popular in parts of Europe but it has almost disappeared from the North American market. Once sold in Canada in about two dozen sizes, the cap is no longer marketed by a single company in Canada and is available only through a handful of clinics and private doctors who import it in a limited range of sizes from England. Unlike the diaphragm, the cap can be left in place for days at a time, allowing for more spontaneity in sex. Annie Thurlow, executive director of Planned Parenthood in Charlotte-
The Contraceptive Factor
(Number of pregnancies per 100 non-sterile women)
Actual Use Effectiveness
Rate for users who Average for
employ method correctly all users
Condom & Spermicidal Agent less than 1
Diaphragm (with spermicide) 3
Rhythm method Chance
town, says that when she describes various birth control methods to women at the clinic they become enthusiastic about the cap. “They say, ‘Oh, Lord, that sounds wonderful.’ Then they ask, ‘Where can I get it?’ and I tell them, ‘You can’t.’ ” There are a few clinics and doctors fitting the cap in Vancouver, Edmonton, Winnipeg, Toronto and Montreal, but it remains out of reach in smaller Canadian cities and rural areas.
The migration to the barrier methods seems to be a grassroots movement that is taking place despite the indifference—and sometimes even hostility—of doctors.
Women report pressure from doctors to get on the Pill and stay on it. “My doctor pressured me for years to go on the Pill,” says Valverde. “I’d go to him for a sore throat and he’d offer me a year’s supply of birth ¿control pills.” Dr. Marion Powell, medical director of Toronto’s Bay ^Centre for Birth Control, that the medical ^profession is not generally inclined toward the Ibarrier methods. “If you l go to a doctor, you’ll end i up with the Pill, the IUD oor sterilization,” she says.
This preference among physicians for more complex methods of birth control springs partly from their training. Dr. Adrienne Ross, a Vancouver general practitioner, remembers that, although she was told about the diaphragm in medical school, she was never actually taught how to fit one. She recalls one Vancouver doctor advising her that diaphragms were easy to fit since all women who have not had children take the same size—a statement she now knows to be completely untrue.
Still, most doctors concede that the barrier methods can be highly effective. If used properly, condoms combined with spermicidal foam are more than 99 per cent effective, only slightly less effective than the Pill and slightly more effective than the low-dose Pill. Diaphragms and cervical caps combined with spermicide are theoretically 97-per-cent effective, only marginally less effective than the IUD. Actual effectiveness
rates for barrier methods fluctuate wildly from study to study, however, partly because people often neglect to use them at all. Winnipeg’s Dr. Susan Wood says that among the highly motivated women she fits with diaphragms and cervical caps the pregnancy rates are almost as low as among Pill-users, since women often forget to take their pills.
Some health-care workers say doctors are partly to blame for not fitting diaphragms properly and teaching women how to use them. Rebecca Fox, a Vancouver birth control counsellor, has grown cynical about doctors who fitted patients with diaphragms and then send them on to the clinic for the crucial, but more time-consuming, task of teaching the patient what to do with them.
“And the doctor has often fitted her wrong,” saysFox.“She’s spent $14 and she’s three sizes off.”
Shirley Burstall, counselling co-ordinator for the Calgary Birth Control Association, also finds doctors uninterested in learning about the cervical cap, despite growing interest in Calgary. “Doctors seem too busy to be bothered to learn about new methods. They don’t seem particularly interested,” she says.
While the barrier methods have an impressive health record over decades of use, one ominous note was struck last year in a study that found slightly higher rates of birth defects in infants of women who had used spermicides 10 months prior to conceiving. The study’s authors, from the Boston Collaborative Drug Surveillance Program, cautioned that the results were inconclusive since it was not even clear whether the women in the study had used the spermicides they had been given.
The Pill’s dangers, on the other hand, have been solidly established in repeated studies. Even a massive California investigation last year, which seemed to show that the Pill was safer than had been previously thought, actually confirmed most previous findings of the Pill’s dangers. Indeed, a Boston University study published last summer suggested for the first time that the Pill’s effects may linger in a longterm user, increasing a woman’s chance of having a heart attack up to 10 years after she has stopped taking it.
With more than 50 known adverse reactions to the Pill, some women are left resentful that they were ever exposed to
it. “You’re taking your chances by not using it, but you’re also taking your chances by using it,” says Carolyn Klopstock, a supervisor with Toronto’s Family Planning Services. “It’s a question of playing the statistics.” Klopstock knows only too well. Ten years ago, when she was 26, she developed clots in her legs. A doctor diagnosed the condition at an early stage and took her off the Pill immediately. After a week in bed she recovered.
The Pill becomes more risky for women as they get older, particularly if
they smoke. Still, doctors argue that by screening out older smokers and other high-risk cases, the chances of serious side effects can be reduced significantly, although never eliminated. But there is little protection for a woman whose doctor fails to screen her adequately. A 23-year-old Montreal woman, left partially paralysed after a stroke likely caused by the Pill, won $218,963 in legal damages last summer against a doctor who had prescribed the Pill despite her history of thrombophlebitis, an illness that is easily inflamed by the Pill.
The Montreal case raises the question of just how much information about the Pill a woman should have in order to make an informed choice. The U.S. government requires each Pill package to come with a detailed two-page insert that spells out the dangers of the Pill in easy-to-understand language and describes various birth control alternatives. It even includes a chart showing that the barrier methods—backed up by abortion in the event of failure—pose the fewest health risks for all age groups. A similar insert required by the Canadian government for pills sold in Canada is not nearly so informative. It basically advises women to see their
doctors if they develop certain symptoms and mentions no birth control alternatives. “Ours is short and sweet, and that’s the way we like it,” says Dr. Robert Kinch, who heads a federal advisory committee on oral contraceptives which is now reviewing the insert. “We want women to be informed, not frightened.”
Just how many Canadians suffer serious side effects from the Pill is not clear. Certainly no one seems to be keeping track. Ortho President Skuy grows visibly irritated when asked and refuses to reveal the number of adverse reactions the company has on file. “We don’t play games with this,” he says. “The media like to play games.” Skuy says Ortho passes its cases along to the federal government. The government then stores them away, refusing to reveal even the number of cases it has received from drug companies. Canada does, however, invite doctors to report suspected adverse reactions to all “¡drugs. Since 1970 it has 387 reports of ¡»¡serious adverse reactions—including 10
z deaths—suspected to be Ï linked to the Pill. Since the reporting system is entirely voluntary and
unsystematic, Dr. Edward Napke, chief of the federal Product-Related Disease Division, says the reported cases probably represent only a small proportion of the suspected Pill-related illnesses. Still, behind the numbered cases on Napke’s 45-page computer print-out lie some compelling personal tragedies: a 26-year-old with no history of heart problems who died of a heart attack after nine months on the Pill; a 48-yearold who permanently lost the sight in her right eye after developing clots in the eye’s blood vessels.
For many of those raised on the dream of a perfect contraceptive, the Pill’s fall from grace has been disheartening. Thurlow, of Charlottetown’s Planned Parenthood, says women ask sadly, “Is that all?” after she describes all the birth control choices available to them. But that choice might seem more appealing—to both men and women—if some of the simple barrier methods were made more desirable. As more North American women become disillusioned with the Pill, the demand is only going to keep growing for improvements to these techniques—improvements that remain so close and yet so agonizingly out of reach,