“The Pill” is the most common contraceptive used by women in Western countries, and certainly the most high-profile one.[1] The Pill combines ease of use (daily oral administration of a small capsule) with high contraceptive effectiveness (more than 99% with correct use). In 2010, both scientists and journalists celebrated the fifty years of the Pill, praising its safety and its role in the sexual revolution of the 1960s.[2] Opinions on the Pill are, however, divided. Recently, media have emphasized the bad side-effects experienced by some Pill users.[3] But regardless of whether the Pill is hailed or blamed, some questions lurk in the background: why is there no equivalent Pill for men? If the Pill works so well for women, why can’t men make use of a similar technology? And if, conversely, some women are stuck with the bad effects of the Pill, why could their male partners not take up some of the burdens of hormonal contraception themselves?
These questions become more pressing when noting that clinical trials to develop a “male Pill” already started in the 1970s. After 50 years, there is still no male Pill on the market. In this essay, I address the strange history of the male Pill. I believe that the fate of male Pill helps in understanding the challenges of contraceptive development, as well as contributing to ongoing debates on the role of biological and social factors in the development of medical technologies. In particular, I engage with the work of Science and Technology Studies (STS) scholar Nelly Oudshoorn, author of the 2003 book The Male Pill: A Biography of a Technology in the Making. To my knowledge, this is the only historical book ever written about the male Pill, which makes examining Oudshoorn’s work all the more important.
First, I outline Oudshoorn’s explanation for why the male Pill was never developed, and I illustrate her argument through my reading of eight male contraception studies, published between 1970 and 2000. Research on the male Pill involved many institutions operating in different countries, from the World Health Organisation (WHO), which sponsored research in England, Thailand, and Chile amongst others,[4] to more local research institutions, such as the Münster Institute of Reproductive Medicine.[5] I have tried to reflect part of this global effort by choosing papers from different organizations and countries. Many of my chosen studies overlap with Oudshoorn’s sources. My interpretation of these studies, however, differs from Oudshoorn’s on a crucial point.
In The Male Pill, Oudshoorn took a strong social constructivist position, stating that biological facts about contraception are always constructed by social reality. Biological facts can therefore not explain the failed development of the male Pill.[6] Without denying the importance of social processes, I point out that researchers stumbled upon some stubborn biological obstacles whilst trying to develop an effective male hormonal contraceptive. The male Pill shows the value of taking a perspective in which biological and social factors mesh with each other, rather than a social constructivist view in which biological facts are subordinated to social reality. But before further elaboration on this point, I want to explain what Oudshoorn’s book says about the male Pill.
In her book, Oudshoorn aimed to challenge the idea that the absence of a male Pill is due to natural properties of the Pill or of men’s bodies.[7] According to her, this “naturalistic” view is often embraced in scientific publications.[8] Indeed, when I first scanned through scientific papers on male Pill clinical trials, the answer to why the male Pill was never developed seemed deceptively simple: oral hormonal contraception can provoke nasty side-effects on the male body. Possible effects mentioned in these studies include higher risk of cardiovascular disease, renal toxicity, weight gain, gynecomastia (development of breast tissue), as well as mood swings and decrease in libido and sexual potency.[9] “Too bad”, we might think, “the Pill just isn’t for men”.
As Oudshoorn pointed out, however, if bad side-effects are really the issue with the male Pill, this does not explain why some female contraceptives passed clinical trials with similar undesirable effects. Side-effects experienced by women included irregular bleeding, ovarian enlargement, weight gain, fever, pain, anxiety and depression.[10] But often, these side-effects were portrayed as mild or transient, and were not taken as indications that a contraceptive should not be used.[11] For example, changes in lipid concentration, potentially leading to higher cardiovascular risk, were examined in female hormonal contraceptive users, but the tendency was to portray lipid changes as potentially beneficial rather than to emphasize their risk to some women.[12] Apparently, side-effects – and the suitability of certain contraceptives – are evaluated differently for women than for men. [13]
In my reading of male Pill studies, as well as in Oudshoorn’s work, this difference becomes very clear when focusing on one side-effect that concerned both female and male Pill users: libido loss. From the very first male Pill trials, researchers were concerned that hormonal contraceptives would negatively impact sexual health and performance.[14] As research progressed, some studies focused entirely on the male Pill’s effects on sexuality, and clinical trials took into account many sexual well-being indicators, including: intensity of sexual desire, sexual satisfaction with partner, total orgasm frequency, sexual thoughts and fantasies, satisfaction with sexuality, and frequency of erections.[15] By contrast, as Oudshoorn noted, women had been complaining about the adverse effects of oral contraception on libido since the 1960s, but researchers only started investigating problems with sexuality in the 1990s, after pressure from women health advocates.[16]
According to Oudshoorn, the gender difference regarding concerns about libido and sexual health, illustrates that standards to assess side-effects depend on gendered cultural norms. Sexual potency is often considered a natural male attribute, rather than a female attribute.[17] In general, the male body tends to be viewed as a strong, natural object, an object that must not be tinkered with. This, Oudshoorn argued, can explain why side-effects were perceived to involve risks for men more than for women. Because the evaluation of side-effects affects whether a medical compound is considered appropriate for use, these gendered cultural norms may have, in turn, affected the fate of the male Pill. So, cultural attitudes and identities, far from being separated from the process of (medical) technological change, are part and parcel of that process.
Oudshoorn insisted, in fact, that the successful introduction of a new contraceptive technology such as the male Pill would require a change in the cultural identity of men.[18] Among the scientists working on the male Pill, some indeed attempted to alter the mainstream perception of masculine identity. In my own sample of studies, this was especially visible in social studies on the acceptability of hormonal contraception in the male population. Consciously or unconsciously, some authors associated the male Pill with a new, positive masculine identity, a “modern” masculinity.
Several of these studies aimed to demonstrate a relationship between a positive attitude towards the male Pill, and “modernity” in outlook and personality.[19] As one author wrote in a 1979 paper, “Men who are less traditional in outlook… ought to be more hospitable to new methods of birth control.”[20] This particular study concluded that men favourable towards the male Pill were more “introspective”, “attentive to others” and “open to change”, whereas less favourable men were “forceful”, “assertive”, “resistant to change”. The beliefs and personality traits of the latter group of men were therefore associated with a “traditional” and implicitly outdated masculine identity. Conversely, the characteristics of the men in favour of the male Pill became indicators of a new, desirable masculinity. In these studies, scientists promoted a particular type of modern masculinity, one that included use of the male Pill.
Scientists were not the only ones who tried to redesign masculinity. According to Oudshoorn, the media and the men who participated in the trials also contributed to that project.[21] Although the lack of a male Pill suggests that the new masculinity found little resonance, the development of the male Pill still involved a great deal of social and cultural work, aiming to reconfigure gender identities and to make them compatible with male hormonal contraception. Oudshoorn concluded that the failed development of the male Pill was not the result of inevitable technical logics, nor of intrinsic properties of bodies.[22] Rather, Oudshoorn claimed, the reason why male hormonal contraception was never developed has to do with sociocultural norms and practices.
This conclusion matches the social constructivist perspective that Oudshoorn adopted in her book. Social constructivism examines how social forces shape scientific practices and concepts. Oudshoorn started The Male Pill with the claim that bodily, biological phenomena about contraception have different interpretations, which she termed the “interpretative flexibility of biological facts”. [23] She went on to cite STS scholars who introduced the idea that “the naturalistic reality of phenomena as such does not exist, but is created by scientists as the object of scientific investigation”. “Adopting this constructivist approach”, she continued, “I view the gender asymmetry in contraceptive technologies as ‘a reality created in practice’ rather than as ‘a reality rooted in nature’”.[24] If biological facts are “constructed” by social processes, biological facts about bodies and contraceptives are not independent of social reality, and therefore cannot explain the failed development of the male Pill.
Oudshoorn’s sociocultural explanation, however, is not the only available option to explain the fate of the male Pill. There is another interpretation of male Pill studies that points to an alternative explanation, which grants a role to the biological, bodily processes that Oudshoorn dismissed, whilst still asserting the force of sociocultural factors. I now want to draw attention to one biological problem that hampered the development of the male Pill: the difficulty of lowering sperm levels in men’s bodies.
Much of the research on the male Pill focused on using hormones to suppress sperm from the ejaculate of men. However, several researchers were concerned that they could not reach “azoospermia”, the complete elimination of sperm levels in men, which would guarantee a very low pregnancy risk.[25] Oudshoorn recounted that, because of difficulties in reaching azoospermia, the target of zero sperm was changed to low sperm levels, a criterion called “oligospermia”. But even when sperm levels were very low, some scientists remained sceptical because occasional pregnancies occurred among partners of these men.[26]
Oudshoorn interpreted the change from azoospermia to oligospermia primarily as a strategy that “consisted of delegating the risks to women”, since oligospermia exposed women to increased pregnancy risk.[27] She did not mention that there is at least one other way to view the concerns about azoospermia. The problems encountered with lowering sperm levels suggest that something in the interaction between the male Pill and men’s bodies was “stubborn”, in the sense that it did not easily comply to scientists’ actions and negotiations. After all, the problems encountered with eliminating sperm levels were not a fleeting characteristic of male Pill research. In my sample of studies, they lasted from the 1970s all the way to the late 1990s.[28] Thus, the unsuitability of the male Pill as a contraceptive technology may involve a biological difficulty, independent of social processes.
The importance of taking into account such biological or “stubborn” factors when discussing the development of contraceptives becomes even clearer, in my opinion, when realizing that Oudshoorn herself relied on such “stubborn” biological phenomena to explain differences between male and female contraceptive research. Despite her claims about the flexibility of biological facts, when Oudshoorn discussed the side-effects of the female Pill, such as the loss of sexual desire, she implicitly assumed that these side-effects produced persistent, biological regularities in women’s bodies.[29] In fact, it was the persistence of those negative side-effects that revealed the unfairness of safety standards for women, as compared to men. This way of treating side-effects for the female Pill stands in sharp contrast with her treatment of male Pill scientists’ problems with sperm levels. Oudshoorn did not dwell on how the change from azoospermia to oligospermia might have derived from equally persistent bodily processes. Yet, a symmetrical analysis of female and male contraceptives must also be symmetrical in its stance towards those biological phenomena.
Moreover, “stubborn” bodily phenomena need not be at odds with sociocultural explanations. Philosopher of science Bruno Latour has put forward the idea that what we call the “natural” and the “cultural” are actually merged with each other.[30] According to Latour, all of the objects that surround us, including a technology such as the male Pill, are “hybrids”: they are a mixture of natural and cultural. This symmetrical view contrasts with social constructivist ideas such as Oudshoorn’s. For her, deep down, everything is social, since “natural” facts are always constructed by, and subordinated to, social reality. Interestingly, Oudshoorn mentioned Latour in the introduction to The Male Pill, but only to refer to another of his ideas: that technologies are underpinned by “sociotechnical networks” made of social relations, clinics and laboratories, and state regulations.[31] The concept of sociotechnical network may fit Oudshoorn’s social analysis of the male Pill. Yet Latour’s work also has the potential to undermine part of Oudshoorn’s interpretation.
Without needing to fully embrace Latour’s position on the merging of the “natural” and “cultural”, I think that it is useful to regard “stubborn” phenomena and sociocultural forces as equally intertwined with each other, instead of believing that one encloses the other. In the case of the female Pill, the sociocultural dynamics that led researchers to overlook side-effects were identified because of the “stubborn” bodily phenomena they created. Similarly, bringing up the problem of azoospermia should not be seen as a denial of the sociocultural dynamics that shaped the male Pill. Those powerful dynamics intertwined with “stubborn” bodily phenomena to determine the fate of the male Pill, and both should be included in explanations for why the male Pill was never developed.
[1] Marc Dhont, “History of oral contraception,” The European Journal of Contraception & Reproductive Health Care 15, 2 (2010): S17. DOI: 10.3109/13625187.2010.513071
[2] Rachel Cook,
“Fifty years of the Pill,” The Guardian, June 6, 2010. https://www.theguardian.com/society/2010/jun/06/rachel-cooke-fifty-years-the-pill-oral-contraceptive
Kristina D. Chadwick et al, “Fifty years of “the pill”: risk
reduction and discovery of benefits beyond contraception, reflections, and
forecast,” Toxicological sciences : an official journal of the Society
of Toxicology 125,1 (2012): 2-9. doi:10.1093/toxsci/kfr242
Marc Dhont, “History of oral contraception,” The European Journal of Contraception & Reproductive Health Care 15, 2 (2010): S12-S18. DOI: 10.3109/13625187.2010.513071
[3] Hayley Gleeson, “Why Can’t We Be More Critical of the Pill?”, Vice, July 9, 2015. https://www.vice.com/en/article/vdxv9b/why-cant-we-be-more-critical-of-the-pill
[4] World Health Organization Task Force on Psychosocial Research in Family Planning, Special Programme of Research, Development and Research Training in Human Reproduction, “Hormonal Contraception for Men: Acceptability and Effects on Sexuality,” Studies in Family Planning 13, no. 11 (1982): 328–42.
[5] Dorothee Büchter et al, “Clinical Trial of Transdermal Testosterone and Oral Levonorgestrel for Male Contraception,” The Journal of Clinical Endocrinology and Metabolism 84, no. 4 (1999): 1244–49.
[6] Nelly Oudshoorn, The Male Pill : A Biography of a Technology in the Making (Durham: Duke University Press, 2003), 9-10.
[7] Ibid., 8-9.
[8] Ibid.
[9] Bruce Schearer, “Current Efforts to Develop Male Hormonal Contraception,” Studies in Family Planning 9, no. 8 (1978): 229–31.
[10] Jessika van Kammen and Nelly Oudshoorn, “Gender and Risk Assessment in Contraceptive Technologies,” Sociology of Health & Illness 24, no. 4 (2002): 442-443.
[11] Ibid., 444.
[12] Ibid., 452.
[13] Oudshoorn, The Male Pill, 107-108.
[14] E.M Coutinho and J.F Melo, “Successful Inhibition of Spermatogenesis in Man Without Loss of Libido: A Potential New Approach to Male Contraception,” Contraception 8, no. 3 (1973): 207–17.
[15] WHO, “Hormonal Contraception for Men: Acceptability and Effects on Sexuality”.
Büchter et al, “Clinical Trial of Transdermal Testosterone and Oral Levonorgestrel for Male Contraception”.
[16] van Kammen and Oudshoorn, “Gender and Risk Assessment in
Contraceptive Technologies,” 436.
Oudshoorn, The Male Pill, 107.
[17] Oudshoorn, The Male Pill, 108, 110.
[18] Ibid., 232.
[19] William Marsiglio, “Husbands’ Sex-Role Preferences and Contraceptive Intentions: The Case of the Male Pill,” Sex Roles : A Journal of Research 12, no. 5-6 (1985): 655–63.
Harrison G. Gough, “Some Factors Related to Men’s Stated Willingness to Use a Male Contraceptive Pill.” The Journal of Sex Research 15, no. 1 (1979): 27–37.
[20] Gough, “Some Factors Related to Men’s Stated Willingness to Use a Male Contraceptive Pill,” 27.
[21] Oudshoorn, The Male Pill, 233.
[22] Ibid., 225.
[23] Ibid., 9.
[24] Ibid., 10.
[25] Büchter et
al, “Clinical Trial of Transdermal
Testosterone and Oral Levonorgestrel for Male Contraception”.
D.M de Kretser, “Fertility Regulation in the
Male,” Bulletin of the World Health
Organization 56, no. 3 (1978): 353–60.
[26] Bruce Schearer et al. “Hormonal Contraception for Men.” International Journal of Andrology 1, no. S2b (1978): 680–712.
[27] Oudshoorn, The Male Pill, 99.
[28] Büchter et al, “Clinical Trial of Transdermal Testosterone and Oral Levonorgestrel for Male Contraception”.
De Kretser, “Fertility Regulation in the Male”.
[29] Oudshoorn, The Male Pill, 107.
[30] Bruno Latour, We Have Never Been Modern, trans. Catherine Porter (New York: Harvester Wheatsheaf, 1993).
[31] Oudshoorn, The Male Pill, 11.