The Pill turns 50

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Momentous change is rarely the thing of a moment. When we celebrate (or denounce) the 50th anniversary of the Pill on Sunday - Mother's Day, for the ironists in the crowd - we're picking out the date in an amazingly far-off calendar when the U.S. Food and Drug Administration voiced its approval for a revolutionary form of birth control.

The little pill was going to transform the entire world, according to its wide-eyed backers, who predicted that dependable family planning would be a source of miracles that went well beyond keeping unwanted babies unborn. As often with utopian believers, they were on the right track for all the wrong reasons.

And according to its critics, the Pill was going to destroy the world. As often with moralizing, fearful conservatives, they were right about the disruption but wrong about the direness of the consequences. It was only their stratified world view that suffered an irreversible body blow.

"After 50 years of the Pill, we're still wrestling with the idea of what it means," says Christabelle Sethna, a professor of women's studies at the University of Ottawa. "Whatever people said at the time, it's taken decades to understand the Pill's effects medically, culturally and politically."

Indeed, the Pill ended up hastening modernity almost in spite of the early, extravagant claims made for and against it. "The biggest mistake in the early days was to see the Pill as a magic bullet," Prof. Sethna says. "It was supposed to do all these amazing things - mend unhappy marriages, make sex lives more satisfying, eliminate the need for abortion, eradicate global poverty, stave off communism and solve the population crisis. Those beliefs now seem funny and even poignant."

Instead of fighting the Cold War and saving Mad Men marriages, the Pill became the marker that separates us from a past belonging to an outmoded people, a drug (and a mode of thinking) that defines a boundary between ancient attitudes and new behaviours - from women's powerful sense of independence in the home and the workplace and the rights of adolescents to take charge of their bodies, to emotional debates over international aid programs and the freedom we now possess to question doctors and drug companies about their contributions to our well-being.

A revolution less in sex than in conversation

Freeing up sex now looks like the least of the Pill's many achievements, despite media fascination with the subversive role it played in rousing the bedrooms of the nation.

As late as the end of the 1960s, says Elaine Tyler May, author of America and the Pill: A History of Promise, Peril and Liberation, four-fifths of the women graduating from universities were still virgins.

"What was most dramatic about the sexual revolution initially was not how much people changed their sexual behaviour but how much more they talked about it. The Pill accelerated that conversation; it didn't create it.

"But in the long term, I think big public discussions generate changes in behaviour," Prof. May says.

After five decades of those conversations, women's ability to control their fertility undeniably determines the innermost workings of our society and our economy. Government ministers may talk openly of restricting foreign-aid funds for family planning in developing countries - with the implication that Canada could come next. But Stephen Harper is politically attuned enough to mute the chatter.

"Every study in the last 15 years demonstrates that it would be political suicide in Canada to start messing with contraception," says John Lamont, president of the Canadian Federation for Sexual Health.

Messing with sex education, the most basic and universal format of conversation about birth control, still has a political advantage, to judge from Ontario Premier Dalton McGuinty's climb-down on proposed curriculum changes. But however much traditionalists prefer to keep a reverent silence on sexual matters, after 50 years of the Pill young people have found their way to an openness unknown a few decades ago.

"The Pill has been a motivator in how society has changed," says Jeff Bloom, physician-in-chief for the family health team at Toronto Western Hospital. "Young women are much more receptive to talking about birth control, and feel much more comfortable about coming in and asking for it."

That freedom of conversation is the starting point of the Pill's gift to the modern world. In the not-so-distant past, the subject of birth control often meant furtive anxiety in family situations, awkward negotiations between man and woman, or simply a cowed silence accompanied by a fear of what the future could deliver: the life-altering accident of pregnancy.

"The Pill put contraception completely in the hands of women - men didn't need to consent or participate or even know about it," says Prof. Tyler May. "But what made the Pill revolutionary as a social force is that it came about at a time when the feminist movement was opening up new opportunities for women.

"The Pill made it possible for women to control their fertility so effectively that they could plan their lives long-term and no longer have to make the choice between career and family," she says.

The idea that a woman's place was in the home sounds unbearably quaint now, but it passed for inescapable logic. Domestic fundamentalism rested on the belief that pregnancy was ultimately unpredictable and inevitable, and therefore should be desirable.

Clearly birth control was practised before the Pill was developed (from hormonal compounds synthesized from Mexican wild yams). Apart from faith-inspired pockets of fecundity such as Catholic rural Quebec, birth rates dropped dramatically during the Industrial Revolution. The acidic lemon-half that 18th-century roué Casanova used as a cervical cap is a testament to the power of human ingenuity - or persuasion - when sex is involved, but by the mid-19th century, mass-produced rubber condoms simplified and democratized contraception.

Up to a point. As with the Pill a century later, moralists became convinced that easy contraception would lead to promiscuity and societal breakdown. Hence, Criminal Code limits on birth control came into effect in 1892. While exceptions could be made in the name of the public good - condoms to prevent dreaded venereal diseases, for example - the law effectively drove contraception underground, silencing public conversations and curtailing research into more effective methods.

The world's most influential science project

It was in this climate of enforced ignorance and avoidance that U.S. birth-control activist Margaret Sanger and women's-rights advocate and philanthropist Katharine McCormick decided to force the issue in the early 1950s. The Pill, amazingly for what is now a multibillion-dollar global industry and a societal sine qua non, was essentially their personal science project.

"Pharmaceutical companies and governments were unwilling to invest money in contraceptive research," Prof. May says. "They thought it was unseemly, or they were afraid of the reaction from the Catholic Church."

Mrs. McCormick's fortune subsidized the investigations of an independent hormonal researcher, Gregory Pincus, with the goal of producing the perfect contraceptive - "harmless, entirely reliable, simple, practical, universally applicable and aesthetically satisfactory to both husband and wife," according to the specs proposed by the Planned Parenthood Federation of America.

The language is revealing, of both the ideals of the Pill's pioneers and the society in which they campaigned - nothing on liberation or sexual freedom, though the genteel phrase "aesthetically satisfactory" sounds like code for the promise of pleasure. Nice people were having sex, even outside marriage, as the Kinsey Report showed, but they still had trouble talking about it with other nice people.

Pharmaceutical companies at first kept their distance. But pent-up demand had a way of loosening corporate inhibitions. In 1957, the Pill was first approved in the U.S. for the treatment of various disorders, such as painful periods. But it was birth control for those in the know.

This legalistic sleight of hand persisted in Canada as late as 1969 - only then were the dissemination, sale and advertising of birth-control products legalized by the Trudeau government. During the so-called Swinging Sixties, at least for those who played by the rules, doctors could provide the Pill only for therapeutic reasons - e.g., for menstrual problems - and married women were the target market.

This guarded approach typified the Pill's risky early years: Its promoters played to fears of encroaching communism by promising that the Pill would banish overpopulation and poverty (though it was unlikely and overly expensive for the conditions of the developing world) while marketers touted the benefits that secure birth control offered for family life.

But the Pill refused to be so easily confined. By 1965, notes Andrea Tone, Canada Research Chair in the Social History of Medicine at McGill University, "the Pill was the most widely used method of birth control in the United States." The demand for easy, efficient, female-driven birth control meant women found ways to get past nervous, moralizing restrictions. Doctors had to adjust to a changed world or lose their patients.

The ban astonishes me now. At the time, my father was an obstetrician and gynecologist who energetically promoted the Pill as a necessity of modern life. I can remember my mother's cool-looking dispensers lying around the house, with the built-in calendar I didn't quite understand - my sisters added her discards to their toys and worked them into the little dramas they invented for their dollies. Moral lawlessness had a very strange face, at least in our household.

"There has always been a huge disjunction in medical history," Prof. Tone says, "between what's officially recommended and what goes on. It's much more politically savvy for companies to declare that they're giving honest married women and their husbands a better way to time their pregnancies than to come out and say, 'Let's empower all women to do what they want with their bodies.'

"These companies were smart. They knew what would sound threatening and what would be reassuring."

So it's hardly surprising that the story of the Pill took a different turn from the first idealistic forecasts, while feeding some of the moralizers' fears. "The Pill doesn't trigger the sexual revolution," Prof. Sethna says, "but it certainly marches hand in hand with it. For single women, the Pill was seen as a godsend."

The fading of that just-pilled glow

All the same, many historians argue that the medicalization of birth control is a far more revolutionary consequence of the Pill than any effect it may have had on sexual relations.

"Prior to 1960, it was rare for a woman to talk to a doctor about birth control," Prof. Tone says. "But the Pill required a gynecological exam, a consultation and discussion about intimate matters, which led to the wider conversation about women's health."

Critical thinking about pharmacology didn't start right away - this product of the buoyant 1950s initially arrived with the kind of optimism attached to its hip contemporary, the tranquillizer. "The Pill fits into the same paradigm," Prof. Tone says. "You can be empowered to take charge of your life, whether it's controlling your emotions or avoiding getting pregnant."

But as the high levels of estrogen in the Pill's early formulations produced painful, even deadly effects (thrombosis, stroke), the sense of empowerment shifted. Skepticism about drug companies became much more habitual. Persistent campaigning by women's-health advocates led directly (if too slowly) to the now-ubiquitous package inserts that spell out a product's many risks and help demystify the claims of the drug makers.

My mother, a long-time smoker and an early user of high-dose birth control, suffered a massive stroke at 62. It's not hard to connect dots.

The Pill remains paradoxical on this front, revealing all too perfectly our society's wish to believe in easy miracle drugs. Whatever else it accomplished, the Pill showed for the first time how much money could be made by selling drugs to people who weren't sick.

Fifty years on, birth-control demand is driven by the kind of marketing hype the Mad Men of the 1950s would never have associated with chancy delights and risks of sexual encounters.

Health advocates like to talk about the broad range of contraceptive choices tailored to suit women's individual needs, and yet hormonal birth control (expanded to include the patch, the implant and the vaginal ring as well) is clearly top of the heap.

Drug companies have touted subtle variations on the 50-year-old theme, such as the ability to have a period only four times a year, or the "do-it-all" benefits of the popular "multitasking" pill. Yes, you can have birth control, but isn't that a bit boring when at the same time you could have better skin tone, less bloating and reduced PMS?

"There's very little that's new," Prof. Tone says. "Pretty well everything's an iteration of what the 1960 Pill brought to the scene, and the tendency is not to be innovative but to stick to the tried-and-true in oral contraception. … It was so successful both medically and financially that it's kept all our options in the hormonal box."

For Sari Kives, who works with adolescents at Toronto's Hospital for Sick Children, the Pill and its variants that promise ease of use, lower-hormone dosages and reduced side effects are a good fit with her young clientele.

At the same time, conscious of the culture in which she lives, Dr. Kives makes a point of noting that "taking the Pill does not equate with being sexually active. Fifty per cent of the time, I'm prescribing for painful periods or profound menstrual irregularity or bad acne. I don't even talk about sex in many cases."

A new wave just says 'no'

But even as health-care researchers extol the myriad benefits of the Pill, dissent is rising from a new wave of young women skeptical of adding hormones to their already potent bodily mix. My 25-year-old daughter, angered by what she suffered during years of drug experiments designed to alleviate menstrual pains, is one of them.

"During my adolescence," Liz told me recently, explaining things I never quite knew at the time, "going on the Pill was a rite of passage into puberty as commonplace as buying one's first soft-cup pre-bra or suffering through condom-on-banana demos in sex-ed programs. I could deal with my own raging hormones, but as new ones were introduced, my body began to feel foreign.

"The moodiness, the anger, the inexplicable sadness weren't me. The drug's merits were continually touted even as I detailed marathon periods, substantial weight gain and depression," she says.

"But when the Pill can be marketed for non-birth-control purposes, companies are able to sell kids on their product and get them hooked while they're young: It's become as practical for their needs at 13 as it will be when they're 18."

In 2010, the biggest challenge with the Pill may be saying no to it, or finding a more body-friendly alternative.

"We're not making it easy enough for women to choose non-hormonal methods of birth control," says Laura Werschler, the executive director of Sexual Health Access Alberta, who advocates a natural, fertility-awareness approach.

Though the designers of the Pill hoped to end abortion, Statistics Canada reports that induced abortions still occur at the rate of 25.7 per 100 live births (as of 2006).

"Why are there so many unintended pregnancies?" Ms. Werschler asks. "It's often said that the best birth-control method is the one you will use. So maybe the Pill isn't a success for everyone."

And yet after 50 years, it's hard to dispute the Pill's place in the annals of reproduction: It's outlasted and outdistanced its cumbersome rivals, made the leap from utopian and dangerous to everyday and normal, offered easy liberation in a convenient oral format and fended off all its critics, as if they were the exception and it had become the rule.