Patricia Braus. The Gale Encyclopedia of Science. Editor: K Lee Lerner & Brenda Wilmoth Lerner. 4th edition. Volume 2. Detroit: Gale, 2008.
Contraception (birth control) is the process of preventing pregnancy by interfering with the normal process of ovulation, fertilization, or implantation. There are different kinds of birth control that act at different points in the process. According to the National Center for Health Statistics, the leading contraceptive method, in the United States, for women 15 to 29 years of age is the birth control pill, followed by female sterilization, and male sterilization.
Every month, a woman’s body begins the cycle that can potentially lead to pregnancy. An egg matures, the mucus that is secreted by the cervix (a cylindrical-shaped organ at the lower end of the uterus) changes to be more inviting to sperm, and the lining of the uterus thickens in preparation for receiving a fertilized egg. Efforts to prevent pregnancy have been attempted since ancient times and in many cultures. Contraception methods ranged from the use of tampons treated with herbal spermicide by the Egyptians in 1550 BC to the use of animal membrane condoms in the eighteenth century. The introduction of the oral contraceptive pill in 1960 launched a new era, making contraception easier and more effective than earlier methods. However, sterilization remains the method used most frequently in the world.
In the United States, about two-thirds of women between 15 and 44 years of age use contraception. Worldwide, contraceptive use increased 10-fold from 1963 to 1993, and have continued to increase in usage since then, now well into the 2000s. However, contraception remains controversial, with some religious and political groups opposed to the distribution of contraceptives.
An Ancient Interest
A survey of early contraceptive methods reflects an odd combination of human knowledge and ignorance. Some methods sound absurd, such as the Variety of contraceptive methods. (Gary Parker Photo Researchers, Inc.) Variety of contraceptive methods. (Gary Parker/Photo Researchers, Inc.) suggestion by ancient Greek Dioscorides that wearing of cat testicles or asparagus would inhibit contraception. Yet some early methods used techniques still practiced today.
The Egyptian contraceptive tampon, described in the Ebers Papyrus of 1550 BC, was made of lint and soaked in honey and tips from the acacia shrub. The acacia shrub contains gum arabic, the substance from which lactic acid is made, a spermicidal agent used in modern contraceptive jellies and creams.
Aristotle was one of many ancient Greeks to write about contraception. He advised women to use olive oil or cedar oil in the vagina, a method which helps inhibit contraception by slowing the movement of sperm. Other Greeks recommended the untrue contention that obesity was linked to reduced fertility.
Roman birth control practices varied from the use of woolen tampons to sterilization, which was typically performed on slaves. Another common ancient practice, still in use today, was the prolonged nursing of infants, which makes conception less likely although still possible.
Ancient Asian cultures drew from a wide range of birth control methods. Women in China and Japan used bamboo tissue paper discs that had been oiled as barriers to the cervix. These were precursors of the modern diaphragm contraceptive device. The Chinese believed that behavior played a role in fertility, and that women who were passive during sex would not become pregnant. They suggested that women practice a total passivity beginning as early as 1100 BC In addition, they suggested that men practice intercourse without ejaculating.
The Chinese were not alone in promoting contraceptive methods based on men’s ejaculation practices. The practice of withdrawal of the man’s penis before ejaculation during intercourse, also known as coitus interruptus, has been called the most common contraceptive method in the world. While it was believed that coitus interruptus prevented conception, preejaculatory fluid can contain sufficient sperm to cause pregnancy. Studies over the past two decades have found that one-third to one-fourth of women in their early child-bearing years who depended on withdrawal became pregnant accidentally within their first year of using the method.
Magical potions were also used extensively throughout the world as contraceptives, including a wide range of herbal and vegetable preparations. Some may have actually caused abortions.
A Controversial Practice
Respectable physicians advocated contraceptive methods in ancient Greek and Roman society. However, by the Middle Ages, contraception had become controversial, in large part due to opposition by the Church. Early Christians were not outspoken about contraception. The first clear statement about sin and contraception was made in the fifth century by Saint Augustine who, with others, wrote that contraception was a mortal sin, a pronouncement that continues to resonate in modern culture. Since the fifth century, the Catholic Church has retained its opposition to all forms of birth control except abstinence and the so-called rhythm method, a calendar-based method involving timely abstinence.
As Christian influence took precedence during the Medieval period, contraceptive knowledge was suppressed. One measure of the primitive level of this knowledge was the writing of Albert the Great (1193-1280), a Dominican bishop, whose writing about sciences included contraceptive recipes. To avoid conception, people were advised to wear body parts of a dead fetus around the neck or to drink a man’s urine.
Many scholars suggest that couples continued to practice contraception during the Middle Ages, in spite of the limited level of official contraceptive knowledge. Even when religious authorities condemned contraception, women passed their knowledge of such practices to one another.
In addition, other religious and cultural traditions maintained support for certain types of contraception during the Middle Ages. Most Jewish authorities supported women’s use of contraceptive devices. Islamic physicians were not limited by the Christian opposition to birth control, and medical writings from the Middle Ages included a wide range of contraceptive information. The Koran, the holy book for Muslims, supported the use of prolonged nursing, and did not oppose other methods. While European Christians condemned contraception, the practice continued in other countries and cultures.
Evolution of the Condom
Prior to the modern era, many of the most effective contraceptives evolved, rather than appearing suddenly as the result of an invention. The development and evolution of the condom is an example of a device that was present for hundreds of years, changing in function and manufacture to fit the times and needs of its users.
Contemporary condoms are used widely for contraception and to prevent the spread of sexually transmitted disease. Initially, condoms were developed for other reasons. Among the earliest wearers were the ancient Egyptians, who wore them as protection against Schistosoma, a type of parasite spread through water. Condoms were also worn as decoration or signs of rank in various cultures.
Condoms emerged as weapons against sexually transmitted disease in Renaissance Europe of the sixteenth century, when epidemics of a virulent form of syphilis swept through Europe. Gabriele Fallopio (1523-1562), an Italian anatomist who performed early studies on the Fallopian tube, advised men to use a linen condom to protect against venereal disease.
By the eighteenth century, condoms were made of animal membrane. This made them waterproof and more effective as birth control devices. Condoms acquired a host of nicknames, including the English riding coat, instruments of safety, and prophylactics. The great lover Casanova (1725-1798) described his use of condoms “to save the fair sex from anxiety.” The Industrial Revolution transformed the condom once again. In 1837, condom manufacturers took advantage of the successful vulcanization of rubber, a process in which sulfur and raw latex were combined at a high temperature. This enabled manufacturers to make a cheaper yet durable product.
In the 1960s and 1970s, many women turned to modern medical contraceptives such as IUDs (intrauterine devices) and birth control pills. However, by the 1980s, condoms experienced another resurgence due to the emergence of acquired immune deficiency syndrome (AIDS), and the discovery that condoms were most effective in preventing its transmission.
For centuries, limited knowledge of women’s physiology slowed the development of effective contraceptives. There was no understanding of the accurate relationship between menstruation and ovulation until the early twentieth century. Yet contraceptive developers did make progress in the nineteenth century.
One major area was in updating the vaginal pessary. The rubber diaphragm and the rubber cervical cap, developed in the nineteenth century, are still in use today. The diaphragm is a disc-shaped object inserted into the vagina designed to prevent the passage of sperm while the cervical cap fits over the cervix.
Spermicides, substances developed to kill sperm, were mass produced by the late 1880s for use alone or for greater effectiveness with other devices such as the diaphragm. Vaginal sponges were also developed for contraceptive use in the late 1800s. Another popular nineteenth century method was douching, the use of a substance in the vagina following intercourse to remove sperm.
Contemporary use of these methods yields varying pregnancy rates. The diaphragm was used by less than 2% of American women who used contraceptives in 2005. Women who depended on spermicides—1.3% of women using contraceptives—experienced about a 20% accidental pregnancy rate in their first year of use. The cervical cap had an accidental pregnancy rate of less than 35% in 2005 among women who had previously given birth at least once. The sponge, which had a first-year accidental pregnancy rate of 18% in 1990 among women who had never given birth, was take off the market in the mid-1990s but was later reintroduced at the end of the decade.
While types of birth control increased in the nineteenth century, the topic of contraception was still considered sordid and unsuitable for public discourse. In the United States, the Comstock Law of 1873 declared all contraceptive devices obscene. The law prevented the mailing, interstate transportation, and importation of contraceptive devices. One effect of this was to eliminate contraceptive information from medical journals sent through the mail.
The social movement to make birth control legal and available challenged the Comstock Law and other restrictions against contraception. By the 1930s, the movement led by Margaret Sanger (1883-1966) had successfully challenged the Comstock Law, and the mailing and transportation of contraceptive devices was no longer illegal. Sanger was also instrumental in developing clinics to distribute birth control devices. Advances in medical knowledge generated new contraceptive methods. The first intrauterine device (IUD), designed to be placed in the uterus, was described in 1909. The IUD was not used widely in the United States until the 1960s when new models were introduced. The copper IUD and the IUD with progesterone made the IUD more effective. Studies in the 1990s and early 2000s found the typical accidental pregnancy rate in the first year of use was less than 3%.
The IUD works by causing a local inflammatory reaction within the uterus causing an increase in leukocytes, white blood cells, in the area. The product that results when the leukocytes break down is deadly to spermatozoa cells, greatly reducing the risk of pregnancy. The IUD devices available in the United States must be inserted by a health provider and typically must be replaced after one to four years. Possible dangers include bleeding, perforation of the uterus, and infection.
Use of the IUD fell from 2.0% in 1988 to 0.08% in 1995, and has dropped even further as of 2005. One reason for this may be fear of lawsuits due to complications. In the United States, government officials pulled the Dalkon Shield IUD off the market in 1974, following reports of pelvic infections and other problems in women using the device. A second explanation may stem from the decision by two major IUD manufacturers to pull back from the U.S. market in the 1980s.
Another method that emerged in the early twentieth century was the rhythm method, which was approved for use by Catholics by Pope Pius XII in 1951. For centuries, various experts on birth control had speculated that certain periods during a woman’s cycle were more fertile than others. But they often were wrong. For example, Soranos, a Greek who practiced medicine in second century Rome, believed a woman’s fertile period occurred during her menstrual period.
As researchers learned more about female reproductive physiology in the early twentieth century, they learned that ovulation usually takes place about 14 days before a woman’s next menstrual period. They also learned that an egg could only be fertilized within 24 hours of ovulation. The so-called calendar rhythm method calculates safe and unsafe days based on a woman’s average menstrual cycle, and calls for abstinence during her fertile period. The method is limited by the difficulty of abstinence for many couples and the irregularity of menstrual cycles.
Several contemporary methods of natural contraception still used. Together, they are referred to as Periodic Abstinence and Fertility Awareness Methods, or natural family planning techniques. They include the rhythm method; the basal body temperature method, which requires the woman to take her temperature daily as temperature varies depending on time of ovulation; the cervical mucus method, which tracks the ovulation cycle based on the way a woman’s cervical mucus looks; the symptothermal method, which combines all three; and the post-ovulation method, where abstinence or a barrier is used from the beginning of the period until the morning of the fourth day after predicted ovulation- approximately half the menstrual cycle. Accidental pregnancy rates for these methods were 20% in the first year of use. Less than 2.1% of Americans used these methods in 2005.
As birth control became more acceptable in the twentieth century, major controversies grew about its social use. A series of mixed court decisions considered whether it is right to force an individual who is mentally deficient to be sterilized. In the 1970s, national controversy erupted over evidence that low-income women and girls had been sterilized under the federal Medicaid program. Federal regulations were added to prohibit the forced sterilization of women under the Medicaid program. Legal debates still continue on the issue of whether certain individuals, such as convicted child abusers, should be required to use contraceptives.
The Pill and Its Offspring
The development of oral contraceptives has been credited with helping to launch the sexual revolution of the 1960s. Whether oral contraceptives, also known as the pill, should take credit for broadening sexual activity or not, their development changed the contraceptive world dramatically. In 1988, oral contraceptives were the most popular reversible contraceptive in the United States, with 30.7% of all women who used birth control using them, second only to sterilization. That rate dropped to 26.9% by 1995, and has further decreased to 19% in 2005. The accidental pregnancy rate among women using oral contraceptives is less than 3%.
The development of oral contraceptives incorporated great advances in basic scientific knowledge. These included the finding in 1919 that transplanted hormones made female animals infertile, and the isolation in 1923 of estrogen, the female sex hormones.
For years, the knowledge that hormones could make animals infertile could not be applied to humans because of the expense of obtaining naturally-occurring estrogen. Until chemist Russell Marker developed a technique for making estrogen from plant steroids in 1936, estrogen had to be obtained from animal ovaries. Scientists needed ovaries taken from 80,000 sows to manufacture a “fraction of a gram” of estrogen.
Once synthetic hormones were available, the creation of oral contraceptives was limited by a lack of interest in the development of new birth control devices among drug companies and other conventional funding sources. Gregory Pincus (1903-1967), who developed the oral contraceptive, obtained only limited funding from a drug company for his research. The bulk of his funding was from Katherine McCormick, a philanthropist, suffragist, and Massachusetts Institute of Technology graduate who was committed to broadening birth control options.
The birth control pill, approved for use in the United States in 1960, uses steroids to alter the basic reproductive cycle in women. Pincus knew that steroids could interrupt the cyclic release of a woman’s eggs during ovulation. Most pills use a combination of synthetic estrogen and progestin, although some only contain progestin. The steady levels of estrogen and progestin, obtained through daily oral contraceptive doses, prevent the release from the hypothalamus of gonadotrophin, a hormone which triggers ovulation. The pill also changes the cervical mucus so it is thicker and more difficult for sperm to penetrate.
Oral contraceptives can cause weight gain, nausea and headaches. In addition, women who smoke and are over 35 are advised not to take oral contraceptives due to risk of stroke. Oral contraceptives slightly increase the risk of cervical cancer, but they decrease the risk of endometrial and ovarian cancers.
Other contraceptives have drawn from oral contraceptive technology, including several which work for a long period of time and do not require daily doses of hormones. Norplant, approved for use in the United States in 1991, is a hormone-based contraceptive which is surgically implanted in the arm and which lasts approximately five years. It distributes a steady dose of the hormone progestin, which inhibits ovulation and alters cervical mucus to reduce movement of the sperm. The implant is highly effective. Of the 1.3% users in 1995, the accidental pregnancy rate was less than 0.95%. However, the side affects include excess bleeding and discomfort, which sometimes force removal of the device, and difficulty in removing the implants. In 2002, the distribution of Norplant in the United States was stopped. It continued to be used until 2004, when supplies were exhausted.
Several long-term contraceptives are injectable and also use progestin to inhibit ovulation. The most widely used is Depo-Medroxyprogesterone Acetate, also known as Depo-Provera or DMPA. The method is used in more than 90 countries but not widely in the United States. The drug, which is given every three months, is popular internationally, with as many as 3.5 million users worldwide. Fewer than 0.3% of women taking DMPA get pregnant accidentally. Most women who take DMPA for long periods of time stop having a regular menstrual cycle. The drug also causes temporary infertility after use.
Morning after pills are used in emergency contraception after a woman has had unprotected sex (such as after a rape). It cannot be used to terminate an already-established pregnancy. Doctors sometimes prescribe higher doses of combined oral contraceptives for use as morning after pills to be taken within 72 hours of unprotected intercourse to prevent the possibly fertilized egg from reaching the uterus. While there is no guarantee, the morning-after pill probably decreases the chance of getting pregnant by 89 to 95%, where effectiveness declines with the delay between sex and the morning after pill. The morning after pill was officially recognized as safe and effective by the U.S. Food and Drug Administration (FDA) in February 1997.
Scientists are not sure exactly how it works, but they suspect that the large doses of hormones either prevent the lining of the uterus from getting thick enough to allow an egg to implant or that the hormones interfere with ovulation in some way, slowing the way the egg travels through the fallopian tube. Unfortunately, the larger doses of hormones may cause side effects similar to (but stronger than) the side effects associated with a regular dose of birth control pills. The next menstrual period may be late because of the pills, but if there is no period within three weeks of treatment, pregnancy needs to be ruled out.
The sponge is a donut-shaped polyurethane device containing the spermicide nonoxynol-9 that is inserted into the vagina to cover the cervix, much like a diaphragm. A woven polyester loop is attached for easy removal. The sponge is a low cost, nonprescription product that protects for multiple acts of sex for 24 hours. It should remain in place for at least six hours after sex for contraceptive protection, but no more than 30 hours after insertion because of the slight risk of toxic shock syndrome. The sponge (Today®) had been taken off the market in 1995 for financial reasons. The sole manufacturer, Whitehall Laboratories of Madison, New Jersey, decided it would cost too much to correct manufacturing problems the FDA had discovered. (The FDA stressed that there never was any problem with the safety of Today®, just with the manufacturing process at the factory.) About 116,000 American women had been using the sponge when its manufacturer stopped production, making it the most popular choice among methods that did not require a doctor’s visit. The only other nonprescription choices were spermicide and male and female condoms; unlike those options, the sponge could be inserted up to 24 hours before sex and did not require new applications for repeated intercourse.
Although competing sponges were sold in France, Canada, and a few other countries, once Today® was off the U.S. market, no contraceptive sponge was sold in this country until 1999, when Allendale Pharmaceuticals of New Jersey reintroduced the sponge to the U.S. market. Because the FDA never revoked the approval of Today®, getting it back on the market was not difficult.
Sterilization, the surgical alteration of a male or female to prevent them from bearing children, is a popular option. While sterilization can be reversed in some cases, it is not always possible, and should be considered permanent. In 1995, 38.6% of all contraceptive users aged 15 to 44 years used sterilization, a slight decrease from the 1988 rate of 39%, which was an increase from 34% in 1982. As of 2004, about 6% of men (aged 15 to 44 years) use male sterilization and around 17% of females (of the same age range) use female sterilization. Internationally, sterilization is also extremely common, with over one-third of all women having been sterilized in Brazil, China, and India.
Sterilization of women is more popular than sterilization of men, even though the male operation, called vasectomy, is simpler and takes less time than the female operation, called tubal ligation. Tubal ligation, which takes about an hour, calls for sealing the tubes that carry eggs to the uterus. The incision to reach the oviducts can either be made conventionally or by using laparoscopy, a technique which uses fiber optic light sources to enable surgeons to operate without making a large incision. Women continue to produce eggs following a tubal ligation, but the ovum is blocked from passage through the fallopian tube and sperm cannot reach the ovum to fertilize it. The ovum eventually degenerates.
A vasectomy is a type of male sterilization in which the doctor seals, ties or cuts the vas deferens (the tube which carries the sperm from the testicle to the penis). Vasectomy is a quick operation (usually under 30 minutes) with only minor post surgical complications such as bleeding or infection. A man can resume sexual relations a few days after surgery, but there may still be some mature sperm in the reproductive tract, so the possibility of pregnancy still exists during this time. Typically, a man should ejaculate 15 times after a vasectomy before he is infertile. It is best to use some other form of birth control method until a doctor can verify the sperm count is zero. Vasectomy and tubal ligation are considered to be safe procedures with few complications.
Very few birth control devices are 100% foolproof; often times, people do not use the methods correctly or consistently. In the event of an unplanned pregnancy, a couple has the choice of ending the pregnancy or carrying the baby to term. If termination is chosen, the woman should seek help from a licensed abortion provider, since the earlier a pregnancy is ended, the less dangerous to the mother. Although abortion is currently legal in the United States, some states do have mandatory waiting periods, some require parental involvement for minors, and some require that a doctor present graphic material designed to discourage abortion.
A medical abortion is an abortion triggered by the use of drugs. Approved by the FDA in 2000, mifepri-stone (Mifeprex®, formerly known as the French abortion pill, or RU 486) has been used as a means of pregnancy termination. Unlike surgical abortion, which is often not done before the seventh or eighth week of gestation, medical abortion can be used earlier—as soon as pregnancy is determined. The drugs use antiprogestins that block the action of natural progesterone; without progesterone’s effects, the uterine lining softens and breaks down, leading to menstruation. This is most effective when used in the first weeks after fertilization and implantation, when progesterone is being produced mostly by the ovaries. As pregnancy proceeds, the placenta takes over progesterone’s role, and the antiprogestins are less effective.
A surgical abortion is the only type of FDA-approved abortion currently available in the United States; in some states, it is very difficult to obtain. Abortion services are offered in hospitals and clinics, and usually are done before 12 weeks of gestation. After 11 to 12 weeks, complication rates escalate. The most common technique is to use suction to remove the uterine contents; if the pregnancy is beyond 15 weeks, the process is more complicated because of the size of the fetus. After a surgical abortion, women will experience light to medium bleeding over five to seven days, and cramps. Most doctors recommend not having sex until the cervix has closed (usually when the bleeding stops).
There is no perfect form of birth control. Every method has a certain failure rate and side effects. Some methods carry additional risks. However, every method of birth control has fewer risks than pregnancy.
Challenges of Contraception
Birth control policies and practices are controversial in the developed and the developing worlds. In developed countries, such as the United States, contraceptive methods fail frequently. Many of the types of contraceptives used commonly by Americans have well-documented rates of failure. One measure of the number of unwanted pregnancies is the rate of abortion, the surgical termination of pregnancy. Abortion and the controversial antigestation drug, RU 486 (Roussel-Uclaf), are not considered routine birth control methods in the United States. Although all individuals who receive abortions do not practice birth control, it is clear that many women do become pregnant when contraceptive methods fail.
Abortion rates typically are highest in countries where contraceptives are difficult to obtain. For example, in the Soviet Union in the early 1980s, when contraceptives were scarce, 181 abortions were performed annually for every 1,000 women aged 15 to 44 years; in 1990, 109 for every 1,000 women; and 1992, 98 per 1,000. In comparison, in the 1980s in selected western European countries where contraceptives are more easily obtained, the rate did not exceed 20 per 1,000.
In the 2000s, the abortion rate in the United States is typically higher than in many other developed countries. According to Advocates for Youth, the United States has a teen abortion rate, as of 2005, that is eight times higher than the rate in Germany, seven times higher than the Netherlands, and almost three times higher than in France. Several studies in the 1990s and 2000s, have found that western democracies with lower abortion rates, especially with regards to teenagers, tended to have contraceptive care that was more accessible through primary care physicians.
Some experts believe that more access to contraceptive services would result in lower rates of accidental pregnancy and abortion. However, vigorous debate concerning programs to deliver contraceptives through school-based clinics and in other public settings has polarized the United States. For example, religious groups such as the Roman Catholic Church have opposed funding for greater accessibility of contraceptive services because they believe the use of any contraceptives is wrong.
Internationally, use of contraceptives has increased dramatically from the years 1960 to 1965, when 9% of married couples used contraceptives in the developing countries of Latin America, Asia, and Africa. By 1990, over 50% of couples in these countries used contraceptives, and that percentage has continued to climb into the 2000s.
China has taken an aggressive policy to limit population growth, which some experts have deemed coercive. Couples—who agree to have one child and no more—receive benefits ranging from increased income and better housing to better future employment and educational opportunities for the child. In addition, the Chinese must pay a fine to the government for each extra child.
Numerous problems exist that prevent the great demand for contraceptive services in developing countries from being met, due in part to the general difficulty of providing medical care to poor people. In addition, some services, such as sterilization, remain too expensive to offer to all those who could use them. Experts call for more money and creativity to be applied to the problem in order to avoid a massive population increase.
Future Contraceptive Methods
The high cost in time and money of developing new contraceptive methods in the United States creates a barrier to the creation of new methods. In the early 1990s, a new contraceptive device could take as long as 17 years and up to $70 million to develop. Yet new methods of contraception are being explored. One device in clinical trials is a biodegradable progestin implant that would last from 12 to 18 months. The device is similar to Norplant but dissolves on its own. A device being explored by a Dutch pharmaceutical company is a ring that rests against the uterus releasing low dosages of estrogen and progesterone. The ring would remain in place for an extended period. In May, 1998, a new oral contraceptive for women— the first to use a shortened “hormone-free interval” and lower daily doses of estrogen—was approved by the U.S. Food and Drug Administration (FDA). In 2006, the FDA approved a new implant called Implanon. It uses one rod as a contraceptive subdermal implant, which is inserted under the skin of the upper arm.
Other research focuses on male contraceptive methods. In 1996, the World Health Organization hailed a contraceptive injection of testosterone that drastically reduces the sperm count and which is 99% effective. At that time, this contraceptive was reported to be available within five to ten years (which failed to materialize). In 2003, Australian researchers performed a trial of the male contraceptive and showed it to be 100% effective and free of side effects. Over the next two years, another study performed by U.S. and Italian researchers performed another study on it. As of November 2006, researchers are predicting that the public release of this male contraceptive is still a few years away. Two other studies in male birth control are ongoing—one focuses on preventing sperm from breaking the egg’s gel-like protective coating; the other on blocking protein receptors on the sperm so it cannot dock with the egg.
Western controversy over contraception continues. There is still disagreement concerning how widely contraception should be made available and how much public money should be spent on birth control. The conclusion of a report from the Institute of Medicine released in May 1996 (but which is still valid in 2006) entitled Contraceptive Research and Development: Looking to the Future, reads, “despite the undeniable richness of the science that could be marshalled to give the women and men of the world a broader, safer, more effective array of options for implementing decisions about contraception, child-bearing, and prevention of sexually transmitted disease, dilemmas remain. These dilemmas have to do with laws and regulations, politics and ideology, economics and individual behavior, all interacting in a very complex synergy that could lead to the conclusion that nothing can be done to resolve the dilemmas because everything needs to be done.”