The Male Pill is the first book to reveal the history of hormonal contraceptives for men. Nelly Oudshoorn explains why it is that, although the technical feasibility of male contraceptives was demonstrated as early as the 1970s, there is, to date, no male pill. Ever since the idea of hormonal contraceptives for men was introduced, scientists, feminists, journalists, and pharmaceutical entrepreneurs have questioned whether men and women would accept a new male contraceptive if one were available. Providing a richly detailed examination of the cultural, scientific, and policy work around the male pill from the 1960s through the 1990s, Oudshoorn advances work at the intersection of gender studies and the sociology of technology.
Oudshoorn emphasizes that the introduction of contraceptives for men depends to a great extent on changing ideas about reproductive responsibility. Initial interest in the male pill, she shows, came from outside the scientific community: from the governments of China and India, which were interested in population control, and from Western feminists, who wanted the responsibilities and health risks associated with contraception shared more equally between the sexes. She documents how in the 1970s, the World Health Organization took the lead in investigating male contraceptives by coordinating an unprecedented, worldwide research network. She chronicles how the search for a male pill required significant reorganization of drug-testing standards and protocols and of the family-planning infrastructure—including founding special clinics for men, creating separate spaces for men within existing clinics, enrolling new professionals, and defining new categories of patients. The Male Pill is ultimately a story as much about the design of masculinities in the last decades of the twentieth century as it is about the development of safe and effective technologies.
About the Author
Nelly Oudshoorn is Professor of Gender and Technology at the University of Twente in the Netherlands. She is the author of Beyond the Natural Body: An Archaeology of Sex Hormones and coeditor of Bodies of Technology: Women’s Involvement with Reproductive Medicine and How Users Matter: The Co-Construction of Users and Technology.
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The male pillA biography of a technology in the making
By Nelly Oudshoom
Duke University Press
Chapter OneDesigning Technology and Masculinity: Challenging the Invisibility of Male Reproductive Bodies in Scientific Medicine
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We are living in challenging times. For the first time in history, male reproductive bodies are in the headlines, breaking the silence that made them largely invisible in the past. The most compelling sign of this change is the hype in the news media following the introduction of Viagra, a pill for the treatment of male impotence, in the late 1990s. Never before has a drug received such rapid worldwide approval and distribution. Viagra was originally developed to treat high blood pressure, but it has been marketed as a drug for impotence, as a response to its subversive use by test subjects who were reluctant to return their leftover pills after they discovered the "unintended consequences" of the drug. As a pharmaceutical product, it has enjoyed the fastest takeoff ever recorded for a new drug (Handy 1998: 39). On the very day Viagra became available in the United States, urologists and sexologists were overwhelmed by requests from men asking for prescriptions. Month-long waits to see a doctor for a consultation were not unusual (Ibid.). Within a year, Viagra had become one of the best-selling drugs in the United States, doubling the value of shareholders' investments at Pfizer, Inc.,the manufacturer of the new drug (Berends 1998: 2).
The story of Viagra illustrates how technology can be instrumental in giving visibility to male reproductive bodies: the drug transformed male impotence from a private matter, confined to the bedroom or the sexologist's clinic and considered the last sexual taboo of the twentieth century, into a health condition firmly entrenched in the public domain (Garschagen 1998). This is not to say that male impotence came to be represented in a manner similar to other dysfunctions of the male body. The manufacturer's promotional materials for Viagra were carefully designed to avoid any suggestion of failing male bodies. Advertisements in the United States emphasized impotence as "a couple's condition" rather than as a dysfunction of the male body (Handy 1998: 45; Mamo and Fishman 1999: 4). Less spectacular, but equally illustrative, is the attention given by the news media to scientific research that reported a decline in male fertility due to environmental pollution. In the mid-1990s, the book Our Stolen Future, dubbed The Silent Sperm by journalists, and similar reports were discussed extensively in Western media (Colborn, Dumnoski, and Meyers 1996; Naald 1996).
This increased attention to the male reproductive body is also exemplified by significant developments in the medical world, which did not receive such extensive news coverage. In the mid-1990s, in London, two clinics that specialized in men's health issues emerged: the WellMan clinic and the Andropause Clinic (Nowak 2000). In 1998 the newly formed International Society for the Study of the Aging Male organized the First World Congress on the Aging Male in Geneva. Co-sponsored by the World Health Organization, the congress attracted more than 350 delegates from over forty countries and issued the Geneva Manifesto: "a call for a new initiative to achieve healthy aging for men and calling on support from governments, industry and philanthropic agencies" (Geurts 1998). In the late 1990s Swedish and American manufacturers introduced the first hormonal patch and a gel as testosterone replacement therapies for aging men, both of which received an unexpectedly positive response (Johnson 1997; Kaufman 2000). And, last but not least, reproductive scientists have been involved for more than three decades in the development of a hormonal contraceptive for men, which is the topic of this book.
Female Reproductive Bodies as Natural Objects of Intervention
All in all, developments in contraceptive technology for men must be considered revolutionary. In the twentieth century most of the attention in reproductive medicine has been focused on women rather than men. The century witnessed the introduction of numerous technologies designed to intervene in female reproductive functions, transgressing boundaries which for ages were perceived as natural. Diagnostic procedures and therapies such as in vitro fertilization (IVF), hormone replacement therapy (HRT), screening programs for breast and cervical cancer, the contraceptive pill, and a wide variety of other contraceptives for women have accentuated the distinct reproductive role of women and thus designated the female body as a natural object for intervention (Dyck 1995: 15; Ploeg 1998: 28).
The identification of the female body as the quintessential medical object has a long history. In the late nineteenth and early twentieth centuries, the view that sex and reproduction were "more fundamental to Woman than Man's Nature" (Moscucci 1990) resulted in the creation of a new specialty in the biomedical sciences: gynecology. In her fascinating account of the rise of the "Science of Women," Ornella Moscucci has described how "the belief that the female body is finalized for reproduction defined the study of 'natural woman' as a separate branch of medicine." With the emergence of gynecology women became identified as "a special group of patients" (2). The turn of the last century witnessed the founding of societies, journals, and hospitals specifically devoted to the diagnosis and treatment of the female body. "Woman" thus came to be set apart in the discursive and institutional practices of the biomedical sciences.
Consequently, "woman" became conceptualized as an ontologically distinct category which firmly established the view of Woman as the Other. This meant a definitive rejection of what Thomas Laqueur has characterized as the one-sex-model of medical practice, in which the female body was understood as a lesser version of the male body rather than as a different sex (Laqueur 1990: viii, 4). The growth of gynecology was not paralleled by the establishment of a complementary science of masculinity (Oudshoorn 1994a). "As the male was the standard of the species, he could not be set apart on the basis of his sex" (Moscucci 1990: 32).
This institutional process of othering was continued and reinforced by the rise of sex endocrinology, a discipline that emerged in the 1920s and 1930s and was devoted to the study of sex hormones. In Beyond the Natural Body I described how the very existence of gynecology as a speciality facilitated a situation in which the new science of sex endocrinology focused almost exclusively on the female body. The then current gynecological practices transformed the female body into an easily accessible supplier of research materials and a convenient guinea pig for tests, creating an organized audience for the products of sex endocrinology in the process. Both laboratory scientists and pharmaceutical firms depended on these institutional practices to provide them with the necessary tools and materials to transform the hormonal model of the body into a new set of disease categories, diagnostic tools, and drugs. Sex endocrinologists integrated the notion of the female body as a reproductive body into the hormonal model, but not without thoroughly changing it. They provided the medical profession with tools to intervene in processes that had been considered inaccessible prior to the hormonal era. The introduction of diagnostic tests and drugs enabled the medical profession to intervene in the menstrual cycle and menopause, thus bringing these "natural" processes of reproduction and aging into the domain of medical intervention.
With the introduction of the concept of sex hormones, scientists explicitly linked women's reproductive functions with laboratory practice. The study of woman as the Other was thus extended from the clinic to the laboratory and thereby firmly rooted in the heart of the life sciences. The existence of established networks of researchers who were focused on hormones and the female body facilitated the development of hormonal contraceptives for women in the late 1950s. This asymmetry in the institutionalization of female and male reproductive bodies in medicine prevailed until well into the second half of the twentieth century. It was only in the late 1970s that scientists and clinicians established andrology as a medical specialty devoted to the study and medical treatment of male reproductive bodies (Niemi 1987; Moscucci 1990: 32, 33). Today, andrology is still a small and marginal profession compared to gynecology.
Gender Asymmetry in Contraceptives
Bearing in mind this short history of the institutionalization of the female reproductive body in medicine, it will come as no surprise that development of the first physiological contraceptives focused exclusively on women. Since World War II thirteen new contraceptives for women have been developed, including the contraceptive pill. This is in sharp contrast to contraceptives for men (Davidson et al. 1985). In the past century, no new male methods have been developed, except for the improvement of existing methods, namely condoms and sterilization, both of which date from the nineteenth century. Rubber condoms were first introduced around 1860, whereas vasectomy (male sterilization) dates from the late 1890s. In the 1950s improved condoms were developed, and in the 1990s condoms made from polyurethane and other polymers were introduced (Clarke 1998: 166, 167). The "contraceptive revolution" thus remained largely restricted to female methods. In the mid-1990s, only approximately 8 percent of the contraceptive research budget was spent on the development of contraceptives for men (Sachs 1994: 17V).
The gender asymmetry in contraceptives was first challenged in the late 1960s and early 1970s. As in the case of the Pill for women, the request to develop new male contraceptives originated outside the scientific community. In this instance, social pressures came from two different sides: feminists in the Western industrialized world and Southern governments, most notably those of China and India. Feminists demanded that men share the responsibilities and health hazards of contraception, whereas governmental agencies urged the inclusion of "the forgotten 50% of family planning" as a target for contraceptive development (Handelsman 1991: 230; Wu 1988: 443). In the 1970s and 1980s the question "What about a male pill?" appeared at regular intervals in newspaper headlines, particularly in periods during which the serious health risks of the female Pill were reported (Gossypol Prospects 1984: 1108). Although research in male reproduction and the development of new male contraceptives has increased as a result of these pressures, the Pill's "male twin" has yet to appear on the market.
Since the early 1970s, our language has thus become enriched with a new term: the male Pill. The fact that this term has been part of our language for almost three decades shows a peculiar pattern in the cultural embedding of a technology. In contrast to other technologies, where embedding processes evolve with the diffusion of the technology, the very idea of an oral contraceptive for men has become firmly entrenched in our culture today, although the technology itself does not exist. The concept of the male Pill thus functions as a confusing cultural symbol. People who are not informed about the contraceptives currently available might be inclined to believe that both women and men can choose oral contraceptives. For others, the term symbolizes a promising technology that nevertheless seems to have had difficulty coming into existence. Over the last two decades, journalistic texts have reported on "breakthroughs" in research on new contraceptives for men, reiterating the phrase "the Male Pill," and thus promoting the idea that it is on the edge of becoming a viable technology. Headlines from U.K. newspapers in the late 1990s-"Race for Male Pill," "So within five years we might have a reliable male contraceptive pill," and "Men will be on the pill in five years"-exemplify this point (Jourdan 1997; Improving men's reproductive health 1997; Lawson 1997). Similar promises can be found in scientific texts in which scientists announce that new male contraceptives will be available within five or ten years. Scientists in the 1970s spoke of the year 1984 as the most likely date when new male contraceptives would become available, whereas in the 1980s and 1990s the year 2000 was frequently mentioned as the magical date. With time, scientists have become more reluctant to forecast the arrival of the male Pill, to avoid continually disappointing the news media and potential users. They seem to realize that it can be risky to forecast specific developments if they are not sure whether they can keep their promises, and that the news media and potential users of male contraceptives may become discouraged by unfulfilled expectations of the technology-in-the-making, eventually losing interest in the entire endeavor. In the case of male contraceptive technology, this is not too far-fetched: male contraceptives have been held up as a promising technology for three decades already, whereas the development trajectories of other contraceptives usually cover a period of twelve to fifteen years (United Nations 1994a: 2).
Beyond Essentialism Reflecting on the history of contraceptive development in the twentieth century evokes the question of how we should interpret the delay in the development of new contraceptives for men. This question has intrigued me for many years and eventually became my incentive to write this book. Explanations for the asymmetry of medical interventions in female and male reproductive bodies usually draw on essentialist views on gender, technologies, and bodies. Since the Enlightenment it has generally been assumed that "a progressive growth of scientific knowledge will uncover the natural order of things" (Smart 1992). Biomedical scientists and traditional philosophers have encouraged us to assume that women's bodies are simply closer to nature, and consequently easier to incorporate into biomedical practice. In this view, techniques to intervene in male reproductive bodies have not proliferated because the male reproductive system is by nature more resistant to intervention than that of women. In women, so the argument goes, contraception requires interference with ovulation, which occurs "only once each month." In men, on the other hand, contraception requires intervention in the production of large numbers of sperm cells, which are produced each day throughout an adult male's lifespan. This representation strategy is used in many texts in scientific journals and newspapers as a tool to convince the reader that the delay in the development of male contraceptives is caused by the nature of male bodies and not by male bias, as has been claimed by feminist health advocates:
What are the facts about male contraceptive research? Is the failure thus far to find a new male method comparable to the pill indicative of male disinterest in women's well-being? I don't think so. The simple fact is that the number of targets-spermatogenesis, sperm maturation, sperm transport, and possibly, the chemical constitution of the seminal fluid-is far more limited in males than females. It is not surprising, then, that the number of approaches under study is fewer for male than for female methods. Even the forces of women's liberation cannot change the fact that the reproductive analogies between male and female end with sperm transport and egg transport, and that all subsequent events potentially subject to controlled interference occur only in the female. (Segal 1972)
It's not easy to design a male contraceptive. All you have to do with women is to knock out the production of one egg per month, but men produce something like 250 million sperm cells per ejaculation. Suppressing this gigantic factory of sperm production in men is a lot more difficult.
Conversely, however, other biologists argue that it is easier to suppress sperm production than the production of eggs:
There is no evidence that it is more difficult to prevent "billions" of sperm from being produced, or acting, than one egg. The difference is not the numbers produced, but the discontinuity of egg production in the female and the continuity in the male. In many ways, it is easier to target a continuous process (where time of treatment may be unimportant) than a discontinuous process. (Schwartz 1976: 248)
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Table of Contents
Part I. Overcoming Resistance: Constructing Alternative Sociotechnical Networks
1. Designing Technology and Masculinity 3
2. How Man Came to Be Included in the Contraceptive Research Agenda 19
3. Creating a Worldwide Laboratory for Synthesizing Hormonal Contraceptive Compounds 52
4. The Inaccessible Man: The Quest for Male Trial Participants and Test Locations 69
5. The Co-construction of Technologies and Risks 86
Part II. Configuring the User: Articulating and Performing Masculinities
6. The Politics of Language: Changing Family Planning Discourse to Include Men 113
7. Making Room for Men: Configuring Men as Clients of Family Planning Clinics 140
8. "The First Man on the Pill": Disciplining Men as Reliable Test Subjects 171
9. On Masculinities, Technologies, and Pain: The Testing of Male Contraceptives in the Clinic and Media 191
10. Articulating Acceptability 209
11. Technologies of Trust 225