2 Contraception before the Pill

Modern contraception has its roots in neo-Malthusianism. Thomas Robert Malthus, in the book An Essay on the Principle of Population (1798), theorized that while the availability of resources to feed humans grows at a steady state, the population expands at a higher rate than those resources. Periodic food shortages and the deaths by starvation that resulted were nature’s way of correlating population growth with resources. War and disease had similar effects, which Malthus called “positive checks,” and these fell in line with “preventative checks,” or individual decisions to practice abstinence, to delay marriage, or to use other means (such as withdrawal) to curb the number of children. The book, as is abundantly clear, justified a lack of care toward poor and indigent people, and it contained the seeds of the doctrine—neo-Malthusianism—that motivated many contraceptive promoters in the late nineteenth and early twentieth centuries.1

Advocates of neo-Malthusianism left behind Malthus’s cruel idea of positive checks on population but developed a new perspective on preventative checks that justified the distribution of contraceptive information and goods. For them, preventative checks were actions that individuals could take to limit offspring and to forward the aim of “population control.” In the late nineteenth century, this term signified the goal of maintaining the human population at a steady level, limiting interclass conflict, and helping people not to produce more children than they wanted or could afford. It is not hard to see how those goals for using contraceptive technologies—which were often classist, racist, and paternalistic—morphed into arguments for using those same technologies for eugenic purposes. And rarely did population controllers mention a connection between freedom from pregnancy concerns and an increase in women’s sexual pleasure and satisfaction.

Thus, although the public discussion, manufacture, marketing, sale, and distribution of goods for contraceptive purposes were illegal in many countries until the late 1920s or 1930s or even later, those goods and knowledge of behavioral methods were nonetheless obtainable depending on multiple factors—access to the goods themselves, funding to purchase them, knowledge of how to use them properly (often requiring literacy or access to healers or medical professionals), motivation to use them, agreement of a partner, and often willingness to break the law. The following sections review each of the methods in use between the 1880s and 1960, some of which were free and available to anyone, and others that were available only for purchase.

Diaphragms and Cervical Caps

The first mention of custom-made rubber cervical caps was in the Berlin-based physician Friedrich Adolph Wilde’s 1838 treatise “Das weibliche Gebär-unvermögen” (“The Female Inability to Give Birth”), but dependable and commercially available contraceptive barrier methods for women were developed after the vulcanization of rubber in the United States and England in 1844.2 Vulcanization made rubber stronger, more heat resistant, and more elastic, and following its introduction in the world market for industrial purposes, rubber goods manufacturers also realized its utility for medical devices. Rubber pessaries marketed as “womb supporters” were available in the US in the early 1860s for women with gynecological problems such as prolapsed or tipped (tilted) uteri, although they were not effective as contraception, even in an unspoken fashion, due to the presence of a hole in the middle to relieve pressure on the vagina.

The contraceptive technology that the Dutch physician Aletta Jacobs provided beginning in January 1882 was a Mensinga diaphragm, also known as an occlusive pessary—a soft rubber barrier held fast in the vagina over the cervix by a flat spring. It was named after its inventor, the German physician W. P. J. Mensinga, who was first active in Leipzig, then later in Flensburg and Breslau. The device, which eventually came in five different sizes, required initial fitting by a physician, but the woman herself could handle insertion and removal with her fingers or an inserter shaped like a narrow shoehorn. In the central German state of Thuringia, obtaining contraception in the 1880s was popularly known as “going to Flensburg.”3 Knowledge of Mensinga’s work spread across northern Europe through word of mouth and through his pseudonymous publications. Jacobs came across Mensinga’s diaphragms while researching contraception on her own and likely obtained her first supply of diaphragms directly from him.4

The Mensinga diaphragm (later known as a Dutch cap) and knowledge of Jacobs’s clinic entered the American market through the writing and efforts of the activist Margaret Sanger. Although diaphragms were illegal in the US under the Comstock Act of 1873, which prohibited the manufacture, distribution, and sale of obscene goods, Sanger intended to find a way to distribute them. She wanted to learn diaphragm fitting from Jacobs herself, but Jacobs, who had closed her clinic in 1894, refused to see her when she visited in February 1915, citing Sanger’s lack of a medical degree. Sanger learned the technique from another member of the Dutch Neo-Malthusian League, Johannes Rutgers, and her public career as a birth controller began in October 1916 with the short-lived Brownsville Clinic in Brooklyn, New York.5 Sanger asked wealthy society women such as Katharine McCormick to smuggle diaphragms into the US illegally (chapter 3), and she herself smuggled them in through Canada, but this transportation method was too irregular and risky to depend on. Sanger, with her second husband J. Noah Slee, financed the Holland-Rantos Company in 1925 to produce diaphragms, cervical caps, and other rubber goods for the clinics that were spreading rapidly across the country.6

Rubber goods manufacturers in the United States and other countries were aware of the market for diaphragms, cervical caps, and condoms and aimed to capture some of the profits for themselves. In addition to the diaphragm, these firms also manufactured cervical caps, which were smaller and also made of rubber and fit directly over the cervix. Julius Schmid, a successful condom manufacturer, started manufacturing diaphragms in 1923, beating Holland-Rantos to the US market by two years. The English advocate Marie Stopes established a firm that produced what she named the “Racial” line of contraceptive technologies, including “Pro-Race” cervical caps, diaphragms, and sponges. She named these devices after her aim to improve the human race through the distribution of contraceptives to poor and indigent women. The Australian gynecologist Norman Haire, who worked for many years in England, collaborated with the London-based company Lamberts (Dalston) Ltd. in 1922 to produce a cap that he publicly endorsed in print advertisements.7

Contraceptive advocates aimed to make diaphragms and caps as widely available as possible. In Germany, diaphragms and spermicides could be ordered through the magazine Sexual Hygiene. In Vienna, both municipally funded and private clinics offered advice, condoms, and cervical cap fittings. In Japan, diaphragms became available in clinics after Margaret Sanger visited Tokyo in February and March 1922. And private doctors could prescribe diaphragms for women in South Africa, have them shipped from England, or obtain them from clinics that opened starting in 1932. Word about the Cape Town clinic soon reached Namibia, and Namibians wrote to its staff for information and supplies. That clinic likewise established a contraceptive mail-order service for rural women that continued until World War II, and it purchased tram tickets for poor city women who could not afford the journey to the clinic on their own.8 On a visit to India in 1936 and 1937, the English feminist and contraceptive promoter Edith How-Martyn observed doctors fitting diaphragms in clinics and chemists’ shops, and she worked with English manufacturers like Prentif to ship contraceptive supplies there. Given their expense, however, diaphragms and caps were available only to middle- and upper-income women, and attempts by both Sanger and Stopes to establish a market for their respective brands of contraceptives in India failed.9

Although the diaphragm was the device that birth control clinics most often recommended to their clients in the 1920s and 1930s, largely because it put contraceptive control in women’s hands, it was far from problem-free. In Control of Contraception: A Clinical Medical Manual Robert Latou Dickinson included images of all the different ways a diaphragm could fail: the physician could fit a woman with a device that was too big or too small, the woman could place it incorrectly, or it could become dislodged during vigorous or prolonged intercourse.10 It was less effective if used without an accompanying spermicide; it was messy and smelly; it needed to be left in for several hours after use, then washed and dried; and proper insertion, removal, cleaning, and storage required the running water and privacy that many poor women simply did not have.11 It was unavailable to American women without a medical precondition until the United States v. One Package of Japanese Pessaries appeals court decision in December 1936.12 Moreover, visiting a birth control clinic for a diaphragm or a cervical cap remained fraught for women who were new to thinking about sex and fertility and who were breaking laws or religious or cultural taboos. Being fitted for a diaphragm was often an exercise in embarrassment. Mary McCarthy’s 1954 novel The Group depicts a new college graduate’s experience of a diaphragm fitting in 1933:

Dottie did not mind the pelvic examination or the fitting. Her bad moment came when she was learning how to insert the pessary by herself. ... As she was trying to fold the pessary, the slippery thing, all covered with jelly, jumped out of her grasp and shot across the room and hit the sterilizer. Dottie could have died. But apparently this was nothing new to the doctor and the nurse. “Try again, Dorothy,” said the doctor calmly, selecting another diaphragm of the correct size from the drawer. And, as though to provide a distraction, she went on to give a little lecture on the history of the pessary, while watching Dottie’s struggles out of the corner of her eye.13

The Irish writer and later feminist activist June Levine had a similar experience when she visited a Dublin doctor around 1949 to have an illegal diaphragm fitted. Her memoir highlighted the precariousness of access to the device: after the doctor gave it to her, he said, “Now, I’ll give you this, but if you know anyone going to England or Belfast tell them to bring one and give it back to me. Size 95 [millimeters]. It’s the only way I can get them, you know.” So even physicians willing to break the law were unable to procure the actual goods that would help their patients regularly. Levine expressed her ongoing frustration with the device and described its effects on her sexual desire: “I doubt that I ever got the hang of that ‘thing,’ hitting some part of the bathroom with it every time it sprang from between my thumb and forefinger. ... Scrambling around the bathroom floor in search of the escapee, fingers sticky and smelly from the cream, at best cooled my ardour, at worst put me in a vicious rage.”14

Thus, the diaphragm and cervical cap largely remained the province of wealthier women in Western countries with access to ongoing professional medical care. It was effective enough for those who could get it fitted professionally and clean and use it properly, but it was far from ideal, and did not provide protection against sexually transmitted infections. While some women may have found relief in using a barrier method under their own control, women like Levine expressed how it dampened sexual desire.

Spermicides, Sponges, Suppositories, and Douches

Once diaphragms and cervical caps became a regularized part of Westernized clinic offerings, most health-care professionals recommended that they be used with an additional spermicide or jelly—in short, pairing a barrier method with a chemical method brought together two different approaches to contraception that would improve efficacy overall. The barrier-chemical combination has its roots in the work of the freethinking Massachusetts-based physician Charles Knowlton, who recommended in his 1832 pamphlet that women place a small piece of natural sponge moistened with water in their vaginas, tied with a ribbon for easy removal. Following intercourse, the woman should then use a syringe to douche with a “solution of sulphate of zinc, of alum, pear-ash, or any salt that acts chemically on the semen.” If no chemicals were at hand, Knowlton recommended douching with plain water. This sponge-and-douche method “not only dislodges the semen pretty effectually, but at the same time destroys the fecundating property of the whole of it.”15 A second edition of the pamphlet landed Knowlton in prison for three months, a fate similar to that of the birth control campaigners Charles Bradlaugh and Annie Besant, who republished Knowlton’s Fruits of Philosophy in England in 1877. As a result of Bradlaugh’s and Besant’s actions, 185,000 copies of the text were published between 1877 and their 1881 trial, and a new generation of English readers learned, and perhaps practiced, Knowlton’s sponge-and-douche method.16

Both douches and suppositories—plugs of a sticky substance designed to melt in the vagina and to have both barrier and chemical spermicidal qualities—contained ingredients that were often available at home or over-the-counter at drugstores. In 1885, the English pharmacist Walter Rendell produced the first commercial suppository, made from cocoa butter and quinine sulfate. Suppositories had their own problems, however, because they melted inside the vagina unevenly, provided incomplete coverage, and usually leaked out during and after intercourse, leaving an unpleasant mess.17

The active ingredients in douches and suppositories are remarkably similar from the 1830s through the 1930s. Common ingredients in commercial douches included weak acids and astringents, such as copper water, baking soda, vinegar, carbolic acid, bichloride of mercury, soap suds mixed with coconut oil, borax, alum, citric acid, and salt. The popular brand Lysol used creosote—a harsh germ killer that was a distillate of wood and coal—as its active ingredient. Zonite used sodium hypochlorite, first discovered as a wound cleanser. One could also soak a wad of cotton, rubber sponge, or sea sponge with these substances to use as a barrier preventative.18 Additional common active ingredients in suppositories included boric acid, quinine, or salicylic acid. Most of these concoctions did little more than irritate women’s vaginal tissue, but some, like quinine, caused dizziness and headaches.

Some birth controllers endorsed homemade remedies, especially for poor and rural women. Margaret Sanger’s first pamphlet, Family Limitation (1914), included recipes for simple astringent douches and cocoa butter–based suppositories.19 Women in Tamil-speaking southern India used neem oil, honey, and scooped-out lime halves as barrier methods and prepared douches from alum, neem leaf tea, neem toothpaste, tamarind tea, and vinegar.20 The Jamaican Birth Control League provided “a pamphlet for women in the countryside explaining a range of home methods (from douches to homemade sponges made from cotton wool and oil), but clearly stated that these methods were ‘not so sure as doctor’s methods,’ advising women to get professionally fitted for a diaphragm.” Marie Stopes continued to promote the cotton wool and oil method for poor and uneducated women in India as late as 1952, even though she did not believe in its efficacy.21

In the late nineteenth and early twentieth centuries, commercial douches came onto the US, German, and British colonial markets and were advertised as providing contraceptive security that was superior to homemade concoctions. However, because there were no government regulations for the dozens of products that existed, their efficacy was not guaranteed. In a 1933 report from the Newark Maternal Health Center in New Jersey, 91.5 percent of 1,978 women had tried at least one contraceptive method, 80 percent had tried multiple methods, 507 had douched with Lysol, and 239 had douched with plain water, with limited success.22 Commercial douches were no more than vaginal deodorant sprays with no contraceptive function and often caused pain and irritation due to their strong astringency.

Birth controllers and pharmaceutical manufacturers also experimented with manufacturing, distributing, and selling spermicidal foam powders and tablets. In the 1930s, the Oxford University zoologist John Rendell Baker favored a mercury derivative as an active ingredient in his Volpar (Voluntary Parenthood) tablets, which were later found to be toxic.23 A German brand of foaming tablets, Speton, were mentioned in a 1930 article in the journal Estonian Physician, and sponges and foam powders were also available for free in the first Bermudian birth control clinic in 1937. Two Florida-based inventors in the 1930s created a foaming powder with sodium lauryl sulfate (a common ingredient in soaps and shampoos) called Duponol that Margaret Sanger had shipped to India and China in 1937 and 1938 as a potentially cheaper diaphragm alternative. After World War II and the partition of India in 1947, a new generation of birth control organizations, including the Rockefeller Foundation–funded Population Council, became interested in developing contraceptives specifically for women living in hot climates. The Population Council underwrote the Khanna Study (1953–1960) on the Durafoam contraceptive tablet in the Indian state of Punjab, but the researchers’ lack of understanding of local mores, health needs, and existing patterns of female infanticide doomed the study from the start.24 Regardless of any activists’ or manufacturers’ ideals or intentions, however, foam powders and tablets did little but visibly foam and cause skin irritation.

In addition to foam tablets and suppositories, which people could use without an additional barrier method, spermicidal jellies, foams, pastes, or creams could act alone but were more likely to be used with a diaphragm or cervical cap, as mentioned above. Many experimented to find the mixture of active ingredient (usually a weak acid, astringent, or solvent) and delivery base that would be most effective alongside a barrier method. After Friedrich Merz released Patentex jelly in Frankfurt-am-Main in 1911 (active ingredients were aluminum, boric acid, and chinosol), more than a hundred brands of spermicides appeared on German pharmacists’ shelves by the 1920s. Spermicides became a specific field of academic research in the 1930s, with Cecil I. B. Voge’s 1933 Chemistry and Physics of Contraceptives providing the most comprehensive guide to the efficacy and safety of the method to date. He tested 133 spermicides and authored the first study of how barrier and chemical methods interacted with each other (according to him, spermicides did not weaken rubber). Dickinson, who wrote the forward to Chemistry and Physics, affirmed in 1938 that he favored lactic acid and a quinine derivative in a vegetable gum base as standard ingredients for a spermicidal jelly, a formulation that Margaret Sanger’s chief physician, James Cooper, also used.25 A breakthrough in spermicide technology came when scientists at the American pharmaceutical company Ortho patented a new spermicide in 1951.26 The surfactant nonoxynol-9 has remained the most widely used spermicidal ingredient ever since, embedded or infused in a wide range of media.

The history of spermicides, douches, sponges, and suppositories from the mid-nineteenth through the mid-twentieth centuries illustrates several broader themes. First, there was a division between contraceptives designed and marketed for poorer women with fewer funds and infrastructural resources and middle-income and wealthier women who could maintain devices like diaphragms with running water and a temperate home. Second, the methods intended for poorer women were less effective, and they were more likely to receive poor-quality or expired goods dumped on colonies and decolonizing states from colonial, industrialized powers. Third, birth control clinics in countries with hot, humid climates faced additional problems with goods developed in cool, dry climates: the rubber on diaphragms disintegrated in hot weather and deteriorated if placed in an icebox; crows carried them off when they dried in the sun; spermicidal tablets and jellies disintegrated if poorly wrapped; suppositories absorbed dye from improper packaging; and spermicidal pastes expanded and burst out of their tubes in hot rainy weather.27 Contraceptive technology that fit the needs of people in diverse geographies, contexts, income levels, and intimate partnership situations did not exist.

Condoms

Although washable, reusable condoms made of animal intestines (usually the cecum of sheep or cattle), fish skins, or fish membranes were available in Europe beginning in the eighteenth century, commercial condoms quickly appeared in countries that adopted the vulcanization of rubber for medical goods in the mid-nineteenth century. Europeans gave them all sorts of nicknames: in England, they were “French letters,” and in France, capotes anglaises (English hoods).28 Before and after vulcanization, however, condoms had a worldwide association with prostitution and sexually transmitted disease prevention.29 It was challenging for public health advocates to convince married couples to use them because they were associated with nonmarital sex instead of pregnancy prevention. Users also objected that their thickness dulled sensation and that putting one on interrupted spontaneity.

Though the US Comstock Act forbade the import, distribution, and sale of sex-related goods in 1873, a nationwide prohibition on widely desired items led to the expansion of an entrepreneurial black market for condoms and inspired manufacturer’s creativity in marketing and advertising. The act did not forbid the importation of whole animal or fish skins or of rubber molds, so those willing to skirt the law could acquire the necessary materials for hand-rolled condoms. The most famous of these was Julius Schmid, who migrated to the United States in 1882, started an animal-skin condom business, and had his factory raided in 1890 under the Comstock Act. Despite that setback, he continued to develop new rubber contraceptive manufacturing techniques for decades. His factory’s cold-cure cement technique produced condoms that were more expensive but also more reliable than those of his competitors.30

Condom availability varied across Europe. Although a revision of the German criminal code in 1900 made it illegal to display or advertise “objects which are suited to obscene use,” condoms, diaphragms, suppositories, and spermicidal jellies could be found widely at pharmacies and through mail order. One of the most widely used brands of German condoms was Fromm’s Act, established in Berlin in 1914 by Julius Fromm. Fromm’s Act condoms used Ceylon (Sri Lankan) rubber molded on glass cylinders and were dusted with a lubricant, and they could hardly be manufactured fast enough: in 1926, the company produced 24 million condoms out of 90 million nationwide. In October 1927, the German Law to Combat Venereal Diseases decriminalized prostitution and allowed advertisements for healing and preventative medical remedies as long as those advertisements were not “offensive” or “indecent.” The law also allowed condom vending machines in railway stations, police stations, restaurants, cafes, nightclubs, public toilets, and military barracks. One result was that condom sales for Fromm’s Act alone reached 50 million units in 1931, and references to the brand became part of piano-bar comedians’ repertoires.31

That law was rescinded in March 1933, and Jewish business owners like Julius Fromm were forced to abandon their businesses, but access to condoms in England expanded in the 1930s. London Rubber, the company that manufactured Durex condoms, produced 2 million units per month from 1932 to 1952 using a semi-automated latex dipping system. In 1954 and 1955, the company’s main factory in Chingford (eleven miles from central London) made 2 to 2.5 million per week after launching a twenty-four-hour automated system. The company focused its manufacturing on single-use, prelubricated, disposable condoms and introduced foil packaging in 1957, dominating the English market.32

Who bought them all? Women expected men to take care of contraceptives without much conversation if they were used at all. One woman stated that “we didn’t do much talking ... he used to get them and I used to rely on him that he got them.” “Aunt Polly” remembered that in Glossop, east of Manchester, in the 1930s “there was this man who came selling Durex to the men in the pub on Fridays. But we wouldn’t like our husbands to use anything like that.” Condoms were available by mail order; in public parks, hygiene and chemist shops, tobacconists, and barber shops; and later in the decade in hairdressers, movie theaters, and dance halls.33 Thus, although men made most condom purchases, their availability via mail order and in vending machines made them available to women as well.

World Wars I and II focused international military attention on the need for condoms in wartime. Needless to say, military regulations were intended to protect men, and not women, from sexually transmitted infections. Pairs of condoms in the form of “hygiene matchboxes” were distributed to Japanese soldiers and officers from the Russo-Japanese War in 1904 and 1905 onward. At army-authorized brothels, condom use was mandatory. From 1938 to 1945, all Japanese rubber factories were placed under military jurisdiction, and condoms were given militaristic names such as “Attack Number One” and “Attack Champion” for the Imperial Army and “Iron Cap” for the Imperial Navy. Germans also had separate field brothels for officers and rank-and-file soldiers in both world wars where condoms were required. Throughout World War II, foreign laborers were forced to produce condoms and other rubber goods in Julius Fromm’s former Berlin factory, and production continued during the subsequent Soviet occupation.34

Condom availability in the first half of the twentieth century continued to shift worldwide due to ongoing legal, regulatory, military, and technological changes. Although the Comstock Act stayed on the US books until 1937, its power was weakening due to further judicial rulings and limited enforcement. A major victory for American birth control advocates came in 1918, when a New York federal appeals court judge ruled that physicians could prescribe contraception to prevent disease (but not to prevent pregnancy). Moreover, the discovery of noncombustible latex in 1920 and the uniform condom ring machine in 1926 (which eliminated the need for hand rolling) shifted the technological landscape of barrier contraceptives once again and made it possible for manufacturers to make sturdier condoms more quickly and safely. In 1938, a revised Federal Food, Drug, and Cosmetic Act placed the condom, as a disease preventative, under the jurisdiction of the US Food and Drug Administration. Only two condom firms could afford the manufacturing changes necessary under the increased federal quality control standards, and others either closed or shipped their lower-quality goods overseas.35 So although condoms were available in many industrial and decolonizing countries by the time the hormonal pill would appear, access, quality, cost, and use varied significantly. The dual function of condoms as both pregnancy and disease preventatives gave their use an ambiguous status and meaning.36 Researchers continued to investigate other options, including the more invasive IUD.

Military regulations were intended to protect men, and not women, from sexually transmitted infections.

IUDs

The intrauterine device, or IUD, was designed to block sperm or to create a hostile environment within the uterus so that an embryo could not implant. Such a method, based on the nineteenth-century stem pessary that was used for uterine problems, would have advantages for some women: it did not need to be cleaned and stored after each use; it did not require a husband’s permission or consent; and it did not require preplanning. The first American patent for an IUD in that shape was issued to a George J. Gladman of Syracuse, New York, in 1895, but it is unclear if he ever manufactured it.37 German doctors, including a Dr. Hollweg in Magdeburg, experimented with IUD designs fashioned with stem pessaries beginning in 1903, though he was criminally charged with negligence causing bodily harm to patients for doing so. A Dr. Richter in Waldenburg also experimented with these devices beginning in 1909, the same year as Ernst Gräfenberg. Gräfenberg decided to abandon the stem pessary form altogether and fashioned a new kind of IUD with silkworm gut and silver wire laced with copper.38 After first hearing about the “Gräfenberg ring,” London-based physician Norman Haire advocated it instead of the diaphragm and jelly method, even though 13 percent of them extruded.39 He tried to use his support of the Gräfenberg ring as a means to gain funding for further research on the device from the Birth Control Investigation Committee in 1927. The BCIC gave the money instead to Helena Wright, who attempted but later abandoned an attempt to manufacture her own IUD with coils covered in India rubber.40 Gräfenberg publicized his ring at European sexological congresses in 1929 and 1930, and he continued to tinker with it in the early 1940s after moving to the United States.41

Even before the IUD got the attention of birth controllers around the world at these congresses, the disadvantages of the device were evident. The contraceptive advocate Ettie Rout, who gathered observations about different methods in her 1922 book Practical Birth Control, pointed out that the IUD caused sepsis, miscarriage, stillbirth, and pain and could expulse spontaneously from the uterus. Dickinson’s contraceptive guidebook included images of multiple IUD shapes and the different ways they could harm women, such as increased bleeding, heavy menstruation, and uterine perforations. The Danish physician and birth control advocate Jonathan H. Leunbach experimented with silver IUD rings that caused patients only bleeding and pain.42 A gold-plated IUD designed by the Japanese physician Ōta Tenrei in 1932, in addition to being painful and ineffective, also caused infections and infertility.43 Some physicians continued to experiment with and to prescribe IUDs in the 1940s and 1950s, but there was little innovation in their design, materiality, and manufacture until the 1960s. Their disadvantages far outweighed their advantages, and many women instead chose to manage their fertility without professional medical assistance.

Herbs

Women across the world have used herbs in teas or douched with them to bring on menstruation and to avoid pregnancy. Herbals, or texts with recipes for homemade medicines, were popular throughout Europe and colonial and early America from the seventeenth through the first decades of the twentieth century. They recommended preparations called emmenagogues with pennyroyal, rue, savin, tansy, and ergot of rye to combat amenorrhea, or a lack of menstrual flow, which could either prevent pregnancy or could end a very early one before fetal movement began.44 A doctor from the German town of Neuenahr (now Bad Neuenahr-Ahrweiler) recorded the words of children’s songs in Bavaria, the lower Rhine Valley, and Brandenberg (near Berlin) in the late nineteenth century. They sang of the herbal wreaths that women wore in their hair during a wedding and could also drink as a tea to prevent pregnancy: “Rosemary and thyme, grows in our garden, young Aennchen is the bride and can wait no longer. Red wine and white wine, tomorrow is the wedding.” Herbal variations in the first line included lavender, myrtle, parsley, and chervil. Another song he heard was a short dialogue between a woman and a gardener: “Good day Mr. Gardner, do you have lavender, rosemary and thyme, and a little wild thyme? Yes, Madame! We have all of these, outside in the garden.”45 Whether or not German women actually used these herbs for these purposes is hard to know, but these songs preserved an association between women and herbs used as emmenagogues.

Herbs used to bring on or to suppress menstruation varied across the world. Ergot of rye was available in northern and eastern Germany because rye was widely grown for bread. Pennyroyal and rue, along with aloes, wild celery, and bracken fern, were also known among European colonists in South Africa, and Welsh and English people who were sexually active between 1925 and 1950 joked and gossiped about using slippery elm and pennyroyal to end unwanted pregnancies. From the mid-nineteenth to the early twentieth centuries in South Africa, Malaysian immigrant women used preparations with red geranium, Khoisan women used a type of thornbush, and Zulu women used a peppery shrub called uhlungughlungu. A 1952 Planned Parenthood Foundation of America report found that nurses and working-class women in Jamaica boiled herbs such as ram goat rose, pennyroyal, pepper elder, or rice bitter, sometimes with rusty nails, in a tea to drink. These methods likely originated during the slavery era in the Caribbean.46

Although knowledge of pennyroyal has appeared on and off in the historical record for almost a millennium, it is hard to know its meaning to the women who used it. One clue appears in Sarah Orne Jewett’s 1896 novel The Country of Pointed Firs, which centers on the experiences of a summer boarder in rural Maine. In the chapter “Where the Pennyroyal Grew,” the locally respected herbalist and widow Almira Todd invites the unnamed narrator to visit a small island where her mother lives. On a walk, they come across a patch of pennyroyal, which delights Mrs. Todd and triggers her memory:

My heart was gone out o’ my keepin’ before I ever saw Nathan; but he loved me well, and he made me real happy, and he died before he ever knew what he’d had to know if we’d lived long together. ... I always liked Nathan, and he never knew. But this pennyr’yal always reminded me, as I’d sit and gather it and hear him talkin’—it always would remind me of—the other one.47

Mrs. Todd’s language is veiled, but she may be referring to using pennyroyal to end a pregnancy with a lover who preceded her husband. Jewett’s father was a physician, and Jewett herself was a gardener and familiar with medicines that rural Mainers used—including emmenagogues and abortifacients. The pennyroyal scene highlights tensions in medicine at the turn of the last century: on the one hand, women could manage their fertility if they had the correct knowledge; on the other hand, using this knowledge could have damaging or deadly results if used improperly.48

At the same time that Country of Pointed Firs was published, pharmaceutical corporations in Western countries were adapting ingredients from homemade medications into marketable, physician-controlled therapeutic products. In the United States, the pharmaceutical company Parke, Davis advertised liquid and pill emmenagogues in its catalogs using traditional ingredients such as cotton root bark, ergot, pennyroyal, rue, and tansy from 1898 through 1937. They also contained a hefty dose of alcohol—up to 75 percent. In Germany, the Prussian Police Ordinance on Trade with Poisonous Substances, which came into effect in 1894 and was revised in 1904 and 1906, limited the sale of “poisonous substances,” which often included the herbal remedies formerly made at home.49 The use of herbal methods continued largely unrecorded throughout the twentieth century, though records of women using them waned.

Timing Methods

Even less expensive than herbal preparations, contraceptive timing methods have been in use for centuries. For example, Henry A. Allbutt’s 1887 pamphlet Wife’s Handbook: Pregnancy and after Delivery recommended temporary abstinence five days before and eight days after a menstrual period.50 Members of some cultures believed that prolonged breastfeeding curtailed the ability to become pregnant, though it is more likely that taboos about sex with nursing mothers were the real reason for lower numbers of pregnancies while breastfeeding.51 However, before the Japanese gynecologist Ogino Kyūsaku and his Austrian counterpart Hermann Knaus pinpointed the time of ovulation in 1924 and 1929, respectively, any timing method beyond complete abstinence was guesswork.52 Although timing methods required no money and no physical technologies, they demanded control and a willingness to deny oneself pleasure that not all were able to manage.

Coitus reservatus and alternative sexual positions were thought to minimize the possibility of sperm and egg connecting in penile-vaginal intercourse. Coitus reservatus involved male tumescence and detumescence in the vagina without ejaculation for up to an hour, and the mid-nineteenth century Oneida utopian community in upstate New York used the practice to limit births. The Chicago-based physician Alice B. Stockham made more Americans aware of the practice a few decades later with her books Tokology (1893) and Karezza (1896). Oral sex and interfemoral intercourse were also possibilities, and some marriage manuals provided detailed instructions about positioning. Nineteenth-century Germans used a method called coitus obstructus or coitus saxonicus, which meant pressing the base of the penis at the moment of ejaculation in order to force semen into the bladder. An Estonian marriage manual called How to Avoid Pregnancy (Kuidas Hoiduda Rasedusest) published in 1934 recommended that heterosexual couples have sex on their sides and that when the man was ready to ejaculate, he should pull partway out and both partners should spread their legs. Thus, the ejaculate would land closer to the outside of the vagina and could be washed away easily. Marie Stopes recommended that women sit up immediately after men’s ejaculation and cough “violently” to contract their pelvic muscles in an emergency if no other methods were available, and middle- and upper-income Indian women were advised to do jumping jacks after coitus to expel semen. As some believed that women’s orgasm was the mechanism for semen to move into the uterus, women in the United Kingdom, the United States, and Czechoslovakia heard or read erroneous advice to avoid orgasm as a means of avoiding pregnancy.53

Sex between two men and two women, masturbation, and anal coitus were other options altogether, but English-language contraceptive advocates disapproved of them when they mentioned them at all. Dickinson believed that primarily “laborer and peasant husbands” used anal coitus, that oral sex was the province of prostitutes, and that vulvar and interfemoral coitus were only premarital practices. “All of the above fall into the class of contraceptive measures to be deplored or displaced,” he sniffed. Ettie Rout claimed that homosexual sex and masturbation were “anti-social ways of controlling fertility.” In Germany, however, doctors in the 1890s tracked the rising prevalence of anal gonorrhea among women.54 It is impossible to know if those women were engaging in anal sex as a form of contraception, for pleasure, or both, but either way, doing so had the unfortunate result of a sexually transmitted infection.

Yet another timing method, withdrawal, required trust in men’s self-control and judgment. The historian Norman Himes asserted that coitus interruptus “is doubtless the most popular, widely diffused method of contraception.” In mid-nineteenth century Søgne, Norway, the practice was called hoppe av i farten (jump off while the going is good), and women in mid-twentieth-century Trinidad, Barbados, and Jamaica referred to it in birth control clinic interviews as “my husband is careful.” In early twentieth-century southern Wales, it was men’s responsibility to decide on the timing of sexual activity and contraception; to practice withdrawal, one would “take the kettle off the fire before it boils over.”55 In Meru, Kenya, a native-born Methodist minister reported in the 1920s and 1930s that young people had coitus interruptus in a standing position. A survey of 11,126 Czechoslovakian women in 1956, most of whom were between twenty and thirty-nine years old, found that 68.4 percent of them used withdrawal as their primary contraceptive method. Stopes opposed this method based on her belief that women received nutrients from ejaculation, and thus “the woman subject to this process is also deprived of the possibility, after the union is completed, of the beneficial absorption from the seminal and prostatic fluid.”56

In mid-nineteenth century Søgne, Norway, the practice [of withdrawal] was called hoppe av i farten (jump off while the going is good).

The Roman Catholic Church disliked the method for yet another reason. According to church law, penile-vaginal coitus, or “the marital act,” was permitted only between a man and a woman married to each other for procreation. A marital act thus required male ejaculation, so the near-universal method of withdrawal was nonetheless sinful. Since the mid-nineteenth century, however, church leadership had quietly permitted married couples to abstain from sex completely from time to time in order to space their children, largely as a means of avoiding withdrawal.57 Any artificial contraceptives, such as condoms or diaphragms, “frustrate the marital act” and so were also sinful. Pope Pius XI affirmed this perspective in the 1930 encyclical Casti connubii (On Christian Marriage), and his successor, Pius XII, officially approved the rhythm method based on women’s menstrual cycles in an October 1951 address to Italian midwives.58

Complete abstinence was yet another option, but evidence of its use is rare and anecdotal. The Finnish author Arvid Järnefelt wrote in his memoir Vanhempieni romaani (My Parent’s Story, 1928–1930) that after his mother gave birth to nine children, his father moved his bed out of their shared bedroom to signal that their sexual interactions had ended for good. A woman interviewed in southeast Norway recalled that a doctor advised her parents to abstain from sex after her mother was seriously weakened from giving birth to five children in seven years (1903 to 1910). Her father then moved to South America, where he remained for ten years.59 For many, the disadvantages of abstinence clearly outweighed the advantages.

Abstinence took on a different cast in India, where it was a central element of brahmacharya—the idea that one must control lustful desires. In the early twentieth century, Mahatma Gandhi advanced the idea that overindulgence of the body was a specific curse of modern Western civilization, and barrier or behavioral contraceptives did nothing to tame the real problem: an overabundance of sexual desire, particularly male desire. Women, in turn, should refuse their husband’s advances. Any child after the first was born of lust, not duty or religion (dharma), and procreation should be limited until India was free from colonial rule. He met Margaret Sanger during her November and December 1935 visit to India, and she thought that she convinced him that the safe period was acceptable. The Indian sexologists A. P. Pillay and N. S. Phadke thought that Gandhi’s beliefs were acceptable (if they did not cause harm) and ridiculous, respectively.60 After partition in 1947, Indians and Western birth control promoters alike turned to advocating sponges, spermicides, and diaphragms instead of timing methods and celibacy.

Sterilization

Although crudely cutting off or maiming the genitals of criminals was not unknown before the twentieth century, sterilization in the early twentieth century became linked with eugenic approaches to controlling populations. Those whom physicians, government officials, prison wardens, and other authority figures deemed “unfit” to reproduce—including un- or undereducated people, recent migrants, criminals, poor whites in rural parts of the US, physically or mentally disabled people, convicted criminals, and people of color—were subject to sterilization beginning in the 1900s. Men and women alike could undergo sterilization, sometimes without their knowledge or consent, for a range of reasons. Sterilization of male genitalia was a relatively simple and short operation: a physician severed the vas deferens, which eliminated the sperm after two weeks and could be reversed later. Sterilization of female genitalia, harder if not impossible to reverse, required major abdominal surgery, either an ovariectomy (the excision of ovaries) or a salpingectomy (an abdominal incision and tying or severing the fallopian tubes).61

The practice of sterilization in prisons began with the coincidentally named Harry C. Sharp, medical superintendent of the Indiana Reformatory in Jeffersonville. He first severed the vas deferens of a male prisoner who complained of uncontrollable masturbation in 1899; he then sterilized 450 prisoners before successfully lobbying the state legislature to pass the first US law mandating the sterilization of the “unfit” in 1907. Twenty-six states followed Indiana’s example, and the right of states to coerce sterilizations was upheld in the now-notorious case Buck v. Bell, 274 US 200 (1927). The majority opinion in the case, involving the forced sterilization of seventeen-year-old rape victim Carrie Bell in Lynchburg, Virginia, upheld the state’s right to sterilize “imbeciles” in the name of protecting public health. Following the Buck v. Bell decision, the scope of the Indiana law expanded, and minors as young as sixteen in state institutions were targeted for sterilization. Between 1907 and 1937, 27,869 Americans were sterilized: 16,241 men and 11,628 women.62

The practice was not confined to the United States. Vasectomy was introduced into Germany in 1894, and a method of salpingectomy was introduced in 1910. Doctors could perform them for “therapeutic purposes,” and they became a favorite method of eugenicists before World War I. The New Zealander Ettie Rout stated a standard elite perspective matter-of-factly: “suitable cases for sterilization are mental instability, hereditary taints, tuberculosis, syphilis, [and] repeated and overfrequent pregnancies which are undermining the sound health and economics of the home.” The physician Norman Haire tried to sterilize women hormonally, but when that did not work, he began to advocate publicly in the 1920s for the “sterilization of the unfit in the interests of the race.” He also tried to market vasectomies in the 1930s as “male rejuvenations.” Also between 1931 and 1934, the British Eugenic Society supported a coerced sterilization bill, but it lacked parliamentary support. Most notoriously, during the Nuremberg Trials, Nazis on trial for war crimes cited Buck v. Bell as part of their reasoning for sterilizing two million Germans during the Third Reich.63

Sterilization had a well-deserved reputation in Europe and beyond as a coercive eugenic operation. In the Nordic countries—Denmark, Norway, Sweden, and Finland—an increase in involuntary or coerced sterilization correlated with the rise of the welfare state. Limiting the ability of mentally disabled people to reproduce began piecemeal at Nordic state institutions in the 1910s but became national law in the 1920s and 1930s. Both adults and minors could be sterilized if they had low mental abilities, could not support potential children financially in the future, or presented a risk of passing on a hereditary disease to offspring.64 Rather than decreasing after World War II, sterilization across the region increased, especially in Sweden and Finland, where it could be carried out on eugenic, social, or general medical grounds. Working mothers with large families who exhibited “weakness” or who were in “social distress” in both countries were specifically targeted, and 99 percent of the 56,080 sterilizations in Finland were carried out on women. Health authorities thought they were less likely than men to refuse consent.65

Forced sterilization laws in the United States and the Nordic countries stayed in place until patients’ rights activism began in the 1960s and 1970s and abortion was legalized (chapter 4). The persistence of laws and practices in democracies that discriminated against people with disabilities would later highlight the need for global affirmation of every individual’s right to have children (chapter 5). Democratic governments alone did not protect the most vulnerable from coerced and involuntary sterilization. It would take declarations of human rights on a global stage and citizen organizing to challenge the practice.

Conclusion

This overview of contraceptive technology before the hormonal pill illustrates the range of methods that people have used to prevent and to space pregnancy. Contraceptive use was intimate but shaped by political, technological, religious, and sociocultural forces. The use of a technique or technology depended significantly on religion, pain tolerance, reversibility, imprisonment, mental health, access to technology and professional care, knowledge of methods, income, correct use, effectiveness, personal motivation, and relationship status, among other reasons. Contraceptive technology could be temporary or permanent, forced or voluntary, painful or pleasurable, effective or pointless. The ability to control and to time when a pregnancy occurred was of such importance that the introduction of a new pharmaceutical contraceptive, the hormonal pill, would have worldwide repercussions that continue to the present.