In addition to the contraceptive devices and methods described in chapter 4, new products and ideas are constantly under development. This chapter outlines some of the novel contraceptives that are now undergoing scientific trials and are newly available to people hoping to avoid pregnancy. The first section identifies the problems that many people have with standardized forms of contraception and the ways that the medical and scientific community needs to respond with more nuance to the diversity of bodies needing contraception. It focuses on ongoing developments in scientific knowledge about bodies, particularly those of transgender, overweight, and obese individuals who may not be able to use certain contraceptives safely and effectively. Current contraceptive technologies need to be precisely targeted or modified in order to work for as many people as possible. The second section provides an overview of contraceptive vaccines directed at men and women and the continuing difficulties of creating new contraceptives that meet standards for safety, efficacy, and limited to no side effects. The third section lists a number of new and newly framed possibilities for using technology to reduce or to eliminate the chance of pregnancy, including the Bimek SLV, “outercourse,” and sex involving toys, dolls, or robots. The last section revisits the themes articulated in chapter 1 and identifies some of the many threats to reproductive health care in general, not only contraception, that are persistent worldwide. National and local governments, conservative nongovernmental organizations, a lack of information and cooperation between sexual partners, cost, a lack of access to medical care, and on-the-ground distribution problems all hamper access to, use of, and choice of contraception. There is a critical, persistent need for activism and advocacy to support reproductive justice for all.
As scientific knowledge and awareness of variety in human bodies increases, and as medical knowledge in general advances, the more exacting medicines and medical treatments need to become. Those who have health conditions that may interact with (particularly hormonal) contraception must be careful to choose a method that does not conflict with existing medications or increase or cause health problems. This section focuses on two populations requiring specific care and technologies for their contraceptive needs: transgender individuals and overweight and obese women.
All sexually active people who want to prevent pregnancy must consider a method of contraception. However, hormonal treatments for transition may complicate transgender individuals’ use of specific technologies and methods, including hormonal birth control pills and IUDs. Transgender teenagers, particularly those who are assigned female at birth (AFAB) and are on a testosterone regimen as part of their transitions, need specialized information and care in order to not become pregnant. Only in the past few years have physicians and health-care professionals started to develop treatment protocols regarding contraceptive technology specifically for transgender individuals—especially teenagers, who are at the most risk for unwanted pregnancy.
For example, inserting IUDs may be complicated for transgender AFAB teenagers because their vaginas may shrink or atrophy due to testosterone therapy.1 Trans men and nonbinary individuals who are taking testosterone should not use combined estrogen-progesterone pills because the estrogen counteracts testosterone. Furthermore, testosterone therapy alone does not prevent pregnancy. A recent survey of AFAB individuals and their physicians in the United States indicated that they were unaware that testosterone is not a form of contraception on its own and that they needed to use barrier or nonconflicting chemical methods.2
Hormonal treatments for transition may complicate transgender individuals’ use of specific technologies and methods, including hormonal birth control pills and IUDs.
At the same time, many transgender men have children already or would like to become pregnant in the present or in the future. The idea that people presenting as men can become pregnant and give birth is often portrayed in popular culture as a subject of mocking or amusement, obscuring these men’s need for gynecological and reproductive health care. Furthermore, twenty European countries still retain laws requiring that transgender individuals submit to some form of surgery (genital alterations, chest modifications, and/or the removal of internal organs), some of which result in sterilization, in order to fulfill legal requirements for transition. However, these laws have begun to be struck down across European countries from the late 2000s onward.3 As one legal scholar put it, “sterilisation should not be a prerequisite for gender recognition.”4 As the European Court of Human Rights continues to scrutinize and strike down sterilization laws in Europe and as transgender rights become more enshrined in international law, more and more people who do not identify as women will be capable of pregnancy in the future. They will need targeted information, technology, and professional care for managing their fertility.
The same is true for overweight and obese individuals with uteri who do not want to become pregnant or want to space their pregnancies. Contraceptives are among the many medications that are not adequately tested on overweight and obese individuals. Clinical testing of different forms of hormonal contraceptives often excludes study participants with a body mass index (BMI) greater than 25—in other words, those the BMI identifies as overweight or obese.5 Overweight or obese women using hormonal contraceptives containing estrogen may also be at risk for additional weight gain and at higher risk for blood clots.6 Overweight or obese women who have health problems sometimes related to weight, such as high blood pressure or diabetes, may have to avoid hormonal pills containing estrogen. Some methods of hormonal contraception (such as IUDs and progestin-only methods) have equal efficacy for those with high body weight, while others (such as the combined pill, the transdermal patch, and the vaginal ring) have less efficacy.7 The nonhormonal IUD is effective across weight classes, as are barrier methods.
Managing contraception for people choosing surgical weight loss is a challenge as well, and there is little research on postsurgery contraception. Because bariatric surgeries, particularly gastric bypass, affect absorption of nutrition, they likewise affect absorption of medicines like oral contraceptives. Those at risk of pregnancy need to take special care with contraception for one to two years after such major surgery because there is potential for harm to the mother and to the fetus while the body is undergoing rapid weight loss.8 Oral hormonal pills may not work, so other methods, such as male and female condoms and nonhormonal IUDs, are the best choice. Future research could address the specific contraceptive needs of people undergoing bariatric surgery and the swift weight loss that happens in the months afterward.
Contraceptives are among the many medications that are not adequately tested on overweight and obese individuals.
Emergency contraception (EC) can be particularly challenging for overweight or obese people. Although progesterone-only pills work well when taken on a daily basis, progesterone-only EC (levonorgestrel, known in the United States as Plan B) may be less effective for people with a BMI over 26 than ulipristal acetate (known in the United States as ella), a selective progesterone receptor modulator.9 Overweight or obese individuals have the best chance of avoiding unwanted pregnancy if they have a copper IUD inserted within five days of unprotected sex, which may be quite expensive. It is a complicated situation to navigate.
In sum, it is clear that the work of including all bodies in reproductive health care is a matter not only of providing access to certain technologies and methods for users but also of overcoming longstanding prejudices against people with bodies that do not conform to sociocultural standards of gender identity, gender presentation, size, and physical and/or mental ability. Inclusivity can be demonstrated in many ways, such as by using gender-neutral language regarding sexual behavior and pregnancy risk on medical intake forms; having medical professionals use up-to-date terms in conversation with transgender and nonbinary patients; providing gender-neutral restrooms in medical offices; keeping costs low; and continuing to keep pressure on pharmaceutical manufacturers to produce wider ranges of chemical and mechanical contraceptives that accommodate all bodies.10
Contraceptive vaccines are part of the medical and scientific community’s longstanding attempt to produce contraceptives that have limited side effects, are easily reversible, and can be used by men. All are currently under development in various forms around the world, using either human or animal testing, though finding a magic-bullet contraceptive that meets those criteria remains elusive. Scientists investigating contraceptive vaccines have pursued three avenues of research: an anti-hCG (human chorionic gonadotropin) vaccine for women, antisperm vaccines for men and women, and a hormonal vaccine for men.
First, from the mid-1970s through the mid-1990s, a coalition of nongovernmental organizations involved in human health (including the World Health Organization and the Population Council) conducted research on an anti-hCG vaccine for women. The idea for the vaccine came from scientists in an emerging field called reproductive immunology who examined the ways that the body’s own antibodies could prevent conception and embryo implantation. One way to achieve that is by inhibiting the function of hCG, one of the hormones produced by a preimplantation embryo and necessary for a pregnancy to begin. However, it is difficult to block the production of only one factor without interfering with the functioning of others or creating other health problems. Clinical trials in the 1990s revealed that the anti-hCG vaccine interfered with some women’s menstrual cycles and that some women were unable to produce enough antibodies for the vaccine to be effective.11 Research on a new generation of this vaccine took place on women in New Delhi in the 2000s, 25 percent of whom were also unable to produce the necessary antibodies. Although a new combined protein-DNA version of the vaccine underwent testing on animals in 2017, the anti-hCG vaccine is still years away from being approved for the general public.12
The second set of vaccines under development fall under the broad category of “immunocontraception,” or the triggering of specific antibodies in order to suppress one of the seventy-six conceptive factors required for embryo development and successful embryo implantation to occur.13 For example, some trial vaccines target sperm-specific proteins. If a vaccine with sperm-specific antigens can produce specific antibodies against these proteins, the proteins can be neutralized, and the physiochemical processes necessary for conception would not take place. Humans diagnosed with infertility produce these antibodies without the vaccine, so the vaccine may trigger the antibodies in people who are otherwise fertile. So far, scientists have tested these vaccines only on mice, and mouse models cannot be translated directly to human models. However, the wide scientific interest in nonhormonal vaccines means that primate and human testing may not be far in the future.14
The third vaccine option was designed specifically for men, and the formula was designed with two aims—to reduce sperm production below the threshold for conception and to maintain that contraceptive level for a period of up to fifty-six weeks. The 320 participants in an 2008 to 2012 international study received an injectable contraception vaccine, which included regular doses of both a long-acting progestogen and a long-acting androgen, testosterone undecanoate. They were required to have a normal reproductive system and be in a stable, mutually monogamous relationship for at least one year with a nonpregnant female partner who also had a normal reproductive system. After the vaccine regimen ended, men’s sperm counts returned to normal.15
The results were striking: the method’s effectiveness rate was 92.5 percent, or roughly equivalent to most hormonal methods for women, including the patch, pill, monthly vaginal ring, and shot.16 However, many of the participants listed mild to moderate related side effects, including pain at the injection site, mood swings, increased libido, depression, acne, and myalgia (muscle pain). An independent Data Safety and Monitoring Committee (DSMC), established by the World Health Organization’s Department of Reproductive Health and Research (WHO/RHR) and by Contraceptive Research and Development (CONRAD), terminated the study early due to the men’s complaints. As critics of the study point out, these symptoms are also common in approved hormonal birth control for women.17 This DSMC took these men’s complaints regarding these symptoms seriously, but women’s complaints about similar or even more severe symptoms are often ignored. As was clear in birth control pill testing in 1950s Puerto Rico and IUD testing in the late 1970s to early 1980s, for example, even severe pain, strokes, permanent physical damage, and death have not been good enough reasons to stop contraceptive technologies for women from being tested and sold. The rapid termination of this study highlights ongoing problems in scientific perceptions of gender difference regarding medical side effects.
Nonetheless, research in the area of nonhormonal and hormonal vaccines continues, despite the significant reported side effects. Antisperm hormonal vaccines delivered in pill and transdermal gel forms have fewer side effects than injections.18 These vaccines are one potential pathway for the creation of a long-acting reversible male contraceptive method aside from injectables.
Although behavioral and barrier methods of avoiding pregnancy are findable around the world, contemporary health-care professionals, inventors, toy designers, and roboticists have reframed the ways that people learn, think about, and contextualize them. They have reframed and reintroduced them as ways to fulfill desires for sexual pleasure without the risk of pregnancy.
For example, Planned Parenthood, a popular English-language source for contraceptive information, advice, and services, refers to sexual encounters that do not involve semen or pre-ejaculate entering the vagina as “outercourse.” Outercourse as a form of contraception with a partner includes kissing, massage, mutual masturbation, grinding (known in the mid-twentieth century as petting), and discussing erotic fantasies.19 PP is careful to state that although oral and anal sex will not lead to conception, unless semen or pre-ejaculate gets onto the vulva or into the vagina through related movements, these behaviors can lead to disease transmission without barrier methods of protection. The nonjudgmental tone regarding nonpenetrative sex on PP’s website, particularly its attitude toward oral and anal sex, is a far cry from most of the scientific and medical community’s silence toward these practices and from the negative attitudes toward them from physicians and advocates in the early twentieth century. PP’s advice for outercourse, as well as for other methods, shows that a wider range of sex-positive information is available online to information seekers than there was in print-only sources in the past.
Current inventors are also attracted to the possibilities of designing and manufacturing new technologies that can help people enjoy penile-vaginal sex while avoiding conception. One technology for mechanically obstructing sperm has been under development in Germany. The inventor Clemens Bimek created a device in 2000 that would block sperm without the need for a vasectomy. This device, called the Bimek SLV, works by implanting tiny valves (the size of a gummy bear, according to the product’s website) in the vas deferens.20 After surgery, the valves can be opened and closed with a small switch in the scrotum. When the valve is closed, sperm cells are not released during ejaculation, rendering the seminal fluid sterile. After an initial flurry of news media coverage in the first half of 2016, the project appears to have stalled due to the lack of funding for a factory meeting international manufacturing safety standards and for the organization of human clinical trials (the creators refuse to conduct animal trials). Even if the Bimek SLV never advances beyond its current trial state, more inventors will likely take up the challenge of mechanical sperm-blocking technologies in the future.
The use of technology for sex play is widespread and continues to grow in manifold ways. Any means of internet play can also involve the participants using toys, dolls, and robots themselves or with others. Sex toys can be used alone, with a partner or partners in private space, or in an internet-mediated space with any number of viewers. Nonconceptive sex can involve technologies as the means of participation (computer, tablet, or smartphone) and as implements in creating sexual images themselves.21
Beyond the toys that can be found at any online or storefront sex toy shop, inventors have experimented with more humanlike entities that raise concerns for both the dolls and robots themselves and the humans who use them. In the 1990s, the artist Matt McMullen created a silicone female mannequin called a RealDoll, and demand quickly exceeded supply. As robotic technology has advanced in the last two decades for all kinds of uses, so too has the technology that makes robots seem more humanlike. Those advances have been used to create robots specifically designed for sexual use. Since 2017, robot-only and combined robot-human brothels have begun to appear in cities like Toronto, Canada, and Mainz and Dortmund, Germany, where one can purchase a half or full hour with an anatomically correct doll that has changeable costumes and customizable vaginal inlays and hair.22 One can also order a customizable doll for home use that can move and have a voice app installed that enables a kind of conversation between doll and user.23
People engage in sex with toys, dolls, and robots with varying degrees of interactivity for any number of reasons. Building that relationship, however, is fraught with problems. There is a growing debate about whether dolls and robots have rights that need protecting or if robot sex is damaging to people and to the technology itself. People might be having sex with robots to avoid sex with another human as a means of avoiding pregnancy, but they might also be damaging their ability to function in the everyday world in the process—not to mention their ability to treat living people with dignity and respect. On the other hand, some argue that falling in love and having sex with inanimate objects, such as robots, is the logical next step in a world where technology is ever further embedded in everyday human life.24
Sex toys, dolls, and robots are not always thought of or used as contraceptives because their use is not limited to those who are capable of conceiving. However, people who purchase a doll or robot for sexual purposes or visit a robot brothel choose consciously to have sex with an entity that cannot become pregnant or make them pregnant. These choices enable sexual pleasure without human interaction or procreation, thus providing an erotic opportunity for those who avoid human-to-human sexual contact.
The themes threaded throughout this book continue to resonate in the present and will continue to shape the future of research, manufacture, distribution, and use of contraceptive technologies. The four themes identified in the first chapter as marking the modern history of contraception—power relationships, camouflage technology, method persistence, and a lack of neutrality—continue to shape the reproductive world now.
First, gender and power relationships continue to shape contraceptive use. Although in most countries women now have the legal right to refuse sex with a marital or nonmarital partner, they may consent to sex only reluctantly or under duress to avoid arguments or violence. Gender systems that reinforce male-female inequality and uphold male virility as a virtue cannot change based on the availability of new technologies alone. So women and others with uteri may need to find contraception that an uncooperative partner cannot see or feel in order to protect themselves from undesired pregnancy. Second, it may be less necessary to obtain a contraceptive under the guise of a “camouflage technology” now than in the past, but new legal threats to access, such as conscience clauses for pharmacists in the United States, have emerged. Short- or long-term partners may camouflage their reasons for using one technology over another or their feelings regarding the chance of pregnancy from each other. A different kind of camouflage—known colloquially as “stealthing”—has one partner pretending to use condoms but then removing them without the other’s knowledge. The emotions and desires behind individual contraceptive use, misuse, or nonuse remain just as complex in the present as they were in the past.
Third, behavioral methods, such as withdrawal and periodic or complete abstinence, endure in the present, though they are regularly repackaged in new frameworks or with new technological add-ons, such as smartphone apps for timing safe periods without barrier methods. The motivations behind the use of behavioral methods range from adherence to conservative religious principles to a desire for a natural, chemical-free lifestyle and have remarkable persistence. Additionally, IUDs, diaphragms, and cervical caps have been invented and reinvented many times over. Fourth, the availability of contraception and the legal and economic frameworks that build and maintain reproductive health programs are often subject to a country’s or state’s interest in increasing or limiting population—and the monetary and human resources it is willing to expend. Poorer people and people living in rural areas have fewer opportunities to visit health-care providers than those in urban areas, and the limited health care available to them may be prohibitively expensive. A perfect method of contraception, aside from complete sexual abstinence, is not available, and many contraceptive methods continue to involve short- or long-term side effects or health risks that users deem unacceptable. Reproductive justice is a clear and admirable goal, but it is still a long way from realization.
The emotions and desires behind individual contraceptive use, misuse, or nonuse remain just as complex in the present as they were in the past.
In the spirit of establishing reproductive justice for all, however, international NGOs, pharmaceutical companies, health professionals, and local activists around the world are working together to improve access, albeit slowly, to contraceptive technologies, information, and services. For example, a partnership of the pharmaceutical company Bayer (which produces hormonal contraceptive pills and three types of IUDs) and NGOs established World Contraception Day in 2007, now marked yearly on September 26, to draw attention to the approximately 225 million women and people with uteri worldwide who currently have unmet needs for contraception and reproductive health care.25 The WHO published a set of guidelines in 2014, “Ensuring Human Rights in the Provision of Contraceptive Information and Services,” based on previous international human rights statements such as the 1994 International Conference on Population and Development’s Plan of Action, the 2001 Millennium Development Goals, the United Nations Secretary-General’s 2010 Every Woman Every Child initiative (for maternal and child health), and the 2011 creation of the Commission on Information and Accountability for Women’s and Children’s Health. It also positions reproductive rights as critical to the full exercise of human rights: “The fulfilment of human rights obligations requires that health commodities, including contraceptives, be physically accessible and affordable for all.”26 Despite international political support for access to and information about contraception as a means of improving women’s and children’s health and longevity and the direct involvement of the pharmaceutical industry, there remain significant obstacles to meeting the needs of those 225 million underserved individuals.
Access to a full range of services, technologies, and information sources regarding contraception and reproductive justice is not improving evenly across the world. Activists with conservative viewpoints on sexual and reproductive issues are highly organized and mobilized against national and international organizations that promote reproductive justice through the provision of contraception and safe abortion. Often, their objections to contraception are based on strict interpretations of religious beliefs, including the idea that any method of obstructing sperm’s path to an egg is a form of abortion.27 Truly living in a world where reproductive justice is guaranteed for all would require a tectonic shift in how national and international systems structure their investments in reproductive health care—not to mention a massive financial and human resource investment in human health care more broadly. We are far from living in a world where everyone’s human rights, including the rights to conceive or not, are respected, and although in some places those rights are firm, they are nonexistent or under attack in others. Supporting access to contraception for all is critical for human health in the present and in the future.
Access to a full range of services, technologies, and information sources regarding contraception and reproductive justice is not improving evenly across the world.
Many people and institutions around the world—nonprofit and for-profit alike—are actively concerned with contraception every day. Pro– and anti–reproductive justice forces clash in print, online, and in person over people’s abilities to determine their own sexual and reproductive futures; inventors create and test the newest sex toys and robots; the pharmaceutical and device industries manufacture, test, and ship thousands of condoms and pills per day worldwide; policymakers write white papers and draft recommendations; and health advocates work in communities on behalf of poor and underserved populations. However, the most frequent daily experience of contraception, although shaped by these outside forces, takes place on an individual level. Sex is individually experienced but shaped by a myriad of sociocultural, economic, and political forces outside the individual’s control. Greater awareness of the past, present, and future of contraception provides a framework for individual decision making and forwards understanding of the role of contraceptive technology in the making of the human world.