In Our Control (42 page)

Media coverage of Gardasil’s extension to boys has been limited, and even as Merck moves to publicize the expanded market, government bodies like the CDC’s Advisory Committee on Immunization Practices have equivocated. While recommending Cervarix for women ages thirteen to twenty-eight who have not received an HPV vaccine, the committee said its recommendation of Gardasil for boys would remain optional.

What to make of the important distinction between telling women to get vaccinated and making it an optional recommendation for men? As one Canadian journalist wryly observed, “There’s a subtle ‘dirty girl’ air to this campaign—as if guys had nothing to do with it. Hello? You don’t get genital warts from the HPV fairy.”
¹²³
If, as recent trials suggest, Gardasil works in men as well as it works in women, it may be to everyone’s benefit to offer the shot to both sexes.

Many, however, balk at the notion that boys—since they aren’t at risk for cervical cancer—have a compelling motive to undergo the expense and discomfort associated with the vaccine. Why would boys want to get the shot? Some argue, “Think altruism. Responsibility. Chivalry, even? Oh, and yes: some explicit details about genital warts and sexual transmission.”
¹²⁴
The prevention of genital warts, long a distasteful and painful outcome of unprotected sex, may indeed prove a compelling reason for men to roll up their sleeves. But a parent of two boys ages eight and twelve provides an alternate perspective: “You don’t want to say it’s just the girls’ problem, but my sons won’t contract cervical cancer. And genital warts are treatable. I’m very skeptical. What risks will I expose them to?”
¹²⁵

This debate drives home the point that concerns that exist for women don’t receive serious consideration until male bodies are at stake. Boys shouldn’t be unnecessarily exposed to risks and neither should girls. And if approving the vaccines for boys is what it takes to have a serious conversation about the risks and benefits of this health measure, than the move to extend the shot to men is a good thing.

International Concerns

Even before approval of the vaccine in the United States, doctors’ hopes for its usefulness in the developing world were building.
¹²⁶
Healthy debate about the shot is valuable in America, but the places where it might do the most good—in poor nations around the globe that still list grossly disproportionate rates of cervical cancer diagnosis and death—are the places with little to no access to the shots.

Internationally, there are 500,000 new cases of cervical cancer each year, and somewhere around 274,000 deaths. Writing in the
New England Journal of Medicine
in 2005, authors noted that screening methods that have dramatically reduced rates of both cervical cancer and death from that illness, such as Pap smears, are more difficult to implement in the developing world.
¹²⁷
Cervical cancer is the second leading cause of cancer death in women, but more than 80 percent of those fatalities are in developing nations, a number expected to rise to 90 percent by 2020.
¹²⁸
Compare that with America, where cervical cancer fails to make the
American Cancer Society’s top ten list of most deadly cancers, and deaths from the disease account for under one tenth of the fatalities caused by cancer of the lung and breast.
¹²⁹

Merck has donated large batches of Gardasil to the World Health Organization for use in poorer countries. Unfortunately, these donations are comparatively small; for example, the initial gift—substantial in terms of monetary value at $375 million
¹³⁰
—was enough to provide 1 million women with full courses of the vaccine. While this is certainly a lot of women and a generous gift, it is not enough to affect the virus’s spread in any serious way. In order to be cost effective in a nation where the gross domestic product is less than one thousand dollars per capita, Sue J. Goldie and Jan M. Agosti argue in the
New England Journal of Medicine
that the vaccine would need to cost as little as one dollar.
¹³¹
In the meantime, public health experts note, “It is essential … for developing countries to allocate their limited resources toward screening, rather than vaccination.”
¹³²

All the existing questions about efficacy, disease change, and safety in America also apply to these populations, and caution in America may ultimately be good for women in the developing world if it turns out that the HPV vaccines aren’t effective after a decade or two of use.

To date, close to a hundred countries have approved Gardasil, and forty-four have given Cervarix the green light.
¹³³
Fifteen countries have issued formal recommendations to their populations.
¹³⁴
Much more information is needed, but the drugs show enormous promise for improving women’s lives. The controversies surrounding the vaccine highlight the way that international health care conversations between doctor and patient, government and community, developed and developing nations are emerging and changing. It is important for women to be able to take advantage of this major advance, while still asking serious questions about safety and efficacy.

Chapter Ten
What About the Boys? Or, Why Is There
Still
No Pill for Men?

Revolution … Often it is sounded to drama, drums and discussion, but sometimes it just settles over us like a mist
.
—Barbara Seaman,
Women and the Crisis in Sex Hormones

Imagine how America might look a year or two from now: the streets are full of green cars, and everyone carries reusable shopping bags. People read the newspaper on their phone, and everyone is talking about the new health care system. Life is much as it is now with the exception of small but important changes. Oh yeah, and men take the Pill.

“Wait!” I can hear you saying. “That won’t happen anytime soon. That’s in the distant future.”

Maybe. Or perhaps it’s right around the corner.

Scientists, doctors, and women have been talking about the possibility of a birth control pill for men since before there was one for women. Gregory Pincus, the father of the Pill, imagined it even as he tinkered with his nascent creation in 1950s America. Feminists in the 1970s, spurred by fears about oral contraceptive dangers, raged that men weren’t made or encouraged to bear similar dangers and wondered loudly why the responsibilities of fertility control weren’t carried more evenly by the sexes. In the 1990s, the runaway success of Viagra got pharmaceutical companies asking if, despite conventional wisdom, men weren’t an enormous untapped market for contraceptive pharmaceuticals.

Today, close to sixty years after the first hormones were given to a male patient with the purpose of curbing sperm production, it’s worth returning to what has become an age-old question: Why is there
still
no pill for men? How would drug safety, reproductive policy, and gender relationships change if the other half of the world began using pharmaceutical contraceptives? And why has the road to making and marketing a male pill been such a long one?

The answers to these questions are part of a larger conversation about the way that our society has historically treated male and female bodies differently, and the pathways through which this is (slowly) changing. It is, after all these years, a deeply contemporary topic. The male pill is a technology whose future is as bound up in the economic uncertainties of the current Great Recession as it is in egalitarian approaches to reproductive health and intimate conversation between sexual partners. It teaches us about the changing relationships between pharmaceutical giants and nongovernmental organizations in the creation of new pills, and the global nature of drug development. It also illustrates the increasing medicalization of men’s bodies and the complicated implications of that process.

Today, the options for male birth control are the same as they have been for a long time: condoms, withdrawal, and vasectomy. Imagining a social world in which birth control is an equal responsibility for men and women is a step toward making it a reality and, in its own way, a radical act.

Always Already: The Long Search for the Male Pill

Alice Wolfson was used to righteous anger, but this time the force of it shocked her. The young Barnard graduate had come into her own as an activist, like so many second-wave feminists, as part of the civil rights and antiwar movements. She had learned firsthand the strategies of fighting for social change and had started, with other young women, to apply those lessons to the long fight for sexual and gender equality. After moving to Washington, DC, with her husband, Wolfson formed a new social circle by making connections with other feminist-minded women and creating the group DC Women’s Liberation.

The group decided to attend the Nelson pill hearings after several members relayed that they’d had bad health experiences with the drug. Though the group often staged activism, in this case, their intention was fact-finding. As the young women listened to the testimony, their outrage and disbelief mounted. Although many of them had experienced unpleasant side effects with the Pill—hair loss, in Wolfson’s case—they had no idea that the drug was potentially fatal. Why hadn’t they been given all the information?

When she could stand it no longer, Wolfson raised her hand to ask questions. After this went ignored, she and the other young women got on their feet and began to yell out their concerns, disrupting the hearing. Years later, health activist Barbara Seaman, whose book had led to the hearings, would recall the scene: “Why are there no patients testifying?” the Wolfson women demanded. “Why is the press whitewashing all the adverse comments against the Pill?
Why is there no pill for men?
”
¹

It was, in its way, one of the foundational questions of the women’s health movement. Seaman would personally take up the issue at several points in her long career, most powerfully in her 1977 book
Women and the Crisis in Sex Hormones
, writing, “Although it’s a well-known fact that it takes two to make a baby, contraception in general is viewed today as a woman’s problem.”
²
The mother of the women’s health movement thought that this state of affairs, which was due at least in part to greater cultural concern for the health of men, was changing: “Partly as a result of today’s egalitarian movement … men and women are coming to regard contraception as a shared problem.”

Wolfson and Seaman were identifying a fundamental issue in women’s health care at that time: the doctor-patient relationship was paternalistic in structure, and unless male patients helped articulate and validate women’s complaints, doctors tended to write them off as the result of suggestion (meaning they expected the problem and imagined it in to being) or even something closer to hysteria. Women were denied even basic mechanisms of informed consent, and doctors were trained to avoid telling patients about potential side effects, lest they materialize.
³
If an unbiased evaluation of the Pill’s risks and benefits was ever to be obtained, activists reasoned, it would happen only after the chemicals were floating through male veins.

In a larger sense, Margaret Sanger’s successful campaign to medicalize contraception had the intended consequence of divorcing birth control and sexuality. Because pregnancy prevention happened in a doctor’s office and was therefore a negotiation between a woman and her doctor, the male sexual partner was effectively removed from the conversation. This allowed “women’s health,” as it was euphemistically called, to be ghettoized and, from a standpoint of medical safety and ethics, to receive less consideration than the already lax standards of the day required.

The women most responsible for the Pill, Margaret Sanger and Katherine McCormick, believed only women should control contraception, and it was for this reason that they chose to focus on hormonal drugs for women instead of other possible approaches that were in the air in the early 1950s, including an antisperm vaccine.
⁴
Part of the issue was social: women were simply more willing to serve as trial subjects. One scientist observed, “Male volunteers for fertility control studies may be numbered in the low hundreds, whereas women have volunteered for similar studies by the thousands … He [the human male] has psychological aversions to experimenting with sexual functions.”
⁵

In addition, the science on men’s bodies and endocrine systems was lagging far behind the science on women’s bodies. Scientists had been synthesizing hormonal compounds for use in female patients for decades, but only limited work had been done on men.

These central concerns—social and cultural myths that men are unwilling to take a birth control pill, a lack of fundamental science and chemical recourses for male bodies, and a dearth of infrastructure for executing contraceptive clinical trials—continue to haunt the development of pharmaceutical contraception for men to this day. What was clear at the time and is still true today is that, unlike the female population that historically lobbied for contraceptive access and technological innovation, “the need to develop male contraceptives was never articulated by the potential users of any new technology: men.”
⁶

Gregory Pincus, to be fair, was always optimistic that men could be included among pill users. By 1957, he was a man in love with his creation and believed that the good results seen in female patients could also be achieved in men. To test his theory, Pincus gave progestin to male prisoners at the Oregon State Penitentiary. While inhumane and unethical by today’s standards, pharmaceutical testing on prisoners and mental patients was common in the 1950s, and Pincus speculated that the lowered sperm counts of the men receiving the drug had the potential to prevent pregnancy, lower sexual desire, and even “cure” homosexuality.
⁷
The side effects experienced by these early male patients, including a loss of libido and feminization, made the idea of marketing the drug to men impractical.