Contra Contraception: The NY Times investigates the new controversey over contraceptives

Contra-Contraception
By RUSSELL SHORTO

The English writer Daniel Defoe is best remembered today for creating the ultimate escapist fantasy, "Robinson Crusoe," but in 1727 he sent the British public into a scandalous fit with the publication of a nonfiction work called "Conjugal Lewdness: or, Matrimonial Whoredom." After apparently being asked to tone down the title for a subsequent edition, Defoe came up with a new one — "A Treatise Concerning the Use and Abuse of the Marriage Bed" — that only put a finer point on things. The book wasn't a tease, however. It was a moralizing lecture. After the wanton years that followed the restoration of the monarchy, a time when both theaters and brothels multiplied, social conservatism rooted itself in the English bosom. Self-appointed Christian morality police roamed the land, bent on restricting not only homosexuality and prostitution but also what went on between husbands and wives.

It was this latter subject that Defoe chose to address. The sex act and sexual desire should not be separated from reproduction, he and others warned, else "a man may, in effect, make a whore of his own wife." To highlight one type of then-current wickedness, Defoe gives a scene in which a young woman who is about to marry asks a friend for some "recipes." "Why, you little Devil, you would not take Physick to kill the child?" the friend asks as she catches her drift. "No," the young woman answers, "but there may be Things to prevent Conception; an't there?" The friend is scandalized and argues that the two amount to the same thing, but the bride to be dismisses her: "I cannot understand your Niceties; I would not be with Child, that's all; there's no harm in that, I hope." One prime objective of England's Christian warriors in the 1720's was to stamp out what Defoe called "the diabolical practice of attempting to prevent childbearing by physical preparations."

The wheels of history have a tendency to roll back over the same ground. For the past 33 years — since, as they see it, the wanton era of the 1960's culminated in the Supreme Court's Roe v. Wade decision in 1973 — American social conservatives have been on an unyielding campaign against abortion. But recently, as the conservative tide has continued to swell, this campaign has taken on a broader scope. Its true beginning point may not be Roe but Griswold v. Connecticut, the 1965 case that had the effect of legalizing contraception. "We see a direct connection between the practice of contraception and the practice of abortion," says Judie Brown, president of the American Life League, an organization that has battled abortion for 27 years but that, like others, now has a larger mission. "The mind-set that invites a couple to use contraception is an antichild mind-set," she told me. "So when a baby is conceived accidentally, the couple already have this negative attitude toward the child. Therefore seeking an abortion is a natural outcome. We oppose all forms of contraception."

The American Life League is a lay Catholic organization, and for years — especially since Pope Paul VI's "Humanae Vitae" encyclical of 1968 forbade "any action which either before, at the moment of or after sexual intercourse, is specifically intended to prevent procreation" — being anti-contraception was largely a Catholic thing. Protestants and other non-Catholics tended to look on curiously as they took part in the general societywide acceptance of various forms of birth control. But no longer. Organizations like the Christian Medical and Dental Associations, which inject a mixture of religion and medicine into the social sphere, operate from a broadly Christian perspective that includes opposition to some forms of birth control. Edward R. Martin Jr., a lawyer for the public-interest law firm Americans United for Life, whose work includes seeking to restrict abortion at the state level and representing pharmacists who have refused to prescribe emergency contraception, told me: "We see contraception and abortion as part of a mind-set that's worrisome in terms of respecting life. If you're trying to build a culture of life, then you have to start from the very beginning of life, from conception, and you have to include how we think and act with regard to sexuality and contraception." Dr. Joseph B. Stanford, who was appointed by President Bush in 2002 to the F.D.A.'s Reproductive Health Drugs Advisory Committee despite (or perhaps because of) his opposition to contraception, sounded not a little like Daniel Defoe in a 1999 essay he wrote: "Sexual union in marriage ought to be a complete giving of each spouse to the other, and when fertility (or potential fertility) is deliberately excluded from that giving I am convinced that something valuable is lost. A husband will sometimes begin to see his wife as an object of sexual pleasure who should always be available for gratification."

As with other efforts — against gay marriage, stem cell research, cloning, assisted suicide — the anti-birth-control campaign isn't centralized; it seems rather to be part of the evolution of the conservative movement. The subject is talked about in evangelical churches and is on the agenda at the major Bible-based conservative organizations like Focus on the Family and the Christian Coalition. It also has its point people in Congress — including Representative Roscoe Bartlett of Maryland, Representative Chris Smith of New Jersey, Representative Joe Pitts and Representative Melissa Hart of Pennsylvania and Senator Tom Coburn of Oklahoma — all Republicans who have led opposition to various forms of contraception.

R. Albert Mohler Jr., president of the Southern Baptist Theological Seminary, is considered one of the leading intellectual figures of evangelical Christianity in the U.S. In a December 2005 column in The Christian Post titled "Can Christians Use Birth Control?" he wrote: "The effective separation of sex from procreation may be one of the most important defining marks of our age — and one of the most ominous. This awareness is spreading among American evangelicals, and it threatens to set loose a firestorm.. . .A growing number of evangelicals are rethinking the issue of birth control — and facing the hard questions posed by reproductive technologies."

It is difficult to state precisely when this rethinking began, but George W. Bush's victory in 2000, which was aided mightily by social conservatives, came around the same time that the abortion pill and the emergency contraception pill reached the market, and that convergence of events might be seen as the beginning of a new chapter in the culture war. State legislatures are debating dozens of bills surrounding emergency contraception, or the "morning-after pill": whether pharmacists have the right to refuse to fill orders; whether it should be made available over the counter; whether Catholic hospitals may decline to provide it to rape victims. To the dismay of many public-health officials, and following the will of conservative Christian organizations, the Bush administration has steadily moved the federal family-planning program in the direction of an abstinence-only-until-marriage program. Some conservative groups and some Republicans in Congress have waged a campaign against condoms in recent years, claiming they are less effective than popularly believed in preventing pregnancy and protecting against sexually transmitted diseases. Important international health experts say the Bush administration has used the government's program for AIDS relief to transmit its abstinence message overseas, de-emphasizing condoms and jeopardizing the health of large numbers of people, especially in Africa. A regulatory challenge has been filed with the F.D.A., and a push by some Republicans in Congress is under way to suspend the sale of the abortion pill (also known by the brand names RU-486 or Mifeprex) on the grounds that it is unsafe. The lead counsel in this challenge, however, admits the underlying motivation is opposition to abortion. Meanwhile, the abortion pill and the emergency contraception pill — because of their ease of use, the mechanisms by which they work and the fact that they are taken after sex — have blurred the line between contraception and abortion and have added a new wrinkle to the traditional anti-abortion movement.

Many Christians who are active in the evolving anti-birth-control arena state frankly that what links their efforts is a religious commitment to altering the moral landscape of the country. In particular, and not to put too fine a point on it, they want to change the way Americans have sex. Dr. Stanford, the F.D.A. adviser on reproductive-health drugs, proclaimed himself "fully committed to promoting an understanding of human sexuality and procreation radically at odds with the prevailing views and practices of our contemporary culture." Focus on the Family posts a kind of contraceptive warning label on its Web site: "Modern contraceptive inventions have given many an exaggerated sense of safety and prompted more people than ever before to move sexual expression outside the marriage boundary." Contraception, by this logic, encourages sexual promiscuity, sexual deviance (like homosexuality) and a preoccupation with sex that is unhealthful even within marriage.

It may be news to many people that contraception as a matter of right and public health is no longer a given, but politicians and those in the public health profession know it well. "The linking of abortion and contraception is indicative of a larger agenda, which is putting sex back into the box, as something that happens only within marriage," says William Smith, vice president for public policy for the Sexuality Information and Education Council of the United States. Siecus has been around since 1964, and as a group that supports abortion rights, it is natural enemies with many organizations on the right, but its mission has changed in recent years, from doing things like promoting condoms as a way to combat AIDS to, now, fighting to maintain the very idea of birth control as a social good. "Whether it's emergency contraception, sex education or abortion, anything that might be seen as facilitating sex outside a marital context is what they'd like to see obliterated," Smith says.

Senator Olympia Snowe of Maine, an abortion rights Republican who has sponsored legislation that would require insurance companies to cover contraception, has seen a major change. "Two decades or more ago, I don't think there was much of a divide on contraception and family planning," she says. "It was one area both sides could agree on as a way to reduce unwanted pregnancies. Now it becomes embroiled in philosophical disputes."

The Guttmacher Institute, which like Siecus has been an advocate for birth control and sex education for decades, has also felt the shift. "Ten years ago the fight was all about abortion," says Cynthia Dailard, a senior public-policy associate at Guttmacher. "Increasingly, they have moved to attack and denigrate contraception. For those of us who work in the public health field, and respect longstanding public health principles — that condoms reduce S.T.D.'s, that contraception is the most effective way to help people avoid unintended pregnancy — it's extremely disheartening to think we may be set back decades."

It was a Friday afternoon at the end of August last year, with most of official Washington on vacation, when a press conference was called at F.D.A. headquarters in Rockville, Md. The occasion was a major drug announcement, but no one from the agency's Center for Drug Evaluation and Research was in the room to hear Commissioner Lester M. Crawford declare that "the agency is unable at this time to reach a decision on the approvability of the application." It was for Plan B.

Plan B, the brand name for the most common form of emergency contraception, has been on the market since 1999 (another form, Preven, came on the market in 1998). The pill, which contains concentrated amounts of progestin, a hormone found in ordinary birth control pills, can prevent a pregnancy most effectively if taken within 72 hours of having sex. (The abortion pill, by contrast, can be taken up to 49 days after the beginning of the last menstrual period and causes the chemical abortion of a fetus.) Plan B's manufacturer applied in April 2003 for permission to sell Plan B over the counter. Reproductive and women's health professionals expected clear sailing for the drug (morning-after contraception has been available in some European countries for more than 20 years). Experts overwhelmingly considered it safe: in December 2003 the F.D.A.'s own joint advisory panel voted 28-0 that it was "safe for use in the nonprescription setting" and then voted 23 to 4 in favor of granting Plan B over-the-counter status.

The hope many people had for the drug was tied to an ugly number: 21. That is the number of abortions in the U.S. per year per 1,000 women of reproductive age, which puts the country at or near the top among developed nations. Put another way, according to a study released this past week by the Guttmacher Institute, there are 6.4 million pregnancies a year in the U.S., 3.1 million of which are unintended and 1.3 million of which end in abortion. In the seven years since the last such study, the overall unintended-pregnancy rate has remained unchanged; for women below the poverty level it increased 29 percent. If women had quick, easy access to a backup contraceptive, the thinking of Plan B proponents went, those rates — and thus the abortion rate — would drop. "I saw it as a win-win situation, something that everyone on both sides of the abortion issue could support," says Dr. Susan F. Wood, who was at the time director of the Office of Women's Health at the F.D.A. "I still don't get what happened."

One thing that happened, which Dr. Wood and many others may have failed to notice, was the change in conservative circles on the subject of contraception. At a White House press briefing in May of last year, three months before the F.D.A.'s nonruling on Plan B, Press Secretary Scott McClellan was asked four times by a WorldNetDaily correspondent, Les Kinsolving, if the president supported contraception. "I think the president's views are very clear when it comes to building a culture of life," McClellan replied. Kinsolving said, "If they were clear, I wouldn't have asked." McClellan replied: "And if you want to ask those questions, that's fine. I'm just not going to dignify them with a response." This exchange caught the attention of bloggers and others. In July, a group of Democrats in Congress, led by Representative Carolyn Maloney of New York, sent the first of four letters to the president asking outright: "Mr. President, do you support the right to use contraception?" According to Representative Maloney's office, the White House has still not responded.

For those who were listening, that silence may have given an indication of what had been going on inside the F.D.A. After the agency's advisory committees voted in favor of over-the-counter status for Plan B at the end of 2003, and after it was further approved at every level of the agency's professional staff, standard procedure would have been for the Center for Drug Evaluation and Research arm of the F.D.A. to approve the application. But one member of the F.D.A.'s Reproductive Health Drugs Advisory Committee had reservations: Dr. W. David Hager, a Christian conservative whom President Bush appointed to lead the panel in 2002. (After an outcry from women's groups, who were upset at Dr. Hager's writing that he used Jesus as a model for how he treated women in his gynecology practice, he was shifted from chairman of the panel to ordinary member.) Dr. Hager said he feared that if Plan B were freely available, it would increase sexual promiscuity among teenagers. F.D.A. staff members presented research showing that these fears were ungrounded: large-scale studies showed no increase in sexual activity when Plan B was available to them, and both the American Academy of Pediatrics and the Society for Adolescent Medicine endorsed the switch to over-the-counter status. Others argued that the concern was outside the agency's purview: that the F.D.A.'s mandate was specifically limited to safety and did not extend to matters like whether a product might lead to people having more sex. Meanwhile a government report later found that Dr. Janet Woodcock, deputy commissioner for operations at the F.D.A., had also expressed a fear that making the drug available over the counter could lead to "extreme promiscuous behaviors such as the medication taking on an 'urban legend' status that would lead adolescents to form sex-based cults centered around the use of Plan B." In May 2004, the F.D.A. rejected the finding of its scientific committees and denied the application, citing some of the reasons that Dr. Hager had expressed.

The drug's manufacturer reapplied two months later, this time for permission to sell it over the counter to women ages 16 and up, seemingly dealing with the issue of youth. Then, last August, Crawford made his announcement that the F.D.A. would delay its decision, a delay that could be indefinite. The announcement made headlines across the country. Dr. Wood, the F.D.A.'s women's health official, resigned in protest. Democrats in Congress asked for an investigation into what they felt was politics — the anti-birth-control agenda of the politically powerful Christian right — trumping science. The Government Accountability Office conducted a study of the events and issued a report last November concluding that the decision to reject the findings of the scientific advisory panel "was not typical of the other 67 prescription-to-O.T.C. switch decisions made from 1994 to 2004." Currently, Senators Hillary Clinton and Patty Murray are holding up the nomination of Andrew von Eschenbach as F.D.A. commissioner until the F.D.A. issues a verdict on the drug.

The saga of emergency contraception and the F.D.A. is developing into one of the iconic clashes of the Bush era: a story of the entanglement of politics, science and religious beliefs. At the heart of it is the question of whether emergency contraception is or could be a form of abortion. "The science is very clear that this does not cause an abortion," William Smith of Siecus told me. The same clarity exists on the other side. One of the "common and intended modes of action" of emergency contraception, according to the United States Conference of Catholic Bishops, "is to prevent the development of the embryo, resulting in his or her death." Dr. Gene Rudd, an obstetrician-gynecologist who is associate executive director of the Christian Medical and Dental Associations, advises his group's member physicians that "those who consider life to begin at fertilization recognize the pills' mechanisms as abortifacient," or inducing an abortion.

The issue is partly — but only partly — one of definition. According to the makers of the emergency contraception pill, it has three possible means of functioning. Most commonly, it stops ovulation — the release of an egg —or prevents sperm from fertilizing an egg. In some cases, however, depending on where a woman is in her cycle, it may stop an already fertilized egg from attaching to the uterine wall. In such a situation, for those who believe that life — and thus also pregnancy — begins at the moment of fertilization, it would indeed function as an abortifacient. According to the American College of Obstetricians and Gynecologists, however, pregnancy begins not at fertilization but at implantation. The medical thinking behind this definition has to do with the fact that implantation is the moment when a woman's body begins to nurture the fertilized egg. The roughly one-half of all fertilized eggs that never attach to a uterine wall are thus not generally considered to be tiny humans — ensouled beings — that died but rather fertilized eggs that did not turn into pregnancies. Federal regulations enacted during the Bush administration agree with this, stating, "Pregnancy encompasses the period of time from implantation until delivery."

People are, of course, perfectly within their rights to believe that pregnancy begins when sperm meets egg. And it is reasonable for groups like the Christian Medical and Dental Associations, Focus on the Family and the American Life League to want to alert their members that something billed as contraception might actually have a function that runs counter to their beliefs. But there are two twists. One is that emergency contraception may not actually work as an abortifacient. "There is no direct evidence that it blocks implantation," Dr. Wood says. "We can't tell for sure because very little research has been done on direct implantation of human eggs. You run into moral problems doing research on a woman's body and a human embryo. And since half of all fertilized eggs do not implant anyway, it would be difficult to know if this was the mechanism responsible." Still, if it's even possible for emergency contraception to stop implantation, then it's right for Dr. Rudd of the C.M.D.A. to advise his group's member physicians, "Regardless of what an assembly of experts define, or fail to define, as the beginning of pregnancy, if a patient retains the moral conviction that life begins at fertilization, she must be made aware of information relevant to that conviction."

But the other twist is that emergency contraception apparently works in a manner similar to that of the ordinary birth control pill. That is to say, the pill, which contains the hormone progestin, also has three possible means of operation: by stopping ovulation, preventing fertilization or impeding implantation. If emergency contraception is a potential abortifacient, then the same would seem to be true for the pill, which tens of millions of women have taken over the past several decades. Dr. Rudd disputed this. "The scientific evidence is that emergency contraception is more likely to have a post-fertility effect than the routine birth control," he told me. But Dr. James Trussell, director of the Office of Population Research at Princeton University and one of the world's leading experts on contraception, said: "That is completely wrong. The evidence is about the same for all hormonal methods of contraception. We can't rule out a post-fertility effect for Plan B, and the same is true for the birth control pill."

What's more, Dr. Trussell added: "There is evidence that there is a contraceptive effect of breast feeding after fertilization. While a woman is breast feeding, the first ovulation is characterized by a short luteal phase, or second half of the cycle. It's thought that because of that, implantation does not occur." In other words, if the emergency contraception pill causes abortions by blocking implantation, then by the same definition breast feeding may as well. Besides that, the intrauterine device, or IUD, can alter the lining of the uterus and, in theory, prevent implantation.

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