Birth Control

CONTRACEPTIVE METHODS Stephanie B. Teal

SOCIOCULTURAL AND HISTORICAL ASPECTS Vern L. Bullough

Hormonal Methods

Hormones are the chemical messengers the body uses to control and coordinate various physical processes. The major hormones influencing the female reproductive organs are estrogen and progesterone. Manipulation of these hormones may disrupt the normal processes required for fertility, such as ovulation, transport of egg and sperm in the Fallopian tubes, thinning of cervical mucus, and preparation of the uterine lining (endometrium) for implantation. Hormonal methods of contraception must affect these processes enough to prevent fertility, without causing too many other bothersome side effects or risks.

Combination oral contraceptive pills. The combination oral contraceptive (COC) pill is a highly effective, reversible female contraceptive. It contains both estrogen and progestin (a compound that mimics natural progesterone). Taken every day for three out of four weeks, it prevents ovulation by inhibiting the secretion of two regulatory hormones from the brain's pituitary gland. The estrogen suppresses follicle stimulating hormone (FSH) and thus prevents preparation of an egg for ovulation. The main contraceptive effect, however, is from the progestin, which suppresses luteinizing hormone (LH). The lack of the LH surge prevents ovulation. The progestin also has effects on the endometrium and cervical mucus. The endometrium becomes much less favorable to implantation due to thinning. Meanwhile, the cervical mucus becomes thick, limiting sperm penetration and transport into the uterine cavity. Even if ovulation occasionally occurs, these other effects contribute to the overall high contraceptive efficacy of 98 percent (Trussell and Vaughan 1999).

The COC pill has significant noncontraceptive benefits, including reduction of menstrual blood loss, reduction of cramps, and improved regularity of the menstrual cycle. It also significantly reduces the risks of ovarian and endometrial cancer, pelvic inflammatory disease, breast cysts, and endometriosis. Both acne and excessive hair growth are improved by COC pill use.

Although the COC pill has many contraceptive and noncontraceptive benefits, it is not appropriate for everyone. Contraindications include breast cancer, severe liver disease, and uncontrolled hypertension. Blood clots in the deep veins are a rare but sometimes serious risk associated with the pill. Women who smoke are already at higher risk of blood clots and heart attack due to their cigarette usage, and smokers are discouraged from COC use. In nonsmokers, however, the pill is safe to use through the age of menopause.

Depo-Provera. Depo-Provera (depot medroxyprogesterone acetate) is a long-acting, reversible injectable contraceptive available in many countries since the late 1970s and in the United States since 1992. It results in initially high progestin levels which taper off over the following weeks. It is given as an injection every twelve to thirteen weeks. The progestin dose results in thickening of cervical mucus and thinning of the endometrium, but also is high enough to suppress ovulation, leading to a high efficacy rate of 99 percent (Trussell and Vaughan 1999). Because of the lack of estrogen with this method, a common side effect is unscheduled irregular bleeding. This usually resolves over several months, and 50 percent of women have no bleeding at all after one year of use (Kaunitz 2001). In fact, this method may be beneficial to women who are troubled by heavy, prolonged menstrual periods. Depo-Provera is also an excellent contraceptive for those who cannot use estrogen, want a private method whose timing is not related to intercourse, or do not want to take a pill every day. Because it can have a prolonged effect on a woman's return to fertility, Depo-Provera is not a good option for women planning Worldwide, many contraceptive methods are available. Factors influencing the choice of method include availability, cost, reversibility, ease of use, cultural preferences, privacy, side effects, and medical risks. RAY ELLIS/PHOTO RESEARCHERS, INC. pregnancy within the next year. It is still controversial whether it promotes weight gain: this effect has only been noted in U.S. trials of this internationally popular method (Kaunitz 2001).

Lunelle. Lunelle, an injectable monthly contraceptive, contains one-sixth the dose of medroxyprogesterone acetate as Depo-Provera, and also contains estrogen. Lunelle is given by injection every twenty-three to thirty-three days. Like Depo-Provera, the progestin in Lunelle inhibits the secretion of the hormone LH, preventing ovulation. Because of the estrogen the bothersome unscheduled bleeding of Depo-Provera is much improved. In the first ninety days of use, 57 percent of Lunelle users report variations in their bleeding patterns, compared with 91 percent of Depo-Provera users (Hall 1998). However, long-term Lunelle users tend to see normalization of their bleeding patterns, and after a year, 70 percent report normal monthly bleeding. Lunelle is highly effective. In studies conducted by the World Health Organization, over 12,000 women in nine countries were followed for a total of 100,000 woman-months use: five pregnancies occurred (Hall 1998). The formulation in Lunelle has been used in some countries for twenty years prior to FDA (Food and Drug Administration) approval in the United States.

Implantables. Several sustained-release progestin-only contraceptives have been developed to reduce the frequency of administration and decrease the high progestin levels associated with Depo-Provera. Norplant consists of six capsules filled with the progestin levonorgestrel that are placed under the skin of the upper arm. The capsules release the hormone at a constant low rate, resulting in a daily dose about 25 to 50 percent that of low-dose COCs. Unscheduled bleeding does occur, especially during the first year, but women often return to a normal menstrual pattern thereafter. Norplant may be used for up to five years.

Implanon. A single capsule system which is effective for three years, Implanon's major benefit over Norplant is the ease of insertion and removal, which can be difficult if the capsules are placed too deeply or irregularly. One of the most obvious benefits of these implants is the low demand on the contraceptive user, especially as compared to daily pill use. Efficacy is also extremely high, with a failure rate of less than 1 percent per year.

Progestin Intrauterine Device. Widely used in Europe, the progestin intrauterine device (IUD) is a low-maintenance method that has high efficacy, rapid reversibility, and reduction of menstrual blood loss. The Mirena progestin IUD is a small, T-shaped flexible plastic device that slowly releases levonorgestrel contained in the long stem of the T. The contraceptive effect is primarily from the thickening of cervical mucus and alteration of sperm motility and function. Although ovulation is not usually inhibited, the failure rate is only 0.14 percent. After placement, the progestin IUD may be left in place up to five years, or removed when pregnancy is desired.

Nonhormonal Methods

Nonhormonal methods rely on prevention of contact of the egg and sperm. Many nonhormonal methods require implementation around the time of intercourse, or place restrictions on when or how intercourse may occur, whereas others require little maintenance. Because of this, these methods have a much wider range of contraceptive failure than the hormonal methods, ranging from as high as 25 percent for withdrawal and natural family planning, to as low as 0.5 to 1 percent for the IUD and sterilization.

Intrauterine Device. The intrauterine device is a highly effective, reversible, long-acting, nonhormonal method of contraception. It is popular in Europe, Asia, and South America. Nonhormonal IUDs come in many different forms, but the most common type in the United States is the TCu-380A, also known as Paraguard. The Paraguard IUD is a small plastic "T" wrapped with copper. It exerts its effect through several mechanisms: first, the copper significantly decreases sperm motility and lifespan, second, the IUD produces changes in the endometrium that are hostile to sperm. The IUD does not affect ovulation, nor does it cause abortions. The overall failure rate of the IUD is less than 1 percent per year, which is comparable to female sterilization (Meirik et al. 2001). After removal, a woman can become pregnant immediately. Despite its benefits, its popularity in the United States waned in the mid-1970s due to a rash of litigation related to reports of increased pelvic infection and infertility related to its use. Later studies largely refuted these concerns, but the bad publicity has lingered (Hubacher et al. 2001). Although slowly increasing, U.S. use rate of the IUD still lags far behind the rest of the world.

Condom: male and female. The male condom is a sheath of latex or polyurethane that is placed over the penis prior to intercourse as a barrier to sperm. It is inexpensive, readily available, and has the added health benefit of providing protection against sexually transmitted diseases, including HIV. Condoms may also be lubricated with a spermicide.

The female condom is a polyurethane sheath with two rings attached, which is placed in the vagina prior to intercourse. In clinical trials it has had high patient acceptance, and has the benefit of being a woman-controlled method of sexually transmitted disease protection. Couples should not use both a male and a female condom during an act of intercourse, as this increases the risk of breakage. The failure rate of condoms is 12 to 20 percent (Fu et al. 1999).

Diaphragm. The diaphragm is a rubber cupshaped device which is filled with spermicide and inserted into the vagina, creating a barrier in front of the cervix. Like the condom, the efficacy rate of the diaphragm is dependent on the user, but ranges from 80 to 90 percent. The diaphragm does provide some protection against gonorrhea and pelvic inflammatory disease, but has not been shown to reduce transmission of HIV or other viral sexually transmitted infections. Although it must be obtained by prescription, a diaphragm is relatively inexpensive, and with proper care lasts for several years. It may be combined with condom use for greater contraceptive efficacy and disease prevention.

Withdrawal. Also known as coitus interruptus, withdrawal requires the male partner to remove his penis from the woman's vagina prior to ejaculation. Although theoretically sperm should not enter the vagina and fertilization should be prevented, this method has a failure rate of up to 25 percent in typical use (Trussell and Vaughan 1999). Withdrawal is probably most useful as a back-up method for couples using, for example, periodic abstinence.

Natural family planning. Periodic abstinence, also known as natural family planning, depends on determining safe periods when conception is less likely, and using this information to avoid pregnancy. The various methods of natural family planning include the calendar, thermal shift, symptothermal, and cervical mucus methods. All of these methods require training in the recognition of the fertile phase of the menstrual cycle, as well as a mature commitment by both partners to abstain from intercourse during this time. If the woman does not have a predictable menstrual cycle, some of these methods are more difficult to use effectively. Although with perfect use the failure rate could be as low as 5 percent, actual failure rates are closer to 25 percent and above (Fu et al. 1999; Trussell and Vaughan 1999).

Female sterilization. Female sterilization is the most common method of birth control for married couples in the United States. The technique is performed surgically, through one or two incisions in the abdomen. The Fallopian tubes may be tied, cut, burnt, banded with rings, or blocked with clips. Sterilization should be considered final and irreversible, although expensive microsurgery can sometimes repair the tube enough to allow pregnancy. Some couples assume that because this method is irreversible, it has a perfect efficacy rate, but this is not true. Each method has a slightly different rate of failure or complication, but the overall failure rate for female sterilization is about 1 percent (Peterson et al. 1996). The failure rate of sterilization is also dependent on the age of the patient, with younger patients more likely to experience an unplanned pregnancy up to ten years after the procedure. Younger patients are also more likely to experience regret in the years following sterilization.

Male sterilization. Male sterilization (vasectomy) is also a highly effective, permanent method of contraception. It is accomplished by making a small hole on either side of the scrotum and tying off the spermatic cord which transports sperm into the semen just prior to ejaculation. Compared to female sterilization, it is less expensive, more effective, easier to do with less surgical risk, and is easier to reverse if necessary. Vasectomy has no effect on male sexual function, including erectile function, ejaculation, volume of semen, or sexual pleasure. However, vasectomy rates consistently lag far behind those of female sterilization in all parts of the world, due mainly to cultural factors.

Emergency Contraception

Emergency contraception, also known as post-coital contraception, includes any method that acts after intercourse to prevent pregnancy. The Yuzpe method uses COC pills to deliver two large doses of hormones, twelve hours apart. These must be taken within seventy-two hours of the unprotected intercourse to be effective. A prepackaged emergency contraceptive kit called Preven is also available. The kit contains a pregnancy test, instructions, and two pills with the appropriate doses of estrogen and progestin. Studies show a pregnancy rate of 3.2 percent for the cycle in which the woman took the emergency contraception, which is a 75 percent reduction of the 8 percent expected pregnancy rate per unprotected cycle (Ho 2000). The main side effects are nausea and possibly vomiting from the high dose of estrogen. Emergency contraception using a special progestin-only pill containing levonorgestrel avoids this side effect. It is marketed as Plan B. A study of 967 women using Plan B showed a pregnancy rate of 1.1 percent, or an 85 percent reduction. Both methods cause a 95 percent reduction in the risk of pregnancy if taken within the first twelve hours after unprotected intercourse (Nelson et al. 2000). The mechanism of action of the hormonal pills is probably the prevention of ovulation, with some contribution of changes in the endometrium. They do not cause abortion.

Conclusion

Control of family size is an important consideration for all adults, in every country. Many different contraceptive methods exist, and no single method is appropriate for all couples. When choosing a contraceptive method, factors such as effectiveness, reversibility, side effects, privacy, cost, and cultural preferences should be considered.

Widespread Public Discussion

Key to the emerging public discussion about birth control was concern with overpopulation, and only later did the feminist issue of right to plan families emerge. The population issue was first put before the public by the Reverend Thomas Robert Malthus (1766–1834) in his Essay on the Principle of Population (1708). The first edition was published anonymously, but Malthus signed his name to the second, expanded edition published in 1803. Malthus believed that human beings were possessed by a sexual urge that led them to multiply faster than their food supply, and unless some checks could somehow be applied, the inevitable results of such unlimited procreation were misery, war, and vice. Population, he argued, increased geometrically (1, 2, 4, 8, 16, 32 . . .) whereas food supply only increased arithmetically (1, 2, 3, 4, 5, 6, . . .) Malthus's only solution was to urge humans to exercise control over their sexual instincts (i.e., to abstain from sex except within marriage) and to marry as late as possible. Sexually, Malthus was an extreme conservative who went so far as to classify as vice all promiscuous intercourse, "unnatural" passions, violations of the marriage bed, use of mechanical contraceptives, and irregular sexual liaisons.

Many of those who agreed with Malthus about the threat of overpopulation disagreed with him on the solutions and instead advocated the use of contraceptives. Those who did so came to be known as neo-Malthusians. Much of the debate over birth control, however, came to be centered on attitudes toward sexuality. Malthus recognized the need of sexual activity for procreation but not for pleasure. The neo-Malthusians held that continence or abstinence was no solution because sex urges were too powerful and nonprocreative sex was as pleasurable as procreative sex.

To overcome the lack of public information about contraception, the neo-Malthusians felt it was essential to spread information about the methods of contraception. The person in the English speaking world generally given credit for first doing so was the English tailor, Francis Place (1771–1854). Place was concerned with the widespread poverty of his time, a poverty accentuated by the growth of industrialization and urbanization as well as the breakdown of the traditional village economy. Large families, he felt, were more likely to live in poverty than smaller ones, and to help overcome this state affairs, Place published in 1882 his Illustrations and Proofs of the Principle of Population. He urged married couples (not unmarried lovers) to use "precautionary" means to plan their families better, but he did not go into detail. To remedy this lack of instruction, he printed hand-bills in 1823 addressed simply To the Married of Both Sexes. In it he advocated the use of a dampened sponge which was to be inserted in the vagina with a string attached to it prior to "coition" as an effective method of birth control. Later pamphlets by Place and those who followed him added other methods, all involving the female. Pamphlets of the time, by Place and others, were never subject to any legal interference, although they were brought to the attention of the attorney general who did not take any action. Place ultimately turned to other issues, but his disciples, notably Richard Carlile (1790–1843), took up the cause. It became an increasingly controversial subject in part because Place and Carlile were social reformers as well as advocates of birth control. Carlile was the first man in England to put his name to a book devoted to the subject, Every Woman's Book (1826).

Early U.S. Birth Control Movement

In the United States, the movement for birth control may be said to have begun in 1831 with publication by Robert Dale Owen (1801–1877) of the booklet Moral Physiology. Following the model of Carlile, Owen advocated three methods of birth control, with coitus interruptus being his first choice. His second alternative was the vaginal sponge, and the third the condom. Ultimately far more influential was a Massachusetts physician, Charles Knowlton (1800–1850) who published his Fruits of Philosophy in 1832. In his first edition, Knowlton advocated a policy of douching, a not particularly effective contraceptive, but it was the controversy the book caused rather than its recommendation for which it is remembered. As he lectured on the topic through Massachusetts, he was jailed in Cambridge, fined in Taunton, and twice acquitted in trials in Greenfield. These actions increased public interest in contraception, and Knowlton had sold some 10,000 copies of his book by 1839. In subsequent editions of his book, Knowlton added other more reliable methods of contraception.

Once the barriers to publications describing methods of contraception had fallen, a number of other books appeared throughout the English-speaking world. The most widely read material was probably the brief descriptions included in Elements of Social Science (1854), a sex education book written by George Drysdale (1825–1901). Drysdale was convinced that the only cause of poverty was overpopulation, a concept that his more radical freethinking rivals did not fully accept. They were more interested in reforming society by eliminating the grosser inequities, and for them contraception was just one among many changes for which they campaigned.

Influence of Eugenics

Giving a further impetus to the more conservative voices in the birth control movement was the growth of the eugenics movement. The eugenicists, while concerned with the high birthrates among the poor and the illiterate, emphasized the problem of low birthrates among the more "intellectual" upper classes. Eugenics came to be defined as an applied biological science concerned with increasing the proportion of persons of better than average intellectual endowment in succeeding generations. The eugenicists threw themselves into the campaign for birth control among the poor and illiterate, while urging the "gifted" to produce more. The word eugenics had been coined by Francis Galton (1822–1911), a great believer in heredity, who also had many of the prejudices of an upper-class English gentleman in regard to social class and race. Galton's hypotheses were given further "academic" respectability by Karl Pearson (1857–1936), the first holder of the Galton endowed chair of eugenics at the University of London. Pearson believed that the high birthrate of the poor was a threat to civilization, and if members of the "higher" races did not make it their duty to reproduce, they would be supplanted in time by the members of the "lower races."

When put in this harsh light, eugenics gave "scientific" support to those who believed in racial and class superiority. It was just such ideas that Adolph Hitler attempted to implement in his "solution" to the "racial problem." Although Pearson's views were eventually opposed by the English Eugenics Society, the U.S. eugenics movement, founded in 1905, adopted his view. Inevitably, a large component of the organized family planning movement in the United States was made up of eugenicists. The fact that the Pearson-oriented eugenicists also advocated such beliefs as enforced sterilization of the "undesirables" inevitably tainted the group in which they were active even when they were not the dominant voices.

With legal obstacles to the dissemination of contraceptive information removed, the remaining challenges are to distribute information and encourage people to use contraceptives for effective family planning. Teenagers are one of the more difficult audiences to reach. PHOTODISC, INC.

Dissemination of Information and Censorship

Population studies indicate that at least among the upper-classes in the United States and Britain, some form of population limitation was being practiced. Those active in the birth control movement, however, found it difficult to contact the people they most wanted to reach, namely the poor, overburdened mothers who did not want more children or who, in more affirmative terms, wanted to plan and space their children. The matter was complicated by the enactment of anti-pornography and anti-obscenity legislation which classed birth control information as obscene. In England, with the passage of the first laws on the subject in 1853, contraception was interpreted to be pornographic since of necessity it included discussion of sex. Books on contraception that earlier had been widely sold and distributed were seized and condemned. Such seizures were challenged in England in 1877 by Charles Bradlaugh (1833–1891) and Annie Besant (1847–1933). Bradlaugh and Besant were convicted by a jury that really wanted to acquit them, but the judgement was overturned on a technicality. In the aftermath, information on contraception circulated widely in Great Britain and its colonies.

In the United States, however, where similar legislation was enacted by various states and by the federal government, materials that contained information about birth control and that were distributed through the postal system or entered the country through customs ran into the censoring activities of Anthony Comstock (1844–1915) who had been appointed as a special postal agent in 1873. One of his first successful prosecutions was against a pamphlet on contraception by Edward Bliss Foote (1829–1906). As a result, information about contraceptives was driven underground, although since state regulations varied some states were more receptive to information about birth control. Only those people who went to Europe regularly kept up with contemporary developments such as the diaphragm, which began to be prescribed in Dutch clinics at the end of the nineteenth century. The few physicians who did keep current in the field tended to restrict their services to upper-class groups. The dominant voice of the physicians in the increasingly powerful American Medical Association was opposed to the use of contraceptives and considered them immoral. That this situation changed is generally credited to Sanger, a nurse.

In 1914, Sanger, then an active socialist, began to publish The Woman Rebel, a magazine designed to stimulate working women to think for themselves and to free themselves from bearing unwanted children. To educate women about the possibilities of birth control, Sanger decided to defy the laws pertaining to the dissemination of contraceptive information by publishing a small pamphlet, Family Limitation (1914), for which she was arrested. Before her formal trial, she fled to England, where she spent much of her time learning about European contraceptive methods, including the diaphragm. While she was absent her husband, William Sanger (1873–1961), who had little to do with his wife's publishing activities, was tricked into giving a copy of the pamphlet to a Comstock agent, and for this was arrested and convicted, an act that led to the almost immediate return of his wife. Before she was brought to trial, however, Comstock died. The zealousness of his methods had so alienated many prominent people that the government—without Comstock pushing for a conviction—simply decided not to prosecute Sanger, a decision which received widespread public support.

In part through her efforts, by 1917 another element had been added to the forces campaigning for more effective birth control information, namely the woman's movement (or at least certain segments of it). Women soon became the most vocal advocates and campaigners for effective birth control, joining "radical" reformers and eugenicists in an uneasy coalition.

Sanger, though relieved at being freed from prosecution, was still anxious to spread the message of birth control to the working women of New York. To reach them, she opened the first U.S. birth control clinic, which was patterned after the Dutch model. Since no physician would participate with her, she opened it with two other women, Ethel Byrne, her sister and also a nurse, and Fania Mindell, a social worker. The well-publicized opening attracted long lines of interested women—as well as several vice officers—and after some ten days of disseminating information and devices, Sanger and her two colleagues were arrested. Byrne, who was tried first and sentenced to thirty days in jail, promptly went on a hunger strike, attracting so much national attention that after eleven days she was pardoned by the governor of New York. Mindell, who was also convicted, was only fined $50. By the time of Sanger's trial, the prosecution was willing to drop charges provided she would agree not to open another clinic, a request she refused. She was sentenced to thirty days in jail and immediately appealed her conviction. The New York Court of Appeals rendered a rather ambiguous decision in acquitting her, holding that it was legal to disseminate contraceptive information for the "cure and prevention of disease," although they failed to specify the disease. Sanger, interpreting unwanted pregnancy as a disease, used this legal loophole and continued her campaign unchallenged.

New York, however, was just one state; there were many state laws to be overcome before information about contraceptives could be widely disseminated. Even after the legal barriers began to fall, the policies of many agencies made it difficult to distribute information. Volunteer birth control clinics were often prevented from publicly advertising their existence. It was not until 1965 that the U.S. Supreme Court, in Griswold v. Connecticut, removed the obstacle to the dissemination of contraceptive information to married women. It took several more years before dissemination of information to unmarried women was legal in every state.

In Europe, the battle, led by the Netherlands, for the dissemination of information about birth control methods took place during the first half of the twentieth century. It was not until after World War II when, under Sanger's leadership, the International Federation for Planned Parenthood was organized, that a worldwide campaign to spread the message took place. At the beginning of the twenty-first century two major countries, Japan and Russia, still used abortion as a major means of family planning. In many countries, more than 60 percent of women of childbearing age are using modern contraceptives, including Argentina, Australia, Austria, the Bahamas, Belgium, Brazil, Canada, China, Costa Rica, Cuba, Denmark, Finland, France, Hungary, Italy, Jamaica, Korea, New Zealand, Netherlands, Norway, Spain, Sweden, Switzerland, Singapore, Thailand, the United Kingdom, and the United States. Many other nations are approaching this rate of success, but much lower rates exist throughout Africa (where Tunisia seems to the highest at 49 percent), in most of the former areas of the Soviet Union and the eastern block countries, and in much of Asia and Latin America. The International Planned Parenthood Federation does periodic surveys of much of the world which are regularly updated on its website (see also Bullough 2001).

Teenagers and Birth Control

With legal obstacles for adults removed, and a variety of new contraceptives available, the remaining problems are to disseminate information and encourage people to use contraceptives for effective family planning. One of the more difficult audiences to reach has been teenagers. Many socalled family life or sex education programs refuse to deal with the issue of contraceptives and instead emphasize abstinence from sex until married. Unfortunately, abstinence—or continence as it is sometimes called—has the highest failure rate of any of the possible means of birth control since there is no protection against pregnancy if the will power for abstinence fails. The result was a significant increase in the 1990s of unmarried teenage mothers, although not of teenage mothers in general. The highest percentage of teenage mothers in the years the United States has been keeping statistics on such matters came in 1957, but the overwhelming majority of these were married women. Although the number of all teenage mothers has been declining ever since, reaching new lows in 1999–2000, an increased percentage of them are unmarried. In fact, it is the change in marriage patterns and in adoption patterns, more than the sexual activity of teenagers, that led to public concern over unmarried teenage mothers. Since societal belief patterns have increasingly frowned upon what might be called "forced marriages" of pregnant teenagers, and the welfare system itself was modified to offer support to single mothers, at least within certain limits, teenagers who earlier might have given up their children for adoption decided to keep them.

Many programs have been introduced since the federal government in 1997 created the abstinence-only-until-marriage program to teach those teenagers most at-risk to be more sexually responsible. Only a few of the programs included a component about contraceptives since the federally funded programs do not provide for it, and only a few states such as California have provided funds to do so. Most of the programs emphasize self-esteem, the need for adult responsibility, and the importance of continence, all important for teenage development, but almost all the research on the topic, summaries of which are regularly carried in issues of SIECUS Report, has found that the lack of specific mention of birth control methods has handicapped their effectiveness in curtailing teenage pregnancy. This deficiency has been somewhat compensated for by the development of more efficient and easy-to-use contraceptives and availability of information about them from other sources.

Still, although contraception and family planning increasingly have come to be part of the belief structure of the U.S. family, large segments of the population remain frightened by, unaware of, or unconvinced by discussion about birth control. Unfortunately, because much of public education about birth control for much of the twentieth century was aimed at the poor and minorities, some feel that birth control is a form of racial suicide. It takes a lot of time and much education to erase such fears and success can only come when such anxieties can be put to rest.