The Complete Guide to How Birth Control Has Changed in Recent Years
A lot has changed about birth control since you may have first learned about it – and if you get birth control information from older people in your life (say, your mom), things could have changed even more since since they were young. Over the past few decades, new technologies have emerged, old technologies have been improved and, in some cases, changes in the legal status of some methods.
In this package, which we call ” The State of Your Birth Control ,” we inform you about your current options – with a focus on things you may have some misconceptions about due to their history or their context in popular culture.
To keep us all on the same page, let’s take a little detour into the history of some of our most popular modern contraceptive methods: where they originated, how they evolved, and where they are now.
condoms
Condoms are one of the oldest known forms of birth control, although they have not always been used specifically for birth control. (In one Greek myth, King Minos’ mistress uses an animal’s bladder as a female condom because the king regurgitates scorpions and snakes.)
By the way, barrier methods used in the vagina have a long history. Diaphragms, cervical caps, and pessaries were commercially available in the 1800s (sold as “womb veils”), and their modern counterparts are still available today.
The Wellcome Medical Museum has vintage examples of soft condoms made from animal membranes and hard condoms made from tortoiseshell. Since ancient times, other materials have also been known: oiled paper, linen, plants and much more. Sometimes they were intended to prevent sexually transmitted diseases or parasites, such as the bilharzia in Egypt. A 1533 book on syphilis describes how a linen condom lubricated with saliva and tied with a ribbon reportedly prevented 1,100 men from contracting syphilis.
“Sheepskin” condoms (usually made from animal intestines rather than skin) were also popular during this period and are still available today . We now know that these condoms can prevent pregnancy, but are not reliable protection against STDs. By the late 1700s, animal-based condoms began to be commercially produced, although they were expensive enough to be considered a luxury item. Around this time, the word “condom” appeared, first appearing in an 1875 London slang dictionary.
Rubber condoms hit the scene in the 1800s, and especially latex, which could be thin and stretchy, in the 1920s. Condoms became more popular in the US after World War II (the first war during which the US distributed condoms to soldiers), but they really boomed during the AIDS crisis in the 1980s.
If you grew up in the 1980s or 1990s, you may remember that condoms and condom-based safe sex propaganda were everywhere . They are still one of the most common methods of birth control , and can be purchased relatively cheaply without a prescription. But they have also been politicized, with religious groups spreading misinformation about how condoms work. (Spoiler: they actually work pretty well.)
Birth control pills
The first birth control pill in the US, Enovid, was submitted for FDA approval in 1957—to regulate menstruation, not to prevent pregnancy. (Historically, talking about making periods more “regular” or inducing periods was a coded way of talking about preventing pregnancy, so the pill’s contraceptive potential was probably understood even if it wasn’t officially used.)
Margaret Sanger, of Planned Parenthood, helped fund the research that led to the development of Enovid. The pill was being tested on psychiatric patients and on low-income women in Puerto Rico who were not told they were participating in trials of the drug. In 1960, it was approved as the first oral contraceptive.
Despite questions about side effects and safety, the FDA decided that the pill was much safer than pregnancy (true), and since they are also very effective in preventing pregnancy, the benefit-risk calculation clearly favored the pill’s approval. That early pill used huge doses compared to what we use today: 10 milligrams of progesterone compared to more than 100 micrograms today – that is, about 100 times more, depending on which pill we compare it to . The amount of estrogen in the pills was also three to five times higher than in today’s pills.
As a result, the first generation of pills resulted in more severe side effects (such as acne, weight gain, and nausea) than modern birth control pills, and there was also a greater risk of rare complications, such as blood clots. After congressional hearings in 1970, doses were lowered and the incidence of side effects and complications decreased. In 1973, mini pills were introduced that use a small dose of progesterone and no estrogen and should be taken at the same time every day.
Since then, we’ve had several “generations” of synthetic hormones used in birth control pills, and there are countless brands and formulations on the market. You can read a bit about the differences between the two in our guide to choosing birth control pills . After more than half a century of birth control pills that have been safe, effective and widely used, at least one brand will finally be available without a prescription in 2024.
In addition to pills, there are other methods that use the same pharmaceutical hormones. You can inject every three months (the most famous brand is Depo-Provera ), put on a patch every week (like Ortho Evra ), or place a hormone-releasing implant ( Nexplanon ) under the skin of your arm.
Navy
Intrauterine contraceptives (IUDs) are also a twentieth-century invention. The first specimen known to us was described in 1909 and was made from silkworm gut (a thick silk material commonly used for seams) in the shape of a ring.
Some of the following versions were made from wire. Metals appear to be effective in preventing pregnancy, possibly because they cause low levels of inflammation in the uterus and/or because the ions released by the metal interact with sperm. Over the years, a staggering number of IUDs have been created, varying in shape and material; The Dittrick Medical Museum in Cleveland has a display featuring dozens of them, some of which you can see here . (I visited the museum and recently mentioned this to a doctor I was interviewing about IUD; she responded by showing me that she had a framed photograph of this very exhibit on her office wall.)
In the early 1970s, the popularity of the Navy in the US suddenly declined. The model, called the Dalcon Shield, allegedly caused infections, infertility, and death in many people who used it. The exact reasons why Dalcon’s Shield was so deadly is still unclear, though one factor may have been the type of rope he used. Other navies of the time were safer and used without incident for many years, but after the Dalcon Shield was withdrawn from sale, the popularity of the navy as a whole plummeted. The FDA began requiring Navy approval before selling, which resulted in existing models being taken off the market and no one wanted them anyway.
However, the Navy is making a comeback: new models appeared in the 1980s, and several of them are available today. Today’s models include one type made of copper and several plastic ones that slowly release hormones (levonorgestrel, a form of progesterone).
The IUD is one of the best reversible contraceptives: once inserted, you are protected from pregnancy for three to 10 years depending on the brand, or until you decide to remove it, whichever comes first. And at the same time, you do not need to remember to adhere to the schedule (for example, take a pill every day). This means that the performance indicators of ideal and typical use are almost identical.
Surgical sterilization
If you want something more permanent than an IUD, there is always surgery. If you have a uterus, you have the option of tubal ligation; if you have testicles, you can have a vasectomy.
The operation we now know as “tubing” was developed in the 1800s and has evolved over the years with many different surgical techniques. They differ in how the surgeon accesses the fallopian tubes that connect the ovaries to the uterus, and what exactly happens to the tubes.
Despite the image you may have in your head, the fallopian tube itself is not tied in a knot; rather, the nickname “tubal ligation” comes from a procedure in which a surgeon ties a suture around the fallopian tube, often removing part of the tube as well. (This is known as tubal ligation.) The tubes can also be blocked in other ways, such as by clamping, or they can be removed entirely.
Tubal sterilization was first routinely performed in women who had multiple complicated or risky pregnancies ( three caesarean sections were one recommendation , while caesarean sections were uncommon) or who had enough children (eight, in one recommendation). The dressing can be done at the same time as the caesarean section. If you did this as a separate procedure, it would require a recovery period of five to seven days. Laparoscopic tubal sterilization, introduced in 1967, allowed for smaller incisions and faster recovery from the procedure.
Meanwhile, vasectomy has a shorter and simpler history. The vas deferens is the tube through which sperm pass as they leave the body, and in a vasectomy, this tube is cut. Because vascular access is through the scrotum, it is a faster procedure and shorter recovery time than tubal sterilization. It became popular during and after World War II.
According to the CDC’s National Family Growth Study , tubal neutering is the most commonly used birth control method in the US. Vasectomy is less popular, but still a common method .
While we usually talk about birth control in the context of people deciding what to do with their bodies, surgical sterilization (of both men and women) has also been widely used to prevent disadvantaged people from having children. A 1927 Supreme Court decision ruled that it was actually quite normal for a doctor to remove the fallopian tubes of a person considered an “imbecile”, who would likely give birth to even more “imbeciles” (then a technical term for a person with a low IQ). . Carrie Buck, the woman who was sterilized in this test case, was never given the opportunity to consent to the operation or even say what the operation was for. An estimated 70,000 Americans were sterilized in the years following this decision . Although many of the laws supporting eugenic sterilization were repealed, the Supreme Court case , Buck v. Bell , was never overturned.
Fertility Awareness
Because pregnancy requires close contact between sperm and egg, one method that could theoretically be quite effective is to avoid unprotected sex during ovulation.
Until around 1930, Dittrick explains , people understood that avoiding sex during ovulation could be effective, but they weren’t sure exactly when ovulation occurred. We now know that in a typical four-week menstrual cycle (in which menstruation occurs at the beginning of the first week), ovulation occurs around the end of the second week—around the middle of the cycle.
Early attempts to use it as a form of contraception included the “OK method” and the “rhythm method”. You mark your period date on a calendar and avoid sex on certain days based on that date. While the idea was sound, menstrual cycles don’t always run like clockwork. Cycle length can vary from person to person and from month to month in the same person. It can also be influenced by other aspects of a person’s health. And, ultimately, the definition of certain days as “fertile” or “infertile” is a judgment. The rhythmic method was not particularly effective.
To make the method more reliable, other measurements came into play. Cervical mucus changes texture as you approach ovulation, and your body temperature rises slightly after ovulation compared to before ovulation. By the 1970s, we had the “symptothermic method” which combined mucus observation, temperature measurement, and calendar counting.
Fertility-boosting methods today are so good that—if you study them and know your body well—their effectiveness can rival that of birth control pills or condoms. There are apps to help you keep track of your fertility window, as well as wearables to help you take your temperature more consistently than with a hand-held thermometer. We have a summary of these methods here .
emergency contraception
Emergency contraception has nothing to do with abortion, but the two are often confused, perhaps because EC and medical abortion are referred to as the “morning-after pill.” (The morning after sex, you are almost certainly not pregnant yet ; more often than not, your body acquires sperm, then releases an egg, and then they can meet. That’s why you have up to five days to take emergency contraceptives – although the sooner you accept them, the higher your chances.)
Taking steps to prevent pregnancy after sex is not a new idea; that was the whole idea of douching, including that weird Lysol douche ad . Unfortunately for people who have used it, douching is not an effective emergency contraceptive. But in the 1970s, people began to realize that there might be a reliable pharmaceutical way to prevent pregnancy after sex.
There have already been studies on the administration of estrogen after sex to prevent pregnancy, mostly in animals. In the 1940s and 1960s, as the Guttmacher Institute explains , estrogen emergency contraception was occasionally tried on people—in one case, a 13-year-old girl who was raped.
Yuzpe’s method of emergency contraception, first published in the 1970s, used the same hormones found in some commonly available birth control pills. You take the appropriate dose (often multiple pills) within 72 hours of having sex, and this reduces the chance of pregnancy. The Yuzpe method does not work as well as current ECs, and side effects such as vomiting tend to be more severe, but it has proven effective enough to stimulate research into the forms of EC we know today.
In 1999 , the FDA approved a two-dose version of Plan B , a pill containing levonorgestrel (a form of progesterone) for emergency contraception. At first it was available only with a prescription, and then in 2006 it became available without a prescription for people aged 18 and over. This age was lowered to 17 years in 2009, and that same year Plan B was replaced with a single dose version (which is why it is called “Plan B One Step”). Only in 2013, emergency contraception became legally available to everyone.
Ulipristal acetate (Ella) was introduced in 2010. It works by blocking progesterone receptors in the ovaries and endometrium and may be more effective than levonorgestrel EC. It’s still prescription only.
Legal status of birth control
Birth control, like abortion , has been at the center of culture wars and religious and political debates.
In 1873 , the Comstock Act effectively banned the delivery or advertising of any form of contraception by mail. This included information about birth control in books and magazines, as well as drugs and devices that were considered “obscene”, such as abortion pills and sex toys. (One lawsuit that successfully challenged the Act that curtailed his powers was called “United States vs. One Package” containing more or less than 120 anti-conception rubber pessaries .)
Over the years, various laws and court cases have weakened the provisions of the Comstock Act, although it has never been repealed, and was even mentioned in a court case this year in an attempt to remove abortion drugs from the market.
State laws also limited access to contraceptives for many people in the early twentieth century. In 1965, the Supreme Court ruled in Griswold v. Connecticut that married couples have a right to privacy in their sex lives, including whether they choose to use contraceptives or not. As a result, states could not outlaw contraceptives for married couples. It was not until 1972 that Eisenstadt v. Baird extended this right to unmarried people.
There are still religious and political groups that are trying to hinder access to birth control, including emergency contraception. They are emerging to oppose over-the-counter birth control pills and emergency contraception, to name but a few.
Contraceptive pills and devices (such as the IUD) are no longer easy to outlaw, so attacks on them have recently taken the form of interference with insurance coverage. The Affordable Care Act requires insurance companies to fully cover the cost of certain preventive services, such as depression screening and childhood vaccines. Since 2012, 17 birth control methods have also been included in this category, including IUDs and emergency contraception.
But lawsuits continue to come in, like the 2014 and 2017 cases, which provided exceptions for religious employers to allow employees to be offered plans that do not cover contraceptives. And since Roe v. Wade was overturned, abortion laws have changed rapidly , so it’s more important than ever to understand the full range of birth control options.