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Monday, August 5, 2013

54

Why There's Still No Birth Control Pill for Men

At Aeon Magazine, there's a long and engrossing article up about what's been causing the dearth of options in male contraception, an arena that contains just the 100-year-old vasectomy and the 500-year-old condom (apologies to anyone who just pictured a 500-year-old condom and died). "In a society that increasingly recognises that men and women should share responsibilities and opportunities equitably," writes Jalees Rehman, "the lack of adequate reproductive control methods for men is striking — and puzzling — especially since many newer methods for male contraception have been developed during the past decades yet none has become available for general use." An example from one of the biggest clinical trials ever conducted, testing a testosterone/progestin contraceptive method delivered via injection:

In April 2011, the trial was terminated prematurely when the advisory board noticed a higher than expected rate of depression, mood changes and increased sexual desire in the study volunteers.

To me, those sound exactly like the average user experience of birth control pills, except a bit better because of the "increased" part. But now:

The discontinuation of the WHO/CONRAD trial was a major setback in bringing male contraceptives to the market. It also raised difficult ethical questions about how to evaluate side effects in male contraceptive trials. Since all medications are bound to exhibit some side effects, what side effects should be sufficient to halt a trial? Female contraceptives have been associated with breakthrough bleeding, mood changes, increased risk of blood-clot formation, as well as other side effects. Why should we set a different bar for male contraceptives?

The twist here is that female contraceptives prevent unintended pregnancies in the person actually taking the contraceptive. Since a pregnancy can cause some women significant health problems, the risk of contraceptive side effects can be offset by the benefit of avoiding an unintended pregnancy. However, men do not directly experience any of the health risks of pregnancy — their female partners do. Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men.

That last part is very interesting, as is this tidbit of country-by-country data:

The willingness of respondents to use newer male contraceptives was highest in Spain (71 per cent), Germany (69 per cent), Mexico (65 per cent), Brazil (63 per cent) and Sweden (58 per cent). Nearly half of the men in the US (49 per cent) and France (47 per cent) expressed an interest. On the other hand, disapproval of newer male contraceptives was highest in Indonesia (34 per cent) and Argentina (42 per cent).

54 Comments / Post A Comment

Rock and Roll Ken Doll

"Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men."

That's an odd thing to say about a product that would be available as an option for adults. And I say this as someone who's generally pretty comfortable with nanny-state intervention in personal health decisions.

j-i-a

@Rock and Roll Ken Doll jes. very interesting phrasing in that piece with that "ethically" indeed.

ColdFinger

@Rock and Roll Ken Doll

Ha! Had an hour-long conversation about this over the weekend! The conclusion we came to is that the benefits so heavily outweighed health concerns when the pill first became available, that women were willing to take the leap. That, in turn, produced enough data, or at least anecdotal evidence, showing that birth control was safe enough to convince later adopeters, etc.

Men just don't have the same incentive, it seems?

Judith Slutler

@ColdFinger OMG there is so much going on here. Just think of the progress the medical establishment has made in recognizing / treating depression in the past decades, and the different ethical environment of medical trials (which used to be pretty fucked up from all I've heard), plus there is the whole "hysterical women who think they are going crazy, who cares" mentality that STILL exists for those who don't do well on the Pill... This whole thing is like a massive intersectionality clusterfuck.

OhMarie

@Rock and Roll Ken Doll It is weird! I don't know too much about it, but I know that there are special, different rules for the actual drug trials that happen before a product gets approved--the people running the trials are required to stop them if the side effects outweigh the benefits. With women, you can measure the side effect and increased mortality rates against pregnancy but it really is hard to find a clinical measure for men in a case like this. It's a much more technical definition of ethical.

None of this is to say that I think you're wrong or that they did the right thing--I totally think that with something like this you need to go to a science place you may not be comfortable with, and it's worth it to let the men make that decision for themselves--I just think it's a valid argument that this is a strange case scientifically.

ColdFinger

@Judith Slutler For sure. The conversation we were having seemed really like grasping at the proverbial elephant in the dark and coming up with a different theory depending on which angle we tried to come at it from. SO MUCH THERE.

snowmentality

@Judith Slutler the whole "hysterical women who think they are going crazy, who cares" mentality that STILL exists for those who don't do well on the Pill...

Aaaaargh yes this. It is so hard to get any doctors to take you seriously. It's either "Oh, the pill doesn't cause that, you're nuts" or "Well, that's just how it is if you take the pill, suck it up."

I am somewhat bitter that guys had their changes in mood/libido taken seriously enough to halt the trial, whereas women get blown off when they suggest hormonal BC might be causing mood/libido changes for them.

Judith Slutler

@snowmentality Imma argue that this is mostly due to advances in how we view mental health, not sexism. But being someone who went completely bugfuck on the pill and was pressured by my doctor to try 4 other ones (DID NOT HELP) I do think that part of it is definitely the idea that birth control woes are just a cost women have to pay for sex, and it can't be that bad anyway because women are just whiners.

Gotta say I am kind of glad that mental health concerns around birth control are finally being taken seriously, even if it is in the BC For Dudes department.

keynesiancutie

@OhMarie If the risks were increased risk of depression, I guess they could weigh the costs of treatment vs the average costs of child support. A pregnancy doesn't have the same physical risks for a man, but (hopefully!) he'll be responsible for that child in some way.

Sophia Jacob

Why should I pay for Viagra and penis pumps? Why should I pay for prostate cancer drugs and treatment? Why should I pay for vasectomies? Or erectile dysfunction treatments? @me

leonstj

Will they let a bunch of dudes make the ethical decision themselves with regards to their own bodies? Cuz every guy I know who isn't actively trying to have kids wishes this were a thing.

(Although I do feel like a thing that holds back a some of discussions of male birth control is that so many of the men who are the loudest supporters of it are wacko assholes who "don't trust" women to not poke holes in condoms or whatever wacky mra shit is current)

leonstj

@leon s I mean imagine if condoms and vasectomies were just as brand-new as male BC medicines?

"Well, there's three choices: We can cut a hole in your sack and tie some of your plumbing up so tight nothing passes through, you can just cover your junk in a bunch of rubber whenever it's time to have sex, or you can take this pill which, in some cases, might temporarily make you sad - in which case you can stop taking it and try one of the other methods."

For fucks sake.

fondue with cheddar

@leon s Seriously. That might be a valid argument if the side effects were severe or life-threatening, but they're not. Anyway, men should be allowed to decide whether or not their sperm meets an egg.

Erectile dysfunction drugs have side effects too but they still went to market.

Jizzcliner

@leon s @fondue with cheddar From what I can tell, the RISUG treatment seems like the best option. It's pretty sad that clinical trials are going so slowly.

fondue with cheddar

@Jizzcliner My boyfriend is really interested in it because he's squeamish about getting a vasectomy (even though I have assured him that it's totally safe and NBD). I urged him to talk to my brother about it but he won't.

Jizzcliner

@fondue with cheddar I'm really interested in it, because my girlfriend can't use hormonal birth control, and we might want children when we're a bit older.

fondue with cheddar

@Jizzcliner Yeah...vasectomy isn't exactly an option for you. And I'm sure there are plenty of people like you. There really are a ton of reasons why this should be a thing.

swirrlygrrl

@fondue with cheddar My ex got a vasectomy. Sadly, he was one of the very small numbers of men with a complication (three ladies I work with had husbands all get it done at the same doctor - no problems.) Several years later, he is very unhappy that we went the vasectomy route. So while I agree - relative to the risks and annoyances of other methods of birth control, it is "totally safe and NBD," but there are risks.

MandyMcAwesome

My husband had a vasectomy a few years back. Through a quirk in paperwork we only paid the $40 co-pay. Best descision ever.

bellekaren

@MandyMcAwesome I love your avatar next to this comment.

renegadeoboe

@MandyMcAwesome Or perhaps...best INCISION ever?

...

RoyRogersMcFreely

I feel such bemusement and chagrin when I read these sorts of articles. There are a number of men I know who have repeatedly stated that they would love the option to take care of long-term birth control themselves.

"However, men do not directly experience any of the health risks of pregnancy — their female partners do. Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men."

I feel like there's some questionable logic going on here. I also suspect that the person who wrote this article has only a hazy idea of what "ethical" actually means.

Judith Slutler

@RoyRogersMcFreely Are there any Pinner medical ethicists who would unpack the logic (or logic-like substance) in there more clearly for us?

leonstj

@Judith Slutler - Not a medical ethicist, but I did study a bunch of ethics. Which means I also don't really feel qualified to answer the question, I just thought your username was awesome and wanted to say that I laughed in my cubicle.

wallsdonotfall

@RoyRogersMcFreely Part of it is certainly specific to the clinical trial. If you are testing out a drug for migraine headaches and you notice serious side effects (and depression counts), you cannot, ethically, continue the trial with your current protocol (which may demand that you keep your subjects uninformed about these newly-revealed risks.)

Rock and Roll Ken Doll

I think the article muddles together the fairly separate questions of: (1) what should researchers do when they realize, partway through a trial, that the treatment is causing unanticipated serious side effects?; and (2) which treatments should be available for members of the public to select with knowledge of the risks, versus which treatments should simply be prohibited because the benefits are small and the harms are great?

leonstj

@Rock and Roll Ken Doll - I was just gchattin' with a friend who's worked in medicine, and he was saying that part of the ethics of it might be that 'medical ethics' are generally about "First, Do No Harm - TO THIS SPECIFIC BODY" - so with female birth control, you can justify it by saying, "oh, if THIS PARTICULAR WOMAN has sex without birth control, x, y, and z, which are worse for her than this pill, might happen" - but with men, there is no equivalanet medical issue for them specifically where "if THIS PARTICULAR MAN has sex without birthcontrol, this BAD MEDICAL THING will happen."

Which, I mean I guess 'makes sense' in terms of using the word "ethically" right if you'd rather be ridiculously pedantic than think about "Ethics" in the broader context.

weathering

@wallsdonotfall Exactly. Even setting aside the question of having to alter a trial's protocol, there are also general standards that a new treatment has to measure up to for a trial to continue. As I understand it, observed side effects (and/or outcomes) cannot be worse that what would happen with no treatment at all (if there is currently no treatment) OR what happens if a patient is given the already-existing standard of treatment (if that exists).

So the question is crucially NOT: "are there individuals who are willing to engage in this trial?" The question is: "as a researcher, can I ethically continue a trial that results in worse health than my subjects would otherwise enjoy, even if they're willing to make the trade?"

And yes, this assumes a narrow standard of what 'health' is: pregnancy is exclusively a woman's health issue, totally irrelevant to her partner; a man's intellectual or emotional comfort in controlling his own fertility isn't part of his health; etc, etc.

Sorry to ramble on. I'm not a medical ethicist, but Mr. Weathering is (and I have a degree in philosophy, so we talk a lot about this kind of stuff from a fairly theoretical perspective).

ETA: @leon s I commented as you were typing! I agree that this is a narrow definition of ethics, but medical ethics is a lot like the common law: it's built up a (mostly) internally-consistent intellectual framework, so that people have some common understanding of what things like: "first, do no harm" actually MEAN. I absolutely think that a lot of it could stand to be reworked, but this is the current standard that medical research is held to.

While it sounds great in theory, it's not enough that there are men willing to take BCP: there's an asymmetric power relationship between patients and the medical establishment, so 'consent' is a lot more complicated than it might be.

Rock and Roll Ken Doll

I guess that makes sense if you don't have a framework for weighing health harms against non-health harms. But my sense is that, while reducing everything to a dollar value is often ugly, it's also often the only way to resolve complicated questions in technocratically-driven decisionmaking. (I mean "technocratic" as something of a compliment here.)

ColdFinger

@leon s as @Judith Slutler was saying above, SO MUCH THERE. Is pregnancy, generally speaking, a "health hazard" that makes it ok to mitigate it with side-effects-laden chemicals? (Don't get me wrong, I'm obviously for birth control - but interesting to see this as a justification.)

On the other hand: might there not be some men out there for whom procreation would be a health risk? Someone with mental health issues, for instance? (And, yes, I see how that's a trap, too. I am NOT suggesting we involuntarily mess with mental patients' reproductive systems.)

ETA: I guess in the first paragraph I mean "mitigate the risk of pregnancy," as opposed to "mitigate pregnancy..."

bureaucrab

@Judith Slutler How about a health policy expert with grad-level medical ethics training? As one of those, frankly I think that argument is a bunch of hooey. There are two main reasons: 1) the health risks in a pregnancy are not the primary reason the pill was created or is prescribed for/used by women (i.e., are not a *major* benefit against which its risks are weighed); and 2) there are plenty of other drugs and procedures out there with less-than-medical benefits but plenty of medical risks, the easiest examples being ED drugs, hair-restoration products, and cosmetic procedures. Men and their doctors can decide whether Viagra, Propecia, or an eye lift is worth their respective risks; as far as I'm concerned, chemical birth control is exactly the same.

fondue with cheddar

Men may not directly experience any of the health risks of pregnancy, but there are financial risks. If a man impregnates a woman and she gives birth to that child against his will, then he is still responsible for supporting that child. Male birth control gives men greater control.

Furthermore, there is a risk of failure with any form of birth control. So if both partners are on a pill, the risk gets so small as to be a non-issue.

fondue with cheddar

@Bookgerm You're right, it is not appropriate in the context of a medical trial. I was just making an argument for the mere existence of said pill. Financial risk to the father is just one of the many reasons for it, I just figured it would be a good argument because money and men's rights are unfortunately more highly valued than a lot of other things in America.

City_Dater

Yet another example of Sexism Hurts Everybody, Eventually.

Hormonal contraception provides no protection from STDs, so it tends to be primarily used by people in committed, sexually exclusive relationships...and if a guy wants to shoulder the side effects burden instead of his partner doing it, shouldn't he have that choice? So EVERYONE can be spared the economic and psychological fallout from an unplanned, unwanted pregnancy?

Ugh.

Daisy Razor

Okay, so hormonal birth control gives me blood clots that could easily kill me. So ethically wouldn't it make more sense for my husband to have more birth control options since I imagine he'd choose "mood changes" over "dead wife" in the side effects sweepstakes?

fondue with cheddar

@Daisy Razor Because a woman who is not a mother is not as valuable to society as any man, I guess.

Megasus

WHAT THE FUCK. THOSE SIDE EFFECTS ARE NOTHING COMPARED TO WOMEN'S BC.

Excuse me, I am going to have a rage stroke now.

MoxyCrimeFighter

@Megasus Helped along by the increased risk of clotting associated with birth control pills. *sigh*

apples and oranges

"higher than expected rate of depression, mood changes and increased sexual desire"
This is different from female HBC side effects how??

Also I'm not taking birth control to avoid the HEALTH RISKS of a pregnancy, I'm doing it to avoid A BABY. Presumably the major thing a MAN interested in birth control would want to avoid as well!

apples and oranges

Instead of a ‘one pill fits all’ approach, male contraceptives might only be effective if individually tailored.

Haha god forbid we apply this principle to women too. Because our bodies are all the same right?! (Forgive me, I'm just reading and raging as I go!)

Springtime for Voldemort

You know, it's times like this I wish the Men's Rights movement was about actually organizing around this kind of thing, instead of mostly about sending rape threats on the internet and fighting for the rights of any man ever accused of rape regardless of evidence.

fondue with cheddar

@Springtime for Voldemort Yeah, there are Actual Things Worthy of Being Upset About with regard to men's rights. Not many (I can actually only think of one other), but still. Isn't this worth fighting for?

fabel

I feel the subtext is something like, "men can't handle being moody"? Which yeah, follows with what everyone is saying (sexism hurts everyone)

bureaucrab

@fabel Because lord knows there are no moody men otherwise. :D

beetnemesis

I wonder if the thinking is "Well, women get moody ANYWAY, so it's not that big a deal if their birth control affects that"

I for one would say that I would pretty much refuse to take a male birth control pill that had any noticeable effect on... well, to be honest, pretty much anything. Moods, sex drive, hormones, bloating, no thanks. Just squeamish that way, I guess.

Lurkasaurus

@beetnemesis uh...bully for you, I guess? There are many, many women who agree with you. And many men who do not. And in some part because attitudes like yours are assumed to be universal, there is no option for couples in which the woman can't or doesn't want to handle the side effects and the man would be willing. Like me and my boyfriend.

Also...women have been dealing with exactly those side effects (along with worse, life-threatening ones) since the inception of the pill. You may not have meant this, but your words are coming across with an attitude of "oh, it's okay for women to put up with that stuff, but heavens, never ME." I hope that is not what you meant.

beetnemesis

@Lurkasaurus I was saying that's exactly the attitude that it sounds like caused the trial mentioned in the post to be aborted- and that it's a bad attitude. Should have made that clearer.

And, that said, I then admitted that side effects like that squick me the hell out. I know that women deal with them- I said as much- but for me, personally, I'd probably get a vasectomy.

swirrlygrrl

So wait: INCREASED sexual desire was listed as a negative side effect? Along with increased rates of depression and mood changes? I am confused about how increased they need to be to count as a problem, versus an unexpected bonus.

tesseract

I fail to see how increased sexual desire is a bad side effect for a BIRTH CONTROL pill. Doesn't that just mean you're getting more *bang* for your buck?

Annie.Bart

Why isn't big pharma jumping on this, since there is obviously money to be made? Let's hear Rush complain about all those slutty men who can't afford their birth control.

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