Newsletter #22 (Fall 1999)

Cervical Caps as 'Bonbons from France' and Other Sights and Scenes in the Working Friendship of Two Birth Control Pioneers

Like many others in the medical profession who became proponents of birth control following World War I, Hans Lehfeldt, a young German doctor newly graduated from the University of Berlin in 1922, found inspiration in Margaret Sanger's international crusade to make birth control safe, legal and accessible. In 1923 Lehfeldt read a German translation of an early Sanger book, most likely an unauthorized translation of Woman and the New Race, which influenced him decisively to pursue a career in gynecology and may have strengthened his inclination to help the working class (Connie Christine Wheeler, "In Memoriam, Hans Lehfeldt, M.D.," The Journal of Sex Research, August 1993, p. 298). Lehfeldt continued to be encouraged and influenced by Sanger for the next 40 years on his way to becoming one of the most influential sexologists in the world and the author of more than 600 writings on contraception, reproduction and sexual functioning.

The 100th anniversary of Lehfeldt's birth (he was born October 28, 1899) offers the opportunity to celebrate his achievements. And recently obtained correspondence between Sanger and Lehfeldt, reproduced for the Margaret Sanger Papers Project by Dr. Connie Christine Wheeler, a close associate and friend of Lehfeldt's, and the caretaker of his papers, together with material in the Sophia Smith Collection at Smith College, document one of Sanger's longest and most harmonious associations with a doctor in the birth control movement. Their correspondence sheds light on Sanger's position on sterilization, an issue she and Lehfeldt discussed at length, and underscores the fragile nature of her alliance with the medical community.

For Lehfeldt and other liberal doctors in Weimar Germany interested in contraception, sexuality and women's health, Sanger was already a recognizable international leader in the early 1920s who won the respect of many German medical professionals by having the courage to visit their war-torn country in 1920 to investigate reports of effective chemical contraceptives and discuss efforts to reestablish birth control organizations. Germany led Europe in the field of sex reform largely due to the pioneering work a select group of sex reformers, including sexologist Magnus Hirschfeld, who first published the influential Journal of Sexual Science (Zeitschrift für Sexualwissenschaft) in 1908 and founded the Institute for Sexual Science in 1919, which included a sex counseling clinic and a commitment to providing contraceptive information.

Sanger had hoped to visit Germany, on the recommendation of her mentor, Havelock Ellis, during her exile in Europe in 1914-1915, but was prevented by the war. When she finally entered Germany in 1920 Sanger was confronted by, in her words, a "grim silence" on all matters of social policy, especially sex reform (MS, "Women in Germany," The Birth Control Review, December, 1920, MSM S70:84). Few were interested in discussing organized birth control campaigns in the midst of widespread hunger and disease, and a sharp decline in the birth rate. Sanger met with Hirschfeld and other sex reformers, formed contacts with labor and suffrage leaders, and obtained a new contraceptive jelly produced in Friedrichshaven that became a prototype for the most widely used jelly in her New York clinic. But throughout her trip she was troubled by the inability of working-class women to obtain birth control even though it remained legal in Germany to manufacture and sell contraceptives. Was it religion, government imposed barriers, a conservative medical profession, she asked both experts and laypeople. "I thin it is the Devil," replied a friend in England ("Women in Germany, Part II," The Birth Control Review, January, 1921, MSM S70:852)

When Sanger returned to Germany in 1927 the devil had lessened his grip, and the German sex reform movement had been revitalized, even in the midst of political uncertainty and economic instability. While Germany was much more liberal in its attitude toward sex than England or America, Sanger had been informed by Communist American writer Agnes Smedley, who reported to Sanger from Berlin, that the abortion rate was very high and contraceptive information scarce. Sanger arrived in Berlin in December 1927, following the World Population Conference in Geneva, and gave several lectures, offered demonstrations on fitting diaphragms, and used her uncanny organizing skills and open checkbook to help bring together select members of the League of German Women Doctors, the Society for Sexual Reform, the National League for Birth Control and Sex Hygiene, and both the Communist and Social Democratic Party to form a German Committee for Birth Control that would organize a network of contraceptive clinics and sex counseling centers in Berlin. "The thing my visit here has done," Sanger told Edith How-Martyn, her chief associate in international work, "is to crystallize the idea & give confidence to those who needed it" (MS to How-Martyn, December 11, 1927 MSM C4:499).

Hans Lehfeldt was likely in the audience in Charlottenburg-Berlin on December 6, 1927 when Sanger addressed several hundred medical and scientific professionals. It is difficult to confirm when he and Sanger first met; unfortunately not all of Lehfeldt's correspondence has yet been collected and some, undoubtedly, was lost or destroyed when he fled Germany in 1934. Lehfeldt had returned to Berlin in 1927 after completing post-graduate studies in Dresden and Vienna. A meeting with Australian-born gynecologist and British birth controller, Norman Haire, influenced Lehfeldt to pursue contraceptive counseling (Wheeler, p. 298). In 1928 he co-founded and served as director of the Clinic for Birth Control and Marriage Counseling in Charlottenburg under the sponsorship of the Society for Sexual Reform. He quickly established himself as a leading figure in the National League for Birth Control and Sexual Hygiene, founded in 1928, and began to compile research for a comprehensive study on lay sex reform in Germany that he published in 1932 (Atina Grossmann, Reforming Sex: The German Movement for Birth Control & Abortion Reform, 1920-1950, 1995, p. 23).

Back in Berlin in August of 1929 to further solidify the clinic movement, Sanger held a contraceptive seminar for doctors. Lehfeldt was invited to the seminar by Dr. Ernst Gräfenburg (inventor of the Gräfenburg ring, an IUD, and better known posthumously for his rediscovered work on the Gräfenburg or "G" spot) to discuss new research on intrauterine devices, a method that Sanger continued to pursue even though it had been widely discredited by American doctors.

Lehfeldt and Sanger met again and cemented their friendship in 1930 at the Seventh International Birth Control Conference in Zurich. Sanger organized the conference of more than a hundred scientists, physicians and clinicians and wisely discouraged moral, ethical and political discussions by restricting participants to purely technical appraisals of contraceptive techniques and devices, and a country-by-country review of birth control work. The effect was liberating; the participants proceeded in their meetings without, in Sanger's words, "shame or prejudice" and with a sense of "fundamental brotherhood" rather than the "bickerings and disagreements" that characterized many of the early international birth control and neo-Malthusian conferences (MS, "Introduction to the Proceedings of the Seventh International Birth Control Conference," 1931, MSM S71:277). Yet just after the conference Sanger criticized the German delegates for their propensity to spout theories and political positions to the detriment of more practical concerns (MS to Smedley, September 30, 1930, LCM 10:512).

Hans Lehfeldt's paper at Zurich ran counter to Sanger's often repeated generalization about the Germans being wed to theory, not practice. In "The Physical and Psychological Aspects of Contraception" Lehfeldt displayed his gift for summarizing vast amounts of material taken largely from his own practice and presenting his findings in an even-handed, apolitical manner. He echoed Sanger's own strong belief that each woman must be treated individually in a medical setting, preferably by a doctor, in order to improve safety and increase effectiveness, but also to insure that reliable records are preserved on the efficacy of particular methods – a point often overlooked by many in the movement who used "word on the street" determinations in judging methods rather than hard statistics. He departed from both Sanger (though he did not mention her by name) and Britain's birth control maverick, Marie Stopes, in questioning their dependence on single methods in their clinics: in Sanger's case the diaphragm and jelly and for Stopes a cervical cap combined with the use of quinine. He called for much greater individualization, arguing that other methods such as intrauterine devices, the condom and even, in some cases, the "safe period," paired with a barrier method, proved more effective and less burdensome for certain women (Hans Lehfeldt, "The Physical and Psychological Aspects of Contraception" in The Practice of Contraception: An International Symposium and Survey, edited by Margaret Sanger and Hannah M. Stone, 1931, p. 141-9).

The intimate setting and collegial atmosphere of Zurich fostered many close associations, especially among the German and American delegates who would soon test the resourcefulness of their friendships during the Nazi years. Along with Sanger, Lehfeldt formed bonds with Hannah Stone, the medical director of Sanger's Birth Control Clinical Research Bureau in New York, and her husband, Abraham Stone, who would assume his wife's position following her death in 1941. Beyond the personal and professional fulfillment that resulted from their friendship, Sanger and the Stones also found Lehfeldt to be a willing accomplice in bootlegging. For a short time in the early 1930s, until spring-form diaphragms were produced in substantial quantities in the U.S., the Stones arranged to buy diaphragms through Lehfeldt, along with several other sources in Europe, and then smuggled them into the U.S. where it was still illegal to transport such materials (Wheeler, p. 298).

Following Zurich, Lehfeldt wrote to Sanger in German to update her on the publication of his Zurich paper and enclosed "snapshots" taken at the conference, and the two started a congenial and, at times, intimate correspondence – though they would remain quite formal and always address each other as "Dr." and "Mrs." Later that year Sanger received Lehfeldt's practical guide to birth control, The Book of Marriage: A Guide for Men and Women (Das Ehe-Buch) which emphasized the major points Sanger made in her 1926 marriage manual Happiness in Marriage and other writings: a reliance on doctor-controlled contraceptive services, an endorsement of the diaphragm and contraceptive jelly method as the most effective for the majority of women, and the promotion of contraception as the best means to reduce abortions. Sanger wrote to another German friend about how "valuable [Lehfeldt's book] could be to us," but thought the present laws in the U.S. would prevent her from having it translated into English "without cutting out all that everyone wants to know" (MS to Kate Stützin, Jan. 9, 1931, LCM 13:1096).

In the early 1930s Sanger encouraged her German associates to centralize birth control activities under one organization. In late 1930, with the assistance of Lehfeldt and several other prominent birth control doctors, Kate Stützin, the wife of a Chilean sexologist teaching in Berlin, organized the Center for Birth Control, an umbrella group for all German physicians involved in birth control. The aim of the new center was, according to Stützin, to overcome "contrast in politics, in ethics and in religion [that] prevented people from working together even in domains where they agreed," and to enable German birth controllers to develop a more visible international presence (Kate Stützin, "Report on Working Centre for Birth Control," November, 1931, LCM 3:1290). Yet just three years after the new center was established the victory of the National Socialist Party in 1933 and the ensuing political and social upheaval effectively put an end to Weimar sex reform (Grossmann, pp.43, 136).

The rise of the Nazis also silenced most of Sanger's correspondents in Germany, including Lehfeldt. Both a Jew and a physician engaged in research on sexuality and fertility control, Lehfeldt fought personal and professional discrimination and knew that he could not remain long in Germany after Hitler came to power. The Nazis closed down birth control clinics and sex reform organizations, arrested several birth control physicians and activists, and forced many more out of the country. In 1933 Lehfeldt was arrested and briefly detained by the SS under charges of performing abortions. He was released, but the inevitability of another arrest and the threat posed to his fiancé, a non-Jew who would be persecuted by association, forced Lehfeldt to flee to the U.S., the country he thought best suited his needs and insured his freedom. His fiancé‚ had to wait six months so as not to risk the threat of arrest for traveling with a Jew (Wheeler, p. 298).

Sanger's many friendships and associations in Germany exposed her to the brutality of the Nazi regime well before most Americans digested the incomplete news reports of the day. "All the news in Germany is sad & horrible," she wrote Edith How-Martyn in May of 1933, "& to be more dangerous than any other war going on anywhere because it has so many good people who applaud its atrocities & claim it's right" (MS to How-Martyn, May 21, 1933, MSM C5:536). Rudolph Elkan, a physician in Hamburg and a leader in the German sex reform movement, wrote to Sanger in late 1933 that "the Nazis nearly killed me and, after my several injuries allowed me to walk again." Safely in England he told Sanger in a postcard: B.C. is a dangerous hobby and more so if it becomes a passion" (Rudolph Elkan to MS, October 12, 1933 and November 29, 1933, LCM 14:126, 131). Sanger received similar reports from a number of Jewish doctors she had known in Germany, Poland, Austria and Italy. Later in the 1930s she would help many of them immigrate to the U.S., by lining up affidavits required of sponsoring American citizens, sending money for passage, using contacts in Washington to cut through bureaucratic red tape, and to secure employment (see "Margaret Sanger and the Refugee Department," MSPP Newsletter Spring 1993).

Soon after Lehfeldt arrived in the U.S. he and Sanger worked together on helping Dr. Ernst Gräfenburg. Lehfeldt had urged Gräfenburg to leave Germany with him in 1934, but Gräfenburg stubbornly remained to run his thriving private practice. He was arrested and imprisoned by the Gestapo in 1934. At Lehfeldt's prodding, Sanger engaged the "refugee department," her secretarial staff at her New York clinic, to secure Gräfenburg's release and bring him to America. Lehfeldt later claimed that Sanger "negotiated his [Gräfenburg's] release by paying a large ransom," but all parties were oddly silent on the details of a remarkable undertaking. Gräfenburg arrived safely in the States in 1940 and later worked for a short time as the only male staff doctor at Sanger's clinic (Lehfeldt, "Margaret Sanger and the Modern Contraceptive Techniques," The Journal of Sex Research, November 1967, 254; Grossmann, p. 153).

Shortly after Lehfeldt's arrival in the States, he and Sanger discussed eugenic sterilization, an issue that had grown far more ponderous and controversial after Hitler came to power and instigated a racial hygiene program featuring sterilization, though the extent of this program was not yet known. Lehfeldt enthusiastically endorsed eugenic sterilization in Weimar Germany and continued to be a proponent in America, though he quelled his zealousness for compulsory sterilization, for obvious reasons, after the war. Both he and Sanger advocated a U.S. government sponsored sterilization program for the "unfit" and "feeble-minded" – open-ended terms to cover most psychiatric illnesses and many physical handicaps – and those with transmissible congenital diseases. They also called for the Federal government to standardize sterilization laws that varied greatly from state to state. Like most liberal eugenicists, Sanger and Lehfeldt sought physical improvement of the human race, not the elevation of any one racial group over others. They believed sterilization policies would both alleviate human suffering and reduce the financial burden of the state.

Hitler had just decreed obligatory sterilization of the insane in Germany when Lehfeldt and Sanger talked in 1935. Lehfeldt viewed the law as progressive and consistent with Weimar sex reforms, but Sanger, he reported later, "was deeply concerned lest the law, enforced by ruthless Nazi agents, might lead to all sorts of horrible abuses. Any opponent of the regime might be declared insane.' Later developments in Germany showed how justified her suspicions had been" (Hans Lehfeldt, "Sterilization in the U.S.A.," The Journal of Sex Education, June-July, 1951, p. 260). As historian Atina Grossmann writes, Sanger's cautiousness and foresight made her "exceptional among watchful American social hygienists" (Grossmann, 153).

Lehfeldt's integration into American society, though successful, was not an easy one. As a Jew he faced social and professional discrimination; as a sexologist he was often ignored – the field was not yet taken seriously in America. And as a socialist and supporter of homosexual rights and liberal causes he found himself on the periphery of a conservative and insular American medical profession, that, in 1935, still had not taken an official position on the medical use of contraception. His support for legalized abortions distanced him even more from associates, many of whom did not distinguish between abortion and contraception. Yet Lehfeldt persevered to open a successful gynecological practice on Park Avenue that served patients until 1991 and to establish in 1958, with several other leading sex experts, the Society for the Scientific Study of Sex, an influential professional society that opened doors to the field. Also in 1958 he started a family planning clinic at Bellevue Hospital. A prolific researcher and writer, Lehfeldt published widely on all aspects of contraception, but particularly the cervical cap and IUD, as well as abortion, and many aspects of sexual functioning, even though he faced considerable anti-sexuality discrimination in medical publishing (Wheeler, pp. 297, 299).

Lehfeldt seemed to have lost touch with Sanger during the immediate post-war years, though pieces of their correspondence may be missing. He may have backed away from Sanger, whose public stance (as a pacifist and a mother of two draft-age sons) against U.S. intervention in the war, alienated her from several long-time friends. But by the early 1950s Lehfeldt and Sanger renewed their friendly correspondence, exchanged family news (such as the birth of Lehfeldt's first child in 1951), updates on articles and conferences, and news of mutual friends. Letters marking the deaths of Norman Haire in 1952 and Ernst Gräfenburg in 1957 brought Sanger and Lehfeldt ever closer together, the circle of international birth control pioneers having shrunk to a frail few.

In 1951 Lehfeldt wrote Sanger in an exhilarated mood, declaring a momentous shift in the birth control movement following the Pope's "defacto endorsement" of birth control (in the form of the rhythm method) and the Indian government's apparent acceptance of it.

It seems to me that the whole debate over birth control has now shifted from the question of principle to one of method and improvement. This indeed is a great step forward in your fight for birth control. It makes me happy to have fought on your side for almost 25 years (Lehfeldt to MS, Dec. 17, 1951, MSM S35:752). </table>

Sanger, who never gracefully accepted statements of victory, responded that "the fight for birth control is certainly not over," and then complained about renewed Catholic opposition (MS to Lehfeldt, Dec. 28, 1951, MSM S35:868).

Their friendship was tested in 1953 when Sanger refrained from publicly supporting Lehfeldt's plans to start a sex research journal, fearing that it would detract from her singular identity as a birth control crusader. She wrote him in 1953, following his request that she serve on an advisory board for The Journal of Sexual Science:

As you doubtless know, I am one who does not spread my interests over many fields, mainly perhaps, because I have so concentrated my studies and interest in the problems of Birth Control and population. This does not mean that I have no interest in sex psychology. . . . I still feel, however, that the International Planned Parenthood Movement will take my entire time . . . (MS to Hans Lehfeldt, May 8, 1953, LCM, 9:122). </table>

Nevertheless, she gave Lehfeldt contacts for raising money and advice on maneuvering around anti-obscenity laws. Lehfeldt seemed grateful for any assistance Sanger offered, and continued to ask her to join boards and committees, inviting her in 1957, for instance, to be a charter member of the Society for the Scientific Study of Sex. She again declined, citing the same reasons as before. Finally in 1960, after several more entreaties from Lehfeldt, Sanger offered a written endorsement for another version of the journal he failed to get off the ground in 1953, now titled the Journal of Sexual Research (MS to Lehfeldt, Dec. 20, 1957 and Jan. 21, 1960, MSM S53:126; S56:504).

By this point in Sanger's career, there were few physicians in the birth control movement who continued to confide in her or seek her opinion. Many doctors discounted Sanger's influence in the American birth control movement after the second World War, when she focused her attention overseas to the formation of the International Planned Parenthood Federation. In fact, in a 1959 article written by Alan Guttmacher, the head of obstetrics at Mt Sinai Hospital in New York, and a leading figure in the post-war movement in the U.S., he referred to "the late" Margaret Sanger (she died in 1966), much to her horror. The mistake may not have been entirely accidental. Margaret Sanger's necessary convergence with the American medical profession in the 1920s created a troublesome marriage of strong-wills and political incompatibilities. Sanger's frustration with medicos and the medical professionalization of the birth control movement contributed to her resolve in the late 1920s to focus more intently on international work and the hope of discovering new contraceptives abroad.

If Sanger's union with American doctors was a cautious, edgy marriage then her relationship with sympathetic doctors in Europe, and Germany in particular, was a liberating affair. European doctors generally did not feel threatened, as did many American doctors, by Sanger's call for clinics, and they usually welcomed the publicity she brought to the issue. A considerable number of birth control emigres during the war also owed Sanger a debt of gratitude for her efforts to facilitate their passage to the U.S. and assist them with finding employment. Yet, over time, many of her international relationships also soured due to such practical problems as language barriers (Sanger only spoke and read English), and Sanger's paranoia over threats, real and perceived, to her leadership of the international movement. She lost touch or parted ways with a roster of leading international birth control figures, including Marie Stopes, Grafenburg (after his short stint at Sanger's clinic where Sanger prohibited him, the world expert on IUD's, from prescribing the devices), and Helena Wright, the English sexologist, to name a few.

Lehfeldt, however, worked carefully at his friendship with Sanger. He both charmed and engaged her, and made sure to credit her whenever appropriate. He never took liberties with her stature or used her name without permission. He was tactful and exceedingly polite. Instead of bluntly criticizing her tendency to oversimplify medical statistics, or fall back on obsolete research, he would send technical material, often his own articles, to bring her up to speed. As he did with many of his German colleagues from the late 1920s and 1930s, Lehfeldt worked at keeping his association with Sanger current and cordial, even sending birthday greetings on occasion. Sanger, in turn, learned to value his opinion, asking, for instance, his advice on International Planned Parenthood Federation matters of the greatest importance, such as who should succeed her as president. She especially appreciated his attention during the later years when so few doctors sought to continue a dialog with her.

Much of their later correspondence discussed specific contraceptives, particularly the cervical cap, which Lehfeldt demonstrated in 1954 was as reliable a contraceptive as the diaphragm, and therefore should be more widely offered to increase women's choice. Sanger was elated over Lehfeldt's findings and thought his work might convince clinics to reintroduce the cervical cap, long abandoned by many doctors due to patient complaints over fitting problems. Sanger had pressed for the use of the cap early on when diaphragms were particularly difficult to obtain:

This, as you doubtless know, was the first mechanical device that I brought over from France, back as far as 1912 or 1913, when I went over to study the French methods. It was also, by the way, this little cap that used to be shipped to American purchasers under the guise of bonbons from France . . . (MS to Lehfeldt, Jan. 14, 1954, MSM S42:578-9). </table>

Lehfeldt also kept Sanger apprised of a research study he conducted at the Bellevue Contraceptive Clinic on Enovid, the first patented version of the anovulant pill that represented the breakthrough contraceptive that both had long worked for. Years later, when many claimed to have a hand in the birth of "the pill," but generally overlooked Sanger's important role (she kept the idea alive for decades and arranged the initial funding for its development), Lehfeldt was one of the few medical men to give Sanger adequate credit.

In 1961, the last productive year of Sanger's life before various health problems necessitated constant medical care, Sanger and Lehfeldt met for the last time at a "World Tribute" dinner to honor Sanger in New York. He wrote to her a short time later about how pleased he was to see her "still carrying on the fight for Birth Control, the beginnings of which I am proud to have witnessed." "Yes," she scribbled in a wobbly hand, "you have been a devoted friend of our cause and I welcome you" (Lehfeldt to MS, May 25, 1961 and MS to Lehfeldt, May, 1961, MSM S58:871-2). The word "welcome" was surely the small error of an ageing mind; Sanger meant to say "thank." But in some ways she was welcoming him, as no one had properly done in 1935, and ushering him in as one of the chosen few to carry on her legacy – which is exactly what he did for some thirty more years until his death on June 18, 1993.