Newsletter #16 (Fall 1997)

The Lowly Condom--Sanger's Missed Opportunity?

Rubber, sheath, shield, cot, Johnnie, French letter, whatever it was called, the condom was never a good fit for Margaret Sanger. Although it was the most commonly employed method of contraception during Sanger's long career, she had little to say about it compared to other popular methods, and her clinic did not recommend it to patients, except under certain circumstances. She and other female birth control advocates discouraged its use even though it may have been the best choice for many couples, especially among the poor and working class---the very groups Sanger aimed, above all, to reach. Critics of Sanger and the movement, then and now, have seized on the failure of early birth controllers to offer easier-to-use and less expensive methods than the diaphragm paired with a contraceptive jelly. Would the movement's greater promotion and distribution of condoms have resulted in higher contraceptive use and success rates among all groups? Or might it have doomed the movement and its goals of achieving sexual autonomy for woman and medical oversight of birth control?

The condom was one of the two methods, withdrawal being the other, that Sanger knew about when she worked as an obstetric nurse in New York in the early 1910s. When young mothers asked her how to keep from having another baby, Sanger told them of "the only two methods I had ever heard of among the middle classes . . . that placed the burden of responsibility solely upon the husband--a burden which he seldom assumed." Each of these women, she related, was seeking "self-protection she could herself use, and there was none." Or at least Sanger was not yet familiar with the many women-controlled methods of the time, including sponges, douching solutions and various plugs and pessaries; although these could be difficult to obtain. (MS, Autobiography, 87.)

Whether or not these type of nurse-patient exchanges were frequent or true to Sanger's experience, she used these stories to substantiate the need for female contraceptive methods. She and other early advocates made it clear that men could not be trusted when it came to contraception and were, generally, unwilling to sacrifice any degree of pleasure to insure protection against pregnancy. "Birth control is woman's problem," Sanger wrote, bluntly, in 1920. "Whatever men may do, she cannot escape the responsibility." (MS, Woman and the New Race [New York, 1920], 100, 93.)

While some women rejected the condom because they wanted to control contraception, it was the condom's sullied reputation that, more likely, disqualified it as a method of choice for many couples. Since first being written about, in the sixteenth century, the condom had been associated with immoral sexual behavior--prostitution, infidelity, promiscuity--and was widely viewed as first and foremost a prophylactic against venereal disease.

The other big drawback to the condom was the unreliability of the product; inferior condoms would rupture, leak and slip off. Sheaths were originally made of either "skin," usually sheep and other animal intestines, and, after the mid-nineteenth century, rubber. Both had benefits but varied greatly in quality, from manufacturer to manufacturer. Before the advent of mass-produced drip latex condoms in the early1930s, anyone with a little determination could make their own, and there were no quality controls in place; the booming condom industry was completely unregulated. Another frequent objection was that condoms interfered with sensation. Early rubber sheaths tended to be so thick that men found them numbing. Women, too, complained of discomfort, and some disliked the strong rubber odor. Summing up these two major disadvantages of the pre-latex era condoms--variations in quality and a dulling of sensation--a German clinic worker said, "From the point of view of prevention a condom is as thin as cobweb, but from the point of view of the joy of the sexual act it is as thick as the wall of a fortress." (Antoinette F. Konikow, Voluntary Motherhood, 1928 [Boston, 1928], 11.)

Nevertheless, the method had many advantages during the early years of the birth control movement. Unlike most other contraceptives, condoms were readily available in drug stores, bars, barbershops and other establishments where men congregated; the Comstock Act did not explicitly ban condoms as long as they were advertised and sold as venereal disease preventives. Simple and easy to use, the condom did not require a prescription or medical supervision. It was well suited to what Robert Dickinson, one of the first and most vocal medical advocates of birth control, called the "untutored contraceptor," that is, men and women who did not want to take on the instruction required to use other devices. Condoms were also relatively cheap, and many rubber and skin varieties could be washed and reused a number of times, increasing cost efficiency. If tested beforehand (inflated to check for holes and weakness) and used with care both before and after intercourse, the condom was and remains an effective contraceptive. (Robert Dickinson, Control of Conception [Baltimore, 1938], 123.)

Sanger recognized these benefits in Family Limitation, her 1914 do-it-yourself guide to birth control. Giving explicit, frank instruction, she wrote:

The condoms are obtainable at all drug stores at various prices. From two dollars a dozen for the skin gut tissues to one fifty a dozen for the rubber tissue. These are seamless, thin and elastic and yet tough; if properly adjusted will not break. . . . If space has not been allowed for expansion of the penis, at the time the semen is expelled, the tissue is likely to split and the sperm finds it way into the uterus. The woman becomes pregnant without being conscious of it. If on the other hand care is given to the adjustment of the condom, not fitting it too close, it will act as one of the best protectors against both conception and venereal disease. (Family Limitation, 1st Edition, 1914.)

There was an additional benefit, she noted;

It has another value quite apart from prevention in decreasing the tendency in the male to arrive at the climax in the sexual act before the female. . . . The condom will often help in this difficulty. (Family Limitation, 1st Edition, 1914.)

Sanger included a short guide to condom use in Dutch Methods of Birth Control, her 1915 adaptation of the Dutch Neo-Malthusian League's late 19th century contraceptive advice pamphlet, Means of Preventing Large Families. It provided practical information devoid of bias for or against any particular method. The pamphlet also gave detailed instructions, including the care and storage of condoms:

The same French Letter should not be too often used, perhaps two weeks or six times, and it should not be too old, for in the lapse of time it loses its properties. Like all things made of India rubber, it is well to keep it in a rather damp cool place, and shield it from light or frost. It must not be touched by greasy substances, such as oil, fat, vaseline, paraffin, etc., nor with carbolic acid or other substances which act upon India rubber. (MS, Dutch Methods of Birth Control, 1915.)

The Dutch pamphlet also explained how the woman must take control and slyly employ the condom when forced to submit to a drunken husband:

When the husband is drunk, and his wife, fearing that a miserable child will be born, has not other preventive at hand, she can perhaps apply the French Letter as if caressing him, when he does not know what he is doing. At all events, she should always take care that one or two French Letters be ready for use. (MS, Dutch Methods of Birth Control, 1915.)

Just a few years later, as she began to focus on delivering contraception under medical supervision, Sanger was more critical of the condom. Emphasizing the critical importance of woman-controlled methods, she disparaged the condom and withdrawal, not only for assigning the contraceptive responsibility to the male, but for interfering with the intimacy and sacredness of the sexual union. In 1919, she wrote:

The methods to be used by the man -- withdrawal and the condom -- have their objections for many people. While it is true that the employment of either of these methods lessen the trouble for the woman, they also deprive her of that great sacred closeness or spiritual union which the full play of magnetism gives when not checked by fear, as in withdrawal, or interfered with, as in the use of the condom. Some sensitive men object to the use of these methods, as also do many women. (Family Limitation, 9th Edition, 1919.)

Closely related to the idea that the condom was detrimental to the emotional and physical connection between husband and wife--an "estranging shield" as George Orwell called it in a bit of verse--was another theory put forth by British birth control advocate Marie Stopes, and others, that centered on the physiological benefit of the sex fluids. Stopes claimed that the use of the condom and withdrawal deprived a woman of beneficial vitamins and hormones contained in semen and absorbed into the vaginal walls. Where did that leave women who did not marry or engage in heterosexual sex? These experts did not say. (George Orwell, Keep the Aspidistra Flying [New York, 1956], 151; Marie Stopes, Contraception [New York, 1931], 154.)

Sanger was less swayed by this shaky science and much more concerned with a woman's sexual satisfaction. With male-controlled methods, Sanger thought many women would be too worried about trusting their partner to enjoy the experience. For this and other reasons, she wrote in her marriage manual, "The use and direction of the method should be determined by the wife rather than the husband." Sanger added that "The two methods generally used by men are known to be unsatisfactory to many men and to their wives likewise." While she distrusted the condom, she outright rejected the use of withdrawal. She went to great lengths in her early writings to warn couples away from coitus interruptus, not just because it was among the most ineffective methods, but because it left women unfulfilled and susceptible to nervous disorders, and was, she believed, the cause of "other serious conditions of the generative organs in women." (MS, Happiness in Marriage [New York, 1926], 209-10; MS, English Methods of Birth Control, 1915, 6.)

Sanger realized that "there is no one method of contraception that is suitable to be used by all men and women," and recognized that the condom was a good choice for certain couples. If the condom had performed better in early clinical surveys and assessments, Sanger might have been more forgiving of its disadvantages. But the limited data on the condom as a stand alone method showed a high failure rate. In 1924, Dorothy Bocker, the doctor who ran Sanger's Clinical Research Bureau during its first two years, measured a 50% failure rate for the 42% of the clinic's 1,208 patients who reported using the condom, compared to a failure rate of only 10% for the diaphragm. Of course, the sample was skewed because patients satisfied with the condom had no need to visit the clinic. Variation in the quality of condoms also made it difficult to assess the method as a whole; by some estimates, half of all condoms were defective. However, respected voices in the movement, including Sanger's own clinic director, Hannah Stone, and the American Birth Control League's medical director, James Cooper, admitted that, as Stone wrote in 1926, "When carefully tested and properly applied, the condom is a reliable means of contraception." Yet, even after these medical nods of approval, Sanger made no effort to encourage condom use. (MS, Happiness, 209; Bocker, Birth Control Methods [New York, NY], Feb. 1, 1924; James F. Cooper, Technique of Contraception [New York, 1928], 50; Hannah Stone, Contraceptive Methods of Choice [New York, 1926], 4.)

Despite problems with quality control, the association with prostitution and venereal disease, and the birth control movement's strong preference for woman-controlled methods, the condom flourished in post-World War I America. Even though the American military had not officially condoned condom use or made them available to soldiers during the Great War (as the Germans and French did), servicemen serving overseas relied on rubbers, plentiful in much of Europe, to protect them against VD. Many continued using them when they returned home to wives and girlfriends. "Every soldier in the World War was told to use them," Sanger later wrote, "and they have not forgotten." One study reported that couples married before 1912 used condoms 20% of the time, while couples married after 1921 relied on the method 40% of the time. By the mid-1920s, as many as two million condoms were used each day. (MS to Katharina Stutzin, March 22, 1932 [LCM 14:42]; Regine K. Stix and Frank W. Notestein, Controlled Fertility: An Evaluation of Clinic Service [Baltimore, MD, 1940], 51; Cooper, Technique of Contraception, 51.)

Innovations in rubber manufacturing in the 1930s, government intervention, and market forces led to the production of higher quality condoms. In 1930, condom makers won the right to copyright trademarks to protect brands, and in 1937, the Food and Drug Administration classified the condom as a drug, subject to FDA standards. The government seized lots of faulty and misbranded ("100% effective") rubbers and forced manufacturers to improve testing. With standards and regulations in place, many fly-by-night businesses went under, including, presumably, the Sanger Company of Newport, Rhode Island, manufacturer of "Sanger's Pro-Tek-Tube" brand of prophylactics--sold without Sanger's permission. These changes resulted in product improvements and the industry's consolidation into five big condom makers to dominate a lucrative market. (Abraham Stone and Norman Himes, Planned Parenthood [New York, 1951], 196; Andrea Tone, Devices and Desires [New York, 2001], 131; "The Accident of Birth," Fortune [February 1938], 108, 110.)

Nevertheless, most American clinics, built on the model of Sanger's Clinical Research Bureau, continued to promote the diaphragm over all other methods. Clinics prescribed the condom when women found the diaphragm too difficult to use or experienced irritation, and when sizing and fitting a diaphragm was a problem, such as after giving birth. But it remained in the clinical category of back-up birth control even though studies in the 1930s and after World War II found the condom to be as reliable as the diaphragm. It was also easily adaptable for use with other methods--a spermicide, a douche, the diaphragm--for even greater effectiveness. Indeed, Robert Dickinson took Sanger to task for searching far and wide for new methods when the old standby was proving to be a pretty good choice: "The method generally condemned by clinics, the condom, has been very greatly improved in strength and keeping quality and popularity so that, if proper factory testing can be enforced, it becomes the most effective, accessible and cheapest device on the market." But still Sanger would not be sold on it. (Dickinson to MS, October 28, 1936 [LCM 126:12].)

Along with her concern about a woman sacrificing responsibility and her sexual independence to the man, other problems with the condom would not go away for Sanger. First, the more women relied on the condom for marital birth control, the less need they had to attend a contraceptive clinic, often a woman's entry point into the health care system. Almost from the start, Sanger believed that women would benefit in a number of ways from visiting a clinic: they would learn about sexual function and be better able to experience sexual pleasure; they could be tested for pregnancy and venereal disease, and be evaluated for various health concerns; and they would receive instruction in reproduction and become more adept at using all types of contraception, even the condom.

Secondly, the condom, more than any other sexual device, continued to symbolize sexual immorality. In Sanger's ongoing struggle to win the backing of the medical establishment and in her lobbying efforts in Washington, she had to distance the movement from its early associations with sexual freedom and wanton sexuality. Practically anyone, including the underage and the unmarried, could purchase a condom, while access to the diaphragm fell under medical supervision. Moreover, contraceptive clinics did not serve unmarried women during Sanger's career, and the condom, if promoted by clinics, would have elicited the criticism (already voiced in some quarters) that birth control clinics encouraged premarital sex and licentious behavior. The diaphragm and other female methods better represented the concept of family planning and marital birth control. The last major issue with the condom for Sanger and other birth control advocates was a practical one: typical clinic patients did not like it, and many of their husbands, Sanger wrote, are "not willing to accept it." This preference was reinforced by clinic medical staff, but there was no doubt that most people had strong feelings, one way or the other, about the condom. (MS to Frank Boudreau, June 25, 1940 [MSM S18:86].)

We don't know if Sanger could have changed perceptions about the condom if she had publicly advocated it as a safe and effective method, suitable for most couples. Similarly, if she had encouraged men to take a more active role in birth control decision-making and responsibility, it is possible that more couples would have achieved greater contraceptive success and experienced better sexual relations. And if she had pushed the condom as a method for the masses, at home and abroad, with the same energy and resources she invested in foam powder, a problematic method from the start, contraceptive use among lower income groups and in developing nations may have been higher.

But there is a strong argument to be made that the medical endorsement of birth control, finally achieved in 1937, came about because doctors controlled the distribution of female contraceptives. If the controversial condom had been ascendant in the birth control movement, doctors may have taken a pass. And medical endorsement reinforced the steady march toward the legalization of birth control across the country and eventually helped sway the public health system to incorporate contraceptive services.

Not long after founding the movement, Sanger abandoned do-it-yourself methods in favor of the diaphragm and medical oversight of contraception with the aim of winning medical, legal and public acceptance for birth control as an "instrument" of medicine and science. She largely succeeded, but at a cost to many poor and working class people who resisted or were unable to adapt to the diaphragm (it required running water and hygienic conditions) and other medically-supplied female methods, or who could not afford, did not trust, or did not live near doctors and clinics. It is possible that these groups may have benefitted from a campaign to legitimize the condom and a coordinated effort to make condoms more available to women as a method of marital birth control. But by then, Sanger had hung the lowly condom out to dry. (MS, Pivot of Civilization [New York, 1921], 221.)