Beyond the Pill

Georgene led him lightly by one finger upstairs to her bed. ... When he worried about contraception, she laughed. Didn't Angela use Enovid yet? "Welcome," she said, "to the post-pill paradise."

--John Updike, "Couples"

The post-pill paradise.

In 1960, Enovid-10, the first oral contraceptive for women, was introduced to America. The drug-obsessed society that spent billions of dollars a year on prescriptions soon called Enovid the pill, as if it were the only pill. It was seen, in that innocent era, as the solution to that one big worry posed by sex.

By 1965, 15.3 percent of married American women aged 15 to 44 used one or another of the proliferating oral contraceptives. Enovid, Ortho-Novum, Norlestrin, Norinyl, Provest, C-Quens, Oracon: The names of the products had the paradoxical antique-futuristic ring of knights and lords in a science-fiction romance ("Quick, Norinyl, fire the laser." "They'll never catch us in this time warp, Oracon!"). Comic-book names with the echo of Latin, cut off from our common vocabulary--and yet somehow familiar in their alien sounds, because they had the same catchy semiscientific resonance as all the other drugs we took, which, like the pill, were more trusted than understood.

By 1970, 22.3 percent of married American women aged 15 to 44 were using oral contraceptives. By 1973, with 25.1 percent, the pill was entrenched as the contraceptive of choice. The next most popular method, the condom, was used by only 9.4 percent. The diaphragm was preferred by only 2.4 percent. The pill dominated the sexual heavens, as amazing as a second sun that had just appeared in the sky. People basked in the glow.

"The pill was a blessing," says Margo, a woman who started taking it in 1972. "It really agreed with me. I used to have heavy periods, always a problem. The pill regulated them. They were lighter. My skin cleared up. But most of all, I could relax. There was no more of that worry every month: Am I pregnant? That constant low-level stress. It used to drive me absolutely crazy. Before taking the pill, whenever I went to bed with a man--whether we used a condom or a diaphragm--I assumed the worst. Just so I would be prepared if the worst happened. And I lay there while we were making love, thinking, Is this worth it? Is it worth getting pregnant? The pleasure of the moment always had to be measured against my whole future. So, of course, it never seemed ... enough.

"The first time I made love after taking the pill, out of habit, I started going through that old routine: Is it worth it? And, suddenly, I realized that the question no longer made any sense. I wasn't going to get pregnant.

"Then something incredible struck me. Something really scary, but exciting, too. I realized that, before the pill, I had this narrow idea of the kind of men I'd go out with--just in case I got knocked up. I wanted the father to be--I don't know--good genes, good circumstances, family, status. Just in case.

"And it suddenly hit me that, since I wasn't going to get pregnant, I could date anyone--even guys I would never in the world want to be the father of my children. Anyone. That may not sound like much, but for me back then, it was like escaping. Like I had been locked up in this country club all my life and I had finally broken out into the real world."

The real world sustained such attacks by the millions, and the effects of the sudden tilt toward sexual anarchy are still hotly debated. Of the dozens of researchers interviewed for this article, some denied that the pill had anything to do with the sexual revolution of the past couple of decades; some even denied that there had been a sexual revolution. One inscrutably claimed that the sexual revolution had occurred decades ago--possibly hundreds of years ago--and its effects had taken years to reach us.

But despite the conflicting opinions, it seems safe--at least relatively safe--to say that in the past 20 years, there have been changes in how Americans deal with sexuality. For example, the age of first intercourse has dropped; there is more divorce; and there is certainly more talk about sex. Those changes have been influenced in part by changing habits of contraception.

"Following World War Two, after the baby boom was over, it became clear that, given the new contraceptives and the increased availability of the old methods, it was possible to have sex without consequences," says Dr. Henry Grunebaum, associate professor of psychiatry at Harvard Medical School. "And I think that--however you want to describe it--led to a sexual revolution."

The pill paradise lasted about ten years. Like zealots in other revolutions, women remained loyal to the cause only until the cause let them down. In the late Sixties, reports started coming out linking oral contraceptives to blood clots and cancer. Women started reassessing their liberator.

The pill, it turned out, might under certain circumstances cause a smorgasbord of side effects, some dangerous and some not: acne (as well as cleared-up skin), anxiety, appetite change, asthma, benign liver tumors, birth defects, bleeding gums, blood clots in the brain, eyes, heart, legs, lungs, pelvic area, bleeding irregularities, cancer of the breast, cervix, ovaries, pituitary, uterus and vagina (in animals) and of the cervix, liver and skin (in humans), cataracts, chemical diabetes, cholesterol- and triglyceride-level increases, contact-lens intolerance, cramps, dizziness, epilepsy, eye lesions, fatigue, gall-bladder disease, growth of already existing fibrous tumors of the uterus, hair loss on the head and gain on the face, heart disease, herpes susceptibility, high blood pressure, infertility (permanent), jaundice, kidney disease, libido changes, menstrual-cycle changes, mental depression, migraines, nausea, anxiety, rash, reduction of wax in the ears, spotty darkening of the skin, stroke, swollen ankles, tender breasts, thromboembolism, thrombophlebitis, thyroid disorders, tubal pregnancies (in progestogen-only pills), more frequent urination, vascular disease (other than thromboembolisms), varicose veins, vaginitis, venereal-disease susceptibility, vitamin deficiency, vomiting and weight gain or loss.

Package inserts for oral contraceptives, dense with text and printed in the tiny type that announces by its inaccessibility the pinstripe-gray seriousness of the corporation lawyer, read like contracts. Now we find that, in fact, they are contracts, contracts any woman who uses the pill makes with her own flesh.

Suddenly, the pill, in its thoroughly modern pastel designer case, is no longer the benign nightstand decoration it once was. Kicking the habit has been a screwy, haunting dilemma: Are you willing to sacrifice your body for the cool, carefree efficiency of the pill? (Some women hated to give it up because it made their breasts swell.) Or do you sacrifice a fraction of a percentage point of efficiency and the convenience of taking it with your morning vitamin?

Significant numbers of women have also found that their gynecologists have little regard for their fears. "When I started hearing the scare stories, I went to my doctor," says a woman who later allowed her pill prescription to run out. "He said that since I wasn't overweight, didn't smoke and had no bleeding symptoms, I had nothing to worry about. I mentioned the broken capillaries that had developed in my legs. He got impatient, really angry. I was wasting his time--didn't I trust him? He dismissed it all as women's-magazine hysteria and made me feel embarrassed to ever bring it up again."

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Critics and advocates of the pill argue about the evidence and the interpretation of the evidence. Some defenders of the pill claim that if more users than nonusers get malignant melanoma, it is because pill users tend to be women who lie for hours in skimpy bathing suits in the sun--that it's the sun, and these women's lifestyle, that causes malignant melanoma. Or defenders of the pill may assert that if users get cervical cancer more frequently than nonusers, it is not because they use the pill but because they do not use condoms, which protect women from the viruses that may cause cervical cancer. Or defenders of the pill may point out that there are some indications users get breast cancer not more but less frequently than nonusers.

The crosscurrents of thinking on the subject finally erupted last October when preliminary results from a multimillion-dollar 12-year study of pill risks were released to the public. The report, done at Kaiser-Permanente Medical Center in Walnut Creek, California, carried news from the study's authors, Drs. Savitri Ramcharan and Frederick Pellegrin, that pill health risks are "negligible." Sensing a good thing, G. D. Searle & Co., a huge pill manufacturer, financed a public-relations campaign to spread the word. Slick press kits were sent out; only some identified the Searle connection. In true David-and-Goliath fashion, the National Women's Health Network, a nonprofit group, tried to counter Dr. Ramcharan's conclusions by stressing the actual seriousness of the findings. Perhaps Searle should have looked beyond Ramcharan's remarks, because her study really confirms most of the previous maladies attributed to the pill: changes in blood pressure, blood clotting and sugar metabolism, higher risk of suicide among pill users; increased risk of eye, gastrointestinal, urinary and vaginal disorders and greater risk of a special kind of stroke called subarachnoid hemorrhage. The report bears out the suspected cancer/pill link. Of the five women under the age of 40 in the study who died of cancer, all of them were pill users. Higher rates of skin, lung and cervical cancer were found among users. Ramcharan supplies the usual set of rationalizations to absolve the pill: Women with cervical cancer are more promiscuous; women with skin cancer sun-bathe more; and women with lung cancer may smoke more. In the same vein, Ramcharan suspects "diagnostic errors" by doctors to explain away increased blood clots among pill users.

Despite what the drug companies--several of which helped fund the Kaiser-Permanente study--would have us think, it appears that neither we nor the pill is home free. Arguing the merits of a particular symptom's relationship to the pill is a way of avoiding the obvious conclusion: It is like arguing about the precise number of megadeaths in the moment between ground zero of the bomb and the blast wave. Even if only one tenth of the symptoms were directly related to pill use, the lesson learned would be valid: The pill is not the perfectly safe, perfectly effective contraceptive that it was touted to be.

Learning that desultory lesson has produced a reversal in female thinking. Whereas women used to proclaim their right to use the pill (remember demonstrations in front of campus health clinics?), many now proclaim their right not to, forcing a new look at contraception and a new role for men in choosing a contraceptive.

Even a longtime pill advocate such as Dr. Elizabeth B. Connell, the former research project coordinator of Northwestern University's Program for Applied Research on Fertility Regulation, admits that pill use is down. "It's not been a dramatic drop," she says, "but it's been a slow drop. There are particular individuals who are less apt to be using the pill now than they were in the past: the over-30 group, since new data has come out about smoking and cardiovascular problems and pill use, and the teenage-to-early-20s group, because of a growing anxiety on their part about side effects--much of which is based on reality but a considerable amount of which is based on fears that have so far no basis in fact."

By 1976, pill use among American women 15 to 44 had dropped to 22.3 percent. From 1975 through 1978, there was a decline of 23 percent in the number of pill prescriptions filled by retail pharmacies--from 64,000,000 to 49,000,000. In those four years, retail pharmacy sales of one of the most popular oral contraceptives, Ortho-Novum, dropped an astonishing 49 percent.

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When the first doubts about the pill began circulating, "some women," according to Dr. Connell, "went for a time to the I.U.D., especially the second generation of smaller, medicated I.U.D.s." Small devices made out of copper or plastic, I.U.D.s look like mutated zodiac signs: the Saf-T-Coil, Aries with ingrown horns; the Lippes Loop, Leo with a long tail. Placed in the uterus, they set up conditions that prevent conception; no one knows exactly how. At first, they promised to be as perfectly safe and perfectly effective as the pill had once seemed. By the early Seventies, women blithely were wearing them as internal charms, gynecological rabbits' feet. In 1973, 6.7 percent of American women aged 15 to 44 used I.U.D.s--compared with 5 percent in 1970 and only .7 percent in 1965.

But, like the pill, I.U.D.s betrayed their promise. In 1974, one of the most popular I.U.D.s, the Dalkon Shield, was withdrawn from the market because of its link to serious pelvic infection. Studies have shown I.U.D.s can cause anemia, cramps, hemorrhages, pain, spotting, (continued on page 112) Beyond the Pill(continued from page 102) uterine and cervical perforations and, most seriously, pelvic inflammatory disease that can lead to permanent sterility or death. In fact, women who use I.U.D.s are two to four times more likely to suffer pelvic inflammatory disease than those who do not.

"I had a Dalkon Shield," says Peggy. "I started having these terrible pains. Terrible. I went to the hospital and they said appendicitis. I said, no, I knew it wasn't appendicitis. So I went to my gynecologist and I was right; it was the I.U.D. He took it out. I've never felt pain like that before."

Between 1973 and 1976, the percentage of women using I.U.D.s spiraled downward from 6.7 to 6.1--and there is evidence that in the past five years, the drop has been even more significant. Another lesson learned.

And now that the wonders of chemistry (the pill) and technology (the I.U.D.) look increasingly malevolent, more traditional methods of contraception are enjoying renewed popularity. The condom and the diaphragm have returned like royalty from exile. In 1978, condom sales started to climb by about 12 percent a year. Diaphragm sales also rose--from 503,000 in 1975 to 1,205,000 in 1978, a startling 140 percent increase in only three years.

Attitudes have changed from the old skulk and blush of the Fifties, when condoms were palmed from hand to hand as though they contained microdots of defense secrets being passed from spy to spy. In 1955, the Schmid Company finally got permission to discreetly display Ramses, the first public display in America; but 20 years passed before condoms left the pharmacist's drawer for the shelf.

Even their names are bolder. Instead of evoking the classical past and ancient civilizations (Trojans, Ramses, Sheiks), the new names designate erotic play: Fiesta, Excita, Stimula. They're shaped, ribbed, studded and colored (incidentally, the racial fantasies of at least two cultures can be gauged by condom use: In Sweden, black is the most popular color; in Kenya, it's white).

Due to FDA restrictions, American condoms are not yet as sensitive as their Japanese counterparts, which are thinner by half. Philip Harvey, former director of Population Services International, says that reducing the thickness of American condoms by one half would mean an increase of only one additional pregnancy for every 2,500,000 to 5,000,000 incidents of intercourse. We suffer by binding our pleasure to our paranoia.

Actually, the current effectiveness of American condoms is greater than most people realize. Condoms used with spermicidal foams have a theoretical effectiveness of better than 99 percent. Diaphragms used with spermicidal gel have a theoretical effectiveness of 97 percent. Pills have a theoretical effectiveness of 99.7 percent and I.U.D.s of 97--99 percent. Theoretically, then, condoms can be almost as effective as pills and more effective than I.U.D.s; diaphragms are virtually as effective as I.U.D.s.

The key word is theoretically. Unfortunately, theoretical effectiveness can lead to real pregnancies. But just as condoms can pop and diaphragms slip, pills can pass through women undigested and, if passion can pre-empt caution (aroused couples ignoring condoms in their giddy lust), so can absent-mindedness (pills left behind on vacations or forgotten during weekend romances).

When actual use effectiveness is compared, pills (90--98 percent) and I.U.D.s (95 percent) turn out to be no more effective than condoms used with spermicides (90-95 percent)--and only marginally more effective than condoms used alone (90 percent) and diaphragms used with spermicides (87 percent). There even is some evidence that among highly motivated women who have been taught how to use diaphragms properly, diaphragm effectiveness (95--98.1 percent in this case) may be equal to that of pills or I.U.D.s.

Admittedly, there are problems. Condoms break. "I'd be pumping away," says one condom veteran, "and all of a sudden my girlfriend would say, 'Hey, something feels a lot better.' " It's not difficult to see why they resisted jumping out of bed to put on a new one.

Women using diaphragms complain that the romance goes out the window when they have to insert the thing ahead of time. A diaphragm user's lament: "If I want to make love tonight, I'll put in the diaphragm ahead of time. Then, if nothing happens, if he turns over and goes to sleep, I'll be upset. So I finally said, 'I've had it. From now on, you just tell me and I'll prepare.' But that's so unromantic and it just gets everything off sync."

Effectiveness and convenience aside, few questions had ever seriously been raised about the safety of using the diaphragm. But this past spring, the Boston Collaborative Drug Surveillance Program at the Boston University Medical Center reported the results of a study indicating that women who become pregnant while using spermicides--foams, creams, suppositories and gels--may be more likely than nonusers to bear children with serious birth defects. The study is not conclusive, but even the suggestion of such a serious side effect can't help but cause many people to forgo--at least for the time being--the effectiveness edge their spermicides gave them. Without spermicidal gel, of course, the diaphragm is virtually useless.

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If the pill and the I.U.D. tend to separate the sex act from contraception, condoms and diaphragms tend to focus attention on the genitals. Before the liberalizing of sexual attitudes, that focusing of attention often led to embarrassment. But now, no one can afford to be embarrassed. Today's upheaval in contraceptive habits forces people to talk, and there's plenty to talk about: Is the responsibility of contraception a power or a burden? And whose power or burden is it, his or hers? In the Fifties, when there was no discussion, men were supposed to be responsible, no wallet complete without its condom. In the Sixties and early Seventies, women were supposed to be responsible, on the pill or using an I.U.D. Today, particularly among those who practice casual sex, neither the man nor the woman can assume his or her partner is prepared; they must negotiate.

"I'm not sure what the power implications of the whole thing are," says Dr. Ira Reiss of the University of Minnesota, one of the country's leading sociologists of sexual behavior. "In a way, if a woman can get a man to use the condom because she doesn't want to take the risk of using the pill, then she has the power. On the other hand, you could argue that anyone who controls contraception is in the power position because he's controlling the likelihood of pregnancy. So the answer really is in how that contraceptive method got decided on, not just who's using it--whether it's the pill for the woman or the condom for the man. The power is more a matter of using a technique that both parties want or of using a technique that one party is imposing on the other."

This is the first hint of what the future of contraception might involve: bringing out even more into the open the struggle between the sexes that sometimes makes fucking seem like a fight between competing biologies--the viscerally conservative (one egg released once a month) and the viscerally prodigal (continued on page 194) Beyond the Pill (continued from page 112) (30,000,000 sperm produced every day).

The future of contraception lies in a method that answers both the needs and the mood of the times. The ideal method divides the burden equally between man and woman, is not directly related to the sex act, does not introduce foreign substances into the body and is 100 percent effective and 100 percent safe.

The ideal method does not exist.

But there are three traditional methods that at least partly fulfill the specifications and that, like the condom and the diaphragm, have been given new life in the wake of disillusionment with the pill and I.U.D.s. They are sterilization, the cervical cap and natural family planning.

When a man and a woman make love using a foolproof method of contraception--when there is no possibility of conception--the sex act is isolated in the moment. It is disconnected. Biologically, it occurs outside time.

It is not insignificant, then, that sterilization has become the second most popular method of birth control after the pill (which, to the extent it is almost perfectly effective, also isolates the sex act in the moment). The number of men and women sterilized has climbed from a total of 7.8 percent in 1965 to 19.3 percent in 1976. By 1979, almost 12,000,000 Americans had been sterilized, and the figure is climbing at a rate of close to 1,000,000 annually.

This boom is due partly to advances in the methods--for both men and women. "Since the early Seventies, female sterilization especially has become significantly easier to do," says Miriam Ruben of the Association for Voluntary Sterilization. "Now, like the male operation, it is an outpatient procedure under local anesthetic. Both female and male sterilizations are safe, quick and relatively painless--usually, the worst pain is the needle administering the anesthetic.

"For the woman, it can be as simple as a one-to-one-and-a-half-inch incision at the pubic-hair line; for the man, a tiny incision in the scrotum--either one incision along the center line or two, one over each vas deferens. Then a little stitch. Fifteen minutes. My husband had a vasectomy, and I'll be damned if I can even find the scar.

"Most of the anxiety (for men, especially) centers on how it will affect their sexuality. They can become sexually active almost immediately. It all feels the same: same arousal and same sensations. You still feel an ejaculation, except there is only semen, not sperm, in the ejaculate."

But the boom in sterilization is due not just to the advances in methods. It is also a result of the growing acceptance of the idea. Ten years ago, sterilization--especially for men--seemed extraordinary. Today, while not yet common, it no longer seems uncommon.

"The only problems we run into," says Ruben, "are the older men (and it usually is men) who were married, had kids, got vasectomies, and then got divorced. Now they're with a young woman who wants kids, and the men come back to us asking about the possibility of having reversals done.

"But even that is getting more and more likely. Some doctors are already having good results with reversals, though it's still on a limited basis. And as microsurgical techniques are improved, the chances of reversals will improve--although no one should get sterilized counting on a reversal.

"The best rule of thumb is: If you have any doubts, don't do it."

Despite that caution, sterilization is increasingly advocated by doctors for married women who have had enough children or who are past the safe childbearing age and do not want children. And there is a determined attempt on the part of prosterilization groups--such as Zero Population Growth--to push the method, to make it even more acceptable by leavening the subject with humor, even trivializing it. Last year, for Father's Day, the Denver Zero Population Growth Foundation raffled off a vasectomy. Second prize was a year's supply (estimated at two gross) of pastel-colored condoms. Booby prize was one month's free diaper service.

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"Everybody says there's no method of contraception that is both not directly related to the sex act and safe," says Barbara Seaman, cofounder of the National Women's Health Network and an expert on women's health and contraception. "But I think there is one method--the cervical cap."

The cervical cap is exactly what it sounds like: a small cap that fits over the cervix. It is a traditional method of contraception, thousands of years old. The modern cervical caps, developed in 1838, originally were made out of gold, platinum or silver, precious ore that women secreted within their bodies. Today, the caps are made of less romantic substances, such as plastic or rubber.

In terms of effectiveness, safety and convenience, the cervical cap compares well with the competition. It is far more convenient than either the diaphragm or the condom. Like the diaphragm, it can be inserted and withdrawn by the wearer; unlike the diaphragm, it can be worn for relatively long periods of time. The metal cap used to be worn for a month and taken out just before each menstruation. The new rubber cap can be worn from three to five days, though if it is left in too long--more than five days--it develops an odor. Also, the diaphragm needs fresh spermicide with each act; the cap does not. Some women put in spermicide when they insert the cap: other women follow tradition and do not use spermicide at all, a benefit of the cervical cap that takes on greater importance in light of the recent Boston University study.

The only inconvenience involved in using the cap is that some men report feeling it when they are making love; however, some women report that the cap heightens their arousal, perhaps from the pressure against the cervix.

So much for convenience and safety. Now, effectiveness.

Like foams alone (which have a use-effectiveness rate of 78 percent), suppositories (75--80 percent), withdrawal (75--80 percent) and lactation (only 60 percent), the cervical cap tends to be dismissed as not a serious contraceptive method in America--even though it may have a use-effectiveness rate surpassing that of the condom and the diaphragm and just short of the I.U.D. and the pill: 91.4 percent, according to a study released in 1953, one of the rare studies done in the U. S. on the cervical cap.

"It amazes me that nobody in this country seems to want to do the low-cost research to improve barrier methods like condoms, diaphragms and cervical caps," says Seaman. "I sometimes get very cynical about it."

Her cynicism leads her to a couple of possible explanations: "If you work in systemic methods fiddling with body functioning--as in the case of the pill--you may stumble into a Nobel Prize; but if you make a more effective and more sensitive condom or prove to the FDA that cervical caps work, it is less likely that Stockholm will call."

But ambition, says Seaman, is probably not as responsible for the neglect of cervical caps as is greed.

"I felt there was pressure against the revival of the cervical cap from both the medical community and the pharmaceutical industry," she says, "so in 1979, I testified at Ted Kennedy's Senate hearings on women and health. I said the bias against cervical caps in this country was probably due to the fact that it is such a low-profit method. Cervical caps don't have to be replaced as often as diaphragms, so the companies making them would not sell as many. And doctors don't like it because it takes so long to fit it, because it's not a high-turnover procedure." The cervical cap just has lots of satisfied women supporting it, especially in Europe. Even though about 50 centers across the United States are now dispensing caps, the method is struggling.

While the cap seems relatively risk-free, researchers at Harvard Medical School report that it has a tendency to dislodge during intercourse. Eight out of 60 women studied became pregnant after their caps dislodged. It may be that the cap, like the diaphragm, should be removed more often.

The FDA has reclassified cervical caps as devices approved only for investigative studies. Although it is unclear how that will affect distribution of the caps, Seaman says, "It's ironic that the pill and I.U.D.s--both demonstrably more dangerous than the cap--are readily available. Yet the cap, which in the past 15 years has never led to a death or any serious complication, is almost unknown and hard to get."

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The medical community and the pharmaceutical industry would dislike natural -family planning for the same reasons they dislike the cervical cap. But at least N.F.P. has the backing of the Catholic Church, an ally that can certainly hold its own against the American Medical Association and the American Pharmaceutical Association. There are several natural-family-planning methods.

The calendar method, traditionally called the rhythm method, involves calculating, on the basis of her previous menstrual cycles, a woman's likely fertile period and abstaining during that time.

The ovulation method (also called the Billings Method after Drs. John and Evelyn Billings, the Australian husband and-wife team who developed it in 1974) involves learning to read changes in cervical mucus. From the first show of moistness after menstruation to the fourth day after ovulation (the wettest day), a woman is probably fertile.

The basal-body-temperature method involves keeping track of the woman's temperature every day with a special basal thermometer, watching for the slight drop that in some women precedes ovulation and the rise that follows from 24 to 72 hours after ovulation. It is considered safe to have intercourse only after the temperature has been elevated for three days.

And for the past decade, there has been a grass-roots surge of interest in a method called the symptothermic--or fertility awareness--method, which combines aspects of all three. In the combined regimen, a woman takes her temperature daily before getting out of bed. Then, two or three times during the day, she examines her cervical mucus and the position of the cervix. Before and after ovulation, the cervix is firm, low and closed; during ovulation, it's soft, high and open. If checking sounds like a drag, fertility-awareness enthusiasts claim it just takes a moment and soon becomes second nature when combined with a regular trip to the bathroom. The process takes about ten minutes per day.

But N.F.P. tends to be dismissed by many as a mixture of naïveté and near magic. "We have a name for people who practice natural family planning," says Lyn McKee, a consultant for Planned Parenthood of Contra Costa County, California. "We call them parents."

Theoretically, however, N.F.P.'s record is surprisingly good. Although the traditional calendar-only method has an effectiveness rate of only 81 percent, the basal-body-temperature method is 93 percent effective, comparable to the condom, diaphragm, I.U.D. and pill. The Billings Method by itself has a stunning theoretical effectiveness rate: 98 percent.

The problem with N.F.P. methods, of course, is cheating. Actual use-effectiveness rates lag at between 75 and 80 percent.

Users of N.F.P. have to remember a simple fact that the sexually conservative traditional supporters of the methods often fail to point out: Abstinence from intercourse doesn't necessarily mean abstinence from sex. Couples can indulge in oral and anal sex and masturbation without any danger of pregnancy.

As for the combination symptothermic method, a study conducted in the Los Angeles area by doctors from Cedars-Sinai Medical Center and sponsored by the National Institute of Child Health and Human Development has found that it can have a significantly higher actual use-effectiveness rate than either the Billings or the rhythm method used alone. Although other statistics would place it slightly below the condom and the diaphragm, the symptothermic method's effectiveness is certainly good enough to keep it in the running.

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The search for safe, effective birth control has changed society before and will again. As a matter of fact, we've already changed, because we realize finally that safe is a relative term.

"There is no safe contraceptive," says Dr. Carl Djerassi, the man who synthesized the first oral contraceptive. "But not just contraceptives--there is no safe anything. Aspirin, sugar, anything. You can cross the street and get hit by a car. It is naïve to expect safety."

Contraception, it turns out, is a matter of each individual's balancing the risks of pregnancy against a contraceptive method's risk to health. The blithe assumption current when the pill was introduced--that we now had a perfectly safe, perfectly effective contraceptive that freed us from all consequences--has burst like a colored party balloon. We have to relearn that trite, true lesson: There is no free lunch. We can have our nearly foolproof contraceptives and the explosion of sexual activity they produce; but the side effects, whether pregnancy or health hazards, are there to remind us that we're inextricably locked into an equation that includes sex and mortality.

Of course, that's nothing new, and it need not be depressing. Other generations found that the acknowledgment of the connection between sexuality and mortality heightened its pleasure. If you believed, as the Elizabethans did, that every orgasm (which was called the Little Death) made you die a day sooner--brother, you made sure those orgasms were worth it. Our teachers ought to be Shakespeare, Rabelais, Boccaccio. So we must learn that life is a party in a plague. Is that any reason to wear a hair shirt instead of something from Frederick's of Hollywood?

"No one can afford to be embarrassed. Today's upheaval in contraceptive habits forces people to talk."