Some of the first trials of hormonal contraception were conducted on both women and men back in the 1950s.
Those women and men were at an asylum for mentally ill people in Massachusetts, and they didn’t know it was happening, let alone consent to it.
But when the trials got legitimate, they weren't continued on men.
Because, well, they already had condoms.
“When the pill was first released it was initially embraced by women; they could have control over their fertility... and it shouldn't be underestimated what that meant, socially it had a huge impact,” says Dr Clare Boerma from Family Planning NSW.
Sixty years on though, that control has become a burden for some women and many are wondering whether men can help carry some of the emotional, physical, and financial loads of hormonal contraception.
So why isn't there a pill equivalent for men?
This week on The Case we're looking at the three things we need to try and understand when it comes to the delay in making more male contraceptive options available; are there biological complications? Is big pharma to blame? Or is there a lack of demand from men?
Is it biology?
If a male body produces about a thousand sperm per second, and a female body produces one to two eggs per month, does that mean it's more complex to create male hormonal contraceptives?
Well not quite.
Testosterone is the hormone that drives sperm production and it comes in droves, according to Professor Rob McLachlan, a specialist in male reproduction health and the Medical Director at Healthy Male.
He says while a woman might make 50 micrograms of estrogen a day, a man makes around 6000 micrograms of testosterone per day.
“So it’s much, much more hormone you have to get from the bottle into your bloodstream,” Prof McLachlan told The Feed.
Hormonal contraceptives like the pill work by replacing those naturally occurring hormones with synthetic versions, tricking the body into thinking that it doesn't need to produce them.
And when the body itself doesn't produce those hormones, the brain stops sending signals to the testicles or ovaries to produce sperm or ovulate.
While men need to ingest 20 times more hormones to fool their bodies than women, the challenges of doing that aren't exactly more complex, they're just different, according to Dr Boerma.
"I think there is a bit of a myth that men's reproductive physiology is more complicated than women's," she says.
Dr Boerma says a male hormonal contraceptive is possible to make, it's about fine-tuning the process.
For example, delivering 6000 micrograms of testosterone in a pill form is impractical, because testosterone is broken down by the liver when taken orally, and it could cause liver damage.
So Professor McLachlan believes it's better delivered via injection, and he has helped develop one that's taken every eight weeks.
"From an intellectual sense it works similar to the female pill," he says. "But it isn't a pill."
Even still, there are male contraceptive pills in development alongside injections and gels. But they’re all at least 10 years away according to experts.
So if it isn’t biology standing in the way of hormonal male contraceptives, what is?
Is it big pharma?
Just because it’s biologically possible to make a male hormonal contraceptive, it doesn’t mean big pharmaceutical companies are convinced it’ll make them any money.
Financial incentives for pharma companies might be lacking.
“It is potentially harder to push through and advocate for the need for the male contraceptive options when there are lots of female options around already,” Dr Boerma says.
And then there’s the issue of oversight.
In the 1960s, only 130 women tested the pill before it hit the market. The scientists were sneaky though, instead emphasizing the number of menstrual cycles - and the number of pills handed out.
Medical ethics were pretty lax back then and that wouldn’t really fly today.
Professor McLachlan says “the regulatory bar, the oversight… and the whole approach to clinical science is much more sophisticated than it was fifty years ago”.
It’s made harder for him and his team to get their hormonal injection into the market, even though it was roughly as effective as some female pills.
The study was stopped early because the World Health Organization was concerned about some men reporting side effects like mood swings, acne and depression.
Which is weird, because side effects can be much worse than that for some people taking female birth control.
The injection also wasn’t effective in about one in 25 men. For some unknown reason, those men simply kept pumping out sperm. That means if it were to reach the market, men would need a way to check their sperm count and ensure the injection works on them.
Despite that, 75 percent of the men in that trial wanted to continue with the contraception.
But the pharma company behind it backed out.
“The physiology is well understood, we know how to do it. We had an approach that would work, but without the actual machinery to bring it to market... it's not going anywhere, so you can imagine a level of frustration” Professor McLachlan says.
So, what is missing when it comes to convincing companies more male birth control options are a worthwhile venture?
Is it men’s willingness?
Do men actually want a hormonal contraceptive enough to go and get a shot every eight weeks, or take a pill every day?
“The female is the person who has to carry a pregnancy were the contraception to fail,” says Dr Boerma. “And so the motivators are potentially a little bit different.”
Surveys have demonstrated there is interest among men around using contraceptive methods other than condoms and vasectomies, maybe where the male pill can really make a dent, is in committed relationships.
Research published in 2016 shows that more than half of men would take hormonal contraception and that their partners could trust them to take.
“It’s something that’s sought by couples...And in stable relationships the men are very happy to take that responsibility, the couple are, so it’s not a question of [men] not wanting to step up and do it, they will, they just want something,” says Professor McLachlan.
The Verdict
Whether it’s in the form of a pill, an injection, or a gel, giving men more options will ultimately change the conversation about who is responsible for contraception. And just because it doesn’t exist yet, doesn’t mean it’s not worth hoping for.
