The international growth and influence of bioethics has led some to identify it as a decisive shift in the location and exercise of 'biopower'. This book provides an in-depth study of how philosophers, lawyers and other 'outsiders' came to play a major role in discussing and helping to regulate issues that used to be left to doctors and scientists. It discusses how club regulation stemmed not only from the professionalising tactics of doctors and scientists, but was compounded by the 'hands-off' approach of politicians and professionals in fields such as law, philosophy and theology. The book outlines how theologians such as Ian Ramsey argued that 'transdisciplinary groups' were needed to meet the challenges posed by secular and increasingly pluralistic societies. It also examines their links with influential figures in the early history of American bioethics. The book centres on the work of the academic lawyer Ian Kennedy, who was the most high-profile advocate of the approach he explicitly termed 'bioethics'. It shows how Mary Warnock echoed governmental calls for external oversight. Many clinicians and researchers supported her calls for a 'monitoring body' to scrutinise in vitro fertilisation and embryo research. The growth of bioethics in British universities occurred in the 1980s and 1990s with the emergence of dedicated centres for bioethics. The book details how some senior doctors and bioethicists led calls for a politically-funded national bioethics committee during the 1980s. It details how recent debates on assisted dying highlight the authority and influence of British bioethicists.
During the interwar years, women doctors medicalised birth control in Britain by developing a number of strategies to position themselves as experts in contraception and sexual disorders. 1 Among these strategies were publication of medical articles on birth control and participation in medical conferences. Yet these forms of dissemination of medical knowledge were not restricted to the national sphere; British women doctors also took part in international conferences on birth control. In fact, in a context where the quality and quantity of the world's population was an object of intense scientific debate, birth control was receiving increasing attention. These meetings were determinant spaces for doctors working in birth control, not only for gaining knowledge on new contraceptive methods and updates about clinical trials but also for asserting their expertise and debating the social and medical benefits of contraception. The international role of women doctors’ work reveals how birth control and its medicalisation needs to be understood as a history of internationalism.
This chapter compares the roles of British and French women doctors in advancing knowledge of birth control at international conferences. By focusing on women doctors from two countries with strikingly divergent legal access to contraception, relationships with population issues, and women's political rights, this chapter explores the way national experiences shaped international debates.
In France, the sale and publicity of contraceptive devices was made illegal by the 1920 law, which was the culmination of years of pronatalist campaigning fuelled by anxieties around depopulation. After 1920, a radical minority mostly comprised of anarchists and neo-Malthusians continued to promote birth control; some of these activists, such as Eugène and Jeanne Humbert and Madeleine Pelletier, were arrested as a result. While the French context, compared to the British one, was repressive in terms of access to information and contraception, women's place within society also differed drastically. British women aged over 30 who met specific qualifications obtained suffrage in 1918, and this right to vote was extended in 1928 to all women on the same terms as men, while French women only gained political rights in 1945. However, French women benefited from more state protection and support under the Third Republic than women in Britain.
Notwithstanding this difference in political power, when it came to women's position within the medical community, both British and French women occupied only a peripheral place within the male-dominated field of medicine. In France, although women had been able to practise medicine since 1870, it remained a profession for the masculine elites until after the Second World War, owing to the fear of overcrowding. Male doctors tried to restrain women from entering ‘their’ field, but the state ‘allowed for moderate, steady progress toward equality’. 2 Between 1900 and the Second World War, the number of women medical students multiplied by six, though they still represented only 2 per cent of all potential doctors in 1928. Women doctors were assigned to ‘feminine’ fields and to more precarious hierarchical positions in both countries, such as public and community health, gynaecology and general practice in Britain, and medical gynaecology in France. In 1931, a survey of the 275 members of the French Association of Women Doctors revealed that the largest concentration of women doctors worked in the field of gynaecology and obstetrics. 3 Whereas obstetrics and gynaecology were unified in Britain after the First World War, this was not the case in France, where these two fields remained distinct from each other. The process of medical specialisation – including reproduction-related specialties – in France has a complicated history. 4 In 1949, four different specialties were recognised in France: obstetrics and gynaecology; surgical gynaecology, which was the most prestigious field and predominantly male; obstetrics; and medical gynaecology, which was almost entirely populated by women. 5 One important difference between the British and French situations was that British women doctors were strongly involved in the birth control movement, whereas French women doctors were not, as a consequence of the 1920 law.
This chapter assesses the relationship between national politics and birth control stances by comparing the norms of contraceptive practices articulated by British and French female doctors as transcribed in proceedings of international conferences on birth control. In addition, the chapter looks at the gender dynamics around positions on birth control expressed at international conferences. I try to determine whether women doctors held different stances on the subject as compared to male doctors, and how their position within the national medical landscape impacted their stances at the international level.
Internationalising birth control
The first decade of the century witnessed the advent of an international birth control movement led by the Malthusian League and later by Margaret Sanger, the well-known US birth control activist. Neo-Malthusians considered that excessive population resulted in poverty, and consequently they believed that limiting the size of the population would favour prosperity. 6 Founded in 1877 by the famous Annie Besant and Charles Bradlaugh, convicted and sentenced for having republished an ‘obscene pamphlet’ written by Charles Knowlton, the Malthusian League promoted the education of individuals in sexual matters and contraceptive use so as to reduce poverty. The League published its first leaflet, entitled Hygienic Methods of Family Limitation, in 1913, the first medical birth control publication of the twentieth century. The League began its international path in 1900. At the turn of the century, a wide range of international activities and associations flourished in relation to a diversity of topics: overpopulation, health, tropical medicine and labour, to name a few. 7 These international connections were also reinforced by the expansion of colonial empires. The issue of population, in particular, became an international concern. A first international meeting was held in Paris (1900), then further meetings in Liège (1905), The Hague (1910) and Dresden (1911). This movement brought together scientific experts and doctors from Britain, the United States, the Netherlands, France, India, Sweden, Belgium and Spain to discuss and share knowledge on the ‘population problem’. The period between 1900 and 1911 was referred to as ‘the high era of international meetings’ by Alison Bashford. 8 Close cooperation was therefore sought between activists from different countries. The scope of these conferences, argued Bashford, was broader than birth control alone and encompassed many aspects of the population question: the issue of space, world resources, food, population growth, eugenics, political economy and natural history, among others.
These international meetings paved the way for the increasing importance of conferences as spaces for knowledge acquisition and transfer across national borders. In the following decade, three international neo-Malthusian and birth control conferences took place: London (1922), New York (1925) and Zurich (1930). For the first time, birth control was included in the title, suggesting that the idea had become accepted. Representatives from Britain, the United States, Germany, Austria, Holland, Denmark, France, India, China, Japan and Sweden were present. In addition, Margaret Sanger, with the help of the British feminist and birth control activist Edith How-Martyn, set up the World Population Congress (WPC) in Geneva in 1927 to promote scientific interest in contraceptive research. At this congress, however, birth control was left off the agenda in favour of more demographic and economic concerns linked to the population question. 9 These conferences again gathered experts from different fields: demography, medicine, sociology, agriculture, economics, biology, etc. The majority of the male experts were strong supporters of birth control methods, but not because of concerns over women's health. Here lies the main difference between the stances taken by women doctors and many of the male attendees. As Bashford convincingly demonstrated, for these male experts birth control represented a ‘means by which food scarcity might be ameliorated, war averted, and global security achieved. As a rule, geopolitics not gender politics energised these prominent men.’ 10 The quality and quantity of the population was also a key motive for British male speakers, whereas women doctors, in contrast, understood birth control as a way of improving women's health and giving them reproductive autonomy. The strategist Margaret Sanger understood that a mixture of arguments between population, food resources, issues of war and peace, and women's health was necessary to attract international support for the cause of birth control.
Following the Geneva conference, an International Birth Control Information Centre, which functioned as an advice and teaching hub for members’ countries, was set up in London under the direction of the British suffragist Edith How-Martyn and the leadership of Margaret Sanger. At the same time, international associations were created, such as the Medical Women's International Association (MWIA) in 1919. Set up in New York by unifying national branches of women's medical associations, this association aimed at ‘providing means of communication between all medical women, promoting their general interests and furthering friendship and understanding between the medical women of the world. At the same time [affording] opportunities to confer upon questions relating to the health and well-being of humanity.’ 11 The MWIA, based on its membership, organised a conference on birth control in 1934 in Stockholm and another on maternal mortality and abortion in 1937 in Edinburgh, showing how women's reproduction had become an international health concern. Meanwhile, other international meetings were also organised by the World League for Sexual Reform, an organisation officially created in 1928 by Magnus Hirschfeld and aimed at reforming social attitudes about sex. Among the aims of the association was support for the dissemination of information on birth control and the self-determination of couples in terms of conception or non-conception. 12
Thus, the period between 1920 and 1937 saw the institutionalisation of international conferences and the positioning of birth control as a matter of international significance that attracted a broad range of experts including doctors, biologists, economists, statisticians, demographers and so on. In this new international network, British women doctors were to play an increasing role in the medicalisation of birth control, contributing to framing it as an international health concern and aligning with American, German and Austrian female doctors in their call for medical and reliable forms of contraception to safeguard women's health.
1922–30: towards medical arguments
Organised in 1922 in London by the New Generation League – the rebranded name for the British Malthusian League – the Fifth International Neo-Malthusian and Birth Control Conference was divided into seven sections: individual and family aspects of birth control, economics and statistics, morality and religion, eugenics, national and international perspectives, medical perspectives, and contraceptives. 13 While British doctors were present and actively involved in these debates, there was only one French birth control advocate among the speakers. Plausibly due to the 1920 law, Gabriel Giroud, a neo-Malthusian activist who had attended prewar international conferences, participated in the conference under the pseudonym G. Hardy, and described the legal situation in France and the risks incurred in publicly supporting birth control. Out of thirteen British delegates who presented papers during the 1922 conference, four were doctors. They were Dr Norman Haire, former medical director of the Walworth Women's Welfare Centre in London; Dr Killick Millard, medical officer for health in Leicester and a convinced eugenicist; Dr Binnie Dunlop, Scottish doctor and leading member of the Malthusian League and of the Eugenics Society who proffered birth control advice to working-class mothers in East London in 1914; 14 and the only woman doctor, Dr Frances Mabel Huxley, 15 gynaecological surgeon to the Marie Curie Hospital and founding member and then in 1928 president of the Medical Women's Federation. In 1929, Huxley was elected as a Foundation Fellow of the Royal College of Obstetricians and Gynaecologists. 16
In all contributions to the 1922 conference, British male doctors advocated for birth control with the aim of improving national and sometimes even global welfare. Even though they invoked the medical dimension of birth control, these doctors softened its significance by drawing on eugenic or neo-Malthusian rationales. Their close affiliation and previous engagement with the Eugenics Society and the Malthusian League might explain this ideological orientation. 17 While he was not a medical doctor, it is worth developing the view of the president of the 1922 conference, Charles Vickery Drysdale, son of the famous birth control activists Dr Alice Vickery and physician Charles Robert Drysdale, since he set the tone of the debates. 18 Eugenics arguments permeated his opening. He appreciated that birth control would ‘remove untold suffering from millions of hapless men, women and children[,] make early marriage and social purity possible, [and] improve the quality of the race’. 19 He urged public health authorities to provide birth control instruction ‘to all whose circumstances or bodily or mental characteristics render them unfit for satisfactory parenthood’. 20 Drysdale linked women's agency with the eugenics argument, since birth control empowered women and this would eventually benefit the whole of society: ‘By being able to have her children only when she feels able to do justice to herself and them, she becomes mistress of her fate, and from the point of view of the race the eugenic effect of birth control would be enormous.’ 21 But Charles Drysdale did not aim at empowering women per se from an individual welfare perspective, but rather at achieving a eugenics society, for ‘global welfare’. The contributions of male doctors presented the audience with the same strategy of legitimising birth control with eugenic or neo-Malthusian rhetoric. In his keynote address during the first evening's public event, Killick Millard resorted to eugenic arguments when he called for the spread of birth control to tackle the issue of ‘the reckless lack of caution of the C3 class’. 22 He asserted that the fertility of the C3 class (the expression derived from the classification of substandard military recruits) represented a ‘world-wide danger’ for ‘the individual, the nation and the race’. Binnie Dunlop gave a paper entitled ‘Contraception is necessary for the elimination of poverty and is therefore moral’ in the morality and religion session; in this paper, he underlined the threat that a high birth rate represented for the world's inhabitants: ‘if God disapproves of contraception, He must approve of poverty’. 23
Killick Millard chaired the medical session. Nine papers were presented; eight were by male doctors and scientists and one by a female doctor. Millard opened the session with a paper on ‘Birth control and the medical profession’ and called for medical men and women to study ‘the various medical problems connected with Birth Control which are [awaiting] solution’. He provided the audience with a brief overview of the work of the founder of the Malthusian League and went on to present the results of two inquiries he had made into the views on birth control held among the medical profession in Britain. The first inquiry was made in 1918, when questionnaires were sent to medical men and women; seventy-four were returned. Fifty-two respondents stated that they did not think birth control methods were ‘injurious to health under ordinary circumstances’. The answers that considered birth control as detrimental to health were not backed up with ‘any actual experience’. But Millard quoted the answer of a woman doctor who supported birth control by referring to her clinical experience: ‘In nearly thirty years’ practice among women, of which nearly twenty years have included experience on the staff of a women's hospital, I have not met a single case in which I could trace ill-health to this cause.’ 24 The second inquiry was made by Millard with the help of Dunlop in 1921. They addressed 160 questionnaires to ‘eminent gynaecologists’, and ‘some women doctors of standing were also included’; sixty-five had been returned. The questionnaires revealed that medical men and women who approved of birth control were three times more numerous than those who disapproved, and condoms came out as the ‘favourite’ method of birth control. By providing an overview of his inquiry and sharing the results at the international conference, Millard sought to make the point that ‘it cannot be claimed in the future that the medical profession condemns contraception’. 25
The other contributions by British males referred to doctrinal elements. A resort to the eugenics argument was central to the speech of the famous sexologist and medical practitioner Norman Haire, chief honorary medical officer of the Walworth Women's Welfare Centre, a birth control clinic in central London. He spoke about the ‘sterilisation of the “unfits”’, a negative eugenic measure to prevent their ‘multiplication’. 26 Similarly, Dunlop's paper in the medical session explicitly referred to doctrinal aspects and was entitled ‘A Malthusian view of death rates and on the average duration of life’.
In comparison, the only British medical woman to address the 1922 conference limited her contribution to her personal medical experience of birth control. This attested to a different vision and construction of expertise, foregrounded on facts and applied knowledge rather than on moral considerations. British female doctors were strikingly underrepresented in these conferences. Having only one paper from a British woman does not allow me to make any conclusive or general arguments. However, her contribution, based on medical grounds, appears to be unusual in comparison to the general trend towards moral considerations in the medical session. She limited herself to describing her medical experience, in an attempt to underline the scientific legitimacy of birth control. Frances Huxley delivered a talk on ‘Birth control from the point of view of a woman gynaecologist’. As the title made explicit, her practical experience in Britain formed the core of her paper. She clearly explained that she came to support birth control due to what she found in ‘the course of her work’ and the observation of ‘facts and conditions’. 27 Her use of a neutral scientific vocabulary, such as ‘facts’ and ‘conditions’, helped objectify birth control, reducing the moral components in favour of a scientific, objective and medical approach to the subject. Birth control, after all, explained Huxley ‘is here with us now’, 28 and she called for a ‘rational’ answer from the medical profession. Based on her clinical experience, she advanced three arguments in favour of birth control. First, the self-determination of married couples to decide upon their family size: ‘it is they who are responsible for the wellbeing of their children, and it is they alone who can judge their sexual needs’. 29 She presented the knowledge of birth control as a ‘right’: ‘it is the right of every married couple to know, if they wish to know, how best to regulate the size of their family’. Secondly, she urged her listeners not to label birth control as an antinatalist measure, as she asserted that married women from all classes wanted more than one child, and that ‘birth control will not alter this’. 30 Third, she turned to medical considerations on the advantage of spacing births for the health of the mother, irrespective of her social class, thus mirroring a shift in the understanding of birth control away from eugenic and moral considerations towards individual welfare: ‘a woman has the right to expect to be as well after the birth of her family, as before it’. 31 Huxley specifically stressed the benefit of birth control for working-class women, who were generally ignorant of birth control, which resulted in the bad health of both the mother and the child. In support of her claim she presented the example of a ‘woman of thirty-six, looking forty-six, who has had twelve confinements and three miscarriages, seven children now living. She has never time to recover from one confinement before the next is upon her.’ 32
She then turned to the methods available. Discouraging coitus interruptus, she advocated four requirements for the choice of birth control methods: ‘to be ideal the methods used should be aesthetic, safe, harmless and inexpensive […] and precautions should be taken by the wife’. 33 (The word ‘aesthetic’ refers to the notion that contraception should not disturb intercourse due to any odour or the mode of application. 34 ) These recommendations would later form the basis for birth control clinics, reflecting the medical expertise of Frances Huxley which anticipated the main leitmotiv of scientific recommendation of birth control. By giving responsibility to the wife, Frances Huxley nonetheless recognised women as sexually active agents. She ended her speech by calling for further ‘scientific investigation’ into birth control methods.
What is compelling in Huxley's speech is her reference to her medical experience. She was able to use experience gained at the national level and to turn it into an asset for legitimising birth control on medical grounds at the international level, to a male-dominated audience. Thus, the ‘feminine’ domain of expertise made women doctors not only particularly aware of their patients’ concerns about additional pregnancies, but also well equipped and qualified to deal with this problem in a scientific manner at international conferences. Moreover, while the title of her talk did refer to her gender, she only presented ‘objective’ and medical facts to support birth control, and clearly put forward the health of the mother as the main reason for birth control. However, her position was marginal in the 1922 medical session since a resolution was taken that underlined the eugenic character of birth control despite acknowledging the medical responsibility for birth control issues: ‘Birth control instruction should become part of the recognised duty of [the] medical profession, and such instruction should especially be given at all hospital and public health centres to which the poorest class and those suffering hereditary disease or defectiveness applies for relief …’. 35 Only in 1930, when British women doctors were becoming the leading figures in the birth control movement at the national level, were they also able to influence the debates at the international level.
Finally, the last session on contraception was chaired by Haire. This session was private and reserved for members of the medical profession, showing that information on techniques of contraception was thought to be within the realm of doctors alone. This session was attended by 164 members of the medical profession. 36 Haire read a paper on contraceptive techniques. He first denounced the medical profession's neglect of the issue, which, he argued, resulted in failure to help women avoid pregnancy as the appropriate means to do so were not being described and explained; this failure, he maintained, ‘opened the way for the quacks and charlatans’. 37 Haire was assuredly reacting to the commercialisation of contraceptive powders and devices by laypeople. 38 He concentrated on the advantages and disadvantages of different methods of birth control, stating that ‘all methods but one are faulty’, 39 praising the Dutch Mensinga pessary, which he claimed he had introduced into England. He underscored the necessity of the device being fitted by a medical professional for correct choice of size, which ensured protection, therefore placing birth control under medical responsibility. He also recommended permanent sterilisation for people considered unfit for parenthood, who might ‘contaminate the race’, testifying to his eugenic ideology. He urged the medical profession to undertake ‘research and experiment’ in the field of contraception and called for the opening of birth control clinics. Frances Huxley participated in the debate that followed Haire's presentation, showing the expert position she held on the subject. She put forward the necessity of recommending methods that were efficient both for the wife and the husband. She explained that she prescribed condoms, but so far had not had the opportunity to try the female pessary. However, she held the view that women who wanted to use birth control should have personal help, ‘because the anatomical structure is so different in different women’. She questioned the accuracy of Haire's affirmation of the reliability of the Dutch pessary, arguing, ‘I should have thought there was sufficient gap there (between the rim and symphysis) to be a danger to the patient, although Dr Haire says it is not.’ She put efficiency, reliability and harmlessness at the centre of her argument, testifying to her concern about providing couples with efficient ways to avoid pregnancies. This concern was undoubtedly dictated by her patients’ needs.
The Sixth International Neo-Malthusian and Birth Control Conference was organised by Margaret Sanger and held in New York in 1925. Again, birth control was directly associated with eugenics. The French jurist, anthropologist and racial eugenic theorist Georges Vacher de Lapouge gave a paper entitled ‘Eugenic birthrate for France’. The British physician, sexologist and social reformer Havelock Ellis delivered a talk on ‘The evolutionary meaning of birth control’, while Norman Haire spoke on ‘Health aspects of birth control’. In his talk, Haire referred to the necessity of preventing unhealthy parents from reproducing, via birth control advice. While his views were embedded in eugenic ideology, he nevertheless placed birth control under the sole responsibility of the medical profession and called for the provision of birth control advice in ‘every hospital, every dispensary, every asylum and every welfare centre’. 40 There were no British or French female doctors in this session.
1930: birth control as a (female) medical responsibility
By 1930, a change in argumentation was noticeable at the international level; there was a detachment from the doctrinal perspective of eugenic and neo-Malthusian considerations of global welfare in favour of scientific objectivity, where facts and evidence were central. Thus, a process of medicalisation of birth control was under way. Women doctors played an influential role in this shift. Apart from British ones, prominent voices among female doctors came from the American doctor Hannah Stone, close friend of Margaret Sanger and in charge of the New York Birth Control Clinic, Dr Rachel Yarros, a gynaecologist, social hygienist and director of the Illinois Birth Control League who opened the second birth control clinic at Hull House, and German doctors such as the physician, abortion activist and founding member of the German Birth Control Committee Martha Ruben-Wolf, and the member of the Frankfurt Advice Bureau Dr Lotte Fink.
This process was made visible at the seventh International Birth Control Conference held in Zurich in 1930, organised by Margaret Sanger. In preparation for the event, Sanger asked every national birth control movement to fill in a questionnaire ‘relating to the methods and organisation of birth control clinics’. 41 The questionnaire covered the history of the clinics, the number of patients admitted, the marital situation of the patients and the practical running of the clinic (who prescribed and then instructed birth control methods, the types of methods prescribed and the number of failures for each method, as well as the follow-up policy). This conference was one of the first to categorise birth control as an international health measure which was part of preventive medicine. Sanger triumphantly underscored the radicalism and the international dimension of this gathering, as shown by the following quote from her introduction of the proceedings of the edited collection:
On September 1, 1930, an earnest group of experts – men and women – from various parts of the civilised world gathered quietly together in Zurich, Switzerland. These men and women were delegates to the Seventh International Birth Control Conference. They came together in the interest of the scientific quest for contraceptive knowledge. For 5 days, more than one hundred scientists, physicians and clinicians discussed the technical problems of contraception. They compared notes, reported progress made in research laboratories and birth control clinics, and proved beyond doubt that the much troubled subject now universally known as Birth Control had entered a new phase of development. 42
She drew attention to the unprecedented aspect of the meeting by saying that the ‘Zurich conference represents a milestone in the history of modern civilization’. Moreover, she flagged up the new direction taken by the science of medicine from the ‘art of curing to the art of prevention’. 43 In this new paradigm, birth control had to play a vital role in improving the conditions of life.
Experts framed birth control as a medical responsibility through the use of scientific vocabulary and by focusing on its practical aspects. The 1930 conference covered four themes, among which three were indicative of this new ‘medical’ and scientific orientation: reports from birth control leagues and clinics; contraceptive devices and techniques; and birth control in relation to the health and economic conditions of men, women and children. 44 The titles of the papers also reflected this process of medicalisation. Among the 130 physicians, clinicians and researchers who attended the 1930 sessions, the eugenicist C. P. Blacker spoke on the ‘Need for research on contraception’; the British specialist in spermicide, Dr Cecil Voge, talked about ‘Future research upon sterilisation and contraception’; and Dr John Baker, another British specialist in spermicide, delivered a paper on ‘Chemical contraceptive’. These three male experts were all members of the BCIC and spoke on the research aspect of birth control. Women doctors, as we shall see, focused on their practical experience in working in birth control clinics, and, as I have shown in Chapter 1, acted as liaisons between research carried out in the laboratory and patients’ experiences with contraceptive methods.
The conference clearly defined birth control as a medical subject by stating that it was the first birth control symposium to focus on ‘practical, medical, and scientific considerations of birth control’. Even though one can still find traces of eugenic rhetoric, especially from the male doctors’ contributions, 45 this conference aspired to remove such doctrine by emphasising ‘the impersonal and scientific abstraction’ 46 of the issue. It is worth remembering that contraception was not part of any medical training in either country until long after the Second World War (see Chapter 1 for Britain). Thus, it is not surprising that the only way to inform medical considerations on birth control was to rely on the practical experience of doctors dealing with the issue in their individual exercise of medicine; these were predominantly women doctors.
The fact that the practical aspects of birth control as reported ‘by those actively engaged in the movement’ 47 were the focus of the Zurich conference meant that numerous women were present and taking an active part in the medical debate on birth control. Until then, male scientists dominated the conferences in terms of both number and the orientations of the debates. Thus, this medicalisation process opened the door for women doctors’ involvement at international conferences, as they were the experts in the practical aspects of birth control. Indeed, as shown in the previous chapters, the majority of British birth control clinic workers who dealt with the day-to-day aspects of birth control were female. This was also the case in Germany, and German women doctors were also present in great numbers. The experience acquired at the national level constituted a valuable source of knowledge of contraception that women doctors used to position themselves as experts at the international level. In addition, male experts increasingly described contraception as a female medical responsibility. The American obstetrician and birth control advocate Robert L. Dickinson urged women to be involved in birth control activism since the issue was a feminine one, relying upon gendered expertise: ‘In the past, a few physicians and a number of prominent masculine thinkers have been advocates for birth control. But in a movement for mercy for mothers, and particularly in urgency for widespread practical application, the vigorous leaders have to be women: mothers, nurses, scientists, social workers, women doctors.’ 48 The majority of the women doctors that attended the 1930 conference were working in birth control clinics and were also members of the MWF, such as Dr Helena Wright and Dr Joan Malleson. 49 Whereas the individual members of the MWF increasingly supported birth control, especially from the mid-1920s onwards, the organisation as a whole ‘maintained a somewhat cautious attitude towards this increased dissemination of contraceptive knowledge’. 50 The following examples illustrate this new role of women doctors as legitimate experts and agents of knowledge transfer on birth control. British women doctors and laywomen speaking on behalf of the birth control clinic staff medicalised contraception in different ways.
First, they placed contraception under the medical flag by affirming that a medical consultation and supervision were necessary and essential steps for choosing an appropriate method. For instance, the lay birth control activist Flora Blumberg, who introduced the audience to the work carried out in the Salford clinic in Manchester, insisted that a female doctor was in charge of seeing the patient and performed a thorough vaginal examination with the help of the speculum. The use of the speculum had been advocated by Wright (see Chapter 1) to spot any abnormalities or diseases that could affect the choice of method. Similarly, Evelyn Fuller, the secretary of the Society for the Provision of Birth Control Clinics, explained that in each of the association's centres, every patient ‘was given a gynaecological examination by a woman doctor’. 51 This requirement was aimed at boosting women doctors’ professional standing and framing contraception as a technical medical specialty.
Female speakers also discussed in great detail the advantages and disadvantages of various methods of birth control. For instance, one of the most prominent birth control activists in Britain, Wright, discussed the presentation given by Dr Ernest Gräfenberg, a German scientist, on the intrauterine device. 52 Her speech at the international conference revealed her engagement with the production and assessment of scientific knowledge about birth control and her willingness to learn new methods. As I will show in Chapter 5, she met Ernest Gräfenberg in Berlin. She then started to study the use of the Gräfenberg ring in her own private practice in England, fitting patients with this contraceptive device, and thus translating the knowledge she gained from him into practical research. She presented her first results based on a case study of fifteen patients she had fitted with the Gräfenberg ring. She then asked Gräfenberg questions about the difficulties she had encountered when placing the ring into the vagina, showing her interest in improving the method. Taking into account the different knowledge she acquired, Wright continued her research and published her results in 1931. 53 She also presented two papers, ‘Notes on the North Kensington Women's Welfare Centre’ and ‘Indication for the use of the Dumas and Prorace cervical caps’. Based on her own practical medical experience, she elaborated on the advantages and inconveniences of these methods, their effectiveness and the possible problems one could encounter when placing Dumas and Prorace cervical caps. Here again, she articulated her description in scientific and medical terms:
The cap lies in the roof of the vagina with its concavity upwards. The circular ring fits closely to the vaginal mucous membrane just outside the circle of the upper limit of the intravaginal part of the cervix, and therefore occupies all four fornices. The mucous membrane surrounding the external os uteri should not be in contact with the dome of the cap. 54
Several other women doctors also conveyed observations they gained from their practical work and shared advice on the best way to insert a cap, using diagrams to illustrate their explanations. Chief among them was the American Dr Hannah Stone, who worked closely with Margaret Sanger.
In addition to describing methods of birth control, women doctors provided statistics based on clinic records and case cards. The latter served the purpose of challenging the assumption that use of contraceptives led to sterility, but it was also a means of showing the extent of their accumulative experience and asserting their authority and expertise on the matter. For instance, Evelyn Fuller reminded the audience that methods prescribed at the centre did not cause permanent sterility. To support her statement she referred to the ‘many cases in which the patients have deliberately conceived after a long period of using the appliances’. 55 A member of the MWF, Dr Lily Butler, gave a talk on her work at the Walworth and East London clinics, focusing on the failure of contraceptive methods, based on the 7,000 cases of patients attending the clinics between 1921 and 1927. She said that 3,596 patients failed to report and 2,893 had ‘been successful with the appliance recommended’, and then provided insights into the reasons why the other women failed to apply the methods. 56
These statistics reveal that there existed no methods of birth control that were truly reliable. Consequently, while acknowledging the significance of gathering statistics for the basis of research, Fuller nevertheless warned against too much effort wasted on their collection and too much reliance on their accuracy. There were different definitions of the term ‘failure’ across the centres, and therefore the lack of a common denominator did not allow for definitive results. She suggested instead that there was an urgent need for ‘further research work’. She used the international platform to call for an effort to be made towards discovering the ideal contraceptive: ‘The results we hope for from this world wide conference is that an impetus be given to the search for the ideal contraceptive.’ Such a contraceptive should be ‘aesthetically suitable’, reliable, simple and inexpensive. She painted this search as a feminist imperative to ‘place within every woman's reach the power to control her own destiny’. 57 This use of language suffused with medical terminology, combined with a scientific precision in describing the diverse methods of birth control, contributed to positioning women doctors as active and legitimate agents in the handling of birth control issues and the shaping of production of sexual scientific knowledge at the national and international levels.
In addition, British female doctors paid great attention to the experience of their patients with birth control, showing the amount of practical experience they gained from being in direct contact with this subject in their own offices or at birth control clinics. Furthermore, this reveals their commitment to putting individual welfare at the centre of the birth control issue. For example, during the 1930 conference, Helena Wright commented on Baker's paper on ‘chemical contraceptives’ with regard to applied experience with her patients of a laboratory-based study carried out on guinea pigs. During her comment, she referred to patients’ concerns and experiences. Adopting the ‘point of view of poor patients’ 58 who did not have running water, she recommended the use of a specific spermicide that did not require women ‘to douche when using it […] the pellet costs the patient just about one penny each’. 59 Meanwhile, Lily Butler justified the follow-up appointment with patients after their first visit by referencing their vulnerable psychological situation during their examination, since they were ‘nervous and frightened’. 60 Thus, a second visit appeared to be the best way to ascertain that the patients understood the instructions given to them. Similarly, Evelyn Fuller pointed out the centrality of the patient in the way the work is carried out: ‘the desire to meet the patients’ point of view is one of our guiding principles. The main thing is to get the confidence of the women – to treat them not as so “many cases” but as individual human beings to whom a knowledge on birth control is a matter of vital and urgent importance.’ 61 Interestingly, Fuller also called for patients not to be used ‘experimentally as test cases’ for new contraceptives, putting the emphasis on the fact that the factor of paramount importance for the patient who attended the clinic was that they should not conceive, and therefore only the most reliable contraceptive should be prescribed to them. Flora Blumberg also drew attention to the relationship between patients and doctors. She explained that women doctors dealt with patients with ‘great patience and care’. 62
Thus, this conference provided the ideal platform for sharing the latest updates on birth control methods and practical experiences among practitioners, and especially among women doctors. Here women doctors functioned as agents of the transfer of knowledge about birth control between the national and international spheres. As such, they helped to develop a system of legitimate knowledge of the effects of contraception on the female body. The method on which they seemed to reach a consensus was the combined use of mechanical devices preventing contact between sperm and egg, such as a diaphragm or a cervical cap, and chemical spermicide substances. These methods were to be the responsibility of the female patients, as these female doctors wanted to give women control over their reproductive functions.
The knowledge that British women doctors gained at the international level was brought back to Britain, where it nurtured their own work. They enabled the circulation of contraceptive knowledge by drawing on international scientific research in the medical manuals they published. For instance, Dr Gladys Cox referred to the presentations of other doctors made at the Zurich international conferences, such as Dr Hans Hehfeldt from Berlin, on the advantage of the cap in her handbook on contraception. 63 She also displayed four diagrams on the adjustment of the diaphragm pessary that she had borrowed from Dr Hannah Stone. She was not the only one to make use of Stone's work. Dr Joan Malleson extensively quoted data collected in birth control clinics in Britain, but also drew on the work of other scientists, Stone in particular, to support her demonstration of the harmlessness of birth control to fertility. With these references to other works, she showed her awareness and knowledge of contemporaneous international debates on this topic.
French versus British women doctors: 1934–7
The close analysis of British and French women doctors’ positions on birth control at the 1934 international conference offers a valuable lens through which to assess the impact of the national context. One prior assumption is that French and British women doctors would have shared similar views on birth control due to their shared understanding of the female body. But national reproductive politics and women's previous engagement played a determinant role in shaping French women doctors’ views on birth control. Whereas British women doctors were involved in the running of the clinics – and many of them held feminist stances, given that they sought to advance knowledge on contraception to give women power and control over their reproduction – this was not the case in France. In a context of lacking political representation, the French feminist movement, mainly reformist and familial, tended to fight for causes in line with the mainstream political agenda (motherhood as a social duty) to rally male politicians to support women's enfranchisement. 64 In addition, campaigning for birth control, an action prohibited at home though not at international conferences, was at odds with the mainstream political involvement of many women doctors in familial feminism, as I show.
The 1934 conference brought together the national branches of the MWF, and delegates from member countries took part in the event. Anna Louise McIlroy, Professor of Obstetrics and Gynaecology at the Royal Free Hospital, University of London, presented a report on birth control based on the answers to the questionnaire sent by the MWIA to members for Britain, the US, New Zealand and India. 65 Out of the thirteen British contributors to the report, eight were already involved with the birth control issue. Of these, those previously discussed in this book include Dr Lily Butler, Dr Helena Wright and Dr Frances Huxley; other contributors were the general practitioner Dr Annis Gillie, member of the Royal College of Physicians and later member of the executive committee of the Family Planning Association; Dr Olive Gimson, appointed doctor at the Manchester, Salford and District Mothers’ Clinic in 1926 and at the birth control clinic at Withington Hospital in 1931; 66 Dr Mary Macaulay, medical officer for the Liverpool branch of the National Birth Control Association; Dr Lilias Jeffries, general practitioner and gynaecologist at the New Sussex Hospital in Brighton; and Dr Louisa Martindale, British physician and surgeon and Fellow of the Royal College of Obstetricians. McIlroy and Martindale had a more traditional attitude towards birth control than their colleagues, due to their adherence to social purity feminism. A late nineteenth-century construct, the social purity movement aimed at eradicating prostitution and the sexual double standard. It was a movement that sought to elevate morality from a Christian perspective and improve the sexual treatment of women by advocating for sexual restraint. In 1921, Martindale delivered a talk on birth control to the London Association of the Medical Women's Federation, where she expressed her anxiety that birth control risked ‘encouraging sexual excess and the possibility of eventual sterility’. Her talk was in line with social purity feminists that considered women to be less sexual and consequently morally superior to men. Similarly, McIlroy, who testified in favour of the Catholic doctor Halliday Sutherland during his trial for libel against Marie Stopes in 1923, also belonged to the social purity feminists. In the special issue on birth control published in The Practitioner in 1923, she wrote that contraceptives ‘will not bring to women freedom but worse slavery in sexual matters, for they will remain the instruments of men's uncontrolled desires’. 67
For the French report, Dr Denise Blanchier explained that only 15 of 300 members of the French Association (5 per cent) answered the questionnaire about birth control from the MWIA. She completed the report using answers from thirty-one male doctors, gynaecologists and psychiatrists. The national difference here is noticeable. French women doctors did not refer to their position as women doctors only, and indeed sought the opinion of their male colleagues, suggesting that birth control was not perceived as a female medical responsibility in France. This situation reflected both the absence of training on the subject for these women and the power relationship within the French medical profession and more broadly in French society, where women were not enfranchised.
What is clear from the French report is that the French branch would not have approached this subject if it were not for this international conference. Indeed, due to the 1920 law, French women doctors could not have addressed the subject of birth control publicly. Thus, it was ‘under constraint’ that the national French branch was ‘forced’ to address this issue. As Blanchier explained, she struggled to obtain answers from physicians, possibly because they were afraid of getting into trouble with the law, and was able to do so only when she presented the subject as a foreign one, imposed by foreign branches from countries where the movement for birth control was already widespread. 68 Moreover, she added that the term ‘birth control’ was difficult to translate into the French language due to its foreign etymology and foreign meaning, which were unknown to the French way of thinking. She used the British word ‘birth control’ alongside ‘prophylaxis anticonceptionnelle’ in the French report. 69 Notwithstanding this attempt to distance the term ‘birth control’ from the French experience, the conference did give the French branch the opportunity to understand the birth control movement. Dr Germaine Montreuil-Strauss, president of the French association, wrote a historical report on the evolution of birth control. 70 In a neutral style, she presented the arguments for and against birth control. Since more than half of the article was devoted to introducing French members to the work of the birth control movement in Britain and the wide range of support it received, one could argue that the tone of the report was positive; this long historical introduction might be perceived as an attempt to overcome the 1920 law. Though her historical presentation was politically and morally neutral and scientific, she nonetheless familiarised women doctors with the issue of birth control, providing them with arguments to support the movement.
Secondly, the French report did not follow the recommendation to leave moral and political aspects out of the debates. The questionnaire recommended focusing only on the physiological and medical point of view in order to avoid any ‘political and religious controversy’. 71 In its introduction, for instance, the French report underlined the ‘tendentious character’ 72 of the questionnaire, perceived as being in favour either of a feminism ‘that allowed women to live a free sexual life without any dangers as do men’ 73 or of licentious propaganda that led to ‘ethnic national suicide and moral depravation’. 74 Both qualifications were negatively depicted and reflected the fears of depopulation that pervaded the French elite. In addition, sexual relations, in the Catholic context, were meant for procreation and not for pleasure. Separating sexuality and reproduction was condemned by the Catholic Church. Furthermore, the report clearly stated that hygiene and morals could not be distinguished: ‘one can only advise a woman, in the name of hygiene, of the two alternatives to sexual life that are not anti-biological: motherhood or chastity’. 75 These positions were again in line with those of the Catholic Church, reflecting the possible influence of the latter, and more broadly with those of the conservative position of the French association. 76 Indeed, historian Anne Cova has shown the involvement of women, and among them women doctors, in the natalist movement, and she has shown how Catholic women were at the forefront of the interwar development of family policy. 77 However, this position was not shared by all women doctors; Blanchier reported having noticed a slight difference between the answers from female and male doctors, with women tending to be more tolerant of birth control when it came to protecting the individual well-being of a child. She attributed their answer to ‘maternal nature’. 78 Thus, an essentialist vision of motherhood permeated this report. This is not surprising given the fact that many French women doctors were part of the ‘familial’ feminist movement.
Historian Karen Offen defined familial feminism as a type of feminism that ‘predicated a biologically differentiated, family-centred vision of male–female complementarity’. 79 Thus, familial feminists tended to emphasise motherhood as a social duty. In addition, French women doctors were active in advancing social and familial reforms in the interwar years, and played an important role in the fight against venereal disease. For instance, many French women doctors were members of familial associations – associations that fought for the defence of the family and familial Christian values. Denise Blanchier and Germaine Montreuil-Strauss were members of the Committee for Female Education of the French Society for Sanitary and Moral Prophylaxis, a group that promoted sex education as a way to fight venereal diseases through ‘biological education for maternity’; 80 Denise Blanchier and Dr Madeleine Thuillier-Landry belonged to the National Committee for Childhood, a committee promoting child hygiene; and from 1936 Denise Blanchier was a member of Medicine and Family, an association bringing together parents of numerous children. 81 Although many female doctors were involved in providing sex education to young women after the First World War through the Committee of Female Education, the topic of contraception was never approached. 82 Women doctors were absent from the debate on birth control during the interwar years, with the notable exception of the radical feminist Dr Madeleine Pelletier, who advocated abortion and birth control. 83 This familialist feminist orientation of the association was clearly stated in the French report. In fact Blanchier negatively referred to the feminist ‘emancipatory rhetoric’ supporting birth control, while emphasising that ‘we do not accept this definition of feminism’. 84 Apart from being part of the familialist feminist movement that supported natalist policy, French women doctors, as suggested by historian Yvonne Knibiehler, might have tried to secure their respectability in the battle for access to medical positions by holding natalist stances. 85 In this context, campaigning for an immoral subject such as birth control might have been perceived as an obstacle to achieving this. 86 Thus, this essentialist vision of motherhood has to be understood as part of their position within the French medical scale and society.
Only one remark on the ‘maternal nature’ was found in the British report and unsurprisingly came from Martindale. She maintained that ‘maternity is the normal and natural state for women and if well taken care of there is physiological benefit’. 87 Despite this essentialist vision, the conclusion of the British report advised ‘the use of contraceptives in the case of married women, who because of social and economic stress are unable to rear their children in a condition of health and happiness’. 88 In addition, chastity, while strongly recommended before marriage, was described as non-natural after marriage as it could lead to neuroses. Furthermore, British medical women kept to the practical aspects of the subject of birth control and based their observations on their own professional experience.
Thirdly, judgements about the medical effects of birth control practices on the female body differed between the French and British reports. In the former, birth control practices were in general depicted as both inefficient and dangerous. Going against biological laws or the ‘law of nature’ (maternity) was ‘anti-medical’, since maternity was beneficial for ‘the normal female organism’. 89 For Blanchier, this argument should have convinced doctors to refrain from considering contraception as part of ‘hygiene’ to be taught to healthy individuals. She drew on the pronatalist argument to reject the idea of creating birth control clinics, arguing for encouraging births in a context of declining fertility. 90 British doctors, meanwhile, recommended the combination of either the male condom or the Dutch rubber vaginal cap with a spermicidal jelly – with a slight preference for the latter. This recommendation was in line with the conclusions of the Zurich conference but also reflected the strong preference for female-controlled devices in birth control clinics in England. British women doctors put forward the autonomy of women as the main advantage of the Dutch rubber vaginal cap: ‘Easy to insert and remove by the woman herself when taught properly […] Can be used by woman without cooperation of the husband’. 91 Thus, through these advantages, women doctors placed responsibility for birth control in women's hands. This autonomous rhetoric was not surprising in a context of enfranchised working women doctors who were used to working in birth control clinics created to give every woman control over her own fertility. 92 These feminist British women doctors drew upon psychology and patients’ individual experiences to support their stance, stressing the psychological benefits of birth control for individuals. For instance, a specialist in psychological medicine, Dr Doris Odlum, ‘very rarely found the use of contraceptives harmful as the relief from the fear of pregnancy is so beneficial’. 93 In her feminist opinion, women had a right to pleasure, and relieving them from the anxiety of pregnancy encouraged sexual satisfaction: ‘In women, orgasm is slower than in men and intercourse is, therefore, distasteful if no satisfaction is obtained. It is of the greatest importance physiologically that all conscious or unconscious anxiety should be removed during coitus.’ 94
Fourthly, the conclusions of the reports differed between the two countries. In the French report, women doctors agreed not to present a conclusion officially because of the divergent opinions among the medical body, but most probably because of the 1920 law. This testifies to two things, namely the lack of agency of French women doctors, who were unable to speak openly on the subject, even though some of them were clearly in favour of spreading information on birth control, and the adherence of French doctors to familial feminism. In the British report, a majority of women doctors were in favour of birth control and called for the integration of this subject into medical curricula and the development of scientific research to find a cheap and reliable method of contraception that was accessible to women of all social classes. The only female doctor who expressed some form of hesitation was Martindale, and this was not surprising given her previous stance on birth control and her adherence to social purity feminism.
Two similarities in the reports deserve to be mentioned. The first is that female doctors from both countries disapproved of public propaganda, feeling that birth control should remain within the scope of the medical body. The other similarity was that sterilisation and abortion received little attention in either report. Although birth control was thought to reduce the number of abortions according to both reports, women doctors tried to distinguish birth control from abortion. French women doctors were, nonetheless, reluctant to recommend the prescription of birth control methods, presumably for fear of legal consequences linked with the 1920 law. They appeared over-determined by the legal context but also by lack of suffrage and civil power.
Contrastingly, the issue of abortion was debated at length in 1937 at the Edinburgh conference. The theme was suggested by the British branch; abortion was topical in Britain at the time, notably due to the inquiries on maternal mortality commissioned by the Minister of Health in 1932 and 1937. The latter had led to the establishment of an interdepartmental committee on abortion by the Home Office and the Ministry of Health. 95 Here again, the French position remained highly traditional and familial compared to the British one. The questionnaire devised for the conference addressed the legal situation in each country and public opinion on this contentious issue. The French report, written by Dr Anchel-Bach, the former chief of the obstetrics clinic in Paris, underlined that while therapeutic abortion was legally forbidden, exceptions were made when the mother's life was endangered by an additional pregnancy. In that case, doctors were held morally responsible for making the decision and undertaking the procedure. Anchel-Bach contended that public opinion supported abortive procedures when the mother's health was in danger. However, she added that ‘the medical pretext served as a screen for the desire to have an abortion’, 96 betraying the conservative views shared by the majority of the pronatalist medical profession, who depicted abortion as an abominable practice and denied women the agency of making their own informed decisions. The report nevertheless suggested that the law should be changed, if only for medical reasons, to grant immunity to women who undertook illegal abortions so that women in need of medical help would no longer be afraid of seeking it, and to prosecute only the abortionists. The British report, written by Janet Campbell, senior medical officer at the Ministry of Health, in contrast, showed how much more tolerant British female doctors and British public opinion were towards the practice. The report explained that while abortion was unlawful, therapeutic abortion could be obtained with ‘no difficulty’ 97 when it was ‘genuinely needed on medical grounds’. Public opinion could be divided between two ‘extremes of opinion’: Catholics, who regarded abortion as a sin, and people who considered that a woman ‘has a right to decide for herself whether or not she will bear a child or terminate her pregnancy’.
The French and British means for reducing the number of illegal abortions and their related casualties diverged from one another, reflecting again the legal, religious and political conditions of each country and, moreover, the familial inclination of French doctors who suggested pronatalist solutions to illegal abortion. French women doctors advocated three means. First and foremost, they foregrounded the necessity to address the main causes of abortion, namely poverty, the social conditions in which women found themselves, and the selfishness shown by rich and well-off families, by developing appropriate policies to support single, unmarried and poor women and their families. The second way they proposed to limit illegal abortions was to spread information among the public on their dreadful consequences and dangers, and the third was to apply the law on the matter with rigour and severity. No mention was made of any form of information on birth control, not even natural methods. In stark contrast, British women doctors asserted the necessity of educating wife and husband on birth control, since ‘successful contraception is a positive means of reducing the incidence of illegal abortions’. 98 Educating the public on the danger of abortion was also credited, as well as the need to encourage women in difficult situations to seek postnatal advice. These considerations indicated that British women doctors did not consider abortion as a means of birth control, but as a last resort procedure that could be avoided by adequate teaching of birth control to married people. Although British women doctors appeared more liberal than their French counterparts, they remained nevertheless limited by the traditional framework of the married couple, ignoring the significant number of abortion-seekers that were unmarried young girls.
In the interwar years, British women doctors, although not numerous in the medical field, were transnational agents for the legitimacy of birth control. In the national medical field, as shown in Chapter 1, they tried to make birth control a new specialty of medicine by opening clinics, fitting individuals with contraceptive devices and writing scientific articles. Empowered by this experience grounded in their daily practice of medicine, they were vocal on the international scene and tried to medicalise birth control. While birth control tended to be framed in eugenic or neo-Malthusian terms by male doctors before 1930, it gradually became a medical subject in which scientific vocabulary and individual welfare predominated. Women doctors played a major role in bringing about this shift. The international conferences on birth control and population issues positioned women as experts in this medical field, but also revealed national differences. While British women doctors acquired recognition for their work at an international level and shaped the debate in favour of the more practical and medical aspects of birth control from the 1930s onwards, French women doctors, by contrast, were either absent from those debates or publicly aligned themselves with the politically sanctioned and legally safe pronatalist stances of their male colleagues. This difference could be explained by the lack of practical experience of the latter about contraception due to the 1920 law. In France, it would have been extremely difficult for French women doctors to publicly support the birth control movement without risking legal consequences, including imprisonment. Another significant element is their engagement with familialist associations that fought social scourges such as venereal disease. As members of familialist feminist associations, French women doctors adopted natalist stances. Thus, the two different conceptions of feminism and population policy and reproductive health greatly contributed to positioning British women as comparative leaders in reproductive knowledge.