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.
I am writing about an important uncertainty affecting many women doctors working in family planning. As you will no doubt be aware many of us have acquired over the years considerable expertise in this field and there seems to be a strong possibility in light of the government proposals that this work will largely be taken over by General Practitioners of very varied training in family planning and of course mostly male.
It is also true that some hospitals are opening Birth Control Clinics but in many instances these are staffed by registrars who are birds of passage and incidentally again mainly male.
One outcome of these changes is that an important source of work for women doctors, and one … which they are ideally qualified to undertake, many being wives and mothers, will be closed. I feel it is important that the MWF should approach the British Medical Association and also make representations to the department of Health and Social Security about the uncertain future many of us now face.
There are about 1,900 doctors, mostly women, in the FPA and one suspects that if there were to be any suggestions of the work of a similar number of male doctors being in jeopardy, very strong representations would be made. I would be grateful if you could place this letter before the next committee meeting of the MWF. 1
In 1967, Labour MP Edwin Brook's Family Planning Act allowed local authorities to provide birth control to all women, married or single; in the same year, the Abortion Act legalised abortion by registered practitioners in Britain. On the other side of the channel, French authorities revoked the 1920 law and authorised the provision of contraceptives. In 1974, contraception became free under the NHS in Britain. These new laws were the culmination of long battles fought by British women doctors in Britain, and indirectly in France. But they nevertheless opened up a new front on struggles for control of female bodies that would later be denounced by feminists: the increasing burden on women to control their own fertility, the extensive power given to the predominantly male doctors in reproductive health, and the threat this power posed to the women doctors who staffed family planning clinics. The letter of a female doctor and member of the Medical Women's Federation reproduced at the beginning of this conclusion vividly illustrates the concerns that this power provoked among organised female doctors.
Women doctors played a key role in the provision of contraception and family planning advice in the decades preceding the introduction of these new laws. Highlighting their role, and the social context, networks, opportunities and constraints faced by women doctors, helps to challenge two types of narratives: the negative narrative of medicalisation as an oppressive process and the celebratory narrative of progress and scientific discovery underpinning the idea of sexual liberalisation. In so doing, this book adds to a growing body of research that has cast doubt on the notion of a linear process of emancipation or liberalisation. 2 Moreover, this study is part of a burgeoning field of research on the history of birth control practices and sexuality, and on the leading international role of women during the twentieth century. 3 It has shed light on the lived experiences of women doctors and their scientific contributions to birth control and family planning, as well as the many ways through which women doctors developed knowledge on this subject and shaped the national and international debates around it.
Most feminist historical analyses have depicted the medicalisation of the female body during the twentieth century as an exercise of the power of male doctors over their female patients. The medicalisation process in England only partially matches this description. Women doctors actively contributed to it. They did so with a view to empowering women to avoid pregnancies and adopt female-oriented methods of birth control. But they also aspired to take these issues away from the moralists; instead, birth control, contraception and family planning were to be regarded as medical fields of research and practice in which female doctors would be central actors. By engaging medically with this topic and entering the field in large numbers, women doctors were trying to secure territory for themselves. Despite a feminist sensitivity to and awareness of their patients’ needs, they were nevertheless wielding authority over the female body.
At the national level, women doctors tirelessly advocated for access to contraception and reliable methods of birth control. They did so despite the opposition of the majority of the medical profession. In addition, they harnessed the public and specialised discourses around the quality and quantity of the population by bringing to the fore the medical side of birth control. Furthermore, women doctors were instrumental in challenging the moral arguments against birth control. By participating actively in debates at national conferences and in scientific publications, a small group of vocal women doctors developed arguments running counter to common assumptions about the negative effects of contraceptives on women's fertility and the state of the nation. Drawing on their own experience in birth control clinics, which they used to assert their professional authority, women doctors presented data that established contraception as a cornerstone of preventive medicine, and a driver of women's health and the well-being of the family. They produced scientific knowledge on contraceptive methods that were tested in laboratories based on well-defined scientific criteria. In so doing, women doctors collaborated with eminent scientists who lent their work an air of respectability and gave them the financial support they required, as shown by the example of the testing of the Gräfenberg ring by Helena Wright. British women doctors also forged alliances with famous individuals such as Lord Horder or with scientific bodies they helped to create such as the Birth Control Investigation Committee. This generated support and legitimacy for a field of medicine hitherto considered inferior or marginal. Women doctors were able to exploit opportunities in this area partly because of its low status. They disseminated contraceptive knowledge to a wider audience via books, manuals and scientific articles, as well as training sessions on birth control for medical students and their fellow colleagues. In this way they developed a specific form of communication that favoured technical language when addressing their colleagues; the development of this technical language contributed to medicalising family planning and securing job opportunities by increasing the value of this new field of medicine.
In addition to this active role in the production of contraceptive knowledge and expertise, British women doctors also expanded the notion of family planning and gave it a new meaning. From the mid-1930s onwards, family planning no longer encompassed solely the provision of contraceptive advice, but also advice on sexual disorders and infertility, two new subjects born out of patients’ needs and demands. Helena Wright and Joan Malleson were the forerunners of sexual counselling – compared to their colleagues who wrote and engaged with the issue of sexual pleasure in the 1930s, their approach was nothing short of radical. Wright and Malleson set up sexual counselling sessions centred on female sexual pleasure. They put forward a strong narrative of female emancipation from traditional norms in that they encouraged women to take an active role during sexual intercourse, breaking with the expected passive role of women in sexual relations. Wright called for a revision of gender roles and focused on the importance of the clitoris as the locus for pleasure; Malleson put her patients’ demands at the centre of her work. She used psychological theory to help patients overcome their sexual disorders. Overall, the period between 1935 and 1956 saw women doctors undermining traditional notions of gender roles based on the patriarchal order. However, this radical period proved short-lived: women doctors taking over after Malleson's death in 1956 turned to the formal training available at the Tavistock Clinic, reverting to the traditional vision of sexual roles in the process.
Birth control became a topic intensively debated at the international level in a context where the state of the world's population created many anxieties, between fears of overpopulation and degeneration. Furthermore, population was coming to be framed in terms of struggles for world resources and issues of peace and war. Birth control was therefore presented as a possible solution and a way of maintaining peace. British women doctors participated in debates about the medicalisation of birth control at conferences in the 1920s and 1930s, alongside other famous international figures such as Margaret Sanger. They contributed to positioning birth control as an international health issue. Several British women doctors were able to use the experience they gained from working in birth control clinics as a tool for advancing the cause of birth control at the international level. This book has used international conferences as a lens through which to assess the respective positions of British and French women doctors within their national medical fields and the extent to which divergent political contexts impacted their stances. British and French women doctors were a minority in the male-dominated field of medicine, and while British women doctors became agents of the medicalisation of birth control, French women doctors remained constrained by their political and social contexts and were highly familialist. The experiences of British women doctors and the connections they established in the interwar years were useful elements when it came to reactivating the international movement of birth control after the Second World War and shaping it into planned parenthood. Finally, they also had an influence at the transnational level; for instance, they helped establish family planning centres in France. Britain seems to have been seen as an acceptable and legitimate model on which to base the French family planning movement. By drawing on the experience of a well-organised movement, French doctors found an efficient model and adapted a debate that came from abroad to the French context. In addition, Britain functioned as a hub for training French doctors and as a channel for importing contraceptives into France.
This book has challenged the idea of a progressive liberalisation of birth control. Indeed, women's journey to advance and medicalise the cause of birth control has not been an entirely successful one. Women doctors pressed for the integration of contraception within the medical curriculum, without much success. At the international level, their role in setting up and organising conferences on birth control and family planning was too often obscured by the famous male scientists who chaired these conferences. Thus, women remained in a marginal position within medical hierarchies; family planning centres provided opportunities for women doctors who were married with children to work part-time, but their work conditions were very poor. ‘Sub-fertility’ and sexual counselling were slow to develop, and no formal or compulsory training was instituted until 1974. Furthermore, in the 1960s, sexual counselling was increasingly framed through traditional and gendered roles.
With the advent of the ‘second wave’ of feminism, the widespread adoption of male-controlled forms of contraception was increasingly criticised, as was the medicalisation of women's bodies. 4 What was at first perceived by female doctors as an essential step for women's emancipation would, with the advent of the contraceptive pill and the legalisation of contraception, be increasingly seen as oppressive since general practitioners and gynaecologists, the majority of them male, became the main providers of both mechanical and hormonal contraceptives, i.e. the contraceptive pill, IUDs and sterilisation. In addition, fears arose due to the potentially fatal adverse effects of these new forms of contraception. 5 In this context, feminist health activists denounced the medicalisation of the female body and found alternative forms of medical practices; some were also pressuring the National Health Service to improve the quality of its service for women. 6 Psychiatry and psychology, too, would be called into question by feminists who perceived them as intrinsically misogynist. 7 While there is no doubt that psychology was a powerful tool for controlling and spreading the normative vision of sexual behaviours, this book nevertheless shows that psychological tools could also be used with another agenda in mind: that of giving women control over their sexuality and sexual pleasure, at least in the early form of sexual counselling. But with the advent of the medicalisation of sexuality, through Viagra and other medicines designed to improve sexual performance, a new form of domination has been taking place that no longer denies women the right to pleasure, but on the contrary has made sexual pleasure an imperative that needs to be monitored. 8 As a result, lack of sexual pleasure has become a pathological problem that needs to be addressed through medicine and magic pills; female sexual dysfunctions are today the object of aggressive pharmaceutical campaigns and marketing. 9 Joan Malleson might well have been ahead of her time when she warned against the ‘fallacy’ of over-emphasis on orgasms.
By placing women centre stage in the history of birth control, this research has shed light on the centrality of characters who had until now remained overshadowed by more famous and prestigious advocates of birth control. Precisely because they were marginalised in the medical field, women doctors colonised birth control and developed expertise in a field that was until then deemed illegitimate. This book has argued for the integration of women into histories, be they doctors, nurses or social workers, as active agents in the medicalisation of reproduction. This focus allows for the reconciliation of contradictory narratives of oppression and emancipation. Paying attention to broader national and international political and social contexts, as well as the structural stratification of the field of medicine, makes it possible to rethink a history that has too often lacked nuance.
The story of these women doctors did not end in 1967. Helena Wright retained her fighting spirit and remained a strong voice within reproductive health organisations. She was especially active at the international level with the IPPF; she travelled around the world to teach birth control and visited Sri Lanka in 1974, at the age of 87. She semi-retired in 1975 and died in 1982. Margaret Jackson remains a famous figure in the field of infertility. She practised as a doctor for fifty-three years and continued treating patients until she was 83, helping many infertile couples to have babies. She died in 1987. In honour of her work, a Margaret Jackson Centre was opened in Exeter, in the premises of her private clinic. The centre provides counselling for individuals facing personal difficulties. Sylvia Dawkins pursued her career in the FPA clinic and acted as a sexual counselling group leader. When she retired from the FPA, she continued to lead groups in London and Cambridge. 10 She died in 1996. Prudence Tunnadine continued her engagement in psychosexual counselling and was a founding member of the Institute of Psychosexual Medicine in 1974. She also started her own private practice on Harley Street in 1974.
Today, as I write these concluding remarks, the FPA has been placed into liquidation. These pioneers would have been very sad to see this organisation, for which they relentlessly fought, being closed. Its disappearance means that an important page of the history of reproductive health has now been turned. This closure reminds us how important activism is when it comes to sexual health and how precious and vulnerable our reproductive rights are. This book is dedicated to all the wonderful women doctors who created and worked in this organisation. I hope this book contributes to keeping their spirit alive.