A lot has changed about birth control since you may have first learned about it—and if you’re getting information about birth control from older people in your life (your mom, say) things may have changed even more since they were young. The past few decades have brought new technologies, improvements on old technologies, and in some cases, changes to the legal status of some methods.
In this package, which we’re calling “The State of Your Birth Control,” we bring you up-to-date on your current options—with an emphasis on things that you may have some misconceptions about, due to their history or their context in popular culture.
To get us all on the same page, let’s take a little tour of the history of some of our most popular modern contraceptive methods: where they started, how they developed, and where they are now.
Condoms
Condoms are one of the oldest known forms of birth control, although they weren’t always used for birth control specifically. (One Greek myth has King Minos’s lover using an animal bladder as a female condom because the king ejaculates scorpions and serpents.)
Barrier methods used in the vagina have a long history of their own, by the way. Diaphragms, cervical caps, and pessaries were commercially available in the 1800s (marketed as “womb veils”) and their modern counterparts are still available today.
The Wellcome collection, a medical museum, has antique examples of soft condoms made of animal membranes, and hard ones made of tortoiseshell. Other materials are known from antiquity: oiled paper, linen, plants, and more. Sometimes they were intended to prevent sexually transmitted diseases or parasites, like bilharzia in Egypt. A 1533 book about syphilis describes how a linen condom, lubricated with saliva and fastened with a ribbon, reportedly prevented 1,100 men from contracting syphilis.
“Lambskin” condoms (typically made of animal intestine, not skin) were also popular around this time period, and you can still buy them today. We know now that these condoms can prevent pregnancy but aren’t reliable protection against STDs. By the late 1700's, animal-derived condoms were being produced commercially, although they were expensive enough to be considered a luxury item. The word “condom” dates from around this time, first appearing in an 1875 dictionary of London slang.
Rubber condoms came on the scene in the 1800s, and latex ones specifically—which could be thin and stretchy—in the 1920s. Condoms became more popular in the U.S. after World War II (the first war in which the U.S. issued condoms to soldiers), but they really boomed with the AIDS crisis of the 1980s.
If you grew up in the 1980s or 1990s, you may remember that condoms, and safe-sex messaging centering on condoms, were everywhere. They’re still one of the most common methods of birth control, and can be purchased relatively cheaply over the counter. But they’ve also been politicized, with religious groups promoting misinformation about how condoms work. (Spoiler: they work pretty well, actually.)
Birth control pills
The first birth control pill in the U.S., Enovid, was submitted for FDA approval in 1957—for regulating menstruation, not explicitly for preventing pregnancy. (Historically, talking about making your period more “regular” or bringing on menstruation was a coded way of speaking about avoiding pregnancy, so the contraceptive potential of the pill was likely understood even if it wasn’t the official use.)
Margaret Sanger, of Planned Parenthood fame, helped secure funding for the research that developed Enovid. The pill was tested in psychiatric patients and on low-income women in Puerto Rico who weren’t told they were part of a drug trial. In 1960, it was approved as the first oral contraceptive.
Despite questions about side effects and safety, the FDA judged that the pill was much safer than pregnancy (true), and since it was also highly effective at preventing pregnancy, the benefit/risk calculation clearly favored approving the pill. That early pill used doses that are enormous compared to what we use today: 10 milligrams of progesterone, compared to more like 100 micrograms these days—so approximately 100 times more, depending on which pill we’re comparing it to. The amount of estrogen in the pill was also three to five times higher than modern pills.
As a result, that first generation of pills resulted in stronger side effects (like acne, weight gain, and nausea) than birth control pills today, and there was also a greater risk of rare complications like blood clots. After congressional hearings in 1970, the doses were lowered, and rates of side effects and complications dropped. In 1973, the mini-pill was introduced, which uses a small dose of progesterone and no estrogen, and must be taken at the same time every day.
We’ve since had multiple “generations” of the synthetic hormones used in birth control pills, and there are countless brands and formulations on the market. You can read a bit about the differences between them in our guide to choosing a birth control pill. After more than half a century of birth control pills being safe, effective, and commonly used, in 2024 at least one brand will finally be available over the counter.
Besides pills, there are other methods that use the same kind of pharmaceutical hormones. You can get an injection every three months (Depo-provera is the best known brand), apply a patch every week (Ortho Evra, for example), or have a hormone-releasing implant (Nexplanon) placed under the skin of your arm.
IUDs
Intrauterine devices, or IUDs, are also a twentieth-century invention. The first one we know of was described in 1909, and was made of silkworm gut (a thick silk material commonly used for sutures) in a ring shape.
Some of the following versions were made with wire. Metals turn out to be effective at preventing pregnancy, possibly because they create a low level of inflammation in the uterus, and/or because the ions that are released from the metal interact with sperm. A dizzying array of IUDs have been made over the years, varying in shape and material; the Dittrick medical museum in Cleveland has a display showing dozens of them, some of which you can see here. (I’ve visited the museum, and mentioned it recently to a doctor I interviewed about IUDs; she responded by showing me that she had a framed photograph of that exact display on her office wall.)
The popularity of the IUD in the United States was suddenly squelched in the early 1970s. A model called the Dalkon Shield allegedly caused infections, infertility, and death in many of the people who used it. The exact reasons why the Dalkon Shield was so deadly are still unclear, although one factor may have been the type of string that it used. Other IUDs of the time were safer and had been used uneventfully for years, but after the Dalkon Shield was pulled from the market, the popularity of IUDs in general plummeted. The FDA began requiring IUDs to be approved before sale, which resulted in existing models being pulled from the market, and nobody wanted them anyway.
The IUD is making a comeback, though, with new models appearing in the 1980s and several available today. Today’s models include one type that is made of copper, and several that are plastic and release hormones (levonorgestrel, a form of progesterone) slowly over time.
An IUD is one of the best reversible contraceptives out there—after insertion, you’re protected from pregnancy for three to 10 years depending on the brand, or until you decide to get it removed, whichever comes first. And in the meantime, you don’t need to remember to keep up with a schedule (like taking a pill every day). That means its perfect-use and typical-use efficacy rates are nearly identical.
Surgical sterilization
If you want something more permanent than an IUD, there’s always surgery. If you have a uterus, you have the option of getting a tubal ligation; if you’ve got testicles, you can get a vasectomy.
The surgery we now know as “getting your tubes tied” was developed in the 1800s, and has evolved through many different surgical techniques over the years. They differ in how the surgeon accesses the fallopian tubes that connect the ovaries to the uterus, and what exactly happens to the tubes.
Despite the image you may have in your head, the fallopian tube is not itself tied into a knot; rather, the nickname of getting your “tubes tied” comes from a procedure in which the surgeon ties a suture around the fallopian tube, often also removing a portion of the tube. (This is known as tubal ligation.) The tubes can also be blocked in other ways, for example being secured by a clip, or they can be removed completely.
Tubal sterilization was first commonly done in women who repeatedly had complicated or risky pregnancies (three Caesarian sections was one guideline, back when c-sections were rare) or had had enough children (eight, in one guideline). The ligation could be done at the same time as a c-section. If you had it done as a standalone procedure, it would require a five- to seven-day recovery period. Laparoscopic tubal sterilization, introduced in 1967, made the incisions smaller and the procedure quicker to recover from.
Vasectomy, meanwhile, has a shorter and simpler history. The vas deferens is the tube that sperm pass through on their way out of the body, and in a vasectomy, this tube is cut. Since the vas is accessible through the scrotum, it’s a quicker procedure with a shorter recovery time, than tubal sterilization. It became popular during and after World War II.
Tubal sterilization is the most commonly used method of birth control in the U.S., according to the CDC’s National Survey of Family Growth. Vasectomies are less popular, but still a common method.
While we usually talk about birth control in the context of people deciding what to do with their own bodies, surgical sterilization (on both men and women) was also widely used to prevent disadvantaged people from being able to have children. A 1927 Supreme Court decision held that it was just fine, actually, for a doctor to remove the fallopian tubes of a person deemed an “imbecile” who was likely to beget more “imbeciles” (then a technical term for someone with low IQ). Carrie Buck, the woman who was sterilized in that test case, was never given an opportunity to consent to the surgery, or even told what the surgery was for. An estimated 70,000 Americans were sterilized in the years that followed the decision. While many of the laws supporting eugenic sterilization have been repealed, that Supreme Court case—Buck v. Bell—was never overturned.
Fertility awareness
Since pregnancy requires a sperm and egg to come into close contact, one method—which can be fairly effective, in theory—is to avoid having unprotected sex around the time of ovulation.
Before about 1930, the Dittrick explains, people understood that it could be effective to avoid sex around the time of ovulation, but they weren’t sure exactly when ovulation occurred. We now know that in a typical four-week menstrual cycle (in which your period occurs at the start of the first week), ovulation occurs around the end of the second week—about in the midpoint of your cycle.
Early attempts to use this as a form of contraception included the “OK method” and the “rhythm method.” You mark the date of your period on a calendar, and avoid having sex on certain days based on that date. While the idea was sound, menstrual cycles don’t always operate like clockwork. The length of a cycle can vary from person to person, and from month to month in the same person. It can also be affected by other aspects of a person’s health. And ultimately, the designation of certain days as “fertile” or not is a judgment call. The rhythm method wasn’t particularly effective.
To make the method more reliable, other measurements came into play. Cervical mucus changes in texture when you’re about to ovulate, and your body temperature is slightly elevated after ovulation compared to before ovulation. By the 1970s, we had the “sympto-thermal method” that combined mucus observations, temperature readings, and calendar counting.
Today, fertility awareness methods are good enough that—if you study them and know your body well—their effectiveness rates can rival those of birth control pills or condoms. There are apps that help you keep track of your fertile window, and wearables that can help you measure your temperature more consistently than using a hand-held thermometer. We have a rundown of these methods here.
Emergency contraception
Emergency contraception has no relation to abortion, but it’s common to get them mixed up—perhaps because EC and medication abortions have both been referred to as the “morning-after pill.” (The morning after you have sex, you almost certainly are not pregnant yet; most commonly your body acquires the sperm, then releases the egg, then the two can meet. This is why you have up to a five-day window to take emergency contraception—although the earlier you take it, the better your odds are.)
Taking action to prevent a pregnancy after having sex isn’t a new idea; that was the whole idea behind douching, including those weird ads for Lysol douches. Unfortunately for the people who used it, douching is not an effective emergency contraceptive. But in the 1970s, people began to figure out that there might be a reliable, pharmaceutical way of preventing pregnancy after sex.
There was already research on administering estrogen after sex to prevent pregnancy, mainly in animals. In the 1940s to the 1960s, the Guttmacher Institute explains, estrogen emergency contraception was occasionally tried in people—in one case, for a 13-year-old who had been raped.
The Yuzpe method of emergency contraception, first published in the 1970s, used the same hormones that are present in some commonly available birth control pills. You take an appropriate dose (often multiple pills) within the 72 hours after sex, and this decreases the chances of pregnancy. The Yuzpe method does not work as well as modern EC, and the side effects like vomiting tend to be more severe, but it was effective enough to encourage research into the forms of EC we know today.
In 1999, the FDA approved a two-dose version of Plan B, a pill containing levonorgestrel (a form of progesterone) for emergency contraception. It was prescription-only at first, and then in 2006 it became available over-the-counter for people ages 18 and older. That age was lowered to 17 in 2009, and that same year, Plan B was replaced with a single-dose version (that’s why it’s called “Plan B One-Step”). It wasn’t until 2013 that emergency contraception became legally available over the counter for everyone.
Ulipristal acetate (Ella) was introduced in 2010. It works by blocking progesterone receptors in the ovaries and endometrium, and may be more effective than levonorgestrel EC. It’s still prescription-only.
The legal status of birth control
Birth control, much like abortion, has found itself at the center of culture wars, as well as religious and political debates.
In 1873, the Comstock Act effectively outlawed the shipping or advertising of any sort of contraception by mail. This included information about birth control in books and magazines, as well as medications or devices that were considered “obscene”—like abortion pills and sex toys. (One lawsuit that successfully challenged the Act, limiting its powers, was called United States v. One Package, containing 120, more or less, Rubber Pessaries to Prevent Conception.)
Various laws and court cases chipped away at the provisions of the Comstock Act over the years, although it was never repealed, and was even cited in a court case this year in an attempt to take abortion medication off the market.
State laws also restricted access to birth control for many people in the early twentieth century. In 1965, the Supreme Court ruled in Griswold v. Connecticut that married couples have a right to privacy in their sex lives, and that this includes whether or not they choose to use birth control. As a result, states could not outlaw contraception for married couples. It wasn’t until 1972 that Eisenstadt v. Baird extended that right to people who are not married.
There are still religious and political groups that are trying to make birth control, including emergency contraception, harder to access. They show up to argue against over-the-counter birth control pills and over-the-counter emergency contraception, to name a few.
Birth control pills and devices (like IUDs) can’t easily be outlawed anymore, so attacks on these have lately taken the form of interfering with insurance coverage. The Affordable Care Act requires insurance providers to fully cover the cost of certain preventative services, like depression screenings and childhood vaccines. Since 2012, that category has also included 17 methods of birth control, including IUDs and emergency contraception.
But the court challenges have kept coming, like the 2014 and 2017 cases that carved out exceptions for religious employers to offer employees plans that don’t cover contraception. And ever since Roe v. Wade was overturned, abortion laws have been changing rapidly, making it more important than ever to understand the full range of your birth control options.
