Woman of Valor (41 page)

By 1936, the bureau had its own research publication called the
Journal of Contraception
, and later renamed
Human Fertility
, issued under the editorial direction of Hannah and Abraham Stone. But invariably research got short shrift, because of the clear emphasis on reliable service delivery. Robert Dickinson's National Committee on Maternal Health would prove a far more successful agent for pure research, on which it concentrated exclusively after 1935. His principal colleague and benefactor in this enterprise was Clarence Gamble, M.D, a self-styled do-gooder then teaching at the University of Pennsylvania Medical School, and an heir to the Ivory Soap fortune. Gamble had graduated from Harvard Medical School in 1920 but quickly grew bored with a career in applied medical research. Presented in his own marriage with the problem of finding an effective contraceptive, he became captivated by the broader pharmacological and sociological questions the subject presented and dedicated himself and a large part of his inheritance to the goal of discovering a simple and effective contraceptive product.

Gamble's first venture began in 1929 when he provided the seed money for a birth control clinic in his hometown of Cincinnati, Ohio, dedicated to the memory of his late mother and run by her distinguished friend, Elizabeth Campbell, M.D. He then mobilized the local charitable community in nearby Columbus to support another clinic, and as a Pennsylvania resident at the time, also became active in that state's new birth control league. Quickly despairing of the high costs of working through doctors and of the substantial diaphragm rejection rate, he then teamed up with Dickinson to try to establish laboratory standards for the effectiveness of the commercial contraceptives flooding the Depression market. Their research helped expose fraud in the industry and led to regulation by some states.

Relying on their data,
Fortune
magazine in 1937 would expose a $350 million-a-year industry in commercial contraception, where profits to manufacturers ran at the astonishing rate of 30 percent of retail sales. Condom sales represented little more than a tenth of this trade, with the balance comprising more than 600 known products marketed and widely advertised under the euphemism of “feminine hygiene.” The diaphragm represented less than 1 percent of this huge market. Small businessmen could make enormous profits in birth control with very little capital investment, but unlike the Holland-Rantos operation Noah Slee had staked, many sold worthless products.
Fortune
called on the federal government to regulate the trade, but while the Federal Trade Commission did intervene on numerous specific occasions to stop individual companies from making insupportable statements about the contraceptive utility of their products, no systematic investigation was undertaken. This left only the voluntary birth control advocates to coordinate efforts on behalf of research and reform and created the paradoxical situation of making them advocate more and less birth control at the same time. Having made the nation conscious of birth control—having changed public attitudes and helped secure laws to protect its use—Margaret unwittingly left the market open to a commercial exploitation far more substantial than anything she could have contemplated.
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Yet Margaret's growing resolve in favor of research on simpler contraceptives did not diminish her enthusiasm for the kind of clinical facility she continued to operate in New York. To the contrary, she remained convinced that obstacles to success with the diaphragm and all other contraceptives could best be overcome if women were simply better educated and better served in matters of reproductive health and sexuality. To this end, she continued to promote voluntary birth control clinics with high standards, provoking the dismay and confusion of many social scientists and philanthropists, who dismissed them as costly and ineffective expressions of a kooky, sentimental feminism that was inconsistent with her larger and, in their view, more mature aspirations to affect economic and demographic trends on a broad scale. She, on the other hand, was never afraid to pursue different agendas at the same time. She could never fully explain her attachment to the New York clinic, moreover, because in several dimensions it operated perilously close to the edge of respectability and legality. Nowhere was this more evident than in the responsibility she assumed during the Depression for treating patients who became pregnant.

To safeguard her credibility with the public and with the medical profession, Margaret had carefully disassociated birth control from the even more controversial subject of abortion. She always emphasized the superior virtue of pregnancy prevention. A 1929 memorandum from Hannah Stone, for example, instructs physicians to refuse any new patient requesting a pregnancy examination. No risk was to be taken that an unknown woman who subsequently aborted her pregnancy and suffered complications would implicate the clinic. Registered clinic patients, however, were given the Aschheim pregnancy test and, if found to be pregnant, were referred to Hannah Stone for counseling.

Three years later, alarmed by a reported rise in the incidence of illegal abortion as a consequence of the deepening economic crisis, Margaret instructed Stone to permit staff physicians to administer pregnancy tests without qualification and to make direct referrals to hospitals when therapeutic abortion was indicated. She also created a fund to pay the laboratory costs of these procedures. Statistics prepared for her estimated an even higher incidence of abortion than the Dickinson-Kopp figures for her own clientele. A first study suggested that more than 1 million pregnancies had been aborted in the United States during 1930, representing an astonishing 40 percent of all conceptions, with 30 percent of the total having been performed criminally, and 3 percent, or more than 30,000, having resulted in fatalities. Subsequent estimates made on the basis of the Dickinson-Kopp data then pared these figures down to 700,000 abortions nationally, and 16,000 deaths, an admittedly conservative number. More refined data, published in 1935 on the basis of follow-up interviews in their own homes with Sanger clinic clients who came from the Bronx, showed an overall abortion rate of about 25 percent, with a sharp increase from 1929 to 1931, as the Depression set in, especially among young married women, acting out of economic considerations. (This final sample of living women obviously showed no fatalities.)

Whatever the exact dimensions of the problem, it was clear that therapeutic referrals could help save lives. Medical standards for determining when a pregnancy might endanger life were considerably more lenient at this time than they became after World War II, when pronatalist sentiments stirred public controversy over abortion and placed hospital policies under intensive scrutiny. The diagnosis of tuberculosis and many other diseases considered hazardous to pregnancy were routinely considered grounds for intervention. Therapeutic interventions, indeed, became so widespread during the Depression that they provoked a conservative reaction in the early 1940s, when legislation was introduced unsuccessfully by social conservatives in the New York State legislature to ban them altogether.

In 1932, Margaret also asked that a study be undertaken to determine how many women were becoming pregnant as a result of contraceptive failures and how many subsequently terminated their pregnancies through abortion. “It will always distress me to feel that women in this condition [more] desperately in need of sound advice than any other group have to be turned out without follow-up, check-up or any further notice,” she wrote.

There were no secrets, yet nobody called special attention to what was going on. A private room at the clinic was set aside. A staff social worker volunteered to work over the lunch hour to accommodate the “overdues,” as they were called, and in a year's time, Stone had gathered 430 case histories. Approximately half of the women surveyed turned out not to be pregnant and began to menstruate regularly once their anxieties were allayed. Of the 205 actual pregnancies, Stone could verify that only fourteen were carried to term. Seventy-five abortion referrals were made, several of them directly to hospitals, and the rest to physicians who presumably took charge of the necessary arrangements, though exactly how they did so is not clear. Stone claimed that “contact was lost” with the remaining 100 patients, a statistic which may have been legitimate or may have deliberately obscured known outcomes that were criminal.
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That at least one illegal abortion was arranged directly by a physician who worked on the clinic staff is documented in a random and unusually revealing letter to Sanger from 1932, which tells the story of an unmarried and unemployed Polish emigré, pregnant and allegedly deserted by her fiancé, who was referred to a “Dr. Seigal” for an abortion. The letter identifies three additional facts about the woman—that she was an “exceptional type of the class where you and I felt an exception could be made,” that she had $100, and that she promised not to violate “the confidential nature of our assistance.” The abortion went well, and the woman was also given job and personal counseling. Since clinic case records overall have been destroyed—and since abortion referrals of this sort were not characteristically documented in any event—the extent of this kind of situation, with its decidedly subjective criteria for referral, can never be determined with certainty. On at least three subsequent occasions, however, clinic personnel found it necessary to circulate a memorandum clarifying the official policy prohibiting physicians from referring patients for abortion, and it is hard to believe they would have brought the subject up if infractions were not, in fact, standard practice. One social worker, in making two abortion referrals to doctors employed at the clinic part-time, claimed that she thought she was acting in accord with Margaret's wishes.

Just how discreet the clinic doctors had to be is underscored by a memo from the lawyer Harriet Pilpel, who at this time was beginning her lifetime commitment to the cause of reproductive freedom as a young associate to Morris Ernst, who had replaced Jonah Goldstein as Margaret's counsel, when Goldstein became a judge. In 1942, Pilpel would advise birth control officials in New York not to risk taking a stand on the abortion question then being raised in Albany, since it had taken them so long to distinguish birth control from abortion in the public mind. Even in the 1960s, Mary Calderone, M.D., then medical director of the Planned Parenthood Federation of America, could still not get the organization to sponsor any kind of abortion counseling services officially, though doctors at the Sanger clinic, an affiliate of the parent organization, were still widely known as sources for therapeutic and illegal abortion referrals. No one talked about the situation, and no case records were ever kept, according to Charlotte Levine and Elizabeth Arnold, who administered the clinic at the time, but everyone knew what was happening and assumed that it had always been that way. Between 1967 and 1970, in the final years before New York's restrictive abortion law was repealed, the clinic would cooperate with the New York Clergy Consultation Service on Abortion, founded at the nearby Judson Memorial Baptist Church in Greenwich Village. This courageous voluntary effort would counsel nearly 30,000 women in just three years, many of whom were sent to the Sanger Bureau for examination and confirmation of their pregnancies before being referred to criminal abortionists, whose practices the concerned clergymen and their indefatigable staff then closely monitored. In Levine's view, this unofficial abortion referral policy exemplified a commitment to guaranteeing the right of women to autonomous control over their own bodies.

“We always thought of ourselves as feminists, protecting women's choices,” she added, “even when that word was out of vogue.”
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In many respects then, the Sanger clinic regimen was an exacting one, just as its critics charged. The costs and staff requirements of individualized services were high. Under Hannah Stone, initial examinations could run up to two hours. An extensive case history was taken from each patient, which included medical, sexual, and socio-economic data. Painstaking instruction with the diaphragm followed. Stone or one of her subordinates employed a three-dimensional model of the female pelvis and explained the specific function and structure of each of the reproductive and sexual organs, often to women hearing this information for the first time. They then fit the diaphragm, removed it, and had the patient make the insertion herself. Return visits were scheduled within the week and at regular six month intervals thereafter. A conscious effort was made to establish an atmosphere where women could feel free of the inhibitions usually met with in standard gynecological practice.

Some patients welcomed this thorough indoctrination. One newlywed from Long Island, who came to the clinic four days after her marriage, exclaimed its success, saying she owed Stone “everything in the way of personal happiness.” A few complained that the treatment was brusque and the instructions unclear—one client got pregnant because even after instruction, she used the diaphragm upside down. Still others were put off by the enforced intimacy and even found it condescending. The young, still unmarried protagonist of Mary McCarthy's novel, for example, is so uncomfortable with her sexuality—and finds the jelly-covered diaphragm so difficult to maneuver—that when she tries to insert it on her own, it shoots across the room, and she is horrified with embarrassment. She leaves Dr. Stone, walks to nearby Washington Square, and abandons the bulky package of contraceptive materials under a park bench.
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What complicated the clinic transaction was then not just the problem of technology. The intensive one-on-one client interviews uncovered the fact that concern over reliability and comfort with the diaphragm often masked a disturbing level of anxiety about sexuality itself. In this respect, the clinic became a social laboratory for testing the assumptions of prescriptive sex literature like Margaret's own
Happiness in Marriage
. Only six out of ten women in the Dickinson and Kopp survey, for example, reported what was identified as a “normal” attitude toward sexual intercourse. The rest expressed opinions ranging from indifference to outright hostility—from toleration to loathing. In many cases concern about getting pregnant was itself the cause of the neurosis, and reliable contraception provided a solution. In others, however, the problems were deeper still, with many patients expressing frustration about the nature and adequacy of their sexual responses. Though eight of every ten women said they had experienced orgasm at least once in their lives, only half of those answering this question affirmatively claimed that climax was a usual occurrence, while the rest admitted the experience was seldom. Often the meaning of the term itself had to be explained before a response was possible. Few patients could locate the clitoris precisely or understood its function. The Sanger Bureau patients may have constituted a self-selected population, with a higher level of expectation about contraception and sexuality than the average woman who did not bother to pursue specialized services. The data, nonetheless, revealed a more serious level of disturbance than existing surveys by questionnaire typically uncovered.
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