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Lance Wahlert, PhD and Autumn Fiester, PhD
Virtual Mentor. 2013;15(9):733-756. doi: 10.1001/virtualmentor.2013.15.9.ecas2-1309.
Ms. Forte is 6 months pregnant with her second child, a daughter. She was impregnated via insemination by an anonymous donor and comes to her prenatal care visits with her wife, Ms. Smith. Ms. Forte’s obstetrician, Dr. Bustamante, begins to discuss Ms. Forte’s plans for breastfeeding after the birth, which Ms. Forte did successfully with their first child. Ms. Forte explains that she plans to breastfeed the second child as well but would like her wife, Ms. Smith to also breastfeed their newest child. Ms. Smith, who is also Dr. Bustamante’s patient, asks Dr. Bustamante if she can help induce her lactation.
Dr. Bustamante has known both women for several years. She was extremely happy for them when they got married and helped them to find a pediatrician for their first child who would be supportive of same-sex parents. However, this request for induced lactation strikes her as medically unnecessary. The baby will already have one mother who can breastfeed her, and the process of inducing lactation may carry some risks for Ms. Smith.
In the United States, the typical context for inducting lactation in a nongestating mother pertains to an adoptive mother who wants to breastfeed an adopted infant [1-3]. In other parts of the world (most significantly across parts of Africa), induced lactation is sometimes initiated as a feeding method when infants are orphaned or maternal illness prevents breastfeeding and for infants with seropositive mothers concerned about virus transmission via breastfeeding [4, 5]. In the U.S. context, both the American Academy of Family Physicians [6] and the American Academy of Pediatrics [7] recommend induced lactation for breastfeeding the adopted infant in their policy statements. But the newest Forte-Smith baby in the above case, like the baby boy who preceded it in the family, will not join this family via adoption and will already have one the gestational carrier who can provide the baby with the nutritional benefits of breastfeeding. In the narrative of this case, then, inducing lactation strikes Dr. Bustamante as a pointless duplication of effort that carries risks without benefit. Accordingly, the physician resists the couple’s request, despite her earlier demonstrations that she is supportive of same-sex couples as parents. This essay argues that Dr. Bustamante’s reservation about providing induced-lactation counsel and services to Ms. Smith defies widespread recommendations in the American medical literature for other non-biological mothers and bespeaks a potential, latent discrimination of lesbian parents’ breastfeeding needs in even the most sympathetic of physicians.
In standard medical practice, there are both pharmacologic and nonpharmacologic methods of inducing lactation that can be used alone or in combination—ranging from prescription drugs to herbal therapies to manual stimulations. Each category of intervention has been successful in inducing lactation in women both with and without prior pregnancy and lactation, though pharmacologic support is usually necessary in women who have never lactated. The nonpharmacologic method of inducing lactation carries no risks, but it may not be successful in Ms. Smith’s case [3]. This method involves repeated nipple stimulation for several weeks before the anticipated birth, preferably with a hospital-grade electric pump [1, 8]. In women who have been pregnant and lactated before, extremely high success rates have been achieved with this method [9], but success rates vary in nulliparous women.
The most common approaches to inducing lactation involve pharmacologic intervention in conjunction with nipple stimulation. There are several possible pharmacologic methods with a range of potential short-term side effects for breastfeeding mothers [1, 3], but overall the interventions are considered to be of only minimal risk. One study of women who had never lactated achieved 100 percent success with a single dose of medroxyprogesterone (Depo-Provera) and then either chlorpromazine or metoclopramide for 5-13 days [5]. Both chlorpromazine and metoclopramide can sometimes produce side effects for the mother. With metoclopramide, sedation is the most common side effect, albeit with a 10 percent occurrence rate in women [1]. Depression is experienced less frequently than sedation, and approximately 1 percent of women experience extrapyramidal side effects [1]. With chlorpromazine, side effects include weight gain, sedation, bradykinesia, and tremor [3]. However, in the above-mentioned studies, none of the women experienced any sustained side effects from the intervention [5]. (The potential risks of these pharmacologic methods to the infant are either minimal or nonexistent. Both chlorpromazine and metoclopramide are classed in Hale’s Lactation Risk Categories as L2 (safer), indicating that the studies available found little evidence of risk to the infant [10].) As a precaution, studies recommend stopping hormonal therapy 24-48 hours before the onset of breastfeeding.
The unlikely risks of induced lactation to both mother and infant can be put in proper perspective by considering the recommendations of the American Academy of Family Physicians [6] and the American Academy of Pediatrics [7], both of which advocate for induced lactation in cases of adoption. The AAFP states, “The physician should offer the adoptive mother the opportunity to breastfeed her child” and “should support lactation induction” [6]. The AAP includes in its breastfeeding recommendations: “Provide counsel to adoptive mothers who decide to breastfeed through induced lactation, a process requiring professional support and encouragement” [7]. These recommendations suggest that the very minimal (if any) risks attached to induced lactation in nongestating mothers are far outweighed by the benefits (emotional, nutritional, and practical) to the breastfeeding relationship between nonbirth mother and newborn child.
In Dr. Bustamante’s defense, one could argue that the nutritional benefit for the typical adopted infant outweighs even the minimal risk for the adoptive mother in most cases of induced lactation. According to this line of reasoning, the risk-benefit justification would not apply to lesbian couples with a gestational carrier, such as the Forte-Smith parents, whose child will receive traditional breastfeeding nutrition from Ms. Forte. But this defense of Dr. Bustamante’s position misidentifies the central benefit of induced lactation in conventional adoptive mothers. Such (mostly heterosexual) nonbiological mothers who induce lactation are widely appreciated as being usually unable to achieve an adequate supply of milk to be the sole (or even primary) source of nutrition for their infants [1, 3, 8]. Moreover, across the medical spectrum, nutrition is not viewed as the primary benefit of induced lactation by either adoptive mothers or the AAFM. Data from multiple studies shows that mothers view induced lactation as worthwhile even if adequate milk supply is never achieved [2]. Wittig, for example, reports that women “who attempt to induce lactation do so to achieve the enhanced mother-infant relationship that breastfeeding promotes rather than the nutritional benefit it brings” [3]. And the American Academy of Family Physicians concurs, writing in its policy statement: “In many cases, the opportunity to emotionally bond during nursing is the primary benefit of breastfeeding for adoptive mothers and babies” [6].
But we need not be limited to the dilemmas of hypothetical nongestating mothers on this issue. Consider the sentiments of nonbiological lesbian mothers. Faith Soloway, in Confessions of the Other Mother: Nonbiological Lesbian Moms Tell All!, writes of her conflicted feelings about her female partner’s natural breastfeeding relationship with their child as the gestational carrier: “Basically, I am insanely jealous of their flesh-on-flesh, boundaryless, nurturing, complicated relationship” [11]. By contrast, there are the testimonials of nonbiological lesbian mothers—such as Offbeat Families blogger Liesbeth Koning—who attest to the invaluable emotional, practical, and psychological benefits of having both lesbian moms able to breastfeed their children in her article “How Two Lesbian Mamas Share Breastfeeding Duties” [12]. Like these real lesbian nonbiological mothers, the fictional Ms. Smith in the above case is drawn to induced lactation not merely for the nutritional benefit it will bring to her soon-to-be-born daughter, but for the emotional bond it will forge between child and nongestating mother.
In light of the very minimal health risks to Ms. Smith or to her future daughter, and the immeasurable benefits of the emotional bonds that breastfeeding generates for mother and child, any ethical reservations on Dr. Bustamante’s part are unfounded. She should proceed with a plan to induce lactation for Ms. Smith, just as she would (without hesitation) for a non-lesbian nongestating or adoptive mother. Failing to do so will either demonstrate a troubling unfamiliarity with the clinical facts of lactation induction or (far worse) a worrisome concern that even the most progressive physicians may be treating their LGBTQ patients and families according to a different standard than they use for heterosexual patients.
American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). http://www.aafp.org/about/policies/all/breastfeeding-support.html. Accessed July 29, 2013.
Riordan J, Wambach K. Breastfeeding and Human Lactation. 3rd ed. Sudbury, MA: Jones and Bartlett; 2005.
Hale TW. Medications and Mother’s Milk. 12th ed. Amarillo, TX: Hale; 2006.
Soloway F. Betsy loves bobbies. Confessions of the Other Mother: Nonbiological Lesbian Moms Tell All!. Boston: Beacon; 2006:77-80.
Koning L. How two lesbian mamas share breastfeeding duties. Offbeat Families. http://offbeatfamilies.com/2011/02/co-breastfeeding. Accessed June 15, 2013.
Virtual Mentor. 2013;15(9):733-756.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
Lance Wahlert, PhD is an assistant professor in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine and a core faculty member in the Department of Gender, Sexuality, and Women’s Studies at the University of Pennsylvania in Philadelphia. He is the director of the Bioethics, Sexuality, and Gender Identity Project.
Autumn Fiester, PhD is the director of education in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. She is the director of the Penn Clinical Ethics Mediation Program and co-director of the Bioethics, Sexuality, and Gender Identity Project.
Copyright 2021 American Medical Association. All Rights Reserved. ISSN 2376-6980

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Home » Marriage » The Pill: Did It Cause The Sexual Revolution?
The Pill: Did It Cause The Sexual Revolution?
Photo by Anastasiia Ostapovych on Unsplash
Does a woman really become strong and liberated by submitting herself to the rules of the male sexual market?
No student of the family can ignore this remarkable milestone: Mother’s Day marked the 50th anniversary of the FDA’s approval of a tiny tablet that dramatically changed the face of the family and culture.
This little pill – the first medicine ever designed to be taken by the healthy – chemically altered a woman’s hormonal cycle, preventing ovulation and thus, pregnancy.
What made this new development so remarkable was that it was, for the first time, contraception…
G.D. Searle applied for approval of their new product (Enovid) in 1959 and soon announced the Pill in this advertisement in Obstetrics & Gynecology.
The image in this first advertisement was prescient; depicting the mythological Andromeda breaking free from her shackles, for this is what the new pill was to accomplish. Ironically, the name Andromeda literally communicates “to be considerate or mindful of the man.” This is a profoundly important point as we consider the long-term impact of the pill upon women, the family and culture.
There are compelling reasons why the Pill did not start the sexual revolution. First, there is no single event – not the Pill, the advent of pornography, taking prayer out of schools, etc. – that started the sexual revolution. In fact, historians refer to the American Sixties as the “the second sexual revolution” because there was quite a robust sexual revolution that took place in the 1910-20s, personified in the iconic Flapper as well as bold epidemics of sexually transmitted diseases and pornography.See Glenn T. Stanton, Why Marriage Matters, (Pinion Press, 1997), pp. 34-39.
A strong case can be made that cultural affluence, materialism and increasing secularism over both the 1910-20s and 1960s-to-present fueled the loosening of our sexual values. Consider also that the Pill has been available in most parts of the world for decades and some (i.e. Saudi Arabia, India) have not experienced sexual revolutions like ours. This revolution in sexuality was the result of many important factors converging, of which the emergence of the Pill was certainly key.
Did Contribute to the Second Sexual Revolution
Even though the Pill was not available to unmarried women until the late 1960s and early 70s – many clinics required young single women to provide a note from their minister attesting to an impending wedding date – there are few who would contend it didn’t play a significant role in fueling these changes. (More on this in the “Iron Curtain” section below)
Only Fine-Tuned Control of Family Size
The Pill did allow women to control the number and spacing of their children, but women knew how to do this for quite some time. In 1800, the average American woman had eight or more children. By 1850, the average was 7 births per woman, shrinking to 3.5 by 1900.Susan E. Klepp, Revolutionary Conceptions: Woman, Fertility and Family Limitation in America, 1760-1820, (U. of N.C. Press, 2009). While the Pill did allow women greater control of their fertility, it is just not true that wives were mere “baby-making machines” held captive to run-away fertility prior to the Pill. Women being smart, long knew how their fertility worked and how to manage it.
Became a Virtual Iron Curtain Between Sex and Babies
Even though women long knew how to limit their fertility, the Pill made (along with corresponding legal and cultural developments) the separation between sexuality and the possibility of babies nearly an inalienable right. The fact that a woman could be sexually active and virtually guaranteed (by medical science no less!) of not becoming pregnant had the effect of making her feel cheated when an unexpected pregnancy did happen. Writing recently on the impact of the Pill, Al Mohler says the “severing of this relationship [between sex and childbearing] represents a quantum change in human life and relationships, not to mention morality.”Albert Mohler, “The Pill Turns 50 – TIME Considers the Contraceptive Revolution,” April 26, 2010. albertmohler.com.
This “iron curtain” between sex and the possibility of babies had the unintended consequence of dramatically boosting the rate of abortion, which spiked dramatically around 1968-70, well before 1973’s Roe v Wade. This was because of the growing sense of having a “right not to be pregnant” if a sexually active woman didn’t want to be. She could also face pressure toward abortion from her partner who didn’t want his sexual partner hampered by pregnancy. The Pill was expected to actually reduce abortion by reducing unwanted pregnancies.
Nobel prize-winning economist George Akerlof explained in a celebrated essay how increases in the use of the Pill and abortion contributed to the near extinction of the “shot-gun wedding” which were never about forcing people to get married. They were about “doing right by the woman,” an action of respect and honor toward her and her family. They formed a great many good, healthy, happy families. However, the Pill effectively let men off the hook, forcing the woman to alone deal with that which was never supposed to happen and was now her primary responsibility to prevent.George A. Akerlof, “An Analysis of Out-of-Wedlock Childbearing in the United States,” The Quarterly Journal of Economics, 151 (1996): 277-317.
Decreased Age of Sexual Debut / Increase in Delay of Marriage
Studies show the Pill contributed to a strong more delay in marriage as well as a lowering in the age of sexual debut. This is because the security that marriage provided – both in the terms of moral reputation (due to shifting cultural mores) and accidental pregnancy – no longer seemed as necessary. Claudia Goldin and Lawrence F. Katz, “The Power of the Pill: Oral Contraceptives and Women’s Career and Marriage Decisions,” Journal of Political Economy, 110 (2002): 730-770.
Generally, the Pill is seen as a benefit to women, allowing them to better time their fertility to correspond with attaining a college education and early career establishment uninterrupted by surprise pregnancy. And this also made it more likely for employers to invest time and training in young women for higher level careers. Women have gained from this.
But it has hurt women deeply as well. Professor Bruce Wydick, an economist at the University of San Francisco, specializing in family relationships, explains that because of the different ways men and women are wired and
therefore value sexuality, “a world where social norms dictate that sex and commitment go together is a world that upholds the happiness and dignity of women.”
And as such, Wydick contends, “the revolution that brought sexual freedom allowed women to unwittingly undercut each other in the competition for men, providing men greater access to more sex for lower and lower levels of commitment, to the obvious benefit of the men.” Women thus became weaker players in the sexual market place and men became stronger.
He concludes, “Women’s sexual freedom became the greatest thing that ever happened to men who wanted as much sex as possible with as little commitment as possible, and hence made women much worse off.” Thus, he calls the embrace of this freedom by the woman’s movement “a mistake of incalculable magnitude”
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