Do you know about the racist history of the contraceptive pill?

At no point in my medical education – nearly a decade of university, three degrees and countless hours spent on the wards – did anyone mention how the legacies of colonialism and racism affect my decisions as a doctor.

Shortly after completing my master’s (at arguably one of the world’s best public health schools, the London School of Hygiene and Tropical Medicine), I became disillusioned with how healthcare is taught and discussed. I’d spent a year studying sexual and reproductive health, particularly that of countries in the Global South, and I felt that there were gaping holes in many of our discussions.

It was the same feeling that I had felt in my undergraduate medical education. I would sit in lectures and listen to senior doctors disparagingly make sweeping generalisations about why some Black people were at risk of high blood pressure and how these patients often did not take their medication. We never discussed the tension between majority white, middle-class doctors and racially marginalised patients. We never discussed how our health institutions had been shaped by imperialism.

“Only a few bodies have ever historically mattered: usually those of white, male, able-bodied and heterosexual people.”

Nobody challenged these narratives. No one was given the space to do so. The system was heavily weighted in favour of a few. Medicine and healthcare is taught the way it is practised. Only a few bodies have ever historically mattered: usually those of white, male, able-bodied and heterosexual people.

While the contraceptive pill brought liberation to many white women living in the West, this would not have been possible without scientific trials on poor, working-class women in Puerto Rico. Many previous efforts to create a hormonal pill for ‘birth control’ had largely failed, partly due to conservative views that it would lead to sexual promiscuity and a lack of willing test subjects. Yet, as concerns about the changing demographic within the US grew and interest in eugenics mounted, scientists saw birth control as a unique opportunity.

Margaret Sanger (1879–1966), founder of Planned Parenthood – now one of the largest reproductive health and rights organisations in the US – is often credited as the driving force behind the pill trials.

Sanger gained considerable influence with more conservative members of the political establishment as they began to see the long-term benefits of birth control and had financial backing from philanthropists, which allowed her work to progress. She was able to enlist the help of Harvard scientists Gregory Pincus and John Rock and received financial backing from Katharine McCormick, also a biologist and one of the earliest women to graduate from the Massachusetts Institute of Technology (MIT), to conduct trials on the hormonal contraceptive pill.

The US territory of Puerto Rico, which in many ways functions like a colony, was selected as a trial location due to a combination of hostility surrounding birth control in the US as well as concerns about a surging population and poverty in Puerto Rico. The first trial took place in Rio Piedras, an area where the government was trying hard to regenerate and where women were eager to find work and raise their living standards. Since the 1930s, there had already been in place widespread sterilisation programmes and contraception clinics, partly funded by the US government.

Approximately two hundred women were enrolled in the Rio Piedras trial, unaware of the potential risks of the pill or that they were part of an experiment, most thinking that the contraceptive was safe to use. It was estimated that a fifth of the study participants suffered side effects, some even dying as a result. The connection between the contraceptive pill and serious side effects for some patients, like bloods clots and strokes, had not yet been made. During the trial, much higher doses of hormones were given than the dose that was eventually licensed in the final Enovid medication. The trial subjects were likely deliberately chosen due to their unfortunate circumstances. Many of these women were keen to access birth control, having already had multiple children and living in poverty. But they did not realise the risk. Ultimately, poor Puerto Rican women gave their lives so that countless others could access safe contraception. Today, at least 150 million people use the oral contraceptive pill.

Sanger’s approach to reproductive rights changed decisively as she became influenced by eugenicists.