Revolutions take time. Successful revolutions are nothing less than defining processes that transform our understanding of life itself. The discovery of fire, the Copernican view of the universe, the concept of the microprocessor, and the cross on Calvary are examples of revolutions that do not allow us to turn backwards in our way of viewing the world around us. They have a ripple effect that moves through all disciplines, altering their reference points, redirecting their perspectives. We who live at the end of the twentieth century have been witnesses of several profound revolutions such as the one that began in the Gdansk shipyard, with a labor union called Solidarity, and ended with the collapse of the Iron Curtain. We in the "developed world," however, have been more intimately involved with another revolution-one that has involved our parents and our children, altered our view of the marketplace and the family, "liberated" literally millions of women, helped redefine the purpose of government, and divided policy and praxis in our church. It continues even today. I am referring to the sexual revolution, of which the contraceptive mentality has been the foundation since the turn of the century. As a Diplomate of the American Board of Obstetrics and Gynecology, and as one who sees the human person as both body and soul, I want to examine several of the medical fruits of the contraceptive revolution. These include, but are far from limited to, the literally exploding number of sexually transmitted diseases and negative contraceptive side effects. And I will call attention to a new spirit that is being created in my medical practice at the Tepeyac Family Center. Here I am witnessing a revolution in the heart of people struggling against the prevailing contraceptive mentality. They have become for me living examples of Augustine's observation that our hearts are restless until they rest in Him.

Sexually-Transmitted Diseases

Sexually-transmitted diseases (STDs), a major consequence of the sexual revolution and the wide-spread use of contraceptives, are headline topics at gynecology conferences the world over. People today are having intercourse with more people who are not their spouses. Exclusivity and permanence are no longer the norms of sexual engagements. The rapid advancements in contraceptive development, such as "the pill," in the early 1960s made possible and encouraged such activity, worsening a problem that human beings have dealt with since prebiblical times. And the STD problem grows steadily worse. Increasing numbers of people are becoming infected with more severe ailments[1]. No longer are we dealing with treatable entities, such as syphilis and gonorrhea. Resistant strains of STDs are on the rise. Their long term consequences-pelvic inflammatory disease, infertility, ectopic pregnancy and chronic pelvic pain-have all increased in number and severity[2], along with cancerous sequelae such as cervical cancer and hepatocellular carcinoma, which are closely linked to STDs. Persistent viral infections, including the human immunodeficiency virus (HIV), herpes simplex virus (HSV), hepatitis B virus (HBV) and human papilloma virus (HPV) have afflicted millions of people. Preventing infection is the cornerstone of reducing the adverse consequences of STDs. This is the direction that our profession has taken in the fight against STDs over the last hundred years. More, and more effective, contraceptives along with better treatment and education have been the medical strategies for attacking this epidemic. How has this approach fared? The estimated total number of people newly infected annually with symptomatic STDs is about 13 million[3]. The annual cost of pelvic inflammatory disease and its consequences during this decade in the United States alone is estimated to be $4.2 billion[4]. The human suffering of infertile couples struggling with their childlessness is incalculable. Nor is it possible to quantify the value of lives lost due to STDs, fully one-third of all reproductive mortality in the nation[5]. Sadly, STDs have a predilection for young people. Individuals under 25 years of age account for the majority of cases, with 66% of reported cases of gonorrhea and chlamydia occurring in this age group [6]. Some basic information on several well-known STDs reveals the enormity of the problem. Chlamydia is the most common bacterial STD in the country, with an estimated 4 million new cases annually [7]. As the organism multiplies in the uterus, fallopian tubes, and ovaries, it causes pelvic inflammatory disease (PID). Scarring of the fallopian tubes from PID can cause sterility or ectopic pregnancy, the leading cause of death in pregnant women. The disease is insidious in women, being asymptomatic and chronic, so most women never know they have the condition [8]. Worse still, the popular forms of hormonal contraception increase this condition at the woman's cervix [9]. An estimated 8 to 25% of college students are infected with chlamydia. Human papilloma virus (HPV), the cause of genital warts, is the most common symptomatic viral STD in the United States, with 3 million cases diagnosed annually [10]. It is estimated that up to 30% of sexually active men and women have this virus [11]. HPV can cause changes in the skin cells that may develop into precancerous growths, and eventually into cancer. An estimated 8,000 American women die annually from HPV-associated genital cancers [12]. Gonorrhea affects 700,000 people annually, making it the most reported communicable disease in the country. Including cases not reported, annual projected cases of gonorrhea are 1.5 million [13]. This bacterial infection can produce abscesses, chronic pelvic pain, and lead to PID and scarring that results in ectopic pregnancies or infertility [14]. An estimated 30 million Americans are infected with herpes, and 200,000 new cases are reported each year [15]. Herpes is caused by a virus that produces painful blisters and sores in the genital region. It is incurable. Hepatitis B, with 150,000 cases reported annually,[16] and syphilis, affecting 40,000 annually[17], are further examples of the magnitude of our nation's problem. Symptoms, when present, of Hepatitis B include jaundice, tiredness, nausea, dark urine. Ten percent of those who contract the virus will develop a persistent infection that can result in severe liver damage (cirrhosis, cancer) [18]. Over the past decade, syphilis has reached its highest level in 40 years [19]. It can be treated with penicillin, but if misdiagnosed and untreated, it can irreversibly damage many organs and systems of the body. A discussion of HIV, its magnitude, and its agony is beyond the scope of this paper, but it certainly is integral to the epidemic of STDs in America. Having examined STDs as a physical manifestation and consequence of the sexual revolution that, ironically, promised health and happiness, let us turn to the contraceptives themselves and review their side effects.

Contraceptive Side Effects

Among the 58 million American women of reproductive age, about 60%, or 35 million, use some contraceptive method. Of the other 23 million women, only about one-sixth are at risk for becoming pregnant. Therefore, of all the women capable of becoming pregnant, 90% use a contraceptive [20]. Today, sterilization of women and men is the most common form of contraception, followed in use by oral contraceptive pills, condoms, and Depo-Provera. Intra-uterine devices (IUDs) and implants are each being used by only 1% of the reproductive age population [21].

Sterilization

With over 4 million men choosing vasectomy as their method of birth control, it is important to advise them of two possible consequences. First, between 4 and 10% of them regret having used this permanent method of contraception. Second, on the average, 50% of men will develop antibodies to sperm following the procedure. Over 9 million American women have also undergone sterilization. Their regret over having been sterilized is greater depending on the age of the woman and a change in her marital status [22], and on whether the procedure was done around the time of a pregnancy [23] or an abortion [21]; regret is also greater among poor women, women of Hispanic origin, and women who eventually divorce [24]. Medical complications occur in less than 1% of sterilization cases; the severity of complications varies with the type of procedure and anesthesia used. The pregnancy rate of women who are sterilized is between 0.5 and 1%, of which 16% to 73% are ectopic pregnancies (occurring outside the uterus) [25]. Ectopic pregnancy is a surgical emergency. Hormonal changes, including a decrease in progesterone, have been found after sterilization, possibly associating the procedure with a worsening of premenstrual syndrome [26]. Some authors speak of a "post tubal-ligation syndrome" in which both menstrual flow and pain significantly increase by the fifth year after sterilization [27]; hospitalization for menstrual-related disorders is more common for women who have been sterilized [28].

Oral Contraceptives

The medical breakthrough which enabled the sexual revolution in America is, without a doubt, the oral contraceptive pill, better known simply as "the pill." The hormonal tablet which came to market in the early 1960s is quite different from the variety available today, which are used by approximately 12 million women in the U.S. and 70 million women worldwide [24]. Doses of estrogen and progesterone in today's pills are much lower, changing the side-effect profile from what was seen with higher-dose pills. The very high number of users, however, means that even small percentages of women experiencing side effects translates into a considerable number of women. For example, just 1% of 12 million women is 120,000 women. Before discussing side effects experienced by the mother, it is important to mention the abortifacient potential of the pill. While the predominant mechanism of action for the pill is the inhibition of ovulation [30], it also thickens the cervical mucus and can interrupt implantation of the early conceptus by altering the lining of the uterus [31]. Such interruption is an abortion. As the doses of estrogen and progestin have decreased in the now popular "low-dose" oral contraceptives, escape ovulation will occur in as many as 25 to 30% of cycles if pills are missed early in the cycle [32]. With correct use, one study documents escape ovulation at almost 2% with the multiphasic, and 5% with the monophasic, variety for each cycle [33]. This agrees with the finding that the newer, lower-dose pills do not protect women from ovarian cysts as the older, higher-dose variety did [34]. Because ovulation can occur, and because the lining of the uterus can be damaged, preventing implantation, and with a known pregnancy rate of 1% to 4% among women on the pill, it is clearly possible that an early conceptus would be unable to implant and would die due to the pill. A woman cannot know what mechanism is acting in any given cycle. Considering the millions of women using oral contraceptives worldwide, the abortifacient potential is great. The side-effects profile for the pill has changed drastically since 1975 when low-dose formulations became popular. Today's low-dose formulations do not raise a nonsmoker's risk for heart attack or stroke [35]. Venous blood clots, however, still occur with low-dose formulations at triple the rate for women not on the pill [36]. The subgroup of women who are young, childless and users of the pill for a number of years, is 40% to 1000% more likely to develop breast cancer at a younger age and in a more aggressive variety[37] than non-users of the pill. Even more startling is the finding that the low-dose pill's tendency to protect women from uterine and ovarian cancer is negated by the increased incidence of cervical cancer, thought to be associated with the human papilloma virus, from which the pill offers no protection [38]. The pill's use as a morning-after "recipe" for making the lining of the uterus inhospitable to the implanting conceptus[39] has received much publicity recently. This is yet another way the pill's abortifacient potential is used to prevent a conception from reaching birth. Despite the lessened dangers in oral contraceptive side-effects, over 50% of women stop using the pill in the first year. Their reasons include the continued nuisances of nausea, fluid retention, cyclic weight gain, cervical ectopia, rising cholesterol concentration in gallbladder bile, growth of fibroid tumors of the uterus, and the pill's promotion of red "spider veins." [40] Other unpleasant side-effects include headache, hypertension, breast tenderness, carbohydrate intolerance, depression, fatigue and tiredness [41], some of which may be improved with the newer progestin components of the oral contraceptive pill.

Condoms

Condoms are a popularly promoted method of birth control, and are considered the bulwark against the spread of infectious STDs, including the HIV virus. A recent large survey of studies, however, documented only an 87% rate of pregnancy prevention and a 69% effectiveness rate in preventing the spread of HIV (with the range from 46% to 82%)[42]. Condoms offer no protection from STDs, like herpes and HPV, communicable from contact with areas of skin not covered by the condom.

The two most prominent injectable contraceptives are Depo-Provera and Norplant. Both are progestin-only contraceptives. Depo-Provera has been utilized by 30 million women worldwide [43]. Its mechanism of action is similar to the birth control pill, including in some instances, the stopping of implantation, thereby making it an abortifacient[44]. It is sometimes given to the poor in this country, but is not considered an option for those with insurance or financial means because of the range and severity of side effects: irregular, heavy cycles alternating with no menstruation in 50% of women after the first year, headaches, dizziness, bloating, depression, and weight gain [45]. Norplant, the other injectable, is used by approximately 750,000 women world-wide. It is similar in action to Depo-Provera. Escape ovulation also occurs with Norplant. Because it causes endometrial lining to be inhospitable, it too is an abortifacient. A documented 50% of cycles are ovulatory at the fifth year of use [46].

The Real Tragedy

I see these effects in a very real way in my practice as a gynecologist. Many of my patients are Christians who use contraceptives. To me they seem restless, not at peace with themselves or happy with life. They are searching. Often they talk to me about wanting the best partner, but settle for whomever they are with. So often they seem to have no sense of self-worth. They avoid entering serious relationships with others, while going through serially monogamous relationships or a series of physical interactions with several men at the same time. Often these women have a history of physical, sexual or psychological abuse. They may be physically self-destructive, using tobacco, alcohol and drugs. They see themselves as somehow not being able to "get it together." I see them as restless because they are searching for real meaning and lasting relationships in their lives-they are searching for Christ. There are many grave contra-indications to sexual promiscuity and the use of drugs and devices to thwart the procreative aspect at the essence of our sexuality. But it is not the medical consequences spelled out above, as horrible as they are, that make such a lifestyle unhealthy and unworthy of us. Rather, human beings want to love and be loved, completely, for who they are and what they are. And this is what contraception gets in the middle of. Sexual intercourse belongs exclusively in marriage, and marriage is the bond in which two become one flesh. Each act of intercourse, even outside marriage, by its nature binds a portion of the person's soul to his or her partner. Intercourse, it could be said, enacts a "soul-tie." Multiple "soul-ties" do not allow a person to cleave fully, exclusively and totally to his or her future spouse False soul-ties must be broken if that couple and that marriage are to be healthy, holy and whole. Sadly, the mentality of being closed to the possibility of children, put into practice through contraception, leads spouses to see one another as open to being used, instead of being unconditionally loved. It is not surprising to me that the rate and incidence of divorce have risen with the increased use of contraceptives since the 1960s. I realize that many people think the Church is "behind the times," or simply irrelevant when it comes to its teaching regarding contraception. To me, the teaching that sexual intercourse is reserved for marriage, that partners in marriage must respect one another, and that marriage involves the total giving of oneself to one's spouse in love, in family life, and in sexual intercourse, is a very powerful and positive teaching. It allows us to be open to life, open to love. Its antithesis is the idea that has been adopted by our culture: that individuals have a right to sexual relationships outside of marriage, and that, whether single or married, individuals have a right to sexual intercourse free from any concern that a child might result. Taken one step further, this provides a foundation for the mentality that accepts abortion: if a child results from sexual activity, whether inside or outside marriage, the right not to have to "deal" with that comes into play. More contraception, more education on its use, greater technology is not the answer. We've tried it for 37 years. It has failed miserably. We must instead follow the path of Jesus who took on humanity to teach us the way, to teach us the truth. This is the basis for the next sexual revolution. The revolution is dead. Long live the revolution!

Dr. Bruchalski is a Diplomate of the American Board of Obstetrics and Gynecology and a Fellow of the American College of Obstetricians and Gynecologists, practicing ob/gyn at the Tepeyac Family Center, a center "dedicated to the sanctity of human life and natural fertility awareness"in Fairfax, Virginia.