Testing the Gräfenberg Ring in Interwar Britain: Norman Haire, Helena Wright, and the Debate over Statistical Evidence, Side Effects, and Intra-uterine Contraception

Abstract

This paper examines the introduction to Britain of the Gräfenberg ring, an early version of what later became known as an intrauterine device (IUD). The struggle during the interwar years to establish the value of the ring provides an opportunity for a case study of the evaluation and acceptance of a new medical device. With the professionalization of the birth control movement and the expansion of birth control clinics in interwar Britain, efforts to develop better scientific means for contraception grew rapidly. At the end of the nineteenth century, methods for controlling fertility ranged from coitus interruptus and abstinence, to diverse substances ingested or placed into the vagina, to barrier methods. The first decades of the twentieth century brought early work on chemical contraceptives as well as a number of new intrauterine devices, among them the Gräfenberg ring. Developing a cheap, reliable, and widely acceptable contraceptive became a pressing goal for activists in the voluntary birth control movement in Britain between the wars. Yet, tensions developed over the best form of contraception to prescribe. By situating the Gräfenberg ring within the context of the debates and competition among British medical and birth control professionals, this paper reveals broader issues of power relationships and expertise in the assessment of a new medical technology.

This paper examines the introduction to Britain of the Gräfenberg ring, an early version of what later became known as an intrauterine device (IUD). The struggle during the interwar years to establish the value of the ring provides an opportunity for a case study of the evaluation and acceptance of a new medical device. With the professionalization of the birth control movement and the expansion of birth control clinics in interwar Britain, efforts to develop better scientific means for contraception grew rapidly.¹ By the end of the nineteenth century, available methods for controlling fertility ranged from coitus interruptus and abstinence, to diverse substances ingested or placed into the vagina, to barrier methods such as the cap, pessary, diaphragm and the male condom.² The first decades of the twentieth century brought early attempts at chemical contraception and a series of new intrauterine devices, among them the Gräfenberg ring. These developments found an eager audience among members of the voluntary birth control movement in Britain, who had joined together in a quest for improved methods of female contraception, and strongly condemned the widely practiced technique of withdrawal.³ Developing a cheap, reliable, and easy-to-use contraceptive became a pressing goal for activists in this period.⁴ Yet, tensions developed over the best form of contraception to prescribe. By situating the Gräfenberg ring within the context of the debates and competition among British medical and birth control professionals, this paper reveals broader issues of power relationships and expertise in the assessment of a new medical technology.

Central to deliberations over contraceptive methods in this period was the Birth Control Investigation Committee, the BCIC, founded as the tensions among members of the voluntary clinic movement in Britain gave way to open debate.⁵ The famous biologist and eugenicist Marie Stopes, author of the sex manual Married Love, who set up the first birth control clinic in London in 1921 and subsequently five others across Britain, recommended the use of a greasy suppository in combination with the “pro-race cap” that she designed. She rejected the diaphragm recommended by the Walworth Women’s Welfare Centre, a rival clinic set up by the Malthusian League, on the grounds that it caused cancer, and she was opposed to the sheath.⁶ To resolve such tensions and to examine “the sociological and medical principles of contraception,” lay members of the North Kensington Women’s Welfare Centre and the Cambridge Birth Control Clinics took the initiative in 1927 of forming the BCIC.⁷ The committee was financed by the British Eugenic Society and the Bureau of Social Hygiene, both private bodies aimed at preventing social problems through scientific methods.⁸ Among the early and founding members were its chairman, Sir Humphrey Rolleston, Physician-in-Ordinary to King George V and Regius Professor of Physic at Cambridge; the psychiatrist Carl Paton Blacker, secretary of the Eugenic Society; and the British evolutionary biologist and eugenicist Julian Huxley. The BCIC would finance clinical research on contraceptive substances and devices and mediated the process of contraceptive research, developing standards for the evaluation of contraceptive methods. This group took a key role in mediating the process that would eventually determine the fate of the Gräfenberg ring.

Historians have generally identified the Australian sexologist Norman Haire – a well-known, eccentric figure within London’s elite medical community – as responsible for importing the ring into Britain. Haire had previously designed his own pessary, modifying a vaginal diaphragm that Dr. Mensinga invented in Germany in the 1870s.⁹ There was, however, another important figure, the female gynecologist Helena Wright, who played a crucial role in the early testing and evaluation of the ring. Wright was a relative newcomer to the science of contraception, but she could tick the boxes as a good medical professional, a respectable married woman doctor, and a recognized member of the broader birth control movement. Haire’s and Wright’s different positions within the medical and reform communities were reinforced in part by divergent visions of medical authority and expertise, evident in the criteria they used to assess the ring. Haire had an exclusive, private clinical practice on Harley Street, but he was unable to connect with the research-driven elite of the BCIC, who instead came to embrace Helena Wright. Wright adopted the standardized clinical assessments and reliance on laboratory-based evidence that the BCIC promoted, while Haire, by contrast, cultivated a vision of clinical expertise based in accumulated experience and expert observation. Haire also relied heavily upon his understanding of his individual clients’ needs to justify the value of the ring. A close focus on this rivalry provides a lens through which to examine the ways that medical authority and expertise were obtained and secured for the assessment of a new contraceptive technology.¹⁰

We have very good historical analysis of how early chemical contraceptives were produced and tested in the interwar years,¹¹ but less is known about the evaluation and development of medical devices such the Gräfenberg ring. Historians have explored the invention of the IUD in Germany and the revival of this method after the Second World War; and feminist scholars have provided accounts of IUDs as an oppressive technology and a means for coercive population policy in the 1960s, targeting the Global South especially.¹² Yet, there is no published research on the critical period of the interwar years when private and clinical trials on the Gräfenberg ring helped to establish its use as an early, implanted medical device. Besides filling this gap in the history of birth control methods, a careful study of the Gräfenberg ring contributes to our understanding of the changing nature of medical authority in interwar Britain, and the implications for the development of medical research. Use of the archives of the National Medical Birth Control Committee held at the Wellcome Library, articles published in medical journals, proceedings of international conferences and reports on contraceptive tests and trials, permits a close examination of the trajectory of the device from its introduction by Ernst Gräfenberg at international conferences to its first utilization in Britain and its progressive disappearance from clinical use before World War II.

Experts on the GrÄfenberg Ring

The Gräfenberg ring took its named from its inventor, Dr. Ernst Gräfenberg, a graduate of the University of Göttingen, who was born in Germany in 1881.¹³ Gräfenberg specialized in obstetrics and gynecology at the University of Kiel and undertook research on female physiology at the Berlin Institute of Physiology. He went on to open a private practice in Berlin in 1911 and started working on intrauterine contraceptives in the early 1920s in his own private practice. His first contraceptive, which he tested on 400 patients, was made from star-shaped devices with coils of silkworm gut. In extensive trials of the device, Gräfenberg experienced a “great number of failures… 3.6 percent,” resulting when the star was expelled from the uterus. Undeterred, he tried a different shape using a circle of gut wound with silver thread that he tested on another 1100 patients.¹⁴ He eventually decided to use a ring made of silver or gold wire twisted spirally and placed in the uterus, and fitted 600 silver rings. He claimed that the failure rate with the new device was only 1.6 percent. Based on these results, he presented information about his method widely at international conferences. This device was far from the only contraceptive method available,¹⁵ but it had the special appeal of preventing pregnancy without interfering overtly with the sexual act. In addition, the ring had to be inserted by a physician, giving it greater medical credibility and the prospect of exclusive medical control.

When Gräfenberg presented this device in London in 1929 at the Third International Congress of the World League for Sexual Reform (WLSR), he was not the only one at the conference to report on the ring. Norman Haire also offered a paper describing his experience with the method. The ability to promote this promising new device may have appealed to Haire in his efforts to establish a reputation within London’s elite medical community. The son of a Polish Jew and his London wife, Haire was born in Sydney, Australia. He studied at the University of Sydney and acquired his training in gynecology at the Royal Women’s Hospital in Melbourne. In 1919, he moved to London and opened what became a lucrative gynecological practice on Harley Street, in an office decorated in refined style. Yet, as an outsider to interwar London, a Jew, a homosexual, and an Australian, Haire had a long struggle in his goal to be thought of as a “respectable English doctor.”¹⁶ His expertise in sexology constituted an added obstacle. Sexual medicine was a topic strongly associated with the Continent, and so was something that English doctors engaged with cautiously.¹⁷ Using strategic alliances with well-placed members, Haire was able to establish himself as moderate in his positons, and he was reportedly able to win a fair degree of acceptance. He seemed also to struggle, however, to contain a combative personal style. He was a member of the Malthusian League, but fought with its leading supporters, Dr. Charles Vickery Drysdale and his wife Bessie Drysdale. In 1922, he was the medical advisor to the Walworth Women’s Welfare Centre set up by the Malthusian League. However, after a few months he resigned or was forced to resign, “leaving bad feelings behind him.”¹⁸ Haire later opened his own birth control clinic in 1927, the Cromer Welfare and Sunlight Centre in St Pancras, which was not, however, part of the established Society for the Provision of Birth Control. He also came into dispute with members of the British Society for the Study of Sex and Psychology (BSSSP), although the society aimed for “a greater openness, and a putting aside of received prejudices, in the discussion of sexual matters.”¹⁹ Further, Haire had a problematic relationship with the feminist Stella Brown, a leading figure of the birth control movement. These conflicts with different members may explain why he set up and ran the British branch of the World League for Sexual Research, or the WLSR.

Haire had discovered the Gräfenberg ring while attending the Congress of the International Society for Sex Research in 1926 in Berlin.²⁰ In July 1929, he started fitting the ring for his patients in his own private practice and at his Cromer Welfare and Sunlight Centre, and gave a talk on his preliminary results at the 1929 WLSR congress. As Ivan Crozier has argued, the advocacy of the new device offered Haire a strategy for positioning himself not as a newcomer but rather as a notable British specialist in a novel and promising scientific method. Haire was “stamping out a territory for himself,”²¹ and thereby gaining new patients as well as scientific recognition and credit.

In his work with the ring, Haire’s strategy was threefold. First, he presented the history of Gräfenberg’s research on the device outlining every step with meticulous care and demonstrating a mastery of the subject. Second, he presented the ring as a comparatively safe, new device by differentiating it from the other intra-cervical pessaries, such as the wishbone pessary, which involved a v-shaped spring that was held against the cervix by a metal plate, with the spring extending into the uterus.²² Haire had passing involvement with this latter method in 1922 when he was asked by the famous birth control activist Maries Stopes to accept two patients who wanted to be fitted. He declined, warning Stopes that it could act as an abortifacient by inducing miscarriage.²³ In his 1929 conference, Haire further described these devices as having the potential to cause physical damage. The V-shaped spring created pressure on the walls of the uterus and served to “keep open a passage between the septic vagina and the aseptic uterus and therefore facilitate the entry of pathogenic organisms from the vagina into the uterus.”²⁴ The Gräfenberg ring laid entirely within the uterus and did not occupy the canal of the cervix, as the intra-cervical pessary did. Finally, he presented the ring as a modern medical method that necessitated a sound understanding of gynecology for its use. In order to assess the vaginal space for safety in accommodating the fitting of the ring, a gynecologist would need to be able to recognize any “suspicion of infection of the genital passage,” representing a contraindication for use of the ring. Insertion of the ring required the sterilization of the device and relied on specialized surgical equipment, including a vaginal speculum, the volsellum forceps, and a series of cylindrical bougies of graduated sizes used to dilate the cervical canal. These were all instruments in routine use by gynecologists from the turn of the nineteenth century – although their initial use met with medical opposition, especially the speculum.²⁵ The position of the patient during the fitting – lying on her back with knees bent, legs spread apart, and feet in stirrups –also marked the use of the Gräfenberg ring as an ordinary part of gynecology. Haire stated that the medical office was the appropriate place for the fitting procedure, placing the ring under the responsibility of the medical profession and, he suggested, “the gynecologist only.”²⁶ It was a claim he could expect to find ready acceptance among his fellow gynecologists. By insisting on these features of the ring, Haire positioned himself as a loyal follower of Gräfenberg; a reliable, scientific advocate for the device; and, with any luck, Britain’s leading gynecological expert on the new method.

Despite these attempts to secure control over the use of this new device, Haire’s efforts were quickly contested by Helena Wright. Members of the BCIC also learned about the method at the International Congress of the World League for Sexual Reform and through an article in The Lancet praising a paper by Gräfenberg as “deserv[ing] the most impartial consideration.”²⁷ They decided to finance a mission to Berlin to collect information on the method, and tasked Wright with making the trip.²⁸ Wright came from a wealthy London family, and graduated as a medical doctor from the London Royal Free Hospital School of Medicine for Women in 1915 where she had been trained by Winifred Cullis, Professor of Physiology at the University of London and a future member of the BCIC. Wright had become involved with birth control after meeting Marie Stopes on holiday in Cornwall, in 1918, the year that Stopes published her notorious book, Married Love. In 1919, along with her husband, the captain and surgeon Henry Wright, Helena left for China, where she would serve as Associate Professor of Gynecology at the Shantung Christian University Hospital. When Wright returned in 1927, she became Chief Medical Officer of the North Kensington Women’s Welfare Centre and wrote to the Birth Control Investigation Committee, asking them for an appointment there. Wright’s application was further endorsed by Cullis, Wright’s teacher at the Royal Free Hospital, and the BCIC went on to finance her further training. The committee also thought that it would be valuable to engage her to collect data in British clinics and overseas.²⁹ These connections with the North Kensington Centre and the BCIC gave Wright the credentials and legitimacy that she needed.

In January 1930, Haire contacted the BCIC asking about potential funding to support his research on the ring, with very different results. Without explaining their reasons, they flatly refused Haire’s request. Other comparable research projects fared better. The BCIC considered a proposal by Bertold P. Wiesner, a young Austrian physiologist and “rejuvenationist” who worked at the University of Edinburgh,³⁰ to study the contraceptive action of the Gräfenberg ring. Although the committee eventually declined to fund Wiesner, they gave him a careful hearing and an interview, opportunities that were denied Haire.³¹ The evidence suggests that the BCIC had hesitancies about Haire’s research and expertise. Haire had obvious difficulty positioning himself among the British advocates of birth control, yielding a more central position to Wright in the efforts surrounding the ring.³²

Wright went to Berlin in December 1929 to gain training and information on the method from Gräfenberg directly. She took with her a carefully constructed questionnaire provided by the BCIC, which aimed to gather information to set out a practical guide for inserting and removing the ring. The first questions referred to the number of cases where the method had been tried, its potential side effects, its contraindications and ways to identify the latter. The points that Wright had to raise centered on the technical, medical aspects of the ring. She covered issues around the length of time that the ring could be left in situ, whether it might be embedded in the endometrium, and the extent to which a follow-up system had been in use. Questions focused also on the attitude of the medical profession in Germany, experience of the patients, and available literature on the subject. These questions reflected the scientific approach of the BCIC, namely “to establish facts and to publish these facts as a basis on which a sound public and scientific opinion can be built.”³³

Wright, however, did not confine herself within the scope of the questionnaire articulated by the BCIC. She added questions about the physiological effects of the ring on the endometrium and the uterus, relating to Gräfenberg’s original claim that the device blocked implantation by thickening the lining of the uterus (endometrial hyperplasia). She also asked whether the insertion of the ring was painful for the patient.³⁴ This interest in the patient’s experience was illustrative of Wright’s understanding of what mattered when assessing the ring: side effects, efficiency and potential pain. She wrote that overall, patients were enthusiastic about the method. Regarding the potential pain induced by the ring, she seemed to be extremely cautious, as she underlined that the insertion of the ring only seemed to be painful when Gräfenberg placed the ring with the help of the volsellum forceps. Yet, she underscored that speed and comfort when placing the ring might greatly depend on the dexterity, gentleness, and skill of the doctor.³⁵ She compared the smooth experience of Gräfenberg’s patients with one of Haire’s patients in England, “who found the insertion of the ring so painful that it had to be stopped and was not finished.”³⁶

At this stage, Haire still had something approaching a professional monopoly on the use of the ring in London, and he pressed the advantage of his expert reputation in medical professional circles. Haire wrote a series of letters to medical journals to draw the attention to the new device. In this forum, he presented himself as the only reference for the Gräfenberg ring. In his letter sent in 1929 to the British Medical Journal, referencing an article on the “revocable sterilization of the female,” Haire took the opportunity to present the ring as a means of temporary sterilization.³⁷ The choice of vocabulary is relevant; by emphasizing the reversibility or temporary effect of the ring, Haire was trying to bypass the potential contemporary criticisms of contraception as leading to sterility.³⁸ Haire advocated the use of the device based on both Gräfenberg’s and his personal experiences, at this point limited to 100 cases in his private practice and in the Cromer Welfare and Sunlight Centre. He attributed the reliability of the method to “the skill of the medical attendant, and not (as in most other contraceptives) on the skill or care of the patients.”³⁹ In addition, he emphasized the safety of the ring in the right hands: “the procedure appears to be harmless in the absence of genital infection, provided it is carried out with strict aseptic precautions. The absence of harmful irritative effects is apparently due to the fact that the uterine mucosa is cast off at each menstrual period.”⁴⁰ His hand-on professional experience, coupled with reports of positive results, highlighted his position as the major clinical advocate for the device, even in lieu of institutional support from the BCIC.

This tactic had its own risks, however. Another letter in the British Medical Journal from one Dr. Richard Fawcitt, for instance, described a patient who had experienced “nasty discharge” following the insertion of the ring by a colleague in London, plausibly targeting Haire, who identified himself so closely with the device.⁴¹ Fawcitt asked whether other practitioners had experienced difficulty with the method. In his letter of reply to Fawcitt, Haire did not yield much ground, although his tone softened somewhat in underlining the precautions to follow before and after inserting the ring to “avoid such a condition (i.e. nasty discharge).” He argued that neither the ring nor the process of insertion were necessarily responsible for the discharge, since “it must be remembered that pelvic disturbances which occur subsequent to the introduction of the ring are not necessarily caused by the ring.”⁴² Haire nonetheless acknowledged that if the risk of “such complication (pelvic disturbances) is too great to compensate for the advantages of the method it must be abandoned.”

Alongside Haire’s response, the British Medical Journal also published a letter in response to the doctor’s concerns from Wright – a clear challenge to Haire’s priority in knowledge about the method. By taking part in the debate on the ring, Wright positioned herself as an alternative interlocutor. Seizing the initiation, Wright made sure to mention her travels to Berlin to visit the inventor of the ring: “The letters of Haire and Fawcitt… raise points which need emphasis, in view of the possibility that the method may become widely used in this country. I have just returned from a visit to Dr. Gräfenberg in Berlin.”⁴³ Only Haire and Wright published replies to the question of side-effects from the ring, setting the stage for their contest over the new device and establishing the London medical community as the center of the debate. By 1930, Haire and Wright were both testing the device in their medical practices. The Zurich International Conference on contraception that year provided an initial forum for discussing their results.

A Rivalry over Method

The battle between these two doctors beginning in 1930 pitted them against each other as emerging experts on the Gräfenberg ring. Although Haire initially had precedence and quickly achieved a very substantial clinical experience, Helena Wright, relying heavily on her affiliation with the BCIC, would eventually prevail as the trusted voice. In this context, however, Haire became more aggressive toward colleagues working on the subject, and began to challenge those who were raising concerns. A focal point in the debates was the use of statistical data and the determination of what considerations had priority in assessing the method. In the 1920s the BCIC would join the International Medical Group for the Investigation of Contraception in leading the quest for careful trials with laboratory support and detailed statistical assessment for contraceptive methods.⁴⁴ For these two organizations, developing a scientific birth control method through sound clinical trials was an important step toward establishing birth control as a legitimate endeavor of medicine. Their work took place at a time when the Medical Research Council – set up in 1913 as a single research organization for the whole of the UK, with funds provided under the National Insurance Act for medical research – increasingly defined the laboratory as indispensable to the work of medical trials, and progressively made statistical analysis a major consideration.⁴⁵ The BCIC financed much of the research on fertility carried out in laboratories by physiologists, thus helping to promote the new vision adopted by the MRC. These methods met with resistance, however, from a segment of the medical profession, who called for a more “individualized conception of illness and its treatment,” made possible by the critical eye of individual doctors acquired through long experience at the bedside. ⁴⁶ In such struggles, rhetoric was especially valuable in negotiating boundaries, particularly among the circle of people working on the contentious topic of physician-controlled contraception.⁴⁷ Haire and Wright drew from different visions of medicine in their competing efforts to take ownership of the processes for evaluating the Gräfenberg ring.

A primary difference between Haire’s and Wright’s approach to evaluation lay in how they presented their results. The BCIC took a role in pointing out this difference. In the debate that developed in the British Medical Journal and at the 1930 Zurich Conference, Haire relied heavily on his firsthand experience with the method. He introduced himself as the follower of Gräfenberg and as the only other expert physician working on the subject. Illustrating his priority, he pointed out that, apart from Gräfenberg, he was the only doctor contributing to the compilation of sound data: “There are few statistics yet available about this method. The only ones I have been able to find in the literature are those of Gräfenberg….I am offering a preliminary report of my own cases.”⁴⁸ Noting with restrained modesty that “my own cases are only 270 in numbers,” he pronounced himself “very pleased with the method.”⁴⁹ He then outlined the results, in a fashion that served to diminish the failure rates. He explained that in 13 percent of the 270 cases, the ring had fallen out. However, he added, after reinserting the ring, he obtained a final figure that looked much better, since “the actual failure rate was 1 in 270.”⁵⁰ It is unclear to what extent Haire’s rhetorical turns with the numbers supported his case, but it likely gave the report a more promotional character. Presenting alongside Haire, in her discussion of substantially fewer cases, Wright adopted a cooler tone, although without rejecting the potential value of the ring. She emphasized contraindications to the use of the method and noted Gräfenberg’s careful attention to the process of selecting appropriate cases for use of the ring. She took special care to underscored the precautions that had to be taken to avoid complications, using phrases like “absolute contraindication,” “urgently warns,” and “immediate removal.”⁵¹ She offered a more critical perspective on the efficacy of the device, which was in part unavoidable given the high rate of failures she had witnessed, with the expulsion of the ring in four cases out of fifteen. Yet, she continued to support its cautious use.

In 1931, the International Medical Group for the Investigation of Contraception published a report compiling three articles on the Gräfenberg ring by Wright, Leunbach (a Danish general practitioner who tested the ring in his own private practice on 178 patients) and Haire. This report, as well as the correspondence between Haire and the report’s editor, Blacker, shows how the issue of reliable results, and the handling of statistical and numerical evidence, impacted Haire’s professional position. In the foreword to the report, Blacker underlined contradictory results between Haire, on the one hand, and Wright and Leunbach on the other hand. Haire submitted, Blacker noted, “in general terms a favourable account of his findings…[but] abstains from giving any but the vaguest figures.”⁵² In comparison, Wright and Leunbach presented “detailed and exact figures” that conveyed a “less favourable impression of the ring.”⁵³ Furthermore, Blacker expressed his gratitude to them for “the trouble they have taken in submitting their material to such searching scrutiny and for presenting it with such candidness.”⁵⁴

Indeed, Wright provided a detailed account of the thirty-eight patients she fitted with the ring. She laid out her cautious assessment of the methods in a thorough assessment of individual cases. She was careful to emphasize the recurring problem of ejection of the ring out of the cervix, since only nine of the thirty-eight patients she had fitted still had the ring in place at the time of publication. Despite these unconvincing preliminary results, she laid considerable stress on the satisfaction felt by the nine patients who still had the ring, which encouraged her to “persevere.” She called for the systematic collection of data on the subject: “large numbers of accurate, detailed records will have to be collected before the laws of behaviours of the ring could be deduced.”⁵⁵ The request offered a stark contrast to the methods of Haire, who had referred to his results in vague terms, using words such as “a few,” or “many” to describe his experience with the use of the ring in more than 400 cases.⁵⁶

Haire wrote to Blacker to express his disapproval of the foreword of the issue. Arguing defensively that his results should not be compared to work by inexperienced clinicians, he took a backhand swipe at Wright’s record: “I think that you and your committee or sub-committee are putting yourselves in a ridiculous position when you adopt this omniscient attitude about birth control methods. When I look through the list of names I still fail to see anybody who has any considerable knowledge about contraceptive techniques at all.”⁵⁷ Haire spoke with the backing of extensive experience in the use of the ring, as well as a notable clinical position as a medical officer-in-charge at the Walworth Women's Welfare Centre and a physician who operated his own birth control clinic. Haire also referred to an unnamed colleague who fitted “rings of inferior quality” that broke within the cervix.⁵⁸ It is worth noting that in the original letter that he submitted to the editor, Haire identified the culprit as a “woman doctor,” targeting Wright specifically, with special accent on her sex. The editor altered the text and suggested the word “colleague” instead of woman doctor.⁵⁹ Haire went on to announce that he was buying rings from a Dutch firm, since he found the rings supplied by the German and English firms “far from satisfactory.” Moreover, he implied that clinical experience provided the gynecologist with a certain ease in recognizing “the sort of uterus from which the ring is likely to escape,” implying that his good results with the ring were a result in part of greater expertise and superior judgment. Haire adhered to a traditional vision of medical expertise that was grounded in experience and in cultivated observational skills.⁶⁰ Indeed, he valued his own experience with patients as his main source of knowledge and authority.

However, Blacker had a different vision of what he considered to be good research practices, consistent with the more straightforward and restrained character of laboratory-based medicine.⁶¹ In his letter in reply to Haire, this conception was implicit: “I wrote what I did because I did not wish the report to be construed as an advertisement for you which at the same time would injure the other two contributors on the Gräfenberg ring [Wright and Leunbach] who submitted detailed statistical reports which reflected somewhat unfavourably on their results and present them impartially in my contribution. I did not want them to suffer for it. I am myself persuaded that the results of all birth control methods, including the Gräfenberg ring, turn out to be less favourable when they are carefully analysed than when they are judged by general impression.”⁶² Given the strong disapproval of medical advertisement in the times, Haire had to read Blacker’s note as a subtle rebuke against his more rhetorical, promotional uses of the data he had collected in experience with the ring. The doctor was supposed to show a less self-interested commitment to medical research.⁶³

Haire replied and “was forced” to acknowledge the downsides of the method, “I quite agree that careful analysis reveals less favourable results for all birth control methods than one would think from general impressions.”⁶⁴ However, as a defense, he strongly emphasized that he privileged the care of his patients as his main concern: “It seems to me that there is a fundamental difference in the emphasis we place on two aspects of birth control work – you are primarily concerned with collecting reliable statistical data about the efficacy of various methods, and only secondary is the individual woman who is in need of advice. I am primarily concerned with the urgent need of individual women.”⁶⁵ This assertion again referred to a distinctively different conception of the source of authority in medicine.

The Patient’s Voice

Haire found himself under attack for a lack of scientific rigor and a lack of attention to the requirements for statistical evidence. Yet, his experiences presumably made him more sensitive to his patients’ preferences and needs. Indeed, he underlined the advantages of the ring, noting that it was “free from the aesthetic disadvantages of all the other methods of birth control… does not interfere at all with the spontaneity of intercourse and requires no preparation before intercourse.”⁶⁶ Such concerns were likely central to the choice of birth control methods among the middle class women who constituted the clientele of private practices such as those of Wright and Haire. The oral history study by Szreter and Fisher on birth control practices in Britain between 1918 and 1963 demonstrates this point convincingly. Middle class women found that barrier methods at odds with the spontaneity that they valued so deeply, offered by natural methods of birth control. Szreter and Fisher also found that barrier methods went against “expectation that women should play a relatively passive role in sex.”⁶⁷ In this sense, the cap and jelly typically recommended in the birth control clinics of the time might have been significantly less appealing than the ring, inserted once a year at the doctor’s clinic, which required no further preparation or intervention for contraception. Haire seems to have been well aware of his patients’ preferences and put this aspect at the center of his work. Wright was no less deeply concerned with the quality of her patients’ sex lives, as she made evident in the several sex manuals that she had authored. But her allegiance to the BCIC and the associated desire to make birth control work a “scientific” enterprise, restrained her attention to the aesthetic qualities of sex. She underscored, instead, efficacy and a lack of side effects as the major criteria for judging a good birth control method. These requirements were the utilitarian criteria developed by the BCIC: a good contraceptive method needed to be effective, harmless, easy to employ, and cheap.

Side Effects and Risks of Pregnancy

The debates over the ring also shed light on the significance of side effects as a key element in assessing the contraceptive method. Here again, Haire’s and Wright’s results differed. In his 1931 report, Haire vigorously, but in general terms, supported the reliability of the ring: “Of the catastrophic complications which are supposed by many critics to be an inevitable consequence of the use of this method, I have had no experience….Many of my patients have been wearing the ring for over two years, and the greater my experience with the method the more I am convinced of its value in suitable cases.”⁶⁸ At that time, Gräfenberg was still recommending to change out the device once a year. Without mentioning this admonition, Haire did note that “in a few cases he removed the ring as its presence cause[d] pain or discomfort.” Importantly, he did not consider these side-effects as “catastrophic complications,” although pain might well be considered a legitimate motive for advising against the method.

In comparison, Wright presented a detailed assessment of the full range of specific side-effects. Among her patients, many had experienced bleeding and menstrual irregularity. She also scrupulously followed the guidance offered by Gräfenberg on contraindications and noted that in one case a patient who seemed to have a healthy pelvis at the first medical examination did not inform her of her history of pelvis sepsis, a contraindication to use of the method. As a result, an infection occurred and the patient had to undergo a hysterectomy, a risky operation before the widespread availability of antibiotics.⁶⁹ The fact that Wright shared this negative experience was typical of her commitment to systematic disclosure of results. More problematic for Wright was the potential for the expulsion of the ring to lead to an unwanted pregnancy. In the 1930 Zurich Conference, she discussed the unreliability of the method, explaining that in one case of expulsion the ring was of the correct size and perfectly in place: “I have both the X-ray and the ring, and anyone can see it was not the fault of the size or the position….The ring is sitting there in its perfectly round position.”⁷⁰ In another case, the ring broke in the uterus: “that may have been due to faulty construction in England.”⁷¹ These rings were made by Down Bros Ltd., surgical instrument makers, and were copied from those supplied by Gräfenberg, but were cheaper. Having collected detailed accounts of individual experiences, she offered to share her reports with “anyone interested.”

In the 1931 report, she again stressed the unreliability of the method: “the great obstacle to the spread of the method is obviously, the uncertain protection against pregnancy which it affords.”⁷² In an attempt to address the defects of the method, Wright devised two strategies. First, she designed her own ring and asked Dr. H. M. Carleton, a physiologist from Oxford University, to test it. This experiment was funded by the BCIC. Carleton was tasked with investigating the “effects of foreign bodies in the uterine cavities of animals, with a view to ascertaining the possible effect of the much discussed Gräfenberg ring.”⁷³ Using animals and carrying out trials in laboratories became common in the 1930s under the influence of the Medical Research Council. Carleton presented his results in the British Journal of Obstetrics and Gynaecology in 1933. The ring devised by Wright was made of a silver ring, the coils of which were covered by India rubber, which owing to its smoothness should ease the process of insertion and avoid the ring breaking in situ. The downside of the smoothness of the material was that it facilitated the expulsion of the ring. Apart from this expulsion, the ring was as efficient as the Gräfenberg ring, with the advantage of seeming to avoid the creation of histological changes in the cells of the uterine lining. The second strategy devised by Wright was to fit the patients with the ring on the condition that they would practice other forms of contraception (such as spermicide) continuously during the first, trial year. Then, if after one year it was still in situ, the patient could rely solely on the ring.

Regarding the expulsion of the ring from the uterus, Haire also briefly alluded to it in vague terms: “in a certain number of cases.” Nevertheless, Haire also engaged with the risk of pregnancy, since he mentioned his previous accident with one patient who had delivered a baby despite the presence of the ring. According to Haire, the ring did not provoke a miscarriage and, as such, should not be considered an abortifacient, a recurring accusation against intrauterine devices. This incident was again used by Haire in a debate in the British Medical Journal in 1932. Colonel Green-Armytage, professor of obstetrics and gynecology at the Medical College in Calcutta, wrote a letter to the journal complaining about a “London physician who is a protagonist of birth control” who had fitted the ring and assured his patient of its reliability. The patient became pregnant.⁷⁴ In his reply, Haire avoided any acknowledgement of an involvement in the case, however, he once more used the occasion to position himself as a “reliable” expert on the ring.

Using the case to air his own experience, Haire presented himself as a pioneer in handling such complications: “until August, 1930, no such case was reported in the literature, but in that month I read a paper before the International Society for Sexual Research at the B.M.A in London, in which I reported a case of pregnancy in one of my own patients while wearing a Gräfenberg ring.”⁷⁵ Haire then added that the pregnancy, under careful observation, went well: “The normal nature of this pregnancy would appear to be a reply to Colonel Green-Armytage’s speculation whether pregnancy could continue to full term without damage for the mother or the foetus.”⁷⁶ Clearly, a failure of the ring was perceived not only as a threat to the women but also to the fetus in cases of pregnancy. As criticisms against the method began to appear, Haire sought to rectify claims, putting his own expertise at the center of the discussions. Nevertheless, increasing concern about side effects and efficacy made this tactic difficult. The ardor on Haire’s part to defend a method that seemed less promising than previously began to weaken his position.

Ostracizing Haire

In this process, Haire gradually became ostracized by the medical birth control establishment. His absence from the program of the 1932 conference on medical contraception testified to his colleagues’ hesitations. In July 1932, the National Birth Control Association held a conference in London on Medical Problems of Contraception. Among the speakers was Wright. The correspondence between Blacker, leading organizer of the conference and honorary secretary of the Birth Control Investigation Committee, and Wright is instructive. Wright was gaining a position as the expert on the value of the ring and she began to employ her growing reputation to the detriment of Haire. Wright was invited to the conference to present her latest results on the Gräfenberg ring. She wrote back to share concerns about the possible presence of Haire, pointing out that “last time we met by accident at a public meeting, at which he was only a member of the audience, he took the opportunity to be personally and publicly offensive, to such an extent that the audience protested.”⁷⁷ After hearing her concerns, Blacker made the necessary arrangements to remove Haire’s name from the program, reassuring Wright of the Birth Control Investigation Committee’s opinion: “the general feeling is that official speakers at the Conference whose names appear on the program should be people in whom the committee has confidence and whose report they regard as trustworthy.”⁷⁸ The subsequent review of the conference published in the British Medical Journal added insult to injury. The article emphasized growing disillusionment about the method: “Every new method in medicine passes through three stages: first being new, it was scoffed at, then there followed a phase in which it received passionate support of the suggestible elements in the community, who, very naturally, were disillusioned by the immediate results; and finally there came the time when critical intelligences go to work and assessed the method as its true value.”⁷⁹ It presented the research carried out by Wright and Dr. Carleton of the Department of Physiology at the University of Oxford. The latter outlined his main results based over 100 experiments with rabbits. Both researchers shared their concerns around the efficacy of the method. Haire was mentioned, but only as an “enthusiastic follower” of Gräfenberg and as the only doctor who “applied extensively” the ring in a birth control clinic. Haire had been pushed outside the bounds of that third category described in the introduction, where “critical intelligences go to work.”

Haire was fully excluded by 1933, when the BCIC and the National Birth Control Association held a second conference at the British Medical Association House on medical problems with contraception. His name did not appear on the program, and no mention was made of his work in the published reports. Wright was present and chaired a session. Carleton presented a paper on the after effects of the Gräfenberg ring, and Wright was named as the other expert working on the subject.⁸⁰ In addition, the conference ended with a call to stop fitting patients with a method that was deemed unreliable and harmful: “it could hardly be doubted that there was a potential danger in introducing into the uterine cavity a foreign body which was apt to undergo both chemical changes and physical fragmentation.”⁸¹ In 1936, Wright explained that she had stopped recommending the ring due to its unreliability and side effects and instead recommended the usual pessary and contraceptive jelly.

The device, nonetheless, retained its appeal for some patients. Wright asserted in a letter to the physician and birth control advocate, Gladys Cox, that she would insert the ring “only if the patient insists in spite of knowing the disadvantages of the method.”⁸² This shows a demand on the part of patients, and suggests that Wright’s patients occasionally insisted on being fitted with it – with interesting hints at the concerns about proper informed consent that would stir a decade later.⁸³ In 1932, Haire had fitted more than 400 patients and this number had extended to 1000 by 1939.⁸⁴ However, in his book, published in 1936, he was less enthusiastic about the ring, emphasizing its lack of reliability. This led him to recommend the combination of the ring with a spermicide jelly. Hence, in his view, the ring lost one of its main advantages, namely the absence of preparation before intercourse that supported the spontaneity of the sexual act.

Conclusion

By contextualizing and tracing the evolution of a device from its appearance in limited medical circles to its testing, its brief championing, and progressive condemnation, this study outlines broader issues in the diverging means for judging the value of new medical devices, in a period that saw the consolidation of accepted mechanisms for clinical assessment.⁸⁵ This article shows the value of combining different levels of analysis to assess the adoption and development of a specific contraceptive technology. First, identifying the main actors involved in the production of knowledge around the Gräfenberg ring and their respective positions within the medical landscape – where networks, alliances and interpersonal relationships took shape – helps to explain whose voice was heard and legitimated within the medical circles. This article reveals the rivalry between two forerunners of birth control methods: Norman Haire and Helena Wright. Haire built up an exclusive private clinical practice on Harley Street, but he seems to have been out of touch with the research-driven elites of the BCIC, to which Helena Wright belonged. Indeed, the BCIC declined to finance Haire’s research and gradually ostracized him. Wright, instead, became the trusted voice on questions about the Gräfenberg ring within this influential community.

Here I have argued that Haire’s and Wright’s different positions of power within the medical establishment and birth control movement were reinforced in part by divergent visions of medical expertise, perceptible in the criteria they used to assess the ring. While Wright embraced the clinical and laboratory-based evidence promoted by the BCIC, Haire adhered to traditional criteria based on accumulated experience and expert observation, but also heavily invested in an individual understanding of clients’ needs. The predominance in scientific publications of the issue of the efficacy of the ring heightened the latent tension between Wright and Haire. Wright provided a detailed, objective account of results and adopted a cautious approach to the new method, presenting her negative results alongside positive ones. Haire, on the other hand, generalized from his experience, providing only imprecise numerical results, relying on the strength of his clinical reputation to carry his points. He expressed little interest in statistical analysis, instead privileging his extensive experience with the method and advocating for the needs of his patients. There was evidence of such a demand among patients, for contraceptives that did not interfere with the spontaneity of the sexual act. Haire proved reluctant to give up on a method that was drawing increasing criticism, but he sustained a busy practice, testified to by the numbers of procedures he could report. Despite the potential appeal of this strategy, Haire gradually lost professional credibility in favor of Wright, who developed a transparent approach to the assessment of the use of the ring that was based on the critical and judicious interpretation of clinical evidence.

This paper thus offers a fresh look at the successes and failures of the Gräfenberg ring, showing how evolving scientific criteria for evaluation impacted the device’s reception among the medical community in Britain. A division emerged among members of the birth control movement who prescribed and assessed contraception, between the circle of doctors and scientists which welcomed Helena Wright with her developing command of scientific clinical assessments, and individuals such as Norman Haire and Marie Stopes who, although popular with clients, came to be treated as eccentrics, poorly versed in proper scientific method. These were two visions of medicine, implying also differences in medical engagement with individual preferences in sexual matters. The impersonal approach towards collecting scientific data seems to have won out in this instance, with the publication by the BCIC in 1937 of a list of approved contraceptives, which ratified the required methods for use in assessing contraceptive methods. But this measure did little to resolve the underlying tensions between competing ways of understanding medical goals within the intimate domain where science and sex met.

Footnotes

ACKNOWLEDGEMENTS

I am really grateful to Jesse Olszynko-Gryn and Ivan Crozier who offered valuable feedback on the first version of this article. I am particularly grateful to Lesley Hall who shared materials with me and provided useful comments. I would like to thank the two anonymous reviewers for their useful and stimulating suggestions as well as the editors for their comments. I would like to thank the two anonymous reviewers for their useful and stimulating suggestions as well as the editors for their comments. A special thanks goes to Chris Crenner for his help.

FUNDING

I gratefully acknowledge the support of the Swiss National Science Foundation grant number P300P1_171604.