08/18/94
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STANFORD -- Japan should move its birth control policies and practices out of the 19th century.
That is the recommendation of Carl Djerassi and Mariko Jitsukawa expressed in a policy forum article in the Aug. 19 issue of the journal Science.
"Such a move would be highly beneficial to the people of Japan, particularly its women, and to international family planning efforts as Japan becomes an increasingly important player in this field," said Djerassi, professor of chemistry at Stanford and developer of the first oral contraceptive. Jitsukawa is a Stanford Ph.D. student in anthropology.
Currently, both normal (low-dose) oral contraceptives and "morning after pills" are illegal in Japan, the researchers report.
Japan's population growth rate is lower than that of the United States but higher than many European countries.
Primary birth control methods used are condoms and an old- fashioned calendar-based rhythm method, combined with extensive dependence on abortion. About 35 percent of Japanese women report having had abortions, compared to 25 percent in the United States. In addition, 500,000 to 800,000 Japanese women illegally use high-dose steroid pills designed to treat menstrual disorders for oral contraceptive purposes without the package inserts or other warnings about side effects associated with such pills, the scientists report.
In 1992, Koseisho, the Japanese Ministry of Health and Welfare, indefinitely postponed approval of low-dose oral contraceptives, despite the positive recommendation of its medical advisory committee and completion of clinical trials with thousands of Japanese women volunteers that demonstrated the pill's safety. The reason given was that approval of the oral contraceptive might contribute to the spread of AIDS by reducing condom use.
"Encouraging condom use is a good thing to do, but using this as a justification for continuing to ban oral contraceptives does not make sense," said Jitsukawa. Surveys indicate that 70 percent of married couples use condoms in Japan. But she and Djerassi point out that this figure includes use of condoms only during the woman's fertile period, a practice that would not consistently protect from HIV infection. Also, studies indicate much lower (about 25 percent) condom usage during extramarital sex. The main users of oral contraceptives would be monogamous, married women, who thus far are at little risk of HIV infection and who currently are forced to use abortions or less safe therapeutic pills, they say.
According to the researchers, because of Japanese sexual mores, there is little political pressure from Japanese women's groups for approval of the pill. One source of opposition is a small sector of the medical community, which stands to lose hundreds of millions of dollars from the abortions that are performed for about $1,000 in private clinics outside the universal health-insurance system. The official number of abortions performed in Japan is reported at around 440,000. But the actual number is higher - some estimates place it as much as three times greater - because a number of Japanese doctors perform such operations for cash and do not report them in order to avoid paying taxes. By comparison, about 1.5 million abortions are performed each year in the United States, which has twice the population.
Djerassi and Jitsukawa recommend that the Japanese government also approve the use of RU-486 as a morning after pill, rather than as an abortifacient. Because of the "sexless syndrome" - the relatively low frequency of intercourse - practiced by many married Japanese couples, a dozen of these pills could substitute for the 280 oral contraceptive pills required to prevent an unplanned pregnancy, they say.
The two also advocate the replacement of the calendar-based method that Japanese women currently use to determine the timing of ovulation with more effective methods of "fertility awareness" by means of recently developed home tests that measure hormonal changes in a drop of urine, thus providing users with more precise information about their body's natural cycle.
The researchers point to Japan's increasing participation in international family-planning programs as a reason why their recommendations should be given urgent consideration. Japan is second only to the United States in the amount of money it contributes to development assistance. Earlier in the year, the Japanese government announced its intention to contribute a total of $3 billion by the year 2000 to the most urgent problems facing developing nations, including population problems.
"It is inevitable that, unless they are changed, domestic family- planning practices will adversely effect the Japanese government's ability to take an effective leadership position on birth control," Djerassi said. That is particularly true in the area of bilateral aid, where the Japanese government generally gives "in kind" aid tied to procurement of products in Japan: If oral contraceptives, for example, are not available in Japan, they are not likely to be part of a bilateral aid program, the researchers say.
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