CRACKS IN THE SCIENTIFIC AND THERAPEUTIC. PROGRAM
In the original theory, sex hormones were conceptualized as chemical agents that were strictly sex specific in origin and function. Following this conceptualization laboratory scientists, pharmaceutical companies and gynecologists made two types of sex hormones: male and female. As we saw in Chapter 2, the sexual specificity of sex hormones became a topic of debate during the 1920s and was gradually abandoned. How did this crack in the scientific program affect sex hormone therapy?
From an evaluation of the therapeutic uses of sex hormones it is clear that the idea of a sex-specific function directed the therapeutic application of sex hormones, particularly throughout the 1920s and the early 1930s. The clinical trials as well as the prescription of female sex hormones was restricted exclusively to women. Male sex hormones were prescribed only to men. Although this dualistic approach dominated the therapeutic use of sex hormones, the crack in the paradigm did not leave the clinic untouched. From the early 1930s, the first indications gradually emerged for “paradoxical” hormonal treatment, as the prescription of female sex hormones to males and vice versa was named. W. Petterson, a general practitioner in Berlin, evaluated this development in hormone therapy in 1933:
The recognition of the fact that the living organism, male as well as female, is bisexual in disposition, gave rise to the introduction of paradoxical sex hormone therapy. Until recently, it was an established fact that in the man only testis hormone and in the woman only ovarian hormone was therapeutically effective. The application of heterosexual sex hormones, whether or not in combination with homosexual sex hormones, has recently been shown in interesting cases, particularly with respect to chronic skin diseases. These reports led to critical discussions. Notwithstanding all this, scientists were not inclined to investigate experimentally this remarkable and obviously paradoxical reaction.
Such “paradoxical” hormone therapy came in particular to be applied in
diseases ascribed to an “endocrine imbalance”: a “deficiency” in male or
female sex hormone (Petterson 1933:716). In the 1930s, Menformon was prescribed to men in cases of specific eye diseases (retinitis pigmentosa), prostate cancer and disorders in the vascular system (Organon Archive 17 April 1937). Testosterone was prescribed to women for indications similar to those of female sex hormones, in particular menstrual disorders, psychological disorders and menopause (Tausk 1939a). “Paradoxical” hormone therapy seems to have been directed to women to a much greater extent than to men (Novak 1939). Although the use of sex hormones was no longer strictly sex specific, the model of sex specificity remained the dominant approach in the clinic. The crack in the scientific program led only to minor changes in the therapeutic program. In the Pocket Lexicon of Organ and Hormone Therapy, Organon mentioned “paradoxical” hormone therapy explicitly in just one out of thirty-seven indications in which the prescription of female or male sex hormones was advised. In 1938, Marius Tausk reviewed the practice of the prescription of male sex hormones to women as “very remarkable,” but concluded that
although treatment with testosterone resulted in a striking
improvement, this treatment will certainly not replace the known
hormonal therapy of menopause with ovarian hormone!28
In this manner, clinicians and pharmaceutical companies further reinforced the concept of sex hormones as two separate entities: male sex hormones as new drugs particularly for men, female sex hormones as new therapy for women.
Another crack in the research and therapeutic program appeared when studies were published suggesting that the use of female sex hormones might lead to cancer. In 1932, Lacassagne, a zoologist at the Radium Institute in Paris, reported the induction of carcinoma in experiments with female sex hormone injections into male mice. Since the 1930s, an assumed relation between female sex hormone therapy and cancer had been debated intermittently (Tausk 1934b). The first reactions of Organon to these publications were rather moderate. In 1934, Tausk reviewed these reports in Het Hormoon, concluding that there was no risk involved in the therapeutic use of female sex hormones (Tausk 1934b). In 1936, Organon acknowledged, however, possible negative effects of these publications for the promotion of female sex hormone therapy. In discussing the publicity campaign for a new female sex hormone preparation (Dimenformon), Tausk and Laqueur emphasized that the introduction of a preparation that could be used in smaller dosages had a ‘strong propagandists effect with respect to the actuality of the carcinogenic question’ (Organon Archive 7 December 1936). Following the publicity of the French pharmaceutical company Crinex, who had organized a wide-scale propaganda campaign against the use of concentrated female sex hormone preparations because of the risk of cancer,
Organon decided in 1937 to circulate a special brochure on female sex hormones and cancer (Organon Archive 12 August 1937). In 1939, Organon reassured the medical profession that the risk of cancer was not very serious. Citing Laqueur’s colleague John Freud, Tausk suggested in Het Hormoon that
for fear of unpleasant consequences, one should not use anything for therapy or for food. One does not forbid kitchen salt just because one kilogram, taken at one tune, may cause a deadly toxication.
Tausk concluded that the use of female sex hormones in therapeutic dosages would not cause cancer (Tausk 1939b:127).
The introduction of the first synthetic female sex hormone, preparation DES (diethylstilbestrol), once again fueled the debate over the carcinogenic character of female sex hormones. In 1939, reports were published of breast cancer following injections with stilbestrol. The debate on the carcinogenicity of female sex hormones scarcely affected the promotion and reception of female sex hormones. The medical profession, as well as the pharmaceutical industry, emphasized their positive experiences with female sex hormone therapy.29
This story of hormonal drugs illustrates in a lively way that the development of a drug does not stop the moment it appears on the market—that is just the beginning. The marketing of sex hormones included the continuous testing of hormonal preparations in both the laboratory and the clinic. At the moment this story begins, sex hormones were merely chemical products with a largely unknown therapeutic value and an unexplored market. Sex hormones may best be portrayed as drugs looking for diseases.30 Before the actual process of marketing could begin, the pharmaceutical company had first to create its audiences. It was clear that Organon could succeed in creating a market only if it linked up with the needs of the medical profession: the company had to create arrangements with the medical community in order to find diseases that could be treated with its new products. The only strategy to become informed about the therapeutic value of sex hormones was the organization of clinical trials.
These clinical trials played an important role in establishing the relationships between laboratory scientists, pharmaceutical entrepreneurs and clinicians, with laboratory scientists as intermediaries between the pharmaceutical company and the medical profession. We saw how Laqueur mediated all contacts between Organon and the medical community. Laqueur, as both a laboratory scientist and a trained physician, was the ideal actor to bridge these two worlds. Laqueur managed to convince his colleagues of the benefits of cooperating with Organon by promising the provision of high quality hormonal drugs in exchange for the delivery of raw materials and their cooperation in clinical trials. Laqueur thus enabled Organon to get access to the required raw materials and to a context in which the therapeutic value of its new products could be defined.
Most importantly, clinical trials also functioned as major devices in linking drugs to their audiences. The trials enabled Organon to cultivate a loyal clientele in the medical profession, and they assured Organon of close ties to its market. These alliances with the medical community contributed greatly to the success of Organon as a hormone manufacturer. The contacts Laqueur mediated between Organon and the medical profession were of vital importance for the hormonal enterprise. Without the cooperation of the medical profession the construction of hormonal drugs would have failed altogether.
The story of hormonal drugs also illustrates that drugs must be considered as the embodiment of interests that become mutually defined through social networks. The final drug profile is not shaped by the interests of one specific actor, for example laboratory scientists, but by the interests of different groups of actors, both in and outside the laboratory. The adoption of this view enabled us to understand how the development of hormonal drugs focussed particularly on female sex hormones and women. The production and marketing of female sex hormones as “scientific drugs” matched the needs of both gynecologists and pharmaceutical entrepreneurs to establish their scientific status, an endeavor in which they were mutually dependent. Cooperation with the clinic provided the industry with the institutional context for the organization of clinical trials to negotiate the final drug profile for female sex hormones as a new class of scientific drugs. Moreover, the gynecological clinic provided the industry with an available and established clientele, with diseases that could be subjected to hormonal treatment. The promotion of female sex hormones fitted seamlessly into already existing institutional structures formulated earlier in the century as part of the professionalization of medicine and the rationalized organization of service delivery. Prior to the introduction of sex hormones, clinics and hospitals focused already on reproductive phenomena, thus providing the required institutional structures in which female sex hormones could flourish.31
This cooperation with industry provided gynecologists in turn with a new class of drugs that served their struggle to attain the status of “scientific medicine.” In establishing its status as a scientific profession, gynecologists— and the medical profession in general—claimed to improve medicine, moving away from the earlier medical practice of “folk drugs” and “quackery.” Sex endocrinology provided the gynecologists with the tools to delineate the boundaries between “quackery” and “scientific medicine.” Laboratory scientists provided standardized measurement of hormones and standardized hormonal preparations that could be used in gynecologists’ clinical research and practice. Gynecologists incorporated sex endocrinology into their research and practice because they believed that the theories and tools provided by the laboratory could help to make gynecology more scientific. The use of standardized tests and drugs held the promise “to produce data seemingly independent of the gynaecologists as well as the patients’ subjective judgement. These sorts of technologies strengthened gynaecologists’ claim to objective judgement” (Bell 1987:537). In their striving for a scientific image, the clinic and the pharmaceutical industry matched each others’ needs, a process in which female sex hormones became of mutual interest and gradually developed into big science and big business.
The same success story cannot be told about the marketing of male sex hormones. Although there existed a potential audience for male sex hormones, it was not embedded in any organized market or resource network. The marketing of male sex hormones lacked institutional contexts for both the production and promotion of male sex hormones, as it was not connected to any medical profession comparable with gynecology. Organon and Laqueur promoted male sex hormones mainly to general practitioners and urologists. This network, however, did not provide the required conditions for any systematic clinical trials. The urological clinic provided only a small clientele with a relatively limited area of medical indications, again when compared to the gynecological clinic. Medical treatment in the urological clinic was restricted to urological diseases and did not focus on any other diseases of the male body. Like the manufacture of male sex hormones, the marketing lacked an appropriate institutional context for the promotion of male sex hormone therapy.
These differences in institutional contexts had far-reaching consequences for women. In the 1920s and 1930s, the female body became the major object for hormone therapy. Female sex hormones became applied as universal drugs for a wide array of diseases in women. In this manner, sex endocrinologists constructed the image of the hormonal woman: it was the female body that became increasingly subjected to hormonal treatment. Compared to women, the introduction of sex hormones had rather minor consequences for men. Although endocrinologists created a market for male sex hormones, male sex hormone therapy was introduced for only a relatively small number of medical indications.
The selection of drug profiles was profoundly shaped by cultural norms regarding masculinity and femininity. The pharmaceutical industry and the medical profession anticipated these norms, making the development of certain applications of hormones as drugs more likely than others. This is particularly clear in the promotion of hormones as drugs for male menopause and contraception for women. Laqueur deliberately dropped the hormonal treatment of the male menopause and the development of hormonal contraceptives from his agenda because he was afraid that the association of sex hormones with these types of medication might endanger Organon’s scientific image. In this respect there are striking similarities between the issue of male menopause and female contraception. Involvement with these cultural, controversial issues did not enhance the legitimacy and professional authority of scientists. Scientists and clinicians who actually took part in studies of male menopause and contraception found themselves marginalized within the profession. These cultural constraints have molded reproductive sciences and technologies in Europe and the United States, although there seem to exist graded differences between the USA, Britain and mainland Europe. The cultural climate in Britain with respect to contraception and the male menopause seems to have affected scientific research in these issues to a lesser extent than elsewhere, a quite interesting observation that needs further analysis.
In summary, we can conclude that the marketing of sex hormones was profoundly shaped by cultural and institutional factors. In a context in which contraception and the male menopause were illegitimate subjects in medical science, and the physiology of the male reproductive system was not institutionalized as a medical specialty, sex hormones became marketed as specific drugs for menstruation and the female menopause, and not for contraception and the male menopause. These technological choices shaped the development of sex endocrinology in the following decades. The idea of hormonal regulation of the male menopause has not been taken up by the medical profession at all since the 1930s. The development of hormones into contraceptives was not taken up until the 1950s and 1960s. In the next chapter we follow the hormone researchers, the pharmaceutical companies and the medical profession in their final quest: the transformation of hormones into the contraceptive pill.