Controlling a woman’s fertility is an old idea, though Christians have often viewed contraception with great hostility. One reason for this opposition is practical: ancient methods were often toxic to women or, at the very least, worked by aborting an existing pregnancy, which is unacceptable given what the Bible says about the sanctity of human life.1 Until modern times, there was no safe drug intervention to prevent pregnancy.

Pharmaceutical methods of contraception began in the early 1950s when Gregory Pincus and John Rock developed the first hormonal method of birth control.2 In early formulations, “the pill” used a combination of the female hormones, estrogen and progesterone. These agents inhibit the monthly release of an ovum from a woman’s ovaries while maintaining normal monthly menstrual flow. Enormously successful at first, the high doses of hormones had inconvenient and even dangerous side effects, which eventually led in the 1990s to a decrease in the concentration of hormones and fewer medical issues.3

Yet contraception remains controversial for the church and society. This is especially true after the recent U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization (June 2022), which overturned Roe v. Wade and thus returned the issue of the legality of abortion to the states.4 The renewed abortion debate has heightened tensions across the religious and political divide. Contraception is now a more significant issue than ever, since many believe that access to affordable birth control could help prevent unplanned pregnancies that result in abortion.5

This article reviews the ethical and theological issues surrounding birth control, with an emphasis on hormonal methods. It is written for seminarians, pastors, church elders, and lay leaders who want clarity on these confusing matters for their congregations. After a brief history of the debate and theological analysis, this report considers various perspectives from moral philosophy. Along the way, it examines the arguments from natural law, concerns about the possible abortive effects of hormonal birth control, and the social impact of birth control in society. The discussion also explores other contraceptive methods, including emergency contraception, intrauterine devices, natural family planning, and sterilization. The report concludes with practical implications for church ministry.

1. Defining Terms

To avoid confusion for those without medical training, some opening definitions are provided here, with other terms to be defined later.

Conception is a non-medical term often used colloquially to refer to the creation of human life in the womb. The more specific word is fertilization, the union of a male sperm and a female egg.6

A contraceptive is any medication, device, or surgical procedure intended to prevent pregnancy. Hormonal contraceptives function to prevent ovulation, the release of a human egg—called an ovum (oocyte is a synonym)—from the ovaries, which typically takes place every month during a woman’s reproductive years.7 Barrier methods and natural family planning can also be effective means of birth control.

A new human life begins with fertilization, the union of a male sperm and an ovum as a result of sexual intimacy. In a woman’s womb (uterus), fertilization occurs high in the uterine (fallopian) tubes. After this moment, the newly created embryo begins a five- to six-day journey down the fallopian tubes until implantation into the innermost wall (endometrium) of the uterus.8 The new life in the womb is called an embryo up to eight weeks of development. After that, and up to birth, it is called a fetus. A typical pregnancy lasts thirty-eight weeks from conception, or forty weeks after the woman’s last menstrual period.9

An abortifacient is any drug or device that causes a woman’s uterus to reject a pregnancy by blocking the implantation of an embryo or by inducing a miscarriage.10 To be clear, the consistent view of pro-life Christianity is that the unborn are fully human, having complete moral status at every moment during pregnancy, from fertilization until birth. Thus, the unborn are members of the moral community with the same rights and privileges accorded to all other human beings.11 Therefore, any drug or device that interferes with this natural trajectory is immoral.

2. Historical Views of Contraception in the Church

The Church Fathers taught that sexual intimacy was only permissible within the bonds of marriage, emphasizing procreation as its purpose. Any deliberate interference with having children was considered illicit. The ethicist Ken Magnuson summarizes this view well: “Early Christians saw a close connection between contraception and abortion as methods of birth control, and condemned them together as aspects of the same problem.”12 Typical of this attitude was Jerome, who wrote, “Some go so far as to take potions, that they may insure barrenness, and thus murder human beings almost before their conception.”13

John Chrysostom was even more blunt, declaring that those who used contraceptive agents committed “murder before the birth.”14 The connection that premodern theologians were drawing between contraception and abortion was not without warrant. We now know that many ancient remedies to prevent pregnancy, such as silphium (so-called giant fennel, now extinct), asafoetida, and the seeds of Queen Anne’s Lace, interfered with the action of the hormone progesterone on the pregnant uterus, and so were likely true abortifacients.15

Augustine of Hippo exerted the most influence on the early church concerning sexuality and birth control. In his famous discourse on marriage, De Bono Coniugali (On the Good of Marriage), he emphasizes procreation as its chief aim: “Necessary sexual intercourse for begetting is free from blame, and itself is alone worthy of marriage. But that which goes beyond this necessity, no longer follows reason, but lust.”16 Commenting on this text, Magnuson states, “Augustine’s complaint is that intercourse for ‘carnal pleasure’ alone, apart from a procreative intent, is sinful in some sense even in marriage, though such sin is pardoned by marriage.”17 Augustine, therefore, viewed any barrier to the procreative intent, to whatever extent it was possible in his day, to be as morally culpable as abortion or infanticide.18

Under Augustine’s influence, many early Christian writers viewed sexual intimacy itself with suspicion, only redeemable by the procreative mandate of Genesis 1:28. According to Andrew McCall, while sex was considered throughout much of church history as “necessary to the reproduction of the human species,” it was nonetheless deemed “very wicked to derive any enjoyment from this animal function.”19 Similar ideas held sway in the medieval period, as reflected in that era’s widespread penitentials (confessional handbooks for the clergy). From the sixth to the eleventh centuries, sexual sin was considered especially grave; the practice of contraception required three to fifteen years of penance.20 In the Summa, Thomas Aquinas viewed the sex act as morally licit, but only in accordance with the natural law: “The use of venereal acts can be without sin, provided they be performed in due manner and order, in keeping with the end of human procreation.”21

Martin Luther, in his commentary on Genesis 2:18, firmly opposes birth control of any kind: “Today you find many people who do not want to have children.… Surely such men deserve that their memory be blotted out from the land of the living.”22 Likewise, in John Calvin’s comments on the sin of Onan, he writes, “When a woman in some way drives away the seed out of the womb, through aids, then this is rightly seen as an unforgivable crime.”23 Though less influenced by natural law, Protestants rejected contraception along with their Roman Catholic counterparts until well into the 20th century. However, the 1930 Lambeth Conference, an Anglican assembly convened by the Archbishop of Canterbury, gave limited and cautious approval for some forms of birth control other than abstinence.24 This led to the gradual acceptance of contraception by other Protestant denominations.

Part of the societal context for these changes was the resurgence of neo-Malthusian ideas and the eugenics movements in the U.S. and Great Britain. Thomas Malthus was an eighteenth-century economist who thought that population pressures would increase food demand and eventually outstrip the world’s supply.25 In the 1930s and 1940s, a rapid expansion of the world’s population, especially in developing countries, led to concerns over a scarcity of resources and a sense of urgency about population control and reducing family size.26

Within a few decades, the differing attitudes toward contraception between Protestants and Catholics became more apparent. In 1961, the National Council of Churches sponsored the North American Conference on Church and Family, where there was a radical departure from the traditional Protestant family ethic of many children to a whole-hearted embrace of contraception.27 In contrast, the Magisterium of the Roman Catholic Church has remained consistently opposed to contraception. One small concession came in 1951 when Pius XII, in an allocution to midwives, gave cautious approval to the so-called “rhythm method” (natural family planning through periodic abstinence).28 Paul VI, in his encyclical Humanae Vitae (1968), reiterated the traditional view maintaining the inseparability of the unitive and procreative aspects of sexual intimacy within the confines of marriage:

This particular doctrine, often expounded by the Magisterium of the Church, is based on the inseparable connection, established by God, which man on his own initiative may not break, between the unitive significance and the procreative significance which are both inherent to the marriage act. The reason is that the fundamental nature of the marriage act, while uniting husband and wife in the closest intimacy, also renders them capable of generating new life—and this as a result of laws written into the actual nature of man and of woman.29

The contraception debate took a dramatic turn with the rise of the modern bioethics movement from 1965 to about 1980, with renewed interest in the debate over abortion.30 At the time, Roman Catholics were the principal defenders of the sanctity of human life, among them the influential Catholic jurist and author John T. Noonan.31 The 1973 Roe v. Wade Supreme Court decision on abortion galvanized the growing pro-life movement in the Catholic Church, until then largely ignored by mainline and evangelical Protestants. This trajectory began to change in the 1980s. Albert Mohler put it this way:

The evangelical conscience was awakened in the late 1970s, when the murderous reality of abortion could not be denied. A massive realignment of evangelical conviction was evident by the 1980 presidential election, when abortion functioned as the fuse for a political explosion. Conservative Protestants emerged as major players in the pro-life movement, standing side-by-side with Catholics in the defense of the unborn.32

How did this change impact the discussion about contraception? Mohler continues:

In an ironic turn, American evangelicals are rethinking birth control even as a majority of the nation’s Roman Catholics indicate a rejection of their church’s teaching…. [We must reject] the contraceptive mentality that sees pregnancy and children as impositions to be avoided rather than as gifts to be received, loved, and nurtured. This contraceptive mentality is an insidious attack upon God’s glory in creation, and the Creator’s gift of procreation to the married couple.33

Now more than ever, Catholics, mainline Protestants, and Evangelicals are reconsidering and debating their ethical views on birth control.

3. Contraception through a Scriptural Lens

A biblical understanding of sexuality and procreation begins with a foundational affirmation of the sanctity of human life. As seen in Genesis 1:26–27 (and throughout the Old and New Testament), the inestimable worth of humanity lies in the fact that men and women are created in God’s image and likeness. A complete discussion of the imago Dei is beyond our purposes here, but it denotes how men and women resemble God and share some of his attributes, but not in a way that makes us equal to God.34

3.1. Old Testament Scripture

The key texts concerning marriage appear in the first two chapters of Genesis. Among the many theological implications of Genesis 1:27–28 is the male-female, complementary nature of humankind comprising God’s image. This is implied by the repetitive parallel structure of “male and female” after “image of God.”35 Christian marriage brings this clearly into focus. In the words of Erwin Lutzer, “Marriage brings a unity that is unlike anything else on this earth; indeed, it represents a unity found only in heaven—in God Himself.”36 The imperative “be fruitful and multiply” follows directly from this reality. The so-called “procreative mandate” allows for the continuation of God’s image-bearers and their stewardship over creation.

Despite this imperative rendering, must we take the phrase, “Be fruitful and multiply,” in Genesis 1:28 as a command? Magnuson suggests a good reason to question this: “While human beings can demonstrate an openness to procreation, it is God alone who creates life. Since life is a gift from God … understanding procreation as a command may place too much emphasis upon human procurement of God’s blessing.”37 Magnuson describes how other portions of the Old Testament describe procreation as a blessing rather than a command (Gen 17:20; 28:3; 35:11; 48:4; and Exod 1:7).38

In any case, Genesis 1:28 has been central to the church’s historical view of marriage: from the writings of Augustine, through the Scholastic Era with Aquinas, even to current Magisterial teachings within the Roman Catholic Church. Again, from Magnuson: “The view that has dominated Christian thinking on marriage through much of the history of the Church, [is] that procreation is the primary purpose of marriage.”39

A second purpose for marriage appears in Genesis 2:18, where God addresses Adam’s need for companionship: “It is not good that the man should be alone.”40 This is amplified by God creating Eve from Adam’s side, then heightened as a principle in the “one flesh” of verse 24. Though some writers have equated this phrase with sexual intimacy, other scriptural texts imply a broader sense, where “one flesh” describes marriage as a comprehensive union.41 Magnuson states: “[A] one-flesh union is comprehensive in uniting a man and a woman in a fruitful, exclusive, lifelong relationship.”42 Let us call this view the “unitive” purpose of marriage.43

3.2. New Testament Scripture

In the New Testament, Paul advocates intimate relations within marriage as a way to curb fornication and adultery (1 Cor 7:1–8),44 a biblical text that has caused some confusion for the church: “It is good for a man not to have sexual relations with a woman. But because of the temptation to sexual immorality, each man should have his own wife and each woman her own husband” (7:1–2). In his Commentary on 1 Corinthians, perhaps influenced by Augustine, Luther dismisses the unitive aspect of marriage. He sees marriage only as a “necessary evil” to control lust: “If one cannot have the happy days of celibacy, then one must accept the evil days of marriage.”45 In contrast to Luther, most commentators today would see Paul’s advice to couples in the context of the persecution of the early church—“in view of the present distress” (7:25–26)—not as an overall statement on the purpose of marriage.46

Turning to specific arguments relating to contraception, the debate has centered around the separability of the procreative and unitive aspects of sexual intimacy. As mentioned earlier, Paul VI’s Humanae Vitae reinforced the centuries-old teaching of the church that the unitive and procreative goals are inseparable.47 This view relies on natural law ideas that sex is ordered towards procreation as its purpose; interfering with this goal is therefore immoral.48 Notice how one Catholic writer uses this fundamental understanding to undermine two completely different family planning interventions: “The marriage act is at once unitive and procreative in nature. Contraception destroys its procreative character; artificial fertilization destroys its unitive character.”49 It is now time to address the arguments on both sides of the contraception debate.

3.3. Arguments in Favor of Contraception

Most mainline Protestants and many evangelicals have argued for the moral permissibility of contraception. The main arguments may be summarized as follows.

First, most Protestants are unconvinced by natural law arguments for the inseparability of the procreative and unitive aspects of sexual intimacy. They reject the idea that every act of coitus must allow for the possibility of pregnancy.50

Second, when there are no clear moral commands in Scripture, Christians have moral latitude in their private lives. Although children are seen as a blessing throughout the Old and New Testament witness, this does not imply a direct command that marriages must maximize their offspring.51

Third, in the same verse where God tells us to “be fruitful and multiply,” he also commands us to have dominion over his creation. In a modern Western setting, this instruction may include stewardship over families and the spacing of children based on the limitations of careers and finances.52

Fourth, beyond the procreative and unitive aspects, there are many purposes to marriage and the sexual intimacy that goes with it. Sexual intimacy is a reflection of love, pleasure, and companionship. Worrying about the possibility of pregnancy may detract from those goods.53

Fifth, Christian couples who are open to contraception do not necessarily oppose having children. Indeed, it may allow them to bond more closely with the children they have. If the goal is to honor God, couples may even forgo having children for the sake of gospel ministry.54

3.4. Arguments in Opposition to Contraception

Many conservative Roman Catholics and a growing number of evangelicals have voiced suspicion and even outright rejection of contraception. Let us consider their main objections.

First, sexual unity is both unitive and procreative; these two elements cannot and should not be separated. Contraception, therefore, harms the marriage union, for it destroys one of the main reasons couples remain together: the possibility of children.55 Natural law scholar J. Budziszewski puts it bluntly: “Any so-called intimacy which is deliberately closed to new life eventually becomes a mere collaboration in selfishness.”56 He and other Catholic scholars would claim that Protestants have done a disservice by ignoring the wisdom of Paul VI in Humanae Vitae, who affirms that “every marital act must of necessity retain its intrinsic relationship to the procreation of human life.”57

Second, accepting contraception disposes couples to view children as a potential burden or inconvenience rather than as a blessing.58 As W. Ross Blackburn puts it, Scripture teaches “unqualified enthusiasm for the blessing of children, lamentation at barrenness, and the affirmation that it is the Lord who opens and closes the womb.”59

Third, normalizing contraception undermines the institution of marriage in society by removing one of the principal reasons for couples to enter into a covenantal relationship. This attitude also paves the way for an acceptance of same-sex marriage, where procreation is not naturally possible.60

Fourth, in Ephesians 5:28–32, Paul picks up the “one-flesh” imagery from Genesis and writes that marriage spiritually represents the relationship between Christ and the church. If we fail to conform to God’s original design for marriage, our marriages will misrepresent this witness in the family, precisely where it needs to be the most apparent.61

Fifth, some methods of contraception may be abortive in their mechanism, and abortion itself is frequently used as a form of birth control. To that extent, contraception can foster an immoral disregard for the sanctity of human life.62

3.5. Sanctity of Life Concerns

One crucial ethical question remains: Do any birth control methods work, at least part of the time, by destroying an early human life? This might occur if the mechanism of action prevents the implantation of an embryo in the womb or causes the abortion of an early pregnancy. Such an abortifacient effect, if true, would render the method morally illicit. Christians need to understand how hormonal contraception works in light of this possibility.

4. Mechanisms of Contraception

The following will describe a woman’s typical monthly cycle, with an emphasis on hormonal changes. This will set the stage for an analysis of scientific and ethical concerns about possible abortifacient effects.

4.1. Overview of Normal Monthly Events

The normal uterus is shaped like an inverted leather pouch, with the muscular cervix opening into it from below. The fallopian tubes emerge at each upper side to carry an ovum every month from the ovaries into the uterus for possible implantation. The key hormones made in the ovaries are estrogen and progesterone.

During a woman’s normal monthly cycle, an ovum is surrounded by a shell called a follicle that secretes estrogen, which then promotes the growth of the endometrium. At mid-cycle, ovulation takes place, releasing the ovum into the fallopian tube. The leftover follicular “shell” is called the corpus luteum and is a rich source of hormones, especially progesterone, causing the endometrium to become thicker and more receptive for the implantation of an embryo. After two weeks, the corpus luteum shrinks and stops the release of progesterone. This change removes support for the endometrium, which sloughs away as the woman’s monthly period. The next cycle then begins again, and new follicles develop.63

After sexual intimacy, fertilization of an ovum by a sperm cell typically occurs high in the fallopian tube. The new embryo then travels down the tube and establishes a new pregnancy after implanting into the endometrium five to six days later. What happens to the corpus luteum, which is crucial for the survival of the endometrium? If implantation is successful, the developing embryo produces a hormone that stimulates the corpus luteum to continue its secretion of estrogen and progesterone, keeping a pregnancy healthy.64

4.2. How Oral Contraceptives Work

The most common hormonal contraceptive pill today is a combination of an estrogen and a progestin (a progesterone-like compound), called a combined oral contraceptive (COC).65 The progestin component inhibits the stimulus for follicle development.66 Since ovulation cannot occur, pregnancy is not possible; however, thanks to the combined hormonal effects, a woman will still have regular periods.67

Despite this clear mechanism of action, many have raised concerns about statements in the “package insert” that indicate a different mechanism of action; the same information also appears on the manufacturer’s website. Here is an example: “COCs lower the risk of becoming pregnant primarily by suppressing ovulation. Other possible mechanisms may include cervical mucus changes that inhibit sperm penetration and endometrial changes that reduce the likelihood of implantation.”68 The first phrase of interest is: “cervical mucus changes that inhibit sperm penetration.” As a birth control effect, this is not morally problematic for pro-life Christians. For women who have been on the pill for a while, a change in the cervical mucus composition (sometimes referred to as cervical mucus “thickening”) may act to prevent sperm from passing through the cervix. This process may be effective as much as 80% of the time.69

However, the last phrase—“endometrial changes that reduce the likelihood of implantation”—is a red flag for conscientious believers. Suppose the pill sometimes works by preventing the implantation of a human embryo. As explained earlier, such an effect would destroy a human embryo and would violate pro-life moral convictions.

To be clear, the companies manufacturing these drugs are not as concerned with the finer points of ethics as they are about reassuring customers that their product effectively prevents pregnancy. If taken correctly, the pill suppresses ovulation almost always, but not 100%.70 When “breakthrough” ovulation occurs, meaning that a woman releases an ovum despite taking the pill, what happens then? If a sperm still reaches an ovum despite mucus changes, could the endometrium be unreceptive to implantation and thus bring about an unintended abortifacient side effect? This is a possibility, but in the words of one author, “There is no direct evidence that this contributes to the effectiveness of oral contraceptives.”71 In other words, in such cases, a woman may simply become pregnant anyway.

4.3. The Scientific Debate

Family physician Walter Larimore and well-known Christian author Randy Alcorn have popularized the “hostile endometrium” theory. Larimore first defended these arguments in the scientific medical literature,72 and Alcorn has publicized his views for lay readers.73 Their argument relies on three basic premises.

1. Women on the pill for a long time have a thinner endometrium layer compared with non-pill users.74 Many studies confirm this finding, and both sides of the debate concede this point.75
2. In light of studies of embryo transfer during in-vitro fertilization (IVF), a thinner endometrium might decrease the likelihood of successful implantation. The clinical evidence for this idea is inconclusive, but it makes sense theoretically.76
3. If breakthrough ovulation occurs, the embryo would therefore be less likely to implant.

This last point is where the debate lies. Though a thinner endometrium may be less hospitable for implantation, everything changes physiologically if ovulation occurs. The corpus luteum, left behind after ovulation, is a rich source of estrogen and progesterone. During the five or six days required for the embryo to travel down the tube into the uterus, the endometrium is transformed and becomes receptive for implantation.77 No doubt this is true, at least some of the time, since some pill users do get pregnant. But here are the primary questions: How often does a contraception user ovulate and conceive, only to have the early embryo fail to implant? How does this rate compare with non-pill users?

To address these questions, we need to know the frequency of non-implantation of newly formed human embryos in women who are not using the pill. According to several studies, most fertilized ova (over 60%) fail to achieve a viable pregnancy, with three-fourths of these due to implantation failure.78 These data make statistical comparisons difficult. To prove that a COC has interfered with implantation, the analysis must show that breakthrough ovulation has occurred (a rare event), followed by sperm passing into the cervix despite mucus changes (if intimacy occurs at the right time), followed by fertilization. In addition, the resulting embryo must then fail to implant in the now-less-receptive endometrium—or fail to continue to term—and this failure rate must be greater than that which occurs naturally. This scenario has never been proven scientifically.79

4.4. Ethical Analysis of Sanctity of Life Concerns

The morally salient question is this: Are combined oral contraceptives immoral based on the theoretical concern outlined in the previous section? In the absence of an underlying hostility toward the pill, such a conclusion seems unwarranted. Given the available evidence, the most that we can conclude is that any abortifacient effect would be extremely rare. In other words, there are no compelling scientific reasons to think that COCs are abortifacient in any meaningful sense. Therefore, in the absence of positive evidence of an abortifacient effect, there is no ethical reason to condemn COCs on that basis.

In contrast to the flaws of legalism, moral blame or praise partly depends on an agent’s intent.80 Married couples should carefully think through family planning options, relying on trusted experts to make up for any lack of technical knowledge. Having done this, they must also have a godly intent to practice good stewardship and avoid moral evil, leaving the rest up to God. Such responsible Christianity is not a “free pass” to do something questionable because it seems good. Nonetheless, believers who use contraceptives must be fully convinced they are acting morally. Those who are unsure should never act against their conscience (Jas 4:17). Viable alternatives are available, such as barrier methods and natural family planning (see below).

This section has only dealt with the debate about the possible abortifacient effect of COCs. I will now turn to other potential moral concerns, including philosophical matters and societal outcomes.

5. Philosophical and Social Concerns

Some Christians have legitimate questions about the relationship between contraception and feminism. One immediate challenge, however, is that “feminism” is not a monolithic entity; scholars describe three or four historical waves of feminism, each with its own distinct characteristics. For example, the central accomplishment of first-wave feminism in the late nineteenth and early twentieth century was to give women voting rights and greater legal representation, which is consistent with biblical Christianity. The later variants of feminism—especially the third and fourth waves—are much more antithetical to Christian orthodoxy. My remarks here are limited to the militant feminism now rampant in our modern secular society, which has resulted in some disturbing trends.

The influential French feminist Simone de Beauvoir described sexual intimacy as a moment when “the woman is ‘violated,’ ‘taken,’ ‘grabbed and immobilized,’ and, with conception, ‘alienated’ by another.” Because of the “imposition” by the “alien” child, maternity has “no individual benefit to the woman.”81 Abigail Favale has traced the roots of this modern idea back to eugenicist and contraception advocate Margaret Sanger, who claimed that women’s bodies are the source of oppression: “From the 1960s onward, feminists have followed in the footsteps of Sanger and de Beauvoir, locating women’s oppression in their biology, and advocating for a vision of ‘health’ that pathologizes female fertility…. The ‘disorder’ requiring medical intervention? The normal function of a woman’s body.”82 It should be no wonder, therefore, that both contraception and abortion are often labeled as essential components of “women’s health,” even though, in most cases, no disease is present that needs treatment.

This understanding contrasts with the biblical perspective on health and disease. As a result of the fall, “the whole creation has been groaning together in the pains of childbirth until now” (Rom. 8:22). For man, shalom has been lost. The Hebrew word shalom describes the essence of health as wholeness, completeness, and well-being.83 On this biblical understanding, the role of health care is to help reverse the effects of the fall and to imitate God in restoring shalom. This idea is more than simply a Roman Catholic emphasis on natural law. Focusing on shalom allows us to see the goal of healthcare for women as restoring and preserving their very personhood, in stark contrast to seeing fertility as a disease.

Along with a misunderstanding of women’s health, the secular view of contraception has other unintended adverse effects on society. Favale points out that contraception, rather than reducing the abortion rate in the U.S., has perversely increased it. The reason is simple: “Contraception makes a promise that it can’t always deliver. The promise [is] that a fertile woman can have sex without getting pregnant. The reality [is] that all birth control methods have failure rates…. This is the backup factor: when contraception fails to make good on its promise, abortion fills the gap.”84 Other social evils are wrapped up in the freedoms promised by easy sex without apparent consequences. Such a promise is based only on mutual consent, but is this empowering to women? Favale once again: “Consent is a precarious and hollow platform on which to build an entire sexual ethics…. Only an ethics rooted in the objective value of embodied human personhood can draw clear boundaries against sexual abuse and exploitation.”85

In the modern societal shift toward intimacy without consequences and marriages without children, the ready availability of contraception has doubtless played a part. But does this mean that practicing birth control within marriage is immoral? Not necessarily. Christian couples who desire to honor God must thoughtfully and prayerfully consider their goals and purposes in using contraception. Rather than conforming to secular versions of feminism that view fertility as a disorder, the husband and wife should be open to both intimacy and procreation. If no medical barriers to pregnancy exist, then viewing birth control as a means of godly stewardship, considering it only for a season, and honoring the sanctity of human life are all paramount to the morality of its practice.

6. Emergency Contraception

Commonly referred to as the “morning-after pill,” emergency contraception (EC) is a “backup” method to prevent pregnancy shortly after sexual intercourse. One such medication is now available over the counter (OTC) without a prescription and has a 95% success rate if taken within five days of intercourse. According to the World Health Organization, reasons to use EC medications may include unprotected intercourse, sexual assault, and possible birth control failure (e.g., condom breakage).86

The moral debate over EC is part of an already contentious debate over oral contraceptives.87 As we have seen, the prevailing scientific conclusion about oral contraceptives is that such agents do not have a known post-fertilization effect and that moral concern over their abortifacient potential is unwarranted.88 However, is such an effect nonetheless possible in the case of emergency contraception?

6.1. The Scientific Debate

The most common agent used for EC is a high-dose progestin called levonorgestrel, marketed initially as Plan B One-Step, and given as a single 1.5 mg tablet. Other OTC generic versions include Next Choice, My Way, Take Action, and Aftera.89 If taken just before ovulation, levonorgestrel inhibits the stimulus for follicle development, which may prevent or delay ovulation (similar to COCs).90

Levonorgestrel has a high success rate in preventing pregnancy, up to an efficacy rate of 89%. This efficacy drops with increasing amounts of time between intimacy and medication usage.91 All of this assumes that the woman is only using the medication during the period of her cycle just before or immediately after ovulation. Otherwise, all other considerations are moot since the woman was not at risk of becoming pregnant in the first place. These statistics are well established, but the mechanism of action is poorly understood. This reality has opened the door to considerable speculation about a “post-fertilization effect,” where the endometrium is unreceptive for implantation.

Bolstering this concern is the original FDA-approved “package insert” information for Plan B One-Step, which until recently appeared on the manufacturer’s website: “Plan B One-Step works primarily by: preventing ovulation, possibly preventing fertilization by altering tubal transport of sperm and/or egg, [or] altering the endometrium, which may inhibit implantation. Plan B One-Step is not effective once the process of implantation has begun.”92 The statement, “altering the endometrium, which may inhibit implantation,” suggests the possibility of an abortifacient effect even though there are no actual data to confirm this. Nonetheless, many pro-life conservatives, especially in the Roman Catholic Church, have condemned EC as an abortifacient, assuming such an effect, at least some of the time.

In 2007, Father Nicanor Austriaco, a molecular biologist and Dominican priest, published a scientific review in the National Catholic Bioethics Quarterly, disputing the overall judgment of the Catholic Church. He presented “mounting evidence that levonorgestrel has little or no effect on post-fertilization events.”93 In the years since the approval of levonorgestrel for EC use, researchers have not demonstrated any effect other than ovulatory inhibition.94 A recent comprehensive review summarizing data from many studies found no strong evidence for an abortifacient effect.95 In other words, if women take the medication after ovulation, fertilization and subsequent pregnancy occur just as often as in the absence of a contraceptive.

An interesting but ethically disturbing study took place in Sweden in 2007. In a laboratory environment, Lalitkumar and colleagues developed a model of the human endometrium.96 They accomplished this feat by taking biopsies of endometrial cells from healthy human volunteers. There were three study groups.

The first was the control group, where the researchers took surplus or “leftover” human embryos from fertility treatments and incubated them in a culture with the model endometrium. A large number of the embryos successfully “implanted” in the model.

The second group was an experimental one, where the researchers incubated a similar number of embryos in the cell culture, but this time added the known abortifacient agent mifepristone, which disrupts the ability of a viable embryo to remain attached to the endometrium. As expected, none of the embryos succeeded in attaching to the model endometrium.

Finally, researchers incubated a similar number of embryos in the third study group, but this time added levonorgestrel in large concentrations. Compared to the mifepristone group, there was no difference between the study and control groups regarding implantation effectiveness. Specifically, levonorgestrel showed no endometrial effect, and most of the embryos successfully implanted in the model. Though this study would rightly be illegal in the United States, it bolsters the case that the active ingredient in Plan B and its generic equivalents are not abortive in their action. In late 2022, the FDA changed the labeling of levonorgestrel as an EC by removing the misleading language that suggests such an effect.97

6.2. Ethical Analysis of Emergency Contraception

Much public discussion among pro-life conservatives, especially Catholics, continues to describe EC as an abortifacient. Unlike the typical course of scientific debates, the burden seems to have fallen on the scientific community to prove how a drug doesn’t act by establishing “beyond a shadow of a doubt” how it does act. In the words of one scholar: “While the preponderance of scientific evidence strongly suggests that Plan B does not have an abortifacient effect, the evidence stops short of providing absolute certitude. But is absolute certitude needed?”98 The same writer goes on to say no. What is needed is moral certitude: “What is meant by moral certitude? Moral certitude means that the agent has excluded all reasonable possibility of error. It stands between mere probability, where alternative opinions are equally plausible, and absolute certainty, where any theoretical possibility of error is not only excluded, but is impossible.”99 For couples desiring to serve God through procreation, there is no evidence that EC destroys an early human life. However, believers who continue to have questions or doubts should not sin against their conscience.

7. Other Contraceptive Methods

Three other popular methods of birth control deserve brief discussion: intrauterine devices, natural family planning, and permanent sterilization.

7.1. Intrauterine Devices

An intrauterine device (IUD) is a small plastic T-shaped device that clinicians insert into the uterus as a form of long-acting, reversible birth control.100 The website Human Life International describes the possible non-abortive effects of one type of IUD as follows:

• It prevents sperm from fertilizing ova.
• It releases ions that interfere with fertilization.
• It thickens the cervical mucus.
• It inhibits sperm capabilities.

These mechanisms all prevent fertilization.

However, IUDs also irritate the endometrium and make it inhospitable to the blastocyst (early embryo), which is an abortifacient effect.101 Many writers have attempted to downplay these concerns because of newer, more effective IUDs. Four major brands of hormone-releasing IUDs contain the synthetic progestin levonorgestrel (the same hormone commonly used in EC).102 The hormone is released slowly, and the IUD is a reliable and safe contraceptive, inhibiting follicle development and preventing ovulation.103 Another alternative is a non-hormonal IUD that contains copper. Marketed in the U.S. as Paragard, the copper ions interfere with sperm motility and thereby prevent fertilization.104 Both IUD types have greater efficacy than COCs and can be used for several years. Copper IUDs are highly effective as emergency contraception.105 However, is it possible that either type of IUD could irritate the endometrium and trigger an abortifacient effect?

Father Austriaco, the molecular biologist mentioned earlier, has endorsed levonorgestrel EC and recommended its use in Catholic hospitals after sexual assault. Yet he strongly condemns using IUDs for the same indication. He writes: “It appears that as a local foreign body, the IUD can trigger an inflammatory response that is lethal for preimplantation embryos.”106 Although the primary mechanism of hormonal IUDs is contraceptive and the primary mechanism of copper IUDs is interference with sperm movement, both induce a sterile local inflammatory reaction that may create a hostile environment for implantation if breakthrough ovulation and fertilization occur.107

In summary, concerns remain about the possible abortifacient effects of the five intrauterine devices currently in use. Particularly in cases of sexual assault, emergency contraception with oral levonorgestrel remains a better choice from a pro-life perspective.

7.2. Natural Family Planning

As mentioned earlier, in 1951 Pius XII first approved natural family planning (NFP) through periodic abstinence. This so-called “rhythm method” had a poor success rate. Modern forms of natural family planning are now well-established and have many proponents. For Christians who are uneasy about the use of hormonal birth control, NFP is an attractive alternative. Still, it is “unforgiving of imperfect use,”108 which may lead to unintended pregnancies. This drawback may be reduced if NFP is supplemented with an additional barrier method during the woman’s fertile period (e.g., a male or female condom). As one review put it, “Despite challenges, NFP methods are a viable and effective family planning option for motivated patients, and may be the ideal option for some.”109

7.3. Surgical Sterilization

There are two primary methods for permanent sterilization: tubal ligation for women and vasectomy for men. Typical indications for such procedures include the following:

1. A medical issue where it is unsafe for a woman to become pregnant.
2. A genetic or chromosomal problem where a woman may be at risk for becoming pregnant with a child with various physical or mental handicaps.
3. A marriage or partnership where the couple has decided they have enough children, often for financial or lifestyle reasons.
4. Less commonly, the reason may be a couple deciding that they do not wish to have any children, once again for financial or lifestyle reasons.

Tubal ligation, or more formally bilateral tubal ligation (BTL), is an elective outpatient procedure that occludes or ties off the fallopian tubes. The surgery, often performed by laparoscopy in an outpatient setting, requires only brief general anesthesia and has a short recovery time. Some women can go back to work within a few days. In women undergoing a Caesarian section for childbirth, BTL can often be performed during the same procedure.110 Counselors should advise a woman considering BTL that it is a method for permanent sterility. Later attempts to reverse the procedure, in the best of hands, are about 60% successful, with a few reports approaching 80%.111

Vasectomy for men is a minimally invasive outpatient procedure performed under local anesthesia. The recovery time is very short, with some men able to return to work the next day. Overall, it is considerably less costly than BTL. As before, the procedure should be considered a method for permanent sterility, with a success rate for reversal of about 40%.112 In the United States, BTL is about twice as common a sterilization method as vasectomy.113 Despite rumors to the contrary, it is important to emphasize that performing a vasectomy in men has no detrimental effect on arousal, erection, or overall sexual performance. There is also no evidence of decreased sexual arousal in women after BTL.114

From the perspective of Christian ethics, indirect sterilization has always been considered morally licit, where the uterus, ovaries, or fallopian tubes are damaged because of treatments for malignancy, endometriosis, or other disorders. Sterility may also result from neurological or functional disorders of the male anatomy and after treatments for various cancers. In such cases, sterility is not a direct result of attempting to limit the number of children.

It should, however, be no surprise that the Roman Catholic Church strongly opposes direct or elective sterilization and considers it immoral. Here are some reasons for this judgment. First, as discussed previously, the Catholic Church has historically taught that couples should not separate the unitive and procreative aspects of marriage. Catholics also affirm the principle that direct sterilization is a form of self-mutilation, violating the Principle of Totality. This idea was first taught by Thomas Aquinas115 and later reiterated by Pius XI in his 1930 Encyclical Letter Casti Connubii: “Private individuals have no other power over the members of their bodies than that which pertains to their natural ends.”116 Finally, Pius XI quotes Augustine, comparing sterilization to abortion.117 Paul VI reached similar conclusions in Humanae Vitae in 1968: “Equally to be condemned, as the magisterium of the Church has affirmed on many occasions, is direct sterilization, whether of the man or of the woman, whether permanent or temporary.”118

By contrast, evangelical and mainline Protestants are more open to direct sterilization as a viable form of birth control. Once again, the debate centers around natural law. As Gerald McKenny writes: “[Protestants reject] the claim that any natural process or function, simply by virtue of being what it is in a natural order, is off-limits to human intervention…. At a minimum, in other words, sterilization cannot be said to violate the order of nature significantly more than other forms of birth control, and may even violate it less than some others.”119 Nonetheless, because it is more permanent, direct sterilization seems to remove a meaningful sense of openness to procreation that more reversible methods maintain.

Despite this concern, many Protestants are much more pragmatic on the issue. While marriage partners may be committed to both the unitive and procreative purposes of intimacy, they may prioritize one over the other at different seasons in their relationship. The ethical frame then becomes primarily a prudential one: couples should avoid permanent sterilization if they are unsure about not having more children. Reflecting this judgment, John Piper has said, “Don’t make long-term commitments to sterility when you don’t have enough information to know if it is wise.”120

8. Conclusion: Practical Advice for Couples

In my medical and surgical practice on the mission field, I delivered many babies. I also prescribed contraceptives and performed vasectomies and tubal ligations. During the ensuing twenty-five years when I served as a professor at a Christian liberal arts university, I taught human anatomy and medical ethics to hundreds of students. In addition, my reputation for scholarship in health sciences and ethics led to many private conversations. Senior-year students would typically approach me about their plans to get married during the summer after graduation. At times, this meant formal pre-marital counseling; primarily, the discussions revolved around the ethics of birth control. In that spirit, let me offer some practical advice that summarizes my counseling insights.121

We human beings are sacred because we are created in God’s image (Gen 1:26–28). This majestic truth gives each of us personal value, dignity, and hope. Scripture teaches that God values persons in the womb. A beautiful expression of this is in Psalm 139, which affirms that we are “fearfully and wonderfully made,” and “skillfully wrought in the depths of the earth” (139:13–15). Though not referring specifically to the womb, Psalm 119:73 and Job 10:10–11 also reinforce the idea that we are personally fashioned by God. Interventions that interact with our fertility affect not just us, but future generations of image-bearers. Such treatments are therefore in a different category from any other form of preventative or curative healthcare.

God is ultimately sovereign over life and death (Deut 32:39; 1 Sam 12:6). Yet he entrusts his people to make wise decisions. Couples considering marriage should have deep conversations about the role children will play in their lives, including their timing and number. Proper stewardship of our procreative lives means that finances, education, and careers are all relevant considerations. Having embarked on a well-considered family planning program, a husband and wife should bow to God’s sovereignty when the unexpected happens.

The methods used for birth control will depend on access to affordable health care and a couple’s comfort level. Natural family planning will always be ethically permissible for women with regular, predictable monthly cycles. During a woman’s fertile period, couples may use a barrier method, such as a condom (male or female), that prevents sperm from reaching an ovum. The usual goal of marriage should be to eventually have children if disease or adverse life circumstances do not interfere. Achieving permanent sterility via vasectomy or tubal ligation should be reserved for young couples with true medical contraindications to pregnancy. Even if a couple plans never to have children, perhaps for ministry reasons, life circumstances can change quickly.

The typical combined oral contraceptive (“the pill”) prevents the development of ova in a woman’s ovaries or inhibits ovulation if an ovum develops. Most physicians recommend starting the pill three months before the first sexual intimacy. In Christian pre-marital counseling, this would mean three months before the wedding night. Missing taking the pill for just one day is usually not a problem. However, if a couple is traveling and they forget to bring her contraceptive, they should use barrier methods for the remainder of that month.

The action of the pill is strictly contraceptive. Even if breakthrough ovulation occurs, the thickening of cervical mucus acts as a barrier to prevent sperm from reaching an ovum about 80% of the time. No scientific evidence shows that the pill somehow interferes with the implantation of a human embryo. If an embryo develops despite contraceptives, it is just as likely to implant in the womb as in a woman not taking the pill (about 50% of the time).

Nonetheless, each partner in a marriage must agree and be fully convinced of these ethical conclusions. The book of James teaches: “Whoever knows the right thing to do and fails to do it, for him it is sin” (4:17). This surely also means that, even if a couple is mistaken and believes incorrectly that the pill has an abortive action, that belief must guide their behavior. Couples should never sin by acting against their conscience.

The intrauterine device is a popular method of birth control, but concerns remain about a possible abortive effect. Therefore, given what we know at present, pro-life Christian counselors should steer their clients away from this method. Emergency contraception such as Plan B is also controversial. Despite strong negative evidence that it does not interfere with implantation, much animus remains against it. As things stand currently, it might be wise to restrict this method to couples where the woman has a strong medical contraindication to becoming pregnant.

The debates surrounding contraception can be contentious and confusing. In this overview from an evangelical Protestant perspective, I have tried to clarify the ethical and theological issues surrounding birth control, emphasizing hormonal methods. Much more could be said, but I hope this discussion will stimulate pastors, seminarians, and lay leaders to delve more deeply into the ethics of our reproductive lives. May the Lord use each of us to minister to others more effectively for his honor and glory.122

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[1] Crystal Raypole, “From Acacia to IUDs: The History of Birth Control in the United States,” Healthline, 28 June 2021, https://www.healthline.com/health/birth-control/history-of-birth-control.[2] Gregory Pincus, John Rock, Celso-Ramon Garcia, Edris Rice-Wray, Manuel Paniagua, and Iris Rodriguez, “Fertility Control with Oral Medication,” American Journal of Obstetrics and Gynecology 75 (1958): 1333–46.[3] Dennis M. Sullivan, Douglas C. Anderson, and Justin W. Cole, Ethics in Pharmacy Practice: A Practical Guide (Cham, Switzerland: Springer International, 2021), 87.[4] Lynn Fitch, Dobbs v. Jackson Women’s Health Organization, 597 US 4 (2022).

[5] NCR Editorial Staff, “Editorial: In Wake of Dobbs Decision, It’s Time for Anti-Abortion Catholics to Become Truly Pro-Life,” National Catholic Reporter, 24 June 2022, https://tinyurl.com/ypf53r2n.

[6] Stacy A. Henigsman and Zawn Villines, “What is Conception and When Does it Happen?” Medical News Today, 14 February 2022, https://www.medicalnewstoday.com/articles/conception.

[7] NIH: National Institute of Child Health and Human Development, “Birth Control,” Medline Plus, 12 August 2022, https://medlineplus.gov/birthcontrol.html.

[8] Gary C. Schoenwolf, Steven B. Bleyl, Philip R. Brauer, and Philippa H. Francis-West, Larsen’s Human Embryology (Philadelphia: Elsevier, 2020), 35.

[9] Schoenwolf et al., Larsen’s Human Embryology, 7.

[10] With students and medical colleagues, I sometimes refer to the prevention of implantation as an interceptive effect, to distinguish this from the later termination of an implanted pregnancy. Nonetheless, any abortifacient or interceptive action destroys a human embryo and violates pro-life moral convictions.

[11] Dennis M. Sullivan, “The Conception View of Personhood: A Review,” Ethics & Medicine 19 (2003): 11–33.

[12] Kenneth Magnuson, “What does Contraception Have to Do with Abortion? Evangelicals v. Augustine and Roe v. Wade,” Southern Baptist Journal of Theology 7.2 (2003): 54–67.

[13] Jerome, To Eustochium, Letter 22 (NPNF 6:27).

[14] John Chrysostom, Epistle to the Romans, Homily 24 (NPNF1 11:520).

[15] John M. Riddell, J. Worth Estes, and Josiah Cox Russell, “Birth Control in the Ancient World,” Archaeology 47 (1994): 29–35.

[16] Augustine, On the Good of Marriage 11 (NPNF1 3:404).

[17] Kenneth Magnuson, “Marriage, Procreation and Infertility: Reflections on Genesis,” SBJT 4.1 (2000): 26–42.

[18] Magnuson, “What does Contraception Have to Do with Abortion?” 58.

19 Andrew McCall, The Medieval Underworld (New York: Dorset, 1979), 179.

[20] Malcolm Potts and Martha Campbell, “History of Contraception,” Gynecology and Obstetrics 6 (2002): 1–23.

[21] Thomas Aquinas, Summa Theologica II–II q.153 a.2, trans. Fathers of the English Dominican Province (London: Oates & Washbourne, 1920), 122.

[22] Martin Luther, Commentary on Genesis: Chapters 1–5, ed. Jaroslav Pelikan, Luther’s Works 1 (St. Louis: Concordia, 1958), 118.

[23] John Calvin, Commentaries on the First Book of Moses Called Genesis, trans. John King, vol. 2 (Grand Rapids: Christian Classics Ethereal Library, n.d.), 38:10, https://tinyurl.com/mr39x3dh. Strangely, regarding Calvin’s comments on Genesis 38:10, modern editors and/or publishers have completely omitted his remarks against contraception. For example, see John Calvin, Genesis, ed. and trans. John King (Edinburgh: Banner of Truth, 1965), 281; and Genesis, ed. Alister McGrath and J. I. Packer, Crossway Classic Commentaries (Wheaton, IL: Crossway, 2001), 304. Some Roman Catholics blame this discrepancy on Protestant anti-Catholicism—e.g., Dave Armstrong, “Publishers Omit Calvin’s Anti-Contraception View?!” Biblical Evidence for Catholicism, 9 August 2016, https://www.patheos.com/blogs/davearmstrong/2016/08/publishers-omit-calvins-anti-contraception-view.html.

[24] Dennis P. Hollinger, “The Ethics of Contraception: A Theological Assessment,” JETS 56 (2013): 683–84.

[25] Andrew Brennan, “Environmental Ethics,” Stanford Encyclopedia of Philosophy, 3 June 2002, https://plato.stanford.edu/entries/ethics-environmental/.

[26] Patrick Collins, “Population Growth the Scapegoat? Rethinking the Neo-Malthusian Debate,” Energy & Environment 13 (2002): 401–22.

[27] Evelyn Millis Duvall, “North American Conference on Church and Family,” Marriage and Family Living 23 (1961): 270–72; Allan Carlson, “Children of the Reformation,” Touchstone 20 (2007): 20–25.

[28] Mark A. Pivarnus, “On the Question of Natural Family Planning,” Congregation of Mary Immaculate Queen, 18 February 2002, https://tinyurl.com/3e9zas9s.

[29] Paul VI, Humanae Vitae, On Human Life (Washington, DC: United States Catholic Conference, 1968).

[30] Nigel M. de. S. Cameron, “Christian Vision for the Biotech Century: Toward a Strategy,” in Human Dignity in the Biotech Century, ed. Charles W. Colson and Nigel M. de S. Cameron (Downers Grove, IL: InterVarsity Press, 2004), 21–39.

[31] John T. Noonan Jr., “Abortion and the Catholic Church: A Summary History,” Natural Law Forum 12 (1967): 85.

[32] R. Albert Mohler Jr., “Can Christians Use Birth Control?,” Albert Mohler, 8 May 2006, https://albertmohler.com/2006/05/08/can-christians-use-birth-control.

[33] Mohler, “Can Christians Use Birth Control?”

[34] Millard J. Erickson, Christian Theology, 3rd ed. (Grand Rapids: Baker Academic, 2013), 457–74.

[35] John F. Kilner, Dignity and Destiny: Humanity in the Image of God (Grand Rapids: Eerdmans, 2015) 224.

[36] Erwin W. Lutzer, The Truth About Same-Sex Marriage: 6 Things You Must Know about What’s Really at Stake (Chicago: Moody, 2010), 57.

[37] Magnuson, “Marriage, Procreation,” 28.

[38] Magnuson, “Marriage, Procreation,” 29.

[39] Magnuson, “Marriage, Procreation,” 31.

[40] All scriptural references in this article are from the English Standard Version.

[41] Sherif Girgis, Ryan T. Anderson, and Robert George, What is Marriage? Man and Woman: A Defense, 2nd ed. (New York: Encounter, 2020): 33.

42 Kenneth Magnuson, Invitation to Christian Ethics: Moral Reasoning and Contemporary Issues (Grand Rapids: Kregel Academic, 2020): 179.

[43] Historically, the sin of Onan in Genesis 38:6–11 has been part of the contraception debate, and Roman Catholics have used the passage as an ethical argument against contraception. Protestants generally argue to the contrary. On the debate, see David VanDrunen, Bioethics and the Christian Life: A Guide to Making Difficult Decisions (Wheaton, IL: Crossway, 2009): 114; Charles F. Devine, “The Sin of Onan: Gen. 38:8–10,” CBQ 4 (1942): 323–40. But see footnote 23 above for Calvin’s exegesis of the passage and later Protestant discomfort with it.

[44] Christopher Ash, “The Purpose of Marriage” Churchman 115 (2001): 17–29; Tony Reinke, “Marriage in the Cosmic Plan of God,” Journal for Biblical Manhood and Womanhood 17 (2012): 17–27.

[45] Martin Luther, “Commentary on 1 Corinthians 7,” in Selected Pauline Epistles, LW 28:9.

[46] Thomas R. Schreiner, 1 Corinthians: An Introduction and Commentary, TNTC 7 (Downers Grove, IL: InterVarsity Press, 2018), 153–54; David E. Garland, 1 Corinthians, BECNT (Grand Rapids: Baker Academic, 2003), 340.

[47] Paul VI, “Humanae Vitae,” no. 12.

[48] Magnuson, Invitation to Christian Ethics, 193.

[49] Ralph M. McInerny, “Two Visions of Human Life and Procreation: Christian and Secular,” National Catholic Bioethics Quarterly 22 (2022): 23–30.

[50] Magnuson, “What does Conception Have to Do with Abortion?,” 63.

[51] Magnuson, “What does Conception Have to Do with Abortion?,” 55; Mohler, “Can Christians Use Birth Control?”

[52] Hollinger, “The Ethics of Contraception,” 688–89.

[53] Magnuson, “What does Conception Have to Do with Abortion?,” 59; Ed Wheat and Gaye Wheat, Intended for Pleasure: Sex Technique and Sexual Fulfillment in Christian Marriage, 4th ed. (Grand Rapids: Revell, 2010): 194–204.

[54] Magnuson, “What does Conception Have to Do with Abortion?,” 59.

[55] W. Ross Blackburn, “Sex and Fullness: A Rejoinder to Dennis Hollinger on Contraception,” JETS 58 (2015): 117–30.

[56] J. Budziszewski, What We Can’t Not Know: A Guide, revised ed. (Dallas: Ignatius, 2011): 100.

[57] Paul VI, “Humanae Vitae,” no. 11; Evan Lenow, “Protestants and Contraception,” First Things 279 (2018): 15–18.

[58] Magnuson, “What does Conception Have to Do with Abortion?” 64.

[59] Blackburn, “Sex and Fullness,” 130.

[60] Lenow, “Protestants and Contraception,” 16.

[61] Blackburn, “Sex and Fullness,” 125.

[62] Magnuson, “What does Conception Have to Do with Abortion?,” 56; Mohler, “Can Christians Use Birth Control?”; Lenow, “Protestants and Contraception,” 16.

[63] Gerard J. Tortora and Bryan H. Derrickson, Principles of Anatomy and Physiology, 16th ed. (Hoboken, NJ: Wiley & Sons, 2020), 1127, 1139–41.

[64] Tortora and Derrickson, Principles of Anatomy and Physiology, 1141.

[65] L. M. Keder, “Contraception,” in The Physiologic Basis of Gynecology and Obstetrics, ed. Douglas A. Kniss, David B. Seifer, and Philip Samuels (Philadelphia: Lippincott, Williams, & Wilkins, 2001), 276.

[66] Diana B. Petitti, “Combination Estrogen–Progestin Oral Contraceptives,” New England Journal of Medicine 349 (2003): 1443–50.

[67] For a more detailed discussion, see Dennis M. Sullivan, “The Oral Contraceptive as Abortifacient: An Analysis of the Evidence,” Perspectives on Science and Christian Faith 58 (2006): 189–95.

[68] “Highlights of Prescribing Information: Yasmin,” Food and Drug Administration, 1 February 2012, https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021098s019lbl.pdf.

[69] Leo Han, Rebecca Taub, and Jeffrey T. Jensen, “Cervical Mucus and Contraception: What We Know and What We Don’t,” Contraception 96 (2017): 310–21.

[70] Gabor T. Kovacs, “Pharmacology of Progestogens Used in Oral Contraceptives: An Historical Review to Contemporary Prescribing,” Australian and New Zealand Journal of Obstetrics and Gynaecology 43 (2003): 4–9.

[71] Keder, “Contraception,” 276.

[72] Walter L. Larimore and Joseph B. Stanford, “Postfertilization Effects of Oral Contraceptives and Their Relationship to Informed Consent,” Archives of Family Medicine 9 (2000): 126–33.

[73] Randy C. Alcorn, Does the Birth Control Pill Cause Abortions?, 6th ed. (Gresham, OR: Eternal Perspective Ministries, 2002).

[74] Larimore and Stanford, “Postfertilization Effects of Oral Contraceptives,” 128–29.

[75] Susan A. Crocket, Joseph L. DeCook, Donna Harrison, and Camilla Hersh, “Using Hormone Contraceptives is a Decision Involving Science, Scripture, and Conscience,” in The Reproduction Revolution: A Christian Appraisal of Sexuality, Reproductive Technologies, and the Family, ed. John F. Kilner, Paige C. Cunningham, and William D. Hager (Grand Rapids: Eerdmans, 2000): 192–201.

[76] Jehn-Hsiahn Yang, Ming-Yih Wu, Chin-Der Chen, Mau-Chaio Jiang, Hong-Nerng Ho, and Yu-Shih Yang, “Association of Endometrial Blood Flow as Determined by a Modified Colour Doppler Technique with Subsequent Outcome of In-Vitro Fertilization,” Human Reproduction 14 (1999): 1606–10; P. Lesny, S. R. Killick, R. L. Tetlow, D. J. Manton, J. Robinson, and S. D. Maguiness, “Ultrasound Evaluation of the Uterine Zonal Anatomy During In-Vitro Fertilization and Embryo Transfer,” Human Reproduction 14 (1999): 1593–98; Y. Yuval, S. Lipitz, J. Dor, and R. Achiron, “The Relationships Between Endometrial Thickness, and Blood Flow and Pregnancy Rates in In-Vitro Fertilization,” Human Reproduction 14 (1999): 1067–71; G. Csemiczky, H. Wramsby, E. Johannisson, and B. M. Landgren, “Endometrial Evaluation is Not Predictive for in Vitro Fertilization Treatment,” Journal of Assisted Reproduction and Genetics 16 (1999): 113–16.

[77] Crocket, DeCook, and Hersh, “Using Hormone Contraceptives,” 193–94.

[78] Errol R. Norwitz, Danny J. Schust, and Susan J. Fisher, “Implantation and the Survival of Early Pregnancy,” New England Journal of Medicine 345 (2001): 1400–8.

[79] Sullivan, “Oral Contraceptive as Abortifacient,” 191–92.

80 Wayne Grudem, Christian Ethics: An Introduction to Biblical Moral Reasoning (Wheaton, IL: Crossway, 2018), 102–5; John Jefferson Davis, Evangelical Ethics: Issues Facing the Church Today, 4th ed. (Phillipsburg, NJ: P&R Publishing, 2015), 283. Magnuson, Invitation to Christian Ethics, 34, 40.

[81] Simone De Beauvoir, as quoted in Margaret McCarthy, “The Emperor’s (New) New Clothes: The Logic of the New Gender Ideology,” Communio 46 (2019): 3–4.

[82] Abigail Favale, The Genesis of Gender: A Christian Theory (San Francisco: Ignatius, 2022), 91–92.

[83] John Wilkinson, The Bible and Healing: A Medical and Theological Commentary (Edinburgh: Handsel, 1998), 11–13.

[84] Favale, Genesis of Gender, 103.

[85] Favale, Genesis of Gender, 108.

[86] “Emergency Contraception,” World Health Organization, 9 November 2021, https://www.who.int/news-room/fact-sheets/detail/emergency-contraception.

[87] Modified portions of this section appeared originally in Jeffrey D. Lewis and Dennis M. Sullivan, “Abortifacient Potential of Emergency Contraceptives,” Ethics & Medicine 28 (2012): 113–20.

[88] Sullivan, “The Oral Contraceptive as Abortifacient,” 191; Joel E. Goodnough, “Redux: Is the Oral Contraceptive Pill an Abortifacient?,” Ethics & Medicine 17 (2001): 37–51; Laura Purdy, “Is Emergency Contraception Murder?,” Reproductive Biomedicine Online 18 (2009): 37–42; Roberto Rivera, Irene Yacobson, and David Grimes, “The Mechanism of Action of Hormonal Contraceptives and Intrauterine Contraceptive Devices,” American Journal of Obstetrics and Gynecology 181 (1999): 1263–69.

[89] “Women’s Health Policy: Emergency Contraception,” Kaiser Family Foundation, 4 August 2022, https://www.kff.org/womens-health-policy/fact-sheet/emergency-contraception/.

[90] David T. Baird, “Emergency Contraception: How Does it Work?” Reproductive Biomedicine Online 18 (2009): Suppl. 1:32–36.

[91] A. O. Arowojolu, I. A. Okewole, and A. O. Adekunle, “Comparative Evaluation of the Effectiveness and Safety of Two Regimens of Levonorgestrel for Emergency Contraception in Nigerians,” Contraception 66 (2002): 269–73; Helena van Hertzen and Emily M. Godfrey, “Emergency Contraception: The State of the Art,” Reproductive Biomedicine Online 18 (2009): 28–31; H. Hamoda, P. W. Ashok, C. Stalder, G. M. M. Flett, E. Kennedy, and A. Templeton, “A Randomized Trial of Mifepristone (10 mg) and Levonorgestrel for Emergency Contraception,” Obstetrics & Gynecology 104 (2004): 1307–13; Suk Wai Ngai, Susan Fan, Shiqin Li, Linan Cheng, Juhong Ding, Xiaoping Jing, Ernest Hung Yu Ng, and Pak Chung Ho, “A Randomized Trial to Compare 24 H Versus 12 H Double Dose Regimen of Levonorgestrel for Emergency Contraception,” Human Reproduction 20 (2005): 307–11; Anna F. Glasier, Sharon T. Cameron, Paul M. Fine, Susan J. S. Logan, William Casale, Jennifer Van Horn, Laszlo Sogor, Diana L. Blithe, Bruno Scherrer, and Henri Mathe, “Ulipristal Acetate Versus Levonorgestrel for Emergency Contraception: A Randomized Non-Inferiority Trial and Meta-Analysis,” Lancet 375 (2010): 555–62; Penina Segall-Gutierrez and Ian Tilley, “Emergency Contraception,” in Management of Common Problems in Obstetrics and Gynecology, ed. T. Murphy Goodwin, Martin N. Montoro, Laila Muderspatch, Richard Paulson, and Subir Roy (Hoboken, NJ: Wiley, 2010), 508–11; “Plan B One-Step-Levonorgestrel Tablet: Package Insert,” Foundation Consumer Healthcare, LLC, 1 January 2023, https://tinyurl.com/2s4jch33.

[92] Lewis and Sullivan, “Abortifacient Potential of Emergency Contraceptives,” 115. Italics added.

[93] Nicanor Pier Giorgio Austriaco, “Is Plan B an Abortifacient? A Critical Look at the Scientific Evidence,” National Catholic Bioethics Quarterly 7 (2007): 703–7.

[94] Natalia Novikova, Edith Weisberg, Frank Z. Stanczyk, Horacio B. Croxatto, and Ian S. Fraser, “Effectiveness of Levonorgestrel Emergency Contraception Given before or after Ovulation—A Pilot Study,” Contraception 75 (2007): 112–18; James Trussell and Beth Jordan, “Mechanism of Action of Emergency Contraceptive Pills,” Contraception 74 (2006): 87–89.

[95] M. Endler, R. H. W. Li, and K. Gemzell Danielsson, “Effect of Levonorgestrel Emergency Contraception on Implantation and Fertility: A Review,” Contraception 109 (2022): 8–18.

[96] P. G. L. Lalitkumar, S. Lalitkumar, C. X. Meng, A. Stavreus-Evers, F. Hambiliki, U. Bentin-Ley, and Kristina Gemzell-Danielsson, “Mifepristone, but Not Levonorgestrel, Inhibits Human Blastocyst Attachment to an In Vitro Endometrial Three-Dimensional Cell Culture Model,” Human Reproduction 22 (2007): 3031–37.

[97] Sarah Silbiger, “U.S. FDA Changes Plan B Label to Say It Does Not Cause Abortion,” Reuters, 23 December 2022, https://tinyurl.com/4bkenmya.

[98] Ron Hamel, “Thinking Ethically about Emergency Contraception. Critical Judgments Require Adequate and Accurate Information,” Health Progress 91 (2010): 62–67.

[99] Hamel, “Thinking Ethically about Emergency Contraception,” 64.

[100] NIH: National Library of Medicine, “Intrauterine Devices (IUD),” Medline Plus, https://medlineplus.gov/ency/article/007635.htm.

[101] Brian Clowes, “Abortifacient Brief: The Intrauterine Device,” Human Life International, 5 January 2022, https://www.hli.org/resources/abortifacient-brief-intrauterine-device/.

[102] “What are Hormonal IUDs?” Planned Parenthood, https://www.plannedparenthood.org/learn/birth-control/iud/hormonal-iuds.

[103] “Mirena: Mechanism of Action,” Bayer HealthCare Pharmaceuticals, 2021, https://www.mirenahcp.com/about-mirena/mechanism-of-action.

[104] “What Are Non-Hormonal IUDs?” Planned Parenthood, https://www.plannedparenthood.org/learn/birth-control/iud/non-hormonal-copper-iud.

[105] “Intrauterine Devices: An Effective Alternative to Oral Hormonal Contraception,” Prescrire International 18 (2009): 125–30.

[106] Nicanor Pier Giorgio Austriaco, “Colloquy: Using Levonorgestrel-Releasing Intrauterine Devices in Catholic Hospitals,” National Catholic Bioethics Quarterly 20 (2020): 217–19.

[107] Joy Friedman and Rubiliatu A. Oluronbi, “Types of IUDs and Mechanism of Action,” in Optimizing IUD Delivery for Adolescents and Young Adults: Counseling, Placement, and Management, ed. Mandy S. Coles and Aisha Mays (Cham, Switzerland: Springer, 2019): 29–39; Mandy S. Coles and Aisha Mays, “Addressing IUD Efficacy, Eligibility, Myths, and Satisfaction with Adolescents and Young Adults,” in Optimizing IUD Delivery for Adolescents and Young Adults, 41–54.

[108] Richard J. Fehring, “Efficacy of Natural Family Planning Methods,” 4.

[109] Smoley and Robinson, “Natural Family Planning,” 927.

[110] Sharon Sung and Aaron Abramovitz, “Tubal Ligation,” National Library of Medicine: StatPearls, 18 September 2022, https://www.ncbi.nlm.nih.gov/books/NBK549873/.

[111] Pierre Arnaud Godine, Konstantinos Syrios, Gwennaelle Rege, Sami Demir, Efstratia Charitidou, and Olivier Wery, “Laparoscopic Reversal of Tubal Sterilization: A Retrospective Study Over 135 Cases,” Frontiers in Surgery 5 (2019): 1–7; Anita Madison, Lamia Alamri, Adina Schwartz, Marja Brolinson, and Alan DeCherney, “Conventional Laparoscopy is the Better Option for Tubal Sterilization Reversal: A Closer Look at Tubal Reanastomosis,” Women’s Health Reports 2 (2021): 375–80.

[112] Russell P. Hayden, Philip S. Li, and Marc Goldstein, “Microsurgical Vasectomy Reversal: Contemporary Techniques, Intraoperative Decision Making, and Surgical Training for the Next Generation,” Fertility and Sterility 111 (2019): 444–53.

[113] Committee on Ethics, “Sterilization of Women: Ethical Issues and Considerations,” Obstetrics and Gynecology 129 (2017): e109–e116.

[114] Sung and Abramovitz, “Tubal Ligation,” 3–4; Yang Fang, Junjun Li, Liang Dong, Kun Tan, Xiaopeng Huang, Peihai Zhang, Xiaozhang Liu, Degui Chang, and Xujun Yu, “Review of Vasectomy Complications and Safety Concerns,” World Journal of Men’s Health 39 (2021): 406–18.

[115] Aquinas, Summa Theologica II–II q.65 a.1.

[116] Pius XI, Casti Connubii, no. 71, 31 December 1930.

[117] Pius XI, Casti Connubii, no. 65, 31 December 1930.

[118] Paul VI, “Humanae Vitae,” no. 14.

[119] Gerald P. McKenny, “A Bad Disease, a Fatal Cure: Why Sterilization is Permissible and the Autonomy of Medicine is Not,” Christian Bioethics 4 (1998): 100–109.

[120] John Piper, “Is Permanent Birth Control a Sin?” Desiring God, 13 March 2015, https://www.desiringgod.org/interviews/is-permanent-birth-control-a-sin.

[121] Some portions of this section first appeared, in modified form, in Sullivan, “The Conception View of Personhood,” 31.

[122] My thanks to the following scholars for valuable feedback on an early draft: Marcus Leeds, Brian Humphreys, Robert Drew, Nathanael Davis, Hans Madueme, and C. Ben Mitchell.

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