Japanese Don’t Pop the Pill

It’s smaller than baby aspirin, but Japanese women nonetheless find this pill hard to swallow.

When Japan grudgingly--and belatedly--approved the contraceptive pill last year, expectations were high that millions of women would jump at the chance to exert more control over their own fertility.

Since then, however, something of a pregnant pause has ensued. Just 100,000 of the nation’s 30 million women of childbearing age have gotten prescriptions, according to Japan’s Family Planning Assn. That’s less than half of 1%, compared to a 15% level for U.S. couples.

Pharmaceutical companies, doctors, sociologists and Japanese women say many factors are involved in the slow sales, including ignorance, easy-to-obtain abortions, marketing restrictions, discriminatory pricing and taboos associated with visiting a gynecologist.

Another dynamic may be the continued belief that men are the ones who are supposed to make contraceptive decisions.

In fact, for decades the mostly male Health Ministry was making the decision. A full 34 years after it was first submitted for regulatory approval, the pill received the bureaucrats’ go-ahead last summer--and then only because the ministry had approved the male sexual-performance drug Viagra with unseemly haste four months earlier.

And it appears that the Health Ministry is still calling the shots: Critics say it is far more intent on encouraging children than limiting them. Last year, Japan saw its lowest fertility rate since the country started keeping statistics a century ago.

“Many men dislike giving women the right to choose,” lawmaker Mizuho Fukushima said. “Also, since the Japanese government and many old politicians are anxious about the low birthrate, they don’t provide correct information about the pill in schools and elsewhere.”

Health-care professionals say decades of misinformation and outdated science also have exacted their toll. During the long battle for approval, critics of the pill claimed that it was unsafe, produced dangerous side effects, spurred promiscuity and spread disease, and even that its hormones would pollute Japanese rivers and streams.

Reversing this kind of thinking in a short period has proved difficult.

“There hasn’t been enough accurate information,” said Masayuki Honda, an official with Japanese drug maker Tsumura & Co. “Japanese women are not well informed.”

The ignorance isn’t confined just to the public. Dr. Ruriko Tsushima, chief obstetrician at Tokyo’s Bokuto Hospital, says that despite World Health Organization pronouncements on the pill’s safety, and widespread global use, many Japanese doctors, nurses and pharmacists also continue to harbor, and pass on, misconceptions.

“International common sense,” she said, “just hasn’t made it to Japan.”

Cultural factors also play a part. Most women in Japan rarely visit a gynecologist, the usual way to obtain a prescription. In fact, experts say, the assumption is that anyone who does go and isn’t married either must have a sexually transmitted disease or be looking for an abortion. This can make simply sitting in the waiting room surrounded by married, pregnant patients uncomfortable.

“I get embarrassed,” said Harumi Tampo, a 53-year-old company executive. “So I generally don’t go.”

Furthermore, while the ranks of female gynecologists have swelled in the West, in Japan the field is still dominated by men. The general perception is that they are aloof, old enough to be the patient’s father and look down on young people’s lifestyles as promiscuous, none of which exactly engenders confidence.

Often this skittishness toward youth sexuality carries over to public policy as well, resulting in a lack of well-designed programs, says Mariko Fujiwara, research director with Hakuhodo Life Institute, an advertising agency. This contrasts with the U.S., she adds, where schools and the government tend to be more realistic in assuming that young people are sexually active.

Besides, Japanese women are “quite passive and don’t see it as something they should control,” said Midori Ashida, an activist who campaigned for the pill’s approval. “Everyone blames the government and the doctors, but to some extent the real problem is women themselves.”

Pharmaceutical companies have a direct interest in wider use, but they aren’t allowed to advertise to the general public.

Hemmed in, drug companies are forced to direct most of their energies toward changing the conservative medical establishment, a daunting task. Eleven approved pill makers were allowed to set up a public information hotline, but last month they closed it down because almost no one called.

“There’s been too much negative campaigning in the Japanese media,” griped Sachi Fujimoto, a hotline employee.

Drug companies are quietly trying other angles. Industry executives say they’re seeking a young Japanese rock star or teen idol willing to speak out in favor of oral contraceptives. Their hope: that this might change perceptions and perhaps even make the pill “cool” in fad-conscious Japan.

So far this idea has been a dud, however, because agents tightly control their talent and tend to shun anything controversial.

Another tactic has been to tell women which gynecologists are sympathetic. This is important, the drug executives say, because an estimated 85% of those in the profession won’t readily prescribe the pill.

Industry efforts must be indirect, however. “As soon as we take an active role, the Health Ministry takes an active role against us,” said one drug executive with a Japanese-foreign joint venture company, who asked not to be named. “It becomes the kiss of death.”

A Health Ministry official, however, says the fault lies with teachers and parents for not providing more information.

In the West, the spread of the pill starting in the 1960s kicked off the sexual revolution. In Japan, casual sex among young people spread more slowly, due in part to the pill’s forbidden status and society’s more conservative Confucian traditions.

But young Japanese are making up for lost time, says Bokuto Hospital’s Tsushima. About 40% of high school students report that they’ve had sexual relations, a fourfold increase compared with similar surveys a decade ago.

Other impediments to the pill’s spread include Japan’s entrenched “condom culture.” Japan is the world’s highest user of condoms, according to the U.N. Population Division, with 46% of couples between the ages of 15 and 49 saying they are regular users, and old habits die hard.

Vending machines sell condoms openly on the street, the Condomania outlet in Tokyo’s trendy Harajuku district markets “luminous glodoms, to light up your love life,” and Japanese generally trust them.

This contrasts with the perception many Japanese have of the pill--namely, that it is a fringe drug that produces horrible side effects such as nausea, morning sickness, bloat and strokes. While today’s pill can induce these side effects in individual cases, much of the information dates back to earlier-generation products of 20 or 30 years ago.

“I’d worry about the side effects because it hasn’t become popular in Japan,” said Yuka Watabe, a 25-year-old office worker. “I hear women can’t get pregnant again, even after they stop using it.”

On the vanity side, drug companies say fears of weight gain on small Japanese frames also show up prominently in their focus-group responses.

“No one I know is using it. And maybe the side effects aren’t as bad as I’ve heard, but there isn’t much information,” said Rumi Kai, a 25-year-old “O.L.,” or office lady, working in Tokyo’s banking district. “It’s much cheaper and easier just to ask men to buy condoms. Taking something every day seems like a real bother.”

Women who overcome these hurdles and actually go to a gynecologist in search of a prescription face still more impediments. As part of its grudging approval for the pill, the Health Ministry issued detailed, cumbersome guidelines for anyone who wants it. This includes a pelvic exam, blood test, urine test, uterine cancer test and sexually transmitted disease test.

Then after all that, it’s time to pay the bill. The pill is not covered under Japan’s medical insurance system. The result: Women face costs of $550 to $950 annually for the pill and required exams, depending on the clinic.

The cost of not using it can also be measured. About 52% of pregnancies are unwanted in Japan--compared with about 30% in the United States--with a large percentage of those ending in abortion. Abortion carries almost no moral stigma in Japan, where it has been legal and free of controversy since 1948.

Experts say they expect it to take a decade or more for pill use in Japan to catch up with that of other countries. One promising change, however, is young Japanese, who are far more open about discussing contraception and taking their cue from global trends.

“I’m prepared to talk about contraception when I get a girlfriend,” said Masanobu Yanagi, a 17-year-old junior with his hair cut short. “My high school friends, both male and female, are very open. We certainly don’t think men are dominant in my generation.”

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Rie Sasaki of The Times’ Tokyo Bureau contributed to this report.