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Male fertility control — where are the men?
Contraception 78 (2008) S7 – S17
Original research article
Male fertility control — where are the men? Jacqueline E. Darroch Guttmacher Institute, New York, NY 10038, USA Received 1 April 2008; accepted 1 April 2008
Abstract Control over the timing and number of children continues to be a challenge for many men and women today. While some men are contraceptive users today, current method options are limited. Evidence indicates that many men would welcome more method options, to meet their own needs and goals and to provide a way for them to participate in contraception in a more collaborative way with their partner. © 2008 Elsevier Inc. All rights reserved. Keywords: Male fertility control; Method options
1. Introduction In assessing the status and charting future paths for “male fertility control,” along with looking at the biology and technology of new methods for male use, it can be helpful to look also at the social science of fertility control and contraceptive use among men. Specifically, I propose to consider male contraception in history, men's interest in fertility control today, men's contribution to contraceptive use, opportunities for increased male use and issues that may affect use of new male methods. 2. Male contraception in history Men have participated in efforts to control fertility for millennia. Knowledge and use of both female and male contraceptive practices are thousands of years old, including vaginal formulations and barriers for women, withdrawal (coitus interruptus) for men, as well as prolonged breast feeding, abstinence and induced abortion. By the mid-1700s, men were using condoms for contraception (although their predominant use appears to have been for prevention of infection) and by the late 1800s, the
Author Disclosure: Jacqueline E. Darroch does not report any conflicts of interest with the sponsor of this supplement article or products discussed in this article. E-mail address: [email protected]. 0010-7824/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2008.04.117
vulcanization of rubber made condoms of reasonable quality widely available. By the early 1900s, advances had been made in diaphragms and cervical caps, IUDs, in early knowledge of hormonal female contraception and in both female and male sterilization [1]. Still, until the introduction of oral contraceptives and modern IUDs in the second half of the 1900s, men played a prominent role in contraceptive use. For example, in 1955, men's use of the condom and withdrawal accounted for 32% of all contraceptive use among married white women aged 18–39 in the United States and another 21% of couples relied on periodic abstinence, a method also involving male participation (Fig. 1) [2]. The contraceptive picture soon changed, however, as the widespread availability of a number of new options, including the pill, IUD and easier methods of tubal ligation for women and of vasectomy for men. In 2002, male methods accounted for 32% of contraceptive use in the United States — vasectomy for 9%, condom use for 18%, withdrawal for 4% and periodic abstinence for only 1% of total use [3]. For women, more reliable control over their own fertility was accompanied by widespread social changes in employment, education and gender roles. The new methods, and vasectomy, changed the link between sexuality and contraception as well since these new methods were used separate from the time of intercourse [4]. The requirement for medical prescription for the pill and insertion of IUDs, as well as fitting for diaphragms, led to a medical model for reversible female contraception and development of public family planning
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Fig. 1. Men's direct participation in contraceptive use declined in the USA between 1955* and 2002.
clinics throughout the United States, many European countries and, eventually, throughout the developing world. Such services were often linked to maternal and child health services and gave rise to a wider focus on women's reproductive health services. Medical services were also needed for both tubal ligation and vasectomy, but these did not require ongoing services or supplies, and male reversible methods, the condom and withdrawal, did not require medical services for use. As a result, men were generally left out of women's family planning services and no parallel system of reproductive health care for men was developed. In the past two decades, increased attention has been given to men's involvement in fertility control, as supporters of and participants with women and, increasingly, in their own right [5–10]. The 1994 International Conference on Population and Development in Cairo put forth a new reproductive health paradigm. Part of the shift to a broader agenda included involving men, with a call for efforts “… to emphasize men's shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning; prenatal, maternal and child health; prevention of sexually transmitted diseases, including HIV; prevention of unwanted and highrisk pregnancies…” [11]. Male involvement in fertility control is an ambiguous concept, however, spanning approaches that • Emphasize men as contraceptive users and as clients for reproductive health services, • Address men as partners who can improve — and impede — women's contraceptive use and reproductive health, and • View men as agents of positive change in supporting women's reproductive health and in transforming gender norms and policies that constrain reproductive health and rights [10].
This Supplement focuses on the first type of involvement, men as contraceptive users, to consider the state of contraceptive options for men and men's potential interest in using them. Other articles in this issue survey the state of contraceptive science. My goal is to complement this information with consideration of the social science of men's contraceptive use. Is there evidence that men today care about their fertility? How much do they contribute today to contraceptive method use? What are some differences in men's contraceptive use? Where are there opportunities for increased male contraceptive use? And, finally, what are some of the contextual factors that might affect increased male use? 3. Limitations Any assessment of men's roles in fertility control and contraceptive use is limited by the paucity of relevant data. Because it is women who become pregnant and give birth, and because their health is most directly affected by these events, fertility research historically has focused mainly on women. This focus also paralleled common social assumptions that fertility control was primarily the woman's responsibility, perhaps under a male partner's direction, and reflected the greater number of methods available for women's use. Since the 1960s, The United Nations Population Division staff has used available survey information to estimate worldwide and regional patterns of contraceptive use. These estimates are, however, only for women (couples) in union, reflecting the fact that, although women not in union are now included in many country surveys, their inclusion is fairly recent and they are still not included in all of them. The estimation methodology has evolved from using expert judgment to estimate use patterns for countries with missing data to the current approach of estimating regional subtotals
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Fig. 2. The average number of children men want to have has declined, especially in Sub-Saharan Africa.
based on data from reporting countries, weighted by the numbers of women in union aged 15–49. Estimates in a given year rely on the most recent available national surveys and the most recent United Nations population estimates. As a result, the patterns of method use for a publication year represent a recent time period, but they may lag in monitoring rapid changes. For example, the 1994 estimates are reported to represent use patterns around 1990, and the 2005 estimates, to represent use around 1999. Still, the generally constant approach to estimation and the global perspective provides valuable information on changes in contraceptive use over time and differences across areas of the world. While surveys on fertility and family planning issues have queried women worldwide since the mid-1970s, comparable surveys of men began only in the 1990s. This paper relies most heavily on data from these demographic and health
surveys, using the men's reports when possible. As a result, however, most of the data cover developing countries and they are most complete for Sub-Saharan Africa and Latin America and the Caribbean. Less information is available for men in Asia, the Middle East and North Africa and, especially, China and India. For ease of presentation, much of the information is for large regions of the world. While this does capture differences in attitudes and behaviors, variation across and within countries is often blurred.
4. Men's interest in fertility control today Population growth rates vary across the world, from under the standard replacement level around 2, in much of Europe and China, to well beyond that in many countries,
Fig. 3. Many men say they discuss family planning with their partners, though more than partners report.
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particularly in Africa [12]. Yet, in varying degrees, women and men everywhere seek control over the timing and number of pregnancies and childbearing. Men's reports of the number of children they want to have average around 2–3 in most of the world outside of SubSaharan Africa, where the averages for men aged 15– 24 ranges from 4 to 11 (Fig. 2) [8]. Comparison with reports from men aged 50–54 illustrates that desired fertility has fallen in recent decades, as it has among women, especially in Sub-Saharan Africa. The contrast between low desired fertility relative to biological possibilities and men's long periods of sexual activity mean that, like women, men in much of the world spend most of their sexually active lives trying to avoid having children. However, like women, men often have more children than they want, especially in developing countries. Many men discuss family planning with their wife or partner, but fewer than half of men aged 25–39 in union do so in much of Sub-Saharan Africa and in Pakistan and Egypt (Fig. 3) [8]. 5. Men's contribution to contraceptive use Since the early 1960s, estimated levels of contraceptive prevalence among couples (married or in union) in which the woman was aged 15–49 have been fairly stable in the more developed countries, ranging between 67% and 72% [13]. In less developed countries, contraceptive use levels have increased dramatically, from 9% to 60% in 2001. World levels of contraceptive use track those of the less developed countries quite well, doubling from 30% in the early 1960s to more than 60% in the beginning of the 21st century (Fig. 4). This reflects steady increases in the proportion of the world's population living in less developed countries — from 68% in 1950 to an estimated 86% in 2050. Closer comparisons of 1994 and 2005 contraceptive use estimates provide a number of insights into factors affecting
Fig. 4. Contraceptive use has risen dramatically in less developed countries as a percent of all couples.
Fig. 5. Contraceptive use* has increased in number and as a percent of all couples in developing countries, but fell in developed regions from 1994 to 2005.
male contraceptive use levels. While the total proportion of couples using contraception has declined slightly in the more developed countries (from 72% in 1994 to 69% in 2005), the number of couples using contraceptives dropped 24%, from 136 to 103 million (Fig. 5) [14,15]. These changes may reflect the aging of populations in most of the developed world, as well as the moves away from formal marriage and toward later childbearing. The population of women aged 15–49 who were married or in union dropped from 189 million in developed countries in 1994 to 150 million in 2005. In less developed countries, the number of couples with a woman aged 15–49 rose from 710 million in 1994 to 947 million in 2005. And, the proportion of those couples using a contraceptive increased from 53% to 59% over the same period (Fig. 5). As a result, the total number of couples in less developed countries using contraceptives rose from 376 million in 1994 to 561 million in 2005. The world's
Fig. 6. The percentage of couples' contraceptive use involving direct male participation* has declined.
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Fig. 7. The numbers of men using vasectomy fell in developing countries; use of nonsupply methods fell in developed areas and rose in developing regions, 1994 and 2005.
Fig. 9. Most men say they would be willing to use a new male contraceptive method, except in Argentina and Indonesia.
population increasingly lives in less developed countries, a trend that will continue throughout this century. As a result, global trends increasingly reflect what happens in the developing world. On a worldwide level, the number of couples using contraceptives rose from 512 million to 664 million, representing an increase from 57% of all couples with a woman aged 15–49 in 1994 to 61% in 2005 (Fig. 5). While total contraceptive use has been increasing, the proportion of use involving men has declined, at least in recent years, from 37% in the 1987 estimates to 31% in 1994, 26% in 1999 and to 25% in 2005 (Fig. 6) [15,16]. The drop has been especially steep in the more developed countries, from 60% in 1987 to 47% of contraceptive use in 2005. Putting the changing levels of male method use together with trends in population size and in total contraceptive use indicates that the number of men using contraceptive methods actually remained fairly stable, at estimates of 162 million in 1994 and 165 million in 2005 [14,15]. In developed countries, there was a sizeable decrease in the proportion of men using withdrawal and periodic abstinence for contraception, likely due in large part to increased use of modern, female methods in countries in
Eastern Europe. In developing countries as a whole, use of vasectomy decreased, while use of condoms and traditional methods increased (Fig. 7). Behind these broad patterns of method use, there are many variations, by age, union status, intention for any (more) children, area and culture of the world, urban/rural status. However, some men are involved as method users at all stages of contraceptive use [15]. Reasons behind these differences also reflect methods that are available, especially those promoted by national family planning programs; attitudes about medical technologies, such as an expectation for injections reported in areas of Latin America and Africa; and, individual, cultural and religious preferences, such as restrictions on women's activities when they are menstruating or bleeding.
Fig. 8. More men say they would be willing to use a new male pill than an injection.
Fig. 10. About 200 million women and their partners in developing countries today have an unmet need for effective contraceptives.
6. Opportunities for increased male contraceptive use While predicting the future is a risky endeavor, a number of factors might impact future contraceptive use, with or without new methods, and provide opportunities for increased male use.
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Fig. 11. Contraceptive use will also rise as more couples want to have smaller families.
6.1. Men's attitudes about potential new methods It is very difficult to predict ultimate levels of interest and use of new methods until they are actually introduced, both because it is hard for people to report their reactions to the full range of characteristics of a new method and because the context of method release and aspects of its availability also affect people's reactions. However, three surveys of men about potential male methods provide useful insights. • Martin et al. [17] conducted interview surveys in 1995– 1996 with men in four major cities about their interest in new male methods (Fig. 8). Respondents included new or expectant fathers, fire-fighters and men donating blood. They asked men's willingness to use a new method of male fertility control that would “provide
reliable contraception, would not carry significant risk of side-effects and would take 3–4 months to become effective.” Some 44–83% of men surveyed said they would use the method if it was in pill form and 32–62% would use the method in an injection (Fig. 8). Men were more likely to say they would use a new male method if they thought their partner would like them to do so and less likely if they had concerns that the method would affect sexual desire. Relationships with age and education were mixed and religious beliefs were not related to their likelihood of use. • A study by Heinemann et al. [18] interviewed 9342 men aged 18–59 in 2002. Respondents were primarily from existing survey panels (with response rates of 36-68%) and from household quota samples in Latin America and Indonesia (Fig. 9). They asked men to “Imagine that there could be a pill, a jelly/salve, an injection or an implant with a high efficacy in birth control and good reversibility. Imagine you had an opportunity to use such a product that prevents sperm production and thereby prevents pregnancy” (K. Heinemann, personal communication, June 22, 2007). They found an average of 55% of men would be willing to use such a method, 24% were uncertain and 21% said they would not be willing (Fig. 9). Respondents who were more likely to be willing to use a new male method were those who were current contraceptive users, were willing to undergo vasectomy, had higher education, had higher income and who lived in a city. Those less likely to use had or wanted more children, had multiple partners and had general or religious (Muslims and Buddhists) objections to contraceptive methods. There were no significant differences by men's age, union status or religious commitment.
Fig. 12. Ten percent to 40% of women in union with unmet need say they are not using a method because of concerns about health and side effects of methods.
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Fig. 13. Over time, lack of knowledge has decreased as a reason for nonuse and concerns about health or other side effects have increased.
• Ringheim [19] analyzed surveys of men who had participated in trials of an injectable hormonal method. Follow-up questionnaires were available from 154 men, roughly 12 months after their participation in trials in 1990–1994. Participants were from China (81), Australia (41), the UK (13), USA (13), Singapore (3) and Thailand (3).
○ Nine percent believed in male responsibility or the importance of developing a male method. 6.2. Unmet need
○ Thirty-six percent needed a change in contraceptive method, ○ Twenty-three percent had been encouraged to participate by their partner, ○ Twenty-three percent had been encouraged by their doctor to participate, and
Current use of modern methods lags behind the number of women who are at apparent risk of unintended pregnancy (sexually active, fertile, do not want a child soon or at all). About 200 million women — and their partners — are at risk and either using traditional methods (64 million) — mostly withdrawal or periodic abstinence, or they are using no method at all (137 million) (Fig. 10) [20,21]. These are the couples at highest risk for unintended pregnancy, and potentially in the market for new and different contraceptive methods. Eliminating this unmet need would save the lives of 1.5 million women and children annually, reduce induced abortions by 64%, reduce illness related to pregnancy and preserve 27 million years of healthy life.
Fig. 14. Method-related discontinuation in the first year of use is high for all reversible contraceptives in the USA, especially male methods, 2002.
Fig. 15. Users sometimes choose their contraceptive methods because they do not like other options (data from the United States, 2004).
Men gave the following as main reasons for participating in the trials:
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6.4. Dissatisfaction with current choices
Fig. 16. Continued and increased contraceptive use requires adequate and reliable supplies and services.
If the 200 million couples all moved to modern methods — in the same use proportions as couples in their geographic region, union status and intention to space or limit pregnancies — an estimated 2.7 would turn to vasectomy and 43 million to condoms. 6.3. Increasing need/demand As seen above, the world population is increasing and the number of couples wanting to use contraceptives will rise (Fig. 11). It is estimated that, given current trends, contraceptive use by couples in developing countries (not including those not in union) in 2050 will be roughly 40% higher than in 2000, with half of this increase due to population growth and half to projected increased demand for family planning (Fig. 11) [22]. And, for condoms or other methods that would prevent HIV and other sexually transmitted infections, hoped-for increases to reach international prevention goals are even greater [23].
What indications are there that men and their partners would move to male methods in greater numbers or change from female methods to male-used methods? Concern about health or other side effects from available methods are frequent reasons for unmet need (Fig. 12) [24]. In recent years, the proportions of nonusers citing concerns about health and other method side effects have risen while there has been a decrease in lack of knowledge as a reason for nonuse (Fig. 13) [24]. Method discontinuation is high (Fig. 14) [25]. On average, 57% of new method users discontinue use of their method for reasons related to the method (rather than discontinuation to move directly to another method, to become pregnant or because the woman was no longer at risk because she was not sexually active or had a sterilizing operation). Method “choice” sometimes reflects greater dislike of other options rather than positive attitudes about one's method. In fact, in the United States, more than one in five women using oral contraceptives or long-acting methods (mostly hormonal injection) chose their method mostly because they did not like their other options. Roughly three in five women relying on male condom use chose the method by default, as did about half of those relying on other methods (mostly withdrawal and periodic abstinence) (Fig. 15) [26]. 6.5. Response to changing circumstances and new method options Contraceptive use among married couples in the United States changed dramatically with the introduction of oral contraceptives, with increased fears of their health risk and then with introduction of newer formulations. Tubal ligation and vasectomy both rose with easier methods and with growing popularity of sterilization when childbearing was
Fig. 17. Problems with access and cost of contraception are reasons for some women give for nonuse.
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completed. Condom use increased, after a steady decline, with the advent of the specter of HIV, especially among unmarried couples [27]. 7. Issues that may affect use of new male methods Access to any new contraceptive method can be key to its success or failure. Difficulties men might have getting a new male method would likely swing their cost–benefit evaluation of it to a more negative ranking. Providers also must make evaluation of their costs to provide a method against the likelihood of its use and its ultimate impact in prevention of unintended pregnancies. A new male method would likely require medical services and/or purchase of supplies. This is the case for many method users today, ranging from 43% to 44% in Asia outside of China and in Latin America and the Caribbean to 62% of users in Sub-Saharan Africa (Fig. 16) [20,21]. It comes as no surprise then that problems with access and the cost of contraceptives are reasons some women give for nonuse when they are at risk for unplanned pregnancy (Fig. 17) [24]. And, a consistent observation across developing countries is that couples with higher incomes are more likely to use a contraceptive than are poorer couples (Fig. 18) [28] Experience in the United States shows, however, that subsidized family planning services for poor and lowincome women and men can substantially reduce income differentials in use levels [29]. Cost is one, but not the only, reason why providers do not have constant stocks across a range of contraceptive methods. For example, in Kenya in 1999, fewer than 90% of family planning provider sites offered any particular method and no more than 75% had a particular method in stock (Fig. 19) [30,31]. Many potential users in developing countries will need to turn to public providers for method access (Fig. 20) [32].
Fig. 18. Women in couples with higher incomes are more likely to use a contraceptive than poorer women.
Fig. 19. Family planning provider sites do not offer all methods or have the ones they do offer in stocks (data from Kenya, 1999).*
This raises the important issue of the extent to which a new male method can be integrated into current family planning systems. These are designed primarily to reach women and are often integrated into maternal and child health systems. Changes in them and/or development of new provider options will be crucial for widespread access to any new male method [33]. 8. Conclusions Control over the timing and number of children continues to be a challenge for many men and women today. Development of new methods of pregnancy prevention continues to be an important endeavor. • Men have a stake in fertility control; they have a long history of contraceptive use, but, with the development of effective female-used methods, most of method use has been passed to women, relieving men and/or pushing them out from the sphere of contraception. Development of new methods for men can change this. • Patterns of contraceptive use vary widely, by personal, relationship, service setting and cultural contexts. New methods for men are likely to be integrated into
Fig. 20. Many contraceptive users in developing countries rely on public services, selected countries in East Africa.
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•
•
• •
•
lifetime patterns of male- and female-used methods rather than substitute entirely for female-used methods. Most contraceptive users, and most unmet need, exist in developing countries. Potential opportunities — and needs — for improved use exist among nonusers, users of traditional methods, as well as current users of male and of female methods. Dissatisfaction with currently used methods also indicates opportunities for introduction of new male methods into developed countries such as the United States. Markets for new male methods will need to be activated, rather than be expected to respond to active demand as was the case when modern female-used methods were introduced in the early 1960s. Motivating factors for use of new male methods are most likely to be dissatisfaction with current method options and partner encouragement or interest. Problems evident in female contraceptive use are likely also to exist for male methods, including fears about health and other side effects and access problems, such as cost to users and to public funders. The female-focused service system may not be easy to expand to serving males.
In sum, continued development of new contraceptive methods is important to satisfy women's and men's needs for safe, effective and comfortable ways to time and space pregnancies. Evidence indicates that many men would welcome more method options, to meet both their own needs and goals and to provide a way for them to participate in contraception in a more collaborative way with their partner. What is needed are new options for them to do so. The question is less “Where are the men?” than it is “Where are the methods for men?” References [1] Potts M, Campbell M. History of contraception. In: Sciarra JJ, editor. Gynecology and Obstetrics, vol 6, CD-ROM 2003 Edition. Philadelphia: Lippincott Williams and Wilkins; 2003. [2] Whelpton PK, Campbell AA, Patterson JE. Fertility and family planning in the United States. Princeton: Princeton University Press; 1996. [3] Mosher D, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data Vital Health Stat 2004 Number 350. [4] Darroch JE. The pill and men's involvement in contraception. Fam Plann Perspect 2000;32:90–1. [5] Bankole A, Singh S. Couples' fertility and contraceptive decisionmaking in developing countries: hearing the man's voice. Internat Fam Plann Perspect 1998;24:15–24. [6] Green ME, Biddlecom AE. Absent and problematic men: demographic accounts of male reproductive roles. Popul Dev Rev 2000; 26:81–115. [7] The Alan Guttmacher Institute. In their own right: Assessing the sexual and reproductive health needs of American men. New York: The Alan Guttmacher Institute; 2002. [8] The Alan Guttmacher Institute. In their own right: Assessing the sexual and reproductive health needs of men worldwide. New York: The Alan Guttmacher Institute; 2003.
[9] Salem R. Men's surveys new findings. Population Reports, Series M, No. 18. Baltimore: Johns Hopkins Bloomberg School of Public Health, The INFO Project; 2004. [10] Greene ME, Mehta M, Pulerwitz I, Wulf D, Bankole A, Singh S. Involving men in reproductive health: Contributions to development. Background paper for the UN Millennium Project. http://www. unmillenniumproject.org/documents/Greene_et_al-final.pdf; 2006 [accessed May 5, 2007]. [11] United Nations. Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. New York: United Nations; 1994. Para. 4.27, p. 30. [12] Montgomery K. The demographic transition. http://www.uwmc.uwc. edu/geography/Demotrans/demtran.htm [accessed May 5, 2007]. [13] United Nations, 1994. Adapted from Shah I, Levels and trends in contraceptive use. http://www.gfmer.ch/Endo/Course2003/PDF/ Contraceptive_use.pdf [accessed May 5, 2007]. [14] United Nations. Department of Economic and Social Affairs, Population Division, World Contraceptive Use-1994. New York: United Nations; 1994. [15] United Nations, 1994. United Nations, Department of Economic and Social Affairs, Population Division, World Contraceptive Use-2005. New York: United Nations; 2005. [16] Ringheim K. Reversing the downward trend in men's share of contraceptive use. Reprod Health Matters 1999;7:83–96. [17] Martin CW, Anderson RA, Cheng L, et al. Potential impact of hormonal male contraception: cross-cultural implications for development of novel preparations. Hum Reprod 2000;15:637–45. [18] Heinemann K, Saad F, Wiesemes M, White S, Heinemann L. Attitudes toward male fertility control: results of a multinational survey on four continents. Hum Reprod 2005;20:549–66. [19] Ringheim K. Evidence for the acceptability of an injectable hormonal method for men. Fam Plann Perspect 1995;27:123–8. [20] Singh S, Darroch JE, Vlassoff M, Nadeau J. Adding it op: the benefits of investing in sexual and reproductive health care. New York: The Alan Guttmacher Institute (AGI); 2003. [21] Vlassoff M, Singh S, Darroch JE, Carbone E, Bernstein S. Costs and benefits of providing sexual and reproductive health services: a review, Occasional Report, No. 11. New York: The Alan Guttmacher Institute; 2004. [22] Population Reference Bureau. http://www.prb.org/presentations/ c_proj-rise-contrac-users.ppt [accessed May 5, 2007]. [23] United Nations Population Fund. RH commodities required to achieve the ICPD goals 2000-2015. New York: United Nations Population Fund; 2005. [24] Sedgh G, Hussain R, Bankole A, Singh S. Women with an unmet need for contraception in developing countries and their reasons for not using a method, Occasional Report, No. 37. New York: Guttmacher Institute; 2007. [25] Vaughan B, Trussell J, Singh S, Jones R, Kost K. Discontinuation and resumption of contraceptive use: results from the 2002 National Survey of Family Growth. Paper presented at the 2007 Annual Meeting of the Population Association of America, New York, March 30, 2007. [26] Frost J, Darroch JE. Unpublished tabulations from Guttmacher Institute survey of women at risk for unintended pregnancy; 2007. [27] Darroch JE. Family planning: a century of change. In: Ward JW, Warren C, editors. Silent victories: the history and practice of public health in twentieth-century America. New York: Oxford University Press; 2006. p. 253–78. [28] Population Reference Bureau. http://www.prb.org/presentations/ c_disparity-contrac-use.ppt [accessed May 5, 2007]. [29] Alan Guttmacher Institute. Fulfilling the promise: Public Policy and U.S. Family Planning Clinics. New York: Alan Guttmacher Institute; 2000. [30] Ministry of Health (Kenya). National Council for Population and Development (Kenya) and ORC Macro. Kenya Service Provision Assessment Survey; 1999.
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Original research article
Male fertility control — where are the men? Jacqueline E. Darroch Guttmacher Institute, New York, NY 10038, USA Received 1 April 2008; accepted 1 April 2008
Abstract Control over the timing and number of children continues to be a challenge for many men and women today. While some men are contraceptive users today, current method options are limited. Evidence indicates that many men would welcome more method options, to meet their own needs and goals and to provide a way for them to participate in contraception in a more collaborative way with their partner. © 2008 Elsevier Inc. All rights reserved. Keywords: Male fertility control; Method options
1. Introduction In assessing the status and charting future paths for “male fertility control,” along with looking at the biology and technology of new methods for male use, it can be helpful to look also at the social science of fertility control and contraceptive use among men. Specifically, I propose to consider male contraception in history, men's interest in fertility control today, men's contribution to contraceptive use, opportunities for increased male use and issues that may affect use of new male methods. 2. Male contraception in history Men have participated in efforts to control fertility for millennia. Knowledge and use of both female and male contraceptive practices are thousands of years old, including vaginal formulations and barriers for women, withdrawal (coitus interruptus) for men, as well as prolonged breast feeding, abstinence and induced abortion. By the mid-1700s, men were using condoms for contraception (although their predominant use appears to have been for prevention of infection) and by the late 1800s, the
Author Disclosure: Jacqueline E. Darroch does not report any conflicts of interest with the sponsor of this supplement article or products discussed in this article. E-mail address: [email protected]. 0010-7824/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2008.04.117
vulcanization of rubber made condoms of reasonable quality widely available. By the early 1900s, advances had been made in diaphragms and cervical caps, IUDs, in early knowledge of hormonal female contraception and in both female and male sterilization [1]. Still, until the introduction of oral contraceptives and modern IUDs in the second half of the 1900s, men played a prominent role in contraceptive use. For example, in 1955, men's use of the condom and withdrawal accounted for 32% of all contraceptive use among married white women aged 18–39 in the United States and another 21% of couples relied on periodic abstinence, a method also involving male participation (Fig. 1) [2]. The contraceptive picture soon changed, however, as the widespread availability of a number of new options, including the pill, IUD and easier methods of tubal ligation for women and of vasectomy for men. In 2002, male methods accounted for 32% of contraceptive use in the United States — vasectomy for 9%, condom use for 18%, withdrawal for 4% and periodic abstinence for only 1% of total use [3]. For women, more reliable control over their own fertility was accompanied by widespread social changes in employment, education and gender roles. The new methods, and vasectomy, changed the link between sexuality and contraception as well since these new methods were used separate from the time of intercourse [4]. The requirement for medical prescription for the pill and insertion of IUDs, as well as fitting for diaphragms, led to a medical model for reversible female contraception and development of public family planning
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Fig. 1. Men's direct participation in contraceptive use declined in the USA between 1955* and 2002.
clinics throughout the United States, many European countries and, eventually, throughout the developing world. Such services were often linked to maternal and child health services and gave rise to a wider focus on women's reproductive health services. Medical services were also needed for both tubal ligation and vasectomy, but these did not require ongoing services or supplies, and male reversible methods, the condom and withdrawal, did not require medical services for use. As a result, men were generally left out of women's family planning services and no parallel system of reproductive health care for men was developed. In the past two decades, increased attention has been given to men's involvement in fertility control, as supporters of and participants with women and, increasingly, in their own right [5–10]. The 1994 International Conference on Population and Development in Cairo put forth a new reproductive health paradigm. Part of the shift to a broader agenda included involving men, with a call for efforts “… to emphasize men's shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning; prenatal, maternal and child health; prevention of sexually transmitted diseases, including HIV; prevention of unwanted and highrisk pregnancies…” [11]. Male involvement in fertility control is an ambiguous concept, however, spanning approaches that • Emphasize men as contraceptive users and as clients for reproductive health services, • Address men as partners who can improve — and impede — women's contraceptive use and reproductive health, and • View men as agents of positive change in supporting women's reproductive health and in transforming gender norms and policies that constrain reproductive health and rights [10].
This Supplement focuses on the first type of involvement, men as contraceptive users, to consider the state of contraceptive options for men and men's potential interest in using them. Other articles in this issue survey the state of contraceptive science. My goal is to complement this information with consideration of the social science of men's contraceptive use. Is there evidence that men today care about their fertility? How much do they contribute today to contraceptive method use? What are some differences in men's contraceptive use? Where are there opportunities for increased male contraceptive use? And, finally, what are some of the contextual factors that might affect increased male use? 3. Limitations Any assessment of men's roles in fertility control and contraceptive use is limited by the paucity of relevant data. Because it is women who become pregnant and give birth, and because their health is most directly affected by these events, fertility research historically has focused mainly on women. This focus also paralleled common social assumptions that fertility control was primarily the woman's responsibility, perhaps under a male partner's direction, and reflected the greater number of methods available for women's use. Since the 1960s, The United Nations Population Division staff has used available survey information to estimate worldwide and regional patterns of contraceptive use. These estimates are, however, only for women (couples) in union, reflecting the fact that, although women not in union are now included in many country surveys, their inclusion is fairly recent and they are still not included in all of them. The estimation methodology has evolved from using expert judgment to estimate use patterns for countries with missing data to the current approach of estimating regional subtotals
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Fig. 2. The average number of children men want to have has declined, especially in Sub-Saharan Africa.
based on data from reporting countries, weighted by the numbers of women in union aged 15–49. Estimates in a given year rely on the most recent available national surveys and the most recent United Nations population estimates. As a result, the patterns of method use for a publication year represent a recent time period, but they may lag in monitoring rapid changes. For example, the 1994 estimates are reported to represent use patterns around 1990, and the 2005 estimates, to represent use around 1999. Still, the generally constant approach to estimation and the global perspective provides valuable information on changes in contraceptive use over time and differences across areas of the world. While surveys on fertility and family planning issues have queried women worldwide since the mid-1970s, comparable surveys of men began only in the 1990s. This paper relies most heavily on data from these demographic and health
surveys, using the men's reports when possible. As a result, however, most of the data cover developing countries and they are most complete for Sub-Saharan Africa and Latin America and the Caribbean. Less information is available for men in Asia, the Middle East and North Africa and, especially, China and India. For ease of presentation, much of the information is for large regions of the world. While this does capture differences in attitudes and behaviors, variation across and within countries is often blurred.
4. Men's interest in fertility control today Population growth rates vary across the world, from under the standard replacement level around 2, in much of Europe and China, to well beyond that in many countries,
Fig. 3. Many men say they discuss family planning with their partners, though more than partners report.
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particularly in Africa [12]. Yet, in varying degrees, women and men everywhere seek control over the timing and number of pregnancies and childbearing. Men's reports of the number of children they want to have average around 2–3 in most of the world outside of SubSaharan Africa, where the averages for men aged 15– 24 ranges from 4 to 11 (Fig. 2) [8]. Comparison with reports from men aged 50–54 illustrates that desired fertility has fallen in recent decades, as it has among women, especially in Sub-Saharan Africa. The contrast between low desired fertility relative to biological possibilities and men's long periods of sexual activity mean that, like women, men in much of the world spend most of their sexually active lives trying to avoid having children. However, like women, men often have more children than they want, especially in developing countries. Many men discuss family planning with their wife or partner, but fewer than half of men aged 25–39 in union do so in much of Sub-Saharan Africa and in Pakistan and Egypt (Fig. 3) [8]. 5. Men's contribution to contraceptive use Since the early 1960s, estimated levels of contraceptive prevalence among couples (married or in union) in which the woman was aged 15–49 have been fairly stable in the more developed countries, ranging between 67% and 72% [13]. In less developed countries, contraceptive use levels have increased dramatically, from 9% to 60% in 2001. World levels of contraceptive use track those of the less developed countries quite well, doubling from 30% in the early 1960s to more than 60% in the beginning of the 21st century (Fig. 4). This reflects steady increases in the proportion of the world's population living in less developed countries — from 68% in 1950 to an estimated 86% in 2050. Closer comparisons of 1994 and 2005 contraceptive use estimates provide a number of insights into factors affecting
Fig. 4. Contraceptive use has risen dramatically in less developed countries as a percent of all couples.
Fig. 5. Contraceptive use* has increased in number and as a percent of all couples in developing countries, but fell in developed regions from 1994 to 2005.
male contraceptive use levels. While the total proportion of couples using contraception has declined slightly in the more developed countries (from 72% in 1994 to 69% in 2005), the number of couples using contraceptives dropped 24%, from 136 to 103 million (Fig. 5) [14,15]. These changes may reflect the aging of populations in most of the developed world, as well as the moves away from formal marriage and toward later childbearing. The population of women aged 15–49 who were married or in union dropped from 189 million in developed countries in 1994 to 150 million in 2005. In less developed countries, the number of couples with a woman aged 15–49 rose from 710 million in 1994 to 947 million in 2005. And, the proportion of those couples using a contraceptive increased from 53% to 59% over the same period (Fig. 5). As a result, the total number of couples in less developed countries using contraceptives rose from 376 million in 1994 to 561 million in 2005. The world's
Fig. 6. The percentage of couples' contraceptive use involving direct male participation* has declined.
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Fig. 7. The numbers of men using vasectomy fell in developing countries; use of nonsupply methods fell in developed areas and rose in developing regions, 1994 and 2005.
Fig. 9. Most men say they would be willing to use a new male contraceptive method, except in Argentina and Indonesia.
population increasingly lives in less developed countries, a trend that will continue throughout this century. As a result, global trends increasingly reflect what happens in the developing world. On a worldwide level, the number of couples using contraceptives rose from 512 million to 664 million, representing an increase from 57% of all couples with a woman aged 15–49 in 1994 to 61% in 2005 (Fig. 5). While total contraceptive use has been increasing, the proportion of use involving men has declined, at least in recent years, from 37% in the 1987 estimates to 31% in 1994, 26% in 1999 and to 25% in 2005 (Fig. 6) [15,16]. The drop has been especially steep in the more developed countries, from 60% in 1987 to 47% of contraceptive use in 2005. Putting the changing levels of male method use together with trends in population size and in total contraceptive use indicates that the number of men using contraceptive methods actually remained fairly stable, at estimates of 162 million in 1994 and 165 million in 2005 [14,15]. In developed countries, there was a sizeable decrease in the proportion of men using withdrawal and periodic abstinence for contraception, likely due in large part to increased use of modern, female methods in countries in
Eastern Europe. In developing countries as a whole, use of vasectomy decreased, while use of condoms and traditional methods increased (Fig. 7). Behind these broad patterns of method use, there are many variations, by age, union status, intention for any (more) children, area and culture of the world, urban/rural status. However, some men are involved as method users at all stages of contraceptive use [15]. Reasons behind these differences also reflect methods that are available, especially those promoted by national family planning programs; attitudes about medical technologies, such as an expectation for injections reported in areas of Latin America and Africa; and, individual, cultural and religious preferences, such as restrictions on women's activities when they are menstruating or bleeding.
Fig. 8. More men say they would be willing to use a new male pill than an injection.
Fig. 10. About 200 million women and their partners in developing countries today have an unmet need for effective contraceptives.
6. Opportunities for increased male contraceptive use While predicting the future is a risky endeavor, a number of factors might impact future contraceptive use, with or without new methods, and provide opportunities for increased male use.
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Fig. 11. Contraceptive use will also rise as more couples want to have smaller families.
6.1. Men's attitudes about potential new methods It is very difficult to predict ultimate levels of interest and use of new methods until they are actually introduced, both because it is hard for people to report their reactions to the full range of characteristics of a new method and because the context of method release and aspects of its availability also affect people's reactions. However, three surveys of men about potential male methods provide useful insights. • Martin et al. [17] conducted interview surveys in 1995– 1996 with men in four major cities about their interest in new male methods (Fig. 8). Respondents included new or expectant fathers, fire-fighters and men donating blood. They asked men's willingness to use a new method of male fertility control that would “provide
reliable contraception, would not carry significant risk of side-effects and would take 3–4 months to become effective.” Some 44–83% of men surveyed said they would use the method if it was in pill form and 32–62% would use the method in an injection (Fig. 8). Men were more likely to say they would use a new male method if they thought their partner would like them to do so and less likely if they had concerns that the method would affect sexual desire. Relationships with age and education were mixed and religious beliefs were not related to their likelihood of use. • A study by Heinemann et al. [18] interviewed 9342 men aged 18–59 in 2002. Respondents were primarily from existing survey panels (with response rates of 36-68%) and from household quota samples in Latin America and Indonesia (Fig. 9). They asked men to “Imagine that there could be a pill, a jelly/salve, an injection or an implant with a high efficacy in birth control and good reversibility. Imagine you had an opportunity to use such a product that prevents sperm production and thereby prevents pregnancy” (K. Heinemann, personal communication, June 22, 2007). They found an average of 55% of men would be willing to use such a method, 24% were uncertain and 21% said they would not be willing (Fig. 9). Respondents who were more likely to be willing to use a new male method were those who were current contraceptive users, were willing to undergo vasectomy, had higher education, had higher income and who lived in a city. Those less likely to use had or wanted more children, had multiple partners and had general or religious (Muslims and Buddhists) objections to contraceptive methods. There were no significant differences by men's age, union status or religious commitment.
Fig. 12. Ten percent to 40% of women in union with unmet need say they are not using a method because of concerns about health and side effects of methods.
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Fig. 13. Over time, lack of knowledge has decreased as a reason for nonuse and concerns about health or other side effects have increased.
• Ringheim [19] analyzed surveys of men who had participated in trials of an injectable hormonal method. Follow-up questionnaires were available from 154 men, roughly 12 months after their participation in trials in 1990–1994. Participants were from China (81), Australia (41), the UK (13), USA (13), Singapore (3) and Thailand (3).
○ Nine percent believed in male responsibility or the importance of developing a male method. 6.2. Unmet need
○ Thirty-six percent needed a change in contraceptive method, ○ Twenty-three percent had been encouraged to participate by their partner, ○ Twenty-three percent had been encouraged by their doctor to participate, and
Current use of modern methods lags behind the number of women who are at apparent risk of unintended pregnancy (sexually active, fertile, do not want a child soon or at all). About 200 million women — and their partners — are at risk and either using traditional methods (64 million) — mostly withdrawal or periodic abstinence, or they are using no method at all (137 million) (Fig. 10) [20,21]. These are the couples at highest risk for unintended pregnancy, and potentially in the market for new and different contraceptive methods. Eliminating this unmet need would save the lives of 1.5 million women and children annually, reduce induced abortions by 64%, reduce illness related to pregnancy and preserve 27 million years of healthy life.
Fig. 14. Method-related discontinuation in the first year of use is high for all reversible contraceptives in the USA, especially male methods, 2002.
Fig. 15. Users sometimes choose their contraceptive methods because they do not like other options (data from the United States, 2004).
Men gave the following as main reasons for participating in the trials:
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6.4. Dissatisfaction with current choices
Fig. 16. Continued and increased contraceptive use requires adequate and reliable supplies and services.
If the 200 million couples all moved to modern methods — in the same use proportions as couples in their geographic region, union status and intention to space or limit pregnancies — an estimated 2.7 would turn to vasectomy and 43 million to condoms. 6.3. Increasing need/demand As seen above, the world population is increasing and the number of couples wanting to use contraceptives will rise (Fig. 11). It is estimated that, given current trends, contraceptive use by couples in developing countries (not including those not in union) in 2050 will be roughly 40% higher than in 2000, with half of this increase due to population growth and half to projected increased demand for family planning (Fig. 11) [22]. And, for condoms or other methods that would prevent HIV and other sexually transmitted infections, hoped-for increases to reach international prevention goals are even greater [23].
What indications are there that men and their partners would move to male methods in greater numbers or change from female methods to male-used methods? Concern about health or other side effects from available methods are frequent reasons for unmet need (Fig. 12) [24]. In recent years, the proportions of nonusers citing concerns about health and other method side effects have risen while there has been a decrease in lack of knowledge as a reason for nonuse (Fig. 13) [24]. Method discontinuation is high (Fig. 14) [25]. On average, 57% of new method users discontinue use of their method for reasons related to the method (rather than discontinuation to move directly to another method, to become pregnant or because the woman was no longer at risk because she was not sexually active or had a sterilizing operation). Method “choice” sometimes reflects greater dislike of other options rather than positive attitudes about one's method. In fact, in the United States, more than one in five women using oral contraceptives or long-acting methods (mostly hormonal injection) chose their method mostly because they did not like their other options. Roughly three in five women relying on male condom use chose the method by default, as did about half of those relying on other methods (mostly withdrawal and periodic abstinence) (Fig. 15) [26]. 6.5. Response to changing circumstances and new method options Contraceptive use among married couples in the United States changed dramatically with the introduction of oral contraceptives, with increased fears of their health risk and then with introduction of newer formulations. Tubal ligation and vasectomy both rose with easier methods and with growing popularity of sterilization when childbearing was
Fig. 17. Problems with access and cost of contraception are reasons for some women give for nonuse.
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completed. Condom use increased, after a steady decline, with the advent of the specter of HIV, especially among unmarried couples [27]. 7. Issues that may affect use of new male methods Access to any new contraceptive method can be key to its success or failure. Difficulties men might have getting a new male method would likely swing their cost–benefit evaluation of it to a more negative ranking. Providers also must make evaluation of their costs to provide a method against the likelihood of its use and its ultimate impact in prevention of unintended pregnancies. A new male method would likely require medical services and/or purchase of supplies. This is the case for many method users today, ranging from 43% to 44% in Asia outside of China and in Latin America and the Caribbean to 62% of users in Sub-Saharan Africa (Fig. 16) [20,21]. It comes as no surprise then that problems with access and the cost of contraceptives are reasons some women give for nonuse when they are at risk for unplanned pregnancy (Fig. 17) [24]. And, a consistent observation across developing countries is that couples with higher incomes are more likely to use a contraceptive than are poorer couples (Fig. 18) [28] Experience in the United States shows, however, that subsidized family planning services for poor and lowincome women and men can substantially reduce income differentials in use levels [29]. Cost is one, but not the only, reason why providers do not have constant stocks across a range of contraceptive methods. For example, in Kenya in 1999, fewer than 90% of family planning provider sites offered any particular method and no more than 75% had a particular method in stock (Fig. 19) [30,31]. Many potential users in developing countries will need to turn to public providers for method access (Fig. 20) [32].
Fig. 18. Women in couples with higher incomes are more likely to use a contraceptive than poorer women.
Fig. 19. Family planning provider sites do not offer all methods or have the ones they do offer in stocks (data from Kenya, 1999).*
This raises the important issue of the extent to which a new male method can be integrated into current family planning systems. These are designed primarily to reach women and are often integrated into maternal and child health systems. Changes in them and/or development of new provider options will be crucial for widespread access to any new male method [33]. 8. Conclusions Control over the timing and number of children continues to be a challenge for many men and women today. Development of new methods of pregnancy prevention continues to be an important endeavor. • Men have a stake in fertility control; they have a long history of contraceptive use, but, with the development of effective female-used methods, most of method use has been passed to women, relieving men and/or pushing them out from the sphere of contraception. Development of new methods for men can change this. • Patterns of contraceptive use vary widely, by personal, relationship, service setting and cultural contexts. New methods for men are likely to be integrated into
Fig. 20. Many contraceptive users in developing countries rely on public services, selected countries in East Africa.
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•
•
• •
•
lifetime patterns of male- and female-used methods rather than substitute entirely for female-used methods. Most contraceptive users, and most unmet need, exist in developing countries. Potential opportunities — and needs — for improved use exist among nonusers, users of traditional methods, as well as current users of male and of female methods. Dissatisfaction with currently used methods also indicates opportunities for introduction of new male methods into developed countries such as the United States. Markets for new male methods will need to be activated, rather than be expected to respond to active demand as was the case when modern female-used methods were introduced in the early 1960s. Motivating factors for use of new male methods are most likely to be dissatisfaction with current method options and partner encouragement or interest. Problems evident in female contraceptive use are likely also to exist for male methods, including fears about health and other side effects and access problems, such as cost to users and to public funders. The female-focused service system may not be easy to expand to serving males.
In sum, continued development of new contraceptive methods is important to satisfy women's and men's needs for safe, effective and comfortable ways to time and space pregnancies. Evidence indicates that many men would welcome more method options, to meet both their own needs and goals and to provide a way for them to participate in contraception in a more collaborative way with their partner. What is needed are new options for them to do so. The question is less “Where are the men?” than it is “Where are the methods for men?” References [1] Potts M, Campbell M. History of contraception. In: Sciarra JJ, editor. Gynecology and Obstetrics, vol 6, CD-ROM 2003 Edition. Philadelphia: Lippincott Williams and Wilkins; 2003. [2] Whelpton PK, Campbell AA, Patterson JE. Fertility and family planning in the United States. Princeton: Princeton University Press; 1996. [3] Mosher D, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data Vital Health Stat 2004 Number 350. [4] Darroch JE. The pill and men's involvement in contraception. Fam Plann Perspect 2000;32:90–1. [5] Bankole A, Singh S. Couples' fertility and contraceptive decisionmaking in developing countries: hearing the man's voice. Internat Fam Plann Perspect 1998;24:15–24. [6] Green ME, Biddlecom AE. Absent and problematic men: demographic accounts of male reproductive roles. Popul Dev Rev 2000; 26:81–115. [7] The Alan Guttmacher Institute. In their own right: Assessing the sexual and reproductive health needs of American men. New York: The Alan Guttmacher Institute; 2002. [8] The Alan Guttmacher Institute. In their own right: Assessing the sexual and reproductive health needs of men worldwide. New York: The Alan Guttmacher Institute; 2003.
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