- Email: [email protected]
MOTIVATION FOR VASECTOMY
546
couples.
This
study
consisted of
couples
who had requested
vasectomy (irrespective of whether vasectomy was done or not), unlike some other studies which have dealt only with patients who have had a vasectomy.
Contraception
The age recorded was that of the wife and the range was 20-48 years (table I). In 63% of couples the wife was under 35.
MOTIVATION FOR VASECTOMY
GERALDINE HOWARD TABLE I-AGE AND PARITY OF
376
COUPLES
Department of Gynœcology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF
Men under 35 tend to request vasectomy for different reasons from those given by older men. Potential sexual, marital, or ageing problems seemed to motivate older couples, and problems related to family size, recent pregnancy, and difficulty with contraception the younger ones.
Summary
INTRODUCTION
.
*Low parity=2 children or less, high parity=3 children or more.
STERILISATION is attractive to couples who have completed their families and wish to stop using other methods of contraception. This paper describes a study of the reasons given for vasectomy requests by 376
TABLE II-SOCIAL-CLASS DISTRIBUTION
couples attending vasectomy clinics. z ,
PATIENTS AND METHODS
The requests for vasectomy came from two sources. Family Association (F.P.A.) clinics in the Greater London Area, Norwich, and Nottingham provided the first sources (145 couples during 1971 and 1972). They were studied by ten doctors trained in psychosexual counselling, in a seminar run by Dr Tom Main at the Cassel Hospital. The couples were seen twice-at the time of the request for vasectomy and a year later whether or not vasectomy had been recommended or carried out. The second group comprised 231 couples seen by me at the Margaret Pyke Centre in London in 1971-72.’ The two groups were compared for age, social class, and parity, and no statistically significant differences were found. They were therfore combined to form a single group of 376
Planning
The parity range was 0-7 (table i). 7% of couples had no children and 62% had 1 or 2 children. 64% were in social class in. Table n shows a bias towards social classes i and n and a relative lack of the semi-skilled and unskilled. Possibly couples in the lower social classes are less likely to be informed of new ideas, less willing to practise contraception, less likely to go to F.P.A. clinics, and less willing to pay for vasectomy. Among the 20 couples from social classes tv and v there were only 4 with large families-which suggests a profound lack of enthusiasm for vasectomy among the least skilled with large families.
DR FLENLEY: REFERENCES
1.
Beddoes, T., Watt, J. Considerations on the Medicinal Uses of Factitious Airs, and on the Manner of Obtaining them in Large Quantities. Bristol, 1794.
2.
Haldane, J. S. Br. med. J. 1917, i, 181.
3. MacKenzie, G. J., Taylor, S. H., Flenley, D. C., McDonald, A. H., Staunton, H. P., Donald, K. W. Lancet, 1964, ii, 825. 4. Rawles, J. M., Kenmure, A. C. F. Br. med. J. 1976, i, 1121. 5. Reimer, K. A., Lowe, J. E., Jennings, R. B. Circulation, 1976, 54, suppl. 2, 67. 6. Braunwald, E. ibid. 1976, 53, suppl. 1, 1. 7. Gillespie, T. A., Sobel, E. B. Adv. intern. Med. 1977, 22, 319. 8. Maroko, P. R., Radvary, P., Braunwald, E. Circulation, 1975, 52, 360. 9. Luxton, M. R., Russell, D. C., Murray, A., Williamson, D., Neilson, J. M. M., Oliver, M. F. Br. Heart J. 1977, 34, 493. 10. Madias, J. E., Madias, N. E., Hood, W. B. Circulation, 1976, 53, 411. 11. Kerr, F., Brown, M. G., Irving, J. B., Hoskins, M. R., Ewing, D. J., Kirby, 12.
B. J. Lancet, 1975, i, 1397. Ashbaugh, D. G., Bigelow, D. B., Petty,
T.
L., Levine, B.
E. ibid.
1967, ii,
319. F. Adv. intern. Med.
13. Hopewell, P. C., Murray, J. 14. Branthwaite, M. A. in Advanced Medicine
1976, 343. (edited by H. Besser); vol. 13,
p. 289. London, 1977. 15. Teplitz, C. Surg. Clins N. Am. 1976, 56, 1091. 16. Barrios, R., Inove, S., Hogg, J. C. Lab. Invest. 1977, 36, 628. 17. Mechanisms of Acute Respiratory Failure. National Heart and Lung Institute, Division of Lung Diseases, Workshop. U.S. Department of Health Education and Welfare. D.H.E.W. Publication no. (NIH) 77-981, 1976. 18. Zapol, W. M., Snider, H. T., Schneider, R. C. Anesthesiology, 1977, 46, 272. 19. Hill, J. D., O’Brien, T. G., Murray, J. J., Dontigny, L., Bramson, M. L., Osborn, J. J., Gerbode, F. New Engl. J. Med. 1972, 286, 629. 20. Newland, P. E.Anæsth. intens. Care, 1977, 5, 99. 21. Blake, L. H. in Artificial Lungs for Acute Respiratory Failure (edited by W. M. Zapol and J. Quist). New York, 1976. 22. Dornhorst, A. C. Lancet, 1955, i, 1185.
23. Burrows, B., Nider, A. H. Am. Rev. resp. Dis. 1964, 90, 14. 24. Burrows, B., Fletcher, C. M., Heard, B. E., Jones, N. L., Wootliff, J. S. Lancet. 1966, i, 830. 25. Wagner, P. D., Dautzker, D. R., Dueck, R., Clausen, J. L., West, J. B. J. clin. Invest. 1977, 59, 203 26. Thurlbeck, W. M. Major Problems in Pathology V (edited by J. L. Bennington). Philadelphia, 1976. 27. Von Euler, U.S., Liljestrand, G. Acta physiol. scand. 1946, 12, 301. 28. Fisherman, A. P. Circulation Res. 1976, 38, 221. 29. Abraham, A. S., Cole, R. B., Green, I. D., Hedworth-Whitty, R. B., Clarke, S. W., Bishop, J. M. ibid. 1969, 24, 51. 30. Heath, D., Williams, D. R. Man at High Altitude. Edinburgh, 1977. 31. Weir, E. K., Tuchker, A., Reeves, J. R., Will, D. H., Grover, R. F. Cardiovasc. Res. 1974, 8, 745 32. Flenley, D. C., Franklin, D. H., Millar, J. S. Clin. Sci. 1970, 38, 503. 33. Edwards, C., Heath, D., Harris, P. J. Path. 1917, 104, 1. 34. Guilleminault, C., Tilkilian, A., Dement, W. C. Ann. Rev. Med. 1976, 27, 465. 35. Coccagna, G., Mantovam, M., Brigman, F., Porchi, C., Lugaresi, E. Bull. Physio-Path. resp. 1972, 8, 1159. 36. Flick, M. R., Block, A. J. Ann. intern. Med. 1977, 86, 725. 37. Leitch, A. G., Clancy, L. J., Leggett, R. J. E., Tweedale, P., Dawson, P., Evans, J. I. Thorax, 1976, 31, 730. 38. Kryger, M., Weil, J., Grover, R. Chest, (in the press). 39. Neff, T. A., Petty, T. L. Ann. intern. Med. 1970, 72, 621. 40. Leggett, R. J., Cookes, N. J., Clancy, L., Leitch, A. G., Kirby, B. J., Flenley,
D. C., Thorax, 1976, 31, 414. Leggett, R. J. E., Flenley, D. C. Br. med. J. 1977, ii, 84. Stark, R. D., Bishop, J. M., Br. med. J. 1973, ii, 105. Harvey, R. M., Ferrer, M. I., Richards, D. W., Jr, Cournand, A. Am. J. Med. 1951, 10, 719. 44. Segel, N., Bishop, J. M. J. clin. Invest. 1966, 45, 1555. 45. Aber, G. M., Bailey, T. G., Bishop, J. M. Clin. Sci. 1963, 25, 159. 46. Aber, G. M., Harris, A. M., Bishop, J. M. ibid. 1964, 26, 133. 41. 42. 43.
547 RESULTS
Contraceptive Methods Used A request for sterilisation implies dissatisfaction with other birth-control methods. All the couples said that they used some method, but it was clear that they had done so sporadically. The condom was the most widely used method (44%-a figure that agrees with the findings of Bone2 and PeeP). The pill was the next most widely used method (31%), and withdrawal came third (10%). The use of oral contraceptives was fairly constant at all ages-approximately 30% at, all ages except below 25, when it was 37%. Among couples aged under 35 in social classes 11 and III, more used male methods of contraception than would have been expected.4 One possible explanation is that dissatisfaction is more common with male methods than with female ones. Another is that a man using a condom or withdrawal likes to be in charge of the precautions. Both he and his wife see it as a man’s responsi-
bility. MethodFailure 115 couples (31%) reported failure of their method at some time. Some couples had failed more than once, and with many "non-use" was reported as a failure of the method. The request for vasectomy did not necessarily follow a recent failure but represented the limit of tolerance of failure. Condom failures were reported by 35% overall and by 53% of those under 25 years, suggesting that, despite reports that condoms are effective,5.6 young men may be careless contraceptors. In the under-25s there were no pill failures. In the age-group 30-34 (from which the greatest number of requests came) 26 (50%) reported failure with the condom and withdrawal, 13 with the and "other 2 and with the methods", (29%) diaphragm LU.D. These figures suggest a strong association between vasectomy requests and contraceptive failure. However, there were no failures among the 32 women in this agegroup taking the pill and only 2 pill failures in 115 women on the pill. Although oral contraception seems to have been an effective method, almost a third of the vasectomy requests came from couples wishing to discontinue it.
(100%)
Reasonsfor Requesting Vasectomy The two principal reasons given were prevention of further pregnancies because family size was complete, and protection of the wife from the health hazards of the pill and intrauterine devices (LU.D.), from the danger of childbearing, or from fear of pregnancy. Many couples added that they hoped their sex life would be better once the fear of pregnancy was removed. A recent pregnancy appeared to be a very common factor in the requests (in 63% of wives under 25). The incidence of recent pregnancy fell with age, and there were no pregnancies in women over 45 (see accompanying figure). The wish to protect the wife increased after the age of 40, and this was mainly due to concern about older women taking the pill. It did not appear to be due to increased sideeffects, for the 7 women who had had a deep-vein thrombosis were under 40, as were 7 of the 8 who had devel-
oped hypertension. Unexpected findings whose main purpose in
were the number of couples requesting vasectomy was to im-
Reasons for
requesting vasectomy in relation to age of wife.
prove their
sex life and the increase in this number after the age of 35. Vasectomy requests after age 40 seemed to have little to do with pregnancy.
DISCUSSION
The highest number of requests came from couples of low parity under 35 in social classes II and III. This agrees with the findings of Vessey and Drury.8 The reasons for the preferred smaller family size were not discussed, but vasectomy is seen as proof of determination to maintain this size. More men than was expected were previously using condoms, and it is suggested that many men who prefer to be responsible for contraception see vasectomy as a final male responsibility. Previous method failure seemed acceptable until the limit of parenthood was reached, but the number of failures was unexpectedly high. Whether this high number reflects the couples’ candour in discussion or whether it was being used to obtain approval for vasectomy is not clear. Another unexpected finding was the small number of men with large families. Most of these men had come to the clinics only after considerable pressure and did not want the operation. The interviews suggested that not only do men with small families prefer vasectomy but that men with large families are often very reluctant to undergo the operation. Most couples had good marital relationships, but in some fear of pregnancy and failure with or difficulty over contraception had produced loss of libido or slight impotence, which resolved after vasectomy. In some women "fear of pregnancy" masked severe frigidity. Whereas the husband hoped that by removing this fear the couple’s sex life would improve, the wife’s corresponding hope was that vasectomy would "cool him down". Some older men had become impotent during a depressive illness, and several found they could no longer maintain an erection when using a condom; drug therapy caused impotence in two. In others there had been longstanding marital discord. Irregular periods at the menopause produced fear of pregnancy and anxiety, and a dry vagina resulted in pain and loss of libido and affected potency. The requests from younger couples were mostly related to unwanted pregnancy, completed family size, or difficulty with or dislike of contraceptives. Many older couples were facing ageing problems or longstanding sexual difficulties, and their expectations of vasec-
548
tomy tended to be less realistic than those of the younger
couples. keep the size of the family small impressive. Having so decided, many couples described further contraception as illogical. The men did The determination
to
was
wish to use condoms or withdrawal for the rest of their wives’ fertile years, ’not did they wish their wives to face the hazards of the pill or i.u.D. Past contraceptive failure made many distrust a previously acceptable method, and yet they were not prepared to use the most effective method-the pill. It seemed that contraception could be tolerated while the family was being esablished, but once it was complete sterilisation was pre-
I thank my F.P.A. colleagues in the seminar at the Cassel Hospital and Dr Tom Main for letting me use the seminar material and the results of the research study. I am grateful to the Margaret Pyke Centre for permission to interview their patients and to Prof. A. E. Bennett for his help and advice in the preparation of this paper.
not
ferred
the continued contraceptive methods. to
use
of
even
the
most
effective
REFERENCES
Howard, G. Br. med. J. 1973, iv, 216. Bone, M. Family Planning Services in England and Wales. H.M. Stationery Office, 1973. 3. Peel, J.J. biosoc. Sci. 1973, 5, 241. 4. Cartwright, A. How Many Children?; p. 51. London, 1976. 5. Peel, J. Practitioner, 1969, 202, 677. 6. Vessey, M., Glass, R., Wiggins, P. J. fam. Planning Doctors, 1975, 1, 1. 7. Vessey, M., Wright, N., Wiggins, P., Johnson, B. Fertil. Contraception, 1977, 1, 41. 8. Drury, V. W. M. J. R. Coll. gen. Practnrs, 1974, 24, 812. 1. 2.
Child Health In half the
LEFT
EYE, RIGHT EYE R. A. WEALE
Department of Visual Science, Institute of Ophthalmology, Judd Street, London WC1H 9QS MAN shows many asymmetries. Yet, except for ocular dominance, our eyes are held to perform equally well. The truth of this assumption was tested in a study of visual functions in treated amblyopic children and controls. In the test a pattern of parallel lines had to be seen "sharply" (the concepts of "sharp" contour and "fuzziness" being understood by children of 8 years and over). The distance at which the pattern appeared sharp to each eye in turn was measured: hence inter-observer variations in criterion could be overlooked. 64 normalsighted schoolchildren (age-range 7-75-13.8years; 39 boys, 25 girls) and 16 amblyopic children (age-range 8-17-14-23 years; 8 boys, 8 girls) were examined. The test-pattern was projected onto a white screen in a well-lit room. The procedure was carefully explained to each child. Left and right eyes were tested three times in random sequence. Because the results obtained for the 8-year-old children differed apparently by chance, the statistical analysis was done (a) for all the normal children and (b) for all children aged 9 and over. The data (see figure) for fellow eyes are highly correlated in boths groups: r (amblyopes)=0.782 (P<0.001); r (normal controls912 (p<0.001) for all and 0.900 (p<0001) for 9-year-olds and over. The slope of the regression for the amblyopes is 0.714 with 95% confidence limits of 0-388 and 1.040: the amblyopic eyes were a little poorer than their "good" fellow eyes. The slope of the regression for the normal eyes is 0.833 for all ages, with 95% confidence limits of 0.738 and 0.928. The left eye tends to signal "sharp" at a smaller angle than the right one. The means of these angles for the 9-year-olds and over are 1-47’ for the left eye and 1.52’ for the right (p=0.04). The difference between the amblyopes’ good eyes (2.6’) and the controls’ right eyes (1.5’) is secured with an F-value 2.88(PO-003). Since all the "good" eyes had been occluded during treatment, this difference may be iatrogenic; and congenital factors cannot be ruled out.
amblyopes the "good" eyes were the left performed differently from the right "good" ones of that sample (F<0.03). A difference between the two eyes is not easily explained in such - terms.2 Each eye supplies both cerebral hemispheres; ones, and these
Visual
angles (minutes of arc) at which the parallel-line pattern appeared sharp. Top: amblyopic versus good eyes. Bottom: right eye versus left eye in normal coeval controls. The regression lines are explained in the text.
*Identical values for 2 patients here.
couples.
This
study
consisted of
couples
who had requested
vasectomy (irrespective of whether vasectomy was done or not), unlike some other studies which have dealt only with patients who have had a vasectomy.
Contraception
The age recorded was that of the wife and the range was 20-48 years (table I). In 63% of couples the wife was under 35.
MOTIVATION FOR VASECTOMY
GERALDINE HOWARD TABLE I-AGE AND PARITY OF
376
COUPLES
Department of Gynœcology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF
Men under 35 tend to request vasectomy for different reasons from those given by older men. Potential sexual, marital, or ageing problems seemed to motivate older couples, and problems related to family size, recent pregnancy, and difficulty with contraception the younger ones.
Summary
INTRODUCTION
.
*Low parity=2 children or less, high parity=3 children or more.
STERILISATION is attractive to couples who have completed their families and wish to stop using other methods of contraception. This paper describes a study of the reasons given for vasectomy requests by 376
TABLE II-SOCIAL-CLASS DISTRIBUTION
couples attending vasectomy clinics. z ,
PATIENTS AND METHODS
The requests for vasectomy came from two sources. Family Association (F.P.A.) clinics in the Greater London Area, Norwich, and Nottingham provided the first sources (145 couples during 1971 and 1972). They were studied by ten doctors trained in psychosexual counselling, in a seminar run by Dr Tom Main at the Cassel Hospital. The couples were seen twice-at the time of the request for vasectomy and a year later whether or not vasectomy had been recommended or carried out. The second group comprised 231 couples seen by me at the Margaret Pyke Centre in London in 1971-72.’ The two groups were compared for age, social class, and parity, and no statistically significant differences were found. They were therfore combined to form a single group of 376
Planning
The parity range was 0-7 (table i). 7% of couples had no children and 62% had 1 or 2 children. 64% were in social class in. Table n shows a bias towards social classes i and n and a relative lack of the semi-skilled and unskilled. Possibly couples in the lower social classes are less likely to be informed of new ideas, less willing to practise contraception, less likely to go to F.P.A. clinics, and less willing to pay for vasectomy. Among the 20 couples from social classes tv and v there were only 4 with large families-which suggests a profound lack of enthusiasm for vasectomy among the least skilled with large families.
DR FLENLEY: REFERENCES
1.
Beddoes, T., Watt, J. Considerations on the Medicinal Uses of Factitious Airs, and on the Manner of Obtaining them in Large Quantities. Bristol, 1794.
2.
Haldane, J. S. Br. med. J. 1917, i, 181.
3. MacKenzie, G. J., Taylor, S. H., Flenley, D. C., McDonald, A. H., Staunton, H. P., Donald, K. W. Lancet, 1964, ii, 825. 4. Rawles, J. M., Kenmure, A. C. F. Br. med. J. 1976, i, 1121. 5. Reimer, K. A., Lowe, J. E., Jennings, R. B. Circulation, 1976, 54, suppl. 2, 67. 6. Braunwald, E. ibid. 1976, 53, suppl. 1, 1. 7. Gillespie, T. A., Sobel, E. B. Adv. intern. Med. 1977, 22, 319. 8. Maroko, P. R., Radvary, P., Braunwald, E. Circulation, 1975, 52, 360. 9. Luxton, M. R., Russell, D. C., Murray, A., Williamson, D., Neilson, J. M. M., Oliver, M. F. Br. Heart J. 1977, 34, 493. 10. Madias, J. E., Madias, N. E., Hood, W. B. Circulation, 1976, 53, 411. 11. Kerr, F., Brown, M. G., Irving, J. B., Hoskins, M. R., Ewing, D. J., Kirby, 12.
B. J. Lancet, 1975, i, 1397. Ashbaugh, D. G., Bigelow, D. B., Petty,
T.
L., Levine, B.
E. ibid.
1967, ii,
319. F. Adv. intern. Med.
13. Hopewell, P. C., Murray, J. 14. Branthwaite, M. A. in Advanced Medicine
1976, 343. (edited by H. Besser); vol. 13,
p. 289. London, 1977. 15. Teplitz, C. Surg. Clins N. Am. 1976, 56, 1091. 16. Barrios, R., Inove, S., Hogg, J. C. Lab. Invest. 1977, 36, 628. 17. Mechanisms of Acute Respiratory Failure. National Heart and Lung Institute, Division of Lung Diseases, Workshop. U.S. Department of Health Education and Welfare. D.H.E.W. Publication no. (NIH) 77-981, 1976. 18. Zapol, W. M., Snider, H. T., Schneider, R. C. Anesthesiology, 1977, 46, 272. 19. Hill, J. D., O’Brien, T. G., Murray, J. J., Dontigny, L., Bramson, M. L., Osborn, J. J., Gerbode, F. New Engl. J. Med. 1972, 286, 629. 20. Newland, P. E.Anæsth. intens. Care, 1977, 5, 99. 21. Blake, L. H. in Artificial Lungs for Acute Respiratory Failure (edited by W. M. Zapol and J. Quist). New York, 1976. 22. Dornhorst, A. C. Lancet, 1955, i, 1185.
23. Burrows, B., Nider, A. H. Am. Rev. resp. Dis. 1964, 90, 14. 24. Burrows, B., Fletcher, C. M., Heard, B. E., Jones, N. L., Wootliff, J. S. Lancet. 1966, i, 830. 25. Wagner, P. D., Dautzker, D. R., Dueck, R., Clausen, J. L., West, J. B. J. clin. Invest. 1977, 59, 203 26. Thurlbeck, W. M. Major Problems in Pathology V (edited by J. L. Bennington). Philadelphia, 1976. 27. Von Euler, U.S., Liljestrand, G. Acta physiol. scand. 1946, 12, 301. 28. Fisherman, A. P. Circulation Res. 1976, 38, 221. 29. Abraham, A. S., Cole, R. B., Green, I. D., Hedworth-Whitty, R. B., Clarke, S. W., Bishop, J. M. ibid. 1969, 24, 51. 30. Heath, D., Williams, D. R. Man at High Altitude. Edinburgh, 1977. 31. Weir, E. K., Tuchker, A., Reeves, J. R., Will, D. H., Grover, R. F. Cardiovasc. Res. 1974, 8, 745 32. Flenley, D. C., Franklin, D. H., Millar, J. S. Clin. Sci. 1970, 38, 503. 33. Edwards, C., Heath, D., Harris, P. J. Path. 1917, 104, 1. 34. Guilleminault, C., Tilkilian, A., Dement, W. C. Ann. Rev. Med. 1976, 27, 465. 35. Coccagna, G., Mantovam, M., Brigman, F., Porchi, C., Lugaresi, E. Bull. Physio-Path. resp. 1972, 8, 1159. 36. Flick, M. R., Block, A. J. Ann. intern. Med. 1977, 86, 725. 37. Leitch, A. G., Clancy, L. J., Leggett, R. J. E., Tweedale, P., Dawson, P., Evans, J. I. Thorax, 1976, 31, 730. 38. Kryger, M., Weil, J., Grover, R. Chest, (in the press). 39. Neff, T. A., Petty, T. L. Ann. intern. Med. 1970, 72, 621. 40. Leggett, R. J., Cookes, N. J., Clancy, L., Leitch, A. G., Kirby, B. J., Flenley,
D. C., Thorax, 1976, 31, 414. Leggett, R. J. E., Flenley, D. C. Br. med. J. 1977, ii, 84. Stark, R. D., Bishop, J. M., Br. med. J. 1973, ii, 105. Harvey, R. M., Ferrer, M. I., Richards, D. W., Jr, Cournand, A. Am. J. Med. 1951, 10, 719. 44. Segel, N., Bishop, J. M. J. clin. Invest. 1966, 45, 1555. 45. Aber, G. M., Bailey, T. G., Bishop, J. M. Clin. Sci. 1963, 25, 159. 46. Aber, G. M., Harris, A. M., Bishop, J. M. ibid. 1964, 26, 133. 41. 42. 43.
547 RESULTS
Contraceptive Methods Used A request for sterilisation implies dissatisfaction with other birth-control methods. All the couples said that they used some method, but it was clear that they had done so sporadically. The condom was the most widely used method (44%-a figure that agrees with the findings of Bone2 and PeeP). The pill was the next most widely used method (31%), and withdrawal came third (10%). The use of oral contraceptives was fairly constant at all ages-approximately 30% at, all ages except below 25, when it was 37%. Among couples aged under 35 in social classes 11 and III, more used male methods of contraception than would have been expected.4 One possible explanation is that dissatisfaction is more common with male methods than with female ones. Another is that a man using a condom or withdrawal likes to be in charge of the precautions. Both he and his wife see it as a man’s responsi-
bility. MethodFailure 115 couples (31%) reported failure of their method at some time. Some couples had failed more than once, and with many "non-use" was reported as a failure of the method. The request for vasectomy did not necessarily follow a recent failure but represented the limit of tolerance of failure. Condom failures were reported by 35% overall and by 53% of those under 25 years, suggesting that, despite reports that condoms are effective,5.6 young men may be careless contraceptors. In the under-25s there were no pill failures. In the age-group 30-34 (from which the greatest number of requests came) 26 (50%) reported failure with the condom and withdrawal, 13 with the and "other 2 and with the methods", (29%) diaphragm LU.D. These figures suggest a strong association between vasectomy requests and contraceptive failure. However, there were no failures among the 32 women in this agegroup taking the pill and only 2 pill failures in 115 women on the pill. Although oral contraception seems to have been an effective method, almost a third of the vasectomy requests came from couples wishing to discontinue it.
(100%)
Reasonsfor Requesting Vasectomy The two principal reasons given were prevention of further pregnancies because family size was complete, and protection of the wife from the health hazards of the pill and intrauterine devices (LU.D.), from the danger of childbearing, or from fear of pregnancy. Many couples added that they hoped their sex life would be better once the fear of pregnancy was removed. A recent pregnancy appeared to be a very common factor in the requests (in 63% of wives under 25). The incidence of recent pregnancy fell with age, and there were no pregnancies in women over 45 (see accompanying figure). The wish to protect the wife increased after the age of 40, and this was mainly due to concern about older women taking the pill. It did not appear to be due to increased sideeffects, for the 7 women who had had a deep-vein thrombosis were under 40, as were 7 of the 8 who had devel-
oped hypertension. Unexpected findings whose main purpose in
were the number of couples requesting vasectomy was to im-
Reasons for
requesting vasectomy in relation to age of wife.
prove their
sex life and the increase in this number after the age of 35. Vasectomy requests after age 40 seemed to have little to do with pregnancy.
DISCUSSION
The highest number of requests came from couples of low parity under 35 in social classes II and III. This agrees with the findings of Vessey and Drury.8 The reasons for the preferred smaller family size were not discussed, but vasectomy is seen as proof of determination to maintain this size. More men than was expected were previously using condoms, and it is suggested that many men who prefer to be responsible for contraception see vasectomy as a final male responsibility. Previous method failure seemed acceptable until the limit of parenthood was reached, but the number of failures was unexpectedly high. Whether this high number reflects the couples’ candour in discussion or whether it was being used to obtain approval for vasectomy is not clear. Another unexpected finding was the small number of men with large families. Most of these men had come to the clinics only after considerable pressure and did not want the operation. The interviews suggested that not only do men with small families prefer vasectomy but that men with large families are often very reluctant to undergo the operation. Most couples had good marital relationships, but in some fear of pregnancy and failure with or difficulty over contraception had produced loss of libido or slight impotence, which resolved after vasectomy. In some women "fear of pregnancy" masked severe frigidity. Whereas the husband hoped that by removing this fear the couple’s sex life would improve, the wife’s corresponding hope was that vasectomy would "cool him down". Some older men had become impotent during a depressive illness, and several found they could no longer maintain an erection when using a condom; drug therapy caused impotence in two. In others there had been longstanding marital discord. Irregular periods at the menopause produced fear of pregnancy and anxiety, and a dry vagina resulted in pain and loss of libido and affected potency. The requests from younger couples were mostly related to unwanted pregnancy, completed family size, or difficulty with or dislike of contraceptives. Many older couples were facing ageing problems or longstanding sexual difficulties, and their expectations of vasec-
548
tomy tended to be less realistic than those of the younger
couples. keep the size of the family small impressive. Having so decided, many couples described further contraception as illogical. The men did The determination
to
was
wish to use condoms or withdrawal for the rest of their wives’ fertile years, ’not did they wish their wives to face the hazards of the pill or i.u.D. Past contraceptive failure made many distrust a previously acceptable method, and yet they were not prepared to use the most effective method-the pill. It seemed that contraception could be tolerated while the family was being esablished, but once it was complete sterilisation was pre-
I thank my F.P.A. colleagues in the seminar at the Cassel Hospital and Dr Tom Main for letting me use the seminar material and the results of the research study. I am grateful to the Margaret Pyke Centre for permission to interview their patients and to Prof. A. E. Bennett for his help and advice in the preparation of this paper.
not
ferred
the continued contraceptive methods. to
use
of
even
the
most
effective
REFERENCES
Howard, G. Br. med. J. 1973, iv, 216. Bone, M. Family Planning Services in England and Wales. H.M. Stationery Office, 1973. 3. Peel, J.J. biosoc. Sci. 1973, 5, 241. 4. Cartwright, A. How Many Children?; p. 51. London, 1976. 5. Peel, J. Practitioner, 1969, 202, 677. 6. Vessey, M., Glass, R., Wiggins, P. J. fam. Planning Doctors, 1975, 1, 1. 7. Vessey, M., Wright, N., Wiggins, P., Johnson, B. Fertil. Contraception, 1977, 1, 41. 8. Drury, V. W. M. J. R. Coll. gen. Practnrs, 1974, 24, 812. 1. 2.
Child Health In half the
LEFT
EYE, RIGHT EYE R. A. WEALE
Department of Visual Science, Institute of Ophthalmology, Judd Street, London WC1H 9QS MAN shows many asymmetries. Yet, except for ocular dominance, our eyes are held to perform equally well. The truth of this assumption was tested in a study of visual functions in treated amblyopic children and controls. In the test a pattern of parallel lines had to be seen "sharply" (the concepts of "sharp" contour and "fuzziness" being understood by children of 8 years and over). The distance at which the pattern appeared sharp to each eye in turn was measured: hence inter-observer variations in criterion could be overlooked. 64 normalsighted schoolchildren (age-range 7-75-13.8years; 39 boys, 25 girls) and 16 amblyopic children (age-range 8-17-14-23 years; 8 boys, 8 girls) were examined. The test-pattern was projected onto a white screen in a well-lit room. The procedure was carefully explained to each child. Left and right eyes were tested three times in random sequence. Because the results obtained for the 8-year-old children differed apparently by chance, the statistical analysis was done (a) for all the normal children and (b) for all children aged 9 and over. The data (see figure) for fellow eyes are highly correlated in boths groups: r (amblyopes)=0.782 (P<0.001); r (normal controls912 (p<0.001) for all and 0.900 (p<0001) for 9-year-olds and over. The slope of the regression for the amblyopes is 0.714 with 95% confidence limits of 0-388 and 1.040: the amblyopic eyes were a little poorer than their "good" fellow eyes. The slope of the regression for the normal eyes is 0.833 for all ages, with 95% confidence limits of 0.738 and 0.928. The left eye tends to signal "sharp" at a smaller angle than the right one. The means of these angles for the 9-year-olds and over are 1-47’ for the left eye and 1.52’ for the right (p=0.04). The difference between the amblyopes’ good eyes (2.6’) and the controls’ right eyes (1.5’) is secured with an F-value 2.88(PO-003). Since all the "good" eyes had been occluded during treatment, this difference may be iatrogenic; and congenital factors cannot be ruled out.
amblyopes the "good" eyes were the left performed differently from the right "good" ones of that sample (F<0.03). A difference between the two eyes is not easily explained in such - terms.2 Each eye supplies both cerebral hemispheres; ones, and these
Visual
angles (minutes of arc) at which the parallel-line pattern appeared sharp. Top: amblyopic versus good eyes. Bottom: right eye versus left eye in normal coeval controls. The regression lines are explained in the text.
*Identical values for 2 patients here.