Deference, denial, and exclusion: men talk about contraception and unintended pregnancy.

Individual in-depth interviews were conducted with 20 men, ages 21-48, who have fathered at least one unintended pregnancy. The goal of the interviews was to explore the experiences of these men with unintended pregnancy, their communication with partners and others, contraceptive beliefs and practices, their relationships with their partners, and the outcomes and consequences of the unintended pregnancies. This essay describes results derived from their comments regarding their contraceptive practices and the pregnancy-outcome decisions, with thematic analysis used to identify prominent themes from participant comments. Two strong themes, "deference" and "denial," and one lesser theme, "exclusion," emerged from participant responses. Discussion of the role of communication, the power of denial, and opportunities for further involvement of men in decision making relating to unintended pregnancy are presented.

Keywords: men's behavior, unplanned pregnancy, decision making, contraception, denial

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Research into unintended pregnancy is ongoing across a number of disciplines. Some scholars consider cognitive aspects related to sexual behavior (e.g., Loewenstein & Furstenberg, 1991; Sandier, Watson, & Levine, 1992), others look for socioeconomic contributors and consequences (e.g., Brown & Eisenberg, 1995; Geronimus & Korenman, 1992, 1993; Henshaw, 1998; Williams, 1991), and still others consider the role of communication among partners and family members (Adelman, 1991; Warren, 1992). In response to this research, diverse sexuality education programs have been devised and implemented with varied claims of efficacy (Christopher & Roosa, 1990; Doniger, Adams, Utter, & Riley, 2001; Kirby, 1985). However, much work remains to be done to improve our understanding of unintended pregnancy and its prevention. This essay seeks to expand that understanding by putting faces (or more accurately "voices") to this issue. Specifically, in this research we explore the views of 20 men (ages 21 to 48) who have lathered at least one unintended pregnancy.

Definitions of pregnancy intention statuses vary, and it is important at the outset to identify the definitions employed in the present research. Often the terms "unplanned pregnancy" and "unintended pregnancy" are used interchangeably. While the two concepts are highly related, in the demographic literature on this topic the term "unintended" refers to a very specific subset of pregnancies: those that were either mistimed (wanted at some point in the future but not at the time of conception) or unwanted (those that occurred when no pregnancy was desired at any time). Unplanned pregnancies tend generally to be unintended, but a small fraction are not. In some cases, those experiencing a pregnancy may not have thought much about its timing or occurrence, or they may hold ambivalent feelings about it that preclude categorizing the pregnancy either as unwanted or mistimed. With the exception of a very few ambiguous cases that could not definitively be classified with certainty as mistimed or unwanted, virtually all of the "unplanned" pregnancies discussed by the men we interviewed in the present study were "unintended" by standard definitions.

UNINTENDED PREGNANCY IN THE UNITED STATES

There is no question that unintended pregnancy has important individual, relational, and societal ramifications. For example, recent estimates indicate that roughly 5.38 million pregnancies (excluding miscarriages) were conceived in a typical year in the 1990s and that approximately 2.64 million of those were unintended. Slightly more than half of all unintended pregnancies were estimated to have ended in abortion (Henshaw, 1998). Although higher percentages of pregnancies to teens and women below the poverty level are classified as unintended than is the case among older women and those with higher household incomes, couples of all backgrounds are at risk for unintended pregnancy throughout their childbearing years. Among women 30-34 years of age, close to a third of pregnancies have been estimated to be unintended. Among those whose family incomes exceed 200% of the poverty level, 41% of recent pregnancies were estimated to be unintended, with that figure climbing to more than 61% among those living below the poverty level (Henshaw, 1998). Hence, while younger and poorer individuals continue to report higher percentages of their pregnancies as unintended than do those who are older and wealthier, unintended pregnancies are a matter of concern for most men and women throughout their adolescent and adult lives.

Unintended pregnancies are reported to have varied but usually significant consequences. In addition to the emotional and moral difficulties created for some who consider or choose abortion, such pregnancies often have negative economic, health, and social outcomes for parents and children. For example, studies have suggested that marriages created after conception of an unintended pregnancy have higher failure rates than other marriages (Teachman, 1983; Wineberg, 1992). Others have found that women's views of their pregnancies' "intendedness" as well as the level of couple agreement about a pregnancy can affect marital satisfaction during pregnancy (Snowden, Schott, Awalt, & Gillis-Knox, 1988). In addition, having an unintended conception decreases the likelihood that a woman will receive sufficient prenatal care (Brown & Eisenberg, 1995).

As is evident from this brief summary, previous research has tended to focus largely on women's experiences with unintended pregnancy. Despite the relational nature of sex, contraception, and pregnancy, historically men have been the focus of relatively little substantive research on the topic of unintended pregnancy and its consequences (for some exceptions and further discussion, see Card & Wise, 1978; Chapin, 2001; Forste & Morgan, 1998; Parke & Neville, 1987; Marsiglio, 1993, 2003; Sonenstein et al., 1997).

In the past decade and a half, however, the importance of men's roles and attitudes increasingly has been recognized. For example, the fall 2003 issue of Perspectives on Sexual and Reproductive Health (Allan Guttmacher Institute, 2003) highlights research on services for men at clinics and in reproductive health initiatives, while articles included in the Alan Guttmacher Institute's (AGI) volume entitled Readings on Men (1996) cover a wide range of topics including abortion attitudes, contraceptive use, family planning services, paternity, sexual behavior, sexually transmitted diseases, and survey design.

It is interesting to note that the bulk of the studies on paternity focus on adolescent males. For example, largely through analyses of narrative accounts, Marsiglio's work (1993, 2003) provides a view of adolescents' "procreative consciousness" and "procreative responsibility." The first concept refers, among other things, to a man's sense of his masculinity and competence as a sexual partner. The second concept "encompasses men's involvement and sense of obligation regarding contraception, pregnancy resolution, and child support and care" (Marsiglio, 1993, p. 23).

AGI's 2002 volume entitled In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men provides abundant data on this topic and clearly expresses a need for education and other reproductive health services for men in the U.S. For example, the report indicates that nine out of 10 men have intercourse before age 20. Among pregnancies involving teen fathers, about 60% end in a birth, and about 40% end in abortion. About one third of men in their 30s and early 40s reported that their most recent birth was unintended. Further, roughly 20% of pregnancies to partners of men in their 30s and 33% of pregnancies to partners of men in their 40s end in abortion. AGI highlights the fact that, to date, the sexual "and reproductive health needs of men in their own right, as individuals, have been largely ignored" (AGI, 2002, p. 7). Bradner, Ku, and Lindberg (2000, p. 37) concur, noting that partly because of structural factors, adolescent men who are at risk of HIV or other STD infections tend to get better information about disease prevention than do young adult men, even though "young adulthood is the age of greatest sexual risk." Those agencies that do provide services to men note that they face a number of barriers, the most common of which is the apparent lack of awareness among men in their target audience that such services are available (Finer, Darroch, & Frost, 2003).

To further explore the role of men in this area, the present study was designed to foreground the experiences of a sample of adult men up to the age of 50, providing additional insights into the ways in which men's experiences with contraception and unintended pregnancy are articulated. The research questions that guided our study and analysis were:

RQI: What is the experience of this sample of men in the decision-making process regarding contraceptive practices?

RQ2: What is the experience of this sample of men in the decision-making process regarding the outcome of their unintended pregnancy(ies)?

DATA AND METHODS

The results reported in this paper are based on in-depth individual interviews that were carried out with men in a larger mixed-method study of unintended pregnancy in the northeastern United States. In this essay we analyze data from interviews that were conducted with 20 men who ranged in age from 21 to 48 and whose average age was 31.8 years. We opted to use a broad age range for this study since we sought to include participants with varied life experience in our analysis and to add depth to our exploration of changing contraceptive practices, pregnancy outcome decisions, and long-term consequences. (Age 50 was used as a cut-off because relatively few pregnancies occur to partners of men over 50; Alan Guttmacher Institute, 2002.) No noticeable differences were found in the thematic analysis based on respondent age, however, so the resultant themes appear to be of relevance to our participants across the full span of years.

The sample is quite homogeneous in terms of its racial composition; 19 of the men included in this study were Caucasian, and one was Asian American. Although the county in which the research was conducted was more than 80% white at the time of the interviews (according to 2002 U.S. Census Bureau data), the lack of minority responses during recruitment was initially disappointing. Since unintended pregnancy issues relating to men remain poorly understood across all ethnic, socioeconomic, and racial groups (Goldscheider & Kaufman, 1996), however, and since relevant concerns (e.g., cultural patterns, gender norms, communication practices, views on unintended pregnancy, etc.) often vary among groups (Greene & Biddlecom, 2000; Upchurch, Aneshensel, Sucoff, & Levy-Storms, 1999), it may have been difficult to identify coherent and useful themes from a highly diverse sample of this size. In our view, the responses of the 20 participants in this small, largely white sample provide valuable information about this subgroup and may provide a useful framework for pursuing additional research with participants from other racial and ethnic groups. Assessing the views of respondents from other ethnic groups remains an important area for further research, and comparing themes between various samples may prove more valuable (highlighting what may be interesting differences among groups) than trying to draw themes across diverse groups in a single study of this size.

Certainly, this sample of 20 men is not representative of the population at large, and it was not intended to be. National surveys such as the National Survey of Family Growth (NSFG) and organizations such as the Alan Guttmacher Institute provide up-to-date national statistics on levels and trends in unintended childbearing and other reproductive health issues drawn from larger, more representative samples. The in-depth interview was used in this research to gain access to the perceptions and personal experiences of the participants (e.g., Fontana & Frey, 1994; Rubin & Rubin, 1995) rather than to develop larger trends or statistics. This study was designed to gather narratives from a group of individuals willing to share their experiences surrounding these sensitive topics and to ascertain how their detailed answers might provide information beyond what can be learned from larger surveys. Hence, our intent is not to suggest that the story we tell here is generalizable but rather to suggest that the experiences of this group, unique or shared, provide an in-depth view of issues and concerns that statistics and surveys cannot achieve.

Together, the men in this study had fathered a total of 34 unintended pregnancies. The average age at conception of the first unintended pregnancy was 23.9 years (average reported for their partners was 22.89), with 29.1 years as the average age of the most recent unintended pregnancy (27.78 for their partners). Level of education among the men ranged from having completed 11th grade through completion of a master's degree. The average level of education overall was 15 years (through junior year of college). Ten of the men indicated that they were currently either single or divorced, while nine were married and one was living with his partner. Overall, this was a relatively well-educated and mature group of males who indicated at least some familiarity with sexuality education and contraception, yet they still engaged in risky sexual behavior and fathered unintended pregnancies.

Participants in the study were recruited through flyers and an advertisement that was run in a community newspaper that is widely read in the targeted area. The flyers and the advertisement described the study in brief, requested participation of those who had experienced at least one unplanned pregnancy, offered remuneration for participation, and included a call-back phone number. These proved to be effective methods of attracting participants, with calls received from interested parties across a range of socioeconomic levels, educational backgrounds, recency of pregnancy experience, and number of unplanned pregnancies. Those responding were selected for participation in the study if they were between 18 and 50 years of age and had experienced at least one unintended pregnancy. Upon completion of our interviews, our full sample included 25 men. In this paper, we concentrate on the experiences of the 20 men who reported fathering an unintended pregnancy through inconsistent or no use of contraception; this selection was made to allow us to focus on understanding higher-risk contraceptive behaviors and their outcomes.

This study was IRB approved, and full written informed consent procedures were followed for all participants. Participants were guaranteed confidentiality, reminded that their participation was entirely voluntary, and told that they would receive compensation even if they became uncomfortable and chose to discontinue the interview at any point. No adverse events were reported, and all participants were paid $30 for their participation in the 60-90 minute interviews.

In-depth individual interviews, guided by one of two trained interviewers (both male), were conducted with participants about the circumstances of all previous pregnancies that they had experienced, regardless of pregnancy intendedness. They were asked to describe their own and their partner's feelings at the time of each pregnancy, the state of the relationship, their intentions toward childbearing at the time the pregnancy occurred, and any steps that they had taken to prevent conception. If the pregnancy was mistimed or unwanted, they were asked about the pregnancy-outcome decision process, including whether they had considered terminating the pregnancy, and they were asked about the circumstances surrounding those decisions. If the pregnancy was mistimed (occurring too soon), informants were asked to consider when circumstances might have been more favorable. All study participants were asked about the nature of communication with their partner(s) and about discussions they may have had with friends, family members, or others about each pregnancy. Finally, they were asked about consequences of each pregnancy.

With questions of this type on sensitive topics, the risk of social-desirability bias is always of concern. In the present study, the interviewers used extensive probes, asked for specific detail, and provided assurances of confidentiality to encourage participants to be as honest as possible in their responses. All of the men (keeping in mind that all had volunteered to participate in this study knowing the topic in advance) discussed their situations openly and comfortably, with many describing painful experiences, negative behaviors on their own parts, and sincere regret and even embarrassment for some actions or omissions. Ultimately, while some social-desirability bias may have been present, it was controlled to the extent possible. Interviewers reported that participant comments seemed generally appropriate and trustworthy.

DATA ANALYSIS

Data were analyzed using a thematic framework. Thematic analysis takes an inductive approach, drawing themes from the data themselves rather than imposing a set coding scheme. Various forms of thematic analysis have been used to examine a broad range of social issues--from role-appropriate themes (Beier & Pollio, 1994) to alcohol-related themes in country western music (Conners & Alpher, 1989) to themes of sexuality in Playboy cartoons (Matacin & Burger, 1987), among others. Owen (1984) used the criteria of recurrence, repetition, and forcefulness when identifying themes in relational discourse, while others have proposed similar criteria in attempting to derive "categories" or "patterns" from interview data (e.g., Patton, 1980). Guba (1978) suggested the key issue in analyzing ethnographic data is identifying "convergence" (where things fit together)--and it is in this spirit that our analysis was conducted.

For the present study, a three-step analysis process similar to the "constant comparison" method of Strauss and Corbin (1998) was used. (See also Baxter & Degooyer, Jr., 2001). First, a complete and careful read-through of all transcripts was conducted by the lead researchers. Second, transcripts were carefully reread line by line, and each statement that answered one of the research questions was considered a datum. Each datum was compared for similarity and difference with all others, with each unique datum establishing a new category. Data found to be similar to one another were grouped together into categories. Using an iterative process, categories were then combined and revised until the most coherent final categories or "themes" were achieved. Only the most prominent and illuminating themes in the data are discussed here. Third, a researcher unfamiliar with the study was provided the transcripts and themes and asked to engage in a similar process of analysis toward assessing the presence and prominence of the themes and to see whether additional themes could be identified. No significant discrepancies were identified in the coding process or assignment of data to themes, and all three researchers agreed on the clarity, prominence, and importance of the primary themes for these respondents.

The goal of the present analysis was to identify within the comments of these participants the most influential elements of participant contraceptive practices and pregnancy-outcome decision making. The two primary themes ultimately drawn from the analysis of participant comments were selected because they were identified in the comments of at least 80% of the participants (16 of the 20) and were prominent in both areas (contraception and outcome). All of the participants made comments consistent with at least one of the two primary themes when talking about each area (contraception and outcome). While present to varying degrees in the comments of each of the men, these two themes were prominent, significant, and clearly influenced their decision making and behavior.

Wherever possible, quotations are inserted in the sections that follow, both to offer support for the selection of themes and to allow the voices of these men to be heard. To ensure anonymity, a list of relatively common male names was derived, and a name from that list was assigned at random to each participant. Also, all other potential identifiers (e.g., places, work, partner names, etc.) have been removed.

RESULTS

Without question, two themes here titled "deference" and "denial" stood out across all aspects of the unintended pregnancy experience for the men in this research. These themes in many ways parallel the ones Marsiglio (1993) identified in his research ("women's realm" and "lack of procreative responsibility"). We have chosen to label the first theme "deference" because, in matters of discussion, planning, decision-making, contraception, and pregnancy outcome, virtually all of these men in some ways deferred to their partners. A subtheme, "exclusion," describes conditions going beyond deference to those in which the man failed to contribute to decisions, not entirely because he relinquished his right to do so, but at least in part because others opted not to include him. We begin by discussing deference, then exclusion, and our final section describes the theme of denial.

DEFERENCE

In comments about contraception, one of the men (Frank) describes what he calls a "classic case" wherein an acquaintance was said to have deferred responsibility for birth control to his partner resulting in a pregnancy. Not surprisingly, Frank's "classic case" mirrors his own experience:

   The second time it happened, birth-control-wise, was pretty much
   the same as the first time. It was almost the same kind of
   scenario.... It was like an exact replay, I think.... Because I
   wasn't an assertive person at all.... I was passive.... It's her
   body, and it's, and I don't see it as my responsibility. I see my
   responsibility as like asking the woman about the birth control
   because you've got to remember, if it's like a diaphragm, it's
   always her responsibility usually, or if it's a pill. It's only
   if you use the condoms that the man is playing an active role ... in
   my mind, it was a woman's realm.

Frank's sentiments were shared by a number of the men, some as directly, others in more vague terms:

   I totally relied, I completely relied on the woman I was with to
   take care of birth control. I was very irresponsible about that. Um,
   I just relied on them.... I didn't even think about it. I figured,
   "Hey, she knows when she's fertile. She knows when she isn't." I
   just left it completely up to her. (Bob, discussing his first
   unintended pregnancy)

   She never actually went to the doctor to find out, but she thought
   she couldn't have babies [so no birth control was used]. Well, I
   thought (that was stupid on my part, wasn't it?), I thought since
   she'd already had kids that she was, well, I hate to say fixed....
   (Lou)

This happened to Lou a second time:

   She told me she couldn't get pregnant, so no birth control. (Lou)

   I left the method entirely up to her ... whatever she wanted to use
   was fine with me 'cause I'm that kind of guy. (George)

This series of quotes (and the numerous others that might have been included) show the pervasive nature of the deference of responsibility for contraception to women.

In addition to contraception, the men provided additional examples of "deference" when discussing the pregnancy-outcome decision. For roughly one-third of the pregnancies, men seemed to feel as though the pregnancy-outcome decision was mutually derived (most common in long-term relationships and when partners had matching opinions on the desired outcome). However, a clear majority of the decisions were made by the woman. In only one case was the decision made by one of the men ("She said, 'I could go either way. You decide.' I said, 'Well, let's have an abortion'"--Bob). This was the exception, though, with most comments on pregnancy-outcome decision making similar to the following:

   I figured the correct thing to do would be to support her in
   whatever decision it was that she was going to make. (Sam)

   She wants to [have the baby], so that's her choice, and I have to
   live with that choice, I guess. (Pete)

   I think she just told me. Yeah, I mean, I don't think I had any
   opinions either way. l was just being swept along.... (Al)

   Part of me probably also was saying, "Well, let her make the
   decision, and then I don't have to accept responsibility or
   consequences for it." She made a decision to keep the child, and I
   supported that. I did support her. (Marty)

While the pregnancy may have been discussed at length and in-depth by some of the couples, it was clear that, overall, the women carried the most weight during the decision-making process and made, in the end, the final decision for almost all of the couples. Some of the men agreed with and supported the outcome decisions of their partners, while others were in lesser agreement, were opposed to the decision, or were unaware that a decision had been made. For some of the men, a decision by the woman to continue the pregnancy had significant long-term ramifications, while for others the choice of abortion had a painful emotional impact.

EXCLUSION

As we have indicated, several of the men extended this theme beyond deference and discussed feeling marginalized throughout the process. Dean's experience was similar to that of a few others: "I found out four or five months after the fact ... she'd been [out of the country], and she came back. And ... we were startin' to date again, and that's when she told me that ... she'd been pregnant.... She had already had the abortion at that point." Dean's sense of being excluded from the process was discussed at length:

   ... men are just a sideline, you know, in the whole
   sexuality-pregnancy thing ... because the baby is gestated in the
   woman, but, speaking as a man ... a man has a whole emotional,
   spiritual attachment to the whole process, and not including the man
   is kind of writing men off before they even have a chance to do
   anything.... The whole general attitude of society says that ... man
   is just, ah, just this agent that provides this tiny little seed,
   and that's really the only claim that he can make.... My personal
   experience with it was, I was very attached to the process when I
   found out, it was a big loss for me....

In a few cases family members intervened and created situations in which the men felt they were pushed to the side and had little or no input. "Because her aunt right away wanted her to have the baby. And she has a real strong influence on her. She still does.... I knew that I was outgunned by this aunt" (John). Steve added, "... and her mother hates me to this day ... and she accused me of raping [his partner].... I think the [pregnancy outcome] decision was really made between her and her mother."

Some participants indicated that more formal support in the community could have helped mediate the feelings of isolation they had felt. For example, Paul said "... I don't think there's services available for men involved with this process. There are some institutions in town.... Yet I don't think that there is immediate ... men's support for the difficulties that we might lace at this time."

Deference to their partners and the sense of being outside the whole process (from contraception through pregnancy outcome--and in some cases continuing through child-rearing) were pervasive in the comments of the men in this study.

DENIAL

Denial can be defined as a defense mechanism "... through which a person attempts to protect himself (sic) from some painful or frightening information related to external reality" (Breznitz, 1983). Some research has considered the role of denial in sexual behavior decision-making, most commonly associated with AIDS or other sexually transmitted diseases (e.g, Baldwin & Baldwin, 1988; Moore & Rosenthal, 1991). Denial has been studied as a variable in risk-taking sexual behavior among homosexual men (Beltran, Ostrow, & Joseph, 1993; Bosga et al., 1995) and African-American adolescent males (Chapin, 2001). However, the role of denial in contraceptive practices related to unintended pregnancy has yet to be fully explored. In the present study denial includes possessing an awareness of the risks of fathering an unintended pregnancy yet ignoring those risks and choosing behaviors that increase the likelihood of conception.

The participants in this study expressed a clear sense of the risks of pregnancy, and most seemed to have had at least some awareness of these risks prior to conception. Most also indicated having had a strong desire to avoid conceiving a child at that time: "l never wanted children, in fact, I could positively say that if I'd been honest with myself at the time, I did not want children" (Bob); "I didn't spend a lot of time thinking about it, and anytime I did, it was .just that I did not want to have one" (Chuck). Not all of the men were unhappy about the pregnancy. Several expressed feeling happy and excited upon hearing the news (typically those having mistimed pregnancies with long-term partners). Before fully focusing on denial, it is important to recognize that virtually all participants discussed the tremendous responsibility of pregnancy and childbearing:

   It's scary. The whole deal is scary, but I don't know, you've got to
   do it, right? I got myself in the trouble; I've got to take care of
   it, so ... I could leave if I wanted to, I guess, but I don't want
   to do that. You know, I'm going to go ahead and stick with it.
   (Pete)

   I don't feel like I'm old enough and mature enough to raise a child
   right now, much less doing it again, and it is just an incredible
   responsibility. I mean, we really, as parents, have an incredible
   effect on our children. (Al)

   Well, once again, it was just, it was responsibility. I was
   terrified at the responsibility of having a child. I didn't think I
   was ready. I didn't think we were ready ... just the whole financial
   ramifications of it and everything. (John)

Unfortunately, this perception of children as responsibility (often derived after the fact) did not seem to influence perceived responsibility regarding contraception. Despite their feelings about fathering a child, in most cases the men were not willing to use condoms or in other ways take responsibility for pregnancy prevention. Some quotes presented previously under "deference" support this point, as do the many comments made by the men regarding intentional non-use of contraception. All of these men engaged in unprotected intercourse on at least one occasion, with most doing so over periods of time. Even among those couples who used contraception often, there were occasions when these practices were abandoned, such as during short visits after one partner had been away and the female partner had stopped using oral contraceptives. In other cases, discomfort from and/or men's general dislike of condoms inspired their occasional non-use or complete avoidance. A few comments illustrate the reasons these men offered for not using contraceptives:

   I don't know why. Ah, we didn't normally, you know. I guess
   sometimes, half the time we did, and half the time we didn't.
   That's about all. (Pete)

   We used condoms off and on, but really not ... effectively enough
   every time we had sex. I mean, it was pretty much, I just tossed
   them out, didn't even use them because we were getting too lucky.
   I thought, "Geez, it ain't meant to be!" (Tom; Tom's sense of
   feeling "lucky" highlights, in one sentence, both his awareness of
   and denial of the risks of pregnancy.)

   ... she was using a diaphragm, and I was using a condom, and it
   was just a moment of passion, basically, so we just slacked off and
   were irresponsible.... (Don)

It should be noted that a few of the men frequently practiced withdrawal, assuming it would be adequate for pregnancy prevention, denying the risks associated with it as a contraceptive method. For example, Harry said, "... we never really discussed it because ... I never used a condom or nothing, but on top of that, when the time came where I got excited, I always pulled out, and I never did it inside her. But, so that was pretty much the way I used to do a kind of 'sate sex.'" The lack of consistency applying this method is but one of the reasons it is ineffective: "... but there was one time in particular that I remember where, urn, we achieved orgasm, and normally I would pull out, or I'd be wearing a condom, and, ah, ... I just didn't pull out" (Rick). Marty added that his use of withdrawal was "... just part of the denial.... We had some, a couple of, actually, I think we had one instance before when we thought she was pregnant, and it turned out she wasn't." When asked whether the pregnancy scare had affected their contraceptive behavior, Marty said, "No.... A couple of times we used condoms, then we kind of stopped again." The combination of awareness and denial of risk created, in retrospect, negative associations or feelings for many of the men in the study. For example, Gary commented, "I thought it was kind of careless on my part because it was obvious that we weren't doing what we could to protect against having a baby." He also said their lack of contraception use may have been due to laziness or feelings of invulnerability. At one point, Bob said he felt "disgusted" with himself for not preventing pregnancy. Steve added, "I think it's still disturbing to her, as it is still disturbing to me. I mean, I already felt like crying once in this conversation, because the more I go into it, the more disturbing it is. If I think about it briefly, I think, you know, the response is automatically there. It's bad."

Further, the men often made comments specifically related to their denial of the risks. For instance, when discussing his response to being told his partner was pregnant, Bill said:

   ... it was a complete surprise, I guess, although having had sex
   without protection, l imagine that there must have been something
   in the back of my mind that was not surprised, you know. Because
   intellectually, obviously, there is that possibility. (Bill)

He later added,

   ... and I, yeah, I did blame her.... And I was angry at her for, for
   at least not verbally taking the responsibility, more responsibility
   for what happened, for getting pregnant.... We just weren't taking
   responsibility. I might have asked if it was a sate time, but not,
   you know, clearly ... so there's, you know, a certain denial of
   responsibility on my part.

Marty was overwhelmed by a sense of irresponsibility:

   I felt irresponsible. Like, I was not responsible. I've always been
   a person who I felt and who people have told me I seem responsible.
   I, ah, I think ahead. I usually am a planner for things and try to
   be ready for unexpected things to try to steer things in the
   direction I want to go, and by not using contraception we didn't do
   that.

Later, Marty said:

   So I think a little bit of denial, too. And, in fact, l think ...
   it's definitely denial. It's just avoiding any kind of scary issue
   that there could be, you know? As far as disease, as far as
   prevention of anything like that. On the birth control side, as I
   said, we had been fine so far; she hadn't been pregnant, so....

It seems clear that denial was a significant element in the contraceptive behavior of these men. They were not unaware of the risks in a general sense, and in many cases perceived the risks to be significant and frightening, but they did not seem to want to accept the extent to which they were personally at risk of fathering a pregnancy, and their non-use or inconsistent use of contraceptives reflected that denial.

DISCUSSION

The picture that emerges of the experiences of the men in this study from the themes discussed above points both to problems and potential solutions. The most apparent issue is the lack of involvement of these men in prevention of and response to unintended pregnancy. The men typically relied on their partners to use contraception, and most presented themselves as taking a "supportive" role when it came to making the pregnancy outcome decision, supporting whatever decision their partners made. While in some ways this "supportive" approach might be viewed as laudable, in a very real sense it appears that they distanced themselves from the responsibilities of pregnancy outcome just as they distanced themselves from the responsibilities of contraception. Many of the men consistently engaged in risky sexual behavior without taking responsibility for preventing or responding to unintended pregnancy (particularly obvious with those men who fathered multiple unwanted pregnancies), while others did so occasionally or at specific times. Despite experience, knowledge, and for some even previous unintended pregnancies, the high-risk behavior continued. How might the unintended (especially the unwanted) pregnancies have been prevented? Several possibilities arise from the literature and from suggestions of some of the men.

First, the themes identified in this research confirm recommendations of Edwards (1994) cited in Brown & Eisenberg (1995, p. 14) that "men must be involved in pregnancy prevention in a variety of ways beyond just encouraging condom use." Further, according to Darroch (2000),

   [A]s women gained more control of contraception, men were distanced
   from method choice and use. Some men have undoubtedly
   been glad to leave this responsibility to women. Others, it is
   probably fair to say, have been excluded by women who see fertility
   control as their sole prerogative. The heavy reliance on methods
   independent from intercourse has meant that sexual partners do
   not need to alter their behavior around intercourse or even discuss
   contraception in the context of sexuality. (p. 90)

We strongly concur with this point. In addition, although the most common approach to involving men in contraceptive decision making has been (and continues to be) encouraging condom use, these efforts are clearly not enough. Condoms were not at all popular with the men in the present study (or with many of their partners); participants indicated that condoms are uncomfortable, reduce sensation, and/or inhibit spontaneity. Only one of the males interviewed used condoms consistently over an extended period of time. Despite being educated on the value of condoms in preventing disease and pregnancy, all but one of the men engaged in intercourse without them some or all of the time. Continued efforts to promote condom use are certainly important, but it seems clear that additional means of involving men in pregnancy prevention are necessary.

Further, even the more educated men who participated in this study did not always have accurate information about contraceptive methods other than the condom. Hence, another way to encourage male involvement in preventing unintended pregnancy may be to broaden contraceptive education for males (both during and beyond the school years). From his experience with multiple unintended pregnancies, Bob supported this assertion when he said, "Become an expert at it [birth control], and don't rely on the other partner." The men were often unclear about the effectiveness of alternative methods of contraception and about how and when they should be used. In some instances this uncertainty led to withdrawal from participation in decision making about contraception. The heavy emphasis on condom education programs (which remain vital due to the prominence of sexually transmitted infections) among males may be leading to assumptions that it is less important for them to be familiar with other contraceptive methods. The men also seemed to assume women were educated about contraceptive methods and their own menstrual cycles. Although some recent research has suggested that women may be somewhat snore knowledgeable than men on average (see Gallagher, Lall, & Johnson, 1997), it is clear that the men in this study were not typically able to rely on their partners for accurate information. Expanding education for males regarding conception and encouraging them to remain finn regarding contraception despite a partner's belief that it is unnecessary at a given time may contribute to reductions in unintended pregnancy.

As we indicated earlier, once men are beyond school age, there are very limited pregnancy-prevention programs directed toward them (Alan Guttmacher Institute, 2002; Bradner, Ku, & Lindberg, 2000), and all too often men remain unaware of the services that do exist (Finer, Darroch, & Frost, 2003). The present research reinforces the point that public policy should continue to foster programs geared specifically for older men and find more effective ways of involving them snore fully in the prevention of unintended pregnancies.

Part of involving men more fully in these issues undoubtedly depends on improving partner communication. Most participants in this study reported having very limited verbal interaction with their partners regarding contraception and pregnancy. Heavy reliance on deference of responsibility and on assumptions that contraception was being used by their partners created situations in which no contraception was used, and the inconsistent nature of contraceptive use over time (even among couples who were relatively careful regarding contraception) meant that there were instances wherein additional discussion would likely have resulted in more effective pregnancy prevention. Many of the men indicated that most of their contraceptive discussions occurred early in the relationship and were limited to passing comments regarding specific methods. Devising programs for men that specifically seek to enhance communication about sexual issues in relationships may be helpful in reducing assumptions and denial, thereby improving consistency of contraceptive practices. With improved communication, these men may well have relinquished less responsibility to the women and made more informed decisions about contraceptive practices.

A number of other researchers have established the importance of enhanced communication for increasing contraceptive use. For instance, Adelman (1991) has found that safe-sex talk, particularly within a "playful frame," is useful for increasing condom use. Such research considers ways couples might adapt their communication toward safer-sex behavior. Warren (1992) and Warren & Neer (1986) consider the importance of family sex communication in establishing attitudes toward sex in children, suggesting that greater openness in the family about sex will result in decreasing rates of unwanted pregnancy. Similarly, Battle (1998) indicates that effective communication with both parents helps daughters develop a sense of their sexuality and their expectations of relationships. Such studies point to the importance of positive communication in framing sexuality in general and in providing knowledge and confidence in teens that should aid in lowering their chances of experiencing an unintended pregnancy in particular.

Finally, the "denial" theme raises a number of significant and interesting issues, some of which have been considered in other research on sexual behavior. For example, Bauman & Siegel (1987) examined the relationship between anxiety and perception of the risk of sexual behavior for contracting AIDS among homosexual men. Their research found that lower levels of anxiety were associated with a tendency to engage in higher-risk sexual behavior. Following the "Health Belief Model" (HBM) (Leventhal, Meyer, & Nereng, 1980), they state,

   ... the HBM posits that an individual must first recognize and
   acknowledge that he is at risk for AIDS before he will experience
   heightened anxiety, which, in turn, motivates the adoption of
   safe-sex practices. Gay men who deny or misperceive that they are at
   risk for AIDS (i.e., who exhibit unrealistic optimism) experience
   lower anxiety, which, in turn, generates little motivation for
   practicing safe sex. Therefore, such men continue to engage in
   high-risk sexual practices. (p. 345)

Evidence of an "optimistic bias" has also been found in research among African-American adolescent males regarding their sexual behavior (Chapin, 2001), suggesting that the tendency toward denial in males crosses age and racial boundaries. Comments like this one from Tom, "... we were getting so lucky I thought, geez, it ain't meant to be," show clear evidence both of denial and unrealistic optimism. He appeared to feel a sense of invulnerability and continued the high-risk behaviors until a pregnancy was conceived. Bauman and Siegel (1987) also suggest cognitive dissonance (Festinger, 1957) may play a role as men seek to resolve contradictory feelings (desires for free sexual expression versus fears of pregnancy) through denying or distorting available information regarding the risks of sexual behavior.

One model of denial, proposed by Breznitz (1983), is particularly interesting in light of the comments of these participants. Breznitz's model incorporates seven kinds of denial, all stemming from responses to initial information that is perceived as threatening. The seven kinds of denial Breznitz proposes are related to different stages in the processing of threatening information, and each can be related to a defining question: first--denial of personal relevance ("Is it threatening to me?"); second--denial of urgency ("Is it threatening to me right now?"); third--denial of responsibility ("Can I handle/control it?"); fourth--denial of affect ("Am I anxious/afraid?"); fifth--denial of affect relevance ("Is my anxiety relevant?"); sixth--denial of information ("is there information?"); seventh--denial of threatening information ("Is the information threatening?") (Breznitz, 1983, p. 259).

Whether Breznitz's seven kinds of denial exist in a hierarchy is not particularly relevant here, since the pervasive presence of all seven in the comments of the men highlights the prominence of denial in their decision making. It also emphasizes the likelihood that there is no simple "fix" for denial in contraceptive use, since answering one kind of denial with an effective argument may inspire the use of a new kind (e.g., new information about the urgency of the risk that increases anxiety might inspire denial of affect relevance and be met with a "tempt-fate" mindset). Hence, while a particular education program may provide information to answer some specific denial question, other kinds of denial may be quickly applied, reducing dissonance and allowing the high-risk behavior to continue. This provides one potential explanation for the widely varying successes and failures of prevention programs. Though some education and prevention messages/programs may be effective for many people, those who apply denial more pervasively in their sexual-behavior decision making may turn to alternative types of denial instead of adjusting their high-risk behavior. Why some individuals might utilize denial to a greater degree than others remains an open question; however, finding answers to such questions about denial may be useful in creating a more complete understanding of unintended pregnancy. Intervention strategies for individuals who are, for one reason or another, predisposed toward denial might be of particular use if these attributes could be identified during childhood or adolescence (see the denial-intervention work of Aronson, Fried, & Stone, 1991). Had these men faced the risks of pregnancy directly, they might have responded with increased attention to contraception (even if that meant insisting on their partners using diaphragms or oral contraceptives more consistently) and been more involved in the pregnancy-outcome decisions as well.

The themes drawn from the in-depth interviews with the 20 men in our study provide a unique window into their experiences and views. Their tendencies toward deference of responsibility to their partners (for both contraception and pregnancy-outcome decisions) and their denial of the risks of unprotected sexual intercourse seemed to be primary contributors to their unintended pregnancies. These themes support previous calls for greater involvement of men in every aspect of sexual behavior decision making. It is important, however, that future research assess whether the themes identified here are peculiar to men who have experienced unintended pregnancy or whether denial of risk and responsibility and feelings of exclusion are experienced more generally among sexually active men of reproductive age. In studies with larger sample sizes, for example, scales might be developed to assess associations between levels of denial, deference, and exclusion and the experience of unintended pregnancy.

The enhancement of men's knowledge regarding contraception should be pursued, and additional research into male sexuality education and contraceptive understanding is necessary. The communication between partners about sexual issues is also a vital area of further research and program development, since communication avoidance supports an environment conducive to denial, leads to misunderstanding, and encourages deference in decision making to partners. The sense of responsibility among men for contraception and pregnancy outcome and their willingness to face the reality of the risks inherent to sexual intercourse are also areas wherein improvement may help reduce unintended pregnancies. Finally, continuing this research to explore relevant themes among men from varied racial and ethnic groups and from varied geographic and socioeconomic backgrounds is essential if a more complete understanding of the role of men is to be derived.

REFERENCES

Adelman, M.B. (1991). Play and incongruity: Framing safe-sex talk. Health Communication, 3, 139-155.

The Alan Guttmacher Institute (1996). Readings on Men from Family Planning Perspectives 1987-1995. New York: Alan Guttmacher Institute.

The Alan Guttmacher Institute (2002). In their own right: Addressing the sexual and reproductive health needs of American men. New York: Alan Guttmacher Institute.

The Alan Guttmacher Institute (2003). Perspectives on sexual and reproductive health, 35. New York: Alan Guttmacher Institute.

Aronson, E., Fried, C., & Stone, J. (1991). Overcoming denial and increasing the intention to use condoms through the induction of hypocrisy. American Journal of Public Health, 87, 1636-1638.

Baldwin, J.D., & Baldwin, J.I. (1988). Factors affecting AIDS-related sexual risk-taking behavior among college students. Journal of Sex Research, 25, 181-196.

Bartle, N., with Lieberman, S. (1998). Venus in blue jeans." Why mothers and daughters need to talk about sex. Boston: Houghton Mifflin.

Bauman, L.J., & Siegel, K. (1987). Misperception among gay men of the risk for AIDS associated with their sexual behavior. Journal of Applied Social Psychology, 17, 329-350.

Baxter, L.A., & DeGooyer, D.H., Jr. (2001). Perceived aesthetic characteristics of interpersonal communication. Southern Communication Journal, 67, 1-18.

Beier, B.F., & Pollio, H.R. (1994). A thematic analysis of the experience of being in a role. Sociological Spectrum, 14, 257-272.

Beltran, E.D., Ostrow, D.G., & Joseph, J.G. (1993). Predictors of sexual behavior change among men requesting their HIV-1 antibody status: The Chicago MACS/CCS cohort of homosexual/bisexual men, 1985-1986. AIDS Education and Prevention, 5, 185-195.

Bosga, M.B., de Wit, J.B.F., de Vroome, E.M.M., Houweling, H., Schop, W., & Sandfort, T.G.M. (1995). Differences in perception of risk for HIV infection with steady and non-steady partners among homosexual men. AIDS Education and Prevention, 7, 103-115.

Bradner, C.H., Ku, L., and Lindberg, L.D. (2000). Older but not wiser: How men get information about AIDS and sexually transmitted diseases after high school. Family Planning Perspectives, 32(1), 33-38.

Breznitz, S. (1983). The seven kinds of denial. In S. Breznitz (Ed.), The denial of stress (pp. 257-280). New York: International University Press, Inc.

Brown, S.S., & Eisenberg, L. (Eds.) (1995). The best intentions: Unintended pregnancy and the well-being of children and families. Washington, DC: National Academy Press.

Card, J.J., & Wise, L. (1978). Teenage mothers and teenage fathers: The impact of early childbearing on the parents' personal and professional lives. Family Planning Perspectives, 10, 199-205.

Chapin, J. (2001). It won't happen to me: The role of optimistic bias in African American teens' risky sexual practices. Howard Journal of Communications, 12, 49-59.

Christopher, F.S., & Roosa, M.W. (1990). An evaluation of an adolescent pregnancy prevention program: Is "Just say no" enough? Family Relations, 39, 68-72.

Conners, G.J., & Alpher, V.S. (1989). Alcohol themes within country-western songs. The International Journal of Addictions, 25, 445-451.

Darroch, J.E. (2000). The pill and men's involvement in conception. Family Planning Perspectives, 32, 90-91.

Doniger, A.S, Adams, E., Utter, C.A., & Riley, J.S. (2001). Impact evaluation of the "not me, not now" abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. Journal of Health Communication, 6, 45-60.

Edwards, S.R. (1994). The role of men in contraceptive decision-making: Current knowledge and future implications. Family Planning Perspectives, 26, 77-82.

Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press.

Finer, L.B., Darroch, J.E., & Frost, J.J. (2003). Services for men at publicly funded family planning agencies, 1998-1999. Family Planning Perspectives, 35, 202-207.

Fontana, A., & Frey, J.H. (1994). Interviewing: The art of science. In N.K. Denzin & Y.S. Lincoln (Eds.), Handbook of qualitative research (pp. 361-376). Thousand Oaks, CA: Sage.

Forste, R., & Morgan, J. (1998). flow relationships of U.S. men affect contraceptive use and efforts to prevent sexually transmitted disease. Family Planning Perspectives, 30, 56-62.

Gallagher, C.K., Lall, R., & Johnson, W.B. (1997). Contraceptive knowledge, contraceptive use, and self-esteem among Navy personnel. Military Medicine, 162, 288-291.

Geronimus, A.T., & Korenman, S. (1992). The socioeconomic consequences of teen childbearing reconsidered. Quarterly Journal of Economies, 107, 1187-1214.

Geronimus, A.T., & Korenman, S. (1993). The costs of teenage childbearing: Evidence and interpretation. Demography, 30, 281-290.

Goldscheider, F.K., & Kaufman, G. (1996). Fertility and commitment: Bringing men back in. Population and Development Review, 22, 87-99.

Greene, M.E., & Biddlecom, A.E. (2000). Absent and problematic men: Demographic accounts of male reproductive roles. Population and Development Review, 26, 81-115.

Guba, E.G. (1978). Toward a methodology of naturalistic inquiry in educational evaluation. CSE Monograph Series in Evaluation No. 8. Los Angeles: University of California.

Henshaw, S.K. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30, 24-29, 46.

Kirby, D. (1985). The effects of selected sexuality education programs: Toward a more realistic view. Special Issue: Sex education past, present, and future. Journal of Sex Education & Therapy, 11, 28-37.

Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of illness danger. In S. Rachman (Ed.), Contributions to medical psychology (Vol. 2, pp. 7-30). New York: Pergamon Press.

Loewenstein, G. & Furstenberg, F. (1991). Is teenage sexual behavior rational? Journal of Applied Social Psychology, 21, 957-986.

Marsiglio, W. (1993). Adolescent males' orientation toward paternity and contraception. Family Planning Perspectives, 25, 22-31.

Marsiglio, W. (2003). Making males mindful of their sexual and procreative identities: Using self-narratives in field settings. Family Planning Perspectives, 35, 229-233.

Matacin, M.L., & Burger, J.M. (1987). A content analysis of sexual themes in Playboy cartoons. Sex Roles, 17, 179-186.

Moore, S.M, & Rosenthal, D.A. (1991). Condoms and coitus: Adolescents' attitudes to AIDS and safe-sex behavior. Journal of Adolescence, 18, 211-227.

Owen, W.F. (1984). Interpretive themes in relational communication. Quarterly Journal of Speech, 70, 274-287.

Parke, R.D., & Neville, B. (1987). Teenage fatherhood. In S.L. Hofferth & C.D. Hays (Eds.), Risking the future: Adolescent sexuality, pregnancy, and childbearing, Vol. 11. Working papers and statistical appendices (pp. 145-173). Washington, DC: Nat'l Academy Press.

Patton, M.Q. (1980). Qualitative evaluation methods. Beverly Hills, CA: Sage.

Rubin, H.J., & Rubin, I.S. (1995). Qualitative interviewing: The art of hearing data. Thousand Oaks, CA: Sage.

Sandler, A.D., Watson, T.E., Levine, M.D. (1992). A study of the cognitive aspects of sexual decision making in adolescent females. Journal of Developmental and Behavioral Pediatrics, 13, 202-207.

Snowden, L.R., Schott, T.L., Await, S.J., & Gillis-Knox, J. (1988). Marital satisfaction in pregnancy: Stability and change. Journal of Marriage and the Family, 50, 325-333.

Sonenstein, F.L., Stewart, K., Duberstem Lindberg, L., Paternas, M., & Williams, S. (1997). Involving males ill preventing teen pregnancy. A guide for program planners. Washington, DC: Urban Institute.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research (2nd ed.). Thousand Oaks, CA: Sage.

Teachman, J.D. (1983). Early marriage, premarital fertility, and marital dissolution. Journal of Family Issues, 4, 105-126.

Upchurch, D.A., Aneshensel, C.S., Sucoff, C.A., & Levy-Storms, L. (1999). Neighborhood and family contexts of adolescent sexual activity. Journal of Marriage and the Family,. 61, 920-933.

Warren, C. (1992). Perspectives on international sex practices and American family sex communication relevant to teenage sexual behavior in the United States. Health Communication, 4, 121-136.

Warren, C., & Neer, M. (1986). Family sex communication orientation. Journal o[ Applied Communication Research, 14, 86-107.

Williams, L.B. (1991). Determinants of unintended childbearing among ever-married women in the United States: 1973-1988. Family Planning Perspectives, 23, 212-215.

Wineberg, H. (1992). ChiLdbearing and dissolution of the second marriage. Journal of Marriage and the Family, 54, 879-887.

This research was funded by grants from Cornell University's Bronfenbrenner Life Course Center and the University of Richmond Faculty Research Committee.

Correspondence concerning this article should be sent to Scott D. Johnson, Department of Rhetoric and Communication Studies, University of Richmond, Richmond, VA 23173. Electronic mail: [e-mail].

SCOTT D. JOHNSON

University of Richmond

Richmond, VA

LINDY B. WILLIAMS

Cornell University

Ithaca, NY