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No more larking around! Why we need male LARCs.

Modern contraceptives--especially long-acting, reversible contraceptives, or LARCs--are typically seen as a boon for humanity and for women, the majority of their users, in particular. But the disparity between the number and types of female and male LARCs is problematic for at least two reasons: first, because it forces women to assume most of the financial and health-related responsibilities of contraception, and second, because men's reproductive autonomy is diminished by it. In order to understand how to change our current contraceptive arrangement, I want to look at some of the historical and contemporary factors that contribute to this disparity, especially gender norms that associate women with reproduction and distance men from it. (1)

Why Should We Develop Male LARCs?

One reason we need male LARCs is that most of our current contraceptives target women's bodies. Today, there are eleven contraceptive options for women and only two for men. (2) This means that women assume all associated financial and health-related burdens. On the whole, female methods tend to be more expensive than male methods (3) because most require at least one physician visit, and some involve a renewable prescription. Many insurance plans do not cover contraception, (4) and a man cannot bill his partner's contraceptives to his plan (assuming his plan covers them) since, according to our individualistic medical model, they are seen as being only for her use and benefit. (5)

Side effects for female methods are more serious than for male methods, as well, in part because various contraceptive methods for women involve hormones, while no methods for men do. (6) The most common reason women discontinue contraceptive use is unwanted side effects, (7) and most forms of contraception have discontinuation rates approaching fifty percent after one year of use. (8) Also, side effects not only cause women to stop using contraception, but fear of them also prevents women from starting new methods. (9) Finally, the two available male forms of contraception, condoms and vasectomy, also carry fewer health risks than their corresponding female methods, female barrier contraceptives and tubal ligation. (10) It is no wonder that women sometimes continue to use a particular contraceptive even if they are not happy with it simply because it is their best worst option. (11)

Another reason we should develop male LARCs is so that men can more feasibly and effectively share contraceptive responsibility with their partners. Neither of the two male contraceptives currently available is well suited to the contraceptive needs of men in long-term, monogamous relationships. And for men who still want to maintain the possibility of having biological children, the only method available to them is the male condom. Yet given the condom's high failure rate of 16 percent during typical use, men are not able to regulate their reproduction as effectively as women can--many female hormonal methods and IUDs have failure rates under three percent. (12) The lack of effective and reversible options for men leads many men to rely on their partners for contraception. And even if men use a condom, they often depend on women to use another form of contraception concurrently to minimize the possibility of pregnancy.

This dependence on women reduces men's reproductive autonomy. Men have to trust that their partners are correctly and consistently using contraception. If a pregnancy unintended by either or both partners does occur, men have no recourse. They cannot mandate that a woman get an abortion. Regardless of the circumstances under which the pregnancy transpired, men are still held socially and financially responsible for any children they father.

Why Are There So Few Male LARCs?

Women tend to be more associated than men with reproduction in general, and relatively recently, particularly with contraceptive responsibility. Prior to the invention of the birth control pill, contraceptive use was tied to the actual sex act, and for this reason men had to participate in it (for example, by using a condom or withdrawing). Additionally, men were often involved in decisions about and use of contraception because of their traditional role as heads of their households. (13)

Contraceptive responsibility began to shift from being a shared responsibility to being solely a woman's responsibility (14) in the 1930s, when contraceptive manufacturers first labeled female contraceptives as "feminine hygiene" products to avoid having them judged obscene and therefore illegal according to the Comstock Law of 1873. Not only did the manufacturers' campaign "encourage more women to use birth control, but it also ensured that the single largest proportion of those who did used female-controlled, commercially acquired contraceptives." (15) The new alignments between women and contraceptive responsibility and between contraception and private companies paved the way for the success of the pill. Its overnight popularity reinforced women's role as contraceptive consumers, leading health care providers and researchers to focus almost exclusively on women's reproductive health. (16)

Scientists did not begin researching new types of male contraceptives until the 1970s, fifty years after they first started researching "modern" female contraceptives. (17) The result is that, since the female reproductive system has been studied longer, more is known about it, and this has facilitated the development of new female contraceptives. In contrast, scientists working on hormonal male contraceptives basically started from scratch because of the lack of available androgens. (18) And even after researchers started looking for new male contraceptives, not much work was done in this area; (19) instead, scientists studying the male reproductive system were, and still are, mainly focused on male infertility, rather than controlling male fertility. (20)

Increased attention to male contraceptives coincided with the establishment in the United States and Europe of the field of andrology, devoted to the study of the male reproductive system, in the late 1960s. (21) Compared to its sister field of gynecology, however, the field of andrology was and remains quite small. Furthermore, the field is fragmented. According to Nelly Oudshoorn, "practitioners with specific knowledge of the male reproductive system were distributed over a variety of medical specialties, particularly urology, endocrinology, gynecology, and andrology, rather than being concentrated in one specialty, as was the case for the female reproductive body." (22) In sum, the later establishment, small size, and fragmentation of the field of andrology make research and development of male contraceptives more difficult.

Another barrier to the development of male contraceptives is the scarcity of funding for such research. Sixty percent of research and development money in the 1990s went to high-tech female methods, 3 percent to female barrier methods, spermicides, and natural fertility control methods, and 30 percent to multiple methods--in other words, those methods that cannot be attributed to a single type of contraception, such as synthesis of new compounds that could be used in a variety of ways or general-purpose grants for contraceptive research broadly speaking. (However, even in this last category, the majority of the funding went to female methods.) In contrast, only 7 percent of research and development money went to strictly male methods. (23) Pharmaceutical companies are typically not interested in male contraceptive research because they do not think male contraceptives will be lucrative, (24) especially when compared to blockbuster drugs to treat diseases affecting the aging population in the West. (25) With private companies and even public sector organizations like the World Health Organization halting contraceptive research, the U.S. government has by default played a larger role in this arena. For example, between 1970 and 1988, the percent of contraceptive research that received federal funding rose from 25 to 60 percent, (26) and the majority of contraceptive product launches in the United States in the 2000s have been initiated by publicly supported programs. (27)

Another reason there are no male LARCs is because dominant gender norms surrounding trust and reproductive responsibility lead many to conclude that no market exists for male contraceptives. Because this claim is so prevalent, it is important to address and respond to two factors that contribute to this belief. First, there are the perceptions that men do not think they should be responsible for contraception and that they are not interested in using it. Yet empirical evidence often suggests otherwise. For example, a study by Anna Glasier and colleagues revealed that more than 70 percent of men think men should take more responsibility for contraception. (28) Furthermore, there is evidence that men are not only interested in using current male contraceptives, (29) but also that they would use potential hormonal methods. Glasier's study found that 55 percent of men would take a hormonal contraceptive pill, (30) and other studies have found that 75 percent of men would consider using a hormonal contraceptive,31 while between 44 and 83 percent of men would use a hormonal contraceptive pill. (32)

There is also a perception that women will not trust men to use contraception. This is reflected in many mainstream news articles on future male contraceptives and is made explicit in their titles: for example, "Rely on a Man to Take the Pill? Surely They Have Got to Be Joking," and "Why Should We Women Surrender to the Tyranny of a Male Pill?" (33) But again, most mainstream articles fail to present empirical evidence for this perception. Instead, articles like these seem to be relying mainly on gender norms when they claim that most women's response to male contraceptives would be something like, "Are you kidding? I can't even trust him to take out the garbage!" (34) In contrast, social science studies published in academic journals confirm that women in committed relationships would trust their male partners to use new contraceptives. (35) Furthermore, while they may not be a representative sample, it seems safe to assume that women who have agreed to join clinical trials for male contraceptives, knowing it meant they could not use any other forms of contraception, trusted their partners to use the new contraceptives. (36) And many couples already rely on male contraception, which presumably means these women trust their male partners to use it. (37)

There is an obvious disconnect between mass media stories and empirical studies regarding whether women will trust men to use contraception. (38) This disconnect can be explained by distinguishing between trust for individuals and trust for groups. (39) On an interpersonal level, women generally trust their well-known male partners to use contraception, whereas they do not trust men as a group (or some abstract man) to do so. We are all typically more reluctant to trust unidentifiable, amorphous groups than identifiable individuals because we perceive the risks associated with trusting a group--especially the possibility of broken trust--to be greater. In contrast, we tend to feel more secure trusting an identified individual because he is a known entity. Glasier and colleagues noticed this distinction in their study on whether women would trust men to use contraception, remarking, "On the whole many women have rather cynical views of men in general which do not reflect their views of individual men--especially their partner." (40)

The perception that women will not trust men to use contraception is buttressed by (and buttresses) the cultural belief that men are not interested in taking responsibility for contraception. Some claim men are less motivated to use contraception because pregnancy entails fewer consequences for them than for women. (41) Besides the fact that women are the ones who actually carry a child, though, the main reason a pregnancy is thought to have more long-term consequences for women is that women are assumed to be the primary caretakers of children. Yet this assumption is based on socially constructed gender roles. If men were expected to be the primary caretakers of children, then pregnancy would also carry significant consequences for them. (42)

What Changes Are Needed for Male LARCs to Succeed?

To begin with, we need to devote more resources to developing male LARCs. However, developing male LARCs is not enough: without any changes in dominant gender norms for contraceptive responsibility, men will still be unlikely to use contraception at the same rates women do. The mere existence of a particular technology is not enough to change our current contraceptive arrangement. This is epitomized by the case of sterilization. Although it is available for both women and men, tubal ligation is nearly three times more common in the United States than vasectomy, and this trend is repeated worldwide. The differing rates cannot be attributed to availability of technology, nor to the procedures themselves--vasectomies are quicker, easier, safer, and cheaper than tubal ligations. The alignment of femininity with contraceptive responsibility, and with reproduction more broadly, mostly explains why tubal ligation is so much more popular. (43)

It is also important for health care professionals to involve men more fully in reproductive health care in order for male LARCs to succeed. Currently, men are often excluded from reproductive matters. Most family planning programs are geared toward women, (44) and family planning providers are sometimes hostile to men. (45) Many family planning providers don't discuss sex and contraception with men, even when the primary reason for the man's visit is treatment of a sexually transmitted disease. Whereas women are supposed to see a gynecologist as soon as they become sexually active, men have no equivalent expectation. Postsecondary schools for health care professionals should include andrology in their curricula and highlight empirical evidence for men's interest in using contraception to counter the common perception that men do not want it. Expanding the health care professional school curricula could lead to structural changes that foster the burgeoning of the field of andrology, and this, in turn, would not only increase the availability of male LARCs, but also improve men's reproductive health overall. (46)

Acknowledgments

I would like to thank Lisa Schwartzman, Sarah Rodriguez, and my anonymous reviewers for their valuable feedback.

(1.) Due to space limitations, I will only focus on heterosexual couples in the United States using contraception to prevent pregnancy.

(2.) The two male contraceptives are male condom and vasectomy, and the eleven female contraceptives are female condom, tubal ligation, cervical cap, diaphragm, implant, injectable, IUD, patch, pill, ring, and sponge.

(3.) R.A. Hatcher et al., Contraceptive Technology (New York: Ardent Media, 2004), 245.

(4.) As this paper went to press, the Obama administration had just issued new standards requiring health insurance plans to cover all government-approved contraceptives for women without copayments or other charges as of August 2012. That the government has chosen to make such a move only reinforces my claim that contraception can be a financial burden for women.

(5.) L.M. Knudson, Reproductive Rights in a Global Context: South Africa, Uganda, Peru, Denmark, United States, Vietnam, Jordan (Nashville, Tenn.: Vanderbilt University Press, 2006); K.R. Culwell and J. Feinglass, "The Association of Health Insurance with Use of Prescription Contraceptives," Perspectives on Sexual and Reproductive Health 39, no. 4 (2007): 226-30.

(6.) Hatcher et al., Contraceptive Technology, 223.

(7.) S.J. Nass and J.F. Strauss, III, eds., New Frontiers in Contraceptive Research: A Blueprint for Action (Washington, D.C.: The National Academies Press, 2004), 119; A.F. Glasier et al.. "Would Women Trust Their Partners to Use a Male Pill?" Human Reproduction 15, no. 3 (2000): 646-49.

(8.) Nass and Strauss, New Frontiers in Contraceptive Research, 125-26.

(9.) Ibid.; G.S. Grubb, "Women's Perceptions of the Safety of the Pill: A Survey in Eight Developing Countries. Report of the Perception of the Pill Survey Group," Journal of Biosocial Science 19, no. 3 (1987): 313-21; G. Larsson et al., "A Longitudinal Study of Birth Control and Pregnancy Outcome among Women in a Swedish Population," Contraception 56, no. 1 (1997): 9-16.

(10.) Hatcher et al., Contraceptive Technology.

(11.) Indeed, Nass and Strauss assert, "Couples may use a particular method not because they like it especially but because it may be 'the best of a bad lot.'" Nass and Strauss, New Frontiers in Contraceptive Research, 115-16.

(12.) Hatcher et al., Contraceptive Technology, foreword.

(13.) P.L. MacCorquodale, "Gender Roles and Premarital Contraception," Journal of Marriage and the Family 46, no. 1 (1984): 57-58.

(14.) Arguably, contraception can still be viewed as a shared responsibility by couples who have active discussions to determine what form of contraception they will use. And men may participate in contraception even when female methods are used by reminding their partners to take the pill, picking up the prescription, going to the doctor with them, etc. However, the fact remains that most contraceptives target women's bodies, so women are the ones experiencing any negative side effects, as well as the ones responsible for ensuring correct and consistent use.

(15.) A. Tone, "Contraceptive Consumers: Gender and the Political Economy of Birth Control in the 1930s," in Women and Health in America, ed. J.W. Leavitt (Madison: University of Wisconsin Press, 1999), 309.

(16.) S.R. Edwards, "The Role of Men in Contraceptive Decision-Making: Current Knowledge and Future Implications," Family Planning Perspectives 26, no. 2 (1994): 77-82.

(17.) PBS, American Experience, "Timeline: The Pill," http://www.pbs.org/wgbh/amex/pill/timeline/index.html, accessed July 21, 2008.

(18.) N. Oudshoorn, The Male Pill: A Biography of a Technology in the Making (Durham, N.C.: Duke University Press, 2003), 27.

(19.) It is worth noting that Gregory Pincus, one of the inventors of the female pill, also included eight men in his first trial of the female pill to determine the contraceptive qualities of hormones. Oudshoorn, The Male Pill, 70.

(20.) Ibid., 19.

(21.) S. Niemi, "Andrology as a Specialty: Its Origin," Journal of Andrology 8 (1987): 201-3.

(22.) Oudshoorn, The Male Pill, 26.

(23.) K. Yanoshik and J. Norsigian, "Contraception, Control, and Choice: International Perspectives," in Healing Technology: Feminist Perspectives, ed. K.S. Ratcliff (Ann Arbor: University of Michigan Press), 70.

(24.) R. Callaghan, "Nip It in the Bud?" The West Australian, May 6, 2006; S. Dow, "No Pill for Him Just Yet," Sydney Morning Herald, September 29, 2005; S. Godson, "Baby, This Is Crazy," The Times, April 22, 2006; S.J. Segal, Under the Banyan Tree: A Population Scientist's Odyssey (Cambridge, U.K.: Oxford University Press, 2003).

(25.) C. Djerassi, This Man's Pill: Reflections on the 50th Birthday of the Pill (New York: Oxford University Press, 2001), 77.

(26.) J.W. Knight and J.C. Callahan, Preventing Birth: Contemporary Methods and Related Moral Controversies (Salt Lake City: University of Utah Press, 1989), 308.

(27.) Segal, Under the Banyan Tree, 138.

(28.) Glasier et al., "Would Women Trust their Partners to Use a Male Pill?" 649.

(29.) See, for example, F. Bourke, "Boys May Be Offered Male Pill," Sunday Mercury, May 7, 2006; J. Bradbury, "Male Contraceptive Pill Would Be Acceptable to Men and Women," Lancet 335 (2000): 727.

(30.) Glasier et al., "Would Women Trust Their Partners to Use a Male Pill?" 649.

(31.) G.C. Weston, M.L. Schlipalius, M.N. Bhuinneain, and B.J. Vollenhoven, "Will Australian Men Use Male Hormonal Contraception? A Survey of a Postpartum Population," Medical Journal of Australia 176 (2002): 208-210.

(32.) C.W. Martin et al., "Potential Impact of Hormonal Male Contraception: Crosscultural Implications for Development of Novel Preparations," Human Reproduction 15 (2000): 637-45.

(33.) R. Madeley and J. Finnigan, "Rely on a Man to Take the Pill? Surely They Have Got to Be Joking," The Express, December 2, 2006; C. Sarler, "Why Should We Women Surrender to the Tyranny of a Male Pill?" Daily Mail, November 28, 2006. See also, for example, J. Christman, "Would He Even Take the Pill, If He Could?" Arkansas Democrat-Gazette, November 7, 2006, and H. Eyre, "The Male Pill Could Change the Future . . . : The Man Wants to Quit Taking the Damn Thing--He Thinks the Pill Is Making Him Fat," The Independent, December 2, 2008.

(34.) Segal, Under the Banyan Tree, 130.

(35.) Glasier et al., "Would Women Trust Their Partners to Use a Male Pill?"; Martin et al., "Potential Impact of Hormonal Male Contraception"; Weston, Schlipalius, Bhuinneain, and Vollenhoven, "Will Australian Men Use Male Hormonal Contraception?"

(36.) L. Scott, "Contraception: Take it Like a Man," Northern Echo, October 17, 2003.

(37.) However, it may be easier to trust men with the available contraceptive methods, since the use of condoms and withdrawal both take place in the presence of women and vasectomy is a permanent procedure.

(38.) In a 1999 paper, Oudshoorn compared news media coverage of the results of clinical trials on male hormonal contraceptives with the original press bulletins and research papers on these trials. She, too, found a discrepancy between the two sources, with the news media undermining the scientists' arguments about safety and trust. N. Oudshoorn, "On Masculinities, Technologies, and Pain: The Testing of Male Contraceptives in the Clinic and the Media," Science, Technology, and Human Values 24, no. 2 (1999): 265-89.

(39.) Distinguishing between trust for individuals and trust for groups is too big a topic to tackle in this paper. See author's dissertation, which covers this topic in depth.

(40.) Glasier et al., "Would Women Trust Their Partners to Use a Male Pill?" 649.

(41.) F. Macrae, "The Instant Male Pill: Scientists Reveal Contraceptive a Man Can Take Before Sex . . . While Hours Later His Fertility Returns to Normal," Daily Mail, November 27, 2006; Segal, Under the Banyan Tree, 114.

(42.) Although men cannot take on all of the responsibilities associated with pregnancy, they can be involved socially and financially.

(43.) Tubal ligation is very popular in many African and Asian countries, in particular, because it is offered to women in the context of population control programs. These programs often rely upon the association of women and reproduction (including contraception) for promotion and justification. R. Dixon-Mueller, Population Policy and Women's Rights: Transforming Reproductive Choice (New York: Praeger Press, 1993); S. Correa and R. Reichmann, Population and Reproductive Rights: Feminist Perspectives from the South (Atlantic Highlands, N.J.: Zed Books, 1994).

(44.) B. Hartmann, Reproductive Rights and Wrongs: The Global Politics of Population Control (Boston, Mass.: South End Press, 1995), 52.

(45.) Edwards, "The Role of Men in Contraceptive Decision-Making," 78.

(46.) T. Rankin, "Andrology as the Medical Specialty to Focus Medical Training on Men's Health?" The Journal of Men's Health and Gender 2, no. 1 (2005), 45-48.

Lisa Campo-Engelstein, "No More Larking Around! Why We Need Male LARCs," Hastings Center Report 41, no. 5 (2011): 22-26.

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Title Annotation:Essays
Author:Campo-Engelstein, Lisa
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Sep 1, 2011
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