Abstract
Study Objective:
Access to contraception is a necessary component of reproductive autonomy for adolescents and young adults (AYAs). AYAs persistently face barriers to accessing confidential, affordable contraception. In this study, we characterize and describe the most common reasons AYAs perceive that their sexually active peers might not use prescribed contraception.
Methods:
Using a cross-sectional national text-based survey of AYAs aged 14–24, we conducted a content analysis of open-ended text responses to a question about why AYAs’ sexually active peers might not use prescribed contraception (n = 554). We identified the most common reasons for non-use and examined differences in reported reasons for non-use by demographic factors.
Results:
AYAs reported that their sexually active peers may not use prescribed contraception because they have concerns about it being harmful, they may be stigmatized for using contraception, and it can be logistically difficult for AYAs to obtain. Older and pregnancy-capable respondents were more likely to perceive contraceptive harm as a reason for prescribed contraception non-use (P < .05) but were less likely to perceive stigma and logistical barriers as a reason for non-use (P < .05) compared to younger and pregnancy-incapable respondents.
Conclusion:
We found that perceptions of contraceptive non-use by peers vary by respondents’ age and pregnancy capability, likely due to differences in exposure to contraception information in peer groups and their own contraceptive use experiences. Understanding AYAs’ perceived reservations towards prescribed contraception is vital to inform clinicians’ counseling conversations and for public health messaging.
Keywords: Adolescent, Young adult, Contraception, Surveys and Questionnaires
Introduction
Contraceptive access for adolescents and young adults (AYAs) reduces sexual and reproductive health inequities and improves AYAs’ well-being.1 Moreover, the ability to freely access and choose from the full range of contraceptive methods is recognized as a necessary component of reproductive autonomy.2 Recent contraceptive policies and practices like the Affordable Care Act,3 online contraceptive services,4 and updated clinical guidance specific to AYAs,5 have expanded contraceptive access for this population. Recent national data indicate increases in adolescents’ overall contraception use, including a notable rise in the use of prescription-based methods.6
Despite these advancements, AYAs continue to encounter barriers to contraceptive care, including high costs, lack of confidentiality, and low-quality information. These barriers are likely heightened for AYAs when accessing prescription-based methods due to the greater time, cost, and health-care interactions needed to obtain these methods.7 Ensuring contraceptive access and empowering AYAs to control if and when they wish to become pregnant has become more urgent by the increasingly restrictive abortion and contraception environments in the United States (US).8 As evidenced by recent policy initiatives, AYAs’, specifically minors’, access to contraception and abortion are often the first to be curtailed by restrictive policy efforts.9
The changing reproductive health landscape and lack of national comprehensive sex education have likely resulted in knowledge deficits, misinformation, and mistrust around contraception for AYAs.1,10,11 Despite research showing that contraceptive knowledge is positively linked to reductions in unprotected penile-vaginal sex,12 fewer young people now receive formal sex education than in previous decades.13 In the absence of adequate sex education, online and in-person social networks are significant sources of contraception information for young people.14
AYAs are greatly influenced by their peers, and their social relationships can influence their sexual behaviors.15,16 Thus, AYAs’ perceptions of their peers’ contraceptive attitudes have a strong association with their contraceptive behavior.12 For example, research shows that young women are less likely to find contraceptive methods acceptable if their friend or family member dislikes the method.17 Further, social networking sites have expanded peer networks and may influence what AYAs perceive as typical attitudes or behavior for people their age.18 In this study, we use a novel text-message-based nationwide survey to identify the most common reasons why AYAs think their sexually active peers might not use prescribed contraception and examine variation in perceived reasons for non-use by respondents’ demographic characteristics.
Methods
Data Source and Measures
We conducted a cross-sectional study of AYAs through the MyVoice study.19 MyVoice is a national poll of youth living in the US. MyVoice nationally recruits AYAs online and at community events to receive weekly open-ended text message surveys on health and health policy topics that impact AYAs.19 To participate in MyVoice, participants must be 14–24 years old, living in the US, fluent in English, and have access to a phone with texting capabilities. The MyVoice study was approved by the University of Michigan Institutional Review Board with a waiver of parental consent for minors, and all participants completed an online consent process.
MyVoice partners with researchers and has a multi-step process for piloting and approving new survey questions. Collaborators must complete a standardized protocol, including a list of questions they want to ask. The MyVoice team, which consists of academic researchers, project managers, and students from high school through graduate school, reviews the document to ensure that questions are developmentally appropriate for AYAs and mission-appropriate for MyVoice. Questions are refined through a collaborative process between researchers and the MyVoice team and piloted to a pre-identified group of MyVoice participants before release to the entire cohort. This process has previously been used to study aspects of sexual and reproductive health, including abortion and menstruation.20–22
Our research team developed a 5-question open-ended survey to ask AYAs about their and their peers’ contracepion knowledge, experience, and decision-making factors. The survey was sent to MyVoice participants in May 2023. We sought to understand young people’s views on contraceptive use by asking them to provide responses about their own experiences or the perceived experiences of their peers. This technique allowed us to collect information from AYAs even when the question may not be directly relevant to their current behaviors, such as those who are not sexually active or using contraception, thus capturing a wider array of voices. ___This analysis focuses on the responses to the question: What are reasons why sexually active people your age might not use prescribed birth control?
We created categorical variables for demographic characteristics linked to contraceptive behaviors: age, pregnancy capability, racialized identity, Hispanic ethnicity, rurality, region, parents’ education, and free school lunch (a proxy for family socioeconomic status) (see Appendix A for question wording). For this study, pregnancy capability includes respondents who identified as female or trans-male/man/masc. Pregnancy-incapable includes respondents who identified as male or trans-female/woman/fem(me). Unknown pregnancy capability includes respondents who only identified as nonbinary, queer, genderqueer, genderfluid, agender, unlabeled, or neutrois (i.e., non-binary, gender-less). We assessed pregnancy capability instead of self-reported gender identity since perceptions of contraceptive use may differ based on an individual’s own contraceptive needs.
Analysis
Text responses were manually qualitatively coded by the multidisciplinary study team, including high school and college students, to ensure youth involvement. Students were paired with academic researchers who had qualitative experience.23 All coders were trained on the MyVoice protocol and basic qualitative methods before coding. The coding team frequently met to answer questions, conduct on-going training, and ensure consistent coding. The team developed an a priori codebook, which was refined iteratively through coding check-in meetings. Two independent coders coded the survey responses, and investigators (ROK and SN) resolved discrepancies. Each response could have multiple codes applied. After thematic qualitative coding was completed, a content analysis approach was used to categorize the data. This process allowed us to systematically reduce data, quantify responses, and examine variation by demographics. This approach has been successfully used in previous MyVoice studies.20,24 Additionally, we conducted bivariate analyses in Stata 18.0 to assess differences in reasons for prescribed contraceptive non-use by demographic characteristics.
Results
A total of 794 AYAs received the survey, and 596 (75%) responded to the analysis question. We excluded 42 blank or ineligible responses (“n/a”, or illegible) for a total analytic sample of 554 responses. Respondents in this analysis ranged from 14 to 24 years, with a mean age of 19.9 years (Table 1). Approximately half (51%) identified as female, 36% as male, 6% as nonbinary, and 6% as another gender identity, including trans. Over half (55%) of the sample were pregnancy-capable, approximately 36% pregnancy-incapable, and 9% unknown. Most respondents identified as white (61%), with smaller proportions of Asian (15%), Black (11%), and multiracial (9%) respondents. The majority identified as non-Hispanic (87%). Respondents represented all regions of the US, and most were from suburban areas (62%). Respondents indicated high parental education levels, with 43% reporting that at least one parent had a graduate degree. However, over one-third of respondents (37%) reported receiving free or reduced-price school lunches in middle or high school.
Table 1.
Participant Demographics (N = 554)
| n | mean/% | |
|---|---|---|
| Age (mean) | 554 | 19.9 |
| Age | ||
| <18 | 113 | 20.4% |
| 18–19 | 124 | 22.4% |
| 20–22 | 217 | 39.2% |
| 23–24 | 100 | 18.1% |
| Gender | ||
| Female | 285 | 51.4% |
| Male | 199 | 35.9% |
| Nonbinary | 35 | 6.3% |
| Trans man | 18 | 3.2% |
| Genderfluid | 5 | 0.9% |
| Genderqueer | 3 | 0.5% |
| Trans woman | 1 | 0.2% |
| Agender | 1 | 0.2% |
| Transmasc nonbinary | 1 | 0.2% |
| Transmasc | 1 | 0.2% |
| Unlabeled | 1 | 0.2% |
| Transfem | 1 | 0.2% |
| Neutrois | 1 | 0.2% |
| Transgender nonbinary | 1 | 0.2% |
| Pregnancy-capable | ||
| No | 201 | 36.3% |
| Yes | 306 | 55.2% |
| Unknown* | 47 | 8.5% |
| Racialized identity | ||
| White | 340 | 61.4% |
| Asian | 84 | 15.2% |
| Black | 61 | 11.0% |
| Multiracial | 52 | 9.4% |
| Other† | 11 | 2.0% |
| American Indian or Alaskan Native | 4 | 0.7% |
| Native Hawaiian or Other Pacific Islander | 1 | 0.2% |
| Missing | 1 | 0.2% |
| Hispanic ethnicity | ||
| Yes | 72 | 13.0% |
| No | 481 | 86.8% |
| Region | ||
| Midwest | 178 | 32.1% |
| Northeast | 102 | 18.4% |
| South | 147 | 26.5% |
| West | 126 | 22.7% |
| Missing | 1 | 0.2% |
| Rurality | ||
| Urban | 151 | 27.3% |
| Suburban | 342 | 61.7% |
| Rural | 60 | 10.8% |
| Missing | 1 | 0.2% |
| Parent’s education | ||
| Graduate school | 240 | 43.3% |
| Bachelor’s degree | 130 | 23.5% |
| Some college or less | 182 | 32.9% |
| Missing | 2 | 0.4% |
| Free lunch | ||
| Yes | 207 | 37.4% |
| No | 342 | 61.7% |
| Missing | 5 | 0.9% |
Unknown includes respondents who identified as nonbinary, genderfluid, genderqueer, agender, unlabeled, neutrois, or transgender nonbinary.
Other includes Middle Eastern and Hispanic-identifying individuals who did not indicate a race.
Reasons Why Respondents Think Their Sexually Active Peers Might Not Use Prescribed Contraception
We categorized the qualitative text responses into 7 distinct groups: concerns or perceived harms of prescribed contraception; stigma, fear, and societal influences; logistical barriers; knowledge barriers; contraceptive ambivalence or desire for pregnancy; personal preferences; and other or unsure. Each response could be coded into multiple groups, and subgroups were identified within each group (Table 2).
Table 2.
Most Commonly Reported Reasons for Why Sexually Active Peers may not use Prescribed Contraception (N = 554)
| Response category | Description | n | % | Exemplary quotes |
|---|---|---|---|---|
| Concerns or perceived harms of prescribed contraception | Responses related to concerns or potentially harmful effects of contraception. | 232 | 41.9% | |
| Side effects | Responses that mention side effects of birth control, including side effects that are untrue or misinformation. | 186 | 33.6% | “… because of bad symptoms they don’t trust their doctor to care about” “because of the adverse side effects, especially weight gain, being more emotional, or moody, or having to deal with changing birth control methods based on 1 not working well with your body” “The side effects and inherent risk of each of them.” “research showing it isn’t the best for your body. hormonal ones anyways.” “It causes immense side effects that are hard to ignore.” |
| General harm – reason not specified | Responses that mention using contraception may be harmful but were not specific about the reason. | 63 | 11.4% | “I don’t know I guess some birth control methods could have health risks for people who have maybe pre-existing condition. but I don’t know anybody who’s ever had too much trouble getting onto some form of birth control” “Because its a scam” |
| Hormones | Responses that specifically mention “hormones” | 42 | 7.6% | “Fear of side effects, past side effects, hormonal issues that went undiagnosed because healthcare for AFABs SUCKS, lack of availability of healthcare” “Due to hormonal balance or fear of it harming or changing their body” |
| Weight gain | Responses that mention weight gain or physical body changes | 19 | 3.4% | “It is bad for your body/can make you gain weight” |
| Mood swings or depression | Responses that mention mood changes or can specify depression | 15 | 2.7% | “The various side effects. Hormone disruptions, suicidal thoughts, weight gain or loss, etc.” |
| Painful insertion | Responses that mention the pain of an insertion (e.g., of an IUD or arm implant) | 8 | 1.4% | “…For IUDs, there’s a reputation that they are very painful to insert and remove…” |
| Decreased libido or sexual pleasure | Responses that mention decreased libido or pleasure/enjoyment related to sex | 8 | 1.4% | “Birth control has a long list of side effects including libido changes as well as metabolism changes and for these reasons it can make a person who is sexually active not want to use it for fear of not enjoying sex” |
| Future fertility | Responses that mention fertility or the ability to get pregnant at a time when birth control is not being used | 5 | 0.9% | “It can cause long term effects, reduce fertility and be unpleasant or they may have issues accessing birth control” |
| Stigma, fear & societal influences | 223 | 40.3% | ||
| Stigma/fear of judgement | Responses that describe a person not taking prescribed birth control due to concerns or experiences of embarrassment, stigma, or fear of judgment from others. | 97 | 17.5% | “They may be too embarrassed to ask, or not have someone to talk to about it” “Because they are scared of the stigma from family” “They may not want their parents to know that they are sexually active” “Fear of being judged by their peers or parents” “Because they don’t want their parents to find out they are using birth control” |
| Parental awareness/consent or family values | Responses that describe family involvement, parental awareness, or the values that come from family/parents as a reason to not use birth control. | 92 | 16.6% | “Many people might be embarrassed when their parents find out because they will find out and others might just not know enough about it. “not being able to access a doctor or fill a prescription without judgement from parents” |
| Fear | Responses that mention being scared or fearful of consequences | 80 | 14.4% | “They might be scared of how their body is going to react to it and if it is healthy for them, also they might be scared to ask their parents for permission” |
| Pressure to not be on contraception | Responses that indicate that an individual may not use birth control due to pressure to not use birth control. | 34 | 6.1% | “i think the main reason is because their parents either don’t know or don’t approve of their kids being sexually active, and therefore won’t allow them to get birth control.” |
| Religion or morals | Responses that mention religion or a religious culture as a reason someone might not use birth control. | 31 | 5.6% | “There is a lot of judgement around using birth control from numerous sources (ex. Religious beliefs that birth control is prohibited, the use of vulgar names for people on it because it is associated with promiscuity, etc.) Young people are also never taught about birth control in class and most will never get a conversation with their parents. This leads to a lot of shame about their bodily functions and fear of the procedures/hormones used in birth control. A lot of stories of people having their health ruined by certain forms of it too are prevalent online, further scaring young adults.” |
| Partner’s responsibility | Responses that describe how the decision or the control around taking birth control belongs to the other person in the relationship or more broadly another gender | 2 | 0.4% | “They believe they don’t need since the man might be using protection” |
| Logistical barriers to using prescribed birth control | 215 | 38.8% | ||
| Hard to obtain/access | Responses referring to the process of obtaining birth control as a barrier to birth control. Lack of access may be a reason respondents mention. | 188 | 33.9% | “I imagine there are many barriers, including legislation in conservative areas, parental consent or control issues, insufficient healthcare availability or affordability, and maybe social pressure.” “illegal according to state/federal law, cost prohibitive, too unintuitive.” “hard to come by without parental consent” “birth control is not easily accessible especially to those whose parents disapprove of it” |
| Cost | Responses that cite cost as a barrier to birth control | 107 | 19.3% | “The high price without insurance “ “They don’t know how to pay for it.” “They might not know much about it or can’t afford it.. because let’s be honest here, birth control pills are not cheap. They cost a lot.” “Most likely the costs. At this age, every dollar counts and prescribed birth control, unless covered by insurance, costs a decent amount.” |
| Challenge to take contraception daily | Responses that indicate not taking prescribed birth control may come from difficulties remembering to take it or forgetfulness. | 21 | 3.8% | “If they are on the pill, it is sometimes hard to remember.” “they might forget to take their medicine and don’t want to risk it, or they may not have a need for it” “too much of a hassle” |
| Knowledge barriers to using prescribed birth control | 114 | 20.6% | ||
| Lack of awareness or knowledge | Responses that indicate they feel like people may not know about birth control or birth control options. | 101 | 18.2% | “Because they don’t understand it, don’t think they will get pregnant, thing condoms are enough, or are afraid/embarrassed or cant afford to ask for birth control. Some parents may also not understand the value of birth control and may not allow youth to get it” “They don’t know about all the birth control options, there isn’t a provider near by, they don’t want to tell their parents, or they just don’t have enough sex education.” “They may not be aware of it” |
| Misinformation | Responses that are misinformed | 15 | 2.7% | “A lot of them aren’t giving completely informed consent and also being misinformed by social media” “They might not believe in its efficacy or not believe in it due to other beliefs that they hold. Alternatively, they may just not want to use it.” |
| Contraceptive ambivalence & pregnancy desires | 71 | 12.8% | ||
| Lack of urgency/need | Responses that indicate someone may not use birth control due to perceived lack of need of contraception (may or may not include a specific reason such as not being capable of pregnancy or not being at risk). | 47 | 8.5% | “They aren’t capable of pregnancy“ “Not thinking they need it” “they think their pull out game is strong” “They believe they don’t need since the man might be using protection” |
| Desire pregnancy | Responses that describe desiring pregnancy or starting a family as a reason to not use birth control. May be an individual desiring the pregnancy, or in the context of a partner’s desire for them to get pregnant / coercion. | 29 | 5.2% | “Im not sure about that maybe because they want to have a reason their partner stays instead of just having sex and leave?” “They want a child” “They want to have kids, they over estimate themselves or underestimate risks” |
| Individual attitudes | 52 | 9.4% | ||
| Critical/Criticizing | Responses that place criticism (judgement) on sexually active peers who do not use birth control. | 28 | 5.1% | “Ignorance, forgetfulness or maybe greed if a person may want their partner to stay with them via pregnancy and having a child” |
| Personal choice | Responses that mention someone may not use birth control due to personal reasons/beliefs | 24 | 4.3% | “…personal preference of ‘raw dogging it’” “They don’t want to” “people just prefer not to? i’m not sure; none of my friends are sexually active” “They have a choice to do that” |
| Other & not sure | 39 | 7.0% | ||
| Not sure or don’t know | Responses that indicate that an individual does not know or is unsure of why someone their age would not take prescribed birth control. | 20 | 3.6% | “Idk man” |
| Other | Responses that highlight a reason other than the most common responses | 19 | 3.4% | “because they are too young” |
Concerns and Perceived Harms of Prescribed Contraception
Approximately 42% of respondents mentioned perceived harm as a reason why sexually active peers may not use prescribed contraception, with many of these responses highlighting concerns about negative or undesired side effects of contraception (e.g., weight gain, hormones, mood swings). Potential harm from contraceptive side effects was particularly salient for respondents over 18 years of age:
“The textbook sized list of side effects for sure”
– pregnancy-incapable 21-year-old
“because of the adverse side effects, especially weight gain, being more emotional, or moody, or having to deal with changing birth control methods based on 1 not working well with your body”
– pregnancy-capable 21-year-old
Stigma, Fear, and Societal Influences Affecting Prescribed Contraception Use
A similar percentage of respondents (40%) identified stigma, fear, and other societal influences as potential reasons why sexually active peers might not use prescribed methods. Specifically, younger respondents reported that AYAs who use contraception might be stigmatized by parents, family, or peers because their contraceptive use would expose their sexual activity which would be judged negatively. Respondents discussed how sexually active young people are often stereotyped by society as “irresponsible” for wanting to have sex but not wanting to parent at a young age. To avoid the stigma and judgment that may come from others about their sexual activity, respondents indicated that some of their peers may not use prescribed birth control:
“Based on their age, people might think that they’re being careless [about sex] and just resort to not wanting to take care of a baby. People will think they all people my age want to do is have sex. People my age may feel judged when they have to use or purchase birth control and then have to suffer through stereotypes.”
– pregnancy-capable 17-year-old
“There is a lot of judgment around using birth control from numerous sources (ex. religious beliefs that birth control is prohibited, the use of vulgar names for people on it because it is associated with promiscuity, etc.). Young people are also never taught about birth control in class, and most will never get a conversation with their parents. This leads to a lot of shame about their bodily functions and fear of the procedures/hormones used in birth control.”
– 16-year-old with unknown pregnancy capability
“young people often get slut shamed for using it [birth control] or being on it by adults”
– pregnancy-capable 16-year-old
Logistical Barriers to Using Prescribed Contraception
More than a third of respondents (39%) reported that sexually active peers might not use prescribed contraception because of logistical barriers to access and use. These responses encompassed difficulty obtaining contraception, cost barriers, and challenges maintaining consistent contraceptive use:
“For some people accessibility may be difficult (seeing a doctor, going to appointments to get shots, money)…”
– pregnancy-capable 19-year-old
“Insurance/cost could be a problem for some since the world is too expensive for basic living needs…”
– pregnancy-capable 22-year-old
“…it’s a bit of a hassle to remember if you’re taking pills.”
– pregnancy-capable 18-year-old
Knowledge Barriers to Using Prescribed Contraception
Additionally, 1 in 5 respondents (21%) identified knowledge barriers as contributing to non-use of prescribed contraception. These barriers included a lack of awareness of contraceptive methods and where to access them, as well as common misconceptions about contraception:
“…I think most people just don’t know what options are out there and think condoms are the most convenient.”
– 24-year-old with unknown pregnancy capability
“Some teenagers have misconceptions about birth control. For example, some teenagers may believe that birth control is only for preventing pregnancy, or they may believe that birth control is not effective.”
– 17-year-old with unknown pregnancy capability
Contraceptive Ambivalence and Desire for Pregnancy
More than 1 in 10 respondents (13%) identified that their sexually active peers might desire pregnancy or may be otherwise ambivalent about contraception leading to non-use. Some respondents highlighted how pregnancy-incapable partners may feel like they have less responsibility for pregnancy prevention, placing the onus of contraceptive use on the pregnancy-capable partner, largely women and girls:
“Some people think it’s never going to happen to them. I have friends that don’t feel they need to take responsibility that’s the girls job.”
– pregnancy-incapable 21-year-old
“Because they either want the baby, or they are too afraid to ask for birth control”
– pregnancy-incapable 18-year-old
Individual Preferences and Beliefs
Some respondents (9.4%) also mentioned that someone’s choice to use or not use prescribed contraception is likely a result of individual preferences and beliefs:
“They might not believe in its efficacy or not believe in it due to other beliefs that they hold. Alternatively, they may just not want to use it.”
– pregnancy-incapable 18-year-old
“Because they don’t like it”
– pregnancy-capable 18-year-old
Demographic Variation in Reasons Why Respondents Think Their Sexually Active Peers Might Not Use Prescribed Contraception
Figure 1 and Table 3 show respondents’ most commonly reported reasons for why their sexually active peers may not use prescribed contraception, by the respondents’ age group. Older respondents were significantly more likely than younger respondents to report contraception as potentially harmful as a reason for non-use. Specifically, 44% of respondents aged 20–22 years and 54% of respondents aged 23–24 years reported prescribed contraception being harmful as a possible reason for non-use compared to 31% of respondents less than 18 years of age (P-value = .020 and P-value = .001, respectively). Conversely, respondents less than 18 years of age were more likely to report stigma, fear, and societal influences (49%) as a potential reason for prescribed contraception non-use compared to older respondents aged 20–22 years (33%) (P-value = .006). There were no significant age differences in the frequency of reporting logistical or knowledge barriers.
Fig. 1.
Most commonly reported reasons for why sexually active peers may not use prescribed contraception, by respondents’ age group.
Table 3.
Differences in Most Commonly Reported Reasons for Why Sexually Active Peers May Not Use Prescribed Contraception, by Demographics
| Most commonly reported reasons for prescribed contraception non-use | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Concerns or harms | Stigma, fear, and societal influences | Logistical barriers | Knowledge barriers | |||||||||
| % | n = 232 | P-value | % | n = 227 | P-value | % | n = 215 | P-value | % | n = 114 | P-value | |
| Age | ||||||||||||
| <18 | 31.0 | 35 | ref | 48.7 | 55 | ref | 33.6 | 38 | ref | 20.4 | 23 | ref |
| 18–19 | 37.9 | 47 | .263 | 46.0 | 57 | .677 | 39.5 | 49 | .348 | 19.4 | 24 | .847 |
| 20–22 | 44.2 | 96 | .020 | 33.2 | 72 | .006 | 41.5 | 90 | .166 | 19.4 | 42 | .829 |
| 23–24 | 54.0 | 54 | .001 | 39.0 | 39 | .157 | 38.0 | 38 | .506 | 25.0 | 25 | .419 |
| Pregnancy-capable | ||||||||||||
| Yes | 45.4 | 139 | ref | 42.5 | 130 | ref | 41.5 | 127 | ref | 22.2 | 68 | ref |
| No | 35.8 | 72 | .032 | 37.3 | 75 | .246 | 31.8 | 64 | .028 | 17.4 | 35 | .189 |
| Unknown | 44.7 | 21 | .924 | 38.3 | 18 | .589 | 51.1 | 24 | .219 | 23.4 | 11 | .856 |
| Rurality | ||||||||||||
| Urban | 41.7 | 63 | ref | 42.4 | 64 | ref | 37.8 | 57 | ref | 25.8 | 39 | ref |
| Suburban | 42.1 | 144 | .937 | 39.2 | 134 | .504 | 39.5 | 135 | .717 | 20.2 | 69 | .163 |
| Rural | 40.0 | 24 | .819 | 41.7 | 25 | .924 | 36.7 | 22 | .884 | 10.0 | 6 | .015 |
| Parent’s education | ||||||||||||
| Graduate school | 45.0 | 108 | ref | 39.6 | 95 | ref | 37.9 | 91 | ref | 20.0 | 48 | ref |
| Bachelor’s degree | 43.9 | 57 | .831 | 46.2 | 60 | .222 | 39.2 | 51 | .804 | 17.7 | 23 | .591 |
| Some college or less | 35.7 | 65 | .055 | 36.8 | 67 | .562 | 39.6 | 72 | .731 | 23.6 | 43 | .370 |
| Race or ethnic identity* | ||||||||||||
| Non-Hispanic white | 42.7 | 128 | ref | 40.0 | 120 | ref | 38.7 | 116 | ref | 17.3 | 52 | ref |
| Non-Hispanic Black | 37.9 | 22 | .504 | 36.2 | 21 | .589 | 27.6 | 16 | .112 | 22.4 | 13 | .360 |
| Non-Hispanic Asian | 42.2 | 35 | .935 | 49.4 | 41 | .126 | 45.8 | 38 | .243 | 21.7 | 18 | .365 |
| Non-Hispanic Other† | 52.5 | 21 | .241 | 40.0 | 16 | 1.000 | 40.0 | 16 | .871 | 20.0 | 8 | .678 |
| Hispanic | 34.7 | 25 | .220 | 33.3 | 24 | .298 | 40.3 | 29 | .801 | 31.9 | 23 | .006 |
Racial and ethnic categories were condensed for statistical analysis.
Other includes American Indian, Alaska Native, Native Hawaiian, Other Pacific Islander, Indian, Iranian, Middle Eastern, Jewish and Multiracial.
We also found significant differences in the most commonly reported reasons by pregnancy capability (Fig. 2 and Table 3). Notably, 45% of pregnancy-capable respondents reported perceived harm of prescribed contraception as a reason for non-use compared to 36% of pregnancy-incapable respondents (P-value = .032). Additionally, 42% of pregnancy-capable respondents reported logistical barriers as a reason for prescribed contraception non-use compared to just 32% of pregnancy-capable respondents (P-value = .028).
Fig. 2.
Most commonly reported reasons for why sexually active peers may not use prescribed contraception, by respondents’ pregnancy capability.
There were no significant differences in reporting across other demographic measures examined, including rurality, parent’s education, race, and ethnicity (Table 3). However, the small sample sizes for some categories may prevent the detection of meaningful group differences.
Discussion
Findings from our study highlight 6 explanations for why young people perceive that their sexually active peers may not use prescribed contraception: concerns or perceived harm; stigma, fear, and societal influences; logistical barriers; knowledge barriers; contraceptive ambivalence; and individual preferences. We find that perceptions of why AYAs may not use prescribed contraception vary by both age and pregnancy capability, suggesting multi-level influences on perceived contraceptive use.
The perception of the potential harmfulness of contraception was particularly salient among older respondents and pregnancy-capable respondents. Many young people reported that side effects likely influence their sexually active peers’ choice to use, not use, or discontinue prescribed contraception, which reflects findings from other research.25 We also found that with pregnancy capability and increasing age, there was an increasing percentage of respondents who said that contraceptive harm is a potential reason why sexually active peers may not use prescribed contraception. This trend may be due to greater individual exposure to their own and others’ contraception use with age and more interactions with social media, which may increase knowledge of potential side effects and influence contraceptive decisions.26–29 Moreover, differences in contraceptive method mix among AYAs may lead to the use of contraceptive methods with different side effect profiles (i.e., increasing use of IUD or pills with age).30
Our study also finds concerns about societal judgment, such as fear of being stigmatized by adults or peers, as a potential reason why AYAs’ sexually active peers may not use prescribed contraception. Young people in our study perceived that AYAs’ contraceptive use is shamed by others because of its association with sexual activity and promiscuity, discouraging use. This finding supports other research showing that an inability to access or use contraception confidentially deters use among young people.31 Concerns about stigma and shame were more common for respondents under 18 in our study than older respondents, likely reflecting age-specific stigma about sexual activity that is heightened for younger teens.
Lastly, we found logistical and knowledge barriers to be commonly perceived reasons why young people’s sexually active peers may not use prescribed contraception. This mirrors the substantial research evidence that young people encounter a range of barriers to accessing prescription-based methods, including difficulty accessing care, cost, and lack of information.1,31,32 We found that pregnancy-incapable respondents were less likely to report logistical barriers as a reason for contraceptive non-use. This difference may be due to pregnancy-incapable people being less likely to be exposed to informal, gendered networks of contraception information-sharing, where access information may be discussed.33,34 It also likely reflects that pregnancy-capable partners disproportionately carry out contraceptive labor. Thus, pregnancy-incapable partners may be less aware of access barriers.
As reproductive healthcare access is increasingly dependent on state-level policies, and AYAs’ access is often the first to be attacked by restrictive policy efforts,9 centering AYAs’ experiences and needs in policy efforts is critical. Moreover, as organizations and agencies develop policies related to contraceptive access, AYA perspectives should be considered at every level, such as with the introduction of the Opill, the first over-the-counter oral contraceptive pill.35 Lastly, for clinicians who care for AYAs, confidential, non-judgmental conversations about contraception and potential side effects with AYAs can strengthen trust between clinicians and patients and improve patient satisfaction with both clinical experiences and contraception.35
While the MyVoice data is a novel mechanism for collecting targeted and timely data, our analysis faced several limitations. Despite the intentional recruitment of a diverse national sample, there is potential selection bias in who responded to the poll and limited generalizability given that the MyVoice sample is not nationally representative. Further, the short, open-response format of the qualitative data collection does not allow for follow-up or response probing. Additionally, a person’s perception of why someone else may not use prescribed contraception may not accurately capture an individual’s reasons for non-use. Still, these perceptions can influence their own experiences and behaviors.
Access to confidential, affordable contraceptive care is crucial to ensure reproductive autonomy for AYAs. Assessing perceived reasons for the non-use of prescribed contraception is timely, given the rapidly changing reproductive healthcare landscape for young people. We found main reasons why AYAs believe that their peers may not use prescribed contraception, including concerns and perceived harm; stigma and fear; logistical barriers; knowledge barriers; contraceptive ambivalence; and individual preferences. Variation in responses by age and pregnancy capability suggests that reasons for contraceptive non-use may change over developmental periods and are influenced by both social networks and contraceptive needs. Awareness of these potential reasons for contraceptive non-use is important for clinicians who are delivering care to AYAs and for broader public health messaging.
Supplementary Material
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpag.2025.04.004.
Conflicts of Interest
Dr. Wilkinson’s university receives project funding for Dr. Wilkinson from Organon, Cooper Surgical and Bayer. All other authors report no conflicts of interest.
The MyVoice project was funded by the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. Additionally, this study was deemed exempt by institutional review boards at University of Texas at Austin, University of Washington, University of North Carolina at Chapel Hill, and Rutgers University. The views and opinions expressed are those of the author, or authors, and do not necessarily represent the views and opinions of the funders. Funders had no part in the study design, data collection, analyses, interpretation of findings, or the decision to submit the manuscript for publication. Brooke Whitfield received support from the grant, T32HD007081, Training Program in Population Studies, awarded to the Population Research Center at the University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Zoe Pleasure received support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number F31HD114364. Cambray Smith was supported by NIH grant F30HD116454. Dr. Narasimhan is supported by the Center for Reproductive Health Research in the Southeast (RISE) through support from an anonymous foundation and the Collaborative for Gender + Reproductive Equity (CGRE), a sponsored project of Rockefeller Philanthropy Advisors, the Building Interdisciplinary Research Careers in Women’s Health of the National Institutes of Health (NIH) Award Number K12HD085850, the Georgia Clinical and Translational Science Alliance Award Number KL2TR002381, and the Georgia Clinical and Translational Center (GCTSA) Grant Award Number U1TR002378. Dr. Wilkinson was partially supported by the NICHD K23 Award (HD099274-01). The content is solely the responsibility of the authors and does not necessarily represent the official views of the CGRE, National Institutes of Health, or the GCTSA.
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