Teenage pregnancy prevention: the role of young men

Abstract

Purpose of review

Although teenage pregnancy is declining in many parts of the world, it remains associated with considerable social, health, and economic outcomes. Pregnancy prevention efforts focus primarily on young women, with minimal attention to young men. This review highlights recent literature pertaining to the role of young men in pregnancy prevention.

Recent findings

Young men have varying views on contraception as well as which partner(s) should be responsible for its use. Limited contraception knowledge reduces young men’s sexual health communication as well as their contraception use. Healthcare providers play a major role as one of the main sources of sexual health information for young men, but there are gaps in young men’s sexual health care so new guidelines have emerged.

Summary

Recent literature highlights young men’s range of views on contraception as well as their low sexual health knowledge and sexual health communication. To address teenage pregnancy and improve young men’s overall wellness, healthcare providers should routinely address sexual health. Healthcare providers may use our newly proposed acronym, Hello. Initiate. Sexual health assessment. Both condoms and female dependent methods. Examine genitals. STI screening. Talking to partner(s). Talking to parent(s) or guardians, to incorporate current clinical recommendations.

INTRODUCTION

Although teenage pregnancy rates are in large part declining [1], having a pregnancy as a teen, compared with as an adult, is linked to numerous outcomes such as poverty, decreased educational achievement in young women, and increased rates of death during childbirth [1]. Children born to teen parents are more likely than those born to adult parents to have health problems as well [1]. To date, women have been the focus of pregnancy prevention research [2], rather than men – the majority of whom need family planning [3▪▪]. The WHO, recently, highlighted the need to develop teen pregnancy prevention efforts that are focused on both young men and women [4].

It is essential that healthcare providers understand the role of young men (ages 14–25) in pregnancy prevention in order to adequately address these patients’ sexual and reproductive health needs. In this update, we highlight what is known about young men’s views, knowledge, communication about, and use of contraception. We also discuss the role of healthcare providers in preventing teen pregnancy among young men and review current recommendations for family planning with young men.

YOUNG MEN’S VIEWS ON CONTRACEPTION

Young men express contradictory views on the importance of contraception and their actual use. In the National Survey of Reproductive and Contraceptive Knowledge, 85% of US young men state their friends think using contraception is important [5] and 74% strongly agree that pregnancies should be planned [6]. However, only 45% are committed to avoiding pregnancy [5].

Relationship status impacts young men’s intent to avoid pregnancy along with their perceived utility of contraception [7]. In casual relationships, young men are less worried about preventing pregnancy and more concerned about sexually transmitted infections (STIs), which motivates their condom use [7,8▪]. Condom use then declines as the relationship progresses and trust grows [7,8▪]. Young men generally attribute this behavior change to low or no concern for STIs. The use of condoms in long-term relationships can even take on a negative connotation, as a sign of infidelity [7,9]; with a quarter of United States and French men discontinuing condom use before the end of their first relationship [10,11▪]. This transition period from a casual to a long-term relationship may be a time of high pregnancy risk, with a gap between cessation of condom use and initiation of female hormonal contraception [7].

Young men have a variety of responses about which partner bears responsibility for contraception and pregnancy prevention. Some young men feel it is the sole responsibility of their female partners [6,12], whereas others believe it is a shared responsibility [6,13]. Smith et al. [12] conducted semistructured interviews in which many young Australian men speak about pregnancy prevention being a woman’s responsibility. One participant states: ‘when you’re in a relationship with someone I guess the expectation is then obviously that the girl will be on the pill or move on to the pill…I think it does become a girl’s responsibility in a relationship’ [12]. Other studies, such as one done by Merkh et al. [13], include US men speaking about pregnancy prevention being a shared role; a participant states ‘I think the two people in a relationship, whether casual or long term or whatever, I think that both of those people should have an equal part in discussing those matters (decisions about contraception), because it’s important’. A young man’s feelings of responsibility over contraceptive use impacts the methods he and his partner(s) use. Compared with men who report not feeling this responsibility, those who feel it is a ‘joint thing’ are more likely to report dual method use – the concurrent use of a condom and female contraceptive method [12].

YOUNG MEN’S KNOWLEDGE OF CONTRACEPTION

Slightly more than half of young men feel they have the information they need to prevent a pregnancy [6], highlighting an opportunity for health education. They consistently demonstrate low knowledge of contraception and sexual health; much lower than young women [13,14]. For example, a survey of young Australian men and women found men have significantly lower knowledge about pregnancy and STIs than women [14]. One study of young men attending a family planning clinic in the US found a quarter incorrectly think that all sperm die inside a woman after 6 h and nearly half think a woman is most likely to get pregnant during her period [15▪▪].

Young men are most knowledgeable about male-dependent methods, specifically male condoms and withdrawal, compared with other methods [6,16]. In a US nationally representative sample, almost all males (99%) have heard of condoms [6]. High knowledge about condoms is also reported, including awareness that condoms expire (94%) and cannot be reused (97%) [6]. Condoms are considered highly effective for pregnancy prevention by young men, who trust condoms and withdrawal more than women do [16].

Young men’s knowledge deficit is most notable with regards to hormonal methods, including short-term and long-acting reversible contraception (LARC)[14]. In a US nationally representative sample, more than half of young men knew little or nothing about hormonal methods [5]. Knowledge among these young men about intrauterine devices, a form of LARC, is even lower than knowledge about oral contraceptive pills (OCPs) [17]. In fact, a US qualitative study of 41 young men found 54% incorrectly consider OCPs as the ‘most effective’ contraceptive method, whereas 10% correctly categorize intrauterine devices as the ‘most effective’ [13]. Side-effects related to hormonal method use are also inaccurately reported by many young men [13].

This shortfall in knowledge extends to hormonal emergency contraception as well [18]. In a literature review, approximately one-third of adolescent men compared with the majority of adult men are familiar with emergency contraception [19]. Young men are more likely than women to falsely consider emergency contraception an abortifacient [19]. Insufficient knowledge extends to the understanding of emergency contraception access; only half of young men report knowing how to obtain emergency contraception [18], acting as a barrier to emergency contraception purchase.

The significance of lower health knowledge among young men in the United States is reflected in their contraceptive use. One-fifth of young men have no sex education before coitarche; these men are half as likely to use condoms at coitarche compared with those with any sex education [10]. This information deficit impacts hormonal method use as well. Those with lower contraceptive knowledge have decreased odds of a partner using a hormonal or LARC method [5]. These young men with low contraceptive knowledge also have decreased odds of dual method use [13]; recommended as the most effective contraception method by the American Academy of Pediatrics [20] and the Centers for Disease Control and Prevention [21]. Increased sexual health knowledge among young men ultimately leads to half the odds of becoming an adolescent father [22▪▪]. Thus, it is imperative young men receive sexual health education, including the topic of contraception.

YOUNG MEN’S USE OF CONTRACEPTION

According to the 2015, Youth Risk Behavior Surveillance Survey, four in 10 US high school students have ever had sex, and nearly one in three students are currently sexually active [23▪]. Yet, nearly one in seven students report no contraceptive use at last sexual intercourse [23▪]. Nearly half of young men report they are likely to have unprotected sexual intercourse in the next three months [5].

The male condom is the most commonly used contraception among adolescents; the method about which young men are most knowledgeable. Three-quarters of young men report condom use at coitarche [10], and similar frequency reported use at last intercourse [20,24]. The American Academy of Pediatrics reports advantages of condoms including: male involvement in contraceptive responsibility, ease of access, and low cost [20]. Young men in the United States and France with positive attitudes regarding condoms, in new relationships, and who discussed more health topics with their parents are more likely to use condoms [10,25]. Condom use is less likely among individuals who are concerned its use will reduce sexual pleasure, those who are older at first or most recent sexual encounter, those with an older sexual partner, and those with a partner who used female contraception [10,24,26].

Adolescents also commonly use withdrawal as a means of contraception, with 60% of young women reporting its use [27]. In the National Survey of Family Growth, men who feel condoms reduce their pleasure are more likely to use withdrawal alone or in combination with female-dependent contraceptive methods [26]. Focus groups of young men acknowledge withdrawal requires discipline by both partners, and recognize its effectiveness at pregnancy prevention is less than other methods [16].

Female-dependent contraceptive method use is reported by 27% of sexually active US high school students at last sexual intercourse [23▪]; 18% use OCPs, 3% use a LARC, and 5% use a shot, patch, or ring [23▪]. Over half of men in need of family planning report their partner does not use a hormonal method any of the time, with a quarter reporting use all the time [28▪]. In terms of the most effective female methods, LARC use is associated with increased IUD knowledge, older age, and earlier onset of sexual activity among young men and women [29].

Dual method use is increasing, with 9% of US high school students reporting its use at last inter-course in 2015 [23▪]. Perceived risk of pregnancy and STIs, personal and partner support of condoms, casual partners, and self-efficacy of condom negotiation are associated with dual method use in adolescents [20,24]. Parental communication about sexual risk and approval of contraception also increase dual method use [24]. Healthcare providers must be aware of these factors to provide effective counseling on dual method use.

YOUNG MEN’S SEXUAL HEALTH COMMUNICATION

Sexual health communication involves the exchange of knowledge, experiences, and views regarding sexual health. Young men and women with more open sexual health communication have increased condom use [30,31] as well as more dual method use [31]. However, less than half of adolescents report any such communication with their dating partners [31], and young men report less communication regarding sexual topics than young women [32].

Similar to patterns regarding views and use of contraception, young men’s sexual health communication varies based on relationship status. In casual relationships, young men report feeling such conversations are irrelevant as they will likely use condoms [13], thus reducing their concerns for pregnancy and/or STIs. As relationships progress, young men are more likely to correctly report their partner’s use of contraception at last intercourse [13], suggesting increased communication between partners. However, these studies are based solely on a young man’s self-report and therefore do not corroborate with their partner’s report. Young men may also make assumptions regarding their partner’s contraceptive use merely based on a willingness to have sex without a condom or withdrawal [13]. Couple dynamics, such as each partner’s personality type, also affect contraception use. For example, an adolescent couple with moderate levels of assertiveness based on self and partner assessment is more likely to use condoms compared to those with very low or very high assertiveness [33].

Young men’s limited knowledge of contraceptives [13,14] not only diminishes their contraception use, but also reduces their confidence and ability to discuss sexual health with their partners [13]. For instance, young men knowledgeable about emergency contraception are significantly more likely to discuss contraception with their female partner [34▪▪].

THE ROLE OF HEALTHCARE PROVIDERS

Adolescents consider healthcare providers a highly trusted source of sexual health information [20], with young men reporting providers as one of their main sources [9]. However, young men may not have an opportunity to discuss sexual health topics with their provider as an average of 36 s is spent on sexual health during adolescents’ annual physical exams [35]. This time is likely even less for young men as providers are half as likely to discuss sexual health with young men as young women [35].

If sexual health is addressed at all with young men, providers’ sole focus is often on condoms [13,36]. Female-dependent methods (e.g., OCPs, LARC) are discussed even less with young men than women: studies report a range of discussion regarding female-dependent methods and/or emergency contraception from 20 to 60% [34▪▪,36]. The vast majority of young men, and their older adult peers, want more information about different methods, including further details on proper condom use. However, less than half of these men are receiving such care [36].

These low rates of sexual health discussion between young men and their providers are likely exacerbated by the absence of clear clinical guidelines until recently. Marcell et al. [37] aimed to establish a foundation for guidelines by surveying primary care providers focused on male health. Consensus was reached regarding a core set of six topics during a 15-min annual visit, which include: counseling on STI/HIV risk reduction, assessing pubertal growth/development, assessing substance abuse and mental health, assessing non-STIs/HIV genital abnormalities, assessing physical/sexual abuse, and assessing male pregnancy prevention methods [37]. Though nearly three-quarters of providers feel male-focused pregnancy prevention should be discussed in a 15-min annual visit, just one-quarter of providers feel female-focused pregnancy prevention methods should be discussed. Additionally, no consensus has been reached for addressing sexual health during acute visits [37].

In contrast, Bell et al. [38] recommend that young men’s sexual and reproductive health include: screening for sexual activity, discussing and appropriately screening for STIs, promoting condom use, educating about emergency contraception, and educating and promoting dual contraception with males. This advice is further supported by the Centers for Disease Control and Prevention’s report on Providing Quality Family Planning Service [21] and the National Coalition for Sexual Health [39▪▪], both offering specific guidelines for men’s sexual and reproductive health, as well as other emerging literature [9,35].

We, the authors of this review, propose an acronym Hello. Initiate. Sexual health assessment. Both condoms and female dependent methods. Examine genitals. STI screening. Talking to partner(s). Talking to parent(s) or guardians (HIS BESTT) (Fig. 1) to summarize current recommendations for the clinical approach to young men’s sexual health. The healthcare provider should say ‘Hello,’ establishing confidentiality [9,35] and rapport [9,21]. Then he/she should initiate the conversation regarding sexual health [36,38], making it commonplace [9]. A sexual health assessment should be performed (Table 1); addressing sexual practices, pregnancy prevention methods, pregnancy history, partners, protection from STIs, past STI history, and partner violence [21,37,38,39▪▪]. Both condoms and female dependent methods should be recommended as part of dual method use [20,21,24,38,39▪▪]. Method effectiveness, appropriate use, and side-effects should be reviewed [21,38] and misconceptions dispelled [36]. Highlight the importance of condoms for both pregnancy and STI prevention, including HIV prevention [20,21,24,38,39▪▪] and make condoms readily available in clinic. Provide emergency contraception information and a prescription, if desired [19,34▪▪]. Examine genitals as indicated by history [21]. Perform STI screening as indicated by history and/or physical examination [21,37,38,39▪▪]. Talking to partner(s) about sexual health should be encouraged; providers should present young men with tools for effective communication as well as resources for both them and their partner to augment knowledge, access, and use of contraception [21]. Talking to parent(s) or guardian(s) about sexual health, while maintaining patient confidentiality, should also be encouraged [21,38]. We recommend this clinical approach for all young men, regardless of sexual orientation, given the evidence of pregnancy involvement among sexual minority men [40].

FIGURE 1.

Newly proposed clinical approach to young men’s sexual health: HIS BESTT, Hello. Initiate. Sexual health assessment. Both condoms and female dependent methods. Examine genitals. STI screening. Talking to partner(s). Talking to parent(s) or guardians.

Table 1.

Components of a sexual health assessment

Topics	Discussion Points
Sexual practices	Any sexually activity
	Type of sexual activity (i.e., oral, vaginal, and/or anal).
Partner(s)	Sex identity
	Sexual orientation
	Number of partners, in the past and currently
	Sex of partner(s)
Protection from STI’s	Condom use
	Barriers to condom use
Past STI history	Personal history
	Partner(s) history
Pregnancy prevention	Current and past contraception use, including emergency contraception
	Goals for future contraception
Pregnancy history	Prior or current pregnancy history
	Living children, miscarriage(s), or termination(s)
Partner violence	Screen for abuse

STIs, sexually transmitted infections.

Adapted from CDC [21,37,38,39▪▪].

CONCLUSION

Recent literature has highlighted the role young men play in teenage pregnancy. Prevention efforts should recognize young men’s range of views on contraception and their sense of responsibility in pregnancy prevention, as well as their knowledge deficit and unmet needs around contraception. These campaigns should aim to increase young men’s contraception use and equip them with tools for sexual health communication with their partners. Healthcare providers can improve their care by routinely addressing young men’s sexual health, using our newly proposed acronym, HIS BESTT, to incorporate current clinical recommendations.

KEY POINTS.

• Young men have a range of views on their role in pregnancy prevention, from solely their partner’s responsibility to a shared responsibility.

• Young men’s views and use of contraception depend on relationship status.

• A lack of knowledge regarding contraception is associated with young men’s sexual health communication and use of contraception.

• Healthcare providers should routinely address young men’s sexual health, including a review of contraception methods.