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American Journal of Men's Health logoLink to American Journal of Men's Health
. 2015 Jul 23;11(4):1182–1189. doi: 10.1177/1557988315596361

Male Contraception: Research, New Methods, and Implications for Marginalized Populations

Olivia Plana 1,✉
PMCID: PMC5675331  PMID: 26206159

Abstract

The majority of research on contraception has focused on manipulating the female reproductive system. Recent studies have identified novel contraceptives for males, including hormonal- and nonhormonal-based therapeutics. Although these new contraceptives are still undergoing clinical trials, their development and potential future use in society necessitate serious consideration of their implications for reproductive health. Through my analysis of the research conducted on male contraception over time and the current therapeutics available, it is clear that male contraception has the potential to shift societal gender dynamics and provide males with greater control over their own reproduction. This article also identifies the implications of these novel contraceptives for marginalized populations, especially men of color and men of lower socioeconomic positions. To overcome barriers to contraception among these populations, public policy efforts are needed in order to motivate the development of programs that facilitate coverage of these new male contraceptives by health plans and to increase their availability to underserved communities. Health care providers will be responsible for educating patients about these novel male contraception options and the need to continue using existing methods (e.g., condoms) in order to prevent sexually transmitted infections. This article analyzes the research conducted on male contraception and identifies the implications of these novel therapeutics for marginalized groups of men in the United States to identify the interventions that will be necessary to help ensure that all men have access to these promising scientific innovations.

Keywords: male contraception, male reproductive rights, male reproductive health, men of color, economically challenged

Unintended pregnancies account for approximately 50% of total pregnancies in the United States yearly (Finer & Zolna, 2013) according to women’s perspectives and 36% according to men’s perspective (Lindberg & Kost, 2014). This high percentage is due to a variety of factors, including barriers to accessing and obtaining contraceptive methods among women, inadequate sexual health care, and lack of knowledge about which contraception options are available and how to use them. An influential factor often not considered is the absence of male contraceptive methods. Since the development and approval of the oral contraceptive pill for women in the 1960s (Martin et al., 2000), there has been significant research efforts directed at improving contraceptive methods for women, such as decreasing side effects of the pill and developing alternative therapeutics, including implants and intrauterine devices. There has not been an equivalent level of research conducted on developing similar contraceptives for men. Male contraception is an underrepresented reproductive issue in the scientific research field despite the fact that studies have indicated that 78% of men believe that women and men “should share equal responsibility for decisions about contraception” (Dorman, 2012). Just as women should have the reproductive right to decide if or when to have children, men should similarly be able to control their fertility and reproductive outcomes.

Sexual reproductive relations inevitably involve the interaction of men and women; therefore both parties should play a role in contraceptive decisions. Both sides currently face limitations either as a result of structural barriers that limit women’s access to contraception or through the lack of contraceptive methods available to men. This article conceptualizes male contraception as a reproductive rights issue and identifies the potential implications of novel male contraceptive methods for gender dynamics in society, namely, the burden of reproductive control currently placed on women, and the reproductive health of marginalized populations, especially men of color and men of low socioeconomic positions in the United States.

Before examining the potential implications of new contraception methods for marginalized groups of men in particular, I identify existing methods of male contraception, review the research conducted on this topic over time, and describe the novel therapeutics being developed. I critically examine the potential barriers that may arise for these marginalized individuals to access and use the new contraception with regards to race, ethnicity, and socioeconomic status. Based on this analysis, novel male contraception has the potential to improve reproductive control for men, decrease the burden of unplanned pregnancy on marginalized populations, and motivate social change toward more equally shared responsibility in reproductive decisions and outcomes. It also necessitates the implementation of public policy to alleviate financial and accessibility concerns regarding the new therapeutic, and endorsement by the medical community so that male contraceptives may be incorporated into primary care interactions and community health programs that target various reproductive health issues, such as contraception and sexually transmitted disease prevention.

Background of Male Contraception

Currently Available Contraceptives

The current methods of male contraception that are most common in society are condoms and vasectomy, which is considered a more permanent form of contraception, as vasectomy reversal procedures are not always successful. Although these methods are available, they are not accessible to all populations of men due to various structural barriers including access to a clinic in the case of vasectomy, financial limitations in relation to insurance coverage status, and knowledge transmission about contraceptive methods. Over the last 10 years, various programs have been implemented to provide free condoms to the male population; however, a recent study identified that only 17.9% of men of color report use of free condoms as compared with 82.1% of White men (Reece, Mark, Schick, Herbenick, & Dodge, 2010). Also, only 16.6% of men of color use self-purchased condoms. This shows that there is an inequality in access to condoms among American men that is linked to financial ability to pay for the condoms and physical access to free condoms.

Condoms dominate as the most widely used form of male contraception as they provide a somewhat high contraceptive success rate (98% with perfect use but only 83% with actual use; Kost, Singh, Vaughan, Trussell, & Bankole, 2008) without involving a clinical procedure. Long-term use of condoms is generally low, as 57% of men discontinue use within the first year (Dorman, 2012) often because condoms may cause a decrease in sexual pleasure, fail if they break or are misused, or cause allergic reactions if they are made from latex (Mathew & Bantwal, 2012). Condom use also decreases as relationships become more established and reproductive partners move to using noncoital female contraceptive methods. From 2011 to 2013, only 34.4% of men aged 15 to 44 years used condoms, while 22.1% used the contraceptive pill through their female partners (National Survey of Family Growth, 2015).

Vasectomies, on the other hand, are more invasive in that they involve a surgical procedure; however, this operation is safe, has minimal postoperative pain, and has a fairly high effectiveness rate over time. The aforementioned disadvantage to this method is that its reversibility decreases with time and is thus generally consider to be irreversible (Mathew & Bantwal, 2012). The fact that condoms have a low continued use rate and that only a small percentage of men, 14% for White men and 4% each for Hispanic and Black men, undergo vasectomy procedures (Borrero, Farkas, Dehlendorf, & Rocca, 2013) indicates that there is a need and desire for new or better forms of male contraception to be made available to the public.

Overview of Male Contraception Research

Despite this need, the research conducted on male contraceptive methods over the past 50 years has failed to develop an effective contraceptive drug or therapeutic for men. The research has primarily focused on both hormonal contraception, attempting to mirror the female oral contraceptive pill that regulates the hypothalamus-pituitary pathway to limit fertility, and nonhormonal interventions. Over the past 10 years, there have been significant advances in this research as a new therapeutic called Vasalgel is currently undergoing clinical trials in the United States. This contraceptive method was originally developed by Guha in rhesus monkeys in the late 1980s (Guha et al., 1985) and has been under investigation since then to characterize its reversibility and efficacy (Mathew & Bantwal, 2012). The procedure is called reversible inhibition of sperm under guidance and involves the injection of a polymer substance into the vas deferens, which solidifies once inside the patient and blocks the transport of sperm, thus achieving reversible infertility with a faster onset than that of vasectomies (Mathew & Bantwal, 2012). Also, the polymer can be flushed out in a similar method to the initial injection at any time to restore fertility.

In regard to hormonal contraception research, the use of testosterone injections has been widely explored and studied. For instance, the World Health Organization (World Health Organization,1990) conducted a study that involved administering weekly intramuscular injections of testosterone to Asian and Caucasian men. The efficacy achieved by this method was fairly high as 65% of men became azoospermic1 within 4 months but was accompanied by some disadvantages, including its inconvenient injection-based administration method and its 3- to 4-month delay in the onset of its contraception function (Mathew & Bantwal, 2012). It is also important to note that the hormonal studies were mostly conducted on Chinese and White men and did not include any Black or Hispanic men despite the study being conducted in seven countries. This is important to consider as the contraceptive methods being developed will most likely be used by a diverse array of men, so testing the therapeutic on men of diverse racial/ethnic backgrounds is essential to establish efficacy and to ensure safety in these populations since some studies suggest that there is a “large ethnic difference in efficacy of hormonal contraception” (Dorman, 2012). The reasons for the observed ethnic differences in achieving azoospermia in response to contraceptive therapeutics are not yet known, but they may be due to differences in male germ cell rates or testosterone production rates among Asian and White men (Liu et al., 2008; Wang & Swerdloff, 2010). Additionally there has not been any research on the effect of male hormonal contraception among male-to-female transgender individuals who may be taking hormone supplements that could negatively conflict with this contraceptive method.

The research efforts on male contraception that developed these potential novel methods encountered many obstacles, such as achieving high efficacy of a treatment—defined as decreasing the sperm count in the semen to a level that achieves nonpermanent sterility—developing a suitable delivery system for the contraceptive therapeutic, and minimizing side effects. In addition, researchers faced significant financial challenges as the pharmaceutical industry withdrew its support during the past 10 years because the task of creating a male contraceptive treatment that was safe, effective, and reversible seemed too formidable to achieve and unlikely to be profitable (Murdoch & Goldberg, 2014). Although hormonal treatments have been successful in certain populations of trial patients, they often harbor undesirable side effects, such as liver dysfunction, significant mood changes, depression, and weight gain (Kogan & Wald, 2014). Side effects reported in clinical trials are deemed passable if they do not exceed the discomfort or normal symptoms of the disease being treated. Since contraception does not treat a disease, the side effects of contraceptive methods have to be as minimal as possible to be acceptable to the target populations. The depression side effect observed was concerning and caused the termination of clinical trials for some hormonal contraceptives.

Another challenge that faces male contraceptive research today is that there have not been studies on the long-term effects of novel contraceptive methods largely because of the limited amount of research that was being conducted on male contraceptives over the last 50 years. The unknown acceptability of male contraception has remained a barrier for research. The perception held by pharmaceutical industries was that men would not want or use a new contraceptive method developed, however, various studies have countered this belief, such as the Heinemann et al. study, which identified that greater than 55% of men were willing to consider the use of male contraception for fertility control if it were made available.

Discussion of Novel Contraceptive Methods

Hormonal Contraception

To access the potential impacts of new male contraception methods, Martin et al. (2000) conducted a study of over 900 men from the United Kingdom, South Africa, Hong Kong, and Shanghai to characterize their attitudes toward new hormonal contraception for men. The majority of participants was in favor of male contraception and stated that they would take a contraception pill if it were made available. However, the study did report significant differences in attitudes toward new contraceptive options among men of different cultures as men from Edinburgh and Cape Town preferred the pill over the condom, while Chinese men still favored the condom (Martin et al., 2000). This indicates that there may be ethnic or racial influences on knowledge about sexual health and acceptability of novel contraception methods in addition to the already noted racial differences in efficacy of hormonal contraception. However, this study did not include any individuals from Latin America, South Asia, or the Middle East, leaving out many other cultures that may react differently to male contraception. Nonetheless, despite these shortcomings, the study did highlight the differences in knowledge about contraceptive methods, as Black men in Cape Town were less likely to know about contraceptive methods, while men in Shanghai were the most likely to know about various contraceptive options. Although this study was not conducted in the United States, its findings suggest that reactions to and knowledge of novel male contraceptive therapeutics may vary among American men of color.

Nonhormonal Contraception

Another study that was conducted in the United States analyzed the acceptability of a transdermal gel-based hormonal contraceptive in a randomized trial of 99 men, of which 79 completed the questionnaire on their attitudes toward the therapeutic (Roth et al., 2014). Roth et al. (2014) reported that the majority of the men found the contraception acceptable and that one third of the subjects “reported that they would use this as their primary method of contraception if it were commercially available.” This study had a diverse subject population that included Black, Asian, and Native American men but lacked Hispanic men. This suggests that non-Hispanic men of color would likely accept novel contraception methods upon the condition that the contraception be made accessible to them, a frequent challenge for sexual and reproductive health efforts today. A more comprehensive study including 9,000 men from 9 different countries comprising France, Sweden, Germany, Spain, Brazil, Mexico, Argentina, Indonesia, and the United States identified that the average acceptance2 of male contraception was 55% (Heinemann, Saad, Wiesemes, White, & Heinemann, 2005), although it varied somewhat by country. The subject population included men of a range of ages, education level, religion, and socioeconomic position.

Although they analyzed the influence of education level and religion on acceptance of male fertility control, they did not examine any potential correlation between acceptance and socioeconomic position. Analyzing this study within a political economy of health framework (Zierler & Krieger, 1997) indicates that socioeconomic position is a very important aspect of sexual and reproductive health, and, thus, would presumably have an effect on the acceptability of new male contraceptive methods, as men of low socioeconomic positions may have concerns about the cost of the treatment and limitations to access (e.g., needing a prescription from a health care provider). Specific research on the acceptability of novel male contraceptive methods among low-income men in the United States is needed to anticipate their potential use of the new contraception and the implications it may have on this marginalized population if made accessible to them.

Implications of New Contraceptive Therapeutics

Various studies have established that a majority of males will use male contraceptive methods that are made available to them and have a manageable therapeutic administration method. The research that has been conducted on male contraception has developed two methods that may soon become available: hormonal treatments of exogenous testosterone administration and the nonhormonal treatment of a polymer injection that blocks movement of sperm through the vas deferens. There are various considerations that need to be made for these methods to become available to our target population of men of color and low socioeconomic status.

Financial Burden of New Male Contraception

One of these considerations is financial cost of the contraception. Minority and low-income men are less likely to have “Medicaid coverage than are their female counterparts” and to have private health insurance (Barone, Johnson, Luick, Teutonico, & Magnani, 2004). They are unlikely to be able to afford these novel contraception methods unless Medicaid coverage expands or the new Affordable Care Act health care system being implemented decides to cover these contraceptives. The uncertainty of the future implementation and effects of the Affordable Care Act and the scope of Medicaid coverage represent policy barriers to decreasing the financial burden of novel male contraception.

Importantly, financial burden has been seen to greatly affect use of contraception. When Medicaid was allowed to expand in the early 2000s to include women whose incomes disqualified them for coverage, Kearney and Levine (2009) identified that the family planning services now offered to these women, including contraceptive methods and sexual health examinations, were able to reduce “one birth for every 36 additional Medicaid” recipient. Therefore, expanding coverage of Medicaid was able to prevent some unplanned pregnancies and provide women with greater control over their reproductive rights. Thus, similar expansion to include novel male contraceptives should yield positive outcomes from men’s reproductive rights as well. Also, decreasing the financial burden of contraception in the case of vasectomies was seen to increase the number of procedures performed by 20% (Barone et al., 2004). This suggests that novel male contraception methods may be more commonly used by low-income men if they are made more financial accessible. This would disproportionately affect men of color, who tend to be of lower socioeconomic positions relative to White men in the United States, and thus could also improve their access to and use of contraception.

Knowledge Transmission About New Methods

Another consideration to take into account when working to increasing the availability of novel male contraception to low-income men of color is dissemination of knowledge about reproductive health and contraception options. There is a significant gap in the awareness of contraception and sexual health resources among men based on race and ethnicity. A study motivated by the fact that Black and Hispanic individuals “experience poorer reproductive health outcomes” and have “higher rates of unintended pregnancy and abortion” analyzed the reproductive health survey responses of over 900 men of varying race and ethnicity (Borrero et al., 2013). This study reported that Black and Hispanic men were less likely than White men to know about various forms of contraception aside from the condom and the pill, such as intrauterine devices, emergency contraception, and the vaginal ring (Borrero et al., 2013). An unexpected finding was that Hispanic men were more likely than White men to believe that pregnancies should be planned. This is in discordance with the high rate of unplanned pregnancies among Hispanics, suggesting that social and structural barriers may be what are really causing these higher rates and that the stereotypes about the hyperfertility of women of color are unsupported. In this case, Hispanics are likely disadvantaged from accessing family planning resources and contraceptives because not only do they face similar structural barriers as other men and women of color, such as financial limitations and inadequate access to medical care, but they also face language barriers that may inhibit their ability to register for health insurance and gain knowledge from communication with medical professionals (Pérez-Escamilla, Garcia, & Song, 2010). There are also shortcomings in communication of knowledge about sexual health and contraception from physician to patients partly because some health care providers are “not informed about what services men should receive and when” (Kalmuss & Tatum, 2007).

Race/Ethnicity and Male Contraception

An interesting finding from the study by Borrero et al. (2013) was that Black men were more likely to believe that the government “attempts to limit minorities by promoting birth control.” This distrust of the government is not unfounded because of the Tuskegee Institute’s study of untreated syphilis in Black men in the United States, which clearly violated the health and reproductive rights of men of color. These men were informed that they would receive free health care, but instead the physicians withheld penicillin treatment to observe the effects of untreated syphilis (“U.S. Public Health Service Syphilis Study at Tuskegee,” 2013). This study fortified the distrust that men of color harbor for government health programs. Further distrust was created during the eugenics movement in the 20th century that explicitly used forced sterilizations of women to limit the reproductive capabilities of persons deemed unfit, which included many minorities (Stern, 2005). There have also been documented cases of forced sterilizations conducted on female inmates without their knowledge (Flavin, 2009), and since men and women of color are disproportionately represented in the prison system, this practice disproportionately affected racial/ethnic minority populations. There have been attempts to include forced sterilization or compulsory long-term contraception as part of sentences in court cases. Although there have been arguments in favor of compulsory contraception (CC) claiming that it could break the cycles of depravity that low-income men of color are trapped within by preventing children from being born into these hostile environments (Adams, 2008), the potential misuse of CC is too dangerous a risk to take. Instances of forced sterilization and CC are important issues in the reproductive justice community, but the misuse of these reproductive control options in regards to men is inevitably linked to women’s reproductive justice. Preventing men from making their own reproductive decisions by limiting their reproductive abilities through sterilization or CC affects their partners and takes agency away from both women and men.

Based on previous misuses of reproductive health advances such as sterilization and the birth control pill (Briggs, 2002), external forces should not be involved in making reproductive decisions for an individual, unless their health is directly threatened. This would be a clear violation of their reproductive rights. Instead of imposing CC as a sentence for cases of unfit parenting, the judicial and penitentiary system could use this opportunity to educate these individuals on their contraceptive options and make these options accessible to them if they so choose to use it. This would increase men of color’s access to contraception without encroaching on their reproductive rights.

Some of the main barriers to contraception for low-income men and men of color are financial accessibility, knowledge of sexual health resources and potential new male contraceptives available, and distrust of clinicians and government programs promoting birth control due to perceived racial/ethnic prejudices against them. Another barrier that may arise with the release of these new male contraception methods would be access. It is already known that currently available contraceptive methods such as vasectomies are not always offered where “uninsured low-income men and women go for health care” and that “fewer than 25% of the nation’s public clinics offer vasectomy services” (Barone et al., 2004). This lack of contraceptive services at public clinics leaves many low-income men and women of color at greater risk for unwanted pregnancies. Many sexual and reproductive health clinics are focused on providing services for women and men who have sex with men, primarily for sexually transmitted infections (STIs; Kalmuss & Tatum, 2007). This may deter men from seeking out health services at these clinics due to social perception concerns.

There are concerns that increasing reproductive health care for men at such clinics would deplete the resources they need to treat women. Ensuring there is adequate funding for all services offered at these clinics would assuage this concern. There may also be social barriers to access rooted in the constructed ideals of masculinity “which deter men from acknowledging their health care needs and accessing services” (Kalmuss & Tatum, 2007). This combined with distrust of prejudiced medical professionals, excessively long wait times at public clinics, lack of services offered at these clinics, and insurance status make it particularly difficult for low-income men of color to access reproductive health services. These issues may arise when the new Vasalgel or hormonal contraceptive methods are made available for use unless specific policy and social actions are taken to increase their accessibility for particularly high-risk populations, such as minorities.

Reproductive Control for Both Sexes

These novel male contraceptives will have important implications on the gendered interactions in our society. The burden of reproduction is commonly believed to rest with the females as most contraception research and developments have been focused on female contraception. However, many women and men believe that they should share equal responsibility in reproductive decisions and outcomes (Grady, Tanfer, Billy, & Lincoln-Hanson, 1996). Currently, the situation is not equal in that men have to negotiate with their sexual partner to use their available form of contraception, the condom, while women can engage in contraception use regardless of permission of their male partner through the birth control pill. It is important to note that in some cultures, men do have power over the contraceptive use of women (Fennell, 2011). Considering the situation in which women do not need to negotiate their use of contraception and have access to contraceptive options, women are at an advantage in controlling their reproductive abilities. Men cannot control their reproductive ability as well as women because of the efficacy problems associated with condoms. The development of novel male contraceptive methods would allow them to have a more equal role in reproductive decisions with their female partners. There may be a drawback to the use of new male contraception in that the hormonal and nonhormonal methods do not protect against disease transmission. The combined use of contraception and STI protection as Dual Protection3 has been recognized as best practice for reproductive health rendering condoms a necessary part of reproductive health (Cates & Steiner, 2002). Although women can use female condoms to achieve Dual Protection with novel male contraceptive use, for men to maintain control over their reproductive decisions and health outcomes, condoms would need to remain in use to protect from STI transmission. However, it is uncertain whether or not males will continue to use condoms considering they already have a high discontinuation of use rate. This would inevitably affect the sexual partners of these men and may require women to assume more responsibility for STI prevention.

Actions to Accommodate Novel Male Contraceptives

There are three settings in which changes can and should be made to prepare for the release of novel male contraceptive methods and to improve reproductive health services for marginalized men: the health care system, schools, and communities. Public policy is needed to improve funding for reproductive health clinics in order to expand their services and reach into communities in need, specifically communities of color that harbor the highest rates of unplanned pregnancies. The government can generate policy requiring that public insurance programs expand their coverage to include contraception for men. Health care facilities should also include male contraception in primary care so that health care providers can educate their male patients about these new contraceptive options during regular visits.

To increase the accessibility and use of these new male contraceptive methods among low-income men and men of color, public schools should incorporate information on male contraceptive options into their sex education programs. It is important that specifically public schools include this information into their sex education curriculum to reach as many youth as possible, particularly marginalized populations that may not have access to such knowledge about reproductive health. Schools can also improve the access to male contraception for male adolescents by expanding the services provided by school-based health services (SBHSs). SBHSs provide health services for patients regardless of their financial ability and offer contraceptive counseling, pregnancy testing, sexual assault counseling, and diagnosis and treatment for STIs (Boonstra, 2015). However, only 37% of SBHSs provide contraceptives for their patients (Boonstra, 2015). More SBHSs need to offer novel male contraceptives and educate their patients about these new methods. Supportive government policies that secure funding for these centers are also needed to ensure that the SBHSs can provide male contraceptives, among other reproductive health resources, to patients.

Lastly, community-led programs that target negative stereotypes about male reproductive health and motivate men to actively use contraception and share equal responsibility in reproductive decisions with their female sexual partners are needed. Admittedly, these reforms are strenuous and complex and will certainly not be feasibly executed within a short time period. These are actions that need to be taken to begin to remove the structural barriers that limit reproductive choice and control among all U.S. men, including men of color and men of low socioeconomic positions.

Acknowledgments

I would like to acknowledge Madina Agénor, ScD, MPH, for her guidance in the research and writing of this text, and my family for their unwavering support of my academic and personal endeavors.

1.

Azoospermic is a medical term for the state of having no measurable amount of sperm in the semen, rendering the individual sterile.

2.

Acceptance was defined as the willingness to use the method of contraception.

3.

Dual Protection is the combined effort to protect against unintended pregnancies and STI transmission either by the use of condoms alone or condoms with contraceptive pills. It has been recommended as common practice and used for family planning programs since 2002 (Adeokun et al., 2002).

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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