“It’s her body”: low-income men’s perceptions of limited reproductive agency^☆,☆☆

Abstract

Objectives:

While some attention has been paid to men’s contraceptive use and attitudes in international contexts, relatively little is known about the attitudes towards contraception and pregnancy of low-income, urban men in the U.S.

Study design:

We conducted semi-structured interviews with 58 low-income men in Pittsburgh, PA, to explore their perspectives on contraception, pregnancy, fatherhood, and relationships. We analyzed the interviews using a combination of content analysis, the constant comparison method, and thematic analysis.

Results:

Men who we interviewed frequently described feeling that they lacked agency regarding when pregnancies occurred and whether or not they became fathers. Several factors contributed to their sense of low agency, including the belief that women should control contraception and reproduction, a reluctance to have conversations about contraception in some contexts, a lack of acceptable male-controlled contraceptive methods, experiences with pregnancy-promoting behaviors by women, and fatalistic attitudes towards pregnancy occurrence.

Conclusions:

Many men in our study described perceptions of limited reproductive agency. In describing their lack of agency, men reinforced contemporary gender norms in which the “work” of pregnancy prevention is a woman’s responsibility. Responses to men’s perceived limited reproductive agency should work towards deconstructing gendered norms in the work of pregnancy prevention and promote shared and mutual gender responsibility over reproduction while also supporting women’s reproductive autonomy.

Implications:

This study identifies several factors that contribute to low-income men’s sense of low reproductive agency and highlights the complexity of acknowledging men’s feelings and perceptions about reproductive control in the broader context of gender and power.

1. Introduction

Unintended pregnancy is a commonly described phenomenon in the United States, with an estimated 45% of pregnancies occurring each year being reported as either mistimed or unwanted [1,2], despite concerted public health efforts to help people plan pregnancies [3]. Additionally, unintended pregnancy disproportionately occurs among low-income and racial/minority populations [1,2,4]. Reasons for these disparate rates are multifactorial and require consideration of healthcare and contraceptive access, as well as a wide range of complex socio-cultural and structural issues including reproductive autonomy (i.e., locus of control); partner relationships; unequal opportunities for economic advancement and upward social mobility; and social norms related to sexuality, parenthood, pregnancy and contraception.

One area that has been relatively understudied is the role of male partners. Previous studies have found that male partners can be influential in supporting and encouraging women’s contraceptive use, with more involved partners leading to greater adherence to contraceptive regimens [5–7]. However, other research has found that, in some cases, increased male involvement in contraceptive decision-making is linked to increased interference with contraceptive use by male partners [8], and reproductive coercion on the part of male partners is associated with both interpersonal violence and unintended pregnancy [9,10]. Thus, we know that men can influence women’s contraceptive use and decision making in ways that support or hinder women’s autonomy. Additionally, with the exception of Borrero and colleagues (2013), who found that men have relatively low knowledge about forms of contraception other than the condom and the pill, and that approximately half of men felt that contraception was the woman’s responsibility [11], most literature exploring men’s attitudes towards contraception and family planning is either decades old [12–15] and/or focused on adolescents or college students [16–19]. Given the influence that men can have on women’s contraceptive use, as well as the fact that men have contraceptive needs themselves, it is important to understand the attitudes of men towards family planning and contraception.

To do so, we conducted a qualitative study, the Men’s Fertility Attitudes and Behaviors (MFAB) study, with low-income Black and White men in the Pittsburgh region. Because unintended pregnancy disproportionately occurs among low-income populations in the United states and because lower access to economic resources means that an unintended pregnancy may have more severe financial and social consequences, members of our team had previously studied low-income women’s fertility-related attitudes and behaviors [4]. MFAB was conceptualized as the male counterpart to that previous study, and sought to understand low-income men’s perspectives and experiences regarding fatherhood, contraception, and sexual relationships, in order to better contextualize reproductive decision making in low-income and minority populations. Among the findings from these interviews was a predominant theme of low-income men, both Black and White, feeling that they lack reproductive agency – that is, perceptions that although they have some influence in the matter, they frequently cannot control whether or not they have children. In this manuscript, we focus on factors men identify as contributing to their experiences and perspectives on limited agency around reproduction.

2. Methodology

2.1. Study sample

Study personnel (MH and a research assistant) posted flyers advertising the study in health care and community centers that serve low-income populations in Western Pennsylvania. We also posted ads on Pittsburgh’s Craigslist. Men who responded to the advertisements were screened via telephone by the interviewer (MH) to determine their eligibility for the study. Men were considered to be eligible if they were between the ages of 18 and 45, self-identified as Black or White, and had had sex with a woman during the past 3 months. We excluded men who had not had sex with a woman during the past 3 months, because we wanted the issue of contraception or pregnancy to be a potentially active concern for participants. The age range of 18 to 45 was selected because most unintended pregnancies occur in the adult population, yet previous research focused on unintended pregnancies in adolescent populations [2,18] and because while men can father children after the age of 45, most do so before that age [19]. Men were considered to be ineligible if they were not fluent in English, if they had had a vasectomy, and/or if they had a household income above 200% of the federal poverty level, as determined by asking for annual household income and the number of people living in the household during the screening. We used a sampling matrix to ensure reasonable representation of men by race, age categories within the eligibility range (i.e., men 18 to 24, and 25 to 45), and paternity status. Because qualitative sampling is driven by thematic saturation, which is typically reached at 12 to 16 interviews [20,21], our goal was to interview at least 12 men per racial, age, and paternity group. We did not reach that goal for White men under the age of 25, but themes emerging from the interviews were consistent enough to determine that we had reached thematic saturation regardless.

2.2. Data collection

Following recruitment into the study, we engaged men in an hour-long, semi-structured telephone interview about their views on fatherhood, contraception, sexual relationships, abortion, and their preferences for family planning programming for men. Interviews were conducted by a trained interviewer with considerable prior experience in interviewing on sensitive topics (M.H.). Immediately following the interviews, the interviewer (M.H.) administered a demographic questionnaire to the participants, also via telephone. The interviews were conducted between November 2014 and February 2016. All interview sessions were audio-recorded and subsequently transcribed verbatim by members of the study team (M.H. and research assistants), with any identifying information redacted from the transcript. Each participant received $50 as compensation for his time. This study was approved by the University of Pittsburgh Institutional Review Board.

2.3. Analysis

Our analysis incorporated content analysis, the constant comparison method [22], and thematic analysis [23,24]. The interviewer and primary coder (M.H.) developed a preliminary codebook consisting of codes that categorized likely participant responses to interview questions on a very basic level – i.e., “Talks With Partner About Contraception: Yes,” “Talks With Partner About Contraception: No.” Then, as interviews were complete and transcripts were produced, additional codes were generated inductively by the team members who would serve as primary and secondary coders (M.H., M.E.) using a process known as “editing,” in which researchers descriptively characterize aspects of the text [20]. These inductively generated codes were more descriptive or topical, and reflected concepts brought up by interviewees — i.e., “Pregnancy Inevitable,” “Thoughts on Contraception,” “Women Control Reproduction.” We combined all codes into a finalized codebook. The primary (M.H.) and secondary (M.E.) coders then independently coded the first 15 (~25%) transcripts, and fully adjudicated coding differences, to ensure that the primary coder was applying codes consistently, following which she coded the remaining 43 transcripts. Both coders used Atlas.ti to assist in their coding [25].

After the data was organized through this coding process, the coders met to discuss broad themes that they identified in the interviews. These themes were then discussed with the study’s primary investigator (S.B.), who read all transcripts but had not participated in coding. One of the themes identified was that the men interviewed had expressed a lack of control of or autonomy regarding reproductive decisions. M.E. then identified a series of subthemes that were refined by M.H. and S.B. through the constant comparison method [22] — i.e., they compared quotes associated with codes related to the subthemes (identified and discussed below) in order to fully describe men’s experiences as they informed each subtheme. At this time, the primary coder (M.H.) also compared responses across racial, age, and paternity groups using the same process. This thematic analysis was then shared with other investigators (E.M., M.B., and D.B.) in the study for the purposes of analyst triangulation given their topical expertise in subjects related to the study [26], to ensure that the themes were articulated clearly, and that they would be situated appropriately within the broader literature on gender and contraception.

Results presented below are organized into the themes that we identified and refined using this process. When direct quotes are provided below, we identify each participant with a pseudonym, as well as some basic demographic data. While we have made efforts to quote from as wide an array of participants as possible, some are quoted more than once due to the clarity or detail with which they discussed their experiences.

3. Results

A total of 58 men participated in interviews. Thirty-one participants were Black, and 27 were White. Participant ages ranged from 19 to 45, with a mean age of 29. Thirty-eight participants were already fathers, while 20 did not have any children. Of the 20 men without children, one was expecting his first child at the time of the interview. Only 14 of the men had never gotten someone pregnant. Full demographic information can be found in Table 1.

Table 1.

Demographics of MFAB Participants (58 men aged 18–45 in Pittsburgh, PA during November 2014-February 2016).

Characteristic	Black Men	White Men
	(n=31)	(n=27)
Age (y)
18–29	65% (n=20)	48% (n=13)
30–45	35% (n=11)	52% (n=14)
Education
<High school diploma	13% (n=4)	8% (n=2)
High school diploma/GED	55% (n=17)	44% (n=12)
Trade/technical school	6% (n=2)	15% (n=4)
Some college	10% (n=3)	18% (n=5)
College degree	16% (n=5)	15% (n=4)
Household income (US$)
0–9999	39% (n=12)	37% (n=10)
10,000–19,999	26% (n=8)	41% (n=11)
20,000–49,999	35% (n=11)	18% (n=5)
50,000–69,999		4% (n=1)
Marital status
Single	74% (n=23)	70% (n=19)
Engaged	7% (n=2)	11% (n=3)
Married	16% (n=5)	8% (n=2)
Divorced/separated	3% (n=1)	11% (n=3)
Living with female partner
Yes	52% (n=16)	52% (n=14)
No	48% (n=15)	48% (n=13)
# of Pregnancies
0	13% (n=4)	37% (n=10)
1	19% (n=6)	26% (n=7)
2	6% (n=2)	15% (n=4)
3	23% (n=7)	11% (n=3)
4	13% (n=4)
5	10% (n=3)	4% (n=1)
6 or more	13% (n=4)	7% (n=2)
Don’t know/unsure	3% (n=1)
Insurance
Yes	61% (n=19)	52% (n=14)
No	39% (n=12)	48% (n=13)
Religion
None	19% (n=6)	33% (n=9)
Protestant	7% (n=2)	4% (n=1)
Catholic		26% (n=7)
Other Christian	58% (n=18)	22% (n=6)
Muslim		7% (n=2)
Other	9% (n=3)	15% (n=4)
Fatherhood status
Has children	68% (n=21)	63% (n=17)
No children	32% (n=10)	37% (n=10
Wants to get someone pregnant In the next year
Yes	13% (n=4)	11% (n=3)
No	84% (n=26)	70% (n=19)
Don’t know/unsure	3% (n=1)	19% (n=5)
Birth control use*
Male method	62% (n=19)	41%(n=11)
Female method	45% (n=14)	63% (n=17)
No method	26% (n=8)	22% (n=6)

^*Male birth control methods included condoms and withdrawal. Female birth control methods included all hormonal and barrier methods, LARCs, the rhythm method, and sterilization. Overlap between numbers indicates that some individuals were using both male and female birth control methods. Those in the “no method” category were using no method themselves, nor were their female partners using any method.

One of the original goals of the study was to compare the perspectives of Black and White men; however, when we compared the attitudes of the men that we interviewed across racial, age, and paternity lines, we found remarkably similar attitudes across all groups regarding perceptions of low reproductive agency. Many men felt that they cannot and do not control when or whether they have children, but rather that their sexual partners control this aspect of reproduction. Although some men had discussed and come to an agreement on having children (or avoiding having children) with their partners, it was also common for them to have had no such discussion, and nearly half reported ultimately having no influence in their partners’ contraceptive and reproductive decisions. Participants’ perceived lack of reproductive agency centered around five themes: (1) women do and should control reproduction; (2) discussions about contraception and pregnancy do not always occur; (3) there is a paucity of acceptable male contraceptive options; (4) women engage in pregnancy-promoting behaviors; and (5) men often have fatalistic attitudes towards pregnancy.

3.1. Women do and should control reproduction

Many of the men we interviewed felt that because contraception or reproduction occurs in a woman’s body (i.e., many non-barrier methods of contraception, with the exception of withdrawal and the copper IUD, influence women’s bodies hormonally, and pregnancy and abortion occur in a woman’s body), they ultimately had no control over when or whether or not they had children. In their view, they could make their opinions known, but in the end they could not force a woman to use contraception, nor could they control whether or not she continued with a pregnancy in the event that one occurred. As one man put it:

They [men] will be part of the discussion, but when it comes down to it, a woman’s going to want to do what she want[s] with her body. And that’s usually who has to deal the most with the contraception, is the woman.

(“Marcus,” 44 years old, Black, Father).

Additionally, citing the importance of women’s bodily autonomy, many men felt that they should not have influence over women’s contraceptive and pregnancy decisions.

How men felt about women’s control of reproduction varied. For some, it was considered right and just that women control whether and what type of contraception they use, as they are the ones who have to contend with potential side effects and risks of contraceptive use. Likewise, for some men it was considered a moral good that women have bodily autonomy with respect to pregnancy, childbirth, and abortion. The majority of the men we spoke to, for example, felt that women should have more control than men over decisions about abortion. As one man put it, when discussing who should have influence on the decision to have an abortion:

It’s her pain. It’s her body. And I think that the society is a lot tougher on a woman that walks out on their child than a man. Um, I don’t agree that there should be any variance, but if a woman abandons her baby, it’s just thought so much more harshly on, so it’s much more bigger, like, decision, for a woman to make. What she has to deal with, both emotionally and physically, is a lot more her burden than any guy could imagine, I would think.

(“James,” 26 years old, White, Father).

Thus, for some men, their perceived lack of reproductive agency was perhaps personally regrettable, but they did not see any remedy to the situation that would not harm women. For other men, lack of reproductive agency was something that they felt should be remedied through increased reversible male contraceptive options comparable in efficacy to contraceptive options for women, or through shared decision-making around condom use in particular. One young man, who reported routinely using condoms to control his fertility, lamented his male friends’ ceding of condom decisions to women:

Most of my friends are just like, ‘Well, it’s her decision. She wants to use condoms, you use condoms, she don’t, you don’t.’ And, I think that’s how most of them go about it, ‘It’s up to her.’ And I’m like, ‘Uh, but it’s your life too!

’ (“Sean,” 35 years old, Black, Not a Father).

Rarely, some men thought that legal options should be codified to allow for a formal process to disavow himself from a pregnancy or child and/or recuse himself from any financial obligation in the event that a woman wanted to continue with a pregnancy despite the man’s stated intent that he did not want the child.

3.2. Discussions about contraception and pregnancy do not always occur

Some of the men in our study reported mutual decision-making with partners regarding contraceptive use and pregnancy. However, slightly more than a third of participants (n=21) reported not discussing contraception with their sexual partners, and nearly one quarter (n=14) reported not discussing pregnancy or potential pregnancies. Reasons for avoiding discussion were varied. Reflecting the theme that women control reproduction, some men simply did not broach the topic of contraception with their partners, even in long-standing, committed relationships, due to the sense that such a conversation would be pointless because contraception is solely or largely a woman’s decision. One man who reported not discussing contraceptive use with a woman with whom he had already had children said, “It’s up to her if she would want to get on it or not. I don’t really force that. I’m not really able to force that on her” (“David,” 22 years old, Black, Father) Another man described his wife’s having made the decision to have her tubes tied after the birth of their last child without involving him in the decision, arguing that “she made a choice with her body, you know, she do[es] what she feels best for her body” (“Samuel,” 39 years old, Black, Father).

In other cases, men reported not talking about pregnancy or contraception and could not elucidate a reason why, or had never previously thought about why they had not discussed it with their partners, as in the following example, from a man who had been in a relationship with his partner for three years: “It just really never came up or anything, like. (“Joseph,” 31 years old, White, Father).

Often men felt that conversations about contraception were unwarranted in casual relationships, or could make a relationship seem more serious than it was. One man described his reasons for not discussing contraception use: “With the new partner it’s kind of been a very jocular sort of thing, so it’s kind of like not been an issue that comes up. We’re just sort of playing it by ear sort of thing, and not getting too serious” (“Mike”, 23 years old, White, Not a father) This man reported using condoms with this new partner, but also acknowledged that while it was his intention to use condoms, he frequently did not “in the heat of the moment.” Another man said that he had not discussed contraception with a recent partner with whom he had had a one-night stand, because “I hadn’t seen her in a while, it was kind of a spur of the moment hookup. We haven’t talked since. I think we both knew that we were just trying to get laid on Halloween, and I think that’s why [we didn’t talk about it]” (“Nate,” 22 years old, White, Not a father).

Additionally, one man felt that conversations about contraception use or pregnancy intentions could cause offense, and therefore avoided them:

And, you know, sometimes girls get offended or kind of argue about that stuff, and you just kind of be like, explaining to them, like, girls don’t be knowing, this shit is serious, like, you feel me? […] They get a little, like, ‘Oh, I ain’t good enough [to have a child with you]?’ or ‘Ain’t nobody worried about that!’ They get real offended, like I’m trying to say, it’s not that I don’t want you, it’s like I don’t want to be your partner and be taking care of something that’s somebody’s life.

(“Miles,” 23 years old, Black, Father).

Other men reported brief, initial conversations to determine whether or not a partner was using contraception, following which the topic was not revisited. In these conversations, men report listening to the contraceptive preferences of their partners, but do not portray themselves as active participants in a shared decision-making process, as in the following example:

Like, we talk about it as in, like, I might ask or something if a girl’s already on it, I’ll just be like, ‘Oh, she got that Mirena,’ you know, just playing around. But not really, not really talking about, hey you have to get this type of, you know, like, it would be nice if you had birth control, and a girl has her preferences, or her knowledge of birth control, and you just go with it from there.

(“Miles,” 23 years old, Black, Father).

Although men did not explicitly frame contraception and pregnancy decisions as “women’s topics” or “women’s responsibility,” most of them were not framing contraceptive use as something for which they, themselves, were responsible.

3.3. There is a paucity of acceptable male contraceptive options

Men were largely dissatisfied with the currently available male-controlled, reversible contraceptive options (i.e., condoms and withdrawal), leaving them unable to effectively mitigate their risk for an undesired pregnancy. Condoms were frequently viewed as useful for sexually-transmitted infection (STI) prevention, and thus were more likely to be used at the beginning of a relationship or for casual sexual encounters. Once trust was established in relationships, however, condoms were frequently discontinued due to dissatisfaction with the method. Men reported disliking the disruption of putting a condom on, as well as the decrease in sexual sensation that came with condom use, and sometimes reported that their female partners also disliked the decreased sensation and/or that they found them to be drying. For example, one man described his thoughts on condoms as follows:

To me they just, like, well, apparently they get in the way. (laughs) But, that’s’ their job, and I don’t know, it just doesn’t feel right to me to do that, it, like, I don’t know, you’re in the mood, and then you got to open this package, you got to, you know what I mean, struggle with putting it on, and it just kills the whole moment, to my eyes. But, it is a lot safer and it should be done.

(“Joseph,” 31 years old, White, father).

Withdrawal was also reported as being distracting. One man described focusing on withdrawal as “conscious sex” (“Franklin,” 20 years old, Black, Not a father) in which one is constantly distracted from the sex itself by having to focus on pulling out before reaching orgasm.

Additionally, though rarely, men explicitly expressed frustration that there were no contraceptive options for men that are comparable to those available to women in terms of variety, efficacy, reversibility, and acceptability. As one man put it:

Why don’t, why is there not birth control for men? Like […] a pill or something, like how they take a pill, or, you know, so you can’t do it. Because condoms […] you could still get pregnant. It’s just a glove but that pill, that’s in your body, that changes, you know, that changes stuff in your body, not just a cover […] just to make you shoot blanks or something.

(“Franklin,” 20 years old, Black, Not a father).

3.4. Women engage in pregnancy-promoting behaviors

Some men in our study had experienced pregnancy-promoting behaviors by their female partners. These behaviors ranged from perhaps unintentional, such as failing to take the oral contraceptive pill reliably, to overtly intentional and coercive, such as a young man who reported that his partner would try to prevent him from withdrawing despite their having agreed to practice withdrawal. As he described it:

She’ll try to hold me in. She won’t let me pull out sometimes. Like, I’m about to go on strike and stop having sex with her. But I can’t. Like, I try, but I can’t stop, but she’s trying to stay, like, I be trying to pull out and she be trying to just hold on to me. She likes to, she do that shit on purpose, and I be telling her, ‘You think it’s funny. It’s not funny.’ I don’t know.

(“Franklin,” 20 years old, Black Not a father).

It was relatively uncommon for men to report directly experiencing reproductive coercion, as in the above example. However, nearly half of the men we spoke to (27/58) said that a man they knew had experienced some form of deception around contraception. Typically, these reports centered on women lying about their use of contraception, by hiding inconsistent use or non-use in order to conceive and “trap” a man in a relationship. However, men reported that they themselves, or men they know, also engaged in such reproductive coercion with female partners, either by damaging condoms or by intentionally failing to pull out when practicing the withdrawal method. The reasons that men cited for both men and women engaging in reproductive coercion were the same: a desire to ensure that a relationship will last or continue, for either emotional or financial reasons, as a result of sharing a child. Reproductive coercion was thus, in their view, common and not gender-specific.

3.5. Fatalistic attitudes towards pregnancy

For a variety of reasons, some men felt that risk of pregnancy was low, and as such were not particularly concerned about pregnancy or using contraception, despite not wanting to have a child at the time. One man reported relying on withdrawal only during the most fertile days of his girlfriend’s menstrual cycle, feeling this was adequate because “we’re not that sexually active” (“Leon,” 37 years old, Black, Father). Another man had had unprotected sex for so long with the same partner without a pregnancy resulting that he wondered if he or his partner were infertile, and thus felt that their overall risk was low. Additionally, some men expressed the feeling that they simply didn’t think a pregnancy would happen to them, or that it was just something that they do not think or worry about, despite not wanting to have children at that time in their life. A “won’t happen to me” attitude was commonly expressed by men who already had children as well as those who did not.

Additionally, regardless of whether or not they thought about the risk, or perceived it to be low, many men reported behaving either as though their risk was low or as though fertility is not something that can be controlled, in that they had frequent sexual encounters with women without using contraception of any kind, despite not wanting to have a child at the present time. One man, who had had multiple children and had never discussed contraception with any of his partners, said that pregnancies “always just happened” (“Ed,” 32 years old, White, Father). Another man said:

But, you know, coming from my background, we kind of don’t, normally don’t plan it. It kind of happens. You know, I mean, sometimes folks, sometimes it does be planned for a reason, like different reasons, uh, maybe try[ing to keep an] individual with you in your life, you don’t want to let them go, so you plan to have a child, but most situations, they kind of just happen, you know what I mean? You’re sexually active and you, kind of, wasn’t preparing yourself not to have a child, you kind of just did the act, and it’s like now you have a baby, honestly.

(“Leon,” 37 years old, Black, Father).

Similar descriptions of engaging in sex without contraception, but without explicit intentions for pregnancy were common. Additionally, some men described the futility of trying to control fertility, because even reliable contraceptive methods can fail. As one participant put it: “You can use all the protection in the world, and something’s going to happen” (“Dante,” 43 years old, Black, Father). Though uncommon, a few participants attributed such contraceptive failure to the will of God, indicating a religiously oriented fatalism. One such participant described his “lack of faith” in condoms in these terms:

I looked into condoms. […] They’re not even, like, 100% effective, they’re only 99.999, so there’re microscopic holes in them, so to me there’s really, like, no point. If God’s willing for you to get somebody pregnant, then you’re going to get them pregnant regardless of if you wear a condom or not

(“Jordan,” 22 years old, Black, Father).

Likewise, some participants noted that you could not control when pregnancies happened even if you wanted to get pregnant, as in the following quote:

But, I mean, when people are planning a pregnancy, everyone that I’ve ever come in contact like, they were like, Oh, we’ve been trying for a month! And I’m like, well, things just are supposed to happen. I mean, it just happens

(“Sean,” 35 years old, Black, Not a Father).

Thus, participants often displayed a sense of fatalism over the occurrence and timing of pregnancies.

4. Discussion

In this qualitative study with 58 low-income Black and White men in Pittsburgh, we found that men frequently perceive that women are and should be primarily in control of contraception and pregnancy, often do not have conversations with partners about contraception and pregnancy, feel that acceptable male-controlled methods of contraception are lacking, report pregnancy-promoting behaviors on the part of partners, and express fatalism about pregnancy occurrence. These factors allow them to understand and experience pregnancy and paternity decisions as ultimately out of their hands. Men’s perceived lack of agency with respect to contraceptive use and family planning is problematic, as it indicates a perceived lack of autonomy in controlling a major life event that has far-reaching emotional, social, and financial implications.

Additionally, these attitudes and beliefs reflect gendered social structures in which women bear the burden of fertility work [27]. Ingrained gender inequities combined with the lack of acceptable and effective male-controlled contraceptives highlight potential motivational pitfalls in engaging men in family planning to reduce their risk of undesired pregnancy. At the same time, men’s perceived lack of reproductive agency must be interpreted within the framework of the overarching contemporary patriarchal structure, including power dynamics within individual sexual and romantic relationships and reflected in the prevalence of interpersonal violence and sexual harassment in our society; in this context there is an explicit tension between increasing men’s reproductive agency and maintaining and expanding women’s reproductive autonomy and empowerment.

From a family planning programming standpoint, the goal is not to increase men’s literal control over women’s contraceptive and pregnancy choices, but rather to move towards respectful and mutual responsibility over the work of pregnancy prevention. Our research findings indicate a need for increased male contraceptive options, as well as the need for transforming masculine gender norms to encourage men to view contraception as within their purview and engage in reproductive decision making in ways that are not coercive to women. With regard to currently available male-controlled methods, it is tempting to argue for increased efforts to promote condoms as a tool not only for STI prevention but also as effective contraception that, when used consistently and correctly over time, can assure a man some control over his fertility in each sexual encounter. However, data from this study suggest that long-term condom use is not considered preferable by men, and/or by their female partners, and as such promoting condom usage in the absence of other options ignores men’s own preferences, as well as their deference to female partners in contraceptive matters.

However, while acknowledging the structural inequity with regards to contraceptive methods available to men, it must also be acknowledged that men appear to use that inequity to sometimes avoid responsibility for contraception and reproduction, essentially acting in accordance with U.S. society’s casting of contraception as a women’s responsibility. Our society’s framing of contraception as a woman’s choice because it occurs in her body serves to privilege women’s reproductive autonomy (which is a good thing), but at the same time absolves men of any responsibility by ignoring men’s ability and agency to have sex or decline to have sex (even at the possible expense of his reputation as a sexually virile man), and/or to do so without using a condom or even discussing contraception. As such, men in our study revealed the tendency to prioritize sex (and thus conform to sexually virile masculinity) over the work of pregnancy prevention, thereby reflecting and reinforcing current gender inequities in which physical, mental and emotional “fertility work” ultimately falls to women [27]. Additionally, the ways in which men discuss their lack of reproductive agency are reflective of the emerging concept of “hybrid masculinity,” in which men adopt some attitudes or identities at odds with hegemonic masculinity (i.e., women should control reproduction so as to ensure their reproductive autonomy) while at the same time accommodating imbalanced power structures that can at times work in their favor (i.e., absolving themselves of responsibility for the work of pregnancy prevention) [28,29].

Thus our findings indicate the need for bringing contraception and responsibility for reproductive decisions into the purview of healthy masculinity. There has been considerable prior research on involving men in contraceptive decision-making within committed and/or married couples, particularly in the international context [30–43], which indicates that men can be successfully integrated into contraceptive decision making. However, men need to be considered contraceptive users in their own right, and the majority of men need to be educated and encouraged to participate positively in overall contraceptive decision-making, beyond the use of condoms. Prior research has indicated that men are poorly served by family planning programs that focus on women, and has called for family planning programming that addresses, challenges, and transforms gender norms such that men can effectively address their own contraceptive needs [44–46]. Programs such as CHARM, which combined gender equity and family planning counseling for men and their wives in rural India, provide potential guidance for programming that could be developed to address low income American men’s contraceptive needs. In CHARM, three sessions of contraceptive and gender-equity counseling were delivered to young married men by village healthcare providers in rural India. The first two were delivered to men alone, with the third including their wives. [41] Follow-up surveys found that women whose husband’s participated in CHARM were more likely than controls to report discussing contraception with their husbands and more likely to be using modern contraceptive methods, and that men who participated in CHARM were less likely than controls to endorse “attitudes accepting of sexual interpersonal violence” [43]. However, such programming would have to be adapted considerably for American social contexts in which casual sexual relationships are common.

4.1. Limitations

Our study and its results have limitations. First, participants were self-selecting. Although we screened participants for inclusion criteria, they themselves contacted us based on having seen a study advertisement. It is possible that the men who contacted us have different opinions or experiences in some way from their counterparts who decided not to contact us. Second, it is possible that participants were restrained in their opinions by social desirability bias, particularly given that the interviewer (MH) was female. It is possible that men did not want to discuss negative opinions of women, or blunted those negative opinions, due to the gender of the interviewer. The decision to proceed with a female interviewer was made given MH’s considerable prior interviewing experience, and comfort with sensitive sexual topics given her prior research experience in topics related to sexuality. We decided to conduct the interviews over the phone rather than in-person due to feedback from men on the team that having such a conversation face-to-face with a woman might be distracting or uncomfortable. Prior to the interview starting, interviewees were assured that they could refuse to answer any questions that they were uncomfortable answering for any reason. M.H. discussed interviewing issues with S.B. throughout data collection, but largely men appeared to be comfortable with the interview process and the interviewer. Per M.H.’s interviewing notes, only two participants ever refused to answer a question, and the gender of the interviewer did not prevent some men from expressing misogynistic statements or general frustration with women, although of course this does not mean that the interviewer’s gender played no role in the study, or did not cause other participants to hold back. Conducting a similar study, but with a male interviewer, might yield interesting comparative data on this topic. Additionally, the interviewer is from a different socioeconomic and educational background than participants, is of a different race than some participants, and was younger than some participants (and older than others) which may have had similar, unknown effects on what participants disclosed. Participants were not noticeably uncomfortable with the interviewer’s background, but as with gender, conducting similar research with a differently situated interviewer might yield valuable results. Our study team as a whole is diverse with regards to race and gender, which helped to provide nuance during the analytical process. Lastly, our participants were limited to individuals who identified as White or Black within a single urban area. Men from other regions, or with other ethnic or racial backgrounds, may have different opinions and experiences, and results are not transferable to low income US men as a whole.

4.2. Conclusions

Our study finds that low-income men frequently feel that they have low reproductive agency. In order to reduce the negative impact of unintended and/or unwanted pregnancies on this already vulnerable population, development of a greater repertoire of acceptable male-controlled methods is warranted, as well as family planning programming that views men as contraceptive users, and helps to promote more gender-equitable contraceptive practices.