Arch. Gyn/ik. 220, 89-97 (1975) 9 by J. F. Bergmann Mfinchen 1975

Attitudes of Men toward Contraception Louis Keith, D o n a l d Keith, R o d n e y Bussell a n d John W e l l s The Illinois Family Planning Council, Chicago and the University of Health Sciences, Chicago Medical School, Chicago, Illinois Received June 25, 1975

Summary. This report describes a pilot study conducted to determine the attitudes of men toward contraception. A questionnaire elicited responses from 436 males regarding: Personal data; contraceptive responsibility; contraceptive knowledge; use of contraception and preference for future methods. Results include attitudes toward contraceptive responsibility, assistance to pregnant partners and knowledge regarding eight common contraceptives. Usage of contraceptives in general and condoms and withdrawal specifically is reported. Preference for eight common contraceptive methods is also presented, along with data on delay of intercourse due to lack of contraceptives, partners' requests for male use of condoms/withdrawal and attitudes toward dissemination of contraceptive material to the public. Also reported are attitudes toward development of new contraceptives, use of male sterility shots or pills and the prices that men would pay for newly developed male contraceptives. The most preferred male contraceptive for future development is reported. It was concluded that the survey form and methodology were valid; that men desired to participate in family regulation; that the majority of men placed a low economic value on male contraceptives and finally that the overwhelming majority of men wanted contraceptive information to be widely disseminated in the public. The limitation of p o p u l a t i o n g r o w t h is of c o n c e r n to f a m i l y units, social organizations, g o v e r n m e n t a l agencies, and the m e d i c a l profession. In the last 15 years, p e r f e c t i o n of the oral c o n t r a c e p t i v e , the i n t r a - u t e r i n e device (IUD], and of vaginal f o a m s a n d s p e r m i c i d e s has c l e a r l y p l a c e d the r e s p o n s i b i l i t y of contrac e p t i o n on the w o m a n . Each c o n t r a c e p t i v e m e t h o d has b e e n s u b j e c t e d to criticism. During the same period, f e w efforts w e r e d i r e c t e d t o w a r d m e n to a s c e r t a i n t h e i r desires r e g a r d i n g i n c r e a s i n g p a r t i c i p a t i o n in the area of f a m i l y planning. Male a t t i t u d e s t o w a r d c o n t r a c e p t i v e p r a c t i c e are influenced b y religious beliefs, desire for a family, and economic c o n s i d e r a t i o n s . T h e s e beliefs u l t i m a t e l y affect the i n c i d e n c e of v e n e r e a l disease, influence m a r k e t i n g research, governm e n t a l policies, a n d e x p e n d i t u r e s in the public domain. A n initial s u r v e y of attitudes of m e n t o w a r d f a m i l y p l a n n i n g w a s u n d e r t a k e n at Cook C o u n t y Hospital, Chicago, in 1971 [1]. The results suggested that a larger and m o r e c o m p r e h e n s i v e s t u d y might be h e l p f u l in d e v e l o p i n g p r o g r a m s w i t h greater e m p h a s i s on the p a r t i c i p a t i o n of men. 7

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Materials and Methods Interuiem Preparation An undisguised questionnaire was formulated for a personal interview situation. This method gave advantages of flexibility, accuracy, and control over the sample. The project questionnaire was divided into sections, as follows: a) personal information; b) contraceptive responsibility; c) contraceptive knowledge; d) use of contraception, and e) contraceptive preferences. Each question was tested to see whether it facilitated answering the question: "What is your attitude toward contraception?" The anticipation was that most respondents would have the information requested and would give it without effort. Most questions were multiple choice. A few were dichotomous. The exact wording of each question was reviewed to insure technical accuracy. To that end, simplicity of the questions was essential; ambiguity had to be avoided as did leading the respondent, generalizations, and unreasonableness. The survey was pro-tested, revised, and printed. A combination of convenience and stratified random sampling was used in the selection of t h e samples for the survey. The stratification variable, geographic location was qualitative, and decisions on the definition of strata were arbitrary. Stratified selection of locations was combined with the non-probability sampling technique of convenience sampling, so that "men-on-the-street" would actually be chosen as the sample units, a primary objective of this pilot survey. The stratified locations included: Eatontown, N.J., Monmouth College, N.J., Philadelphia, Pa., Washington, D.C., random locations in Monmouth County, N.J., and Anacostia, Va. The desired sample size was 450 units. The actual sample numbered 438. Some men who were asked to participate refused. Accurate statistics about them were not kept, but the estimated number is 5%; all were over 80 years of age. In all instances of refusal, a different additional respondent was sought to participate, thus reducing the bias of non-response.

Data Analysis Computer reduction of raw data was paramount to the success of the project; therefore, the computer program choice was the MERMAC System of Test and Questionnaire Analysis Programs for the IBM System 860 [2]. That system provides frequency distribution of responses, weighted means, standard deviations, a reliability index for items logically grouped, descriptive information about each group (in this case, the demographic questions), and summaries of responses to items for each question. On the initial gross print-out of the data, no attempt was made statistically to test observed differences between groups, to explain why differences existed, or to make recommendations concerning such differences. Subsequent data evaluation has explored each group separately for each item, permitting an analysis of differences among the groups. These differences will be reported at a later date.

Results Age 70'~ of the r e s p o n d e n t s w e r e b e t w e e n the ages of 20 and 39 years; 14'~ w e r e u n d e r 20 y ears of age; and 14'~ w e r e 40 or m o r e (Table 1).

Marital Status 550/0 w e r e married, either for the first or s e c o n d time; 3 8 % w e r e single; the r e m a i n d e r of the r e s p o n d e n t s listed o t h e r categories.

Education T h e g en eral e d u c a t i o n of the sample p o p u l a t i o n w a s higher than that of the n a t i o n a l p o p u l a t i o n : 3 2 % of the s u r v e y r e s p o n d e n t s h ad c o m p l e t e d college or

Attitudes of Men toward Contraception Table 2. Degree of religious feeling

Table 1. Age of respondentsa 10--19 20--29 30-59 40-49 50 and above Not answered

91

14~ 47o/o 23~ 10~ 4o/o 1~

Very religious Somewhat religious Slightly religious Not at all religious Irreligious Not answered

8'o/o 39o/o 31~ 20~ 2o/o 1~

a All data 109~ + l~ because of computer rounding

attained graduate degrees. Only 13% reported that high school had been the last formal education.

Religion The Catholic and Jewish populations surveyed were out of proportion to their national representation. Degree of Religious Feeling Most of the respondents (70%) reported feeling either "some" or a "slight" degree of religious feeling. Only 8~% of the respondents considered themselves "very religious" (Table 2).

Children Produced 53% of those surveyed were childless. Of the respondents with children, 14~ had i child, 15'~ had 2, 10'~ had 3, 5o/o had 4 and 3~ had 5 or more children.

Children Desired The: number of children desired differed significantly from the number of children produced. The most frequent response was 2; the majority wanted 3 or less.

Racial Background The racial backgrund of the respondents approximates the national demographic pattern. This takes into account a 12+/o Black population, half of which are women.

Contraceptive Responsibilit!/ Overwhelmingly, 84~ of the men asked believed that both sex partners had responsibility for contraception. Further, 77% stated that they would help a woman whom they impregnated both financially and morally when contraceptives taken or used by either partner failed. This preponderance dropped to 5 4 ~ who responded positively when asked if they would assist a woman whom they impregnated to get an abortion (Tables 3, 4, 5). 1 1 Note: Survey completed prior to the Supreme Court ruling on abortion January, 1973. 7*

L. Keith et al.

92 Table 3. Contraceptive responsibility

Table 4. Assistance to personally impregnated woman

Man Woman Both sex partners Neither

Morally Financially Morally and financially Neither Not answered

4o/0 10~ 84% 3o/0

60/0

70/0 77~ 8'0/0 3O/o

Table 5. Assist woman to obtain an abortion

Table 8. Who should have access to contraceptive information and devices

Morally Financially Morally and financially Neither Not answered

Anyone Anyone over 18 Anyone over 21 Only married or engaged couples No one Not answered

4% 9~ 540/0 27% 6~/o

76'0/0 15% 20/0 3% l~ 40/0

Contraceptioe Knomledge Th e k n o w l e d g e of the r e s p o n d e n t s r e g a r d i ng eight p r e s e n t day c o n t r a c e p t i v e s w a s high. It r a n g e d f r o m a l o w of 84O/o for the IUD to a high of 98:~ ~or oral c o n t r a c e p t i v e s and c o n d o m s . A l t h o u g h some r e s p o n d e n t s did not a n s w e r parts of this question, all w h o a n s w e r e d h a d k n o w l e d g e of condoms. Th e av er ag e for the eight r e s p o n s e s w a s 91~ (Table 6). Table 6. Contraceptive knowledge Do you have knowledge of the "pill"? Do you have knowledge of intra-uterine devices (IUD's)?

Do you have knowledge of female diaphragms?

Do you have knowledge of contraceptive douches?

Do you have knowledge of contraceptive creams, foams, ore jellies? Do you have knowledge of the rhythm method?

Do you have knowledge of condoms?

Do you have knowledge of withdrawal as a contraceptive method?

Yes No Yes No No answer Yes No No answer Yes No No answer Yes No No answer Yes No No answer Yes No No answer Yes No No answer

98~ 20/0 840/0 16~ 1~ 930/0 70/0 1~ 86o/0 13~ 1~ 900/0 9~ 1% 890/0 10~ 1~ 980/0 O~ 1~ 94~ 50/0 1~

Attitudes of Men toward Contraception Use

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of Contraception

There were nine questions regarding the r e s p o n d e n t s ' p r e s e n t use of methods of contraception. Complete results are s h o w n in Table 7. Of the m e n interviewed, 4 6 % stated that they or their sex partners used some form of contraceptives all of the time; 6 % used c o n d o m s all of the time; 3'~ reported the h a b i t u a l use of coitus interruptus. Conversely, 40'% n e v e r practiced coitus i n t e r r u p t u s a n d 13% n e v e r used condoms. 58~ of the m e n stated that p r e s e n t l y they prefer female oral contraceptives for family planning. 11% reported delaying or p o s t p o n i n g intercourse m a n y times b e c a u s e of lack of a contraceptive. 36'% were n e v e r asked by a female p a r t n e r to use a c o n d o m or coitus interruptus. W h e n asked to use a c o n d o m or coitus i n t e r r u p t u s b y their partner, 31~/o agreed to do so all the time b u t 3~ refused m a n y times. A significant n u m b e r , 76% of those queried, believed that anyone, regardless of age or marital status, should have access to contraceptive techniques and devices (Table 8}. Table 7. Present use of contraceptive methods All of the time Most of the time Seldom Never Not answered

460/0 16~ 12~ 230/0 30/0

Respondents use of condoms All of the time 60/0 Most of the time 8'% Some of the time 20~ Seldom 19% Very seldom 31~ Never 13o/o Not answered 20/0 Repondents practice of coitus interruptus All of the time 3% Most of the time 50/o Some of the time 16% Seldom 10~ Very seldom 23~ Never 400/0 Not answered 4~ Most preferred presently available contraceptive Condom 90/0 Withdrawal 30/0 Pill 58~ IUD 11~ Diaphragm 5o/o Douche lO/o Contraceptive foams, creams or jellies 3o/o Rhythm method 50/0 Not answered 50/0

Postponement of intercourse because of inadequate contraception Many times 11~ Sometimes 21% Very few times 29o/0 Never 36O/o Not answered 40/0 Request for use of condom or withdrawal by female partner Many times 9o/0 Sometimes 280/0 Very few times 240/0 Never 360/0 Not answered 40/0 Agreement by males to use dom or withdrawal Never was asked Agreed all the time Agreed many times Agreed sometimes Agreed very few times Never agreed Not answered

con25% 31% 9% 14o/o 8~ 80/0 4~

Refusal of males to use condom or withdrawal Never was asked 350/0 Refused many times 30/0 Refused sometimes 60/0 Refused very few times 11% Never refused 40~ Not answered 5~

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L. Keith et el. Table 9. Future contraceptive preferences

Would you use a newly developed male contraceptive if it were other than a condom or withdrawal?

Yes No Not answered

700/0 250/0 60/0

Would you use a pill or take a shot to make you sterile for a period of up to 30 days, but capable of intercourse and ejaculation?

Neither Pill Shot Both Not answered

320/0 250/0 30/0 360/0 30/0

What would you consider a reasonable price for a male contraceptive?

More than ~ 5.00 a month

13%

Less than $ 5.00 a month Less than $1.0O a month Not answered

54% 260/0 70/0

Improved condoms

10%

One night sterility, pill or shot One week sterility, pill or shot One month sterility, pill or shot One year sterility, pill or shot Reversible vasectomy Not answered

15% 13% 27% 10% 1~ 50/0

Which one of the following would you prefer in future male contraceptives?

Contraceptive P r e f e r e n c e s F o u r q u e s t i o n s p e r t a i n e d to c o n t r a c e p t i v e p r e f e r e n c e s for the future (Table 9). 70% of the r e s p o n d e n t s s t a t e d that t h e y w o u l d use a n e w l y d e v e l o p e d male c o n t r a c e p t i v e if it w e r e n o t a s s o c i a t e d w i t h c o n d o m s or coitus i n t e r r u p t u s ; 3 6 % w o u l d use a pill or s h o t m a k i n g t h e m sterile for 30 d a y s b u t still c a p a b l e of intercourse a n d ejaculation, 250/o p r e f e r r e d a pill alone. The e c o n o m i c value p l a c e d on c o n t r a c e p t i o n b y m e n w a s low: 54% s t a t e d that the cost s h o u l d be less t h a n $ 5 . 0 0 a month, and an a d d i t i o n a l 2 6 % t h o u g h t that the c o s t of the c o n t r a c e p t i v e s s h o u l d be less t h a n $1.00 p e r month. The last q u e s t i o n a s k e d i n t e r v i e w e r s to s h o w their p r e f e r e n c e in male contrac e p t i v e s for the future. 10'~ d e s i r e d i m p r o v e d condoms, 15~ a one-night sterility pill or shot, a n d 13~/o p r e f e r r e d a o n e - w e e k sterility pill or shot. 2 7 % d e s i r e d a o n e - m o n t h sterility pill or shot, obviously, on the s a m e o r d e r as the female "pill". O n l y 10'% i n d i c a t e d a p r e f e r e n c e for a pill or shot t h a t w o u l d be effective for one year. The s e c o n d l a r g e s t n u m b e r of r e s p o n d e n t s , 19%, p r e f e r r e d a r e v e r s i b l e vasectomy.

Discussion The p i l o t s t u d y w a s done in t h r e e g e o g r a p h i c l o c a t i o n s : P h i l a d e l p h i a , Penns y l v a n i a ; M o n m o u t h County, N e w Jersey; a n d W a s h i n g t o n , D. C. M o r e t h a n 75% of the r e s p o n d e n t s w e r e in M o n m o u t h County, N e w Jersey. Certain limitations are recognized. T h r e e g e o g r a p h i c a l s u r v e y a r e a s do not c o m p r i s e a r e p r e s e n t a t i v e

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national sample. Those locations were selected because they had large populations of men and were easily accessible to the interviewers. Every effort was made to choose as wide a range of respondents as possible regarding age, racial background, and annual income. It is possible that a few respondents who were personally acquainted with interviewer's under-reported, that is, did not answer all of the questions. Some of the questions were personal, so that a number of those surveyed refused to fill in specific responses. Such refusals ranged from 1 - 7 % on specific questions. Statistical results were not weighted in any way to provide for national projectibility; this limitation prevents a generalization regarding the results. The study showed that most men (70'%) would use newly developed contraceptive methods, if available. Of the preferences offered, a monthly pill or shot was most favored [27'~ a figure somewhat less than was observed by Spfllane a~d Ryser. Slightly over 50% of the men in Pittsburgh stated that they would take a birth control pill [3]. Among so-called lower "class" males, Balswick found only 41~ were inclined to take a pill or shot [4]. Consistent use of contraception was admitted by 46% of the respondents while 16% were frequent users. Only 23o/0 of those interviewed stated that they never used contraception. They can be called rejectors. In the Spillane and Ryser study, there was a 21~ non-contraceptive use [3], and 56'o/0 of American-Black men [5] responded similarly. The Westoff study [6] in 1970, showed a slight decrease in the number of all couples reporting that they never used contraception as compared with 1965. Rejection of contraception is an interesting phenomenon in view of the widespread availability of contraceptive methods [7]. As a result of this rejection, almost a third of the first births in the U.S.A. are illegitimate. Among the psychologic reasons for rejection of contraception are: denial, guilt, love, shame coital gamesmanship, sexual identity crisis, hostility, masochism, eroticism, nihilism, fear and anxiety, and the availability of abortion. The results of rejection of contraception are diverse. Not only is the possibility of pregnancy a grave threat, but should this take place, it often leads to a train of disastrous physical and mental events. Contraceptive knowledge was higher in this study than in any other reported series, including a national youth survey by Planned Parenthood - World Population [8] reported in 1972. This may reflect the higher education of the respondents. The finding of 76% respondents who believe that contraceptives should be available to all persons is in agreement with our previous study reported in 1971 which showed 70'% of the respondents in favor of birth control services at public clinics [1]. Almost 9e% of Pittsburgh respondents stated that they would themselves participate as clients of family planning services [3]. The same men held a favorable attitude toward the involvement of government in voluntary family planning services. The youth of the respondents may be reflected in the discrepancy between the number of children produced and the number desired. Our earlier study showed similar results [1]. The implications of this study are clear. 1) From a man's point of view, adequate male contraception is simply not available. If it were, no great economic

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L. Keith etal.

value was placed upon it by the respondents. 80'% would pay no more than $ 5.00 a month for adequate male contraceptives. Although a percentage of the American public could afford up to $ 5.00 a month for male contraception, such a sum would be impossible for many others especially in underdeveloped countries. 2) Men have yet to enter the contraceptive market in significant numbers and with greater enthusiasm. This finding supports the conclusions of Middlemon [9]. Even when presently available methods have been intensively advertised in the public media, such a campaign did not produce significant changes in the birth control behavior of individuals who obtained contraceptives from private doctors or drugstores [10]. Improved male condoms are available. Japan has spearheaded their development. However, these products are not presently marketed in the U.S.A. [11],

Conclusions 1. The vast majority of respondents believed that contraception was the responsibility of both partners. Significant numbers of the men stated that they would provide moral and financial assistance to a woman they had impregnated, but only slightly more than 50% agreed to assist the woman to get an abortion. {N. B. The study was done prior to the 1973 Supreme Court Decision on Abortion.) 2. The knowledge exhibited regarding contraceptive methods was higher than any other survey previously reported. 3. Contraceptive responsibility had been abrogated to female partners or was not used at all. The habitual use of condoms or coitus interruptus was found in a minority of respondents only. 4. Almost two-thirds of the men had been asked to use condoms or coitus interruptus by their partners at some time. 5. Postponement of intercourse for lack of contraception is common. 6. A once-a-month shot or pill for men was the most favored of possible contraceptive suggestions for the future. The next most frequently requested was a reversible vasectomy. 7. 7 0 % of the respondents stated they would use a newly developed male method if not a condom or coitus interruptus.

Bibliography 1. Keith, L., Swartwout, J., Haksar, K., Tamblyn, P., Green, R.: Male Attitudes Toward Family Planning. The Chicago Medical School Quarterly. Vol. XXX, No. 2, 3, 4, pp. 59--63 (1971) 2. Bussell, R., Costa, I., Spencer, R., Aleamoni, L.: Mermac Manual. Urbana: University of Illinois Press 1971 3. Spillane, W., Ryser, P.: Male Household Heads Attitudes Concerning Contraception, Abortion, and Related Policy Issues. Pittsburgh, Pa.: Graduate School of Public Health, University of Pittsburgh 1971 4. Balswick, J.: Attitudes of Lower Class Males Toward Taking a Male Birth Control Pill. The Family Coordinator. pp. 195-199 (1972) 5. Darity, W., Turner, C., Thiebaux, H.: An Exploratory Study on Barriers to Family Planning: Race -- Consciousness and Fears of Black Genocide as a Basis. Excerpta Medical International Congress, April 1971, pp. 20-32 6. Westoff, C.: The Modernization of U.S. Contraceptive Practice. Family Planning Perspectives, Vol. 4, No. 3, pp. 9--12 [1972)

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7. Sandberg, E., ]acobs, R.: Psychology of the Misuse and Rejection of Contraception. Medical Aspects of Human Sexuality, Vol. VI, No. 6, pp. 34-64 (1972) 8. Silver, M., Pomeroy, R., Burbank, J.: National Youth Survey. Paper presented at Annual Meeting of the Population Association of America, Toronto, Canada, April 13--15 (1972) 9. Udry, l., Clark, L., Chase, C., Levy, M.: Can Mass Media Advertising Increase Contraceptive Use? Family Planning Perspectives, Vol. 4, No. 3, pp. 37-44 (1972] 10. Harvey, P.: Condoms, A New Look. Family Planning Perspectives, Vol. 4, No. 3, pp. 27-30 (1972} 11. Middlemon, R.: Services for Males in a Family Planning Program. American Journal of Public Health, 62, pp. 1451-3 (1972) Dr. Louis Keith Cook County Hospital 1825 West Harrison Street Chicago, Ill. 6,0612 U.S.A.

Attitudes of men toward contraception.

This report describes a pilot study conducted to determine the attitudes of men toward contraception. A questionnaire elicited responses from 436 male...
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