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A view of the interior of a health clinic in Long Island City.
Social Mobility Memos

What’s stopping American men from getting vasectomies?

Richard V. Reeves and Eleanor Krause

Contraception is typically seen as women’s work. This is unfair but understandable, given that the most effective forms of contraception are used by women, especially long-acting reversible forms, and that women see their life chances impacted most by an unintended pregnancy.

Vasectomy: You know it makes sense

Once a couple has decided their baby-making years are over, they may opt for sterilization—which is, in fact, the second-most common form of contraception in the United States. Male sterilization, known as vasectomy, is the only long-acting method of birth control available to men, and is a vastly better option than female sterilization, for at least three reasons:

  • More effective: Vasectomies are slightly more effective at preventing unplanned pregnancy than female sterilization (itself very highly effective).
  • Cheaper: Female sterilization can cost as much as $6,000, about six times that of vasectomy.
  • Safer: Risks of major complications following a vasectomy are extremely low. It is generally believed to be a safer technique than female sterilization.

Given these clear advantages, it is no surprise that vasectomy is twice as common as female sterilization in many countries, including Canada and the UK. But in the U.S., the opposite is true (note that figures are for couples):

ccf_20161012_reeves_1

Rates are especially low among minorities: only 1 percent of black women and 3 percent of Hispanic women rely on a partner’s vasectomy for birth control, compared to 8 percent of white women. More educated men are also more likely to opt for sterilization. If the U.S. rates were the same as Canada’s there would be about 4 million more couples relying on a vasectomy for contraception rather than female sterilization.

Why does the ACA cover female sterilization but not male sterilization?

Policymakers missed an opportunity to improve matters during the creation and passage of the Affordable Care Act. The ACA mandates insurance coverage of 18 forms of female contraception, including sterilization, but not vasectomy. As Adam Sonfield of the Guttmacher Institute writes:

This interpretation interferes with the reproductive health decisions of individuals and couples, which could put women at greater risk of unintended pregnancy and undermine their health. And it benefits no one—not men, not women, not families, not health plans.

This asymmetry is the result of the convoluted legislative history of the ACA. Women’s contraception is not covered as an essential health benefit, but under the “preventive services requirements” of the Public Health Service Act—defined there as being “with respect to women.”

The best hope now, as Sonfield says, is that the U.S. Preventive Services Task Force recommends the inclusion of vasectomy on its list of approved preventative services (which would then, after a 1-year grace period, mean ACA coverage). After all, vasectomies prevent unintended pregnancies just as effectively, and much more cheaply, than female sterilization.

But clearly this is an area where culture counts for at least as much as policy. American men may be more reluctant because of greater family instability, or they assume contraception is a “women’s issue.” Perhaps the American ideal of masculinity precludes voluntary infertility. What is clear is that some progress on this front would be welcome.

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