Down But Not Out: Vasectomy Is Faring Poorly Almost Everywhere—We Can Do Better To Make It A True Method Option

Societal Norms and Contraceptive Responsibilities

In most LMICs, FP, like child-rearing, has largely been seen as a woman’s responsibility and domain.³⁰ Certainly, the demands of pregnancy and the brunt of pregnancy-related morbidity and mortality fall on her. Consequently, FP service provision has long been oriented to reproductive-age women, and women are the main users of contraception, including PMs. Health care programs generally focus to a lesser extent on men’s health care needs,³¹ and services for men in FP settings are typically limited. That there are only 2 contraceptive methods for men, both with method-related challenges—the condom, which is nonclinical and has a failure rate in typical use of 5%–13%,² and vasectomy, which must be surgically delivered, is suitable only for limiting fertility, and requires a skilled provider and supportive clinical infrastructure—is also likely a relevant factor in these dynamics.

Awareness and Accurate Understanding

Vasectomy has long been and still is the least known modern method in LMICs.^3,4 For example, in Africa’s most populous country, Nigeria, only 18% of women and 33% of men know of vasectomy.²¹ In contrast, the most widely known method there, the pill, is known by 82%–88% of women and men, injectables are known by 82%–88% of women, and tubectomy is known by 48%–49% of married people. Similarly, in Kenya, only 47% of women and 56% of men know of vasectomy, whereas 84%–87% know of tubectomy and 97% know of the pill.²² Even in countries where PMs are much more widely used, awareness of vasectomy is lower than that of tubectomy. For example, in India, 93%–98% of urban men and women know of tubectomy, whereas only 85%–88% know of vasectomy.²³ In Colombia, where awareness of tubectomy is essentially universal (98% among MWRA), awareness of vasectomy is similarly lower (89%).³² Differences in how providers inform clients about PMs may contribute to such low awareness: one study from the United States found that women received more counseling from their providers on PMs than did men.³³ Studies in Ethiopia found knowledge of vasectomy to be associated with an individual’s level of education,^34,35 positive attitude toward vasectomy, and intention to use vasectomy.^36,37

Furthermore, in surveys of contraceptive use, “knowledge” of vasectomy relates to whether respondents have heard of or are aware of the method but not necessarily to whether they have accurate or correct understanding of it.³⁸ Vasectomy is the method most plagued by widespread, deep-seated, and persistent myths and misunderstandings about it and biases against it.^4,27 People erroneously fear that vasectomy might make a man impotent or “weak,” promiscuous, and/or unable to work and contribute to family well-being. Not only do FP clients or potential clients have deep-seated biases against vasectomy, but health care providers and program leaders often have biases against it as well.^28,39 We have even encountered translators who refused to translate the word “vasectomy” in a discussion of method options because they thought what was being discussed was castration.

Client Demand and Program Prioritization

The normative realities and dynamics discussed earlier lead to a general lack of demand for vasectomy, which has been identified as a major impediment to greater interest in vasectomy among current and potential future FP clients in LMICs.²⁷ Reflecting (and also contributing to) this lack of demand among women and men alike, prioritization of vasectomy has generally been low in FP programming and donor funding.⁴⁰ Low prioritization, over many decades, is also implicit in the low vasectomy prevalence rates seen in almost all LMICs in multiple contraceptive use surveys from the 1970s through the early 2020s.¹¹ A recent informal analysis found that between 2005 and 2015, one major bilateral FP donor had only 5 projects with a vasectomy component, among upwards of 30 FP projects; this and other analyses confirm that funding for vasectomy has been meager.^39,40

On the one hand, low program and donor prioritization are understandable and defensible. Funding for FP has generally been limited, FP programs aim to serve as many people as possible with limited resources, and vasectomy uptake, at least in initial years of programming, will almost certainly be modest. On the other hand, absent support for and attention to vasectomy, its marginal status will not improve. In 2020, the U.S. Agency for International Development (USAID)–funded MOMENTUM Safe Surgery in Family Planning and Obstetrics project, which supported the development of this article, was awarded to “build awareness of, equitable access to, and provision of high-quality surgical care,” including (both) PMs as a priority component.⁴¹ Funding for vasectomy at the service level, however, will depend on decisions taken at individual USAID Missions and be context driven, typically entailing an intent to achieve prompt and substantial results in service uptake.)

Advocacy and Demand-Side Efforts

Less programmatic attention has been given to advocacy and demand-side efforts,^9,40 whose effects are upstream from supply-side interventions that may generate more immediate outcomes in terms of trained providers and new vasectomy users. Consistent advocacy and demand-side efforts could be of greater ultimate impact; however, donor funding for these elements has been sporadic and limited. When funding has been made available, demand-side efforts via multiple communication and messaging have been very effective and successful on their own terms (see discussion of Brazil). Posters developed by 2 USAID-funded projects (ACQUIRE [Access, Quality, and Use in Reproductive Health] and RESPOND [Responding to the Need for Family Planning]) between 2008 and 2014 in Ghana, Honduras, and India that addressed the demand-related aspects of vasectomy as part of holistic vasectomy programming are still relevant and could be useful today.^42,43 The pictured individuals, including a Ghanaian mayor (Figure 2),⁴⁴ were themselves satisfied vasectomy adopters and vasectomy champions. These images directly speak to people’s concerns regarding vasectomy by conveying images of “strength”; joyful, harmonious couples (Figure 3)⁴³; and happy, coherent (and small) families (Figure 4).⁴⁵ Vasectomy provision in project-served areas doubled or tripled during these efforts. Demand-side aspects of vasectomy programming have also been a prominent feature of the work of World Vasectomy Day and Marie Stopes International (both discussed later), coordinated with provider training activities and concurrent and subsequent service provision.

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FIGURE 2

Poster From Vasectomy Demand Creation Campaign in Ghana

Source: The ACQUIRE Project/EngenderHealth via Knowledge SUCCESS (reproduced with permission).⁴²

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FIGURE 3

Poster From Vasectomy Demand Creation Campaign in Honduras

Source: The ACQUIRE Project/EngenderHealth via Knowledge SUCCESS (reproduced with permission).⁴³

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FIGURE 4

Poster From Vasectomy Demand Creation Campaign in India

Source: The RESPOND Project/EngenderHealth (reproduced with permission).⁴⁵

FP Service Delivery

Because client demand for vasectomy has been low to negligible at the population level in most LMICs, vasectomy services have been sparse, and, as noted earlier, bias against it is often found among providers as well as clients.^3,4,27,29 Even when men and couples do have an interest in vasectomy, the availability of knowledgeable, trained, and skilled providers to discuss vasectomy with potential clients or provide it to those who would choose it is generally low at service sites. At the program level, the modest donor funding made available to international nongovernmental organizations (NGOs) working on vasectomy in LMICs has mainly been devoted to provider training and research on details of the surgical procedure itself.²⁸ These supply-side aspects can be addressed relatively quickly and tangibly, although low demand (and therefore few clients) impedes clinical training efforts. With few clients, it can also be difficult for providers to maintain newly acquired surgical or counseling skills.

Metrics of Program Achievement and “Success”

Program leaders and donors generally want measurable and substantial results that will quickly address people’s ongoing and unmet needs for contraception. Common metrics for success in FP programming include “increases in contraceptive uptake,” “cost effectiveness,” “low cost per user,” and similar metrics reflective of prompt results. Prospects for scale-up and sustainability are also important considerations. However, these metrics, as well as the general criteria underlying programming with limited funds—of aiming to help the most people—reasonable as they are, work to vasectomy’s disadvantage. At the program level, it can take several years of tireless work spearheaded by vasectomy champions before vasectomy becomes more widely, substantially, and routinely available in a country’s method mix. At the individual level, the process whereby men and couples move from considering to obtaining a vasectomy also can take several years.³ Furthermore, men often learn of vasectomy from other men who have previously had the procedure; this is difficult when vasectomy prevalence is very low and few men have already accessed it. Metrics related to advocacy events, the (sustained) work of vasectomy champions, and information-providing or demand-generating activities (via multiple communication channels, e.g., blogs, newspaper articles, call-ins, and in-person interactions.) would also be useful and relevant measures bearing on success in helping vasectomy to become truly part of a country’s available method mix, thereby broadening people’s contraceptive options.

The contrast between 2 successful program efforts in Rwanda and Ethiopia illustrates vasectomy’s relative disadvantage in terms of the extent and rapidity of uptake of a programmatically new, highly effective method that affords several years or more of contraceptive protection and broadens the available method mix. In Rwanda, a substantial training effort—successful in context and demonstrating that African men, like men elsewhere, would choose vasectomy—led to more than 2,500 vasectomies being performed between 2010 and 2012.⁴⁶ At 0.2%, Rwanda’s vasectomy prevalence is one of the highest in Africa, and we estimate about 7,000 Rwandan women are now relying on a partner’s vasectomy (of 3.3 million WRA).¹² In Ethiopia, however, for a variety of interrelated reasons having to do with client preferences, gender norms around who uses contraception, mode and ease of method delivery, and program and donor prioritization, more than 1 million women accessed a hormonal implant between 2009 and 2015 when that method became much more widely available due to lowered commodity cost and ease of training multiple service providers.⁴⁷ Rapid uptake of implants has also occurred in other countries,⁴⁸ and this long-acting reversible method is likely serving some people’s reproductive intentions to limit further births, which may dampen demand for PMs

Cost Considerations

Vasectomy has been analyzed to be among the most cost-effective of all contraceptive methods per couple-year of protection when added (and prorated) to an existing program.⁴⁹ However, the cost of a stand-alone vasectomy program would likely be greater, entailing the full cost for facilities, service providers, and related demand-side activities. The rate of vasectomy uptake also needs to be factored in.

Concerns About a “Single-Method Focus”

We have heard program leaders and donors who are sympathetic to the need to broaden vasectomy availability and access still indicate reluctance to support “single-method efforts” or “a single-method project” that would focus on vasectomy advocacy or programming. Because a fundamental guiding principle of international FP programming is to ensure broad method choice, they are concerned that such an approach might privilege a single method. From the standpoint of vasectomy, however, this stance can be problematic: absent a focused and steady, sustained effort for this single method, vasectomy’s prospects at the program level—to become a truly available and accessible method option on the menu of client choices in FP programs—will likely remain as poor going forward as they have proven to be during the past 4 decades. A broader male RH project that might surmount this “single-method objection” could address vasectomy, although the typical male client interested in vasectomy has a different profile than, say, a candidate for male circumcision or a seeker of services for sexually transmitted infections or HIV. We also note that some single-method projects (e.g., for the Standard Days Method) intended to add a less well-known method to the mix of available client options in LMICs have long been donor-funded.⁵⁰

Concerns About Coercion

Forced sterilization has a long and sordid history that may be influencing clients, potential clients, programs, and donors. A bedrock principle of FP programming and service provision is that clients must have free, informed, and voluntary choice in contraceptive decision-making and use. This is particularly and most fundamentally the case with PMs, which must be provided without any undue influence or frank coercion.³ Forced sterilization has occurred during the past 50 years or longer in the United States, Canada, China, India, and elsewhere. The eugenics movement, which arose and flourished during the 19th and 20th centuries in the United States, often entailed forced sterilization, mainly of women; it only ended officially in 1981 and has been reported subsequently.⁵¹ Similarly, forced sterilization occurred in Canada, with indigenous women disproportionately targeted.^52,53 Coercive efforts to force sterilization on people that occurred in India in the 1970s, in a widely publicized campaign aimed mainly at men, still have an impact on the Indian public today.^54,55 This legacy may be exerting an “inverse halo” effect on demand for vasectomy in India, where use of PMs at relatively low parity and age is a societal norm and tubectomy use is extensive, yet vasectomy use is very low and declining. In China, where tubectomy use is also extensive, recent allegations of forced sterilization of minority women have been prominent.⁵⁶

Even the word “sterilization” is problematic, conjuring memories of compulsory sterilization programs directed widely at religious and racial minorities.⁵⁷ Because of these resonances and to avoid inadvertent stigma, in this article, we have used the term “tubectomy”—which is parallel to “vasectomy.” (The surveys compiled by UNDESA that we rely on extensively report prevalence figures for “female sterilization” and “male sterilization.”) Similar sensitivity to language accounts for avoiding the word “targets” in PM programming, as opposed to “goals,” “objectives,” or “desired results”—and then ensuring that program activities protect and reinforce voluntary choice. It is important for FP programs in LMICs to be mindful of these linguistic considerations and the still-potent negative resonances of unacceptable practices, while still working to make vasectomy a true method option for the people they serve.

South Korea

South Korea’s contraceptive method mix is a rare exception to the pattern of higher reliance on female methods that predominates in almost all countries. The male condom and vasectomy are the 2 most commonly used methods, with method shares of 36.6% and 25.3%, respectively. South Korea ranks first in vasectomy prevalence among the world’s 190+ countries and tenth in gender equality among 162 countries—the highest ranking in gender equality of any Asian country.¹⁵ South Korea’s last survey providing method-specific disaggregation is from 2009, but in 3 subsequent surveys, comparable or higher overall contraceptive use was registered (82.3% contraceptive prevalence rate in 2018). Vasectomy prevalence has been in double digits in 7 surveys since 1988, and male condom use has also been substantial, strongly suggesting that constructive male engagement and sharing of contraceptive responsibilities is an entrenched societal and contraceptive norm. South Korea’s socioeconomic ascent from LMIC to HIC and its high gross domestic product (GDP) per capita (US$31600 in 2021) coincide with these achievements and reflect its attainment of a “demographic dividend.”^58,59

Bhutan

In Bhutan as in South Korea, a couple’s choice of vasectomy after attaining desired family size is a longstanding national norm, vasectomy remains the predominant PM used. One of every 5 MWRA contraceptive users in Bhutan relies on vasectomy, and Bhutan has the third highest vasectomy prevalence in the world, higher than that of more than 190 countries. Bhutan has maintained a double-digit vasectomy prevalence of 12%–13% over a recent decade while more than doubling its MCPR to 65.4%, a level of modern method contraceptive use greater than that of Australia and Spain and comparable to that of the United States (66.1%). A 2008 summary analysis found a number of factors in Bhutan that other countries could consider when seeking to improve vasectomy availability in their contraceptive method mix⁶⁰:

• Women encourage their partners to be sterilized because vasectomy is easier [than tubectomy].

• Community attitudes are accepting of men who have had vasectomies.

• Vasectomy services are of good quality, so there is a pool of satisfied clients available to motivate other men to have the procedure.

• Men routinely accompany women during childbirth, a sign of their willingness to share family responsibilities.

• The government provides free vasectomy services and offers seasonal vasectomy camps—temporary service sites that are convenient for villagers to access.

Perhaps not unrelated, Bhutan’s constitution commits its government to promoting conditions that enable the pursuit of Gross Domestic Happiness.⁶¹ These notable achievements regarding vasectomy occurred despite Bhutan being a poor country, with a GDP per capita of US$2193 at the time of its most recent survey of contraceptive use in 2010⁶² and ranking 127th in 2017 on the UNDP Human Development Index.¹⁵

Brazil

The results of a successful mass media effort mounted in the late 1980s in Brazil’s largest city, São Paulo, convey 3 important lessons still relevant today. First, they demonstrate the power of mass media to affect vasectomy-related behavior, not only knowledge.⁶³ As seen in Figure 5, uptake in vasectomy ensued, first after a TV report and then more markedly during each 6-week period that a mass media campaign was conducted. Television also supplanted interpersonal communication as the chief means of conveying accurate knowledge about vasectomy as a method and available service. Second, vasectomy uptake receded to precampaign levels each time the campaigns ended, underscoring why media-driven efforts need to be maintained (Figure 5). Third, this effort, which “promoted male responsibility in a culture celebrating machismo,” was largely implemented by vasectomy-provider champions, themselves Brazilian, including a charismatic physician who led a Brazilian organization, Pro-Pater, that provided male RH services more generally as well as vasectomy. Concomitant with this demand-side effort, vasectomy prevalence tripled between 1986 and 1996, from 0.8% to 2.6%, and doubled again by 2007 to 5.1%. The 2.5 percentage-point increase in 2007 coincided with an 11 percentage-point fall in tubectomy prevalence. Brazil has maintained a vasectomy prevalence of 4%–5% during the past decade and a half, suggesting normalization and sustainability of vasectomy as a method choice regularly considered by Brazilian couples.

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FIGURE 5

Increase in Vasectomies Following Media Events Promoting Vasectomy in São Paolo, Brazil

Adapted from Kincaid et al., Impact of a Mass Media Vasectomy Promotion Campaign in Brazil, (JHU/SPH/CCP & PRO-PATER) with permission.⁶³

Colombia

In LAC, where there is a high prevalence of PM use but less gender equality, Colombia doubled its vasectomy prevalence between 2005 and 2016, from under 2% to almost 4%. The preponderance of FP service provision has been provided by an NGO, Profamilia, an International Planned Parenthood Federation affiliate. Long a pioneer in championing FP in Colombia and LAC, Profamilia has been a predominant provider of contraceptive services, including provision of PMs, making services available and affordable.⁶⁴ Vasectomy’s 1.8 percentage-point increase in prevalence constituted 23% of Colombia’s overall increase in MCPR; vasectomy’s method share rose by 81%; and the F:M differential in PM use declined by almost half, from 17:1 to 10:1—all promising trends and illustrative of the contributions that can be made by the private sector in an LMIC.

Costa Rica

Costa Rica has maintained the highest vasectomy prevalence and method share in LAC since 2010 (in 4 consecutive surveys) and has the highest adjusted rank in GII of any LAC country. The F:M ratio in PM use has narrowed from 6:1 in 2010 to 4.2:1 in 2018 (mainly due to a falloff in tubectomy prevalence). A 2016 issue brief analyzing several decades of USAID assistance to Costa Rica’s FP program noted several reasons that FP thrived there.⁶⁵

• Programs reached all societal levels with high-quality, voluntary FP services aided by a strong social policy framework [that included FP].

• The partnership between the Government of Costa Rica, USAID, and NGOs led to an increase in modern contraceptive use between 1970 and 2015.

• A second project advocated universal coverage of FP.

• Subsequent projects focused on reaching specific client groups and strengthening health systems by improving the quality and availability of services and providing information and counseling to clients, which increased contraceptive uptake by both urban-educated women and rural, more disadvantaged women.

These approaches to ensure wide provision of accurate information and counseling on method options, method use, and side effects management; strengthen the various components of a health system to ensure quality and availability of services; and secure universal coverage for vasectomy (as well as for all other FP options) in insurance and other payment mechanisms, would be important in any country to increase vasectomy availability and access. (In the United States, while female sterilization [tubectomy] and other contraceptive methods for women are mandated to be covered under the Affordable Care Act, a 2021 clarification confirmed that male sterilization [vasectomy] is not included in the mandate.⁶⁶)

World Vasectomy Day

During the past decade, a multinational network of vasectomy champions has mounted World Vasectomy Day (WVD), with activities to further vasectomy awareness, access, and service provision occurring throughout the year in the United States, Canada, and a number of LMICs.⁶⁷ Funded by small grants and volunteering their services, WVD master trainers have trained interested service providers who subsequently have trained others, leading to more than 70,000 vasectomy procedures being provided between 2013 and 2020 in Bolivia, Colombia, Ecuador, Mexico, Indonesia, Rwanda, and elsewhere. Demand-side activities, led by in-country local groups and institutional partners, are also an important part of WVD’s holistic approach. They have used multiple social and mass media channels (e.g., Twitter, Facebook groups, blogs, radio and TV interviews) innovatively and to wide effect, prompting thousands of contacts from individuals interested in vasectomy, as well as recent pieces in influential newspapers and magazines.^68,69 Men and women are informed about what vasectomy is and is not, and potential clients are able to locate and access vasectomy providers. Satisfied vasectomy clients are also engaged as vasectomy promoters and champions. At recent meetings of the International Conference on Family Planning, several vasectomy clients and their providers in the United States were interviewed via teleconference in real time during the client’s vasectomy procedure. In addition to WVD’s fruitful collaboration with Marie Stopes International (MSI)/Bolivia (discussed later), a recent and notable partner achievement has been that of the Mexican Ministry of Health. In 2021, the Ministry of Health provided vasectomy to a monthly average of about 3,500 men from every Mexican state, including 6,600 men accessing vasectomy in November 2021 during WVD’s active week of programming there (written communication, Jonathan Stack, Cofounder, WVD, November 2022, with screenshot of data from the Sistema Nacional de Información Básica en Materia de Salud of Mexico’s Centro Nacional de Equidad de Genero y Salud Reproductiva).

Marie Stopes International

MSI, an international NGO, has been a global leader in vasectomy service provision. Between 2016 and 2021, MSI supported vasectomy services in 26 countries, 22 of them LMICs (written communication, Anna Mackay, Director, Private Foundations, MSI, December 6, 2022). During that 5-year period, more than 225,000 men received a vasectomy via static clinic networks, mobile outreach operations, or capacity-building of public sector providers. Services were supported on the demand side by a range of awareness and promotion activities relying on social media, mass media, and/or community outreach. MSI’s main country partner among LMICs has been Bangladesh,⁷⁰ with more than 145,000 vasectomies having been supported from 2016 to 2021. Substantial reductions in donor funding, however, curtailed MSI’s mobile outreach services and led to a marked decline, from more than 60,000 procedures performed in 2016 and 47,000 in 2017 to fewer than 4,500 performed in 2020 and 2021. This decline, plus the retirement of experienced public sector vasectomy providers and an increased program focus on hormonal implants, were the main contributors to Bangladesh’s decline in vasectomy prevalence, from 1.2% in 2011 to 0.5% in 2019. MSI also served almost 10,000 men with vasectomy in Nepal, which has the highest (though declining) vasectomy prevalence in Asia.

A more positive outcome occurred in Papua New Guinea, where almost 8,000 men chose vasectomy between 2016 and 2021.⁷¹ This contributed considerably to Papua New Guinea’s having attained the third highest vasectomy prevalence in Asia (0.8%; 2018). This success, notable in a country with one of the world’s highest levels of gender inequality, also entailed training men who were satisfied users of vasectomy to facilitate discussions with other men from their community, including challenging and attempting to change negative and harmful gender norms associated with masculinity.