September 18, 2012 | Posted By Lisa Campo-Engelstein, PhD

Thanks to health care reform, beginning last month women with health insurance no longer have to pay for contraception. While I fully support this legislation, I think it has unintended negative consequences for both women and men. Specifically, I am concerned that this legislation, as well as the debate surrounding it, once again conflates reproduction with women, thereby ignoring men’s reproductive responsibility and autonomy.

This legislation is based on and buttresses our current heterosexual contraceptive arrangement in which women are largely held responsible for contraception, especially in monogamous relationships where couples are more likely to depend upon long-acting, reversible contraceptives (LARCs) or sterilization rather than barrier methods. Women today actively participate in all contraceptive methods except vasectomy, which only accounts for 9% of contraception use in the U.S. Part of the reason for this is due the disparity between the number and types of female and male contraceptives: there are eleven contraceptive options for women, including various types of LARCs, and only two for men—male condoms and vasectomy—neither of which are LARCs. Monogamous couples not ready for sterilization generally don’t delegate contraceptive responsibility to men because male condoms are not well-suited to their needs: they are not nearly as effective as female LARCs (16% versus under 3% failure rate for typical use) and they can interrupt and minimize pleasure during sex.

The lack of better contraceptive options for men, namely male LARCs, hurts both women and men. Until this legislation went into effect, women, even those whose insurance covered contraception, were still at least partially financially responsible for the various costs of contraception, such as at least one, but often annual, physician visits to acquire the contraceptive (except for the female condom and sponge) and renewable prescriptions for hormonal methods.  While this legislation alleviates these financial concerns for women with insurance, contraceptive responsibility often entails other not insignificant burdens: time and energy, negative health-related side effects (the number one reason women discontinue contraceptives), medicalization of one’s reproductive health, bodily invasion, mental stress of contraceptive responsibility, social repercussions for contraceptive decisions, and moral reproach for contraceptive failures.

By focusing only on women, this legislation inadvertently condones and upholds a problematic contraceptive arrangement in which women shoulder the vast majority of the responsibility for contraception. Yet, it is important to recognize that men are also harmed by this legislation. On the broader level, this legislation provides important preventative care (e.g. annual physicals, cancer screening) without co-pays and men don’t have access to these benefits. More specifically, like many if not most other reproductive and childcare laws and policies, men are completely overlooked. Ignoring men fails to acknowledge their role in reproduction and that, like women, they should be held responsible for their sexual and reproductive choices.

Furthermore, it fails to acknowledge how men’s reproductive autonomy is inhibited by our current contraceptive arrangement. Without highly effective reversible options, many men feel forced to rely on their partners to use contraception. Men have to trust that their partners are correctly and consistently using contraception. If a pregnancy does occur—either unintended by both partners or when the woman stops using contraception without telling her partner—men have no recourse. They cannot mandate that women get an abortion. And I don’t think they should be able to. My point, however, is that despite their lack of good contraceptive options and regardless of the circumstances under which the pregnancy transpired, men are still held socially and financially responsible for any children they father. In some ways it seems unfair to hold men responsible for unintended pregnancies when they are so poorly equipped to successfully prevent them.

Yet even if male LARCs were to become available tomorrow, women would likely still be mostly responsible for contraception given the social alignment of femininity with contraceptive responsibility. For example, sterilization is an option for both women and men, but tubal ligation is three times more common than vasectomy even though vasectomies are quicker, easier, safer, and cheaper than tubal ligations. Will this legislation lead to an even greater discrepancy in the prevalence of tubal ligations and vasectomies since the former is guaranteed to be completely covered by insurance?

The good news is that gender norms surrounding reproduction are changing, giving hope to the possibility of a more equitable contraceptive arrangement. Empirical research has shown that men would use male LARCs (including hormonal methods) and that women would trust their long-term partners to use male LARCs. However, without laws and policies in place that support both women's and men's reproductive autonomy, the possibility of a more equitable contraceptive arrangement diminishes.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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