Safe, effective birth control for men is long overdue. Consider a tale of two siblings:
When Mary hit middle school, she began having such painful periods that her father once called the paramedics, thinking she had a ruptured appendix. But at age 14, she got a state-of-the-art hormonal intrauterine device (IUD) that cured her terrible monthly cramps. Over time, the IUD not only would virtually eradicate her bleeding and pain, but would also provide top-tier contraception for up to seven years. Once Mary became sexually active, her annual pregnancy risk would be around 1 in 700. By contrast, Mary’s college-age brother, who was relying on condoms (with an annual pregnancy risk of 1 in 5), had to share the emotional and monetary burden of an unwanted pregnancy and abortion.
No parent wants a son depending on the young women he dates to prevent a surprise pregnancy, but the options stink. As one mother of three boys put it:
Every day teens are having sexual relations, and the method of birth control is either left to the girl (most of which aren’t on anything because they don’t want their parents to know), condoms (which are horribly unreliable, especially in the hands of teens), or most often nothing. If parents were more involved and more teens had access to new methods of contraception … more kids would have the ability to make a future. Boys need that option as much as girls.
Sex. Abortion. Parenthood. Power.
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Over the past 50 years, birth control for women has been refined to the point that there are now dozens of alternatives that are far safer than pregnancy, many of which have added benefits like reducing menstrual symptoms, acne, or even the risk of cancer. The array includes three kinds of long-acting “fit and forget” contraceptives that are over 20 times better than the familiar “pill” but allow a quick return to normal fertility. But, after all this time, men are still stuck choosing between two century-old choices: condoms and vasectomies.
Don’t get me wrong—condoms are far better than nothing. They are the best thing we have for reducing sexually transmitted diseases. However, many people have a mistaken perception of how well they work for actual pregnancy prevention. If everybody who relies on condoms could use them perfectly and with perfect consistency, only two couples in 100 would get pregnant each year via condom failure. But from a “human factors engineering” standpoint, condoms stink. In the real world where people fumble, forget, and wait too long to put them on or take them off, many couples depending on condoms end up pregnant. Condoms drop pregnancy rates from 85 percent (the rate for a sexually active couple using no contraception for one year) to 18 percent—a big improvement, but still terrifying for someone whose plans and efforts could be blown apart by a ruptured rubber.
Men want better choices, and women want better choices for men, and parents want better choices for their sons. And yet, as Dr. John Amory at the University of Washington put it, “Everybody’s been saying, ‘within the next five years,’ for the last 30 years,” but no new method for men has made it to market.
Dependable Male Birth Control Could Change Our Lives
We all, men and women alike, should be demanding better birth control for men. First off, there’s the fairness factor. Just like girls, young men should be able to pursue their dreams, confident that they won’t be derailed by a surprise pregnancy. In the 1999
movie A Walk on the Moon, a young mother, locked into a traditional working-class lifestyle by teen pregnancy, feels drawn to the 1969 Summer of Love emerging around her. As she indulges her yearning for freedom and adventure (and Viggo Mortensen), her husband, who “did the right thing” when she first got pregnant, is confronted with his own losses, especially the college education foregone. “You think I wanted to fix TVs?” he asks.
Besides derailing individual lives, the fact that men can’t count on their contraception means we all get stuck living in old cultural scripts. For millennia, our ancestors had no reliable means to manage their fertility. Given the power of the human sex drive, even abstinence commitments backed by a death penalty for sinners couldn’t be considered reliable. In other words, if our ancestors sought sex or intimacy—and we humans crave both—then children were a byproduct, wanted or not.
Consequently, throughout history children came into the world unplanned and mostly when parents would have chosen not to have another child. But to thrive, kids needed just as much care as they do today. In response, both culture and religion evolved messages to help ensure that such children were wanted and loved when they arrived. “Let go and let God,” some Christians say. “Que será, será.” “A baby is a blessing.” Still, today, some fundamentalist sects make passive submission to pregnancy a sacred virtue, and in Western culture at large, go-with-the-flow childbearing is accepted and celebrated. This is true even though we now have good evidence that thoughtful family planning increases maternal and child health, prosperity, marital harmony, and the ability of young men and women to live fulfilling lives.
Thanks to some determined researchers and funders, things may get better in the near future. An array of promising possibilities can be found in various stages of research around the globe. Here are some of the top contenders.
The “Clean Sheets Pill” (London, Oxford): Dr. Nnaemeka Amobi and his team are researching a hormone-free method that has been dubbed the “clean sheets pill” because it decreases or eliminates semen emission while leaving intact the sensation of ejaculation and the pleasure of male orgasm. The pill works by relaxing just the muscles in the vas deferens that normally propel sperm-containing semen forward and out. Without the forward propulsion, circular muscle contractions essentially close down the passage. Reducing or eliminating emission of semen not only prevents pregnancy, it also decreases the spread of semen-born diseases, including HIV. The hope is that this medication can be delivered via pills that men take before sex, much like Viagra.
RISUG (Kharagpur): More than 250 men have undergone a procedure called RISUG (reversible inhibition of sperm under guidance), which researchers hope will provide a cheaper and more reversible alternative to vasectomy. A liquid polymer is injected into the vas deferens, where it provides contraception for up to ten years. In the duct, the positively charged polymer reportedly acts almost like a magnet, reacting with the negative electrical charge on the membranes of passing sperm and rendering them infertile. In research with rats and primates, fertility has been restored by a noninvasive procedure that removes the polymer. Human clinical trials of RISUG are moving forward slowly in India.
Vasalgel (San Francisco): Inspired by RISUG, a similar polymer, dubbed Vasalgel, is under development in the United States, with rabbit research now underway to meet Food and Drug Administration standards and primate studies planned. Over 16,000 men and women have signed up to receive information about clinical trials, expected to begin in 2014.
Ultrasound (Chapel Hill): Therapeutic ultrasound is a common sports medicine treatment for injured joints and muscles. A brief massage of the testes with the same instruments has been shown to reduce sperm count in both animals and humans. Doctors have long known that heating the testes even to body temperature reduces fertility, and we know that therapeutic ultrasound produces a deep warmth. But for reasons that are unclear, the contraceptive effect of ultrasound is ten times that of heat alone. Depending on the level of exposure, contraceptive duration ranges from six weeks to permanent. One major challenge at this point is to find a treatment regimen that is either reliably reversible or reliably permanent. Of the two, use as a nonsurgical vasectomy option is more likely.
Gamendazole (Kansas City): Potential contraceptives are sometimes discovered as side effects of other medications, and gamendazole derives from a cancer treatment that by chance was noted to decrease male fertility. Research shows that the drug works by interrupting sperm maturation. Men taking gamendazole produce and release normal quantities of sperm, but the sperm are “nonfunctional.” In mating studies of rats, the drug achieved 100 percent infertility and was fully reversible. Research with monkeys looks promising.
Adjudin (New York): Like gamendazole, adjudin is an analogue of a cancer drug, lonidamine. It works the same way, causing sperm to be released when they are immature. For lonidamine, the gap between a contraceptive dose and a toxic dose is small, making the drug too dangerous to give to healthy people. But researchers at the Population Council were able to create a related compound that is taken up only by the precise receptors in the testes where it is needed for contraception. This dramatically reduces the needed dose. Two remaining drawbacks to adjudin are that it can be administered only by injection, and its effect is short-lived. Researchers are working to devise a version that doesn’t require frequent injections.
JQ1 (Waco, Boston): JQ1 is related to some familiar drugs, Valium and Xanax, but it has a very different effect. Instead of bringing on sleep or reducing anxiety, it blocks production of a protein in the testes that is essential to sperm growth. In mice that are given JQ1, the number of sperm takes a nose dive, and those that are produced don’t swim very well, which makes the mice infertile. Sex drive remains unaltered, and after the drug is stopped, sperm production rapidly returns to normal.
Testosterone and Progestin (Beijing, Los Angeles, Seattle): If injected or absorbed through the skin, testosterone alters hormonal messaging and reduces production of sperm. When combined with a progestogen and rubbed on in gel form, a daily application has effectively suppressed sperm concentration in almost 90 percent of men, with few side effects. Current research is exploring the best combination of testosterone and progestin, and how such a combination can be delivered to provide long-acting birth control.
With such a variety of options (and more) in the works, it seems like something new for men should be just around the corner. But much of the research is progressing at a snail’s pace due in part to regulatory barriers and lack of funding.
Contraceptives get used by young, healthy people, which means that the bar for safety and efficacy is much higher than for many other drugs. A cancer treatment might be welcomed if it has a 70 percent success rate and makes your hair fall out. Needless to say, either of these is a non-starter for a new contraceptive. The high bar (and the corresponding high risk of liability) makes drug companies and even philanthropists wary of investing in contraception—which has to be almost 100 percent effective and side effect-free to be a success.
Will any of these options make it to market in the next five years? That depends in part on whether drug companies, nonprofit research funders, and public health experts think we’re ready. Do men really want to take responsibility for contraception? Will women trust them to do so? Is there enough demand to make a massive high-risk investment in research and development worthwhile?
Are We Ready?
For a long time, outdated perceptions have contributed to the lack of investment in birth control for men. Since women traditionally have borne the primary burden of unwanted childbearing and parenting, decision-makers have long assumed that men wouldn’t be interested in contraceptives—or would have a very low tolerance for cost, side effects, or hassle. Today, though, in the age of paternity tests and child support, with fathers and mothers sharing parenting responsibility—more and more men want to be in control of their own fertility.
In May 2013, when a Florida man found that his girlfriend was pregnant, he tricked her into taking an abortifacient—an act of physical assault. Ultimately, caught in a web of religion-driven anti-abortion laws, he was charged not with assault but with “fetal murder.” Few people were sympathetic to his actions, but many were sympathetic to his plight. Men, like women, need effective tools for managing fertility if they are to have a hope of charting their own life course.
Interest in better male-controlled contraception varies widely depending on country and culture, but in a wide variety of countries more than half of men say they want better male birth control methods. After one study of male contraception sponsored by the World Health Organization, 85 percent of participants would have preferred to continue an experimental method rather than returning to whatever they used before—even though the experiment required a weekly injection.
A second longstanding misperception is that women can’t and won’t trust men for family planning. In truth, even with today’s limited options, meaning condoms and vasectomies, approximately one-third of U.S. couples rely on the man to provide contraception. A significant number of men who participate in clinical trials for male contraceptives say their wife or partner has had side effects from female methods or that they want to take the burden off of her for a while.
In general, people tend to overestimate the side effects of female birth control, falsely believing, for example, that contraceptives cause weight gain. But some female bodies respond poorly to even the micro-dose of copper or hormones present in top-tier contraceptives, and for other women the cost of the most effective methods is prohibitive. Barriers to access abound. Faced with the health risks of an unintended pregnancy, a woman can feel caught between a rock and a hard place. Consequently, many women appreciate guys who step up to the plate. Of almost 2,000 women surveyed in Edinburgh, Shanghai, Hong Kong, and Cape Town, a vast majority said they thought a male pill was a good idea, and only 2 percent said they wouldn’t trust their partners to use it.
To be frank, more men might do well to ask whether they should trust women to manage contraception. In the United States, with most contraception still in the hands of women, close to half of pregnancies are unintended, and the transition to thoughtful, intentional childbearing has been stalled for decades. Around a quarter of pregnancies occur in a month when a woman says she
had used birth control . Like condoms, female barrier methods and even the birth control pill are quite subject to human error. In one study of 82 women, participants on average missed four or five pills per month, even when they were sent text-message reminders. It’s simply not reasonable to assume that ordinary human beings will do the same thing in the same way at the same time every day for 40 years—or every time they have sex. While longer-acting “fit and forget” contraceptives like IUDs and implants appear to radically change the equation, so would an improved array of options for the male half of the human race.
On the surface, it may seem that scientific challenges are the primary barrier to excellent male birth control. A woman produces an egg only once each month, while men produce millions of sperm daily. Female fertility can be detected and timed. It starts later and ends sooner than male fertility. But those in the know say biology isn’t the problem. The question is one of politics and priorities. The National Institutes of Health summed up the problem in direct (if wonky) terms over a decade ago:
The lack of progress in developing affordable, safe, effective, and reversible male contraceptives is due not to the biological complexity involved in suppressing spermatogenesis [the production of sperm], but rather to social and economic/commercial constraints.
Today, research on male contraception is 50 years behind research on female contraception. The difference is as much as anything an artifact of history and tradition, which ripple into the present. Several years ago in a South African youth hostel, my daughters were dismayed to encounter a young man who casually said that he wanted a dozen children. As they queried him, they got a glimpse into both his culture and our own—into all times and places where child care has been primarily a female concern, and males could count offspring like a banker counts dollars. But gender roles and parenting have evolved in the last 50 years, all in the direction of more equality, mutuality, and flexible division of labor between men and women. For many men, those changes include a desire to be deeply present in their children’s lives.
As men get more involved in late-night diaper changes and storybook reading and getting kids off to school, their perspective on having children may look more and more like the one that has historically been held by many women. They don’t want 12 kids; they want two or four or one, or sometimes, knowing their own limits, none at all. In other words, they want childbearing to be intentional, and they want to decide for themselves when the time is right. It’s time that they had the tools to do so.