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Contraception 89 (2014) 3 – 5
ARHP Commentary ― Thinking (Re)Productively
Putting the man in contraceptive mandate☆
Brian T. Nguyen a,⁎, Grace Shih b , David K. Turok c
a
Department of Obstetrics and Gynecology, Oregon Health and Sciences University, 3181 Southwest Sam Jackson Park Road, Box L466,
Portland, OR 97239, USA
b
Department of Family Medicine, University of Washington, Seattle, WA 98195, USA
c
Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT 84132, USA
Received 20 August 2013; revised 28 September 2013; accepted 1 October 2013
This monthly commentary is contributed by the Association of Reproductive Health Professionals
to provide expert analysis on pressing issues in sexual and reproductive health.
Learn more at www.arhp.org.
Announced on January 20, 2012, and made effective
August 1, 2012, the “contraceptive mandate” is an extension
of the Patient Protection and Affordable Care Act (ACA) that
sanctioned the provision of contraceptives and sterilization
services to women at no cost. While the mandate is a
landmark for women’s health care, it has not yet directly
addressed a role for men. Male involvement is often either
absent or a late addition to reproductive policies, as seen with
past developments in sexual health such as emergency
contraception [1], the human papillomavirus vaccine [2] and
expedited partner therapy for sexually transmitted infections
[3]. As written currently, the ACA does not direct insurance
carriers to reimburse for vasectomy nor prospective male
contraceptives or counseling [4].
Sterilization rates in the USA have remained fairly
constant over the last 40 years. The National Survey of
Family Growth (2006–2010) reported that 27% of women
rely on female sterilization for birth control; only 10% rely on
their partners’ vasectomies [5,6]. The exclusion of coverage
for vasectomy may widen this disparity by comparatively
increasing cost barriers and decreasing social expectations for
☆
Disclaimer: The views expressed in this editorial are solely those of
the authors and do not necessarily reflect the opinions or views of the
Association of Reproductive Health Professionals or its representatives.
⁎ Corresponding author.
E-mail address: brian.trung.nguyen@gmail.com (B.T. Nguyen).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2013.10.001
men. In comparison to female sterilization methods,
vasectomy has benefits with respect to efficacy, cost and
safety [7]; the ACA’s exclusion of vasectomy is neither
ethical nor evidence based and warrants re-examination.
Based on the data from the US Collaborative Review of
Sterilization, the cumulative probability of failure for female
sterilization at 5 years postprocedure was 13.1/1000 procedures (95% confidence interval: 10.8–15.4), compared to
vasectomy at 11.3 (2.3, 20.3) [8,9]. Other sources cite higher
annual failure rates for tubal ligation, 0.13–0.17%, compared
to vasectomy at 0.01–0.04% [10,11].
Female sterilization also carries greater risk of complication
than does vasectomy. Abdominal access for tubal ligation
carries 20 times the risk of major complications compared to
vasectomy, which is performed in the office under local
anesthesia ideally with a single b 10-mm scrotal incision [12].
Postoperative complications, such as bleeding and infection,
are also more common among tubal ligations than vasectomies
(1.2% vs. 0.043%) [13]. Costs of these complications each
year are also estimated to be US$ 62.52 vs. US$ 0.06 for tubal
ligation and vasectomy per procedure, respectively. Pregnancy
complications related to sterilization failure are also more
common and costly for tubal ligation. A failed vasectomy leads
to intrauterine pregnancy that can be terminated for US$ 403
[14] or carried to term and delivered for US$ 9318 [15].
Alternatively, failed tubal ligation carries a 33% risk of ectopic
pregnancy, with significant risk of morbidity and mortality
[16], costs quoted at US$ 10,613 [17].
4
ARHP Commentary ― Thinking (Re)Productively / Contraception 89 (2014) 3–5
In addition to being more effective and safer than female
sterilization methods, vasectomy is less expensive. A 2012 cost
index cites the average cost of vasectomy as approximately US
$ 708, compared to the average cost of tubal ligation methods at
US$ 2912 [18]. Tubal ligations performed in the operating
room incur anesthesia fees, leading to procedures costing up to
US$ 3449. Even office-based transcervical methods, US$
1374, are still more expensive than vasectomy [19].
Despite the comparatively low cost of vasectomy, a quarter
of insurance carriers do not cover the procedure [20]. Even if
insurers paid for 70% of the procedure, the cost to the patient
would still be significant (e.g., a 30% patient portion of the
US$ 708 vasectomy fee is US$ 212) [18]. Men with insurance
may not even see any benefit as they may still be responsible
for the full cost of their deductibles, which, at an average of
US$ 1097, is already greater than the cost of a vasectomy [21].
Some insurance carriers may independently elect to provide
vasectomies without cost sharing; however, a national policy
mandating coverage of this highly effective and cost-effective
procedure would aid efforts to increase widespread uptake.
Even the least costly, most commonly performed and
effective method of female sterilization, postpartum partial
salpingectomy, can only be performed within 48 h of
delivery. Furthermore, only half of women desiring the
procedure ultimately receive it [22,23]. Considered an
elective procedure, postpartum tubal ligations are subject
to routine delays on labor and delivery, as well as the
religious affiliations at approximately 12% of hospitals that
prohibit provision [24]. Regret may also be more common in
the postpartum rather than interval setting [25], especially for
low-income, minority women who may feel pressured to
accept their only perceived opportunity for a Medicaidfunded sterilization [26]. As patients may not seek
sterilization outside the postpartum context or receive less
effective procedures at a later date, the availability of no-cost
vasectomy is especially important [27].
Though health care providers should prioritize the care of
women, the lack of male involvement in reproductive health
care contributes to the excessive burdens of reproduction and
contraception that these women experience. Without guaranteed reimbursement for the care of male patients, reproductive
health clinics will lack the financial incentive to broaden care
to include male-specific services and outreach. The marginalization of men in family planning clinics has the untoward
effect of deterring men who, despite their need for help,
consider these environments too embarrassing or exclusive to
use [28]. Some states already attribute rising rates of
gonorrhea and chlamydia to the inability of low-resource
clinics to reach men [29]. Low rates of male attendance at
reproductive health clinics may mislead funding sources into
believing that men are not interested in these resources, when
in fact more funding is needed to improve the visibility of
vasectomy, train more providers and correct widespread
misconceptions that prevent its uptake [30]. As novel male
contraceptives are currently under study, their subsidy and
support from the government and pharmaceutical manufac-
turers depends on perceived demand as well, which may
decrease due to the ACA’s emphasis on the sufficiency of
reproductive care for women alone [31].
The US government has recognized the importance of
family planning by approving the contraceptive mandate;
however, its exclusion of vasectomy and provisions for
prospective male contraceptives reflect the nation’s current
view of family planning as a “woman’s issue.” An amendment
to the contraceptive mandate would help to establish family
planning as a “human issue,” for which the involvement of
men will increase safety and overall savings, as well as
ethically balance the weight of the reproductive burden.
1. Call to action
The Health Resources and Services Administration of the
US Department of Health and Human Services (DHHS)
recognizes the unique health needs of women and extended
their health care coverage under the ACA to include several
preventive services, including the provision of contraceptive
counseling, contraceptive methods and sterilization. However, the current federal interpretation of this legislation
excludes family planning services for men despite the fact
that women benefit from male reproductive awareness and
use of contraceptives.
There are still multiple avenues for change:
1. The DHHS can directly amend the ACA’s contraceptive mandate to specifically include cost-free coverage
of male contraceptives, sterilization and counseling.
2. The US Preventive Services Task Force can formally
evaluate the benefits of providing not only counseling but
also contraceptive and sterilization services to both men
and women. Should these services receive at least a Grade
B recommendation, all new insurance plans would be
required to cover contraception and sterilization.
3. States have the ability to extend coverage to men when
composing the Essential Health Benefits expected to be
covered by all insurance providers and respective state
Medicaid plans in 2014.
4. In 2016, the federal government will revisit how
Essential Health Benefits are defined and at that point
can explicitly include male and female reproductive care
among the categories of essential health services.
The National Health Law Program, a public interest law
firm serving underserved and underinsured Americans, has
already begun asking the DHHS to extend critical reproductive
services to men. Their efforts will be bolstered by the written
contribution of physicians and health care providers to state
and federal representatives. Government representatives may
otherwise be unaware of the efficacy, safety and cost savings of
vasectomy compared to tubal ligation, as well as the patient
experiences of health care inequality that provide the
emotional impact needed to invoke change. Petitions can
further help representatives understand the demand for gender
ARHP Commentary ― Thinking (Re)Productively / Contraception 89 (2014) 3–5
equality in reproductive decision making. Awareness campaigns and social media need to be used to inform more people
about the significant benefits of male contraception and
sterilization, as well as their underuse compared to female
methods. Support of more research on male methods, their
safety and their impact on reproductive health outcomes will
better inform clinical practice recommendations that will
impact future amendments to the ACA.
References
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[2] Burgess S. FDA approves new indication for gardasil to prevent genital warts
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[4] Department of Health and Human Services. Coverage of certain
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5
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[17] Agency for Healthcare Research and Quality. Healthcare Cost and
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This content was developed by the Association of Reproductive Health Professionals. Since 1963,
ARHP has served as the leading source for evidence-based educational resources for providers and
their patients. Learn more at www.arhp.org.
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