Abstract

Despite a renewed interest in the development of hormonal contraceptives for men, many discussions about the potential acceptability of a `male pill' end by speculating whether women would trust their partners to use the method reliably. To determine the views of women, we undertook a survey of 1894 women attending family planning clinics in Scotland (450), China (900) and South Africa (544). In all centres over 65% of women thought that the responsibility for contraception falls too much on women. More than 90% in South Africa and Scotland thought that a `male pill' was a good idea, with Chinese women (71% in Hong Kong and 87% in Shanghai) only slightly less positive. Only 13% of the total sample did not think that hormonal male contraception was a good idea and only 36 women (2% of the total) said that they would not trust their partner to use it. 78% of Scottish women, 71% of Shanghai women, and 78% of white women and 40% of black and coloured women in Cape Town thought that they would use the method. This survey should dispel the myth that women would not trust their partners to use a `male pill' reliably and illustrates the potential market for the method.

Introduction

Increasing emphasis on the role of men in reproductive health has led to a renewed interest among scientists, funding agencies and policy makers, in the development of hormonal contraceptives for men [United Nations Family Planning Association (UNFPA), 1994; Harrison and Rosenfield, 1996]. Even in countries where the prevalence of male methods (condom and vasectomy) is low, the majority of men who have been surveyed claim to believe that they should take more responsibility for contraception [Ringheim, 1993; United Nations Development Programme (UNDP)/UNFPA/World Bank Special Programme of Research, 1999]. In surveys in which they have been specifically asked, a significant proportion of men from both developed and developing countries have expressed a willingness to use a hormonal method if and when it became available (Ringheim, 1993).

Recognizing that contraceptive failure has far greater personal consequences for the woman, many discussions about the need for, and acceptability of, hormonal contraception for men end by speculating whether women would trust their partners to use a method reliably (Ringheim, 1993; Potts, 1996). As part of a programme of research on the development of new contraceptive methods for men, we have undertaken two separate surveys in a number of different cultural settings. The attitudes of men towards a hypothetical hormonal contraceptive are to be published separately (Martin et al., 2000). In this paper we report the findings of a survey designed to seek the views of sexually active women and specifically to ask whether they and their partner would use hormonal male contraception if it became available.

Materials and methods

A total of 450 women aged 16–50 years attending family planning clinics for contraceptive advice and supplies was recruited from each of three centres in Edinburgh (UK), Shanghai and Hong Kong (People's Republic of China). In a fourth centre in Cape Town (South Africa), a larger group (n = 544 women) was recruited in order to provide a representative sample of the three main ethnic groups, black (n = 286), coloured (n = 151) and white (n = 107). In all centres patients were unselected, and consecutive attendees were invited to complete the questionnaire. In Hong Kong and Shanghai no one refused to participate, in Edinburgh 18 women and in Cape Town 16 women declined to complete the questionnaire, almost all for lack of time. Recruitment took place during 1996 over 3 months in Edinburgh, Shanghai and Hong Kong and over 7 months in Cape Town. A simple questionnaire, piloted in a family planning clinic in Edinburgh and translated into local languages, was administered by a trained interviewer. Questionnaires were completed non-attributably and sought information about demographic characteristics of the interviewees, satisfaction with current contraception and attitudes towards hormonal male contraception and its possible use. Local ethical committee approval was obtained in all four centres.

Statistical methods

Descriptive analyses, including cross-tabulations of each question, by centre were performed first. Associations between pairs of categorical variables within centres were tested by χ2-test.

Results

The demographic characteristics of the respondents, together with their current method of contraception, are shown in Table I. There were marked differences between the centres. For example 96% of women in Shanghai were married or cohabiting compared with only 49% in Edinburgh. The results of the survey have therefore been analysed on a within-centre basis.

Women who were using a method of contraception at the time of the survey were asked whether they were `entirely happy' with that method (Table I) and if not, why not. Only 44% of women in Shanghai said that they were happy with their method, while in all other centres the majority of women were happy (59–93%). The condom was the method associated with the most dissatisfaction, with 48% of women in Edinburgh who used it (15% of the sample), 31% in Hong Kong (where 40% of women used the condom) and 23% in Shanghai (34% condom users) saying that they were unhappy. The main reasons for dissatisfaction were failure of a method (mentioned by 96 women, 58 of them condom users) and side-effects or long term risks (mentioned by 117 women, almost half of them in relation to oral contraceptives). A few women remarked on the inconvenience of having to remember to take the pill.

Women were told by the interviewer that it was now possible to produce a hormonal contraceptive for men which would not interfere with male sexual function and which, if used correctly, would be as effective as the female contraceptive pill. In all four centres the great majority of women thought that in principle this was a good idea (Table I). Asked why they thought so, over 84% of these women in each centre agreed that it would allow a more equal sharing of responsibility for contraception. In Shanghai 39% of them thought a hormonal method would be more effective than the male condom.

Women in Hong Kong were least likely to think that hormonal contraception for men was a good idea [131 women (29%) were either negative or unsure, Table I]. Fifty-eight women in Shanghai (13%) and only 37 in Cape Town (7%) and 28 in Edinburgh (6%) said they were unsure or did not think it a good idea. Chinese women were most likely to be concerned about associated side effects and health risks, whereas women in Edinburgh and Cape Town were more likely to say that they would not trust their partner to use a hormonal method. Between 18% (Hong Kong) and 67% (Shanghai) of these women said simply that they would not want to rely on a hormonal male method. Very few women, even in South Africa, were concerned about the spread of sexually transmitted infections.

Women who currently had a partner were asked whether, if a hormonal method for men was available, they would use it either now or in the future. They were also asked whether they thought their partner would use such a method and if so which route of administration he might prefer. Responses are shown in Table II. In Edinburgh, Cape Town (regardless of ethnic group) and Shanghai one-third or more of women with partners said that they would use a male hormonal method immediately, whereas in Hong Kong only 13% of women would do so. Asked if they would use the method at some time in the future, the percentages rose to over 70% of white women in Cape Town and women in Shanghai and Edinburgh. The percentage for possible future use rose less markedly among black and coloured women in Cape Town while in Hong Kong women who would not use the method now would not use it in the future either. Women in Edinburgh and in Cape Town appeared confident that their partner would be as happy as they themselves were to use a hormonal male contraceptive at some time. In Shanghai, while 71% of respondents felt that they would like to use the method themselves at some time in the future, only 56% felt that their partner would want to. In contrast, in Hong Kong women seemed to feel that their partner would be more likely to want to use a male hormonal method than they themselves.

Fifty-five per cent of women in Edinburgh felt that their partner would be most comfortable taking a daily pill while a monthly injectable was the most popular preparation in Cape Town and Shanghai (Table II). A long-term implant was considered the best mode of administration by only a few women except in Shanghai where 23% thought that their partner would feel most comfortable with an implant.

Discussion

The idea of hormonal contraception for men appears to be extremely popular. In all four centres, despite vastly differing cultures, beliefs and personal contraceptive experience, more than two-thirds of women thought it was a good idea. One-third or more of women who currently had a partner, in all centres except Hong Kong, said that they would use a hormonal male method now, and more than 70% of women in Shanghai and Edinburgh and white women in South Africa would use it in the future. Black and coloured women in South Africa were somewhat less likely than white women to think they they might use the method; nevertheless 40% of women with partners believed that they and their partner would use a hormonal male contraceptive at some time. Although they liked the idea, and although 28% of women in a relationship thought that their partners would use it, very few women in Hong Kong thought that they would ever rely on a hormonal method for men.

Despite what has been suggested, lack of trust really did not seem to be much of an issue. Only 36 women (2% of the total sample) said that they would not trust their partner to use hormonal contraception (Table III). Only among black women in South Africa was lack of trust the most important reason for not liking the idea. Even in Hong Kong, where the idea of the method was least popular, only seven women said that they would not trust their partner to use it. In Shanghai the main reason for not liking the method was because of fear of side-effects. Hormonal methods are not widely used by women in China, with fear of side-effects accounting to some degree for their unpopularity. While we did not ask all women directly whether they would trust their partner to use a hormonal method we must assume that, if they foresaw that they would use such a method now or in the future, they would trust their partner.

Although there have been a number of studies in which men have been asked their views of hormonal methods for themselves (including our own in the same four settings (Martin et al., 2000), we know of only two other studies which have sought the views of women. In a study undertaken in the late 1960s in the USA, Bardwick (Bardwick, 1973) interviewed 107 women, some attending a family planning clinic (FPC) and others students from the University of Michican. Women attending the FPC were planning to start using the combined oral contraceptive pill. The interviews were designed to predict psychological and psychosomatic responses to pill use. One question asked `if there was a pill for men like the pill for women, who would you prefer to be responsible for contraception'? Seventy-two per cent of women said they wanted to be in control of contraception themselves, 16% preferred the man to take responsibility while only 12% felt that responsibility should be shared. Women were not asked anything more about male methods and were not asked specifically if they would use hormonal male contraception. A great deal has changed since the 1960s, however, and the responses contrast with a later study also carried out in the USA. In a randomized telephone survey of 1005 Americans (502 women) aged ⩾18 years, more than 70% of both men and women said that they thought men should play more of a role in using contraception. This study was undertaken by the Henry J.Kaiser Family Foundation (HJKFF, 1997) and was published in 1997. Forty-five per cent of women thought that men would take a `male pill', fewer thought that they would use injectables or implants, while 36% of women in the survey doubted that men would use a hormonal method at all. The apparent lower popularity of a hormonal method for men in the USA compared with the only developed country in our survey (Scotland) may reflect the different populations surveyed since women in our study were currently using contraception, actively seeking advice or supplies and were asked whether they thought their partner, rather than just men in general, would use a method. On the whole many women have rather cynical views of men in general which do not reflect their views of individual men — especially their partner.

The choice of route of adminstration of a hormonal method for men varied between centres and probably reflects familiarity with the most popular delivery system for hormonal contraception for women in each centre — pills in Scotland and Hong Kong, injections in South Africa. In Shanghai, where hormonal contraception is not very widely used, an injectable method was favoured.

Despite the widespread belief that women would not want a `male pill' because they would not trust their partners to use it reliably, our study suggests that a hormonal method for men would be extremely popular and that many women, regardless of culture, would trust their partners to use it. Presently a male pill is likely to be less popular in the Far East than in the West but, despite what many might predict, it may certainly have an important role in Africa. More choices of contraceptive methods for men will allow increasing numbers of men in all countries to accept more responsibility for reproductive health, and certainly their womenfolk are keen that they should do so. Approval of, and intention to use, a hypothetical method of contraception is unlikely to be accurate in predicting behaviour when such a method becomes available. However, even if the number of potential users is overestimated by a factor of 10, a hormonal method for men would still represent a greater share of the market than contraception implants, injectables or the progestogen-only pill in the UK, and no one would dream of questioning their important role in contraceptive choice.

Table I.

Demographic characteristics, current contraceptive use and response to the idea of hormonal contraception for men

 Edinburgh(n = 450) Cape Town (n = 544) Hong Kong(n = 450) Shanghai(n = 450) 
  Black(n = 286) Coloured(n = 151) White(n = 107)   
aAn additional 15% of women in Edinburgh and 5% in Hong Kong were students; in other centres no more than 1% were students. 
bOnly those women who recorded that they were currently using a method were asked this question. 
IUD = intrauterine device; NFP = Natural Family Planning. 
Mean age (years) 27.6 30.0 29.2 28.0 31.3 30.9 
% ⩽20 18 15 14 11 
% >40 11 14 12 
% with higher qualificationa 42 13 32 69 19 
% married/co-habiting 49 35 61 56 71 96 
% with regular partner 44 58 27 25 25 
% with children 31 80 72 25 67 65 
Contraceptive method       
% using oral contraception 72 47 72 28 
% using injectable 90 48 22 
% using IUD 10 36 
% using condom 15 40 34 
Other including NFP 11 
None 15 
% happy with methodb 64 93 84 79 59 44 
% unhappyb 18 21 23 
Male contraception a good idea (%) 94 93 91 97 71 87 
 Edinburgh(n = 450) Cape Town (n = 544) Hong Kong(n = 450) Shanghai(n = 450) 
  Black(n = 286) Coloured(n = 151) White(n = 107)   
aAn additional 15% of women in Edinburgh and 5% in Hong Kong were students; in other centres no more than 1% were students. 
bOnly those women who recorded that they were currently using a method were asked this question. 
IUD = intrauterine device; NFP = Natural Family Planning. 
Mean age (years) 27.6 30.0 29.2 28.0 31.3 30.9 
% ⩽20 18 15 14 11 
% >40 11 14 12 
% with higher qualificationa 42 13 32 69 19 
% married/co-habiting 49 35 61 56 71 96 
% with regular partner 44 58 27 25 25 
% with children 31 80 72 25 67 65 
Contraceptive method       
% using oral contraception 72 47 72 28 
% using injectable 90 48 22 
% using IUD 10 36 
% using condom 15 40 34 
Other including NFP 11 
None 15 
% happy with methodb 64 93 84 79 59 44 
% unhappyb 18 21 23 
Male contraception a good idea (%) 94 93 91 97 71 87 
Table II.

Responses of women with current partners to the idea of hormonal contraception for men. Values are percentages of women giving each response

 Edinburgh(n = 416) Cape Town (n = 486) Hong Kong(n = 432) Shanghai(n = 447) 
  Black(n = 267) Coloured(n = 132) White(n = 87)   
Use now       
Yes 38 33 36 45 13 33 
No 23 29 30 21 44 25 
Use in the future       
Yes 78 43 46 78 14 71 
No 22 18 30 
Would partner use it       
Yes 69 48 53 79 28 56 
No 12 33 24 30 17 
Partner's choice of method       
Daily pill 55 21 17 23 23 24 
Monthly injection 32 39 40 51 22 41 
Long-term implant 11 16 13 23 
Don't know 38 32 10 41 13 
 Edinburgh(n = 416) Cape Town (n = 486) Hong Kong(n = 432) Shanghai(n = 447) 
  Black(n = 267) Coloured(n = 132) White(n = 87)   
Use now       
Yes 38 33 36 45 13 33 
No 23 29 30 21 44 25 
Use in the future       
Yes 78 43 46 78 14 71 
No 22 18 30 
Would partner use it       
Yes 69 48 53 79 28 56 
No 12 33 24 30 17 
Partner's choice of method       
Daily pill 55 21 17 23 23 24 
Monthly injection 32 39 40 51 22 41 
Long-term implant 11 16 13 23 
Don't know 38 32 10 41 13 
Table III.

Reasons why women who did not think a male hormonal contraceptive `a good idea' felt this way. Values are percentages of women giving each response

 Edinburgh(n = 28) Cape Town Hong Kong(n = 131) Shanghai(n = 58) 
  Black(n = 21) Coloured(n = 13) Whitea(n = 3)   
aOnly three white women in Cape Town did not think male hormonal contraception a good idea, one because of health risks and infrequent intercourse and two because the responsibility for failure fell to the woman. 
STD = sexually transmitted diseases. 
Not trust partner 50 38 46  
Health risks 21 23  60 95 
Female responsibility if method fails 21 29 15  16 
Do not want to rely on a male method 64 19 46  18 67 
Infrequent intercourse 23  17 
Concern about STD 11 15  
 Edinburgh(n = 28) Cape Town Hong Kong(n = 131) Shanghai(n = 58) 
  Black(n = 21) Coloured(n = 13) Whitea(n = 3)   
aOnly three white women in Cape Town did not think male hormonal contraception a good idea, one because of health risks and infrequent intercourse and two because the responsibility for failure fell to the woman. 
STD = sexually transmitted diseases. 
Not trust partner 50 38 46  
Health risks 21 23  60 95 
Female responsibility if method fails 21 29 15  16 
Do not want to rely on a male method 64 19 46  18 67 
Infrequent intercourse 23  17 
Concern about STD 11 15  
5
To whom correspondence should be addressed at: Family Planning & Well Woman Services, Edinburgh Primary Care NHS Trust, 18 Dean Terrace, Edinburgh EH4 1NL, UK

This study was supported by the Medical Research Council and Department for International Development (Grant No. G9523250). Mr Raymond Anakwe was supported by a grant from the Scottish Home and Health Department. We would like to thank Audrey Duncan for typing the manuscript. None of the investigators has any vested interest of a commercial nature relevant to the study described.

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