Procreation and sexual behavior are two of the most important of human behaviors. Without sex and procreation the species would not continue. Unfortunately, these behaviors are not well studied due to both methodological challenges and cultural taboos. There are, however, a few basic facts and distinctions that can be identified. According to Warren B. Miller, proception (those behaviors engaged in to produce offspring) can be distinguished from contraception (behaviors designed to prevent unintended pregnancies while engaging in sex). And, although contraception is the focus here, note that there are many issues to consider regarding proception, especially given the fact that about 15% of all couples suffer infertility problems when desiring to conceive a child.
Sexual behavior typically begins during the adolescent years. The term sexual debut has been used to identify the transition from virginity to nonvirginity status. By the age of 16, more than 60% of both U.S. males and females have experienced this debut. According to Robert Hatcher and his colleagues, “most adolescents who have intercourse do so responsibly. The majority of adolescents use contraceptives as consistently and effectively as most adults.” Comparing 1979 statistics with 1990 statistics, those using a contraceptive at first intercourse jumped from less than 50% to more than 70%. The problem is that contraception is not used consistently and correctly, even by most adults. Two of the largest risk factors for women’s health are unintended pregnancy and exposure to sexually transmitted infections (STIs). Contraceptive use is designed to prevent unwanted pregnancies. Some (but not all) contraceptive methods also protect against STIs. These cases provide “dual protection.” Unfortunately, it is still the case that approximately one half of all pregnancies in the United States are unintended and for every 1,000 women 15 to 19 years of age, 71 have an unintended pregnancy—a rate only exceeded by those 20 to 24 years of age, at 96 per 1,000. Contraceptive use is not what it should be.
Two distinctions relevant to contraceptive behavior are important. The first of these is the fact that although it is possible to identify the theoretical efficacy of differing methods of contraception (often labeled “perfect use”), humans are not perfect, and use of contraceptives is often impacted by circumstances, such as the dynamics of the relationship, the cultural context, and the “heat of the moment.” Hence, the actual efficacy of methods is labeled “typical use” and is a lower rate than the theoretical estimate. Consequently, even though a method might be described as 99% effective, when used inconsistently, incorrectly, or tentatively, the observed efficacy may be much less than this, perhaps even in the 70% to
80% range. The second distinction involves the fact that some methods, known as natural family planning methods (NFP), do not depend on the use of products or artificial hormones. Examples of these methods include abstinence, calendar rhythm, withdrawal, and monitoring of a woman’s mucus. Alternatively, methods using barriers and/or hormones are often labeled “modern methods.” Natural and modern methods have varying arguments for their use, demonstrate varying degrees of efficacy, require varying degrees of sophistication by those using the methods, and evince differing gaps between perfect and typical use rates.
The major methods used around the globe vary dramatically as a function of culture and expense. Natural methods used by women depend on an understanding of the female’s body and the functioning of her menstrual cycle. Many women have cycles that are just less than a month in duration. Natural methods depend on estimates of the time of ovulation—typically toward the middle of this cycle. Intercourse is avoided prior to and during ovulation. In a related fashion, a female’s mucus changes consistency and feel prior to ovulation, and thus can be used to estimate the time of ovulation— and intercourse is avoided. A more recent NFP technology is available in Europe (Persona) that identifies the shifts in a woman’s hormones, predicts and identifies her days of ovulation, and can assist in training a woman to understand her own cycle. This product offers an educational opportunity to adolescent women, but is rather expensive. In the United States, less than 10% of all women utilize natural methods for contraception.
Major modern methods throughout the world include barrier and hormonal approaches. Barrier methods include the condom, female condom, and diaphragm. Hormonal methods include the pill, injectables, and the intrauterine device (IUD). Recently, patches have been approved for use, mostly in the United States. It is important to distinguish those couples that intend to have more children from those who do not. In the United States, those not wanting more children depend on female sterilization (46%) and male vasectomy (18%) more than any other methods. Note that there is no protection from STIs with these methods. For those intending to have more children, 51% use the pill and 32% use the condom. In countries such as France and Egypt, the IUD is one of the most popular methods.
Of particular importance to adolescents are some of the more recent contraceptive methods approved for use. These include emergency contraception (EC), patches, injectables of varying duration, and Mirena. Emergency contraception has actually been available for decades, but has just recently been made available by manufacturers and physicians. Simply put, the hormones used in many oral contraceptives (pills) will prevent conception if taken in larger doses immediately after intercourse (perhaps up to 3 days but more effectively if taken sooner). EC is especially recommended for those experiencing an unanticipated, unwanted, or forced sexual experience, or one during which another method has failed, such as a broken condom. Patches that adhere to the woman’s skin in a fashion similar to an adhesive bandage contain hormones similar to those contained in pills. Patches are worn for varying lengths of time, depending on the brand, and not during menstruation. They do not need to be remembered every day, as do pills. Similarly, manufacturers are developing injections (again containing hormones) that prevent pregnancy for varying lengths of time (1, 2, or 3 months). They may become more popular than multiple year injections. Mirena is a product similar to the IUD that not only prevents pregnancy, but also seems to have many reproductive health benefits, such as preventing fibroid growth and reducing the risk for cervical cancers. Mirena has become extremely popular in England, where IUDs are more popular than in the United States. Lastly, researchers are confident that a number of new methods will be developed in the next 10 years. They include a male pill, an externally applied spray (sprayon) for either men or women, and topical microbicides (gels) that might provide dual protection.
Gender, Negotiation, And Relationships
It is difficult to understand behavior related to contraception without attention to gender. In fact, most methods are identified as either male methods (e.g., condoms, vasectomy) or female methods (sterilization, pill, IUD, diaphragm, patches, EC). Furthermore, choice and use of a male or female method are often determined by whether the male or the female member of the couple is making the choice.
Clearly, the nature of the couple relationship also influences choice of method. Only one half of U.S. adolescent couples actually talk about contraception prior to sexual debut. Many methods require some type of negotiation, and all too often it is the young woman who is not in a position to negotiate. Too often sexual behavior is impacted by force, coercion, and power differentials (both gender and gender’s interaction with economics are at play here). Some research suggests that the individual most committed to the relationship actually wields the lesser power, going along with the other’s opinion so as to not scare the partner away from the relationship. The clearest example of differential power involves transgenerational sexual activity. In many African cultures the practice of “sugar daddies” is popular, and increasingly “sugar moms” are as well. In these cases, an older man provides economic incentives (including food, clothing, schooling, etc.) to a young woman (not his wife) for sexual favors. The young woman stays in the sugar daddy relationship for the economic benefits, while also having a same-aged boyfriend for “love.”
On a more positive note, many couples choose among contraceptive methods for the impact that they may have on their intimate relationship. In many cultures, men have criticized the condom as they argue that pleasure is diminished, in spite of data questioning that argument. Some methods are better than others in not disrupting the heat of the moment (pills, injectables, etc.) or requiring one to plan ahead (diaphragms, having condoms handy, etc.). Conversely, new methods such as microbicides or sprayons may provide extra lubrication, thereby making intercourse more pleasurable. The commercial success of similar feminine hygiene products suggests that the creation of contraceptive methods that actually make sexual activity more fun is possible. Such methods might be especially popular with adolescents and those beginning their sexual behavior.
Most importantly, the field of contraception research has much to address. Basic questions remain regarding how we can help people engage in healthy reproductive behaviors and have planned pregnancies, avoid unwanted pregnancies and STIs, access contraceptives in a dignified manner, and use contraceptives safely, consistently, and effectively.
- Agnew, C. R. (1999). Power over interdependent behavior within the dyad: Who decides what a couple does? In L. J. Severy & W. B. Miller (Eds.), Advances in population: Psychosocial perspectives: V 3. London: Jessica Kingsley.
- Alan Guttmacher Institute. (2004). Contraception in the United States: Current use and continuing challeng Retrieved from http//www.guttmacher.org/pubs/contraception-us.html
- Hatcher, A., Trussell, J., Stewart, F., Cates, W., Stewart, G. K., Guest, F., et al. (2004). Contraceptive technology (18th ed.). New York: Ardent Media.
- Manlove, , Ryan, S., & Franzetta, K. (2003). Patterns of contraceptive use within teenagers’ first sexual relationships. Perspectives on Sexual and Reproductive Health, 35,246–255.
- Miller, W. (1986). Proception: An important fertility behaviour. Demography, 23, 579–594.
- National Center for Health Statistics. (1995). Contraceptive use in the United States: 1982–1990. Advance Data Washington, DC: U.S. Government Printing Office.
- Severy, J., & Newcomer, S. (2005). Critical issues in contraceptive and STI acceptability research. Journal of Social Issues, 61(1), 45–65.
- Severy, J., & Silver, S. E. (1993). Two reasonable people: Joint decision making in fertility regulation. In L. J. Severy (Ed.), Advances in population: Psychosocial perspectives: Vol. 1. London: Jessica Kingsley.
- Severy, L. J., & Spieler, J. (2000). New methods of family planning: Implications for intimate beha Journal of Sex Research, 37, 258–265.
- YouthNet, http://www.fhi.org/en/youth/youthnet