Abstract
The present study explored the views of Mexican men concerning vasectomy. One hundred and five men who had not had a vasectomy were asked to complete the following phrase “If you no longer wanted to have more children and a vasectomy was suggested, you would react with . . . or you would think . . . ” with at least five different answers. Participants then had to rank each of their answers according to how well they describe the participant’s feelings in the hypothetical situation. The results were analyzed using the Natural Semantic Networks Technique. The most common words used by participants with a limited educational background were reject, followed by fear and anger, and they did not use any words that implied acceptance of vasectomy. In contrast, the most common words used by participants with higher education were curiosity, followed by acceptance and interest; however, they also used the words fear and insecurity. The most frequent attitudes reported by men with limited education were negative, whereas participants with a higher education reported more ambivalent attitudes. These findings are discussed in light of sociocultural features and could be helpful in designing reproductive health programs with more effective counseling to diminish negative views about vasectomy.
The need to involve men in reproductive and contraceptive behaviors was brought to world attention at the 1994 International Conference on Population and Development in Cairo, where it was stated “Special efforts should be made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning . . . ” (Ipas, 2009). Almost two decades after this Conference, United Nations data revealed that in developed regions there are 63 vasectomies per each 100 female sterilizations (BTL), whereas in developing regions there are only 9 vasectomies per each 100 BTL (United Nations, 2013). In Mexico, there are 6 vasectomies per each 100 BTL (United Nations, 2014), and in Veracruz, the state where this study was conducted, there are 3.5 vasectomies per each 100 BTL (Servicios de Salud de Veracruz, 2012). These data are discouraging since vasectomy is safer, less invasive, and easier to practice than BTL (Shih, Turok, & Parker, 2011). A possible reason for this is that many people believe that contraception is exclusively the responsibility of women (Ulloa Pizarro, 2014; Vega-Briones & Jaramillo-Cardona, 2010).
In several Latin American countries including Mexico, the profile of the “typical” man who has undergone a vasectomy is the following: over 30 years old, has three or fewer children, lives in an urban area, has used other contraceptive methods before choosing vasectomy, and has a higher educational level than the national average (Pile & Barone, 2009). Some researchers have explored the relationship between the vasectomy election as contraceptive method with a man’s education or income level, and the results differ among diverse studies. In the United States, it has been reported that vasectomy is almost six times more common in men who are college graduates or have higher education than in those who have not finished high school (Anderson et al., 2012). Other authors, however, reported that education level did not predict vasectomy utilization in the same country; nevertheless, they suggested that their findings could be explained because most of the studied men had lower educational levels and the data may have been underpowered to detect a difference (Eisenberg, Henderson, Amory, Smith, & Walsh, 2009). In Australia, it has been reported that the likelihood of having a vasectomy is increased with income; education and occupation, on the other hand, are not associated with having a vasectomy (Smith et al., 2010). In Taiwan, it has been indicated that men who have undergone a vasectomy have a higher education level than the national average, but there is no association between family income and vasectomy (Chang et al., 2015). In Nigeria, researchers have not obtained a relationship between educational level and vasectomy election (Ezegwui & Enwereji, 2009). Vernon (1996) reviewed the literature on the issue in some Latin American countries and concluded that men who choose vasectomy have relatively high levels of formal education. Specifically in Mexico, some studies have indicated that men who choose vasectomy are more likely to have higher education and medium or high income (Lara-Ricalde, Velázquez-Ramírez, & Reyes-Muñoz, 2010; Oliva Malagón, Hernández Garduño, Garduño Areizaga, & Calzada Sánchez, 2011).
Beliefs About Vasectomy
There are several misconceptions about vasectomy that have contributed to the reluctance of many men to choose it as contraceptive method. These misconceptions include such negative health consequences as cancer, physical weakness, inability to urinate, accumulation of semen in the body with negative effects, weight loss or weight gain, and loss of body hair (Bunce et al., 2007; Ezegwui & Enwereji, 2009). Other misconceptions are related to sexual function. Previous studies conducted in Mexico have reported that some people associate vasectomy with mutilation and castration, loss of libido, and sexual potency (García Moreno & Solano Sainos, 2005; Vega-Briones & Jaramillo-Cardona, 2010). Some men have even stated that if they had a vasectomy, they would never have sexual relations with a woman again (Gutmann, 2005). However, interestingly enough, in a more recent study conducted in another Latino culture, Colombia, most men did not associate vasectomy with a decrease of sexual desire, potency, or pleasure (Fernández Aragón, Ruydiaz Gómez, Baza Maestre, Berrio Ayala, & Rosales Barrios, 2014).
Other studies conducted in Africa (Ghana and Nigeria) have also reported that vasectomy is associated with castration and the fact that it negatively affects men’s sexual function (Adongo et al., 2014; Ezegwui & Enwereji, 2009). Furthermore, even in developed countries like the United States, there are men who continue to associate vasectomy with a decrease in libido, sexual potency, and virility (Amor et al., 2008).
Vasectomy has also been related to other ideas concerning masculinity. In rural areas of Mexico, some men have said that having a vasectomy would adversely influence their image as men in their sexual relationships outside of marriage because they could not cumplir (satisfy) their lovers if they wanted to have children (García Moreno & Solano Sainos, 2005). In Nicaragua, some men have stated that vasectomy affects the character of the man, making him “like a woman” (Sternberg, 2000). In other non-Hispanic cultures people have similar beliefs: In Ghana, people also believe that vasectomy makes the man like a “woman” or that he is “under the control of his wife” and, as a consequence, many men reject vasectomy because they fear losing authority over women (Adongo et al., 2014). In Turkey, many men reject vasectomy because they fear it will undermine their authority as head of the family (Akin & Ozaydin, 2005).
On the other hand, both men who have undergone a vasectomy and women married to men who have had a vasectomy have stated several positive aspects of the procedure such as: an increase of frequency of intercourse because there is no risk of unwanted pregnancy; women do not have to use any contraceptive method; and vasectomy is a manifestation of the commitment of men, who have traditionally had a passive role in family planning (Amor et al., 2008; Córdoba-Basulto, Mercado-Sánchez, & Sapién-López, 2010; Terry & Braun, 2011).
Psychological Meaning
Besides the individuals’ beliefs, there are other psychological aspects that should be taken into account to understand their decision to choose vasectomy as contraceptive method. In this sense, it is important the psychological meaning held by individuals, which refers to their subjective reaction toward a specific concept (in this case, vasectomy) and involves both affective–evaluative and referential–cognitive components. Thus, psychological meaning is a natural unit of stimulation in the elicitation of behavior and reflects both one’s way of conceptualizing the universe and one’s subjective culture (Szalay & Bryson, 1974; Valdéz-Medina, 2004). Psychologists have made some efforts to evaluate the psychological meaning using different theoretical and methodological approaches. Figueroa, González, and Solis (1981) proposed that the psychological meaning could be evaluated using some models that had been developed to explain the way in which a person organizes the information according to his semantic memory, and developed the Natural Semantic Networks Technique (NSNT). To achieve that, the cited authors took up again some postulates from the semantic network process. First, there is an internal organization of information contained in long-term memory, whose elements are organized in the form of networks of words whose relationship expresses the psychological meaning of a concept. Second, not all the elements forming the network are equally important to define the concept, and as a consequence, there is a distance between them. For this reason, the NSNT requires that respondents tell the words that define a concept and then rank each of the words according to how closely they define the concept under scrutiny. Analyzing this hierarchy of the words used by respondents, the semantic weight of each word is calculated, and finally, the words with the highest semantic weight form the semantic net nucleus (SNN) that reflects the psychological meaning of the concept.
The Present Study
The purpose of the present study was to explore the views of Mexican men concerning vasectomy. The results were analyzed according to the educational level of the participants. It was hypothesized that views regarding vasectomy would be largely negative, especially in men with a limited educational background.
Method
Participants
A nonprobabilistic sample of Mexican adult men was recruited. Participants lived in the city of Xalapa, the capital of the state of Veracruz, which has a population of approximately 650,000 and is located 315 km northeast of Mexico City. The criteria for sample selection were that participants must not have undergone a vasectomy and they had to be at least 35 years old. Of the 135 men invited to participate, 115 agreed (85%).
A researcher went to public places such as stores, parks, or clinic waiting rooms, approached all adult men who were there, and asked them if they would be willing to participate in a research project about vasectomy. Once men agreed to participate, they were asked to answer a few questions to determine if they fulfilled the eligibility criteria for participating in the study. After ascertaining that the criteria were fulfilled, participants agreed on a place, day, and time for the survey to be conducted.
Procedures
The study was approved by the institutional review board of Institute of Psychological Research, Universidad Veracruzana. Signed informed consent was obtained from all participants. Participants were told that the information they provided would remain confidential and anonymous and were instructed not to put any identifying marks on the survey forms. It was emphasized that answers on the survey were neither right nor wrong.
The survey was based on the NSNT developed by Figueroa et al. (1981) to evaluate psychological meaning, which was later modified by Reyes-Lagunes (1993) and validated by Valdéz-Medina (2004). Respondents were told the open-ended phrase “If you no longer wanted to have more children and a vasectomy was suggested, you would react with . . . or you would think . . . ” and were asked to respond with at least five different reactions or thoughts they would have. Respondents were then asked to rank each of their answers according to how well they describe the participant’s feelings in the case the participant would be suggested to undergo a vasectomy. After a participant completed the survey, the researcher immediately put it inside an envelope that contained other surveys so that the participants could see how all surveys were combined. It took from 5 to 15 minutes to complete each survey.
Data Analyses
Data analyses required the construction of a thesaurus in which closely related words were grouped together. It was created and assembled by four people, two of whom were authors. When there were discrepancies in how to group an answer, it was discussed until 100% agreement was reached on all responses. After that, the answers given by participants were analyzed as follows: First, the semantic weight of each answer was calculated according to its frequency and rank; that is, the number of participants who ranked a certain response in first place was multiplied by 10, the number of participants who ranked that same response in second place was multiplied by nine, and so on. All of these values were added, and the result was the semantic weight of the answer that was being analyzed.
The next step was to calculate the quantitative semantic distance (QSD) that existed between the different answers given by participants. The main answer was the one with the highest semantic weight and represented 100%. In order to determine the distance between the main answer and the rest of the responses, the semantic weight of each answer was multiplied by 100 and this result was divided by the semantic weight of the main response (with the highest semantic weight) to present the QSD as a percentage. For example, if the main answer is “fear,” whose semantic weight is 460, and one wants to calculate the QSD between this main answer and the answer “sadness,” whose semantic weight is 407, then one has to perform the following calculation: (407 × 100)/460 = 88. In this example, the QSD between “fear” and “sadness” is the difference between 100% and 88%. The SNN is composed of 10 answers that obtained the highest semantic weights.
After the SNN of the two groups of participants was identified using the procedure described above, the words used by participants were classified into categories according to their meaning as follows: (a) Positive appraisal: answers that implied the acknowledgment of the benefits of vasectomy (e.g., “I would react with acceptance,” “I would think about the advantages”); (b) Negative appraisal: answers that implied unfavorable ideas about vasectomy (e.g., “I would think that it is bad,” “I would lose manhood”); (c) Positive emotion: answers that implied positive affect about a possible vasectomy (e.g., “I would react with happiness,” “I would react with pleasure”); (d) Negative emotion: answers that implied negative affect about a possible vasectomy (e.g., “I would react with fear,” “I would react with sadness”); (e) Interest: answers that implied that vasectomy could be an option (e.g., “I would think about it,” “I would look for more information”); (f) Uncertainty: answers that implied confusion (e.g., “I would be confused,” “I would react with insecurity”). Each answer was assigned to one category, regardless whether they were part of the SNN or they were mentioned only once.
Finally, participants were classified according to their attitude toward a possible vasectomy. All answers given by each participant were read and the participant was classified into one of the following categories: (a) positive attitude, when the participant gave at least one positive answer and did not give any negative answer; (b) negative attitude, when the participant used at least one negative answer and did not give any positive answer; (c) neutral attitude, when the participant did not give any positive or negative answers; and (d) ambivalent attitude, when the participant gave both positive and negative answers. Positive answers were those in which acceptance of vasectomy is implicit; negative answers were those in which rejection of vasectomy is implicit; neutral words were those that implied neither acceptance nor rejection of vasectomy. Two coders who worked independently classified participants’ responses. Agreement between them was assessed using Cohen’s kappa values for each classification (reliability: κ = .93-.97); when there were discrepancies, the responses were discussed until agreement was reached. Chi-square tests were used to measure associations between the educative level and attitudes.
Results
The participants were divided into two groups according to their educational level: (a) Fifty-two men with incomplete basic education, which comprises 9 years of schooling; they were blue-collar workers holding jobs that are usually poorly paid; based on their educational level, the neighborhood in which they live, and the characteristics of their employment, it was inferred that they had a lower or lower middle class socioeconomic status. Their ages ranged from 35 to 52 years (M = 44.76 years, SD = 4.65). (b) Sixty-three men with at least some college education whether they received a degree; they were white-collar workers holding positions that usually are well paid; it was inferred that these participants had an upper middle class socioeconomic status. Their ages ranged from 35 to 55 years (M = 45.74 years, SD = 6.33). All participants claimed to be heterosexual, and 95 (83%) were living with a female partner.
The participants used a total of 39 different words to complete the phrase “If you no longer wanted to have more children and a vasectomy was suggested, you would react with . . . or you would think . . . ,” and 17 of these words (44%) were included in the SNN. There were nine men (five with a limited educational background and four with higher education) who used six different words; five men (two with a limited educational background and three with higher education) gave seven different words; and the rest used five different words.
The results of the SNN from both groups of participants are displayed in Table 1. The main word used by men with a limited educational background was reject, followed by fear and anger; these participants did not use any word that implied acceptance of vasectomy, and in fact, they said it is bad. In contrast, the main word used by participants with higher education was curiosity, followed by acceptance and interest; however, these participants also used the words fear and insecurity. Although both groups of participants used the words fear and insecurity, they ranked these words differently: Men with a limited education ranked them in second and fourth places (QSDs = 92% and 63%, respectively), whereas those with higher education ranked them in sixth and eighth places (QSDs = 48% and 43%, respectively).
Words Used by Participants That Form the Semantic Networks Nucleus (SNN). Their Quantitative Semantic Distance (QSD) Are Presented as Percentage.
After the SNN had been obtained, all words used by participants were classified (as described in the Data Analyses section) into the following categories: positive appraisal, negative appraisal, positive emotion, negative emotion, interest, and uncertainty. These categories were ranked according to the frequency of words belonging to each category used by participants (see Table 2). The most frequent answers given by men with a limited educational background were classified as “negative emotion” followed by “negative appraisal,” whereas the least used words were those classified as “positive appraisal” and “positive emotion.” These results differed from those of participants with higher education, who more frequently gave answers classified as “positive appraisal,” “negative appraisal,” or “negative emotion.” That is, men with higher education were more likely than those with a limited education to use words that imply a positive appraisal.
Number (and Percentage) of Participants’ Answers Belonging to Each Category.
Finally, when the attitudes of participants were analyzed, negative attitudes were the most frequent (n = 252, 42.6%), followed by ambivalent attitudes (n = 216, 36.5%), and positive attitudes were the least frequent (n = 124, 20.9%). Table 3 displays the attitudes of both groups of participants; the most frequent attitudes reported by men with a limited educational were negative. On the other hand, the most frequent attitudes reported by men with a higher education were ambivalent attitudes followed by negative and positive ones (χ2 = 11.27, degrees of freedom = 2, p = .004).
Prevalence (and Percentage) of Positive, Negative, or Ambivalent Attitudes Toward Vasectomy.
Discussion
The results of the present study indicate that views of vasectomy among men with a limited educational level are more negative in tone than those of men with a higher education. This finding is consistent with a previous study conducted with Mexican men and women which identified that participants with the highest educational level were the most likely to acknowledge the benefits of vasectomy (Hernández-Aguilera & Marván, 2016). Moreover, Mexican men with higher education and income have a greater prevalence of vasectomy than those less educated (Lara-Ricalde et al., 2010; Oliva Malagón et al., 2011). This could be because, at least in Mexico, people belonging to the lowest socioeconomic class have less access to counseling about reproductive health issues and fewer health services.
The SNN of the men with a limited educational level contained the word anger. It has been reported that some men who reject vasectomy get angry when even discussing condoms or vasectomy arguing that both are against their religious beliefs and claim that their use is a reason for family disintegration, since they facilitate extramarital affairs (Vega-Briones & Jaramillo-Cardona, 2010). Another possible explanation of this finding is that men might get angry because they relate vasectomy to loss of virility; in fact, it has been documented that some men associate vasectomy with mutilation and castration and are afraid of losing libido and sexual potency after the surgery (García Moreno & Solano Sainos, 2005).
It was surprising that the SNN of neither group of participants contained any word that implied decrease of virility or decrease of sexual function. It is possible that the fear that vasectomy affects the sexual function is hidden in other answers, as has already been suggested (García-Franco, Hernández-Flores, & Góngora-Ortega, 2013). Answers that may hide this fear include “I would react with . . . fear, insecurity, nervousness, confusion, annoyance, disregard,” which were more evident in the SNN of participants with a limited educational level, who have been reported to be more likely than better educated men to believe that vasectomy decreases virility (Hernández-Aguilera & Marván, 2016). However, due to the survey methodology used, one cannot be certain of determining accurately the true cause of participants’ fear. Previous studies have identified that men report a wide range of fears in relation to vasectomy, such as fear of the surgical procedure, of adverse side effects, of the ineffectiveness of the procedure, of diminished libido or impotence after the surgery, or of the “unknown” (Amor et al., 2008; Baldé, Légaré, & Labrecque, 2006; Córdoba-Basulto, Valdepeña Estrada, Patiño Osnaya, Sapién López, & Rosas, 2007; Ezegwui & Enwereji, 2009).
The SNN of men with higher education included both words with positive meanings (i.e., acceptance) and words with negative meanings (i.e., fear). When answers for this group were classified into categories, the two categories positive appraisal and negative appraisal shared the highest and equal prevalence. Moreover, in the analysis of attitudes, these participants reported the most ambivalent attitudes toward vasectomy. In contrast to less educated participants, whose views of vasectomy were clear and whose rejection of it was decided without hesitation (in fact the main word of their SNN was reject), men with higher education were not sure about their views of vasectomy. It is interesting that despite showing both favorable and unfavorable appraisal about vasectomy to the same extent, they still reported more negative emotions than positive ones. Although one would logically assume that the most informed people would have the most favorable appraisal of vasectomy and therefore would be the most likely to choose it as contraceptive method, factual scientific information about vasectomy is not always sufficient to induce acceptance because there are strong emotions that also influence an individual’s decision (Baumeister, Vohs, DeWall, & Zhang, 2007) and, in the current study, negative emotions prevailed in participants with higher education. In a previous study, it was reported that although men with higher education had received better preparation regarding sexual health issues than less educated men, some of them did not react positively when they were asked if they were willing to undergo a vasectomy (Vega-Briones & Jaramillo-Cardona, 2010). García-Franco et al. (2013) reported that although there is a relationship between knowledge about vasectomy and its acceptance, there are men who, despite being informed and having health personnel suggest a vasectomy, reject the procedure because they continue thinking it would negatively affect their sexual potency. It is indispensable to acknowledge that the suggestion of a vasectomy implies something more than a recommendation for family planning, since vasectomy may run counter to some previously acquired values and, for many men, the idea of a vasectomy throws into question the meaning of a culturally learned masculinity (Córdoba-Basulto & Sapién, 2013). Unfortunately, the relationship between counselors and users is frequently too superficial, and counselors often do not allow users to express their needs and fears about a specific contraceptive method arguing instead that the users’ fears do not have any scientific basis (Viveros, Gomez, & Otero, 1998). In order to increase male participation in family planning programs, those in charge of the programs should have certain knowledge and understanding of a variety of issues, including the power-sharing relationship between men and women, as well as to show certain maintaining attitudes of openness and generally supportive behaviors toward their clients (Multazam, Kasnawi, & Adam, 2015).
Although the results of men with higher education were not analyzed according to their discipline, it is important to mention that there were three physicians in the sample studied. Two of them reported a positive attitude toward vasectomy, but the other reported a negative attitude and used words like fear, insecurity, and pain. This is not surprising since it has been reported that in Mexico, some physicians have expressed thoughts such as: “I have operated on thousands of women. I give them tubal ligations and I can operate on all the men you want, but I wouldn’t have it done on myself, no, I wouldn’t, it can give you cancer” (Córdoba-Basulto & Sapién, 2013, p. 75). In another study conducted with Nigerian gynecologist residents, it was reported that although they had an acceptable level of knowledge about vasectomy, most of them were poorly disposed toward its use (Ebeigbe, Igberase, & Eigbefoh, 2011). It is likely that if a physician is biased against the use of vasectomy on himself, he may consciously or unconsciously transmit negative views to his patients.
Finally, some limitations of this study and suggestions should be taken into consideration. First, participants were men living in an urban area and knew how to read and write. Second, all of them agreed to participate in a study on an issue that many men do not want to discuss or even think about. Therefore, one would logically suppose that those who refused to participate would form another comparative group. Third, a larger sample is needed to generalize the results. Last, in the survey question it was not specified who is suggesting vasectomy; and one can assume that a recommendation from a physician or health care provider may get different responses that a suggestion from a friend/family member out of the context of overall health.
In spite of these concerns, the study has some implications that should be considered by health practitioners and researchers to better understand views and attitudes that influence the decision to undergo a vasectomy. The current findings highlight the need to design effective programs directed at providing accurate information, which should include both physical and psychosocial aspects of vasectomy to dispel myths, eliminate fears, and promote this contraception method.
Footnotes
Acknowledgements
The authors thank Rosa Lilia Castillo, Kristian Jasso, and Ania Dafne Ortiz, who assisted us in the collection and analyses of data.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.