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Much attention has been focused on efforts to reduce unintended pregnancy by improving contraceptive use among high-risk women; however, there is limited information to guide interventions to engage young men in contraceptive decision-making. We conducted focus groups of young men, ages 19–26, from diverse racial backgrounds from low-income communities in the San Francisco Bay Area to examine social norms about sexual relationships and how they impact on contraceptive use. The data were analysed using content analysis. A range of relationships were described, however casual relationships predominated. While young men expressed strong desires to avoid pregnancy in casual relationships, the unpredictable nature of relationships, together with low communication and regard for the women involved, made stressing consistent contraceptive use among partners unlikely. The themes expressed by these young men about sex and behaviour in different relationships illustrate a spectrum of decision-making dilemmas and illustrate the inherent difficulty in fully engaging young men in contraceptive decision-making. A strategy is needed to address relationship values, dynamics, and condom use beyond STI prevention frameworks, and young women’s ability to make appropriate contraceptive choices in light of the inherent difficulties and uncertainty associated with casual relationships.
Optimal reproductive health means that women and men have the capability to reproduce and the freedom to decide if, when, and how often to do so, in addition to having a satisfying and safe sex life (United Nations 1994). Over the last 15 years, unintended pregnancy rates in the USA overall have remained essentially unchanged at approximately half of all pregnancies, serving as an important marker of suboptimal reproductive health status (Finer and Henshaw 2006). Most of programmatic and research attention has focused on women since they are at risk of unintended pregnancy. With the exception of male condoms and withdrawal, reversible contraceptive methods are used by women (Darroch 2008). Despite the limited technology to control their fertility, men play both an indirect and direct role in sexual and contraceptive decision-making. To address the problem of unintended pregnancy, it is critical to take into account how men think about and behave in sexual relationships and how they influence contraceptive decision-making.
Male partner’s intentions and desires have been shown to affect timing of first pregnancy, women’s desire for becoming pregnant, feelings upon learning of pregnancy, and subsequent changes in women’s evaluation of pregnancy wantedness during pregnancy (Major et al. 1992, Chalmers and Meyer 1996). Quantitative research demonstrates that increased communication and intimacy within relationships is positively associated with contraceptive use. For example, studies show increased contraceptive use in relationships where women feel more at ease communicating with male partners and when young men participate in more “couple-like activities” with partners before sexual initiation (Rosengard et al. 2005, Ryan et al. 2007). Research has also shown the association of male power and dominance in relationships with lower condom use (Pulerwitz et al. 2002). Other dimensions of relationships, including sexual pleasure and sensation, have been associated with lower condom use as well, and may be associated with differences in contraceptive use, although contraceptive research in this area is limited (Higgins and Hirsch 2008).
While these studies help to illuminate the importance of men, relationships, and communication in contraceptive use, studies that provide insight into how young men think about and behave in sexual relationships and how their attitudes can influence their sex partner’s contraceptive use are needed (Montgomery 1996, Dudgeon and Inhorn 2004). Existing studies also fail to impart a clear understanding of young men’s distinctive attitudes and values that underlie their decision-making. Information is needed to guide the development of interventions to engage young men in meaningful and constructive ways in contraceptive decision-making. Quantitative studies that emphasise the measurement and analysis of individual factors, not processes, do not explicitly address “how” group norms work in complex and often contradictory ways to shape behaviours. In order to understand behaviour, one must not only identify and analyse individual factors; one must also examine these variables within context, which includes social interactions and perceptions. This requires gathering a more extensive understanding of men’s sexual and reproductive stories, and the process of telling these stories among themselves, that existing forms of quantitative research may not capture.
Focus groups are useful for examining complex and sensitive issues regarding sexuality, race, and culture. Advantages of focus groups relative to individual interviews or quantitative data collection include synergism, or the joint effort of the group to yield a broader range of information, understanding, and ideas, as well as candidness because the focus is on the group social norms rather than the individual (Stewart and Shamdasani 1990). Focus groups allow for participants to disclose information that they may have in common with others in the group, and share similar perceptions and experiences, some of which they would not feel comfortable divulging in an individual interview (Krueger 1994).
Our goal in the present study was to examine the male perspective on prevalent types of sexual relationships, how young men see their interactions with women within these unions, and how decisions about pregnancy intentions are reached and contraceptive choices made. We highlight participants’ own descriptions and experiences of sexual and contraceptive decision-making in terms of important underlying domains in relationships, including communication, intimacy, power/dominance, sexual pleasure, trust, and exchange of material support. We examined the intersection of relationships and pregnancy intentions to try to illuminate factors behind patterns of low contraceptive use and high unintended pregnancy.
Young adult men in the San Francisco Bay Area were recruited for focus group discussions from March to May 2005. Men were eligible to participate if they were aged 19 to 26 years, able to speak English or Spanish, and were sexually experienced (defined as having ever had sex). These discussions were conducted as the first phase of an on-going study of hormonal contraceptive use in young women. We sought a racially/ethnically/culturally diverse group of male participants from suburban communities in the San Francisco Bay Area (San Francisco, Oakland, Richmond, Vallejo and Fairfield) with family planning clinic sites where an ensuing longitudinal cohort study, which would examine factors that influence contraceptive continuation among young women initiating hormonal contraception, was to be implemented. The communities selected are residential areas with low to mid-income families. In order to identify potentially eligible young men, we used convenience sampling/community networking techniques including posting flyers, on-line announcements, newspaper advertisements, and one-on-one recruitment at family planning clinics, community programs, college campuses, sport centers, and shopping malls. Participants were reimbursed US$25 for their time; groups lasted approximately 60–90 minutes. This study was approved by the Committee on Human Research, the Institutional Review Board of the University of California, San Francisco.
We developed a standardised focus group discussion guide to ensure that desired topics were explored using open-ended elicitation, with prompts. The major topic areas were relationships, childbearing and pregnancy prevention. Topics explored different types of sexual relationships that young men and women have, with facilitator prompts to focus on each relationship type mentioned and understanding how common it is and how it was defined for the young men. The facilitator then asked whether a young man would consider having a baby in that type of relationship. The next set of questions focused on childbearing among young men that the participants knew and how decisions about childbearing were made. The third major topic was pregnancy prevention, including knowledge and attitudes regarding contraceptive methods. Participants were asked specifically about each method: oral contraceptives, depot-medroxyprogesterone (the shot), the contraceptive patch, and vaginal ring.
Participants were also asked their thoughts and attitudes about three hypothetical scenarios that involved decision-making regarding condom and contraceptive use. In one scenario participants were asked to comment on a situation where they were having sex with a female for the first time without condoms and the female partner asked them about using a condom. In another scenario participants were asked how they would handle a situation where their girlfriend did not want to use birth control pills and they did not want to use condoms. In the third scenario participants were asked what they would do if they thought a casual sex partner wanted to have their baby and they did not want to have a baby but they wanted to continue having sex with the partner. The development of the topic guide was informed by the theory of reasoned action (Ajzen and Fishbein 1980), with the research goal of understanding the intentions of young men’s behaviour that derive from social expectations and norms.
The script was pilot tested and revised based on responses from a sample discussion group to ensure that questions were clear and generated discussion on the desired topics. Our original intent was to convene focus groups with adolescent and young men. However, during pilot testing with adolescent men, the discussions were extremely limited due primarily to their lack of experience in relationships and thus we decided to focus on young men over age 18 years. Because contextual issues vary by racial/ethnic background, groups were stratified by race/ethnicity and language. There were four African-American groups, one Latino-Spanish speaking group, and one Asian-Pacific Islander group. An additional two groups were conducted (in English) in which there was no stratification by race/ethnicity (Combined groups). Participants completed an anonymous survey prior to starting the focus group with socio-demographic and reproductive health items, including number of sexual partners, relationship status, number of pregnancies caused, number of children, pregnancy intentions, and condom and contraceptive use.
Each group was facilitated by a male moderator and a co-moderator (male or female), who received uniform training on focus group techniques from the first author. Moderators used probing techniques to elicit additional information, clarify vague responses, and encourage participation of all group members. Questions were reiterated until no new responses were reported. All groups were audio taped and discussions were transcribed. Data from the Spanish-speaking group were transcribed and translated into English.
Focus group transcripts were read independently by the first three authors and the last author, using standard methodology including content analysis. Analysis was conducted by a multidisciplinary research team, including physicians, and behavioural and social science researchers, with expertise in sexual risk behaviour and contraception among adolescents and young adults. Data were entered into N6 (NUD*IST) software, a qualitative data management program (QSR International Pty. Ltd., Victoria Australia). Master categories were created by each reader based upon repeated trends, consistencies, and themes. In the process of categorising data the following aspects were taken into consideration: frequency of comments (the number of times a topic surfaced in the discussion); extensiveness of comments (the number of people who talked about the same issue); intensity of comments (voice volume, speed, and emphasis on certain words); and verbal interactions within the groups. We employed an intensive analytic technique in which the authors, individually and in group meetings, re-read portions of the transcripts and listened to segments of audiotapes to discern meaning and to understand the influence of group dynamics on a topic of discussion. Master categories and sub-themes derived independently by the three reviewers were then consolidated and differences were discussed and reconciled. Differences in coding and identification of themes arose at times throughout the process and were discussed with the research team members from differing disciplines, until consensus was reached on the inherent meaning (Giacomini and Cook 2000). Findings within and across groups were compared and contrasted to expand, clarify, and refine final categories. Quotes from the focus groups are presented in the results; false names were assigned to preserve the anonymity of participants.
We conducted a total of eight focus groups with 64 participants, and group size ranged from 4 to 10 participants. The surveys given to each participant collected socio-demographic and reproductive and sexual health data. The mean age of participants was 22 years. The majority of participants were racial or ethnic minorities: 48% were African-American, 13% were Latino/Hispanic, 14% were Asian/Pacific Islander, 8% were mixed race, 11% were white, one participant was American Indian, and 5% did not to provide information on their race/ethnicity. Approximately one half of the participants (47%) reported currently being in school (high school or college full or part-time). The educational attainment of the participants ranged from less than a high school education (12%), high school graduate (42%), some college or community college degree (42%) and college or graduate degree (3%). Forty-one percent of the participants reported not working, 22% were working part-time and 36% were working full-time. Median household income for participants was estimated by linking zip code of residence to US census bureau data for 2000. The range for median household income among participants was US$21,124 to US$76,044 with a median of US$42,562.
Thirty percent of participants reported having one partner in the last three months, 25% two partners, and 28% three or more; 13% said that they did not have a partner in the last three months. Forty-one percent of participants reported currently having a “main” sex partner, 18% reported having a “casual” sex partner, and 16% reported having both; 24% said that they did not have a current partner. About half (48%) of the participants stated that they had caused a pregnancy at least once; 5% of participants stated they did not know if they had caused a pregnancy in the past. About a third (31%) of the participants had one or more children. Two-thirds (66%) of participants reported that they would not like to get someone pregnant in the next year and 50% reported that they would be somewhat unhappy or very unhappy if they got someone pregnant in the next year; 31% percent were unsure or did not know how they would feel if they got someone pregnant. When asked what contraceptive they had used at last sex, 44% reported using a condom, 16% reported a partner using a hormonal method (pill, patch or Depo-Provera), 19% reported no method, 9% used withdrawal, and 5% reported “don’t know”.
In response to the topic guide question on the different types of sexual relationships young men and women have, the participants used a range of terms and definitions for sexual relationships, while describing the relationships within more general parameters of casual and committed relationships. Descriptions of casual relationships among their peers with a focus on sexual gratification predominated. Participants in all groups discussed the classic “one night stand”, when a guy meets a woman and has sex. The focus of the relationship is on the sexual act, and by definition, the relationship is short in duration, does not involve intimacy. “Booty calls,” calling a woman just for sex, usually at night, on the other hand, can occur over time, are also low in intimacy, and might involve deceptive communication of the males’ purpose. Participants also commented on casual relationships that seemed to be targeted at particular types of women. They described “sluts,” or in some groups, “hood rats” and “rippers,” as women who have sex with men indiscriminately and it is generally known by other men in the community. Another type of woman or casual relationship discussed frequently in a few of the groups was “work”– the title for women guys have sex with and can obtain material goods from was more intentionally exploitative. The focus on these relationships is the sexual act as strategic or even manipulative, purely for sexual gratification or to garner material goods:
“There’s certain – you know, different types of relationships for different kind of girls that you meet and depending on their background or class, their sophistication. You feel me? You relate to people on their level. You feel me? You kind of use them for whatever you can use them for though basically for what they got.” (Andre, 22, African-American, Oakland group)
The young men talked about the women in these types of relationships often in a disrespectful, detached or matter-of-fact manner. The vernacular language used to describe the women in these relationships was explicitly contemptuous and derogatory:”
“A ripper basically, that’s somebody that you know already doing their thing with everybody else but you just want to have sex with just to have sex with. Because you know that’s what it is. You know that she going to put out.” (Brian, 23, African-American, Richmond group)
“We’ve got the wifey and we’ve got the work…Making love and just f---- somebody, it’s different…That’s sexual ‘cause I ain’t going to make love to no work…That’s what I’m saying… I’m going to make love to my wifey and I’m just going to dog the work…It’s like I don’t care…Just toss out the work, you know what I’m saying?” (Charles, 26, African-American, Oakland group)
A more intermediate type of relationship, “friends with benefits/rights”, was described in all groups, in which participants revealed additional dimensions of feelings, and less of an overt exploitive agenda. Participants were more respectful in describing these relationships in which men have sex with female friends, acknowledging that there is some form of intimacy in these relationships:
“There are relationships [referring to “friends with rights”], of course…where you trust her…You know what I mean? You trust each other. So that leads you to… eventually… it leads you to have a relationship more…how should I say it?…more open… Take for example…She’s your friend…that’s that…that is, you give her…what’s needed…or if she’s not feeling well you’re there for her. But you don’t want to, how should I say it? Get completely involved. You understand? That’s why you try…not to go steady. That’s how I see it.” (David, 24, Latino/Hispanic, Richmond group)
In this type of sexual relationship, some participants expressed concerns about misunderstandings or emotional harm. The confusing nature of mixing a friendship with sexual relations was apparent in the concerns they expressed, as well as their grappling with the difficulty of maintaining boundaries and shared expectations with the woman in this context.
All participants also discussed committed relationships in response to the topic guide question on relationships. In committed relationships, certain features were more characteristic: young men also expressed “feelings” for the women and elements of trust, but additionally there might be emotional and/or financial support and some expectation that the relationship would last. The types of committed relationships discussed, a relationship with a “baby mama” and relationships with women they called “wifey,” “main,” in some groups, and “girlfriend” in all groups, were very distinct yet had some shared domains. Participants discussed how having a child with a woman (non-marital) often creates bonds which are long in duration and sometimes intimate and/or turbulent. There can be on-going sexual activity as well as various levels of emotional or financial support even if the parents are no longer “formally” in a relationship or have moved on to other relationships:
“Even the one-night stands might end up a baby mama; you always end up attempting to be somewhat friends or enemies. What I mean by that? You create and you’ve got that child and you want to deal with it, but you really can’t stand it and you hate yourself for the rest of your life…So it’s one of them love/hate relationships but it works on account of the baby mama. That’s a typical baby mama nowadays.” (Eric, 21, African-American, Vallejo group)
In the other committed main relationships, having a baby might be viewed as a potential future outgrowth of the relationship rather than the factor that perpetuates the relationship. In addition in other committed main relationships, support was often described as multi-dimensional rather than focused on providing for the child as in the relationship with a “baby mama”. In this quote a “wifey” was described in terms of emotional and material support:
“It’s all according to the way a person treats you. Wifey, wife, whatever you want to call it, she’s going to treat you a certain way. She’s going to have you doing certain things that a work ain’t…See, she clothes you, feeds you, house you, supports you, period. Work will do that, too. But the wifey going to do it out of love.” (Felix, 24, African American, Oakland group)
While the young men described types of relationships, they also noted that relationships were fluid and might take different shapes at different times. Domains might change within a relationship type, such as intimacy, or the whole relationship might shift to a different type as intimacy, caring or material dependence intensify. The following excerpts illustrate this:
“[Referring to friends with rights] It also means that…she doesn’t have the right but…she facilitates sex and you facilitate it for her but you don’t have a relationship…you can be with anyone you want. There’s no relationship. You’re friends. You’re just partners…in the relationship…Nothing is official. The problem with that is that you can lose control over it…you may fall in love or something…That’s when people get in trouble.” (Gabriel, 20, Latino/Hispanic Richmond group)
“This how it happen…You get some work that turned into your friends with benefits ‘cause she got some hookup and she’s hooking you up so good and you’re all starting to kick it all the time that she turn into the wifey. But at the same time you’re making her your wifey, she steals some work.” (Harold, 22, African-American, Oakland group)
These complex scenarios, with changing levels of intimacy, caring and trust, arose in the different focus groups as characteristic of relationships among these young men. There was relatively less mention in the discussions of cultivating intimacy over time. In fact, there was discussion of distrust of lasting states and open acknowledgement that desired levels of intimacy in relationships are often mismatched between partners. A recurring theme in all groups was how partners have differing preferences for the relationship with the males more often than not being less attached. Invariably, other partners were mentioned throughout the groups and monogamy was discussed as an exception rather than a predominant theme.
Another theme that was expressed by the young men was that relationship type dictated beliefs about appropriate condom and contraceptive use. This was most evident in casual relationships, such as “one night stands” where trust, communication, and intimacy between partners is low, and risk perception of STIs is high. The focus of the young men was on using condoms to prevent spread of STIs, apart from any notions about pregnancy prevention. Condoms were universally endorsed in all focus groups, with strong assertions that they should be used the first time with a casual partner. When asked about contraceptive methods in the topic guide, the young men always brought up condoms, and were far more likely to start to discuss personal experiences:
“Talk about one-night stands and all that. If you’re talking about like just getting with a girl, I’d use a condom for sure. No STDs, no -- I mean, I’m not trying to catch no STD. (Jordan, 20, Asian, San Francisco group)
For the relationships, such as “friends with benefits” where trust was higher, but the expectations for intimacy and relationship duration were simply for the time being, rather than for the future, men were concerned about protecting themselves from unintended pregnancy, perhaps more than STIs. In these casual, but more connected relationships, young men were more likely to state that they are not trying to get the girl pregnant.
“One disadvantage…the most important one, I guess, is pregnancy. Because if you’re with a friend with rights…I suppose you don’t want her to become pregnant, since you’re not going to make the relationship an official one. Mainly, what you need for this (pregnancy) to happen is love and this is just sex.” (Kevin, 19, Latino/Hispanic Richmond group)
The young men indicated that the goal in the casual relationship types was to use condoms, withdrawal, or have the woman use some kind of birth control to prevent pregnancy because the expectations in turn were more immediate, i.e. sexual gratification and “not to have a baby.” Condoms had to be used or the women had to use some birth control or sexual intercourse would not occur.
When asked about the scenario when a girlfriend did not want to use birth control pills, participants in all groups affirmed, with a somewhat urgent tone, that it was important to avoid pregnancy and to take charge of the situation. In these situations, the male partner explicitly controlled the decision-making about sex and contraceptive use:
“You come at her like this. You be like check it out, you want to be with me and if it’s going down like that, you’ve got to lay it down. You bet you, you just got to lay it down and tell her. If you want to be with me and we going to be together, I ain’t trying to have no kids. If that’s your mindset, we ain’t trying to have no kids and she ain’t trying to compromise like you say, you step, kick rocks ‘cause you ain’t got to sit there and go through no stress that you really don’t want to have to go through.” (Lewis, 22, African-American, Richmond group)
Some men preferred condoms to relying on the women using hormonal methods, since they could not know for sure if she was using a method. The young men spoke about women who had their own goals and tried to undermine men in order to intentionally get pregnant. “Poking holes in condoms” was mentioned in several of the groups. Participants expressed feelings of mistrust of women and lacking control:
“That means you’ve got to bring your own condoms ‘cause if she’s like really trying to have your baby and she doesn’t care how she has it, you’ve got to bring your own condoms so she’s not poking holes in yours.” (Marcus, 21, Mixed race, Vallejo group)
In committed relationships, the young men viewed the risk of STIs as less significant or no longer a concern, and condom use as superfluous. Young men in the groups often referred to an element of trust in committed relationships; trust that their partners were not having sex with other men. In addition, because there were feelings involved in committed relationships and some expectation that the relationship would last, the notion of having a baby was no longer viewed as a potentially negative outcome of the relationship. One participant explained how he ended up with two kids after stopping condom use when the relationship became more intimate after several months together:
“That’s how it happened with me after like about a good six or seven months and I know I’m going to be with that woman and I’m not cheating and she’s not cheating. I mean sooner or later you’re going to take it off. I don’t know nobody that been with their woman for more than two years and they’re still using condoms unless they’re really determined to have no baby.” (Nathan, 21, African-American, Richmond group)
One of the ways that the young men in the groups described committed relationships as different from casual relationships was the degree of communication about contraception within the two types of relationships. In casual relationships there was little or no conversation about contraception; the woman was expected not to get pregnant and the dialogue about this was limited. In addition to having more communication, young men in committed relationships also commented on various ways they might get their partners to use contraception. This could take the form of constant reminders to help a young woman use a method successfully or dynamic negotiations which involve use of persuasion.
“Yeah. Well, she was on birth control, she got off birth control and she told me that she wanted to marry me, she wanted to have my baby and I was like 18 years old working full time and going to school and she laid that on me and I told her that I would be nothing by the time I’m 30 and like you want the child to have a good life, you can wait 5 years and we can both have good incomes and we can get a house and dog and white picket fence and all this stuff. But now we’re just going to live in my apartment in a rough, in a bad neighbourhood and it’s not a good place to raise a kid. I’m still a kid. That’s basically what I told her.” (Owen, 24, White, Fairfield group)
In another example, in response to the scenarios, participants discussed ways in which they exerted more control over a young woman to make her use contraception, or as one young man referred to it: “getting into her head.”
“If you can’t get up in your girl’s head, man, if that’s your chick and you can’t get up in her head – Man, something wrong. You’ve got to be a strong man. If you’re with a female, evaluate your female right enough to where anything that you feeling, your female should do. If it’s humanly possible for her to do, she should do it.” (Lewis, 22, African-American, Richmond group)
Finally, in committed relationships, young men noted they could take explicit steps to help a woman use contraception such as going to a clinic with her to choose a method.
While participants indicated that they often had beliefs about appropriate condom or contraceptive use in different types of relationships, their actions were not always consistent with those beliefs often leading to gaps in protection. While the young men in the focus groups were very clear conceptually about the need for condom use in certain relationships for both STI and pregnancy prevention, and their intentions to use them, they admitted that often in reality they would have sex without condoms. A few participants reported that they were really consistent with their condom use, but this was atypical. Most participants indicated unprotected intercourse occurred commonly and for a variety of reasons, including not wanting to use condoms, alcohol or substance use interfering with judgment, lack of preparation (not having condoms), or being “lost in the moment:”
“For example, at a party most of young men when they meet a girl…he starts drinking and…there’s chemistry. Well, I’ll invite you to my car. F---, it happens and then…a week later, she’s already pregnant.” (Preston, 22, Latino/Hispanic, Richmond group)
“Suddenly you just say, while you’re having intercourse, suddenly you just go ask ‘Are you prepared for protection?’ and whoa, ‘cause you never think about, really never think about the protection when you have sex. Because the sex just happened instantly. Just like something clicked and then you just involved in the intercourse, you know. So you never really prepare before you do it. It’s just like you maybe put it on during or just stop for a while, you know.” (Quentin, 20, Asian, San Francisco group)
In committed relationships, young men admitted that often times they rely on their partners to use birth control to prevent pregnancy, which can bring up feelings of anxiety and mistrust about pregnancy intentions. While their expectation may be for their partner to use birth control, this may not in fact happen:
“It was me and my ex, and she told me while we were having our intercourse that she was on the pill. And to me the pill is the pill. But she told me the next day that like ‘Oh, I’ve got to get a morning-after pill’ and I was like what the f--- are you talking about? You said last night you were on the pill. And she said ‘Oh, I meant that I was going to get the morning-after pill.’” (Robert, 24 Asian, San Francisco group)
In response to questions in the topic guide about childbearing, the young men also noted that since relationships have a dynamic nature, the requirement for condom use may diminish. This transitional period may consequently be a time of increased pregnancy risk, since the woman may not transition to using hormonal contraception. As relationships change, there can be period of low protection:
“As far as my perspective when it comes to brothers having babies, it just be like they be in a relationship with a chick for a certain amount of time and once you get in that comfortable relationship, you ain’t using no condom and you know boom, boom, boom, it’s going to happen.” (Nathan, 21, African-American, Richmond group)
Fear of contraceptives and low knowledge may also contribute to potential gaps in coverage by reducing or eliminating consideration of possible options of highly effective hormonal methods for partners. Most participants knew very little about hormonal contraception, although all were certain that women gained weight and many worried that women forgot to take pills. Participants in several groups asked about a potential “male pill”. One hallmark of relationships with main partners expressed by young men in the focus groups was the notion of having “feelings” or caring about one’s partner. This concept included feelings of intimacy but another important characteristic expressed by young men of committed relationships was caring for the well-being of their partners. Their concerns about health included fear of future infertility and distrust of hormonal methods. Many participants in each of the groups expressed concerns over the safety of contraception for women’s bodies. Some young men expressed highly exaggerated ideas of the danger of contraception, which might preclude young men from taking pregnancy prevention responsibility, unless it is through condom use:
“It can kill you? (Referring to the pill) I heard there’s -- What the place in Daly City? There’s a pill that had killed a girl over there. That they had taken a birth control pill or something like that. I think it was along with like drinking, I think, pot. I don’t know. I just heard that’s why they closed that place down.” (Sean, 22, Asian, San Francisco group)
“That’s why I use condoms, ‘cause I’d rather her not have to take that just as far as I really feel uncomfortable with her body being altered in ways that it shouldn’t be.” (Travis, 23, Mixed race, Vallejo group)
The themes expressed by these young men about sex and behaviour in different relationships illustrate a spectrum of decision-making dilemmas. When these themes are viewed together, it is possible to have an improved understanding of the inherent difficulty in fully engaging young men in contraceptive decision-making. The survey data collected showed that the sample of young men had very low reliance on effective hormonal contraception (lower than one-fifth at last sex) and more than half reported multiple partners. The analysis of the focus group data helped to show why the participants had such low levels of pregnancy and disease protection.
While our focus group participants endorsed a dichotomous relationship paradigm in general, they exposed a much more detailed view of casual relationships and of the fluid nature of relationships, which tend to impede protective behaviours. A host of casual relationships were described with differing intentions and emotions. A smaller spectrum of committed relationships was described. Most casual relationships are not particularly conducive to contraceptive decision-making, since there is little communication, intimacy, or duration to the sexual relationships. Pregnancy intentions were clearly dependent on the relationship type, and many of the participants expressed a desire for more certainty that pregnancy would not occur in casual relationships. We found that despite the casual nature of relationships like “friends with benefits” or “work”, young men have strong feelings about preventing pregnancy. Future research with young men could test ways to strengthen and support pregnancy prevention desires, since we also saw that they may fail to act to prevent pregnancy, even with strong intentions to do so. Participants acknowledged the failings of the condom, a coitally-dependent method, to protect in situations of unplanned sex. The development of new male contraceptive methods could also address young men’s desire to have control and be certain that a method was being used.
The young men in this study reported that their desire to prevent pregnancy was not necessarily in line with their partners’ desires, and that they might not even know a casual partner’s pregnancy intention. Research has shown urban young men from similar communities to be supportive partners of contraception and to even accompany women to the clinic visit, but generally within the context of on-going relationships (Harper et al. 2004). With the predominance of casual relationships described in this study and the significant incongruence between male and female partners in terms of relationship values and goals (at least from the male’s perspective), a better understanding of how to improve relationship dynamics is needed. The extreme disregard for female partners in casual relationships with “rippers”, for example, imply that working with young men and women on issues of mutual respect is important but also obtaining a better understanding of how these young men have experienced and regard intimacy and how it fits (or does not fit) in the context of their lives would be helpful. Inability to maintain intimacy or interpersonal conflicts about intimacy may underlie the high prevalence of causal relationships described by these young men.
These results also highlight the need to acknowledge the fluid nature of relationships with unanticipated changes in various domains that can lead to periods of high exposure to the risk of unintended pregnancy. Survey research of national data in the USA has shown that gaps in contraceptive use and inconsistent use, as well as non-use of contraception leads to unintended pregnancy (Vaughan et al. 2008). Condom discontinuation rates are 67% at six months and 81% at one year (Vaughan et al. 2008). Young men in our study explained that they saw condoms as far more important for casual relationships since they unanimously wanted to prevent STIs in these relationships, and they also recognised the high risk of pregnancy. The current framework for condom use relies heavily on a disease prevention model; increasing the appeal of condoms through social marketing focused on sexual pleasure might also help since the primary motivation for causal relationships is sexual gratification. Recent research has suggested that increased attention to sexual pleasure might also improve the relevance of contraceptive counseling and method adherence (Higgins and Hirsch 2008).
While use patterns were inconsistent, acceptability of male condoms in causal relationships was high in this study. Our findings however indicate further work is required to increase the acceptance and use of condoms in the context of long term relationships and more intimate relationships where condom use can be viewed as a sign of infidelity. An assessment of whether efforts to promote the pleasurable aspects of condom use or associate condom use with other aspects of popular culture (i.e. music or fashion trends) could increase condom use in broader contexts might prove useful. In addition, the frequency of multiple and concurrent partners noted in this study highlights the importance of the need for dual protection with condoms and hormonal methods in this age group.
This study also demonstrates how young men may have confusion and low knowledge about highly effective hormonal methods that could make it difficult for them to serve as allies to help women. Young men’s fears about hormonal methods may also serve as barriers to helping female partners in committed relationships use more effective contraception. This study suggests a need to increase young men’s understanding of the limited health risks associated with hormonal contraceptives. This education could be incorporated within sex education in school settings as well as a part of counseling for men in clinical settings.
The themes expressed in these focus groups by a group of racially and ethnically diverse males are consistent with those from epidemiologic studies of relationships and contraceptive use, which demonstrate strong correlations between relationship type, main or casual, and condom and contraceptive decision-making (Ellen et al. 1996, Ott et al. 2002). Previous qualitative work among inner city minority ethnic men also revealed similar findings to ours in terms of predominant use of condoms in casual relationships and a host of factors leading to inconsistent condom use, including limiting pleasure and sensation (Crosby et al. 2004). However, what these previous studies fail to impart is an understanding of how young males think dynamically about sexual relationships and the complex interplay between these ideas and the factors that produce contraceptive choices or behaviours. Furthermore, these data from all-male focus groups allowed participants to voice negative and harsh underlying social norms that likely influence individual behaviours, but may remain unspoken in individual interview settings. It is important to acknowledge the existence of the negative social norms as well, in order to have a fuller picture of relationship dynamics and contraceptive use.
It is easy to imagine how norms would dictate how to behave in a simple relationship paradigm: casual relationships mean “protect yourself”; committed relationships mean being more open to the possibility of planning and negotiation. Yet when the paradigm becomes more complicated, i.e. fluctuations in emotions and trust, it is also easy to understand how young men fail to behave in a rational or consistent fashion. It would be useful to explore with young women how our finding about the prevalence of and sporadic nature of casual relationships specifically impacts their behaviour and ability to protect themselves from unwanted pregnancy.
There are limitations to the utilisation of focus groups, especially with such a sensitive subject as sexual health. In a group format some participants may present socially desirable or competitive responses that do reflect true sentiments. Since focus groups capture social dimensions and were all-male, masculinity and hyper-masculine attitudes may have been exaggerated. In focus groups it is difficult to discern individual experience from social knowledge; quantitative studies are more useful for this. Participants who are more vocal or prolific tend to dominate discussions and generate results which may not reflect the entire group’s viewpoint. Alternatively, some participants may be reluctant to share personal information, especially within the context of a sexual discussion. We are not able to assess the effects of female co-moderators on discussions given the small number of groups. The presence of female co-moderators may have increased the inclination of participants to give socially desirable responses or alternatively it may have lead to enhanced discussions on the part of participants in an effort to “educate” the female co-moderator. There was a significant amount of consistency across groups; most themes were identified across all focus groups even though the groups were stratified by race/ethnicity. Due to the number of participants and group sizes however, we are not able to make cross-cultural comparisons, i.e. to state whether particular beliefs are held more so by one particular group or another or represent cultural biases per se. The views expressed in these focus groups are specific to the social and cultural environment of the study population and may not be broadly generalisable.
Qualitative methods also do not allow us to determine the percentage of young men or if particular men (i.e. men in casual relationships) held any given attitude. Our intent was not determine the prevalence of attitudes and beliefs but rather to gain insight into how the study population conceptualises sexual relationships and contraceptive behaviours based on shared cultural knowledge. Keeping these limitations in mind, the focus groups provide a contextual view of young men’s role in contraceptive decision-making and should help us to think of ways to create educational, clinical and behavioural interventions to build on young men’s desire to prevent unintended pregnancy. Our results indicate that engaging men in contraceptive decision-making is challenging and may require a strategy that addresses relationship values and dynamics, condom use beyond the STI prevention framework, and the ability to make appropriate contraceptive choices in light of the inherent difficulties and uncertainty associated with casual relationships.
This study was supported by National Institute of Child Health and Human Development Grant R01 HD045480.