double standards

Tubal Ligations Are Riskier Than Vasectomies — Yet They're Performed Far More Often

Vasectomies are cheaper and safer than tubal ligations but misinformation and double standards abound.

by Molly Wadzeck Kraus
Originally Published: 
Vasectomy Time

Peruse online parenting or relationship forums, and you'll find an endless supply of posts from heterosexual women lamenting their partner's unwillingness to undergo a vasectomy, even when they've agreed on family planning decisions. Questions like, "Am I the Buttface for asking my husband to get a vasectomy?" or "Am I wrong to demand my husband get a vasectomy?" are common. So are threads of women frustrated with the outright refusal of their male partners to even consider the procedure, often hosting hundreds of comments.

Although vasectomies are simpler, safer, and less expensive, tubal ligations (getting one’s “tubes tied”) outpace them 3 to 1 in the United States and are still performed far more often worldwide. Recent research from BabyCenter targeting mothers with children under 5 confirms this pattern, revealing tubal ligations as the preferred choice among families, equally as popular as IUDs. This trend is supported by decades of research, with one study even finding vasectomies declined from 2002 to 2017.

It’s no secret that responsibility for preventing pregnancy in heterosexual relationships disproportionately falls on women. Described as an aspect of domestic labor by sociologist Andrea M. Bertotti, this "fertility work" includes not only the physical burden of contraception but also the associated time, stress, and mental strain.

The vasectomy is equally as effective as tubal ligation and one-fourth of the cost.

Female oral contraceptives have been accessible since the 1960s, while cis men still have no comparable option. Safe and effective male contraceptive options have been dismissed due to undesirable side effects commonly experienced by women using female contraceptives, a clear double standard.

Sterilization is the chosen contraceptive method for about half of married or cohabiting couples in the U.S. Of those, only 17% use vasectomy, compared to 30% who rely on female sterilization. “For most of the history of both tubal and vasectomy, there have usually been two or three tubals for every vasectomy,” says Dr. Marc Goldstein, M.D., chief of male reproductive surgery at Weill Cornell Medicine. "When you look at the data about efficacy and safety, it really should be the other way around. In countries where they've advertised vasectomy as a better technique and made a great effort to advertise the advantages, the ratio is reversed." Vasectomy, the only long-acting method of birth control available to men, is twice as common as female sterilization in some other Western countries, including Canada and the U.K.

The vasectomy is equally effective as tubal ligation and one-fourth of the cost. It's a quick outpatient procedure, during which a doctor cuts and seals the tubes that carry sperm. Goldstein says he performs vasectomies on a Friday afternoon, with instructions to take it easy over the weekend. “My average is 10 minutes for the whole procedure. I tell them they can return to work on Monday and resume sex and exercise after a week.”

In contrast, tubal ligation is an abdominal surgery usually requiring general anesthesia and is a much more invasive, involved procedure. The patient's downtime after a tubal ligation, which involves cutting or blocking the fallopian tubes and carries higher rates of complications, is at least two weeks, according to Dr. Layan Alrahmani, M.D., an OB-GYN and member of the BabyCenter Medical Advisory Board.

Given the many advantages, why is vasectomy uptake so low in the U.S.? “I think there are several things at play here,” said Dr. Danielle Jones, M.D., a board-certified OB-GYN, in an email. “Women/AFAB people have traditionally been the ones responsible for contraception management; they are also often in somewhat regular proximity to a doctor who does the tubal ligation surgery, while most men/AMAB people aren't regularly visiting a doctor who provides vasectomies.” Half of tubals are performed within 48 hours postpartum. “Add to that a huge lack of awareness and lots of fear-mongering on side effects, and you have a recipe for avoiding this quick and easy procedure.”

In fact, it’s been found that sexual satisfaction of men actually improves after vasectomy.

The disparity can be attributed to a combination of factors, including cost, misconceptions, and fears about the procedure. The gender bias surrounding contraception and the stigma associated with vasectomy cannot be underestimated, nor can the emotional and cultural significance that men associate with their reproductive organs and their perception of masculinity.

In a recent Us Weekly story, Jessie James Decker, mother of three, opened up about her husband Eric's refusal to undergo a vasectomy, quoting him as saying he thinks it “takes his manhood away.” The article, which was also somehow about her snack endorsement deal, neglects to add any myth-busting context around other quotes in which Eric expresses he "can't pull the trigger" because it feels like "it's a little power being taken." Even the progressive network darling Brooklyn Nine-Nine treated vasectomies as a scary joke.

"There's a lot of misinformation out there," says Goldstein. Some of the biggest myths include a belief that men won’t be able to ejaculate after the procedure. “Only 2% to 3% of the entire volume of semen is where all the sperm is,” he says. Other misconceptions include the belief that there will be adverse impacts on sexual function and that they will experience a significant prevalence of pain or prolonged discomfort. These are quite easy to dispel too, according to Goldstein. “There's really very little pain and discomfort after." In fact, it’s been found that the sexual satisfaction of men actually improves after vasectomy.

Having basic education about the procedure, including the risks and benefits, tremendously impacts uptake. The most common way men learn about vasectomy is by talking to other men who have already undergone the procedure. However, this is challenging when prevalence is so low. "When I see patients, I hear questions related to urban myths like the vasectomy giving men erectile dysfunction, it will cause prostate cancer, or that it will decrease their testosterone levels and make them 'less of a man,'” says Dr. Paurush Babbar, M.D., a urologist at the Urology Group in Cincinnati, Ohio.

Our health care and insurance systems aren’t making things easier. Unlike contraceptives for women, vasectomies are not classified as preventive services under the Affordable Care Act, which means that insurance plans are not obligated by federal law to fully cover them. Additionally, there are still millions of Americans without any form of health insurance.

"No man in North America has ever died from having a vasectomy ever," says Goldstein. Although an overall safe procedure, in comparison, in the U.S. alone, "every year, 25 to 30 women die from getting a tubal ligation.”

Since the Supreme Court overturned Roe v. Wade last summer, both female and male sterilization has attracted increased interest. Google searches for "tubal ligation" spiked by 70% in the week following the court's draft opinion leak, and searches nearly quadrupled in the week following the final decision. According to a Los Angeles Times report, OB-GYNs noticed "a dramatic increase" in women requesting sterilization.

"Preliminary data in certain places around the country do note a significantly higher vasectomy volume since June 2022," says Jones. Cleveland Clinic urologists were the first to publish data showing an increased interest in vasectomy and follow-through with the procedure since the Dobbs decision.

Both Babbar and Goldstein confirmed they also saw increased requests and completed procedures following this timeline. "Certainly in states where abortion has been virtually banned or severely restricted, there was a detectable significant increase in the rate of vasectomies,” Goldstein says. "Even in my own practice, I've noticed an increase in requests. The ruling has had a major influence." Babbar says his clinic saw a “tremendous upswing” in the number of vasectomies they did. “It obviously changed people's decision calculus on what would happen if they had an unexpected pregnancy."

A spike in vasectomies driven by panicked response to the loss of abortion rights, however, does not ensure a transformed future regarding reproductive health equity and responsibility within heterosexual relationships. All it seems to demonstrate is how little men have been paying attention and how much they've relied on women's fertility work and access to abortion. After all, reproductive rights experts predicted this outcome and have been reporting on the long conservative plot to undo Roe. Most women I know weren't shocked at all. Why did it take losing Roe for men to suddenly "step up"?

The conspicuous disparity between tubal ligations and vasectomies tells a bigger story, one that is not just a matter of equity in partnerships, or in shared responsibility for family planning, but a matter of life and death. "No man in North America has ever died from having a vasectomy ever," says Goldstein. Although an overall safe procedure, in comparison, in the U.S. alone, "every year, 25 to 30 women die from getting a tubal ligation.”

“The bottom line is that the tubal has always been more popular because [cisgender] men don't get pregnant."

Of course, there are inherent risks associated with pregnancy itself, whether or not it is brought to term. The United States has the highest maternal mortality rate among developed nations, with a particular disparity observed among women of color, The devastating impacts on the lives of women unable to access abortion after failed contraception are well documented. Additionally, over 50,000 women every year develop severe maternal morbidity, defined by the CDC as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.” In places where abortion has been banned or severely restricted since Dobbs, people who can become pregnant are facing a shrinking list of options, especially given the conservative attempts to restrict other forms of contraception.

People who cannot get pregnant simply don't face the same risks. As Goldstein puts it, “The bottom line is that the tubal has always been more popular because [cisgender] men don't get pregnant."

Although factors such as health insurance coverage, awareness and education, and access to providers all contribute to the low rate of vasectomy, the effects of historical patriarchal norms underscore all aspects of the conversation. It’s no surprise that countries with the lowest gender inequality are among those with the highest vasectomy prevalence, and vice versa. Until we raise expectations for heterosexual men to engage equally in family planning, vasectomy rates will not improve.

Molly Wadzeck Kraus is a freelance writer whose work has appeared in Insider, Scary Mommy, and more. She lives with her husband and three children in the Finger Lakes region of New York.

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