June 2017


The snip

By Ceridwen Dovey
The snip

© Eraxion / iStock

It’s a simple procedure, but having a vasectomy can raise questions of masculinity and equality

Since word got out that my husband was considering a vasectomy – and I was planning to write about it – a lot of men have surprised me by eagerly sharing their “vasectomemories”. Some told me about their first adventures in pubic hair removal. Others relayed wry comments that their vasectomist had made, looming above the operating table (“you may feel a small prick”). There were repeat accounts of terrified men in reception rooms, blanched and jittery, awaiting a common fate, and of freezers stocked with bags of frozen peas in preparation for post-op icing.

A few dug a little deeper and told me they’d been unprepared for the psychological impact of the procedure. For most, that impact was positive, as they relished the prospect of worry-free sex or basked in a partner’s gratitude. Some struggled with mild depression or loss of libido as they came to terms with the fact that they could no longer father children. Nothing very dramatic had happened to their bodies: “It’s not brain surgery,” Australian vasectomy pioneer Barbara Simcock says of the quick, mostly painless process of cutting or blocking the vasa deferentia, the two tubes that ferry sperm from the testes. Yet, for all these men, having a vasectomy threw up larger questions about their identities as partners, lovers, fathers.

At first glance, the topic of vasectomy might appear to be of interest only to heterosexual couples with completed families living in developed countries. But as an intervention in the human body (and, more crucially, in the male sexual and reproductive system), it can act as a wedge to open up reflection on issues of wider significance: shifts in gender identities, old anxieties and new ideas surrounding masculinity, and the correlation between contraceptive and gender equality within societies.

Just how stacked the current system is against men taking responsibility for contraception was brought home to me when my husband visited his GP to enquire about a vasectomy. He was given a pamphlet outlining contraception options, almost all of which were designed for women and came with not insignificant discomfort or health risks. Only two of the listed methods allowed for male agency or responsibility: condoms, and a vasectomy. The GP reluctantly gave my husband the name of a vasectomy clinic, but urged him to exercise extreme caution about going through with it given the permanence of the procedure, his age (under 40), and the fact that our children are young. His parting warning was that “in a year or two, your wife might get broody again”.

More useful was the GP’s question of what we would do if the unthinkable happened and we lost a child. Would we then want to have another? This alone gave us pause. Suddenly what had seemed a simple subject of male plumbing became metaphysical. Like any couple, we had imagined a certain kind of future – ours had two children in it, and we had managed to create them. All futures are precarious, and the effects of grief unknown until they’re upon you. But to find ourselves pregnant again with an unwanted child was for us the more urgent and imaginable fear. (We also felt reassured that vasectomies can sometimes be reversed, and there are new techniques for aspirating sperm directly from the testes, for use in IVF.)

In spite of this verbal hoop-jumping with the GP, the process of getting a vasectomy is fairly straightforward – and popular – in Australia, which has the second-highest vasectomy rate in the world, after New Zealand. Approximately one in four Australian men over the age of 40 has had a vasectomy. After oral hormonal contraception (the pill) and condoms, vasectomy is Australia’s third preferred contraceptive option. This is significant given that vasectomies – unlike the former two options – aren’t pushed by pharmaceutical companies standing to make a huge profit. It also makes Australia one of the few countries in the world where vasectomy is more popular than female sterilisation (globally, female sterilisation is five times more prevalent), which says a lot about how cultural norms surrounding contraceptive use have changed here over time.

By comparison, in France, getting a vasectomy for contraceptive reasons was considered illegal until 2001 because of an obscure provision in the Napoleonic Code outlawing self-mutilation. (In 2000, an international birth control advocacy group launched a “vasectomy tourist” campaign, encouraging French men to pop over the Channel to get the snip.) There is still an obligatory cooling-off period between consultation and procedure for prospective vasectomy patients in France, as there is in some US states. Many countries restrict access to vasectomy: in Finland, for example, you must have had three children or be over 30; in Russia, you must have had two children or be over 35. In some places, such as Iran, vasectomy is illegal, and in dozens of countries the legal status of vasectomy is still unclear.

Even in Australia, the right for a man to openly request a vasectomy for contraceptive purposes has only been won fairly recently. While some individual doctors were discreetly carrying out voluntary vasectomies from the 1930s, the Australian Medical Association (AMA) considered the procedure illegal and unethical until 1971. It took its lead from Britain, where vasectomies were only officially allowed for contraceptive purposes from 1972.

This wariness was in part a response to the horrifying history of forced sterilisations in many countries. Harry Sharp, the American doctor credited with performing the first vasectomy on a human, used the procedure in 1899 to sterilise inmates at the Indiana Reformatory.

In Australia, many of the earliest vasectomists were also often mixed up in the eugenics movement, such as Norman Haire from Sydney, who worked as a birth control advocate and eugenicist in Britain in the 1920s and ’30s. There he promoted “Steinach operations”, a one-sided, open-ended vasectomy for the purposes not of contraception but sexual rejuvenation. (Eugen Steinach, an Austrian doctor, had from 1918 falsely claimed that the reabsorption of sperm would increase libido and delay ageing: Sigmund Freud and WB Yeats both had the procedure done in their late 60s, and Yeats later claimed “it revived my creative power [and] sexual desire”.) Victor Wallace, a Melbourne doctor, sexual counsellor and founding member of the Eugenics Society of Victoria, gave hundreds of male patients voluntary vasectomies for contraceptive purposes in his private practice from 1934 to 1976.

Tiarne Barratt, who researched the 20th-century history of tubal ligation (female sterilisation) and vasectomy in Australia for her masters thesis at the University of Sydney, contends that the awful evidence of forced sterilisation still overshadows the record of substantial public demand for sterilisation as a form of reliable contraception. In spite of the fact that, globally, sterilisation (mostly female) is still the most used method of birth control, Barratt says it is often missing from historical accounts. Canadian historian Ian Dowbiggin agrees, writing in his 2008 book, The Sterilization Movement and Global Fertility in the Twentieth Century, that the “history of the sterilization movement is … more important than the history of the Pill and rivalling the significance of the history of abortion”. He, too, believes that historians have failed to acknowledge sterilisation’s “formidable impact on birth rates and mores regarding sex and gender”.

Another reason that voluntary sterilisation as a popular contraceptive is under-represented in histories of contraception is because the pill has had such an enormous impact, socially and sexually, and it continues to dominate the narrative of birth control. The pill was immensely liberating for women, precisely because it marked a shift in contraceptive responsibility: once “consigned to the public, male world”, Barratt writes, contraception “was reconfigured as a female responsibility”.

Yet, as a result of this new perception – that contraception should be a woman’s question rather than a man’s duty – men and their reproductive choices, and the gendered interactions surrounding contraceptive decision-making, have often been overlooked. This perception is now so entrenched it is easy to forget that until the 1960s, for better or worse, men “shouldered a large share of the responsibility for birth control”, as historian Frank Bongiorno documents in The Sex Lives of Australians. By the late 1930s, for example, almost two-thirds of couples practising birth control in Australia were using withdrawal, condoms and the rhythm method.

Once the pill burst onto the scene here in 1961, the dominant conservative forces within Australian society – the Catholic Church, and a government with a pro-natalist attitude and regular panics over white Australian birthrates dropping – were threatened by its ability to change forever the meaning of sex for women “from procreation to recreation”, as Bongiorno puts it. Sterilisation (still illegal at the time) was seen to be even more threatening, for it signalled the permanent end to future parenthood, and the beginning of a lifetime of sex for no other purpose but enjoyment. The Medical Journal of Australia’s editorial response in 1963 to a petition asking it to reconsider its position on the illegality of sterilisation is revealing: “indiscriminate sterilisation cannot benefit the State, and if widely performed at individual whims would ultimately be detrimental to the nation.”

So it is no surprise that sterilisation was still officially considered illegal in Australia until 1971. What is surprising, according to Barratt, is that sterilisation’s transition by the mid 1970s to becoming an accepted, uncontroversial and popular procedure was not based on any changes to legislation. Instead, this shift in the perceived acceptability of the procedure was mostly driven by the efforts and activism of a tight-knit network of doctors around the country, who during the 1960s were prepared to perform vasectomies covertly. Some of them inadvertently became experts in the field, as word-of-mouth referrals drove many patients to the same few doctors.

Sydney-based doctor Ian Edwards, who died earlier this year, was one of these vasectomy pioneers. In an interview late last year, he told me about his first vasectomy patient, who also happened to be his neighbour in Cronulla, in 1961. This man and his wife already had three kids, and his wife had recently had an abortion on their kitchen table. Edwards recalled him saying, “I’ve heard that in America there’s this operation called a vasectomy – could you do this for me?” Edwards’ surgical partner had done a few of them, so Edwards said to his neighbour, “Well, you know, if you don’t mind being my first vasectomy patient, we’ll give it a go.”

Edwards performed dozens of vasectomies each year after that, eventually tallying up about 10,000 over his career. At first, it was mainly other doctors who came to him. (He and his surgical partner did each other’s vasectomies, as well as those of many other doctors in their social network.) Over time, he would often find clusters of men in male-only workforces coming to see him. “You’d get the whole police force in a certain area, and fire brigades, huge numbers of them,” Edwards said. “The men would talk about these things between themselves and say, ‘I’ve had it done – why don’t you?’”

Other doctors – among them Bruce Errey in Brisbane and Barry Walters in Melbourne – were doing the same, often with huge numbers of patients. Errey was one of the most prolific, performing more than 30,000 vasectomies over a four-decade career, and celebrating every 1000th operation with a cake for the patient. Walters used to keep a tally of the number of vasectomies he’d done on a sign on his fence, causing passers-by much mirth (and a little discomfort). He liked to say that people who knew him well called him Tchaikovsky, “because I run the nutcracker suite”.

When, in 1962, the New South Wales branch of the AMA firmly restated its position that sterilisation was not only illegal but also unethical, Edwards was shocked. “I thought it was a load of bull and we just kept going,” he said. “We were against this load of medical politicians telling us what we should do.” At the time, Edwards was a member of the NSW Humanist Society. The Humanist Frame, a 1961 collection of essays by well-known figures (including both Julian and Aldous Huxley) about developing a non-religious view of life, had a big impact on Edwards. He identified with the anti-authoritarian belief that people are not corrupted by freedom.

Edwards believed the AMA’s statement was misleading, given that “no law dealt directly with sterilisation, no cases had come to court, and there was a variety of legal opinions from which to choose, most of them British”. Inspired by the Simon Population Trust, a population-control advocacy foundation in the United Kingdom that from 1966 began putting prospective vasectomy patients in touch with surgeons willing to do the operation, Edwards decided to try the same strategy in Australia. He contacted the Family Planning Association, but it declined to co-operate or run such a campaign. So he floated the idea with the NSW Humanist Society, which was already active in advocating for abortion law reform. It agreed to take the lead on the campaign, and soon had the support of Humanist societies in other states.

In 1970, the Humanist Society sent a letter to all doctors known to be working in the field, asking if they would be prepared to have their names added to a list of those willing to perform vasectomies in Australia. The letter stated that “no legal actions have arisen” against doctors who were already performing vasectomies in Australia, “but most surgeons remain intimidated by the law, and patients still have great difficulty in finding a doctor who will do a vasectomy for them”. A secondary goal of the campaign was to persuade doctors they could safely perform vasectomies without fear of legal consequences.

The reaction from the medical community was mixed. The Medical Journal of Australia received several hostile letters to the editor about the campaign, one of which accused the Humanist Society of being “anxious to attack life at its very source by promoting sterilization”. Even those doctors who were sympathetic to the cause often responded cautiously or negatively, refusing to have their names added to the list. One wrote, “I do vasectomy operations, but … I am not for one moment prepared to become a ‘vasectomist’.” Another wrote, “Personally, although I may be biased as a man, I think it preferable for a woman to be sterilized … it would be an embarrassment to me to have my practice flooded with these patients.”

However, enough doctors put forward their names that Edwards was able to create a token list in several states. One doctor was so enthusiastic about the procedure that he admitted to having done his own vasectomy five years previously, “the best thing I ever did for myself”. Another wrote, “Count me in on your list of vasectomising doctors. I am already doing them, and don’t mind risking the wrath of the Establishment.”

In September 1970, a story in Adelaide’s Sunday Mail about the list being made public resulted in the South Australian AMA and Medical Defence Union asking the state attorney-general, Len King, for a ruling. A month later, King made the following statement in the AMA Gazette:

Whatever may be thought as to the morality or wisdom of a person undergoing such an operation without grave reason, I am satisfied that the operation of sterilisation on man or woman is not prohibited by the criminal law of South Australia if performed with the consent of the patient.

King’s statement had a flow-on effect. In 1971, the AMA Federal Council deleted the clause forbidding sterilisation from its Code of Ethics, a change accepted by all AMA state branches except Queensland’s. This means performing a vasectomy could still technically be considered unethical in that state, which is laughable if you’ve ever seen the massive billboards on the Sunshine Coast advertising Nick Demediuk, aka Dr Snip, and his booming vasectomy practice.

National vasectomy data was first collected in Australia between 1973 and 1974, and it showed that around 25,000 Australian men had been swept up in what was dubbed “vasectomania”. By 1980, sterilisation (tubal ligation or vasectomy) had become the most widely used method of birth control in Australia for people older than 35. In spite of the renewed papal ban on birth control in 1968, sterilisation became a popular choice even for Catholics: as a once-off procedure, it meant they could avoid “repeat sinning”.

Since the 1994 United Nations International Conference on Population and Development, it has been globally recognised that men’s involvement in contraceptive practices is crucial – not only in terms of population control but also to address the unfair contraceptive burden on women. And that burden is heavy: as Holly Grigg-Spall claims in her 2013 book, Sweetening the Pill, we’ve been forced into an addiction to oral birth control for women because of its profitability. This in turn has reinforced cultural assumptions that contraception is and should remain a woman’s issue.

Yet once women in the developed world are finished having children, they are reluctant to resume drinking big pharma’s Kool-Aid. Generations of women, from the late 1960s through to today, on reaching their 30s or 40s and having completed their families, have chosen to replace the pill with sterilisation. In Australia, that increasingly means male sterilisation; the popularity of female sterilisation has decreased here since the 1980s. (No wonder: a 1999 American study showed that, if compared with vasectomy, tubal ligation has 20 times the risk of major complications, and a death rate 12 times higher.)

A colleague whose husband had a vasectomy told me that, after having kids, she chose not to go back on hormonal contraception because she wanted to know what “normal” felt like: her own, baseline self unadulterated by the artificial hormones she’d been on since the age of 15, which had consistently made her depressed. She is not alone. In a 2015 survey of over 1000 British women, more than a quarter of respondents reported feeling “worried” and “nervous” about taking the pill, and a third said they felt women are simply expected to “put up” with its side effects.

And then there’s the question of financial fairness. Women pay more for health care because they predominantly take on the cost of contraception, something that the US 2010 Affordable Care Act tried to address by requiring employers to provide contraceptive coverage (with no out-of-pocket costs) in their employees’ health plans. A 2016 op-ed in the New York Times supporting this requirement said it “represents an important legislative link between sex equality and reproductive rights”. Under the Trump administration, the Act itself is under attack. The proposed wording of which contraceptives are covered without a patient co-pay has already been changed, so that vasectomies, condoms and any future male-focused contraceptives are not included.

The uncomfortable truth is that, in the five decades since the pill was released, there have been almost no advances in male contraception. Reports of research breakthroughs pop up regularly – injectable hormonal shots, “clean sheets” pills that could create ejaculate-free orgasms, polymer gel injections to damage sperm – but the products never seem to make it to market. There was outrage late last year when an otherwise successful trial of a male injectable contraceptive was stopped early due to supposedly serious adverse effects such as “acne, injection site pain, increased libido, and mood disorders” (all of which are considered to be acceptable, run-of-the-mill risks of female contraceptives – well, except for increased libido).

“The joke in the field is we’re five to ten years away, and it’s been like that since the 1970s,” reproductive bioethicist Lisa Campo-Engelstein said in a 2014 interview. “The pharmaceutical companies have decided it’s not a good business, and so there just isn’t the money to make the jump from research to market.” This is a view that chemist Carl Djerassi, known as the father of the pill, also supported until his death in 2015. In a 2014 interview he said of the male pill’s prospects, “there’s not a single pharmaceutical company who will touch it – for economic and sociopolitical, rather than scientific, reasons”.

This is all the more frustrating given the evidence that men are increasingly supportive of having more options and taking equal responsibility for birth control. In a 2015 poll of more than 80,000 British men conducted as part of the UK Telegraph’s #TakeBackBirthControl campaign, 52% of respondents said they couldn’t wait to take the male pill. A 2005 study of more than 9000 men (from Argentina, Brazil, Germany, Indonesia, Mexico, Spain, Sweden, the US and France) found that 55% of respondents would be willing to use male contraceptives capable of preventing sperm production, if they were available.

Men may be open to the idea of new male contraceptives, but the reality is that many remain ignorant about their own bodies, which means some of the beliefs about basic contraceptive processes or consequences are ill-informed. Take, for example, the enduring fear that vasectomy is a version of castration. This has been a male terror since the 1820s, when the first vasectomy experiments were performed on dogs by a British doctor whose main goal was to demonstrate that vasectomy did not have the same effects as castration. In the NSW Humanist Society’s 1963 “Report on Sterilization”, one of the first points made is that “sterilization is not the same as castration”, a matter which “cannot be too strongly insisted upon, because [it is] not generally understood, and a grasp of the physiological facts is necessary if the social and personal importance of sterilization is to be appreciated”.

This castration anxiety still persists. In the “Vasectomy Pack” my husband was given a few months ago (on its front page, rather reassuringly, was a photograph of New Year’s Eve fireworks exploding across the Sydney Harbour Bridge) the first entry under FAQs included the emphatic response “Vasectomy is NOT castration.”

These fears, no matter how irrational, are valid. They reveal the psychological impact that a vasectomy can have, and how bound up the procedure is with male identity, vulnerability, and questions of self-worth and manhood. It is only recently that men have started opening up about the anxieties and emotions related to getting the snip. A writer for GQ magazine described feeling “strangely emptied, gentled, sad … curled into a question mark” after his vasectomy, and wrote that he still feels a twinge each time he sees a child’s abandoned dummy in a grocery store, “wondering about all those might-have-beens”.

For more than five years, Auckland-based psychologists Gareth Terry and Virginia Braun have been interviewing New Zealanders about what effects a vasectomy has on the patients’ emotions and relationships. In one of their first articles, many of the men interviewed interpreted their vasectomy experience positively, as a minor act of heroism undertaken out of love for their partners and a desire to take contraceptive responsibility within a relationship. This was an important intervention in what Terry and Braun describe as the “largely negative picture around vasectomy, emphasising fears, side effects, and men being pressured into having the operation”.

In a follow-up study, Terry and Braun slightly tempered this framing of vasectomy as a form of heroism. Just as Annabel Crabb took issue in The Wife Drought with the perceived heroism of men who do even small amounts of housework or child care (while their wives do the bulk of this work without credit), Terry and Braun asked if this perception of vasectomy – and the extreme gratitude often expressed by the men’s partners – was a symptom of deeper inequalities within the household economy.

That said, for a growing number of men around the world, getting a vasectomy is not only a contraceptive procedure but also an opportunity to radically rethink masculinity. Sometimes this takes the form of Trumpisms from men in the often alt-right-leaning “men’s rights activists” community, about the desire to control their own fertility to avoid being duped into parenthood by scheming women. More often it marks an authentic shift in how men, such as self-described “male feminist” Ashley Thomson (founder of the Homer website, which he hopes will “act as a bridge between the gender-equal world I want to live in and the men who have yet to see the virtues of that world”), are parsing the new rights and responsibilities of different visions of masculinity. Another male friend, who identifies as a feminist, told me that he and his wife decided on a vasectomy because it’s his way of “smashing the patriarchy”.

In 2013, American filmmaker Jonathan Stack co-directed The Vasectomist, a documentary about Florida-based surgeon Doug Stein. Soon afterwards, Stack and Stein co-founded World Vasectomy Day, a campaign offering education about, and access to, vasectomies for men around the world. There is now a network of more than 1000 participating doctors in more than 40 countries, and Stack says the annual event, which includes live demonstrations of vasectomies streamed globally, is “the largest male-focused family planning event in history”.

For Stack, the motivation for the campaign is twofold. One goal is to overturn often well-founded fears that it is paternalistic and hypocritical for developed countries to encourage birth control in developing countries. Indeed, some internationally funded population-control programs have been appallingly coercive, such as the mass sterilisation campaign carried out in India in the 1970s. Millions of Indian men were sterilised, often against their will.

Yet Stack and other family planning activists believe it’s another kind of first-world prejudice to assume that men in developing countries – or men in low-income communities within developed countries – don’t want to be actively involved in contraceptive decision-making, or that they would reject the idea of a vasectomy if it were cheap and easily available. Karen Hardee, a senior associate at the US Population Council, says, “I think a lot of us are in this mindset of, ‘Oh, men are “problems” in family planning.’ And I really think we need to see men as part of the solution.” Sarah Miller, a family planning specialist working in the Bronx, New York, says, “we have a very diverse population of people … and yet, we are seeing men for vasectomies, and that’s sort of exciting because … we are shifting the demographic and diversifying, but also we’re showing that … the whole idea of ‘those men won’t do it’ is simply not true.”

Stack’s second goal is to use vasectomies as a way of unobtrusively but effectively breaking down wider taboos around men taking responsibility when it comes to contraception. In articles he has written about World Vasectomy Day, Stack says, “It’s not just about getting men to participate, but getting men to do so with more compassion, kindness and care.” The campaign emphasises that a vasectomy can be a chance for a man in any country to commit an act of love for women, and in doing so aims to bundle up “individual acts of kindness into a collective movement for social good”.

This may sound a little corny, but it is more than a symbolic gesture. Contraceptive equality is a useful indicator of gender equality in a society. Vasectomy is one of the few traceable forms of male contraception, and countries with the highest rates of vasectomy (New Zealand, Australia, Canada, the UK, the US, the Netherlands, Belgium, Spain, Denmark, Switzerland, South Korea) tend to rank well in the UN Gender Inequality Index. As global health expert Roy Jacobstein wrote in the Lancet in 2015, “vasectomy is widely chosen in regions and countries with high socioeconomic development and gender equality”. This correlation doesn’t always hold: Sweden and France have quite low vasectomy rates, while Bhutan’s is high, but the link is generally strong.

In societies with more gender equality, it seems that men are happier having conversations about sharing contraceptive responsibility, and putting those beliefs into practice by getting a vasectomy. It’s possible that it works the other way around too: by considering getting a vasectomy, a man is engaged in wider conversations around gender equality, as Stack hopes.

It was comforting to my husband and me to know that in making a private choice to go ahead with his vasectomy we were also quietly asserting our mutual belief in contraceptive and gender equality. Our decision, and my husband’s openness in talking about it, has had a snowball effect in his work and social circles, prompting other men he knows who have been putting off taking responsibility for contraception within their own relationships to consider vasectomy as an option.

I went with him to his appointment, and the doctor was kind – or sadistic – enough to let me observe the procedure for research purposes. High on happy gas, my husband asked the vasectomist the age of his oldest-ever patient. “Eighty-three,” he deadpanned, “which means there’s still hope for the rest of us.” This set my husband off in a fit of giggling, which lasted pretty much the entire ten-minute procedure, while I watched, sober and grim-faced, as his left vas deferens (which looks like a thick white shoelace) was cut in two. I did feel a jolt of emotion: this was the tube through which the seeds that eventually became our sons had travelled. The mysterious act of generating life was suddenly laid bare.

It also struck me then that sterilisation is such a horrible, cold word, implying a sort of death for both partners. Mourning what we would lose was a necessary part of our decision-making process, but so too was anticipating the freedom of our future. We walked home together, and both looked a little wistfully at our youngest son’s miniature socks drying on the line. Then we got settled on the couch with a pack of frozen peas and a bottle of bubbly. We didn’t have to pretend: it felt like a celebration.

Ceridwen Dovey

Ceridwen Dovey is the author of Blood Kin, Only the Animals and In the Garden of the Fugitives. Her latest book is Writers on Writers: Ceridwen Dovey on J.M. Coetzee.

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