Unintended pregnancy rates in the United States are high, particularly among adolescents and young adults.¹ Although efforts to reduce the incidence of unintended pregnancy have focused on females, males also have a role in pregnancy prevention. Yet, in one nationally representative study, male adolescents reported having used condoms, on average, only eight of the last 10 times they had had vaginal sex, and those aged 18–24 reported having used condoms fewer than five of the last 10 times.² In another study, almost two-thirds of unmarried men who had used a condom at last sex said they had done so to prevent both pregnancy and disease (63%), and another 31% had used one solely to prevent pregnancy.³ Nearly half of the 3.1 million unintended pregnancies that occur in the United States each year are the result of contraceptive failure,^4-6 including condom failure due to breakage or slippage,⁷ or of nonuse. One step that males who wish to prevent unintended pregnancy can take following condom failure is to encourage their partner to use emergency contraceptive pills; this approach has been especially feasible since 2006, when levonorgestrel-only products became available over the counter. However, little is known about males’ emergency contraception–related knowledge, attitudes and behavior, let alone their access to and purchase of these products.

Timely emergency contraception may reduce women's risk of unintended pregnancy by 89–95%.⁸ One goal of the Healthy People 2020 initiative is to increase the proportion of family planning agencies that offer emergency contraceptives,⁹ and the American Academy of Pediatrics and the Society for Adolescent Health and Medicine recommend that health care providers routinely offer information and counseling about emergency contraception to all of their patients, whether female or male.^{10, 11} Despite these gender-neutral recommendations, we know little about health care providers’ knowledge, attitudes and counseling behaviors concerning males and emergency contraception.

Emergency contraceptive pills have excellent safety profiles in nearly all females.¹² Systematic reviews have found that advance provision of the pills does not increase the likelihood that females will engage in risky sexual behavior (e.g., have unprotected intercourse), acquire an STD, have a greater number of sexual partners or switch to a less reliable contraceptive method.^{8, 13} However, these reviews have also found that advance provision to females does not reduce pregnancy rates, even though it facilitates access.^{8, 13} This raises the question of whether involving male partners would improve the effectiveness of advance provision.

In this article, our goal is to synthesize the literature regarding emergency contraception–related knowledge, attitudes and behavior of males in the United States; we examine the topic from multiple perspectives (i.e., those of both male populations and health care providers) and focus especially on studies examining advance provision.

METHODS

We searched PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PsycINFO for quantitative and qualitative studies concerning emergency contraception that were published between January 1980 and April 2011. Search terms included "Plan B," "Yuzpe," "postcoital contraception" and "emergency contraception" (as well as variations on the terms "contraception" and "contraceptive"). The search strategy delimited studies that focused on males, or that included both males and females, but not those restricted to females (unless the study examined females’ views on male's involvement in emergency contraception); it yielded 668 references (474 from PubMed, 140 from CINAHL and 54 from PsycINFO), of which 568 were unduplicated. We identified four additional studies via hand-search.

Two investigators independently reviewed all abstracts to assess the studies’ eligibility for this review. Studies were eligible if they assessed male's emergency contraception–related knowledge, attitudes, intentions or behaviors; health care providers’ emergency contraception–related knowledge, attitudes, intentions or behaviors, either in general or specifically related to males or to advance provision of emergency contraceptive pills; or related topics, such as females’ perceptions of males’ involvement in emergency contraception. Studies were excluded if the abstracts contained no information relevant to the topics of this review, if participants did not live in the United States or if the studies were not written in English.

The investigators agreed on studies’ eligibility more than 95% of the time. In cases of disagreement, they reviewed the abstract or article and reached a mutual decision regarding eligibility. Forty-three articles met the inclusion criteria. Two assessed both males and health care providers, and two presented findings from the same data source; thus, the total number of studies is greater than the number of identified references.

One investigator extracted the data from all papers, and a second reviewed and verified the data. We conducted a content analysis of included studies, and report findings from multivariate analyses whenever possible.

RESULTS

Seventeen studies assessed males’ knowledge of, attitudes toward, or intentions or behaviors related to emergency contraception. Of these, 14 studies examined outcomes among males in school or community-based settings, two used clinical samples and one assessed female clinic patients’ perspectives of males’ involvement in emergency contraception.

Twenty-seven studies focused on health care providers. Twelve of these studies sampled primary care clinicians, one assessed clinicians in school-based health settings, three surveyed medical residents and 11 focused on pharmacists.

No studies examined advance provision of emergency contraceptive pills to males. Table 1 provides a summary of the sample characteristics and content domains for each study; a table summarizing the results of these studies is available from the authors.

Male Perspectives

• Nonclinical samples. Twelve quantitative^14-25 and three qualitative^26-28 studies assessed males’ perspectives concerning emergency contraception. Seven studies used representative sampling methods; of these, three were based on national telephone surveys, one used a telephone survey conducted in California, two assessed college samples and one examined a community sample.^{14-17, 19, 23, 25} Four studies focused on or included adolescents, using either household or community-based samples^{16, 19, 22, 27}; the others examined adult populations, either in college settings^{14, 20, 21, 24} or in household or community-based settings.^{19, 22-24, 26-28} Only one study assessed adult males’ attitudes and behaviors related to over-the-counter access to emergency contraceptive pills.²⁵

Delbanco and colleagues were the first to report data on awareness of emergency contraception by gender, using nationally representative samples of adults (in 1994) and teenagers (in 1996). They found that 51% of adult males and 24% of adolescent males had heard of emergency contraception.^{16, 17} More recent assessments found a wide range in the proportion of males who were aware of emergency contraception; the proportion varied according to respondents’ age and location, and was lower among adolescents attending high school (38%)²² than among older males in college or community settings (65–100%).^{21, 24, 25} Studies examining gender differences consistently reported that awareness of emergency contraception was lower among males than among females, regardless of setting or participants’ age.^{19, 21-25} Adults often confused emergency contraceptive pills with the "abortion pill" (mifepristone, or RU 486).^{14, 19, 21, 24}

In studies that examined attitudes and beliefs, the majority of males reported approval of emergency contraception following condom breakage or other forms of contraceptive failure (74–82%), after unprotected sex (59–65%) or in cases of rape (85–91%).^{19, 23} Only a small proportion of adult males (14%) reported moral or religious objections to it.¹⁹

Three studies assessed males’ beliefs concerning emergency contraception decision-making,^{25, 26, 28} and one examined females’ beliefs about the role of males in access to and use of the pills.¹⁸ In a qualitative study, college-age males and females expressed a number of concerns about the method, including that it may be used irresponsibly, that it does not protect against HIV and other STDs, and that males might use it to pressure females into having unplanned or unprotected sex; they also noted that a male's role in emergency contraception depends on the nature of the relationship, but that the decision to use the method is ultimately the female's.²⁶ In another qualitative study, males reported providing their partner with information on contraceptive options, and said that they might try to persuade her to use emergency contraceptive pills but would not force her to do so.²⁸ A quantitative study found that 78% of men believed that a male should be able to purchase emergency contraceptive pills as long as use remains the female's decision; 74% of women believed that they and their partner should have equal over-the-counter access to the pills.²⁵ Another study found that females who perceived power-related issues in their relationship (e.g., felt pressured to have sex) and a strong desire on the part of their partner to avoid pregnancy were more likely than other women to use emergency contraceptive pills.¹⁸

In studies of use and access among adults, 34–46% of males reported that they would recommend emergency contraceptive pills to their partner,^{21, 23} while 13–30% reported that they and they partner had used or discussed the method^{24, 25}; 11% of males reported having ever purchased the pills.²⁵ The most common barriers cited by adult males to obtaining emergency contraceptive pills were not knowing how to obtain them (50%) and preferring that a female get them (38%)²⁵; smaller proportions reported that embarrassment is a factor (14–17%).^{21, 25} The proportions reporting having discussed emergency contraception with their health care provider were even smaller (0–9%).^{19, 21} However, in a mixed-sex sample, 87% of adolescents said that they would recommend emergency contraception to a partner (or use it themselves, if they were female) if they had previously discussed the method with their primary health care provider.¹⁹ One study found that adult males’ comfort with emergency contraception was positively associated with their knowledge of the method and with the belief that it is a contraceptive, rather than an abortifacient.²⁴

• Clinical samples. Two studies assessed male patients’ knowledge of emergency contraception.^{29, 30} In a 1998 study, the proportion of patients who were aware of emergency contraception was substantially lower among males than among females (17% vs. 35%).²⁹ A decade later, 61% of young males participating in a multicomponent health education intervention reported during their initial clinic visit that they had heard of emergency contraception; at a three-month follow-up, the proportion had increased to 95%.³⁰ Because the study did not include a control group, the extent to which outside factors contributed to increased awareness could not be determined.

Health Care Provider Perspectives

• Clinicians. We did not find any studies of providers’ attitudes or behaviors related to male patients and emergency contraception. Sixteen studies, published in 17 articles, assessed providers’ emergency contraception–related knowledge, attitudes or behaviors in general (unrelated to gender).^{15, 17, 31-45} Eleven studies used regional samples,^{31, 33-39, 42-44} and five used national samples.^{15, 17, 40, 41, 45} Several focused on medical residents,^42-44 and one on school health providers.⁴⁵ Three studies assessed interventions.^37-39

In a study published in 1997, a majority of obstetrician-gynecologists (77%) reported having general knowledge of emergency contraception¹⁵; nearly a decade later, in a sample of family physicians, obstetrician-gynecologists and pediatricians, 82% indicated that they understood emergency contraceptive pills’ mechanism of action.³¹ However, in most studies, only small proportions of clinicians had detailed knowledge about the time frame within which emergency contraceptive pills can be prescribed (28–63%).^{32, 34, 35}

Only about one in eight clinicians reported having moral or religious objections to advance provision of emergency contraceptive pills to females^{33, 34}; studies of clinicians in training yielded similar results.^42-44 Findings were inconsistent regarding whether clinicians believe that advance provision to females promotes unprotected sex and discourages consistent contraceptive use.^{32-34, 41, 45} In a national sample of obstetrician-gynecologists, male providers and those reporting greater religiosity were more likely than female and less religious providers to believe that emergency contraception is ineffective and that it displaces use of other contraceptives, promotes earlier onset of sexual behavior and encourages a woman to have a high number of sexual partners.⁴¹ Another national study found that at least half of practitioners at high school health centers believed that students’ parents would object to advance provision (56%) and that emergency contraception is a method of abortion (50%).⁴⁵ Substantial minorities of clinicians in this study believed that advance provision encourages sexual risk-taking (37%), undermines traditional contraceptive use (26%) and puts clinicians at risk for liability (20%).

The proportion of clinicians reporting experience with advance provision of emergency contraceptive pills to females ranged from 20% to 94%,^{15, 17, 33, 35, 36, 45} and 12–60% reported routinely counseling females about the method.^{33-35, 45} Rates of advance provision to females varied by clinicians’ characteristics. For example, the likelihood of such provision was elevated among female clinicians,³⁶ older clinicians,³³ obstetrician-gynecologists,^{33, 36, 44} clinicians with greater knowledge of the timing and mechanism of action of emergency contraceptive pills,³⁵ and clinicians with more positive attitudes and beliefs concerning the method.⁴¹

In a behavioral study that did not focus on advance provision, the odds that school-based clinicians had provided prescriptions for emergency contraceptive pills were reduced among providers who worked in the Northeast and South, whose health centers were sponsored primarily by their school system, who were concerned about liability or who believed that emergency contraception is an abortion method.⁴⁵

In three intervention studies with pretest and posttest assessments, clinicians were more likely to counsel women about the method,^{37, 39} had greater knowledge and more positive perceptions regarding emergency contraception³⁸ and were more likely to offer advance provision to females³⁹ after receiving training in emergency contraception than before.

• Pharmacists. Eleven studies assessed pharmacists’ emergency contraception–related knowledge, attitudes and behaviors; 10 used regional samples,^46-55 and one a national sample.⁵⁶ Two focused on pharmacies’ provision of emergency contraceptive pills to males.^{52, 55}

The majority of pharmacists (85%) reported being somewhat or very familiar with emergency contraceptive pills.⁵⁶ However, the proportions who knew the timing of the first dose of emergency contraceptive pills varied widely, and differed by study region (18–95%).^{46, 50, 51}

In a study that examined attitudes and beliefs regarding access, 71% of Rhode Island pharmacists believed that males should be allowed to purchase emergency contraceptive pills over the counter.⁵² However, only 46% believed that males should be allowed to purchase them in case of later need, and 65% believed that dispensing pills to males to give to females was not a safe or effective method of pregnancy prevention. Less positive attitudes toward allowing males to obtain emergency contraceptive pills were associated with concerns that males would forgo condom use or force female partners to use the pills.

The Rhode Island study was also one of the few to examine pharmacists’ dispensing behaviors to males. It found that 63% of pharmacists had sold emergency contraceptive pills to males in the past year, 60% believed that males rarely purchase the pills and 4% refused to sell the pills to males.⁵² In another study, which conducted site visits of pharmacies in New York, five of the 36 pharmacies visited by male investigators requested information about the intended user; at two of the five pharmacies, staff would not have allowed the men to purchase emergency contraceptive pills and stated that the woman using them would need to come into the pharmacy and show identification.⁵⁵ In general, we found wide variation in the proportions of pharmacists who reported having ever dispensed the method (8–96%) or feeling comfortable counseling clients about it (24–65%).^{47, 49, 51, 52} In addition, some pharmacists were less willing to dispense emergency contraceptive pills than other drugs (including other forms of contraception),⁵³ in part because of moral or religious beliefs.⁴⁹

DISCUSSION

In this review—the first to synthesize the literature on emergency contraception and males from multiple perspectives—we found that although males have positive attitudes about emergency contraception, improvements in their knowledge of, access to and use of the method are needed. In addition, while health care providers report having general knowledge about emergency contraception, they lack detailed knowledge about the timing of prescribing emergency contraceptive pills, and often hold false beliefs about the consequences of use. These findings highlight the need to educate males about emergency contraception and for health professionals at all levels to counsel them about the method. Our findings also suggest the need for future research to examine clinicians’ emergency contraception–related behaviors (e.g., counseling and provision) regarding males and for rigorous studies to examine the benefits and harms of involving males in provision of emergency contraceptive pills.

Given that males’ general knowledge about hormonal contraceptive methods is low,⁵⁷ it is not surprising that males know less than females about emergency contraception,^{19, 21-25} and that teenage males are less knowledgeable than their adult counterparts.^{21, 22, 24, 25} Males’ relative lack of knowledge and of reports of partner use may be due, in part, to a number of factors: marketing strategies that focus on females; males’ poor knowledge of ovulation and fertilization, which may limit their understanding of when and how to use emergency contraceptive pills; the lack of counseling by health care providers about birth control in general and emergency contraceptives in particular⁵⁸; and the potentially prohibitive cost, especially for young people, of purchasing emergency contraceptive pills over the counter (up to $60).⁵⁹

However, little is known about the extent of males’ knowledge of how emergency contraceptive pills work and when to use them, males’ access to the pills over the counter and the barriers they face in obtaining them (including financial barriers). Moreover, many of the studies we identified were done more than a decade ago, underscoring the need for evaluations of more contemporary samples. Although the findings indicate that males support their partners’ use of emergency contraceptive pills and that females support males’ involvement in the process,^{19, 23, 25} we found no studies that examined partner communication about the method. Further work is needed to understand males’ emergency contraception–related knowledge, attitudes, communication and access, and to examine whether improvements in these characteristics are associated with increased use of the method and reductions in unintended pregnancy rates.

The findings also reveal substantial gaps in our knowledge of health care providers’ perspectives. No studies examined clinicians’ knowledge, attitudes or behavior concerning emergency contraception–related counseling or advance provision to males, although a few assessed pharmacists’ views and behavior regarding adult males’ over-the-counter access. The majority of clinician studies involved pediatricians, family physicians and obstetrician-gynecologists; few involved family planning providers or clinicians in other settings where a high proportion of males get their care (e.g., STD clinics).⁶⁰ Research is needed to determine whether providers would be willing to counsel males about emergency contraception and provide them with pills in advance, and to identify factors that facilitate or hinder their doing so. For example, conscientious objection on moral or religious grounds has been negatively associated with providers’ willingness to dispense emergency contraceptive pills to females;^{41, 45, 49, 53} whether such beliefs influence providers’ behavior if the recipient is a male remains unknown. Efforts are also needed to dispel providers’ false beliefs concerning emergency contraceptive pills’ mechanism of action (e.g., that the pills are abortifacients) and the consequences of use (e.g., that they increase rates of STDs and unprotected sex, and discourage use of less reliable contraceptive methods).

Advance provision of emergency contraceptive pills to males may be possible in some states. However, although levonorgestrel-only products are available over the counter to females 17 and older, a number of legal and policy issues would need to be addressed for health care providers to be able to legally provide emergency contraceptive pills in advance to someone who is not the intended recipient. The legal issues that arose during efforts to provide expedited partner therapy for STDs offer insights for state efforts to provide emergency contraceptive pills in advance to males.^{61, 62} First, states’ approaches to advance provision may vary according to such factors as providers’ licensure, scope of practice (i.e., not all types of clinicians may be allowed to offer advance provision), and prescribing and dispensing authority (i.e., whether providers may legally prescribe or dispense in advance emergency contraceptive pills to someone who is not the intended recipient). Local governments may also impose restrictions (e.g., district policies may limit school health clinics’ scope of practice).

Second, prescription labeling requirements and medication repackaging standards (e.g., from bulk to single doses), which vary among states, become relevant when clinicians provide instructions for off-label use of emergency contraceptive pills. For example, clinicians may need to give patients additional instructions when counseling them to use the pills within 120 hours of unprotected sex⁶³ (as opposed to the 72-hour window approved by the Food and Drug Administration) or to take both doses at the same time (rather than 12 hours apart) when providing Plan B or Next Choice. In addition, repackaging of standard oral contraceptives for use as emergency contraception (i.e., the Yuzpe method) would need to be done in accordance with state standards.

Third, state-specific provider liability concerns may arise regarding potential harms to a male patient's partner. Relevant factors include whether emergency contraception falls within the appropriate standard of care, whether a doctor-patient relationship exists with the female partner and whether providers benefit from existing liability protections.

Fourth, financing and reimbursement issues may arise if a male's health insurance coverage does not include emergency contraception–related visits and medication. Determinations of how advance provision to males is financed and reimbursed, including through such programs as Title X, may be needed.

Finally, considerations of privacy, confidentiality (including during billing), minor consent,⁶⁴ and laws and policies governing reporting must be addressed. Given these legal and policy considerations, a 50-state survey is needed to help state policymakers learn about and standardize their laws. In states where advance provision is allowable, health care providers can learn about the practice through continuing medical education, licensure boards or other state-level professional associations.

In one state, pharmacists reported concerns that males provided with emergency contraceptive pills might pressure their partners to use them.⁵² However, this finding may not be generalizable to pharmacists elsewhere. Furthermore, these beliefs may not be well-founded, given that no studies have examined partner communication or related outcomes among couples receiving the method in advance. Future work will need to examine in greater depth the involvement of the male partner in emergency contraception and whether such involvement results in benefits or harms (such as pressure or increased sexual risk-taking) to either partner.

A major strength of this literature synthesis is the use of systematic search strategies to identify relevant studies.⁶⁵ However, our review has several potential limitations. First, the search may have missed pertinent studies; in fact, hand-search methods identified four additional articles. Second, the review may have been affected by publication bias, as our search strategy would not have identified unpublished evaluations; however, the hand-search strategy identified two studies that did not appear in journals.^{19, 55} Finally, the outcomes assessed across studies were not consistent; thus, direct comparative analyses and presentation of trends were not possible. (The over-the-counter availability of emergency contraceptive pills beginning in 2006 also precluded these analyses.) Use of comparable measures across studies examining emergency contraception–related knowledge, attitudes and behaviors will facilitate such comparisons.

This literature synthesis demonstrates that current understanding of males and emergency contraception is limited. Studies are needed to further assess men's role in their partners’ use of emergency contraceptive pills, to determine health professionals’ ability to counsel males about this method and facilitate their access to it, and to determine the impact of males’ access to emergency contraceptive pills (either over the counter or from health care providers) on any relationship issues (e.g., pressure on women to use the pills) and, ultimately, unintended pregnancy.