APPENDIX D

FERTILITY MOTIVATION, DECISION MAKING, AND INTENTION TO ENGAGE IN SEX, CONTRACEPTION, PREGNANCY, ABORTION AND BIRTH

Freya Sonenstein,The Urban Institute

Howard Goldberg, Center for Disease Control

Gontran Lamberty, Maternal and Child Health Bureau

Susan Newcomer, National Institute of Child Health and Human Development

Warren Miller, Transnational Family Research Institute

[This paper is under revision]

Prepared for NICHD Workshop "Improving Data on Male Fertility and Family Formation" at the Urban Institute, Washington, D.C., January 16-17, 1997

Introduction

This review briefly covers the status of knowledge about males' motivation regarding reproductive behaviors. To provide an overall structure for our discussion we use a theoretical framework developed by Warren Miller to describe the psychological sequence that culminates in the reproductive behaviors under discussion--sexual intercourse, contraception, pregnancy, abortion and birth. Miller has used this framework to trace the sequence of how childbearing motivations lead to child timing desires, fertility intentions, proceptive and contraceptive behavior, and post-conception behavior. We think it provides a useful starting point for organizing our discussion of male fertility behavior because it identifies the central concepts that we must consider. We note, however, that another working group is looking at theoretical models in a more explicit way.

In the framework, the first key step in the sequence leading to behavior is the formation of motivations, defined as traits that dispose an individual to react in specific ways under certain conditions. Motivations, in turn, are activated as desires--what an individual wishes for or wants. Desires are then transformed into intentions to act. Intentions must take into account what other individuals desire and what can actually be achieved. Intentions effectively represent decisions made about courses of action. Intentions are subsequently transformed into behavior when an individual encounters a social situation that provides opportunities to fulfill them. The figure below provides a schematic picture of the model.

The sequence shown in the figure helps us to understand reproductive behaviors and their outcomes. Broadly, there are three types of reproductive behaviors which will be the focus of our examination. First engaging in sexual behavior is a necessary precursor to fertility outcomes. Second there are conceptive behaviors which either contravene or promote conception. These behaviors include the use of contraception and actions to limit fertility permanently. They also include behaviors which are intended to result in conception and birth, which we call proception. Third, there are behaviors that occur after conception. A primary step at this time, if the pregnancy was not intended, is participation in the decision to carry to term or to terminate the pregnancy.

In this report we focus particularly on the psychological antecedents to these three broad categories of reproductive behavior. The figure demonstrates the scope of our task. It also demonstrates the importance of gaining better scientific understanding of motivation and the links between motivation, intention and actual behavior.

A nice feature of this model is that it acknowledges that the behaviors under study occur between two people. While motivation and desires describe the psychological states of single individuals, the formation of intention to act by an individual must take account of the motivation and desire of the other person in the dyad. Thus a full picture of fertility behavior requires that we understand the motivation and desires of both males and females: how these come into play in male-female interactions and how the transactions and related behavioral outcomes are modified by the contexts in which they occur. Indeed our working group believes that:

• an understanding of the fertility behavior of males cannot be achieved if males are considered in isolation from their female partners.

  Therefore we look forward to the recommendations of the subgroup that is working on couple dynamics.

  While the framework we have adopted is useful for characterizing and simplifying the psychological antecedents of reproductive behavior, it does not address the precursors of motivation. Motivations are a product of complex interactions between biological forces, ideology and cultural imagery about gender roles, and normative expectation fostered by family, neighbors, peers and other influential people. Indeed the causes of behavior are intricate and extremely difficult to unravel. We acknowledge that the framework is a useful point of departure, but that powerful drivers of behavior such as biology, social structure, proximal and distal context, and random events --alone and in combination-- may be important in exerting influence on male reproductive behavior at specific junctures.

• an understanding of the fertility behavior of males cannot be achieved if the contexts in which male-female motivations and intentions play out are not considered.

  The structure of this brief review is to cover what is known about the stated attitudes and motives of U.S. males regarding the reproductive behaviors that we have described above. In addition the review will discuss what is now known about the formation of motivation regarding reproductive behaviors and about the links between motivation and these behaviors. Very little research has examined motivation or predispositions towards the reproductive behaviors we are examining: sex, proception, contraception, and post-conception behavior. Little is known descriptively about the kinds of predispositions that U.S. males have towards reproductive behavior, the development of motivation in individuals, or the link between motivation and behavior. Throughout we propose recommendations for further work.

  Motivation to Engage in Reproductive Behaviors among U.S. Males

  In the last decade there have been several scientific sample surveys⁽¹⁾ that have collected some information about the motivation of males to engage in reproductive behavior. Least studied are motivations to engage in sexual intercourse. Most studied is motivation to contracept, especially to use condoms, primarily as a result of public health concern about the AIDS epidemic. Very little work has been conducted about men's motivation regarding sterilization. There is some information about men's attitudes towards abortion. Surprisingly little is available about males' motivation towards childbearing and childrearing.

  Men's motivation to engage in sex. As noted above there has been little research describing the levels and character of men (or women's) motivation to engage in sexual acts. The only recent scientifically representative study of the heterosexual behavior of adult men and women was conducted by Laumann, Gagnon, Michael and Michaels (1994). This survey includes a few items about the level of appeal of a range of sexual practices and a measure of how often the respondent thinks about sex. It also contains measures of sexual satisfaction. The survey results document that males consistently rate sexual practices more appealing than females suggesting that there are gender differences in the level of motivation to engage in sex. Given the level of stereotyping that occurs about males' "readiness to have sex,"⁽²⁾ it would be illuminating to know more about actual levels of motivation and how they vary in the population. Therefore we recommend:

• Research about male (and female) reproductive behavior needs to include a focus on motivation to engage in sexual activity. Moreover, we note that the instrumentation to measure these motivations may not be developed yet, therefore we also recommend that:
• Work to develop and test measures of motivation regarding sexual activity needs to occur.

  We note that these recommendations may be politically problematic because there is no widespread public support for the scientific study of sexual behavior. However without this work there will clearly be a missing link in our understanding of male and female reproductive behavior.

• Further analyses of the existing data from the National Health and Social Life Survey and any other similar data sets should be conducted and disseminated to further the understanding of the scientific community and the public about the potential importance of these factors in understanding reproductive behavior.

  We also note that it is also important to examine psychological precursors of the corollary behavior, abstaining from sex. Although there has been a quite a lot of research about factors that predispose teens to delay the onset of sexual activity, the underlying motives for this behavior have not been fully examined. Potential motives include fear of disease, worry about impregnation, religious and moral consideration, and possibly desire to conform to family and peer expectations.

• Further research is needed about motivation not to engage in sex.

  Men's motivations to contracept. The AIDS epidemic has been the impetus for a substantial amount of work about men's attitudes towards condoms and their motivation to use them. Relatively few sexually active males are unaware that condoms are at least somewhat effective at preventing the transmission of HIV and other sexually transmitted diseases. This has been a critical factor in the recent increases in condom use that have been noted both in the U.S. and abroad. There has been little research that has investigated the extent to which condoms have been used to protect the male from infection as opposed to protecting the female from infection. It is generally assumed that when condoms are used for disease prevention, they are most often used by the male to protect himself.

  There has been a substantial amount of work about attitudes that lead to increases and decreases in the use of condoms especially among teen males. Factors that are associated with less condom use include embarrassment about purchasing or wearing condoms and concern about the loss of physical sensation. Factors associated with more condom use included worry about AIDS and positive attitudes towards male contraceptive responsibility. ( Grady, Klepinger, Billy and Tanfer, 1993; Hingson et al., 1990; Norris and Ford, 1994; Ramos et al, 1995; Sonenstein, Ku and Pleck,1997; Wulfert and Wan, 1993). Beliefs that their partners would appreciate their use of condoms were also associated with more condom use (Sonenstein, Ku and Pleck, 1997).

  There is some tantalizing evidence that condom use among males is not totally driven by concern about HIV or other STDs. Research indicates that the main reason men report using condoms is actually for birth control, not the prevention of STDs. In the 1991 National Survey of Men (NSM), among those who reported using a condom in the previous four weeks, 49 percent reported that they used condoms for birth control only, and another 43 percent for birth control and STD prevention; thus, 92 percent say they use condoms for birth control, either by itself or in combination with other reasons (Tanfer, Grady, Klepinger, and Billy, 1993). The NSM data further indicate that use of condoms only for birth control is particularly likely among white (55 percent) compared to Black (18 percent) men, among men aged 30 or older (60 percent) compared to younger men (41 percent), and among married men (83 percent) compared to single men (24 percent). Similar results are found in the National Survey of Adolescent Males. When males who used a condom at last intercourse were asked why they did so, 83 percent reported only to prevent pregnancy, 12 percent to prevent disease, and only 2 percent for both reasons (Sonenstein, Ku, and Pleck, 1997).

  More attention must be paid to men's motivation to contracept and to avoid contraception, and their perceptions of their partner's motivation. Most of the existing research has concentrated on teenage males or slightly older cohorts. There is a need to understand better the contraceptive motivation of adult men, especially adult unmarried men.

• Further research is needed to understand the intersection of concern about STD transmission and about unintended pregnancy in male's motivation to use condoms.

  Men's perceptions of contraceptive responsibility. There has been quite a lot of research documenting males' perceptions of the level of responsibility they have to contracept. These studies show that most men profess that contraception is a joint responsibility (Marsiglio and Menaghan, 1987; Sheehan, Ostwald, and Rothenberger, 1986). Studies have also attempted to assess other aspects of perceived contraceptive responsibility such as who should initiate discussion about contraception or who should pay for contraception. These studies find very high proportions of males reporting joint responsibility (Sheehan, Ostwald, and Rothenberger, 1986; Marsiglio, 1985; Marsiglio and Menaghan, 1987). Results from the National Survey of Adolescent Males confirm the results of prior studies using more limited samples suggesting that men believe they bear a high level of responsibility for knowing or asking partner whether she is using contraception, for initiating discussion about contraception if it has not occurred, for using contraception if he does not want a child, and for assuming joint responsibility for any child if he makes someone pregnant. For these four items, males' mean response is close to ceiling of the response scale. The exception is responsibility for helping pay for the partner's pill use, but even here, more than two-thirds of the sample agrees.

  Predictors of endorsement of male contraceptive responsibility include egalitarian attitudes about women's roles, non-traditional attitudes specifically about men's gender roles, being older, and expecting to complete more years of education (Marsiglio, 1985; Marsiglio and Menaghan, 1987; Pleck, Sonenstein, and Ku, 1993).

• Studies are needed to measure better attitudes about contraceptive responsibility among males and to understand the relationship between gender role ideology and contraceptive motivation.

  Men's motivation regarding sterilization During the last two decades sterilization has become the most widely used contraceptive method used among married couples in the US (Miller Shain and Pasta, 1991). In 1995, the National Survey of Family Growth reported that 41 percent of married women ages 15-44 or their partners had a sterilizing operation. Almost one quarter (24 percent) reported a tubal ligation and one-seventh (15 percent) said their male partners had been sterilized (Chandra, 1997). While the incidence of male sterilization has grown from the early 1970s, its increase has not been nearly as rapid as the increase in female sterilization. Indeed in 1973 rates of male and female sterilization were comparable. There has been some research on motivation of both males and females towards sterilization, most of it focussing on married couples (Chandra, 1997; Forste, Tanfer and Tedrow 1995; Miller, Shain, and Pasta, 1991). Most of this work has also examined couple dynamics. Decisions about who gets sterilized appear to result in the partner who is most motivated to end childbearing having the operation (Miller,Shain, and Pasta, 1991). Thus the fact that more women undergo sterilization may not necessarily reflect male's negative views of vasectomy so much as their female partner's positive motivation to end their childbearing.

• More research is needed to understand the role of male motivation regarding their own sterilization and that of their partner. In particular it would be useful to have baseline data on men's attitudes towards vasectomy since the popular belief is that these are fairly negative.

  Men's motivation to impregnate. Although unintended pregnancy has been shown to be a major problem in the US, very little research has focused on the male perspective on this problem. Indeed male's motivation to impregnate women is not understood, although Marsiglio has given a name to the phenomenon, calling it "procreative consciousness (1988)." The National Survey of Adolescent Males has examined how men say they would react if they impregnated a partner without intending to do so. About one-third of males think they would have to quit school. Almost all males think they would have to give money to help support the baby. Hardly any males think that the availability of the options of abortion and of marriage means that unintended pregnancy is "not worth worrying about" or "not a big problem." Two-thirds say an unintended pregnancy would make them "very upset."

  NSAM investigators also studied the role of attitudes about masculinity in these sexual and contraceptive behaviors in adolescent males'. The questionnaire asked respondents directly "If you got a girl pregnant now, how much would it make you feel like you were a real man?" In common parlance, males' perceptions of masculinity are recognized as central to understanding their sexual behavior. However, this apparently obvious factor has been relatively neglected in research. In our data, only 5 percent say that fathering a child would make them feel like "a lot" like "a real man," and adding in those who say that impregnation would give them this feeling "somewhat" yields only a fifth of the sample. Our later analyses indicate that experiencing pregnancy as validating their masculinity is an important contributor to risky sexual behavior (Pleck, Sonenstein, and Ku, 1993), but it is nonetheless noteworthy that a relatively small proportion of males view pregnancy in this way and that these males may be more numerous in particular communities or subcultures.

  Some analysts have noted the connection between some males' orientation to impregnation, their views of masculinity and their ability to be economic providers, a key male role in US culture. They have hypothesized that lack of access to economic opportunity leads disadvantaged males to perceive sexual prowess and potency as alternative means to establish their masculinity and status (Anderson, 1989, Gagnon and Simon, 1973, Majors; 1986.)

• Research needs to be conducted about male's motivation to impregnate women.
• Measures of male motivation to impregnate women need to be developed.

  Men's motivation regarding childbearing Most men report a desire to have children at sometime during their lives (Mott, 1983, Marsiglio,1991). Psychologists have conducted a substantial amount of research on motivation regarding childbearing typically conceptualizing this motivation in terms of values and disvalues (Beckman, 1987), costs and benefits (Seccombe, 1991), utilities (Townes, Beach, Campbell and Wood, 1980) and attitudes (Davison and Jaccard,1976). Typically the measures focus on the positive or negative values assigned to particular consequences weighted by a cognitive component assessing the likelihood that the consequence occurs (Miller, 1995). In a study of married couples conducted by Miller men rated lower on positive childbearing motivation than women and higher on negative childbearing motivation; those who already have one child are also higher on positive childbearing motivation and lower on negative childbearing motivation. While a little work has looked at male motivation among married couples, there is little work done among other types of couples or among men in general.

• The work done on men in marital relationships regarding motivation to have children needs to be developed more fully and also extended to include a more widespread understanding of men's orientation to childbearing in cohabiting and more transient relationships.

  Men's motivation regarding abortion There have been very few studies that have looked at male perspectives on abortion and their role in the abortion decision. Two surveys of college students indicated that almost all believe that men did not have the right to force a woman to have an abortion, but a man's opinion should be considered (Rosenwasser, Wright and Barber, 1987). A study of the partners of women obtaining abortions found that the majority agreed with their partner's decision. Almost 60 percent had positive feelings about the abortion, 13 percent had negative feelings and the remainder had mixed feeling (Shostak, 1984). Among married couples, men were found to have more liberal attitudes towards abortion than women and among both genders, more acceptance of abortion was generally associated with negative childbearing motivation (Miller, 1994).

  Given the number of unintended pregnancies that occur and that are either terminated or brought to term, it is important to understand better how males feel about abortion and how potentially these feeling play out when a child is born. The National Survey of Adolescent Males contains measures of attitudes towards abortion, and the most recent data include measures of whether abortion was considered when pregnancies occurred.

• More research is needed about the male partner's perspective on unintended pregnancy and his views of abortion as a potential resolution to such a pregnancy.

  The Development of Predispositions

  Since there is so little work done on motivation for reproductive behaviors among males, it should not be a surprise that we also know very little about the factors influencing the formation of these traits. Most work that has been done limits the findings to descriptions of the distribution of these traits in the population by race/ethnicity, age, and education levels

• Once we understand motivation better in the descriptive sense, the next priority should be to develop and test theories describing how motivations develop.

  Biological Factors. The formation of traits which motivate individual behavior is "a long and complicated process in which life experiences act in conjunction with biological characteristics to form learned dispositions (Miller, 1995)." Let us start with the evidence about physiological factors. Human beings, like other primates, are programmed to engage in sexual activity. Although many investigators tacitly accept that sexual behavior has important biological underpinnings that affect "drive" or motivation, relatively little research has actually examined biological factors for their affect on behavior. Udry and colleagues have conducted the most systematic and extensive exploration of the possible biological determinants of age at first intercourse. In one series of studies (Udry and Billy, 1987; Udry et al, 1985; Udry, Talbot and Morris, 1986) they showed that whereas male sex hormones were related to sexual interest and motivation in both male and female early adolescents, the transition to first sexual intercourse was strongly predicted by these hormones for white males but not in white females. Newcomer and Udry (1984) also studied the relationship between the timing of mother's first sexual intercourse and the timing of their adolescent children's transition to non-virginity. A strong positive relationship was observed. Among female children this relationship was partly mediated by the daughter's level of pubertal development, suggesting a possible genetic basis for the intergenerational transmission. The evidence, although quite sketchy, suggests that further research on the genetic and physiological underpinnings of sexual behavior are a promising avenue for future research.

• Little research that has examined the contribution of genetic and physiological factors to sexual behavior in either males or females. This is an important topic for future work.

  Family Influences. The emergence of male and female orientations to reproduction appear early in development and seem to result from the complex interaction of genetics, physiology, individual history, family experience, and normative and cultural influences. Gender differences in orientation to nurturing children, for example, emerge at ages 4 through 6 (Miller, 1995). The characteristics of family of origin--family structure, religiosity, education levels, social class, and employment status of parents, for example--are known to be associated with age of initiation into sexual activity, contraceptive use, and experience with early pregnancies and births among teenage females and males.

• Given the early emergence of gender differences in motivations for reproductive behavior, it is important to support longitudinal studies that begin when the study participants are children and follow them into early adulthood. New technology makes it possible to potentially include bio-measures like genetic mapping, hormonal assays and the like. Longitudinal studies of both boys and girls are needed.

  Peer and Community Influences. The social contexts that individuals live in provide continuous socialization into and reinforcement of the group's expectations regarding behavior. For example, the attitudes and norms of a young man's peers will likely influence his reproductive behavior. A particularly promising line of fertility research has examined the contextual effects of various normative environments on reproductive behaviors of both males and females (Billy, Brewster and Grady, 1994). These studies have been facilitated by two technological advances: (1) the development of linked data sets that are multi-level and provide measures of neighborhood, school, peer group, and polity characteristics and (2) a burgeoning literature on hierarchical statistical approaches.

• Efforts to create multilevel data sets should be supported. The feasibility of adding contextual measures to sample surveys that are currently freestanding should be explored.

  Linking Motivation and Behavior

  The most extensive work linking motivation to behavior has been conducted about contraceptive use. It has been common in recent years to analyze females' contraceptive choices as rational consequences of their perceptions and beliefs about contraception and pregnancy (Adler, Kegeles, Irwin, and Wibbelsman, 1990; Jaccard, Helbig, Wan, Gutman, and Kritz-Silverstein, 1990). Research applying the same approach to males, however, has begun only recently. These studies indicate that whether or not males use condoms indeed varies with the attitudes, beliefs, and perceptions males hold about condoms and male responsibility in contraception (Pleck, Sonenstein , and Ku, 1990).

  Clearly much work needs to be conducted before all the potential links between motivation and the full range of reproductive behaviors are fully explicated, for either males or females. The theoretical model presented at the outset of this paper provides a simplified picture of the processes that we need to understand better. Given the status of existing knowledge we think that the following priorities are important.

• Measures of many of the key concepts are not yet fully developed for females, and even less so for males. Therefore one important research investment needs to be made in developing and testing measures of the traits that predispose men and women to act in certain ways. Only after the measures are developed are we in a better position to study how these predispositions develop and to also study how they are distributed in scientifically representative samples of the general population, or subpopulations.
• Some progress can be made understanding reproductive behavior by adding male respondents to ongoing surveys of females like the National Survey of Family Growth. However we note that more work is needed on the measurement of motivation regarding a number of reproductive behaviors. The area in which we are best poised to gain understanding is contraceptive motivation because more preliminary work has been done in this area.
• The ultimate goal should be to develop a comprehensive understanding of the motivational underpinnings of reproductive behavior for both males and females-- an understanding that incorporates physiological, social and cultural influences and which includes a developmental focus.

  Summary of Principles and Recommendations

  Principles

  1. It is important to gain scientific understanding of motivation and the links between motivation, intention and behavior.

  2. An understanding of fertility behavior cannot be achieved if males are considered in isolation from their female partners and the cultural and social context within which their interaction occurs.

  Recommendations.

  1. Better Description of Predispositions is Needed.

  Sexual Activity Motivation

  o Research about male (and female) reproductive behavior needs to focus on motivation to engage in sexual activity and motivation to be abstinent.

  o Work to develop and test measures of motivation regarding sexual activity should be carried out.

  o Further analyses of existing data from the NHSLS and other data sets should be conducted and disseminated to further the understanding of the scientific community and the public about the potential importance of these predispositions in understanding reproductive behavior.

  Contraceptive Motivation

  o More research is needed about men's own motivation to contracept and their perceptions of their partner's motivation. On the flip side, we need to understand better the motivation not to contracept.

  o Further work is needed on men's real motivation to use condoms, especially among adult unmarried men.

  o Further research is needed to understand the intersection of concern about STD transmission and unintended pregnancy in males' motivation to use condoms.

  Sterilization Motivation

  o More research is needed to understand the role of male motivation regarding their own sterilization and that of their partners. In particular it would be useful to have baseline data on men's attitudes towards vasectomy.

  Motivation to Impregnate

  o Research is needed about males' motivation to impregnate females.

  o Measures of male motivation to impregnate females need to be developed.

  Motivation to Have Children

  o The work on men in marital relationships regarding motivation to have children need to be developed more fully and extended to include men in cohabiting and also transient relationships.

  Perspectives on Unintended Pregnancy and Abortion

  o More research is needed about the male partner's perspective on unintended pregnancy and his views of abortion as a potential resolution to such a pregnancy.

  2. Better understanding of how predispositions develop is needed.

  o There is surprisingly little research that examines the contribution of physiological and biological factors to sexual behavior in either males or females. This is an important topic for future work.

  o Given the early emergence of gender differences in motivations for reproductive behavior, it is important to support longitudinal studies that begin when study participants are children and to follow them into adulthood. New technology makes it possible to include bio-measures like genetic mapping, hormonal assays and the like. Both boys and girls should be studied.

  3. Linking motivation and behavior

  o Measures of key concepts are not yet full developed for females, and even less so for males. An important research investment is the development and testing of measures of the predispositions held by males and females regarding reproductive behaviors.

  o Some progress can be made understanding reproductive behavior of males by adding questions and male respondents to the National Survey of Family Growth.

  o The ultimate goals should be developing a comprehensive understanding of the motivational underpinning of reproductive behavior for both males and females. This understanding should incorporate physiological, social and cultural influences and include a developmental focus.

  4. Needed data efforts

  o More detailed analyses should be conducted with existing data sets, both domestic and international.

  o Male respondents and paired couples should be included in surveys that currently focus on females.

  o New small scale data collection efforts are needed which focus on measuring and understanding motivation and its role in reproductive behaviors.

  o Eventually large scale population based surveys should include measures of motivation, behavior, and potentially biomarkers.

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1. The National Health and Social Life Survey (Laumann, Gagnon, Michael and Michaels (1994), The National Survey of Men (Tanfer, Billy and Grady, 1993), The National Survey of Adolescent Males (Sonenstein, Pleck and Ku, 1989) and The AIDS Surveys (Catania et al, 1992)

2. This is an item that Pleck ( 1993 ) included in his traditional male role ideology scale