Anita Rao
I've had many conversations with myself about the topic of kids, and no big news drop here: We're still very much on the fence about if, and when, that's happening. But, one thing I most certainly do know: The second it's an option for my partner to take care of birth control, I am all in. I've been taking daily oral contraceptives for more than a decade, and while I'm lucky to not have had many bad side effects, I'd also be thrilled to not think about it anymore.
Yeah, an IUD is an option, but how about something that doesn't involve my body? I feel like oral contraceptives for men have been in the clinical trial phase forever. So, if I have kids, or once that option is fully off the table, I'm sending my partner to get snipped.
This is Embodied. I'm Anita Rao.
You wouldn't know it from our cultural conversation, but vasectomies are one of the most effective forms of birth control. They've been around for quite some time.
Matt Coward
The first vasectomy was done in the late 19th century in humans. And then the first real clinical application came with eugenics — population-based sterilization — primarily with criminals. And it wasn't really until the 1950s or '60s when it became a commonly-used form of birth control. It didn't become an accepted, and sort of recommended, form birth control until the 1970s.
Anita Rao
Matt Coward is an associate professor of urology at the UNC School of Medicine. And to be quite honest, I'd want him to perform my vasectomy, because he approaches the whole process with such a chill, open vibe.
Matt Coward
It's one of my favorite procedures because in everything else in medicine, we have to stick to the facts. And we have a lot of things to accomplish in a short amount of time. But during a vasectomy, where a patient's awake, we spend the entire time talking, and we talk about whatever — whatever the patient wants. Sometimes they don't want to talk, and so I'll stay quiet, but I'll do everything I can to keep the patient distracted, you know. So, if he wants to talk about what's actually happening during a procedure, I'm all for it.
Anita Rao
Ninety percent of my family members are physicians, so getting down to the nitty gritty of medical procedures is practically dinner table conversation. But, learning about the science of vasectomies, and how they stop babies from happening, still kind of blew my mind. I had to sit down and Google anatomy diagrams to get all of this straight in my head, so I'll let Dr. Coward do most of the talking.
Matt Coward
It targets a structure called the vas deferens. It's a paired tube that comes off of each testicle. It's a long tube — it's about 18 inches long — and it's about the size of a piece of cooked spaghetti. And it goes up from each testicle, through the scrotum, into the groin, and then back into the pelvis, back behind the bladder and connects to the prostate and the urethra. And it's the sperm superhighway. It takes 100 to 200 million sperm a day up through the vas, and it's a long journey — it takes a couple of months. But, during a vasectomy, we target the creation of a blockage in that tube. And we do it by typically removing a small segment and then using some cautery to seal the ends — after which time, the ejaculate does not contain sperm, and a man is not able to get his partner pregnant.
Anita Rao
So, if I'm envisioning this whole thing: the testicles still continue to produce sperm, but the sperm doesn't have a way to end up getting into the seminal fluid. There's a disconnection there. So where does the sperm go?
Matt Coward
Well, that's one of the greatest medical mysteries. Because, you know, you would think for as much sperm as the testicles make that the testicle would just explode after this. But, it's amazing how the testicle continues to work completely normally. It continues to function normally. It continues to create sperm. The sperm still travels through the epididymis, which is a little tiny worm-like structure between the testicle and the vas deferens, and then the small segment of the vas — right below the vasectomy — becomes an area where the sperm go, and they just kind of disintegrate there. But what's amazing is that, many, many years later — 15, 17, 20 years later — we can go in and actually do a vasectomy reversal and cut right below the vasectomy site and find healthy sperm right there still getting up to the site.
Anita Rao
So, let's get a bit more into the procedure. There are two main types of vasectomies, and the one that you perform is a no-needle, no-scalpel vasectomy. It's kind of mind blowing that you're able to do this procedure without a needle or a scalpel. So, tell me, how do you do that?
Matt Coward
Yeah, it is mind blowing. It's like magic. So, the no needle part: We use a device called a MadaJet that sprays the anesthesia in — it makes like a mosquito bite, basically. And we'll spray each vas about four times, up and down on either side. And men will feel that, and they'll say it feels like the snap of a rubber band. Some men chuckle, but no one really says that it hurts that bad. And it's not nearly as bad as a needle like you might experience at the dentist. And then the no scalpel portion of that is really how the vas deferens is isolated. So, in a traditional vasectomy, an incision is made, but in the no-scalpel technique, what happens is the vas is isolated from the outside of the skin, and then a small puncture site is made — it's usually only about two to three millimeters wide — and because the skin is so stretchy at the end, the vasectomy site just slips back into the stretched open hole and then it just closes back. And so, that's basically how the procedure works. It's done in the clinic on an exam room table similar to like [what] you've seen in any doctor's office, and it takes about 20 to 30 minutes. And by the end, most men say they can't believe how much easier it was than they expected.
Anita Rao
Well, that that really brings us to the question of kind of a lot of the anxiety and fear you hear from a lot of people that the waiting for the vasectomy, and all the anxiety that they have leading up to it was actually a lot worse than the procedure themselves. So, why do you think there's still so much hesitation and anxiety around what, as you describe, is like a pretty simple and non-painful experience?
Matt Coward
It's really the fear of the unknown, and most men have had some sort of testicular injury in the past — being hit with a soccer ball or something — and sort of know that deep pain that's associated with with an injury down there. And so what I've found is most men just expect it to be a lot worse, and so the fear of the procedure comes from the unknown. Once they're going through it, and they realize it's really not painful, the tension seem to ease.
Anita Rao
The biggest part of the fear comes from the unknown. Truth telling from Dr. Matt Coward. So, what goes into the decision making process to get a vasectomy? Here's what some of y'all told us when we asked you that question.
Russ Henry
It was a very easy decision for me. I was coming off of my second divorce. I had a kid with each ex-wife, and after that second divorce, I was like: I'm not gonna go three for three. I'm done. A woman that I had dated — we ended up becoming very good friends — when I decided finally that I wanted to go have this procedure done, I messaged her, and I was like: Hey, you want to help me not have a baby?
Guest
I'm the oldest of four boys, and, you know, by the time I was in grade 12, I'd cleaned and wiped and cleaned and wiped everything that I thought I'd ever want to clean and wipe. So the thought of having a child was just awful. There was no way I was gonna do it.
Andy Bechtel
It wasn't just a physical decision for me at the time. It was a emotional one as well — where I was sort of closing the door on that part of my life as far as having any more children. Understand that a vasectomy is a big change.
Anita Rao
Surgically altering your body is a big change, but Matt says this one is pretty low-risk, all things considered. From a pain perspective, it's very rare to have any long term complications. It has no effect on testosterone levels or erections, and once you're healed, you won't notice a change in the quality of your orgasm or appearance of your ejaculate fluid.
Matt Coward
Some people actually say that their libido goes up, because what happens is: men will have anxiety about having another child or difficulty with their birth control such as like if they're using condoms. [So] once the possibility of having a child [and] not having to use any other form of birth control is off the table, they actually feel more empowered.
Anita Rao
The vasectomy is reversible, although you probably shouldn't go into it with that mindset because a reversal procedure is a bigger surgery, and it's expensive and often not covered by insurance. So, with all of this data and science about vasectomy safety and efficacy, why is the most prominent vasectomy TV storyline about accidental pregnancy? Probably because they're leaving out the most important thing after the vasectomy is over: You've got to wait a few months for everything to take effect.
Matt Coward
I like to say a patient is still firing live rounds for 20 to 30 ejaculations, and they really have to clear all the sperm out from above the vasectomy site, and it just fills incrementally. So, it does take a full two to three months to clear out all the sperm. And so most of the failures are going to occur within the first three months, because a patient's not sterile until they've had that semen analysis, which we do at three months. So, after one sample is negative, a patient's cleared for life to have unprotected intercourse with their partner.
Anita Rao
So, despite the fact that this is the most effective form of birth control, it's not the most common. It's performed less frequently than tubal ligation. So, I guess I'm curious about how accessible it is, and why do you think folks don't choose it more often?
Matt Coward
Yeah, I think the biggest issue is that the majority of reproductive care in the United States is delivered by OBGYNs, and they perform tubal ligations, and it's something they can offer at the time of a C-section. And women are regularly going and seeing their OBGYN and talking about birth control, while men don't go to the doctor as often. Most men have not developed a relationship with a urologist. Although, I like to say every man needs a urologist, it's only a matter of when. A lot of those men will find a urologist at the time of a decision for a vasectomy. But, there is plenty of access for vasectomy. There are plenty of urologists in every city across the country. So, it's just a matter of who you're talking to and who's kind of controlling the birth control decision for the couple.
Anita Rao
There are plenty of urologists around the country, but that doesn't mean it's easy for everyone to get a vasectomy. And if you dive into child free communities on the internet, you'll quickly hear about the struggles folks have finding providers who support their decision - especially if they're seeking a vasectomy at a younger age. We met a listener who took care of his three younger brothers growing up and was certain he never wanted kids of his own.
Guest
The first doctor I went to when I was 19, he just was very patronizing and condescending, but polite and said: No. I went to get it at 22. He was a little more professional, but only barely, and took one look at my age and, again, summarily evicted me from his office. No further questions asked. They just looked at my age and boot. I was gone. The third doctor I got referred to, we just clicked. And we both had long hair, and we were both in our motorcycle leathers. And he just said: You know that it's permanent, right? And I said: Yeah, it better be! And he laughed, and he said: You want to do it now? And I said: Yeah, let's do 'er.
Anita Rao
It's been more than 15 years since that office visit, and he said he's heard it's gotten easier for people who want vasectomies at a younger age to find providers who support them. We chatted with one of those providers about his philosophy: fertility surgeon Charles Monteith.
Charles Monteith
In the provision of a vasectomy, I've had patients come to me because a lot of doctors have refused to do their vasectomy — either because the man has had no kids, or they don't think they've had enough kids, or they think they're too young. I have no reservations, you know, helping someone if they think it's in their best interest. About one out of 10 of my patients don't have kids, and they don't want kids. And that's a choice that they make. I don't make that for them.
Anita Rao
Your body, your choice. It's what the doctor said. Reproductive justice advocates have been working for decades to secure that right, and as recent court cases around the country show, it's far from a guarantee. But, the other piece of this puzzle that I want to get back to: Why vasectomies aren't more common, given how safe and effective they are. There's no one clear answer, but Dr. Monteith says there's no doubt that for some folks getting a vasectomy brings up questions about masculinity.
Charles Monteith
I mean, I believe a lot of men equate vasectomy with castration. Castration has been around since biblical ages. That was a way you punish your enemy or took away a male's masculinity, and so what often happens is, a guy will schedule his vasectomy — and if his friends find out then they started jockeying with him — and then all of a sudden people start sharing these things with him just to kind of kind of poke fun at them. Most of the memes kind of circulate around, you know, losing your masculinity, your voice changing, suffering extreme pain — either temporary or chronic — using frozen peas or ice.
Anita Rao
Yes, we did just take you on a journey from castration to frozen peas, and y'all it's because the links between masculinity and vasectomy are still very much there for some folks. And we wanted to get to the bottom of it. So, we did what any good public radio podcast would do. We called on a sociologist.
Ryan Cragun
First off, it's important to just kind of make it clear that masculinity is something that we do, and this gets to kind of how we do gender, right. So, gender is different from biological sex in that it's something that we do. Masculinity refers to actions that we engage in to try and maintain our position as part of a dominant gender. And that's how we do masculinity.
Anita Rao
Ryan Cragun is a sociology professor at the University of Tampa. He and his wife have one kid, and after they made the decision for him to get a vasectomy, Ryan noticed a surprising worry popping up: Will losing my fertility threaten my identity as a man? Like any good sociologist, he decided to start writing things down and made himself the subject of his own research.
Ryan Cragun
The biggest threat to me that made me start journaling about this was that I was going to become sterile. And there are a lot of jokes about this — that it's a common kind of trope that if somebody loses their fertility as a man, then they become less of a man. And that's what got me journaling about this, as I had never really thought about it at that level. But knowing that I was going to lose my fertility made me start to question my masculinity, and that led to this whole journaling process.
Anita Rao
He wrote down notes about everything, from the months up until the procedure until the day of the operation itself. The procedure went smoothly - and then it was time to follow doctor's orders: go home and rest.
Ryan Cragun
The doctor's recommendation is that you had somebody come with you to drive you home, because it is in fact — I mean, it's a surgery, right? And people will experience shock, which is basically what I experienced. So, after the surgery — it was actually very close to where I live — less than like a two-minute drive. Very, very close. But as I came out, I felt just a little bit off mentally. I felt a little bit lightheaded, but I thought I was fine.
And the doctor's orders were to drive straight home. And then, you know, get the medicine and get some painkillers. So, we walked out to the car. My wife was there. My son was actually there too. And she walked to the driver's side. And I said: You know, I'm fine. It's just two minutes. It's not a big deal. So, she let me drive even though I should not have done this. Nobody should do this. But, she did let me drive. Between our house and where I had the surgery performed was a Walgreens. And so I just said: Well, let's stop, and we'll get the Vicodin. And they had recommended, you know, they'd prescribed Vicodin. So, I was like: Let's stop and we'll get the prescription and then we'll go home, because I was feeling okay.
So we went in. She went with my son to go look at some toys, and I stood in line. And I was only in line for maybe a couple of minutes. But, while I was standing in line, I started feeling worse and worse, just mentally — like there was a fog coming over my brain. So, I finally got called up by the pharmacist. I walk up. I hand him the prescription, and as I hand it to him, I say: You know, I've just got a prescription. The pharmacist takes it, and suddenly I am going to lose it. I put both hands down on the counter. There is sweat just beading on my forehead, and my vision starts to tunnel. And the next thing I remember is waking up. And luckily I hadn't fallen all the way to the floor, but I had literally collapsed. Half of my body — my upper body was on the counter. I hit my face hard enough that I got a bruise on my cheek, but I literally collapsed on the counter, and the pharmacist was kind of like: Sir, you okay? Are you okay? And I raised myself up. There's like, drool coming out of my mouth.
Anita Rao
Oh my gosh. So, you'd passed out essentially. And I mean, I can have my own armchair analysis of why that happened, but you tell me what what was going on for you Like, why did you do that?
Ryan Cragun
I mean, it was clearly a surgery, and my body was adjusting to that. It was probably still in shock from having experienced a surgical procedure. If I had gone straight home like the doctors had recommended, that probably wouldn't have happened. I would have just been home, felt a little weird, and gone right through it. But, the fact that I was standing up in line when I shouldn't have been led to me passing out in a very humiliating fashion.
Anita Rao
So you, as we said, you journaled throughout this vasectomy experience. You kept those journals, [and] you partnered with a friend of yours to analyze these journals through the frame of masculinity studies and really thinking about your own conception of masculinity. And I'd love to get into that. What conclusions did you come to? What did you start to unpack about that link between fertility and masculinity that you hadn't looked at before?
Ryan Cragun
Yeah, so unconsciously, I kept engaging in activities and actions and behaviors that reasserted my masculinity, because I felt like my masculinity was being threatened. So, the one that we just talked about — that story of me, you know, insisting that I'm going to drive home — that's me reasserting my control, because I do typically drive, right. But, it's me getting control, and control is a big part of masculinity. So, me saying: No, no, no. I'm fine. That's a masculine — it's a manhood act is what we refer to them as, so that's me reasserting my masculinity. And then another good illustration of me trying to reassert control — Dr. Coward earlier said that, you know, recovery from this can be pretty quick. I play soccer three days a week for exercise. I had the surgery on Wednesday. I was back playing soccer on Friday. Should I have been playing soccer? Man, that's certainly debatable, but those were ways for me to try and reassert: No, I'm a man. Yes, I may have had a threat to my manhood, but I can engage in these manhood acts that reassert my masculinity.
Anita Rao
And you see a lot of that compensation in these kind of cultural phenomena that arise around vasectomies. Like we mentioned, there was this amazing Wall Street Journal piece of a few years ago about vasectomy parties and brosectomies, and groups of folks who go and get these vasectomies together and then get a lot of alcohol and really make this very masculine celebration out of getting a vasectomy, which seems to me like another kind of compensatory act.
Ryan Cragun
Yeah. Seems exactly like that to me. Now, I do play sports, but I don't really watch sports. It's just not my thing, right. But I certainly understand that — I mean, even the idea of a surge in vasectomies leading up to March Madness where men can kind of, in a sense, reassert their masculinity by saying: Okay, I'm going to get this done — which is a threat to my masculinity —but now I'm going to spend the next weekend watching sports, which is a very masculine thing to do. So, it's even when they're in a weakened state — which is actually fascinating, there are parts of the process that involve that —they're in a weakened state. It's been a threat to their hegemonic masculinity. They reassert their masculinity by saying: And now I'm going to sit and watch sports, and you're not going to threaten that.
Anita Rao
So, after doing this deep dive and thinking about, you know, this idea of hegemonic masculinity and what this kind of masculinity that is upheld culturally is, how have you rethought how you act out your manhood? And I'm wondering how that might affect how you parent your son, for example?
Ryan Cragun
Yeah, again, I'm probably very weird. I'm a sociologist, and we think about weird things. But, one of the things that I did very early on is I tried to not gender my son. And so he's very aware. He has gendered himself. That's why I can call him my son, right? I allowed him that opportunity from very early on to say, like: Hey, you know, however you want to do gender — knowing that it's a social construct, it's an action that we engage in. However he wants to do that is perfectly fine. And so he actually has — he has really long hair. This just happened two days ago, we were out playing pickleball. It's something that he likes to play. And so I was playing with him, and two other men showed up too, and we ended up playing doubles with them. And because of his long hair, even though he's 12 years old, he is often misgendered. And so one of the men was like: Man, she's great. She's really good as a pickleball player. And the other one realized that it was my son, and so he's the one who corrected him. But my son is perfectly fine with that. He doesn't feel these kinds of threats to his gender identity. He's been misgendered so many times, and again, the long hair, I think, contributes to that. He also dances. He does ballet. I did ballet, so there are lots of ways that when it comes to the parenting, we've had very long reflections on what gender is , and it all plays into how we address this with ourselves.
Anita Rao
For folks like Ryan, a vasectomy can prompt self reflection and change far beyond the physical. For others, the choice is a little more simple. Here's Dr. Monteith with his decision making 101.
Charles Monteith
My counseling session is this: Do you want to have kids, or do you want to have any more kids? And if they say: No. I'm like: Well, there's not much more talk about. [A] vasectomy is a great idea.
Anita Rao
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Make sure you're subscribed, so you don't miss a single episode of Embodied. If you want to support our show, tell a friend about us or post about us on social media. We're on Instagram and Twitter at embodiedWUNC. I'm Anita Rao on an exploration of our brains, our bodies and taking on the taboo with you.