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High and low contraceptive use amongst young male offenders: a qualitative interview study
  1. Katie Buston1,
  2. Alison Parkes2,
  3. Danny Wight3
  1. 1Senior Investigator Scientist, MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
  2. 2Senior Investigator Scientist, MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
  3. 3Programme Leader, MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
  1. Correspondence to Dr Katie Buston, MRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK; katie.buston{at}glasgow.ac.uk

Abstract

Objectives There are high rates of fatherhood and sexually transmitted infections (STIs) among young incarcerated men. Here we focus on a sample of men incarcerated in a Scottish Young Offender Institution, analysing their accounts of their contraceptive use. Those who report low or no use of contraception are compared with those who report high use.

Methods Semi-structured interviews with 40 young male offenders, aged 16–21 years. Participants were purposively sampled using answers from a questionnaire administered to 67 inmates. Data from those men (n=31) reporting either high (n=14) or low/no use (n=17) of contraception are analysed here.

Results Low users emphasise their desire for pleasure and appear fatalistic about both pregnancy and disease prevention. High users report a strong desire to protect themselves and their ‘manliness’ by using condoms to avoid the risk of STIs and, to a lesser extent, pregnancy. Both sets of men present themselves in a traditionally masculine way, with high users emphasising power, authority and self-control to justify their non-risk-taking contraceptive behaviour.

Conclusions The masculine narrative regarding self-protection, utilised by the high users, may be an effective method of intervention with potential and actual low users. Conventional masculinity valorises risk-taking but if particular forms of risk avoidance – condom use – can be legitimised as confirming one's masculinity it may be possible to persuade low users to adopt them. The opportunity to work with young men whilst incarcerated should be grasped.

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Key message points

  • Some very marginalised young men do report consistent use of contraception.

  • Adherence to a masculine discourse does not preclude high use of contraception.

  • Interventions might emphasise control and protection of one's embodied manhood.

Introduction

Most prisoners come from the poorest and most socially excluded sections of society.1 ,2 High rates of sexually transmitted infections (STIs) amongst young male prisoners have been highlighted,1 ,3 ,4 with lower rates of condom use than their peers pointed to as one aspect of their riskier sexual behaviour.5 In order to address these problems we need to understand more about use of contraceptives, particularly as prophylactics, amongst this group, prior to their entering Young Offender Institutions (YOIs) when masculine risk-taking behaviours such as excessive alcohol consumption and frequent sexual partner change are high.1 ,2

When analysing male offenders’ risk-taking the role of masculine discourses seems highly pertinent, particularly orthodox archetypes consisting of the valuing of risk, strength, confidence, assertiveness, physical danger, hardness, aggression, and sexist and misogynistic tenets.6–12 Two recent studies illustrate how young offenders’ accounts of their own lives reflect masculine ideals.13 ,14 In sexual health terms, orthodox masculine discourse has been conceptualised as presenting oneself as knowledgeable about sex, and as keen to pursue sexual opportunities and to take sexual risks demonstrated through having multiple sexual partners and rejecting condom use.15–19 However, more recently this has been questioned, with the suggestion that masculine notions of control, ‘taking action’ and power assertion may translate into men presenting themselves as engaging in healthy behaviours.20–22 This article focuses on the contrast between the accounts of incarcerated young offenders who report low or no contraceptive use and those of their peers who report high contraceptive use.

Methods

The study explored young male offenders’ attitudes and experiences in relation to sexual and reproductive health.23 ,24 It comprised two components, described below. Data were collected between February and December 2008. It is, largely, the qualitative interviews that are drawn on in this article.

First, self-complete questionnaires were administered to 67 inmates, aged 16–21 years, at a Scottish YOI housing men reaching the end of long-term sentences, and those transferred from Scotland's other YOI as a reward for good behaviour. For reasons of time and logistics those approached to participate were new admissions and those in contact with a prison officer with a youth support remit. All but one of those approached agreed to participate. Those surveyed were likely to be representative of the population of this particular YOI, though it was not possible to confirm this by collecting or accessing data on the dynamic group of around 89 men housed in the prison at any given time. The questionnaire collected demographic and other background data, experience of, and attitudes towards, sex education, pregnancy and STIs, as well as contraception and their contraceptive behaviour. Twenty men reported using contraception on every or most occasions of intercourse, 10 about half the time and 30 rarely or never (‘low users’) (the remaining seven respondents said they did not know, or did not answer the question).

Second, 40 of these men, purposively sampled25 using questionnaire responses in order to include a broad range of self-reported sexual and reproductive histories, were invited to participate in an in-depth one-to-one interview, conducted by the first author. All agreed. The interview covered sexual and reproductive health topics in greater detail than was possible in the questionnaire, and lasted for an average of 1 hour. There was complete consistency in questionnaire and interview reports of contraceptive use.

The accounts of the men who reported either using contraception on all or most occasions of intercourse (n=14; referred to as ‘high users’) or not very often or never (n=17; referred to as ‘low users’) have been analysed here. Interviews were audio-recorded and transcribed verbatim, with men given pseudonyms. Framework analysis was used to analyse the data.26 ,27 First, descriptive analysis was undertaken focusing on classifying the data and making sense of what was happening in relation to particular areas within the dataset. In the first instance the data were coded according to the areas that the first author had set out to explore at the start of the study, for example, the men's attitudes and experiences of fatherhood,23 as well as areas relating to contraceptive use. This was used as a base in order to move on to higher explanatory accounts that identified patterns and linkages in the data and developed explanations. These were all tested against the relevant data. NVivo™ software (QSR International) was used to facilitate this process.

Ethical approval was granted by the University of Glasgow's Faculty of Law, Business and Social Science Ethical Committee, and from the Scottish Prison Service (SPS) Research Access and Ethics Committee.

Results

Table 1 shows the characteristics of the men who were interviewed, using self-reported questionnaire data. The remainder of the results section will focus on the interview data.

Table 1

Characteristics of the interview sample, by contraceptive use, using self-reported questionnaire data

Low users

Most of the 17 low users said they had used a condom on at least one occasion, often initiated by their partner; use was infrequent. Most reported having at least one girlfriend who was on the pill; a small number reported a partner's implant or intrauterine device use.

Only a few of the low user men said they worried about causing a pregnancy in a partner. For most, sex was about in-the-moment pleasure: “I never think about it [contraceptive use] at the time. It's always, you know, go for it.” [Jason, aged 19]

A small number of the men liked the idea of fatherhood, particularly the idea that there would be small version of themselves: “… if I got a bird pregnant and she has the wean [baby], then the more the merrier ... Happy days for me.” [Paul, aged 18]

This was in contrast to the attitudes of the majority who said they wanted to wait until they were able to provide financially for a child and partner.

Most low users talked about being aware of the risk of contracting STIs, and how they negated this risk through partner selection. Although STIs and some women were both referred to as ‘dirty’, low users claimed they were able to identify ‘dirty’ women and would avoid having intercourse with them, articulating limits to the pursuit of sexual opportunities: “People that look dirty, they look like they could be carrying something, people that you look at them and you're like ‘oh, you're taking drugs, you're putting yourself about’ - I wouldnae [have sex with them].” [Graham, aged 20]

As such, many low users presented condom use as unnecessary. Only Callum (aged 19) explained his sole use of a condom as being to avoid risk from a ‘dirty’ partner: “I think once I've done it ‘cause it was a right dirty dirty one [sexual partner].”

Low users appeared fatalistic about contracting an STI and belittled STIs as commonplace and, perhaps, inevitable: “Everybody catches it [chlamydia] one day in their lives, it's one of the easiest things to catch.” [John, aged 20]

Most did not present themselves as being concerned by this, and said infections were easy to cure. Those who said they worried about STIs or, less often, pregnancy, said that this tended to be only after intercourse.

No low users presented themselves as being in control of contraceptive decision-making. They talked about assuming that their partner had taken care of contraception, or that she would ask, or insist, if she wanted a condom to be used. Most said they were not interested in talking about contraceptive use, and were happy not to know anything about it. Again, this illustrates their concept of sex as a pleasurable act rather than one to be complicated by concerns such as contraceptive use: It's not really a thing that you ever ask. I'd never ask her [girlfriend of 7 months]. It's pretty daft to be honest with you, not checking these things, but I wouldnae.” [Jason, aged 19]

Only four men talked about carrying condoms. This seemed to be related to the possibility of a partner request, ensuring that they would never have to abandon a sexual situation: “I think they [condoms] were all in my drawer and whenever I went to one of the parties I'd always take one with us just in case because I think a lot of the girls that I hang about with would say ‘put one on’.” [Ian, aged 19]

Peer groups were not often referenced. A couple of the low users pointed out that contraceptive use was not something they talked about with friends. Others referred to friends’ attitudes in support of their own non-use: “We arenae that type. We dinnae care about anything like that [contraceptive use].” [Martyn, aged 18]

Condoms impeding sexual pleasure was an issue raised by most low users. They were clear that they did not like condoms because they reduced sensation: “There's nae feeling to it or nothing [sex with a condom]. You last longer, but that's not a thing for me.” [John, aged 20]

The pleasure of the sexual act was key and not to be compromised or complicated by condom use.

Most sex was reported as occurring when inebriated, making condom use even less likely than it would be when sober: “It's ‘cause you're drunk really, you're just not thinking about it. You're just an eager beaver, it's just you're wanting to get in about so I'm not really going to wait and fuck about [putting on a condom].” [Lee, aged 19]

High users

All high users reported using condoms, and 11 reported having a sexual partner who was on the pill. With casual partners, men were likely to report using a condom, whereas in a more stable relationship they reported beginning with condoms and moving on to pill use, sometimes also continuing to use condoms.

All high users talked about being aware and concerned about causing a pregnancy or contracting an STI; the latter appeared to be more salient. ‘Worry’ and ‘fear’ were explicitly mentioned by some; sex was more than simply a pleasurable act for them.

Nearly all high users said that they were not yet ready for fatherhood: “I don't want a wean [baby] at this stage man. That's you tied down for the rest of your life.” [Darren, aged 18]

Casual partners were talked about by some as being ‘dirty’ and potential carriers of infection. This was not something that the men presented as putting them off having intercourse. Sex was, generally, something to be pursued under any circumstances. This dirtiness was, however, the main reason to ensure condom use: “Usually at the weekends you're pure steaming [drunk] and she was a slapper before. She could be shagging about, so obviously you wear condoms. You don't want to catch shit.” [Darren, aged 18]

The men presented themselves as requiring protection against the infection that casual partners were likely to have, due to the women's promiscuity. None of the men presented their condom use as protecting their female partners against infection, even though most of them portrayed themselves as having as many sexual partners as the ‘dirties’ they described. Acquiring an infection that affected the genitals was particularly undesirable, emasculating and threatening: “I'd rather put a condom on than fucking catch some dirty arse dose and that and have to go to the nurse with me cock out. I love me cock.” [Patrick, aged 18]

Unlike the low users, all but one of the high users presented as being in control of contraceptive decision-making. For example, Luke (aged 18) described his current relationship where he said he was finding using a condom a hassle: “I just told her it would probably be easier [if she went on the pill] and safer and better.”

Patrick (aged 18) said:

“It's my decision [to use a condom] ‘cause I don't know where these birds have been.”

A few men even maintained that if a casual partner refused to use a condom they would not go ahead with intercourse, although a couple more said they would have intercourse anyway.

In contrast to the low users, most of the high users talked about having carried condoms from a young age, in order to be ever ready for intercourse: “I just always keep one on me ‘cause you never know when it's gonna happen.” [Mark, aged 18]

Always being ready to have sex did, however, explain the occasional instance of non-condom, or any other contraceptive, use. Fewer high users than low users talked about how being very drunk impeded use. However, several referred to being overcome by alcohol and passion: “[If you've had too much to drink] passion takes over and you get carried away.” [Christopher, aged 18]

Unlike low users, male friends, brothers, or, in one case, a father featured in most of the high users accounts of their contraceptive use. Two men cited a friend's STI as key to making them conscientious about condom use. A few more cited friends or brothers giving them their first condoms, or taking them to the sexual health clinic to get some: “My mate was down [the clinic] getting condoms and he's like ‘aye, if you're gonna be doing stupid stuff go down and get them.” [Warren, aged 18]

Few referred to condom use with casual partners as being standard practice amongst their friends. Conversely, others felt they should use condoms even though their mates did not do so.

High users were mixed as to whether or not using a condom reduced their sexual pleasure. Most said it did not, while referencing conventional wisdom that it did: “They're all right. I don't know why people say they don't feel nothing.” [Parek, aged 19]

For the rest, wearing a condom was presented as a price worth paying to protect against STIs and/or pregnancy. Indeed, men were just as likely to say they were a hassle, or difficult to use due to splitting, perhaps due to large penis size, as to refer to reduced sensation: “I must not be putting it on right. You need to put it on right, so it doesnae burst. Or it's too wee.” [Darren, aged 18]

Discussion

For the low users sex was a pleasurable act, to be enjoyed in-the-moment and not complicated by thoughts of hypothetical outcomes such as pregnancy or infection or, therefore, contraceptive use. Indeed, these men did not feel contraceptive use was relevant to them. The high users, however, conceptualised sex as more than a pleasurable act. They worried about negative outcomes and, except for on occasions when they got carried away, contraceptive use was important to them. The high users were actually more likely to talk about pursuing sexual opportunities relentlessly than were the low users, as they explained that condom use allowed them to confidently have sex with the ‘dirty birds’ that the low users talked about avoiding. The findings suggest that being conventionally masculine can incorporate responses to sexual risk that include routine use of condoms. By, generally, presenting themselves as controlled and rational in their sexual behaviour, the high users demonstrate that one can present as masculine and be concerned about contraceptive use.21 ,22

We question the pessimism involved in assuming that a masculine presentation of oneself will embrace risky behaviours. These findings and others (see references 21, 22, 28) suggest that (some) men are increasingly presenting themselves as engaging in healthy behaviours, whilst still drawing on aspects of orthodox masculine discourses. Being in charge and in control can be drawn on as masculine traits governing health behaviours, with the findings here suggesting that this is not just acceptable for men who are successful financially.22

The YOI is an important site for sexual health and parenting interventions.23 ,24 ,29 ,30 Incarcerated offenders are, literally, a captive audience, motivated to participate by boredom, and desires to present themselves as compliant in order to increase their chances of early release and/or to turn their lives around. These findings suggest that unprotected and unsafe sex are not inevitable amongst offenders.13 ,14 Exposing men to masculine norms that involve taking control of one's sexual health by using condoms, and challenging conceptions that condoms necessarily reduce sexual pleasure – emphasising that some men do not subscribe to this – could be a way forward. We suggest a twin track approach in sexual health intervention which challenges the notion that contraception is an exclusively female responsibility, and which imbues in men a sense of manliness in taking control of their own sexual health in order that their sexual activity is not threatened by diseases.21 More men may be encouraged to pursue positive health outcomes if health promotion initiatives are framed by familiar masculine attributes such as control and threats to manhood (though care must be taken not to exacerbate detrimental hypermasculine norms). As well as capitalising on high users’ positive construction of masculinity in relation to protection, interventions need to help low users to (a) appreciate the consequences of STIs and unwanted pregnancy; (b) understand that their partner selection method is unreliable; and (c) address other problems they may have including their alcohol use, and other issues beyond the scope of this study such as poor mental health.31

This is a small-scale qualitative study, and as such has several limitations. There was limited time available within the prison routines to interview these men, and the sample size was constrained by prison staffing resources. The analysis is based on self-reports, as related to a middle-class female visitor in her thirties talking to young offenders in the masculine environment of the prison. Perhaps some of the men reporting high use of contraception were telling the interviewer what they thought she wanted to hear, though they also reported high use in the questionnaire, completing it when the interviewer was not necessarily present. We did not ask in detail about many other factors likely to be salient in understanding their contraceptive behaviour, such as substance use and self-esteem. Strengths include qualitative interview data on a high-risk and difficult-to-access population supplemented by questionnaire data gathered on a separate occasion. Despite low socio-economic status being linked to risky sexual practices among young men,28 ,32 there have been few in-depth studies focusing on contraceptive use amongst socially excluded young males.33

References

View Abstract

Footnotes

  • Funding This study was funded by the UK Medical Research Council as part of the Sexual and Reproductive Health Programme (WBS U.1300.00.005) at the Social and Public Health Science's Unit (Funding No. MC-UU-12017/9).

  • Competing interests None.

  • Ethics approval University of Glasgow's Faculty of Law, Business and Social Science Ethical Committee and Scottish Prison Service Research Access and Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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