Mood changes. Acne. Low libido. As anyone who’s taken hormonal contraception knows, these are just some of the side effects we’re expected to deal with when preventing an unwanted pregnancy. (The alternative, of course, is praying each month that the condom our partner used didn’t break — if one was used at all.)
Nearly half of all pregnancies globally are unintended, according to a 2022 report by the United Nations Population Fund (UNFPA), which makes contemporary attacks on our reproductive healthcare even more devastating. "Clearly," says Dr Melanie Balbach, a reproduction biologist and postdoctoral fellow at Weill Cornell Medicine, when it comes to this statistic, "something is wrong."
Part of the issue could be that only half of the human population has the ability to take medical contraceptives. Although condoms and vasectomies are options for cis men, the contraceptives with the highest efficacy are female hormonal medications. Despite the terrible side effects, we’re expected to deal with them — partly because there are currently no other options.
That could be changing soon. Across the world, dozens of studies and trials of male contraceptives are taking place. This isn’t exactly a new development. Testosterone has been trialled as a contraceptive, with promising results, since the 1990s. However, these trials have often been halted. As recently as 2012, a trial was concluded earlier than planned because the side effects were too intense – side effects that look all too familiar to those caused by female hormonal contraceptives.
NES/T (Nestorone®/Testosterone) is the first male birth control product that has progressed past the initial stages of the clinical trial process. It’s currently being tested on human participants to evaluate safety and contraceptive efficacy, and investigators are hopeful. Applied daily as a hormonal gel to the shoulder, the drug tackles two important goals: (temporarily) inhibiting sperm production, and maintaining sexual drive and function.
While NES/T could be the option we’ll see on our shelves soonest, there’s another method being investigated. Although still in the early stages, a recent study by Weill Cornell Medicine showed proof-of-concept for an on-demand, non-hormonal enzyme inhibitor that would render men temporarily infertile. The important difference from hormonal drugs that have long been in the works? It would be taken half an hour before it was needed and would last for just 24 hours, both of which could mean fewer side effects.
Soon-to-be-published research by DESIRELine, co-funded by the Bill & Melinda Gates Foundation and the Male Contraceptive Initiative, surveyed over 13,000 men globally and found that demand for male contraceptives is extremely high across the world. But even if men want them now, would they really take them when available? When the consequences of an unintended pregnancy usually weigh heaviest on those who can conceive, who will the responsibility ultimately fall upon?
Michael, 27, who lives in California with his long-term girlfriend, said that he would try male contraceptives if his girlfriend’s IUD stopped being their best option. While the potential for fewer side effects with the non-hormonal option sounded enticing, he worried the on-demand nature would feel too risky. "There is a risk that you forget, in the moment, right? And there are obviously big consequences for that. So that’s scary." For Michael, the reliability of a hormonal drug (even with some side effects) seemed worth it for sustained peace of mind.
Joseph, a 27-year-old living in New York, agreed that he would take contraception in the form of a pill or gel, with the caveat that it had been thoroughly researched. "I think I'd probably be more likely to take a non-hormonal one if it became available… I know that the (female) birth control pill can have pretty gnarly side effects for people taking it. I’d want to avoid that if at all possible." Currently single, a short-term, non-hormonal contraceptive makes the most sense for Joseph. Dr Balbach, of the Weill Cornell trial, says that this is one key motivation behind the quest for non-hormonal options: "Why would you take something [every day] if you’re not exactly sure when you’ll next be having sex? That’s the problem with hormonal approaches, that you have to take it constantly. We want something for everybody."
Worries about side effects are completely reasonable but such stances do beg the question of why women are expected to cope with such a reality. Men, it seems, have the privilege to be picky. Conner, a 26-year-old from Manchester, UK, is aware of this discrepancy. "I hear guys, when asked 'Would you take a pill?', answering 'No, because of all the side effects', but they don’t realise that’s absolutely no different from the current pills that most women take on a daily basis." Is it that they don’t realise, or is it that women are simply expected to deal with any side effects, given that the onus for preventing pregnancy is ultimately on them?
Alex, who lives in Scotland, has gone a step further than the speculating men above. He’s been on NES/T for a year now, in a trial facilitated by the University of Edinburgh’s MRC Centre for Reproductive Health. The best part (besides the lack of an accidental pregnancy in his partner, of course)? He’s experienced no notable side effects so far. "They explained that there are all these side effects you [might] get, like hair loss, hair gain, weight loss, weight gain, your sex drive might increase or decrease… I wouldn’t say I’ve had anything like that."
Apart from the clear goal of contraception, why did he decide to take part in the trial? "Like many women, [my girlfriend] has had some issues with different contraceptives in the past." During continuous conversations about what contraceptive she could go on, Alex noted that it was strange that the pressure was always on her to take responsibility. "She's now very happy being off contraceptives and being her normal self and we now don't have to worry about contraception. It’s just been so easy." Applying it to his shoulder every day, he said: "It just becomes like brushing your teeth, and you don't need motivation to brush your teeth every day."
The question becomes not just whether men would take contraceptives but whether those who can become pregnant will be able to put their trust in those who can simply walk away from any unintended consequences of having sex.
Alex might feel great about it and consider it just part of his morning routine but would we be able to trust everyone to be so responsible? When alcohol and passion are involved, who knows what could be said in the heat of the moment? It could be as innocent as forgetting to take your pill (there’s a reason so many of us have a daily alarm set as a reminder) but it would be naive to ignore the risk of deception, too. When an Australian study found that rates of stealthing (nonconsensual condom removal) by a male partner are as high as 32%, there’s a risk that some could deceive their sexual partners by falsely claiming that they’d taken a contraceptive drug.
Doubts around men’s trustworthiness aside, it’s undeniable that more contraceptive options are long overdue. "For some people it could be a lifeline. Some women respond badly to their hormonal birth control so I think having the option for men would be great," said Michael.
Dr Balbach explains that it "helps everyone at the end of the day. It will help females because then the burden isn’t just on the individual who can get pregnant." Alongside the aforementioned doubts, there’s also room for generosity towards men. "For those who can impregnate, they don't really have options right now. [These options] really help them to gain some agency in controlling their own fertility."
Joseph says that his previous partners have been severely affected by the side effects of their birth control. "[That] made it very clear to me that what we're talking about is really necessary, because [in those situations] there was nothing that I could really do." He also noted he "would very much hope that it’s something adequately covered by health insurance providers, available at low to no cost, because that can be a big issue with reproductive health in general".
With the risk of physical and financial costs, men may simply choose not to take a contraceptive drug. When the consequences aren’t as immediate, is this choice easier for them? The question becomes not just whether men would take contraceptives but whether those who can become pregnant will be able to put their trust in those who can simply walk away from any unintended consequences of having sex.
Accessible, affordable male contraceptives, along with conversations surrounding them, are essential. "It’s important to get the conversation started so that it would be an option for men that might be potentially coming. Because there needs to be that shift as well – it gets into people's brains that it's not just individuals who get pregnant," says Dr Balbach.
After saying that his life hasn’t really changed at all, and that taking his contraceptive is now just a normal part of his day, Alex apologises that his story is "boring" but perhaps there’s another way of looking at it. If safe and effective male contraceptives become available, it shouldn’t be a sensation. It should be a welcome nudge towards gender equity in reproductive healthcare.