Two
Years'
Outpatient
Experience of an Vasectomy Service
AQUILES J. SOBRERO, MD K. L. KOHLI, PhD
Two years' experience of an outpatient vasectomy service in a family planning center is summarized and patients' responses to a postoperative questionnaire are reported.
Introduction In the late part of 1969. the Margaret Sanger Research Bureau, New York, opened the first outpatient vasectomy service. Since then, the availability of vasectomy service has expanded dramatically and, at present, there are over 300 clinics across the country, including those in hospital outpatient departments. The intent of this report is to present some major findings from the follow-up survey of the first 1,056 men who had vasectomies at the Bureau since its inception of service until December, 1971.
Eligibility In the first year, the policymaking subcommittee of the Bureau developed the following standards as to minimum age and parity for men before agreeing to perform the operation. The candidate must be at least 25 years old, married or in a stable relationship; he must have at least three children if he is less than 40 years old, two children if he is 40 to 45 years old, or one child if he is 46 to 50 years old; if he is over 50, he is eligible without any children. However, the Board of Directors recommended that: ". ..patients be accepted for Vasectomy Service in terms of the needs of the individual family with the understanding that the doctor's judgment is paramount," and the decision to approve the operation for candidates not fully meeting Dr. Sobrero is Director, Margaret Sanger Research Bureau, New York, New York. Dr. Kohli is United Nations Senior Demographic Expert, Department of Sociology, University of Baghdad, Iraq, and was formerly head of the Demographic and Statistical Unit at the Margaret Sanger Research Bureau, New York, New York. This article was presented at the 101st Annual Meeting of the American Public Health Association in San Francisco, California, November, 1973, and revised October, 1974.
these basic criteria was left to the Director of the Bureau in consultation with the psychiatric interviewer and the surgeon. After the first year of operation, no criteria were in force. However, the judgment of the interviewer was used only whenever a doubtful situation arose, i.e., a single male or a young couple without children applied.
Operational Procedure Persons requesting the vasectomy were given an appointment for presurgical evaluation. At the time of the interview, the reasons for requesting the operation were explored and the candidate's eligibility was determined. The irreversibility of the procedure, the possibility of death of children or remarriage, the physical effects on the male, and emotional effects on the husband and wife were discussed with the couple. The operation was always performed under local anesthesia in an informal setting, but under very strict surgical conditions. Postoperatively, the patient was given detailed instructions with stress on the need for continued use of contraceptive measures until final confirmation of azoospermia was made.
Methodology and Background Characteristics Questionnaires were mailed to 1,056 men who had undergone a vasectomy between October, 1969, and December, 1971, at the Bureau. Seventy-eight per cent (822) of the men replied to the questionnaire. We have reason to believe that the respondents are representative of the population of 1,056, since at the time of the surgery we obtained the demographic and socioeconomic characteristics of all the men and these did not differ very significantly from those of respondents to our questionnaire. OUTPATIENT VASECTOMY SERVICE
1091
Table 1 provides background characteristics of vasectomy acceptors. Nearly two-thirds of the men who underwent vasectomies were between 30 and 45 years of age. The mean age was 38.5 years and this mean age was about 4 years higher than that of the national sample described by Bumpass and Presser.' The wives were on an average 3.5 years younger than their husbands and were in agreement with the decision to have a vasectomy. The mean number of living children at the time of operation was 3.0. Nearly 5 per cent of the men were childless and most of these were single. Those having none or less than the desired number of children alive at the time of operation had indicated health, Rh factor, or other genetic problems as the most important factor influencing their decision to have the operation. Most of the men (89 per cent) were white. With respect to religious affiliation, nearly one-third were Catholic; about 1 in 5 were Protestant; 1 in 4 were Jewish; and the remainder were divided between "other faiths" and "no
religion." About 12 per cent had not completed high school; 27 per cent were high school graduates; and over 60 per cent had had at least 1 year of college. This shows that in our TABLE 1-Background Characteristics of Vasectomy Acceptors in the Follow-up Study Total Sample
Characteristics
Age Avg age of acceptors (years) % under 30 %45+ Avg age of acceptor's wife (years) % under 30 %45+ Children Average no. % childlessness % 2 or less % 4 or more Race % white Religion % Protestant % Catholic % Jewish % Other or none % Not indicated Education Median school years completed % high school % university Occupation % Professional and managerial % Clerical and sales % Skilled Income Median family income
1092
(N = 1056)
Respondent
Group (N = 822)
38.5 12.2 22.5 35.0 21.4 6.9
38.8
3.0 4.8 45.3 26.8
3.0 3.8 45.3 25.8
88.7
89.4
21.2 32.1 26.4 19.1 1.2
21.3 31.0 29.4 17.9 0.3
14.0 26.5 60.4
14.0 25.5 62.6
62.3 9.1 14.4
65.3 6.9 15.8
11.1 23.7 35.5 19.9 7.5
clientele the acceptance of vasectomy was directly related to the educational level. By occupation, most of the men were professional and their median family income per week was $260.
Postoperative Complications Based upon the responses to the postoperative questionnaire, about 54 per cent of the men had absolutely no complications of any kind after the surgery. Others reported complications lasting from 1 day to more than 6 months (Table 2). In about 20 per cent of the cases the complications did not appear to be serious, as they persisted for less than 1 week. In such cases, the complications could be interpreted as a part of the normal healing process. The remaining 26 per cent having complications persisting longer than a week were further analyzed and classified as to cause (Table 3). About 12 per cent had specific complications such as infection, small hematoma, bleeding, heavy oozing or heavy discharge, and epididymitis. Another 14 per cent had subjective complaints, such as pain, swelling, or combination thereof. All vasectomies were performed on Friday to allow the weekend (free for most men) for recovery. When asked about loss of working days after the operation, 72 per cent reported no loss of time from work; about 19 per cent lost 1 or 2 working days, and the remaining 9 per cent lost 3 or more days.
Aftereffects of Vasectomy on Sexual Life About 22 per cent of the respondents reported physical discomfort or pain during the first postoperative coital experience, but in most cases the pain subsided within 4 weeks after surgery. Table 4 shows the changes in sexual life after the operation. For those who reported discomfort or pain during coitus, the changes in sexual life could be related to a period after that of the complications. Nearly two-thirds had no change in sexual desire. Of the 35 per cent reporting a change, nearly 33 per cent reported an increase. Most of those reporting a decrease had
indicated health, hereditary, or psychological problems as the reasons for having vasectomy. The "weakened" sex desire in such cases may be attributed to their health or
psychological problems. Nearly two-thirds reported an increased enjoyment of sex while 2 per cent reported a decrease. Of those reporting a TABLE 2-Duration of Postoperative Complications among 822 Vasectomized Men Duration
$260
AJPH OCTOBER. 1975, Vol. 65, No. 10
$268
None 0-1 wk 1-2 wk 2-4 wk 1-2 mo 2-3 mo 3-6 mo 6+ mo
%
Cumulative %
54.1 20.1 10.7 5.2 4.9 1.7 1.1 2.2
54.1 74.2 84.9 90.1 95.0 96.7 97.8 100.0
TABLE 3-Nature of Postoperative Complications of 1 Wk or More Duration among 822 Vasectomized Men No. of Men % of Having Complication Respondents
Nature of Complication
Subjective complaints Swelling or pain Other Specific complaints Infection Small hematoma Bleeding Epididymitis Heavy oozing Total
Cumulative %
111 8
13.5 1.0
13.5 14.5
46
5.6 3.0 1.6 0.6 0.5 25.8
20.1 23.1 24.7 25.3 25.8 25.8
25 13 5 4 212
decrease in enjoyment, the majority complained of physical discomfort or pain during sexual intercourse. The reason for an increase in libido and/or coital enjoyment was attributed by the respondents to the absence of the fear of pregnancy. The sexual desire or enjoyment of wives as perceived by their husbands was reported to be reduced in 2.4 per cent (19 cases), while in the remaining cases it either increased or remained the same as before the operation. In seven cases the wives with reduced desire were the partners of men whose own pleasure had lessened. Interestingly enough, reduced desire in the case of wives was related to their reduced enjoyment.
Marital Harmony Of the 786 respondents, 35 per cent (276) reported no change, 64 per cent (501 cases) improved, and 1 per cent (nine cases) reported a "decrease" in "marital harmony" after vasectomy. Of these nine cases, two frankly stated that the worsened relationship was not due to the operation. Those who reported improved marital harmony stated that it was due to relaxation of fear of unwanted pregnancy. Vasectomy seems to have a great effect in improving the sexual enjoyment and increasing harmony of the household of the group studied.
Discussion Most studies done in the United States have reported that the racial composition of the vasectomy population is over 90 per cent white and on an average the client has three children at the time of operation.2'6 This was essentially true at the Sanger Bureau, too. However, the other demographic and socioeconomic characteristics of the clients at the Bureau were different from those reported in other studies. At the Bureau, the vasectomy client was 3 to 8 years older,2, 4, 6-8 and superior in economic and educational position, from those reported in other studies.2,4,8-11 The findings of the postoperative questionnaire showed that 26 per cent of the men had complications persisting from 1 week to more than 6 months. Although in a majority of the cases, the complications were cured within 4 weeks after the surgery, still the 26 per cent figure is rather disturbing. The present study failed to confirm earlier findings in which the range of postoperative complications was reported as 0 to 4 per cent.4 12 However, it may be pointed out that the findings of earlier studies are based on reports by physicians rather than by the patients, and thus the low morbidity rate in those studies may be due to more restrictive definition of complications by physicians. The findings that 28 per cent of men lost 1 or more working days after allowing 2 days rest at the weekend, and that 26 per cent reported physical complications lasting longer than a week suggest that further research should be considered regarding surgical techniques and postoperative care. About 98 per cent reported unchanged or better sex life and greater happiness in their marriage and family life. These findings are very close to those obtained in several other studies .2, 4, 7, 10, 11, 13 Except for a study reported by Johnson,'4 all studies in the U.S.A. to date have reported declines in sexual desire or activity tending to be below 5 per cent. Such declines could probably be partly attributed to aging or other personal factors and not solely to the vasectomy. The high rate of decline in sexual desire or activity reported by Johnson is attributed largely to the fact that persons were sterilized for psychiatric reasons. Thus, fears of impotence and negative reactions to the barrenness might be the reasons for reducing their interest in sex. From
TABLE 4-Changes in Sexual Life by Factors among 819 Vasectomized Respondents Factors
More
About the Same
Less
Total*
No. (%)
Self Desire Enjoyment Frequency
Ejaculation (volume) Wife Desire Enjoyment *
266 (32.5) 535 (65.3) 281 (34.4) 73 (9.2)
534 (65.2) 267 (32.6) 491 (60.2) 629 (79.3)
19 (2.3) 17 (2.1)
819 (100) 819 (100)
44(5.4) 91 (11.5)
816(100) 793 (100)
305 (38.9) 506 (65.4)
461 (58.7) 257 (33.1)
19 (2.4) 12 (1.5)
785 (100) 777 (100)
Excludes those who did not answer the question.
OUTPATIENT VASECTOMY SERVICE
1093
these studies, one can probably conclude that vasectomy generally has no deleterious effect on men's sexual performance or pleasure. In many cases, it stimulates sexual enthusiasm by removing the anxiety of causing impregnation. However, in order to remove the misinformation and misconception of patients regarding deleterious effects of vasectomy on sexual behavior, we agree with Presser15 that there is a definite need for follow-up studies incorporating in the study design control groups of nonsterilized persons. Such research would also throw light on the extent to which other factors unrelated to vasectomy are responsible for the effects reported. REFERENCES 1. Bumpass, L. L., and Presser, H. B. Contraceptive Sterilization in the U.S.: 1965 and 1970. Demography 9:531-548, 1972. 2. Bryon, D., and Cole, S. G. A Source Book of Vasectomy. Texas Christian University Press, Fort Worth, 1972. 3. Dunbar, E. For Men Only: Foolproof Birth Control. Look Magazine, pp. 45-48, Mar. 9, 1971. 4. Ferber, A. S., Tietze, C., and Lewit, S. Men with Vasectomies: A Study of Medical, Sexual, and Psychosocial Changes. Psychosom. Med. 29:354-366, 1967. 5. Landis, J. R., and Poffenberger, T. The Marital and Sexual Adjustment of 330 Couples Who Chose Vasectomy as a Form of
Birth Control. J. Marr. Fam. 27:57-58, 1965. 6. Rodgers, D. A., Ziegler, F. J., Altrocchi, J., and Levy, N. A Longitudinal Study of the Psycho-social Effects of Vasectomy. J. Marr. Fam. 27:59-64, 1965. 7. Ziegler, F. J., Rodgers, D. A., and Kriegsman, S. A. Psychological Aspects of Male Sterilization. Presented at the First International Congress of Social Psychiatry, London, 1964. 8. Ziegler, F. J., Rodgers, D. A., and Kriegsman, S. A. Effect of Vasectomy on Psychological Functioning. Psychosom. Med. 28:50-3, 1966. 9. Campbell, A. A. The Incidence of Operations That Prevent Conception. Am. J. Obstet. Gynecol. 89:694-700, 1964. 10. Landis, J. T., and Poffenberger, T. Population Control: Vasectomy. Presented at the Annual Meeting of American Sociological Association, Los Angeles, California, 1963. 11. Truesdale, C. W. Assessment of Vasectomy as a Means of Voluntary Sterilization. Lancet 85:155-156, 1965. 12. Poffenberger, T. Two Thousand Voluntary Vasectomies Performed in California: Background Factors and Comments. Marr. Fam. Living 25:469-474, 1963. 13. Poffenberger, T., and Poffenberger, S. B. Vasectomy as a Preferred Method of Birth Control: A Preliminary Investigation. Marr. Fam. Living 25:326-330, 1963. 14. Johnson, M. H.: Social and Psychological Effects of Vasectomy. Am. J. Psychiatry 121:482-486, 1964. 15. Presser, H. B. Voluntary Sterilization: A World View. Rep. Popul. Fam. Plann. 5:36, 1970.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
NEEDLEWORK VS. NICOTINE Ten years ago I stopped smoking and took up needlework to occupy my hands. I have many lovely crewel pillows to show for it. At our school, even male teachers have adopted this practice successfully. Sylvia Lerin South Senior High School Great Neck, NY
1094
AJPH OCTOBER. 1975, Vol. 65, No. 10
Years'
Outpatient
Experience of an Vasectomy Service
AQUILES J. SOBRERO, MD K. L. KOHLI, PhD
Two years' experience of an outpatient vasectomy service in a family planning center is summarized and patients' responses to a postoperative questionnaire are reported.
Introduction In the late part of 1969. the Margaret Sanger Research Bureau, New York, opened the first outpatient vasectomy service. Since then, the availability of vasectomy service has expanded dramatically and, at present, there are over 300 clinics across the country, including those in hospital outpatient departments. The intent of this report is to present some major findings from the follow-up survey of the first 1,056 men who had vasectomies at the Bureau since its inception of service until December, 1971.
Eligibility In the first year, the policymaking subcommittee of the Bureau developed the following standards as to minimum age and parity for men before agreeing to perform the operation. The candidate must be at least 25 years old, married or in a stable relationship; he must have at least three children if he is less than 40 years old, two children if he is 40 to 45 years old, or one child if he is 46 to 50 years old; if he is over 50, he is eligible without any children. However, the Board of Directors recommended that: ". ..patients be accepted for Vasectomy Service in terms of the needs of the individual family with the understanding that the doctor's judgment is paramount," and the decision to approve the operation for candidates not fully meeting Dr. Sobrero is Director, Margaret Sanger Research Bureau, New York, New York. Dr. Kohli is United Nations Senior Demographic Expert, Department of Sociology, University of Baghdad, Iraq, and was formerly head of the Demographic and Statistical Unit at the Margaret Sanger Research Bureau, New York, New York. This article was presented at the 101st Annual Meeting of the American Public Health Association in San Francisco, California, November, 1973, and revised October, 1974.
these basic criteria was left to the Director of the Bureau in consultation with the psychiatric interviewer and the surgeon. After the first year of operation, no criteria were in force. However, the judgment of the interviewer was used only whenever a doubtful situation arose, i.e., a single male or a young couple without children applied.
Operational Procedure Persons requesting the vasectomy were given an appointment for presurgical evaluation. At the time of the interview, the reasons for requesting the operation were explored and the candidate's eligibility was determined. The irreversibility of the procedure, the possibility of death of children or remarriage, the physical effects on the male, and emotional effects on the husband and wife were discussed with the couple. The operation was always performed under local anesthesia in an informal setting, but under very strict surgical conditions. Postoperatively, the patient was given detailed instructions with stress on the need for continued use of contraceptive measures until final confirmation of azoospermia was made.
Methodology and Background Characteristics Questionnaires were mailed to 1,056 men who had undergone a vasectomy between October, 1969, and December, 1971, at the Bureau. Seventy-eight per cent (822) of the men replied to the questionnaire. We have reason to believe that the respondents are representative of the population of 1,056, since at the time of the surgery we obtained the demographic and socioeconomic characteristics of all the men and these did not differ very significantly from those of respondents to our questionnaire. OUTPATIENT VASECTOMY SERVICE
1091
Table 1 provides background characteristics of vasectomy acceptors. Nearly two-thirds of the men who underwent vasectomies were between 30 and 45 years of age. The mean age was 38.5 years and this mean age was about 4 years higher than that of the national sample described by Bumpass and Presser.' The wives were on an average 3.5 years younger than their husbands and were in agreement with the decision to have a vasectomy. The mean number of living children at the time of operation was 3.0. Nearly 5 per cent of the men were childless and most of these were single. Those having none or less than the desired number of children alive at the time of operation had indicated health, Rh factor, or other genetic problems as the most important factor influencing their decision to have the operation. Most of the men (89 per cent) were white. With respect to religious affiliation, nearly one-third were Catholic; about 1 in 5 were Protestant; 1 in 4 were Jewish; and the remainder were divided between "other faiths" and "no
religion." About 12 per cent had not completed high school; 27 per cent were high school graduates; and over 60 per cent had had at least 1 year of college. This shows that in our TABLE 1-Background Characteristics of Vasectomy Acceptors in the Follow-up Study Total Sample
Characteristics
Age Avg age of acceptors (years) % under 30 %45+ Avg age of acceptor's wife (years) % under 30 %45+ Children Average no. % childlessness % 2 or less % 4 or more Race % white Religion % Protestant % Catholic % Jewish % Other or none % Not indicated Education Median school years completed % high school % university Occupation % Professional and managerial % Clerical and sales % Skilled Income Median family income
1092
(N = 1056)
Respondent
Group (N = 822)
38.5 12.2 22.5 35.0 21.4 6.9
38.8
3.0 4.8 45.3 26.8
3.0 3.8 45.3 25.8
88.7
89.4
21.2 32.1 26.4 19.1 1.2
21.3 31.0 29.4 17.9 0.3
14.0 26.5 60.4
14.0 25.5 62.6
62.3 9.1 14.4
65.3 6.9 15.8
11.1 23.7 35.5 19.9 7.5
clientele the acceptance of vasectomy was directly related to the educational level. By occupation, most of the men were professional and their median family income per week was $260.
Postoperative Complications Based upon the responses to the postoperative questionnaire, about 54 per cent of the men had absolutely no complications of any kind after the surgery. Others reported complications lasting from 1 day to more than 6 months (Table 2). In about 20 per cent of the cases the complications did not appear to be serious, as they persisted for less than 1 week. In such cases, the complications could be interpreted as a part of the normal healing process. The remaining 26 per cent having complications persisting longer than a week were further analyzed and classified as to cause (Table 3). About 12 per cent had specific complications such as infection, small hematoma, bleeding, heavy oozing or heavy discharge, and epididymitis. Another 14 per cent had subjective complaints, such as pain, swelling, or combination thereof. All vasectomies were performed on Friday to allow the weekend (free for most men) for recovery. When asked about loss of working days after the operation, 72 per cent reported no loss of time from work; about 19 per cent lost 1 or 2 working days, and the remaining 9 per cent lost 3 or more days.
Aftereffects of Vasectomy on Sexual Life About 22 per cent of the respondents reported physical discomfort or pain during the first postoperative coital experience, but in most cases the pain subsided within 4 weeks after surgery. Table 4 shows the changes in sexual life after the operation. For those who reported discomfort or pain during coitus, the changes in sexual life could be related to a period after that of the complications. Nearly two-thirds had no change in sexual desire. Of the 35 per cent reporting a change, nearly 33 per cent reported an increase. Most of those reporting a decrease had
indicated health, hereditary, or psychological problems as the reasons for having vasectomy. The "weakened" sex desire in such cases may be attributed to their health or
psychological problems. Nearly two-thirds reported an increased enjoyment of sex while 2 per cent reported a decrease. Of those reporting a TABLE 2-Duration of Postoperative Complications among 822 Vasectomized Men Duration
$260
AJPH OCTOBER. 1975, Vol. 65, No. 10
$268
None 0-1 wk 1-2 wk 2-4 wk 1-2 mo 2-3 mo 3-6 mo 6+ mo
%
Cumulative %
54.1 20.1 10.7 5.2 4.9 1.7 1.1 2.2
54.1 74.2 84.9 90.1 95.0 96.7 97.8 100.0
TABLE 3-Nature of Postoperative Complications of 1 Wk or More Duration among 822 Vasectomized Men No. of Men % of Having Complication Respondents
Nature of Complication
Subjective complaints Swelling or pain Other Specific complaints Infection Small hematoma Bleeding Epididymitis Heavy oozing Total
Cumulative %
111 8
13.5 1.0
13.5 14.5
46
5.6 3.0 1.6 0.6 0.5 25.8
20.1 23.1 24.7 25.3 25.8 25.8
25 13 5 4 212
decrease in enjoyment, the majority complained of physical discomfort or pain during sexual intercourse. The reason for an increase in libido and/or coital enjoyment was attributed by the respondents to the absence of the fear of pregnancy. The sexual desire or enjoyment of wives as perceived by their husbands was reported to be reduced in 2.4 per cent (19 cases), while in the remaining cases it either increased or remained the same as before the operation. In seven cases the wives with reduced desire were the partners of men whose own pleasure had lessened. Interestingly enough, reduced desire in the case of wives was related to their reduced enjoyment.
Marital Harmony Of the 786 respondents, 35 per cent (276) reported no change, 64 per cent (501 cases) improved, and 1 per cent (nine cases) reported a "decrease" in "marital harmony" after vasectomy. Of these nine cases, two frankly stated that the worsened relationship was not due to the operation. Those who reported improved marital harmony stated that it was due to relaxation of fear of unwanted pregnancy. Vasectomy seems to have a great effect in improving the sexual enjoyment and increasing harmony of the household of the group studied.
Discussion Most studies done in the United States have reported that the racial composition of the vasectomy population is over 90 per cent white and on an average the client has three children at the time of operation.2'6 This was essentially true at the Sanger Bureau, too. However, the other demographic and socioeconomic characteristics of the clients at the Bureau were different from those reported in other studies. At the Bureau, the vasectomy client was 3 to 8 years older,2, 4, 6-8 and superior in economic and educational position, from those reported in other studies.2,4,8-11 The findings of the postoperative questionnaire showed that 26 per cent of the men had complications persisting from 1 week to more than 6 months. Although in a majority of the cases, the complications were cured within 4 weeks after the surgery, still the 26 per cent figure is rather disturbing. The present study failed to confirm earlier findings in which the range of postoperative complications was reported as 0 to 4 per cent.4 12 However, it may be pointed out that the findings of earlier studies are based on reports by physicians rather than by the patients, and thus the low morbidity rate in those studies may be due to more restrictive definition of complications by physicians. The findings that 28 per cent of men lost 1 or more working days after allowing 2 days rest at the weekend, and that 26 per cent reported physical complications lasting longer than a week suggest that further research should be considered regarding surgical techniques and postoperative care. About 98 per cent reported unchanged or better sex life and greater happiness in their marriage and family life. These findings are very close to those obtained in several other studies .2, 4, 7, 10, 11, 13 Except for a study reported by Johnson,'4 all studies in the U.S.A. to date have reported declines in sexual desire or activity tending to be below 5 per cent. Such declines could probably be partly attributed to aging or other personal factors and not solely to the vasectomy. The high rate of decline in sexual desire or activity reported by Johnson is attributed largely to the fact that persons were sterilized for psychiatric reasons. Thus, fears of impotence and negative reactions to the barrenness might be the reasons for reducing their interest in sex. From
TABLE 4-Changes in Sexual Life by Factors among 819 Vasectomized Respondents Factors
More
About the Same
Less
Total*
No. (%)
Self Desire Enjoyment Frequency
Ejaculation (volume) Wife Desire Enjoyment *
266 (32.5) 535 (65.3) 281 (34.4) 73 (9.2)
534 (65.2) 267 (32.6) 491 (60.2) 629 (79.3)
19 (2.3) 17 (2.1)
819 (100) 819 (100)
44(5.4) 91 (11.5)
816(100) 793 (100)
305 (38.9) 506 (65.4)
461 (58.7) 257 (33.1)
19 (2.4) 12 (1.5)
785 (100) 777 (100)
Excludes those who did not answer the question.
OUTPATIENT VASECTOMY SERVICE
1093
these studies, one can probably conclude that vasectomy generally has no deleterious effect on men's sexual performance or pleasure. In many cases, it stimulates sexual enthusiasm by removing the anxiety of causing impregnation. However, in order to remove the misinformation and misconception of patients regarding deleterious effects of vasectomy on sexual behavior, we agree with Presser15 that there is a definite need for follow-up studies incorporating in the study design control groups of nonsterilized persons. Such research would also throw light on the extent to which other factors unrelated to vasectomy are responsible for the effects reported. REFERENCES 1. Bumpass, L. L., and Presser, H. B. Contraceptive Sterilization in the U.S.: 1965 and 1970. Demography 9:531-548, 1972. 2. Bryon, D., and Cole, S. G. A Source Book of Vasectomy. Texas Christian University Press, Fort Worth, 1972. 3. Dunbar, E. For Men Only: Foolproof Birth Control. Look Magazine, pp. 45-48, Mar. 9, 1971. 4. Ferber, A. S., Tietze, C., and Lewit, S. Men with Vasectomies: A Study of Medical, Sexual, and Psychosocial Changes. Psychosom. Med. 29:354-366, 1967. 5. Landis, J. R., and Poffenberger, T. The Marital and Sexual Adjustment of 330 Couples Who Chose Vasectomy as a Form of
Birth Control. J. Marr. Fam. 27:57-58, 1965. 6. Rodgers, D. A., Ziegler, F. J., Altrocchi, J., and Levy, N. A Longitudinal Study of the Psycho-social Effects of Vasectomy. J. Marr. Fam. 27:59-64, 1965. 7. Ziegler, F. J., Rodgers, D. A., and Kriegsman, S. A. Psychological Aspects of Male Sterilization. Presented at the First International Congress of Social Psychiatry, London, 1964. 8. Ziegler, F. J., Rodgers, D. A., and Kriegsman, S. A. Effect of Vasectomy on Psychological Functioning. Psychosom. Med. 28:50-3, 1966. 9. Campbell, A. A. The Incidence of Operations That Prevent Conception. Am. J. Obstet. Gynecol. 89:694-700, 1964. 10. Landis, J. T., and Poffenberger, T. Population Control: Vasectomy. Presented at the Annual Meeting of American Sociological Association, Los Angeles, California, 1963. 11. Truesdale, C. W. Assessment of Vasectomy as a Means of Voluntary Sterilization. Lancet 85:155-156, 1965. 12. Poffenberger, T. Two Thousand Voluntary Vasectomies Performed in California: Background Factors and Comments. Marr. Fam. Living 25:469-474, 1963. 13. Poffenberger, T., and Poffenberger, S. B. Vasectomy as a Preferred Method of Birth Control: A Preliminary Investigation. Marr. Fam. Living 25:326-330, 1963. 14. Johnson, M. H.: Social and Psychological Effects of Vasectomy. Am. J. Psychiatry 121:482-486, 1964. 15. Presser, H. B. Voluntary Sterilization: A World View. Rep. Popul. Fam. Plann. 5:36, 1970.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
NEEDLEWORK VS. NICOTINE Ten years ago I stopped smoking and took up needlework to occupy my hands. I have many lovely crewel pillows to show for it. At our school, even male teachers have adopted this practice successfully. Sylvia Lerin South Senior High School Great Neck, NY
1094
AJPH OCTOBER. 1975, Vol. 65, No. 10
