Exploring Factors that Affect Male Veteran’s Vasectomy Decision-making: A Mixed-methods Approach

Objective: To examine the sociodemographic, healthcare, and service-related characteristics that predict vasectomy among US male veterans, and associated patterns of decision-making.

Design: We conducted a cross-sectional survey of a probability sample of US veterans and interviewed a subset of respondents about their contraceptive use. Focusing on male veterans, we used a weighted Wald test of association to explore the association between independent variables and vasectomy and a weighted multivariate logistic regression to examine factors that increased the odds of having a vasectomy. We qualitatively coded for decision-making themes.

Results: Adjusting for marital status, age and income, parenthood status was significantly associated with increased odds of having a vasectomy (OR = 2.59, 95% CI 1.53–5.44 p = 0.012). Those with higher income had increased odds of having a vasectomy (OR = 7.68 95% CI 2.49–23.7, p<0.001). Our qualitative results suggest that male veterans make decisions about having a vasectomy after family completion.

Conclusion: Income and parenthood status are predictors of vasectomy status. While service-related chemical or hazard exposure was not significantly associated with vasectomies, some male veterans qualitatively described that trauma and other military-related experiences led them to decide not to have children.

Keywords: vasectomy, mixed-methods, veterans, sterilisation

Introduction

Vasectomies, a safe, outpatient, surgical form of contraception, remain one of the only forms of male contraception.^1,2 In the general US population, recipients are more likely to be Caucasian and have higher incomes as compared to Black, Hispanic or lower-income men.^3,4 On average, US males receive vasectomies between the ages of 36–37,⁵ and 84% have at least two children.⁶

As healthcare access plays a role in vasectomy status, researchers have examined rates of vasectomy among two insured groups—US active-duty servicemen and US veterans with access to Veterans Health Affairs (VHA).^7,8 This research shows that vasectomy rates in an active-duty population are comparable to US civilians.⁷ Active-duty military males who are Caucasian, Protestant and married have the highest rates of vasectomies.⁸ Across both civilian and military populations, there have been shifts in demographics of males who receive a vasectomy after the Dobbs v. Jackson Women’s Health Organization Supreme Court decision (Dobbs),^7,9 with younger, unmarried males both inside and outside of the US military being more likely to receive a vasectomy after the Dobbs decision than before it.^6,7

US male veterans have greater access to healthcare than US civilians¹⁰ and may receive vasectomy care through the VHA. However, some male veterans may have to pay a co-pay depending on their income, disability rating and service history. It is largely unknown if male veterans use VHA benefits to gain access to vasectomies. It is also unknown if VHA benefits can help overcome some of the demographic differences in vasectomy rates between socioeconomically advantaged and disadvantaged groups that are seen in the general population. Examining male veterans is important as their decision-making process may provide additional insight into how vasectomy decisions are made for those with full or partial coverage of the procedure. In addition, these veterans may have unique contraceptive needs because of their service in the military (e.g., concerns about exposure).

Our recent study on veterans’ contraceptive access and experiences suggests that male veterans have higher rates of sterilisation as compared to a nationally representative civilian sample—28% of male veterans reported being sterilised compared to about 13% in the general population.¹¹ While our previous study illustrated the differences between civilian and veteran sterilisation rates,¹¹ it did not examine predictors of vasectomy rates in the veteran population.

Using nationally representative survey data surrounding male and female veterans’ contraceptive use, we examine if sociodemographic characteristics, service-related characteristics and receipt of veterans’ benefits are associated with vasectomy status among male veterans. We also use qualitative data with males who had, and had not, received a vasectomy to better understand their decision-making processes.

Materials and methods

Using two probability-based samples (NORC’s AmeriSpeak and Ipsos’s Knowledge Panel), we surveyed a nationally representative sample of male and female US veterans of reproductive age (18 to 49) in March 2025 about their use, attitudes and concerns surrounding contraceptives. We also asked veterans questions related to their previous service activities and their VHA healthcare access. As all individuals were part of an existing survey panel, we received participants’ standard sociodemographic questions (e.g., income, race and ethnicity). Then, we interviewed a subset of survey participants to better understand their contraceptive perspectives. See Rollison et al. for a full description of survey and interview development, methods and survey weighting.¹¹

Survey analysis

This paper focuses on individuals eligible to receive a vasectomy. To determine eligibility, we used questions surrounding sex and the type of contraception that one used—traditionally ‘female methods’ (e.g., the pill, intrauterine device) or traditionally ‘male methods’ (i.e., vasectomy, male condom). We classified those who identify as ‘male’ or use ‘male methods’ as ‘male veterans’, although we recognise that some of these veterans may have a different sex and/or gender identity. We used the National Survey for Family Growth’s question surrounding vasectomy status.

Age was dichotomised (18–39 vs 40–49) to reflect the distribution and average age of sterilisation.³ Race/ethnicity, marital status, parenthood status and education were also included.

We created a dichotomous service-related disability variable based on whether the veteran reported having a disability and a follow-up question on whether they had a service-related disability rating (i.e., their disability was determined by VHA to be incurred or aggravated during military service to qualify for specific benefits). Individuals were then classified as either having a service-related disability of 70% or more, or a rating less than 70% or no disability. History of combat service was dichotomised as ‘yes’ or ‘no’. The survey also asked veterans to report how likely they were to have been exposed to chemicals or hazards during their time of service using a Likert scale ‘definitely yes’, ‘probably yes’, ‘probably no’, ‘definitely no’ and ‘don’t know’. We collapsed the ‘yes’ and ‘no’ categories and retained the ‘don’t know’ category.

To understand differences in access to healthcare, we created a new proxy variable to distinguish between those who enrolled in VHA benefits, those who were not enrolled in VHA benefits and those who accessed and did not access healthcare services in the last 12 months. This proxy variable, which accounted for VHA enrolment status and access to healthcare in the past year, had five levels ‘unknown’; ‘veterans enrolled in VHA benefits who accessed services somewhere’; ‘veterans enrolled who did not access care’; ‘veterans not enrolled who accessed services somewhere’; and ‘veterans not enrolled who did not access any care’.

We assessed beliefs about birth control through a modified Rocca et al.’s six-item Contraceptive Concerns and Belief Scale (e.g., ‘Using birth control is unnatural’) to make it gender neutral.¹² Items were rated on a 5-point Likert scale, with higher scores indicating a more positive perception of birth control. Analyses were performed using R version 4.5.1.

Qualitative interviews

For a full description of interview methods, see Rollison et al. (2025).¹¹ Interviewers asked 33 male participants a variety of questions about their and their partners’ (if applicable) contraceptive decision-making and use. Nine veterans who stated they had a vasectomy in the survey were specifically asked about their decision-making process. For example, we asked, ‘Can you tell me about your decision to have a vasectomy?’ and ‘What was important to you when choosing a method?’ Twenty-four veterans who did not report sterilisation during the survey were asked about the specific methods that they and their partner had used and if they wanted to use or considered other methods of contraception, including vasectomy. All qualitative analyses were performed using Dedoose version 10.0.35.

This study was approved by RAND’s Human Subjects Protection Committee. Participants were compensated $25 for completing the survey and $50 for participating in the interview.

Quantitative analysis

Our quantitative analysis consisted of bivariate and multivariate analyses. We used a weighted Wald Chi-squared test to examine the likelihood that sociodemographic variables and healthcare use variables contributed to a significant difference in sterilisation status. We also used multivariate binomial logistic regression to estimate the odds of being sterilised relative to not being sterilised for sociodemographic, service-related and healthcare access variables independently associated with sterilisation status. We also ran a weighted multivariate binomial logistic regression model that included all sociodemographic, service-related and healthcare variables.

Qualitative analysis

The qualitative interview data were analysed using thematic analysis.¹³ For this specific analysis, we compared codes across two categories: males who had received a vasectomy and those who had not received a vasectomy but had considered it as a form of contraception. We coded for themes related to childbearing status, service-related injuries that impacted decision and discussions with one’s provider.

Results

Table 1 describes our population. Most individuals were married or living with a partner (78%), made $100 000 or more (57%), identified as Caucasian, non-Hispanic (63%), lived in a metro area (63%), and reported having no disability or a service-related disability of 70% or less (78%). About half of individuals were aged 1839 (52%), enrolled in VHA healthcare and used healthcare services in the last 12 months (52%), served in a combat zone (52%) and reported exposure to, or likely exposure to, chemicals or hazards during service (49%).

Table 1

Weighted demographics of male veterans

Age, marital status, income, and identifying as a parent were all statistically associated with the likelihood of being sterilised (see Table 2). However, service-related characteristics and health care status were not associated with vasectomy status.

Table 2

Weighted associations between sociodemographic characteristics, service characteristics and health care characteristics of sterilised and non-sterilised male veterans

After adjusting for marital status, age and parenthood status, those who had a household income of $100 000 or more had 7.68 times the odds of being sterilised as compared to those who earned less than $49 999 (95% CI 2.49 23.7, p<0.001). In addition, after adjusting for other factors, those veterans who identified as parents had 2.59 times the odds (95% CI 1.23 5.44, p = 0.012) of being sterilised as compared to those without children. Marital status and age were not statistically significant. There were no significant differences in the predictors of vasectomy in the model that included all the independent variables of interest (see Table 3).

Table 3

Weighted odds of a male veteran being sterilised

Our quantitative findings that parenthood status increased the odds of being sterilised is mirrored in our qualitative findings. We interviewed 33 male veterans, and nine of those had had a vasectomy (see Supplement for demographics of interviewed participants). Veterans consistently cited completion of family building as the primary decision factor. These male veterans talked about the permanency of sterilisation being important to them once they had finished having children. Conversely, those who were not sterilised, spoke to the desire to finish having children before undergoing a vasectomy.

‘We were using birth control for a while and then we had two kids and then it was kind of—we wanted a more permanent way of not having more kids.’ —40–44, married, has children, >$100k, sterilised >12 months ago (non-VHA), not enrolled in VHA benefits but healthcare access in last 12 months.

‘I know I definitely want to have more children. So, vasectomy is definitely out of the question for that.’ —35–39, divorced, has children, <$49 999, not sterilised, VHA enrolled with healthcare access in the last 12 months.

While most veterans who had a vasectomy had children, four veterans suggested that they had a vasectomy to prevent having children altogether. Two veterans cited exposure to hazardous chemicals during their time of service and concerns about their mental health as driving their decision to have a vasectomy.

‘What I’ve been exposed to up to that point and then my own medical history… I wouldn’t feel right passing something like that onto a child, so it was pretty easy. It was a pretty easy decision.’ —35–39, married, no children, ($50 000-$99 999), sterilised>12 months (non-VHA), VHA enrolled with healthcare access in the last 12 months.

One veteran suggested the cost of raising a child drove his decision:

‘I don’t know who can afford a kid. I see everyone else struggling and I didn’t want to struggle.’ —35–39, married, no children, >$100k, sterilised <last 12 months (non-VHA), VHA enrolled with access to healthcare somewhere in last 12 months.

Two veterans suggested that the political climate drove their decision to have a vasectomy, including lack of access to contraceptives and abortions.

‘I mean, the whole, you know, birth control and what’s going on with abortions and things of that nature. I feel like people would be a little bit, you know, more concerned and would be more likely to get, you know, vasectomies or things of that nature.’ —40–44, married, has children, >$100k, sterilised>12 months (non-VHA), VHA enrolled with healthcare access in the last 12 months.

For some veterans, vasectomy also offered advantages over female methods of contraception. Veterans perceived vasectomies as having fewer side effects than hormonal contraceptives. Some also directly compared male and female sterilisation procedures, highlighting the reduced recovery time and minimally invasive nature of a vasectomy.

‘It’s easier for me to do it [have a vasectomy], you know, there’s less recovery time, there’s less risks of complications.’ —35–39, married, no children, ($50 000-$99 999), sterilised > 12 months ago (non-VA location), VHA enrolled with healthcare access in the last 12 months.

Most veterans did not report receiving a vasectomy at the VHA, but rather received a vasectomy through VHA community care, at a private outpatient clinic or during their time of service. Some veterans suggested barriers to receiving a vasectomy, especially if they were younger, did not already have children, and attempted to receive a vasectomy through VHA. They suggested that physicians often questioned their choice or made them wait after an initial visit. For some, provider reluctance meant that they did not pursue a vasectomy.

‘I got a vasectomy, and I did try to go through the VA and the hoops they wanted me to jump through were like arduous. And so, I gave up that pursuit and I just went to a local doctor.’
—35–39, married, no children, >$100k, sterilised <last 12 months (non-VHA), VHA enrolled with healthcare access in the last 12 months.

‘So that was one of the rules in active duty is that you had to have two children or be over the age of 35 to get a vasectomy. And I never did end up doing it, but I chickened out.’
—45–49, married, >$100k, not sterilised, VHA enrolled with healthcare access in the last 12 months.

One veteran specifically suggested that receiving a vasectomy while in the military was easy, as he had already had three kids. He suggested that the proximity to those who have already had a vasectomy made it easier to understand the experience and view it as normal. Other veterans talked about the role of peers in normalising the experience of having a vasectomy, relying on friends and family members’ previous experiences when making decisions to have a vasectomy.

‘As you tell people, “I’m thinking about having a vasectomy,” you find out how many have already gotten it and what their experience was. Not that they’re oversharing, but [you] realise, oh this is much more common than I would have thought.’ —Age 40–44, married, has children, >$100k, vasectomy >12 months ago, VHA enrolled with healthcare access in the last 12 months.

‘[My friends and I] were just like, well, is it painful? And I’ve had one friend who’s like, I don’t know. I had it 20 years ago. It’s going to be easy.’ —40–44, married, no children, >$100k, vasectomy outside the VHA, VHA enrolled with healthcare access in the last 12 months.

Discussion

Our mixed-methods findings suggest that completion of family building drives veteran males’ vasectomy decision-making process. That is, those who have decided not to have more children or any children at all are likely to choose a vasectomy as a permanent, safe method of contraception.

As outlined in our previously published report, veterans are more likely than civilians to be sterilised.¹¹ However, this additional analysis did not identify any veteran-specific factors that explain why sterilisation rates are higher among veterans. The predictors of sterilisation—such as higher income—were similar to those reported in studies of vasectomy rates among the general male population.^3,4,14 Unlike in the civilian population, however, many male veterans are eligible for healthcare coverage through the VHA. Thus, the cost of receiving a vasectomy should not be a barrier for lower-income veterans. Our qualitative data, however, point to a perception that vasectomy services are difficult to access through VHA, with some men reporting that they did not know this benefit was available. This lack of awareness may partly explain why we did not observe significant differences in vasectomy rates between veterans enrolled in VHA and those not enrolled.

Strong peer networks formed during service may also explain higher rates; conversations with fellow veterans can normalise vasectomy. Broader cultural narratives of masculinity may further shape these decisions. Gendered expectations of manhood have been proposed as one reason lower-income men are less likely to pursue sterilisation than higher-income men.¹⁵ These narratives suggest that some men view sterilisation as a threat to masculinity, associating virility and continued fertility with proof of manhood. This framework may also shed light on the higher vasectomy rates among veterans as compared to civilians: having already affirmed their masculinity through military service, some may feel less pressure to demonstrate it through continued fertility—particularly if they already have children.

Although this is the first investigation into factors associated with vasectomy among male veterans, the study was not specifically designed to explore men’s decision-making processes. Other factors likely influence vasectomy rates, including the number and ages of children, and attitudes towards future childbearing. We also attempted to examine whether concerns about contraceptive side effects affected vasectomy decisions, but most responses focused on female forms of contraception. Different patterns might have emerged had we asked specifically about attitudes towards condoms and vasectomy. Questions about masculinity, gender identity and mental health concerns may help clarify how these constructs shape decisions about male sterilisation. The small number of veterans who received a vasectomy in our interview sample limited our ability to fully understand their decision-making patterns. Future research should more directly examine how service-related exposures and trauma experienced during service affect contraceptive use.

Conclusions

Few nationally representative studies have examined how sociodemographic and healthcare factors influence male vasectomy rates,^3,4,6 and none has focused on veterans. Our findings suggest that vasectomy is an acceptable contraceptive option for males who have completed their families. Men who discuss contraception with peers and can effectively navigate the healthcare system may be more likely to obtain a vasectomy than those without such support or knowledge. Some veterans faced barriers in receiving a vasectomy at the VHA, suggesting an increased need for VHA providers to more actively engage male veterans about their contraceptive options, including the process for getting a vasectomy. These discussions may improve men’s contraceptive awareness and help them make informed decisions consistent with their family goals. Policies requiring waiting periods or parenthood before the procedure should be reconsidered, as they present barriers to care.