Vasectomy incidence in the Military Health System after the reversal of Roe v. Wade

Vasectomy incidence in the Military Health System after the reversal of Roe v. 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Wade Benjamin Pierson, Amanda Banaag, Miranda Janvrin, Tracey Koehlmoos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3958871/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 May, 2024 Read the published version in International Journal of Impotence Research → Version 1 posted 10 You are reading this latest preprint version Abstract Dobbs v. Jackson Women’s Health Organization has already had profound impact on reproductive health care in the United States. Some studies have reported increased incidence of vasectomy after the Dobbs decision. The Military Health System (MHS) provides a unique opportunity to evaluate this relationship in a universally insured, geographically representative population. We conducted a retrospective cross-sectional study of vasectomies among all male beneficiaries in the MHS, ages 18 to 64, from 2018 to 2022. Analyses included descriptive statistics on patient demographics, rate change, time analysis, logistic regressions for the odds of a vasectomy after the Dobbs decision, and state-level analysis. Our analysis indicated a 19.7% increase in vasectomy utilization in 2022 compared to the average from 2018–2021. Analysis by state showed that the relative increase in vasectomy after the Dobbs decision was greater in a state immediately implementing a restriction on abortion access (Texas, 29.3%) compared to a state with no such restriction (Virginia, 10.6%). Our findings highlight the impact of the Dobbs decision on reproductive health care utilization outside of abortion. Health sciences/Health care Health sciences/Risk factors Reproductive Health Roe v. Wade Dobbs v. Jackson Women’s Health Organization Vasectomy Military Medicine Military Health System Figures Figure 1 Figure 2 Introduction The Supreme Court decision in Dobbs v. Jackson Women’s Health Organization (“Dobbs decision”) delivered on June 24, 2022, has already had a profound impact on the delivery of reproductive health care in the United States.( 1 ) The most visible of these has been the restriction on access to abortion and other reproductive health care services implemented by several states with the overturning of Roe v. Wade .( 2 ) There have also been several important downstream effects from this decision on health systems and the delivery of contraceptive services including the utilization of vasectomy procedures throughout the United States.( 3 ) Vasectomy is a safe, effective, reversible, relatively inexpensive contraceptive service that can be performed in an outpatient setting and requires minimal recovery time.( 4 , 5 ) It is associated with significantly less complications and recovery time than the female equivalent, tubal ligation.( 6 ) However, the prevalence of vasectomy has traditionally lagged that of tubal ligation.( 7 ) Historically, motivations for men to request vasectomy have included previous unwanted pregnancy, completed family size, or dislike of other contraceptive options.( 8 ) Other studies have shown vasectomy rates to be associated with multiple individual factors including knowledge of procedure, cultural and religious norms, insurance coverage status, and other socioeconomic indicators.( 9 , 10 ) In 2009, the reported prevalence of vasectomy in men aged 30–45 years was 11.4%.( 10 ) In 2002, the reported incidence of vasectomy in in the US was 10.2 per 1 000 men aged 25–49.( 11 ) During the early 21st century, studies have shown a decline in the rates of vasectomy in the United States.( 12 , 13 ) In the wake of the Dobbs decision, however, studies have shown up to a 29% increase in vasectomy rates throughout the United States.( 14 – 16 ) Larger increases have been seen in states with ‘trigger bans’ on abortion access as compared to those that did not immediately implement access restrictions to abortion services.( 14 ) Reasons for seeking vasectomy amongst those motivated by the Dobbs decision included the high success rate of the procedure, concern that vasectomy may be outlawed next, or as an act of solidarity with women.( 14 ) The Military Health System (MHS) provides health care to approximately 9.6 million beneficiaries comprising service members, retirees, and their families. The system is composed of 49 inpatient hospitals and medical centers and 465 ambulatory care clinics throughout the US and internationally as well as over 500 000 network providers. Analysis of the MHS allows for a unique opportunity to examine the effects of health policies in a universally insured, geographically representative population.( 17 ) Given the age and gender distribution in the military, the population provides a diverse sample of individuals of male reproductive capacity in which to study utilization of vasectomy services. Historically, the military has lagged the general population in vasectomy utilization, with an estimated incidence of 7.1 vasectomies per 1 000 male service members per year from 2000 to 2009 and 8.6 vasectomies per 1 000 male service members per year from 2000 to 2017.( 13 , 18 ) Additionally, with the dispersion of the MHS throughout the United States, the system provides additional opportunity to study vasectomy rates between states implementing more onerous restrictions on abortion access post Dobbs decision (i.e., Texas) as compared to those not implementing restrictions on abortion access (i.e., California). The objective of this study was to retrospectively assess the utilization of vasectomy within the MHS with evaluation of the impact of the Dobbs decision, and differences amongst states with differing levels of restriction on abortion access. Materials/Subjects and Methods Data Source and Study Population We retrospectively evaluated administrative health care claims data extracted from the MHS Data Repository (MDR). The MDR holds administrative and healthcare claims for all service members and retirees of the United States Army, Air Force, Navy, Marine Corps and Coast Guard and their dependents. It includes data on care provided directly through Military Treatment Facilities (MTFs) as well as private sector care through the Department of Defense’s TRICARE benefit. It does not include care delivered in a deployed setting, or through the Veterans Health Administration. Study Population Our study population included all male beneficiaries, ages 18 to 64, of the MHS during the time period of 2018 through 2022. We excluded service members (and their dependents) who were members of the National Guard or Military Reserves due to their inconsistent access to the MHS. Data Extraction We queried all encounter data for International Classification of Diseases 10 (ICD-10) codes Z30.2 and Z98.52 and Current Procedural Terminology (CPT) codes 55450 and 55250 to identify vasectomies performed within the MHS. For each unique individual identified, their first visit with one of these codes was counted as a vasectomy. Each unique individual could only be counted for one vasectomy during the study period. Data Analysis We conducted a descriptive analysis on patient demographics and time period for individuals receiving a vasectomy. Descriptive analysis included patient demographics (age, race/ethnicity, military service branch, and rank), the month and year of their first vasectomy visit, and the state in which the visit occurred. Rank has been utilized in a variety of military studies both as an indicator of socioeconomic status as well as educational attainment. We performed logistic regression analysis on the effect of these demographic covariates to determine if certain groups were more likely to receive a vasectomy after the Dobbs decision as compared to before the decision. We examined crude logistic regression models on each covariate, as well as a full logistic regression model adjusting for all covariates. We further evaluated numbers of individuals receiving a vasectomy in each month of each year under study to evaluate for general trends, and any potential deviation from these trends in 2022 following the release of the Dobbs decision in June of 2022. Additionally, we assessed the relative change in numbers of vasectomies in the months following the release of the Dobbs decision in 2022 as compared to those month’s average from 2018 through 2021 between a state immediately imposing restrictions on abortion access (Texas) and one that had no such immediate increase in abortion access restrictions (Virginia). All analyses were performed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). This study was considered exempt by the Institutional Review Board of the Uniformed Services University of the Health Sciences. Results A total of 96,617 men aged 18–64 received a vasectomy covered by the MHS from January 2018 to December 2022. The demographic breakdown of these men is presented in Table 1 . The groups in which the largest number of vasectomies were performed was in those aged 30–39 (53.97%), White (73.82%), active duty service members (78.24%), in the Army (36.58%), of senior enlisted rank (64.11%), and married (85.37%). We evaluated these demographics in a logistic regression model to determine factors associated with higher odds of receiving a vasectomy after the Dobbs decision (Table 2 ). The results of our adjusted logistic regression model show that the odds of receiving a vasectomy were the highest in MHS beneficiaries in ages 18–29 (aOR 1.11, 95% CI 1.07–1.15) as compared to the reference group of those aged 30–39, and in unmarried beneficiaries (aOR 1.06, 95% CI: 1.02–1.10). Dependent beneficiaries were more likely to receive a vasectomy (aOR 1.42, 95% CI: 1.27–1.58) as compared to active duty service members. Senior officers were the least likely of the formal military ranks to receive a vasectomy. No significant differences in odds of vasectomy by race were noted. Table 1 Men Ages 18–64 in the MHS with Vasectomies 2018–2022 (N = 96,617) N Percent of Total Age Group 20–29 21 152 21.89 30–39 52 142 53.97 40–49 17 226 17.83 50–59 4 512 4.67 60+ 1 585 1.64 Race White 71 327 73.82 Black 11 203 11.60 Asian/PI 3 179 3.29 AI/AN 1 045 1.08 Other 7 975 8.25 Missing 1 888 1.95 Beneficiary Category Active-Duty 75 589 78.24 Dependent 4 447 4.60 Retiree 16 581 17.16 Branch of Service Army 35 344 36.58 Coast Guard 4 175 4.32 Air Force 27 425 28.39 Other 5 08 0.53 Marine Corps 9 210 9.53 Navy 19 955 20.65 Rank Junior Enlisted 9 502 9.83 Senior Enlisted 61 943 64.11 Junior Officer 10 956 11.34 Senior Officer 9 060 9.38 Warrant Officer 3 051 3.16 Other 2 105 2.18 Marital Status Married 82 484 85.37 Unmarried 14 133 14.63 All 96 617 100.00 Table 2 Unadjusted and Adjusted Logistic Regression Results for the Odds of a Vasectomy After the Dobbs Decision Unadjusted Adjusted Effect OR 95% Confidence Limits p-Value OR 95% Confidence Limits p-Value Age Group 18 to 29 1.17 1.13 1.21 < .0001 1.11 1.07 1.15 < .0001 30 to 39 (ref) 1.00 1.00 1.00 1.00 1.00 1.00 40 to 49 0.96 0.93 0.99 0.0187 1.00 0.96 1.04 0.9519 50 to 59 0.91 0.85 0.97 0.003 0.97 0.90 1.05 0.4282 60 and older 0.94 0.88 1.01 0.1027 0.94 0.83 1.06 0.2757 Race White (ref) 1.00 1.00 1.00 1.00 1.00 1.00 Black 1.04 1 1.08 0.0866 1.04 1.00 1.09 0.0654 Asian/Pacific Islander 0.96 0.89 1.03 0.2692 0.97 0.90 1.05 0.4053 American Indian / Alaskan Native 1.04 0.91 1.18 0.5953 1.00 0.87 1.14 0.9631 Other 0.99 0.94 1.03 0.5293 1.01 0.96 1.06 0.6469 Beneficiary Status Active Duty (ref) 1.00 1.00 1.00 1.00 1.00 1.00 Dependent 0.96 0.91 1.02 0.2272 1.42 1.27 1.58 < .0001 Retiree 0.92 0.89 0.95 < .0001 0.94 0.90 0.98 0.0076 Rank Junior Enlisted 1.44 1.36 1.53 < .0001 1.33 1.24 1.43 < .0001 Senior Enlisted 1.19 1.13 1.24 < .0001 1.17 1.12 1.24 < .0001 Junior Officer 1.26 1.19 1.34 < .0001 1.28 1.20 1.36 < .0001 Senior Officer (ref) 1.00 1.00 1.00 1.00 1.00 1.00 Warrant Officer 1.28 1.18 1.39 < .0001 1.27 1.16 1.39 < .0001 Other 0.76 0.69 0.84 < .0001 0.49 0.41 0.57 < .0001 Marital Status Married (ref) 1.00 1.00 1.00 1.00 1.00 1.00 Unmarried 1.05 1.01 1.09 0.0204 1.06 1.02 1.10 0.0043 In the evaluation of the month during which men received vasectomies from January 2018 through December 2022 (Fig. 1 ) we observed fairly consistent levels between 1 500 and 2 000 vasectomies per month during our study. Overall, the year 2022 had the highest cumulative number of vasectomies performed among all calendar years (22 248) representing a 19.7% increase as compared to the average of 2018–2021. There was also a significant decrease in vasectomies performed in 2020, with only 14 642 men receiving a vasectomy. When discounting this significant decrease in 2020, we still observed an 11.8% increase in vasectomies in 2022 as compared to the average of 2018, 2019, and 2021. In the months following the Dobbs decision release, we observed a noticeable uptick in numbers of vasectomies performed, with a peak of 2 236 in August 2022. Time analysis of vasectomy incidence showed substantial increases in the incidence of vasectomy after the release of the Dobbs decision, with a relative increase from June through December 2022 of 22.1% as compared to the average of the same months from 2018 to 2021. Analysis by state (Fig. 2 ) showed that the relative increase in vasectomy after the Dobbs decision from June through December 2022 as compared to the average of the same period in 2018–2021 was greater in a state immediately implementing a restriction on abortion access (Texas, 29.3%) as compared to a state with no such restriction (Virginia, 10.6%). Discussion Our findings demonstrate the striking changes in the incidence of vasectomy following the Dobbs decision in the Military Health System. Not only did 2022 have the highest number of men receiving a vasectomy, but monthly analysis showed a significant increase in vasectomy incidence in the months following the Dobbs decision release in 2022. Additionally, there was a notable difference in vasectomy incidence in Texas, which implemented a trigger restriction on abortion access after the reversal of Roe v. Wade, compared to Virginia, which had no such immediate restriction on abortion access. Texas had a substantially larger increase in vasectomy incidence from June to December 2022 as compared to expected rates from previous years. Further, our study provided interesting insight into the demographics of men receiving a vasectomy within the MHS, with unmarried and younger men having higher odds of receiving a vasectomy. Our analysis also indicated that there was a precipitous decrease in vasectomy incidence in 2020, during the height of the COVID-19 pandemic. Increased incidence of vasectomy in the wake of the Dobbs decision has been noted in several other studies evaluating vasectomy incidence regional health centers and by insurance claims data.( 14 , 15 ) Our study shows that similar increases in vasectomy utilization were seen after the release of the Dobbs decision within the MHS as compared to the populations included in previous studies. Further study of the rate of incidence of vasectomy over the next several years could help to determine if this trend persists and vasectomy becomes a more mainstream and utilized form of contraceptive care. Another possibility is that the release of the Dobbs decision acted as a ‘call to action’ in the short-term leading those already considering a vasectomy to receive one, but that the effect may be short lived, leading to vasectomy incidence returning to normal levels over time. Our findings highlight the potential importance of state-by-state level abortion access restrictions on the utilization of vasectomy, which has notable implications for the MHS. The legalities around providing access to abortion care within the MHS are muddied due to the Hyde Amendment of 1976, which restricts the use of federal funds to be used for abortion care. Typically, for MHS beneficiaries, these services were utilized as needed on an out-of-pocket basis. In some circumstances, beneficiaries were eligible for reimbursement for travel for the procedures due to the care not being available in network.( 20 – 22 ) Our findings show that in our two comparator states (Texas and Virginia), the immediate implementation of abortion access restrictions was associated with higher rates of vasectomy utilization post Dobbs decision. This finding has been replicated in at least one other study; however no direct analysis on the effect of restrictions by differing gestational age, or other factors on the rate of vasectomy post Dobbs has been published to date.( 14 ) Our demographic analysis indicated that younger (< 30) and unmarried men had increased odds of utilizing vasectomy services post Dobbs decision as compared to pre-Dobbs. These findings suggest a significant shift in the demographics of vasectomy utilization, with previous studies typically showing older men at time of family completion were the most likely to utilize the service.( 10 ) Other more recent studies have demonstrated these trends towards increased utilization of vasectomy services by younger men after the Dobbs decision, with Bole and colleagues showing a significant decline in median age of vasectomy utilization, and larger proportions of unmarried and childless men receiving vasectomy post Dobbs.( 15 ) These findings suggest a shift in the landscape of perceptions and beliefs regarding vasectomy in younger generations, and further qualitative study of younger men receiving vasectomy to better characterize their attitudes regarding reproductive care could help provide greater insight into this trend. The impact of the COVID-19 pandemic on vasectomy utilization was an additional significant finding, with 2020 having the lowest number of vasectomies in our study. This finding continues to highlight the myriad impacts that the pandemic had on health care access and utilization, which may drive untold further healthcare needs in the future. Multiple studies have shown varying degrees of decreases in medical care access and utilization from cancer screenings to routine immunizations, and other reproductive services were all significantly impacted by the pandemic.( 23 – 25 ) Further work on the downstream effects of these impacts could help to develop campaigns to ‘catch up’ on the immense amount of delayed care. Our study had several key limitations. First, we were only able to capture vasectomies paid for (directly or indirectly) by the MHS, therefore any beneficiary receiving this service outside of the MHS would not be included. Additionally, we only utilized data back to 2018, which was primarily done to present data comparable to other studies that have been published on this issue.( 14 , 15 ) Further, as we only allowed for each individual to be counted for one vasectomy, it is possible that individuals received a vasectomy, had it reversed, and then received another vasectomy, in which case their second vasectomy would not be counted; however, we believe this to be rare, with only approximately 5% of men seeking an initial vasectomy reversal, and an even smaller proportion seeking re-vasectomy after a reversal.( 19 ) Our analysis supports the hypothesis that the Dobbs decision had an immediate effect on vasectomy utilization within the MHS. We assess that the reversal of Roe v. Wade was a significant driver of a sizable increase in vasectomy incidence within the MHS, specifically amongst younger and unmarried men. Additionally, state level restrictions on abortion access may have mediated this effect; with more stringent restrictions resulting in higher rates of vasectomy utilization. These findings demonstrate the robustness of changes in the landscape of vasectomy utilization in a universally insured, geographically representative population. The MHS must be cognizant of the profound effect that the Dobbs decision has had on the state of reproductive health care access in America. It must be agile in appropriately allocating reproductive care assets and resources to those areas greatest effected by the reversal of Roe v. Wade to best support the needs of service members and their families. Declarations Data Availability Statement: The data that support the findings of this study are available from the United States Defense Health Agency. Restrictions apply to the availability of these data, which were used under federal Data User Agreements for the current study, and so are not publicly available. Acknowledgements: The authors acknowledge critical advice from the Center for Health Services Research and faculty of the Uniformed Services University Department of Preventive Medicine and Biostatistics. Author Contribution Statement: Pierson – Conceived and designed work that led to submission, drafted and revised manuscript, approved final version of manuscript and is accountable for all aspects of the work. Banaag – Designed analysis plan, acquired and interpreted data, revised manuscript, approved final version and is accountable for all aspects of the work. Janvrin – Played an important role in interpreting results, revised manuscript, approved final version and is accountable for all aspects of the work. Koehlmoos – Conceived and designed work that lead to submission, revised manuscript, approved final version of manuscript and is accountable for all aspects of the work. Funding: This study was funded by the Department of Defense, Defense Health Agency: Grant #HU0001-20-20035 Ethical Approval: Due to the secondary analysis of existing, de-identified data, this study was deemed exempt from human subjects review by the Institutional Review Board of the Uniformed Services University of the Health Sciences. Permission and conditions for use of these data were granted by the United States Defense Health Agency. Competing Interests: The authors declare that we have no competing interests. Disclaimer The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The authors declare no conflict of interest. References Stein TB, Vasan A. Public Health’s Role in a Post-Dobbs World - The New York City Abortion Access Hub. N Engl J Med. 2023 May 25;388(21):1926–9. Kulczycki A. Dobbs: Navigating the New Quagmire and Its Impacts on Abortion and Reproductive Health Care. Health Educ Behav Off Publ Soc Public Health Educ. 2022 Dec;49(6):924–8. Paltrow LM, Harris LH, Marshall MF. Beyond Abortion: The Consequences of Overturning Roe. Am J Bioeth AJOB. 2022 Aug;22(8):3–15. Rogers MD, Kolettis PN. Vasectomy. Urol Clin North Am. 2013 Nov;40(4):559–68. Zeitler M, Rayala B. Outpatient Vasectomy: Safe, Reliable, and Cost-effective. Prim Care. 2021 Dec;48(4):613–25. Peterson HB. Sterilization. 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Cite Share Download PDF Status: Published Journal Publication published 18 May, 2024 Read the published version in International Journal of Impotence Research → Version 1 posted Editorial decision: revise 12 Mar, 2024 Review # 2 received at journal 04 Mar, 2024 Reviewer # 2 agreed at journal 04 Mar, 2024 Review # 1 received at journal 29 Feb, 2024 Reviewer # 1 agreed at journal 28 Feb, 2024 Reviewers invited by journal 24 Feb, 2024 Submission checks completed at journal 21 Feb, 2024 First submitted to journal 20 Feb, 2024 Unknown event 19 Feb, 2024 Editor assigned by journal 15 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3958871","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":274130611,"identity":"d2db58bb-3b8d-4145-b6ca-263c14e746df","order_by":0,"name":"Benjamin Pierson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBACAwiWAFKMDWARfiBmBrMOEKtFsoEILWgiBwhoMWfvPVDwM8cij0G6ufFxxR+bPOMb6c+kC/4wyPHdSMCqxbLnXIJh7zaJYgaZg82GZ9vSis1u5JhJz2xjMJbEocXgRo6BAe82icQGicQ2ycaGw4nbbuSwSfM2MCRuwKXl/hsDw78QLe0/G/4cTtw8A+gwnj8M9Ti13OAxMIbZwtjAdjhxg0SCmTQPG0OCAU6/5BgYywK1tAH9ItnYlpY448wbY2veNgnDmWce4AixM2aGb7fVJfZLtz/82PDHJrG/Pf3hbZ4/NvJ8x7HbAgRs4Lhhk0AVlcCmFAaYHxBWMwpGwSgYBSMaAABGwWEOn+4S3gAAAABJRU5ErkJggg==","orcid":"","institution":"Uniformed Services University of the Health Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Pierson","suffix":""},{"id":274130612,"identity":"ed7d621b-cd71-4971-b7de-4ba9bd4669c1","order_by":1,"name":"Amanda Banaag","email":"","orcid":"","institution":"Uniformed Services University of the Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Banaag","suffix":""},{"id":274130613,"identity":"ab78af40-8660-4ed8-9ec4-4deec93da104","order_by":2,"name":"Miranda Janvrin","email":"","orcid":"","institution":"Uniformed Services University of the Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Miranda","middleName":"","lastName":"Janvrin","suffix":""},{"id":274130614,"identity":"f76181a5-31cb-418a-80cb-6857012dcaf8","order_by":3,"name":"Tracey Koehlmoos","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tracey","middleName":"","lastName":"Koehlmoos","suffix":""}],"badges":[],"createdAt":"2024-02-15 14:12:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3958871/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3958871/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41443-024-00905-7","type":"published","date":"2024-05-18T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51767433,"identity":"d6cb65fc-4a90-4624-b7dd-4a208f404b7a","added_by":"auto","created_at":"2024-02-28 19:01:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":120777,"visible":true,"origin":"","legend":"\u003cp\u003eCaption: Number of men in the MHS receiving vasectomy, 2018-2022.\u003c/p\u003e\n\u003cp\u003eSource: Authors analysis of Military Data Repository Data\u003c/p\u003e","description":"","filename":"IJIRVasectomyFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3958871/v1/17e3c8292553a189e8b7ade2.jpg"},{"id":51767430,"identity":"73440cc0-6502-4192-bcae-e2936e574fb1","added_by":"auto","created_at":"2024-02-28 19:01:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":173873,"visible":true,"origin":"","legend":"\u003cp\u003eCaption: Number of men in the MHS receiving vasectomies in Texas and Virginia, 2018-2022.\u003c/p\u003e\n\u003cp\u003eSource: Authors analysis of Military Data Repository Data\u003c/p\u003e","description":"","filename":"IJIRVasectomyFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3958871/v1/2eaaa021bdb53039b66cef81.jpg"},{"id":56723903,"identity":"e9e67cfb-4e6c-4816-8dff-a6fbadf69c00","added_by":"auto","created_at":"2024-05-19 07:06:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":882448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3958871/v1/3736b987-f777-478e-bd1b-9331e388c158.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Vasectomy incidence in the Military Health System after the reversal of Roe v. Wade","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Supreme Court decision in \u003cem\u003eDobbs v. Jackson Women\u0026rsquo;s Health Organization\u003c/em\u003e (\u0026ldquo;Dobbs decision\u0026rdquo;) delivered on June 24, 2022, has already had a profound impact on the delivery of reproductive health care in the United States.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The most visible of these has been the restriction on access to abortion and other reproductive health care services implemented by several states with the overturning of \u003cem\u003eRoe v. Wade\u003c/em\u003e.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) There have also been several important downstream effects from this decision on health systems and the delivery of contraceptive services including the utilization of vasectomy procedures throughout the United States.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVasectomy is a safe, effective, reversible, relatively inexpensive contraceptive service that can be performed in an outpatient setting and requires minimal recovery time.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) It is associated with significantly less complications and recovery time than the female equivalent, tubal ligation.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) However, the prevalence of vasectomy has traditionally lagged that of tubal ligation.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Historically, motivations for men to request vasectomy have included previous unwanted pregnancy, completed family size, or dislike of other contraceptive options.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Other studies have shown vasectomy rates to be associated with multiple individual factors including knowledge of procedure, cultural and religious norms, insurance coverage status, and other socioeconomic indicators.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) In 2009, the reported prevalence of vasectomy in men aged 30\u0026ndash;45 years was 11.4%.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) In 2002, the reported incidence of vasectomy in in the US was 10.2 per 1 000 men aged 25\u0026ndash;49.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) During the early 21st century, studies have shown a decline in the rates of vasectomy in the United States.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn the wake of the Dobbs decision, however, studies have shown up to a 29% increase in vasectomy rates throughout the United States.(\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Larger increases have been seen in states with \u0026lsquo;trigger bans\u0026rsquo; on abortion access as compared to those that did not immediately implement access restrictions to abortion services.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Reasons for seeking vasectomy amongst those motivated by the Dobbs decision included the high success rate of the procedure, concern that vasectomy may be outlawed next, or as an act of solidarity with women.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe Military Health System (MHS) provides health care to approximately 9.6\u0026nbsp;million beneficiaries comprising service members, retirees, and their families. The system is composed of 49 inpatient hospitals and medical centers and 465 ambulatory care clinics throughout the US and internationally as well as over 500 000 network providers. Analysis of the MHS allows for a unique opportunity to examine the effects of health policies in a universally insured, geographically representative population.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Given the age and gender distribution in the military, the population provides a diverse sample of individuals of male reproductive capacity in which to study utilization of vasectomy services. Historically, the military has lagged the general population in vasectomy utilization, with an estimated incidence of 7.1 vasectomies per 1 000 male service members per year from 2000 to 2009 and 8.6 vasectomies per 1 000 male service members per year from 2000 to 2017.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Additionally, with the dispersion of the MHS throughout the United States, the system provides additional opportunity to study vasectomy rates between states implementing more onerous restrictions on abortion access post Dobbs decision (i.e., Texas) as compared to those not implementing restrictions on abortion access (i.e., California). The objective of this study was to retrospectively assess the utilization of vasectomy within the MHS with evaluation of the impact of the Dobbs decision, and differences amongst states with differing levels of restriction on abortion access.\u003c/p\u003e"},{"header":"Materials/Subjects and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source and Study Population\u003c/h2\u003e \u003cp\u003eWe retrospectively evaluated administrative health care claims data extracted from the MHS Data Repository (MDR). The MDR holds administrative and healthcare claims for all service members and retirees of the United States Army, Air Force, Navy, Marine Corps and Coast Guard and their dependents. It includes data on care provided directly through Military Treatment Facilities (MTFs) as well as private sector care through the Department of Defense\u0026rsquo;s TRICARE benefit. It does not include care delivered in a deployed setting, or through the Veterans Health Administration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eOur study population included all male beneficiaries, ages 18 to 64, of the MHS during the time period of 2018 through 2022. We excluded service members (and their dependents) who were members of the National Guard or Military Reserves due to their inconsistent access to the MHS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction\u003c/h2\u003e \u003cp\u003eWe queried all encounter data for International Classification of Diseases 10 (ICD-10) codes Z30.2 and Z98.52 and Current Procedural Terminology (CPT) codes 55450 and 55250 to identify vasectomies performed within the MHS. For each unique individual identified, their first visit with one of these codes was counted as a vasectomy. Each unique individual could only be counted for one vasectomy during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe conducted a descriptive analysis on patient demographics and time period for individuals receiving a vasectomy. Descriptive analysis included patient demographics (age, race/ethnicity, military service branch, and rank), the month and year of their first vasectomy visit, and the state in which the visit occurred. Rank has been utilized in a variety of military studies both as an indicator of socioeconomic status as well as educational attainment. We performed logistic regression analysis on the effect of these demographic covariates to determine if certain groups were more likely to receive a vasectomy after the Dobbs decision as compared to before the decision. We examined crude logistic regression models on each covariate, as well as a full logistic regression model adjusting for all covariates. We further evaluated numbers of individuals receiving a vasectomy in each month of each year under study to evaluate for general trends, and any potential deviation from these trends in 2022 following the release of the Dobbs decision in June of 2022. Additionally, we assessed the relative change in numbers of vasectomies in the months following the release of the Dobbs decision in 2022 as compared to those month\u0026rsquo;s average from 2018 through 2021 between a state immediately imposing restrictions on abortion access (Texas) and one that had no such immediate increase in abortion access restrictions (Virginia). All analyses were performed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). This study was considered exempt by the Institutional Review Board of the Uniformed Services University of the Health Sciences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 96,617 men aged 18\u0026ndash;64 received a vasectomy covered by the MHS from January 2018 to December 2022. The demographic breakdown of these men is presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The groups in which the largest number of vasectomies were performed was in those aged 30\u0026ndash;39 (53.97%), White (73.82%), active duty service members (78.24%), in the Army (36.58%), of senior enlisted rank (64.11%), and married (85.37%). We evaluated these demographics in a logistic regression model to determine factors associated with higher odds of receiving a vasectomy after the Dobbs decision (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The results of our adjusted logistic regression model show that the odds of receiving a vasectomy were the highest in MHS beneficiaries in ages 18\u0026ndash;29 (aOR 1.11, 95% CI 1.07\u0026ndash;1.15) as compared to the reference group of those aged 30\u0026ndash;39, and in unmarried beneficiaries (aOR 1.06, 95% CI: 1.02\u0026ndash;1.10). Dependent beneficiaries were more likely to receive a vasectomy (aOR 1.42, 95% CI: 1.27\u0026ndash;1.58) as compared to active duty service members. Senior officers were the least likely of the formal military ranks to receive a vasectomy. No significant differences in odds of vasectomy by race were noted.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMen Ages 18\u0026ndash;64 in the MHS with Vasectomies 2018\u0026ndash;2022 (N\u0026thinsp;=\u0026thinsp;96,617)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePercent of Total\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge Group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 152\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.89\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 142\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53.97\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 226\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17.83\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 512\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.67\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 585\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.64\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71 327\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e73.82\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlack\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 203\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.60\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsian/PI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 179\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAI/AN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 045\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.08\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 975\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMissing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 888\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.95\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBeneficiary Category\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eActive-Duty\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75 589\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e78.24\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDependent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 447\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.60\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRetiree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 581\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17.16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBranch of Service\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArmy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 344\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36.58\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCoast Guard\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 175\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.32\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAir Force\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 425\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarine Corps\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 210\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNavy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 955\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.65\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRank\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJunior Enlisted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 502\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.83\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSenior Enlisted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61 943\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64.11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJunior Officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 956\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.34\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSenior Officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 060\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWarrant Officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 051\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 105\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82 484\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e85.37\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnmarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 133\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96 617\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUnadjusted and Adjusted Logistic Regression Results for the Odds of a Vasectomy After the Dobbs Decision\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eUnadjusted\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eAdjusted\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e95% Confidence Limits\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-Value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e95% Confidence Limits\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-Value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge Group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 to 29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 to 39 (ref)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40 to 49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0187\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9519\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50 to 59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4282\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60 and older\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.1027\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.2757\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite (ref)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlack\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0866\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0654\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsian/Pacific Islander\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.2692\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4053\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAmerican Indian / Alaskan Native\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5953\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9631\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5293\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6469\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBeneficiary Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eActive Duty (ref)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDependent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.2272\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRetiree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0076\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRank\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJunior Enlisted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSenior Enlisted\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJunior Officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSenior Officer (ref)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWarrant Officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried (ref)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnmarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0204\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0043\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the evaluation of the month during which men received vasectomies from January 2018 through December 2022 (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) we observed fairly consistent levels between 1 500 and 2 000 vasectomies per month during our study. Overall, the year 2022 had the highest cumulative number of vasectomies performed among all calendar years (22 248) representing a 19.7% increase as compared to the average of 2018\u0026ndash;2021. There was also a significant decrease in vasectomies performed in 2020, with only 14 642 men receiving a vasectomy. When discounting this significant decrease in 2020, we still observed an 11.8% increase in vasectomies in 2022 as compared to the average of 2018, 2019, and 2021. In the months following the Dobbs decision release, we observed a noticeable uptick in numbers of vasectomies performed, with a peak of 2 236 in August 2022. Time analysis of vasectomy incidence showed substantial increases in the incidence of vasectomy after the release of the Dobbs decision, with a relative increase from June through December 2022 of 22.1% as compared to the average of the same months from 2018 to 2021. Analysis by state (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) showed that the relative increase in vasectomy after the Dobbs decision from June through December 2022 as compared to the average of the same period in 2018\u0026ndash;2021 was greater in a state immediately implementing a restriction on abortion access (Texas, 29.3%) as compared to a state with no such restriction (Virginia, 10.6%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings demonstrate the striking changes in the incidence of vasectomy following the Dobbs decision in the Military Health System. Not only did 2022 have the highest number of men receiving a vasectomy, but monthly analysis showed a significant increase in vasectomy incidence in the months following the Dobbs decision release in 2022. Additionally, there was a notable difference in vasectomy incidence in Texas, which implemented a trigger restriction on abortion access after the reversal of Roe v. Wade, compared to Virginia, which had no such immediate restriction on abortion access. Texas had a substantially larger increase in vasectomy incidence from June to December 2022 as compared to expected rates from previous years. Further, our study provided interesting insight into the demographics of men receiving a vasectomy within the MHS, with unmarried and younger men having higher odds of receiving a vasectomy. Our analysis also indicated that there was a precipitous decrease in vasectomy incidence in 2020, during the height of the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eIncreased incidence of vasectomy in the wake of the Dobbs decision has been noted in several other studies evaluating vasectomy incidence regional health centers and by insurance claims data.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Our study shows that similar increases in vasectomy utilization were seen after the release of the Dobbs decision within the MHS as compared to the populations included in previous studies. Further study of the rate of incidence of vasectomy over the next several years could help to determine if this trend persists and vasectomy becomes a more mainstream and utilized form of contraceptive care. Another possibility is that the release of the Dobbs decision acted as a \u0026lsquo;call to action\u0026rsquo; in the short-term leading those already considering a vasectomy to receive one, but that the effect may be short lived, leading to vasectomy incidence returning to normal levels over time.\u003c/p\u003e \u003cp\u003eOur findings highlight the potential importance of state-by-state level abortion access restrictions on the utilization of vasectomy, which has notable implications for the MHS. The legalities around providing access to abortion care within the MHS are muddied due to the Hyde Amendment of 1976, which restricts the use of federal funds to be used for abortion care. Typically, for MHS beneficiaries, these services were utilized as needed on an out-of-pocket basis. In some circumstances, beneficiaries were eligible for reimbursement for travel for the procedures due to the care not being available in network.(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Our findings show that in our two comparator states (Texas and Virginia), the immediate implementation of abortion access restrictions was associated with higher rates of vasectomy utilization post Dobbs decision. This finding has been replicated in at least one other study; however no direct analysis on the effect of restrictions by differing gestational age, or other factors on the rate of vasectomy post Dobbs has been published to date.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur demographic analysis indicated that younger (\u0026lt;\u0026thinsp;30) and unmarried men had increased odds of utilizing vasectomy services post Dobbs decision as compared to pre-Dobbs. These findings suggest a significant shift in the demographics of vasectomy utilization, with previous studies typically showing older men at time of family completion were the most likely to utilize the service.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Other more recent studies have demonstrated these trends towards increased utilization of vasectomy services by younger men after the Dobbs decision, with Bole and colleagues showing a significant decline in median age of vasectomy utilization, and larger proportions of unmarried and childless men receiving vasectomy post Dobbs.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) These findings suggest a shift in the landscape of perceptions and beliefs regarding vasectomy in younger generations, and further qualitative study of younger men receiving vasectomy to better characterize their attitudes regarding reproductive care could help provide greater insight into this trend.\u003c/p\u003e \u003cp\u003eThe impact of the COVID-19 pandemic on vasectomy utilization was an additional significant finding, with 2020 having the lowest number of vasectomies in our study. This finding continues to highlight the myriad impacts that the pandemic had on health care access and utilization, which may drive untold further healthcare needs in the future. Multiple studies have shown varying degrees of decreases in medical care access and utilization from cancer screenings to routine immunizations, and other reproductive services were all significantly impacted by the pandemic.(\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Further work on the downstream effects of these impacts could help to develop campaigns to \u0026lsquo;catch up\u0026rsquo; on the immense amount of delayed care.\u003c/p\u003e \u003cp\u003eOur study had several key limitations. First, we were only able to capture vasectomies paid for (directly or indirectly) by the MHS, therefore any beneficiary receiving this service outside of the MHS would not be included. Additionally, we only utilized data back to 2018, which was primarily done to present data comparable to other studies that have been published on this issue.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Further, as we only allowed for each individual to be counted for one vasectomy, it is possible that individuals received a vasectomy, had it reversed, and then received another vasectomy, in which case their second vasectomy would not be counted; however, we believe this to be rare, with only approximately 5% of men seeking an initial vasectomy reversal, and an even smaller proportion seeking re-vasectomy after a reversal.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur analysis supports the hypothesis that the Dobbs decision had an immediate effect on vasectomy utilization within the MHS. We assess that the reversal of \u003cem\u003eRoe v. Wade\u003c/em\u003e was a significant driver of a sizable increase in vasectomy incidence within the MHS, specifically amongst younger and unmarried men. Additionally, state level restrictions on abortion access may have mediated this effect; with more stringent restrictions resulting in higher rates of vasectomy utilization. These findings demonstrate the robustness of changes in the landscape of vasectomy utilization in a universally insured, geographically representative population. The MHS must be cognizant of the profound effect that the Dobbs decision has had on the state of reproductive health care access in America. It must be agile in appropriately allocating reproductive care assets and resources to those areas greatest effected by the reversal of Roe v. Wade to best support the needs of service members and their families.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the United States Defense Health Agency. Restrictions apply to the availability of these data, which were used under federal Data User Agreements for the current study, and so are not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge critical advice from the Center for Health Services Research and faculty of the Uniformed Services University Department of Preventive Medicine and Biostatistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePierson \u0026ndash; Conceived and designed work that led to submission, drafted and revised manuscript, approved final version of manuscript and is accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eBanaag \u0026ndash; Designed analysis plan, acquired and interpreted data, revised manuscript, approved final version and is accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eJanvrin \u0026ndash; Played an important role in interpreting results, revised manuscript, approved final version and is accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eKoehlmoos \u0026ndash; Conceived and designed work that lead to submission, revised manuscript, approved final version of manuscript and is accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Department of Defense, Defense Health Agency: Grant #HU0001-20-20035\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the secondary analysis of existing, de-identified data, this study was deemed exempt from human subjects review by the Institutional Review Board of the Uniformed Services University of the Health Sciences. Permission and conditions for use of these data were granted by the United States Defense Health Agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that we have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStein TB, Vasan A. Public Health\u0026rsquo;s Role in a Post-Dobbs World - The New York City Abortion Access Hub. N Engl J Med. 2023 May 25;388(21):1926\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKulczycki A. Dobbs: Navigating the New Quagmire and Its Impacts on Abortion and Reproductive Health Care. Health Educ Behav Off Publ Soc Public Health Educ. 2022 Dec;49(6):924\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePaltrow LM, Harris LH, Marshall MF. Beyond Abortion: The Consequences of Overturning Roe. Am J Bioeth AJOB. 2022 Aug;22(8):3\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eRogers MD, Kolettis PN. Vasectomy. Urol Clin North Am. 2013 Nov;40(4):559\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eZeitler M, Rayala B. Outpatient Vasectomy: Safe, Reliable, and Cost-effective. Prim Care. 2021 Dec;48(4):613\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003ePeterson HB. Sterilization. Obstet Gynecol. 2008 Jan;111(1):189\u0026ndash;203. \u003c/li\u003e\n\u003cli\u003eACOG Practice Bulletin No. 208: Benefits and Risks of Sterilization. Obstet Gynecol. 2019 Mar;133(3):e194\u0026ndash;207. \u003c/li\u003e\n\u003cli\u003eHoward G. Motivation for vasectomy. Lancet Lond Engl. 1978 Mar 11;1(8063):546\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDejene Wolde Y, Ali M, Gebremeskel F, Ukke GG, Gebreselassie R, Demelash M, et al. Knowledge, Attitude and Associated Factors Towards Vasectomy Among Married Men in Arba Minch Town, Southern Ethiopia, 2021; A Cross-Sectional Study. Open Access J Contracept. 2023;14:1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eEisenberg ML, Henderson JT, Amory JK, Smith JF, Walsh TJ. Racial differences in vasectomy utilization in the United States: data from the national survey of family growth. Urology. 2009 Nov;74(5):1020\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eBarone MA, Hutchinson PL, Johnson CH, Hsia J, Wheeler J. Vasectomy in the United States, 2002. J Urol. 2006;176(1):232\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003ePunjani N, Goldstein M. Vasectomy: is the apparent decline real or not? Nat Rev Urol. 2022 Feb 1;19(2):69\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eZhang X, Eisenberg ML. Vasectomy utilization in men aged 18\u0026ndash;45 declined between 2002 and 2017: Results from the United States National Survey for Family Growth data. Andrology. 2022;10(1):137\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eVasectomies rose by 29% in the three months after the end of Roe. Econ Lond. 2023; \u003c/li\u003e\n\u003cli\u003eBole R, Lundy SD, Pei E, Bajic P, Parekh N, Vij SC. Rising vasectomy volume following reversal of federal protections for abortion rights in the United States. Int J Impot Res [Internet]. 2023 Feb 14; Available from: https://doi.org/10.1038/s41443-023-00672-x\u003c/li\u003e\n\u003cli\u003eZhang TR, Able C, Ramasamy R, Kohn TP. United States vasectomy incidence rises after the reversal of Roe v. Wade in a national clinical and claims database. Fertil Steril. 2023 Jul 1;120(1):196\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eTanielian T, Farmer C. The US Military Health System: Promoting Readiness And Providing Health Care. Health Aff Proj Hope. 2019 Aug;38(8):1259\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eSantomauro M, Masterson J, Marguet C, Crain D. Demographics of Men Receiving Vasectomies in the US Military 2000-2009. Curr Urol. 2012 May;6(1):15\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eRamasamy R, Schlegel PN. Vasectomy and vasectomy reversal: An update. Indian J Urol IJU J Urol Soc India. 2011 Jan;27(1):92\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eRosoff JI. The Hyde Amendment and the future. 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JAMA. 2022 Jan 18;327(3):237\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eSteenland MW, Geiger CK, Chen L, Rokicki S, Gourevitch RA, Sinaiko AD, et al. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception. 2021 Dec 1;104(6):593\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-impotence-research","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijir","sideBox":"Learn more about [International Journal of Impotence Research](http://www.nature.com/ijir/)","snPcode":"41443","submissionUrl":"https://mts-ijir.nature.com/cgi-bin/main.plex","title":"International Journal of Impotence Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Reproductive Health, Roe v. Wade, Dobbs v. Jackson Women’s Health Organization, Vasectomy, Military Medicine, Military Health System","lastPublishedDoi":"10.21203/rs.3.rs-3958871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3958871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cem\u003eDobbs v. Jackson Women\u0026rsquo;s Health Organization\u003c/em\u003e has already had profound impact on reproductive health care in the United States. Some studies have reported increased incidence of vasectomy after the Dobbs decision. The Military Health System (MHS) provides a unique opportunity to evaluate this relationship in a universally insured, geographically representative population. We conducted a retrospective cross-sectional study of vasectomies among all male beneficiaries in the MHS, ages 18 to 64, from 2018 to 2022. Analyses included descriptive statistics on patient demographics, rate change, time analysis, logistic regressions for the odds of a vasectomy after the Dobbs decision, and state-level analysis. Our analysis indicated a 19.7% increase in vasectomy utilization in 2022 compared to the average from 2018\u0026ndash;2021. Analysis by state showed that the relative increase in vasectomy after the Dobbs decision was greater in a state immediately implementing a restriction on abortion access (Texas, 29.3%) compared to a state with no such restriction (Virginia, 10.6%). Our findings highlight the impact of the Dobbs decision on reproductive health care utilization outside of abortion.\u003c/p\u003e","manuscriptTitle":"Vasectomy incidence in the Military Health System after the reversal of Roe v. 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