Of the almost 350 thousand surgical sterilization procedures performed in Colombia during the 5-year period 2017–2021, approximately 80% were performed on women. According to historical records, the F/M surgical sterilization ratio in Colombia has been improving over time (21), from 18 in 1989 and 10 in 1995 to the current 4.1. There is still more to be done to improve this gender gap. This is particularly true for men affiliated with the Subsidized regime, which can be used as a proxy for both education and socioeconomic status, and particularly for men in the Caribbean region. To understand the stronger reticence to the procedure in this coastal region of the country, it is necessary to consider important cultural differences (26).
Research conducted by Professor Yusmidia Solano (27), a native of the Caribbean region and an expert in gender issues, suggests that women in this region play a dominant role in all domestic decisions in a behavioural pattern defined as “matrona” (or “matriarch”), while men are often marginalized from participating in household activities, including the responsibilities of child rearing. This societal structure is influenced by the prevailing 'machismo' culture, which incentivizes men to maintain multiple relationships with women as long as they possess the economic means to support a substantial number of offspring. According to biographical sketches in “Vallenato” music websites, famous regional idols Alejo Durán (1919–1989) or Diomedes Díaz (1957–2013) prided themselves of having 25 and 28 children, respectively.
The last National Demographic and Health Survey, performed by Profamilia in 2015, showed other significant differences in sexual and reproductive health between the Caribbean region and the rest of Colombia. These included the lowest frequency of exclusive breastfeeding, the highest percentage of women who have never had a vaginal cytology or the lowest acceptance of same-sex couples' rights, both among men and women (18).
Another peculiar but culturally acceptable sexual behavior that has its highest prevalence in Sucre and Córdoba (the two departments of the Caribbean region with the highest F/M surgical sterilization ratio in Colombia) is the practice of having sex with female donkeys, particularly as an initiation to sexual activities during puberty and adolescence. This paraphilic behaviour is sometimes maintained during adulthood. According to research by the renowned sociologist Orlando Fals (29), in many rural areas of the region there is the strong belief that this practice leads to an increase in the size of the penis. In his masterpiece One Hundred Years of Solitude, Nobel Prize laureate Gabriel García Márquez, a Colombian from the Caribbean region, alludes to the theme of zoophilia with female donkeys, while one of the most famous local poets wrote a poem with the title “Te quiero burrita” (I love you my little donkey) (30). Interestingly, these two departments, Sucre and Córdoba, also have the highest penis cancer prevalence (31), of which sex with animals has been determined to be a risk factor (32).
From an economic perspective, vasectomy should be the dominant alternative when permanent interventions to prevent unwanted pregnancies are considered. Jokinen et al., in Finland, followed 16,272 women who had been surgically sterilized between 2005 and 2014. The occurrence of spontaneous pregnancies was 1.97 and 2.65 per 1000 follow-up years depending on the surgical technique employed, equivalent to a 99.7–99.8% effectiveness (23). On the other hand, in a publication dating back to 1984, Philp et al. followed 16,976 men operated between 1970 and 1983 and described failure to achieve sterility in 72 of them (0.42%). Success was defined as two consecutive azoospermic analyses at least 4 months after vasectomy; they describe an important variation between surgeons (24). It is safe to conclude that the overall efficacy of both interventions is similar.
From a safety point of view, and considering the practicality of the intervention, vasectomy can be performed with local rather than general anaesthesia, can be performed in an ambulatory setting, has less serious complications, and requires less time off work (9, 25). According to a study published in 2014, in the US, tubal ligation would cost three to four times more than vasectomy ($1776-$2664 vs $644-$713) (25); in Colombia, according to our results, the difference would not be that large (approximately 1.5 times) but would still be significant. For all these reasons, one could infer that male sterilization rates should be higher than in females. However, reality is different.
Three decades ago, the International Conference on Population and Development held in Cairo in 1994 concluded that “special efforts should be made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behaviour, including family planning” (33). Different approaches have been implemented to increase vasectomy acceptance, some of which could be easily implemented in Colombia. Economic incentives have proven useful, both for physicians (34) and for potential vasectomy recipients (35).
A country with a lot to teach could be New Zealand (36); for years, it has shown the highest vasectomy rates worldwide. To complement the mostly quantitative approach followed in this paper, future qualitative studies need to be performed to better understand the reasons behind the reluctance to accept vasectomy in Colombia, particularly in the Caribbean region. We hope these studies will help design multidisciplinary public health interventions to reduce this gender inequity (37).