Being Smart About Condoms

For some, Valentine's Day is an important reminder to romance your loved one. But February 14, which is also National Condom Day, should also serve as reminder of the importance of protecting yourself and your partner from sexually transmitted disease (STD).

According to the American Social Health Organization, there are an estimated 15.3 million cases of STDs diagnosed every year in the United States. And many of these men and women don't know that they have an STD. As a result, people- especially those in committed relationships- tend to underestimate their risk of transmitting or acquiring an STD and are often lax about condom use. By developing a sense of "negotiated safety," couples often come to the unfounded conclusion that they are not putting each other at risk for an STD.

Other couples avoid discussing condom use until they're just about to have sex-and are less likely to make a reasonable decision. And still others use condoms incorrectly, sometimes making sex less enjoyable and the condom less effective.

Below, Richard Crosby, PhD, of the College of Public Health at the University of Kentucky in Lexington, discusses common barriers to condom use and why couples need to make decisions about condom use together.

Are more people using condoms today than they were 10 years ago? There have been some increases and some general trends towards stability, with very little evidence of decline. We have some evidence that condom use among adolescents increased substantially in the 1990s and is now relatively stable. But among young gay men evidence suggests the possibility of decreases in condom use. These are men who have always known AIDS, and who, in a sense, may have accepted AIDS as a normal part of gay life. And it's these men who we're particularly worried about in public health.

What are the main factors that influence use? I think the answer is really a function of whom we're talking about. The factors that influence use for adolescents are going to be quite different than those that influence use for adults. Among adolescents, factors like peer norms are important. For example, adolescents who have friends who use condoms are more likely to use condoms themselves. And there's also evidence suggesting that once pregnancy concerns are addressed with oral contraception, for example, condoms may no longer be used.

In adults, a lot of factors have been studied, and probably one of the most commonly reported findings is adults in steady relationships are far less likely to use condoms than those who are having sex within non-steady relationships.

Why are committed couples less likely to use condoms?

Trust may be part of it. Some couples will eventually get to a point where there is some mutual testing for HIV or STDs. But couples may be more likely to develop a sense of negotiated safety, where they may make some agreement not to have sex with others and they may in a sense make some unfounded judgments about the other person's risk of transmitting an STD or HIV. There's also some evidence that at some point people in a steady relationship subsequently decide to abandon condom use altogether. Although the evidence is not definitive, their thinking may be: "If we were going to have a problem as a result of having unprotected sex, that problem would have occurred by now." That's an unfounded judgment as well.

Is forgoing condom use actually discussed? We have evidence showing that some of that negotiated safety is something that partners discuss and the decision is a mutually agreed-upon decision by the couple. In other cases, though, the decision may be unilateral. It may be a decision that is made by a female or a male partner. In many cases, the evidence suggests that male partners make this decision more often than female partners. This form of unilateral decision-making is clearly problematic if the male partner is unconcerned about transmitting HIV, STDs or causing a pregnancy.

Why don't people like using condoms? Lack of pleasure and irritation caused by condoms are very common. But because people often have very little instruction on the correct use of condoms at all, they wind up experiencing problems related to fit, irritation, and dryness. I want to add that the correct use of condoms and lubrication for condoms can dramatically diminish those pleasure barriers.

Lack of arousal, sensation, and enjoyment in the female partner are some reasons why people don't use condoms during sex

In many cases, men report losing erections prematurely as a consequence of this feeling that "I am not experiencing the sensation of sex," because the condom has become dry. That may also cause lack of arousal, sensation, and enjoyment in the female partner. I think it's important to always purchase lubricated condoms. But for many couples, the amount of lubrication that is provided with condoms when they're sold in a package is not enough, and they may need to add lubrication at some point during sexual intercourse.

Dry condoms can lead to increased friction, which may facilitate the process of the latex breaking down and the condom breaking. Dry condoms can also potentially cause slippage of the condom (perhaps to the point of falling off) during intercourse. Importantly, couples also need to know that only water-based lubricants can be used on condoms because oil-based lubricants will deteriorate latex and grossly compromise any protective value of the condom.

Access is also an issue that deserves some attention. There are some studies suggesting that although cost may not be a primary issue relative to using condoms, general access may be. For example, it may be that people simply are not prepared for sex in terms of having a condom available. And obtaining a condom after the sexual interlude has begun may be something that just doesn't happen.

Do you think most people underestimate their risk of STDs and HIV? There are some studies that show it's not unusual at all for people to underestimate their risk of acquiring an STD or HIV. There is something that has been termed optimism bias, which suggests that people inherently feel that they are somehow protected against maladies as compared to their peers who are like them and who may practice the same forms of risky sex. It's important for couples to realize that regardless of perceptions that one another may be healthy, the vast majority of sexually transmitted infections are asymptomatic, meaning that symptoms, if they're present at all, may not be noticeable to the person. It's not like having a cold. And in many cases, the symptoms may not even be noticeable clinically.

Is it known if people are getting tested for STDs and HIV? The Centers for Disease Control and Prevention estimates that approximately one-third of United States residents currently infected by HIV are unaware of their status, so the lack of HIV testing is an important public health concern. Unlike HIV, however, testing for STDs has not been a "stand alone" health behavior. Instead, people are often tested for STDs only when they experience an otherwise unexplained symptom. An exception of great importance is that testing for HIV and STDs in the first trimester of pregnancy has become a common practice in the United States.

What are some common mistakes people make when they use condoms? One of the most common mistakes that couples make when it comes to using condoms is they fail to use the condom from start to finish of penetrative sex. There's a perception that it's only the moment of ejaculation that creates risk, so what couples will do is use the condom only long enough to catch, if you will, the ejaculation. But before and after ejaculation occurs, there is potential for infectivity.

Other examples would be using condoms that are not stored properly or that for any reason have been damaged. Couples who use condoms correctly should store the condoms in a cool, dry place. They should make sure the condom is not damaged in any way, whether that's a puncture hole through the package or even opening the package incorrectly. Teeth, sharp fingernails, scissors and other objects should never come near a condom.

I again want to provide a caveat here that I think is critical, and that is the most common error of all errors is not using a condom at all.

When do you think couples should talk about condom use? It's critical for couples to have that discussion before they become sexually aroused. When couples have already entered a stage of foreplay, it's much more difficult for most people to really slow down and talk about something as seemingly mundane as the prevention of disease.

This discussion about disease is, in fact, antithetical to the whole scenario of love, romance, trust, intimacy. And so certainly, having the discussion during the sexual interlude or preceding the sexual interlude is highly problematic.

Do you have any advice about how people can best broach the subject? Unfortunately, we really have very little research to suggest that one approach is better than another. I can only suggest that couples entering the conversation in the spirit of mutual decision-making are going to be way ahead compared to couples where one person is making the sexual decisions.