In recent years, condoms have come a long way. Today's condoms are largely reliable and effective, a powerful means to prevent pregnancy and disease if they are used regularly and correctly. The problem with condoms is not their effectiveness. Condoms are not being used as much as they need to be because of negative perceptions about condoms by users and potential users, by cultural and community leaders, by health-care providers and by policy-makers.
People do not like or trust condoms for a host of reasons. Many do not perceive that they are at risk of sexually transmitted diseases. Others say condoms interrupt spontaneous sexual encounters or reduce desired sensation -- it's like wearing your raincoat in the shower. Condoms can cause men to lose their erection, or they can suggest that you don't love or trust your partner. For some, condoms are difficult to get or to use, or they have an offensive odor. And, some believe condoms are not reliable because they break and slip off. Some of these perceptions have more merit than others. Communication between partners about these issues occurs infrequently, contributing to non-use and allowing higher rates of STDs.
Cultural norms that define sexual behavior often preclude communication between women and men about the desire and need to use protection, even when one partner is HIV-positive. A lack of action on the part of couples may reflect the views of those dominant in societies, often men, so that condom use is not yet even a legitimate part of sexual discourse. Those same social and cultural reservations in turn affect local and national policies, inhibiting access to condoms through public policy, unfavorable pricing, poor distribution, cautious information campaigns, and other barriers to making condoms readily accessible and desirable to use.
This monograph has shown the many reasons why policy-makers, program managers and users should have confidence in condoms today, if they are used consistently and correctly.
Research Priorities
Given that most modern condoms are of high quality and can offer very reliable protection, it is disheartening that only about 5 percent of married women of reproductive age worldwide report using condoms as their current method of contraception, and only 3 percent of those in developing countries. In several countries where men have been surveyed about condom use, they report considerably higher ever-use and current-use rates than women do. This may be explained in part by the fact that men use more condoms exclusively for STD prevention or with extramarital partners, or it may indicate men are over-reporting and women under-reporting condom use. Nevertheless, while it is very difficult to make accurate estimates of the overall number of people using condoms, there are undoubtedly millions leaving themselves at high risk of contracting a deadly disease, as rising HIV and STD incidences confirm.
Two priority areas for future research emerge from the data reviewed in this monograph: research to improve product attributes, and research to improve our understanding of acceptability and use. These are complementary domains, both of which will require the support and cooperation of public and private sector partners. Also, past and future research will achieve the greatest health impact if the results are shared with decision makers and condom users.
As this monograph has described, various physical attributes of condoms can influence how well the condoms function and how acceptable they are to users. Research and manufacturing advances in the product attributes themselves may increase satisfaction with condoms and overall use. Even more important is to learn much more about the complex aspects of sexual behavior that affect couples' motivation to use or reject condoms.
The quality of modern condoms is generally good. However, there are still some unresolved design, manufacturing and testing issues that, if fully understood, could lead to improved condom performance in use and greater acceptability to users. The priorities for research to improve product attributes are based on the recommendations of a 1996 expert meeting on latex condoms, convened by FHI at USAID's request, and on the findings presented in this monograph.
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| Even more important is to learn much more about the complex aspects of sexual behavior that affect couples' motivation to use or reject condoms. |
Product attributes play a minor role in condom acceptance compared to strategies that influence individuals' perception of the importance of using condoms and cultural norms which support their use. Donors, national programs, non-governmental organizations and others carry the burden of protecting public health by providing, promoting and evaluating condoms.
Over the years a good deal has been learned from AIDS prevention campaigns about what works and what does not. The scare campaigns of the 1980s equating sex with disease and death were resoundingly unsuccessful. More recent research has demonstrated that sustained condom use is more likely if mass media and individual counseling focus on individual risk, taking positive responsibility for healthy sexuality and offering practical help to build condom use skills. Education and counseling efforts also have to be sustained over time. And, condoms are useful only if they are affordable, accessible and socially acceptable. The challenge in sustaining condom use leaves no room for complacency in public sector programs in particular and calls for more research to elucidate the details of human sexual interactions that impinge on condom acceptability and use.
Final Messages for Condom Users
People working in the reproductive health field including researchers, regulators, program managers, policy-makers and others need to keep the final goal in mind: consistent and correct use of high-quality condoms by those who need them. It is important to end with messages that users need to hear, through the programs that readers of this monograph might influence.
- Condoms have to be used correctly and consistently to work.
- Correct use is more complicated than it may seem because there are lots of ways to get it wrong. But if you learn how to use them well, condoms can be quite satisfactory.
- Some users will have difficulty using condoms successfully and will experience more than their share of breaks. Some of these problems can be addressed (e.g., rough handling of condoms, "pre-testing," re-use), but some may be harder to fix (e.g., penis size, type and length of intercourse, loss of erection).
- While there may be better condoms in the future, for the time being latex is the best option, given price and availability.
- Condoms manufactured in the developed world and many parts of the developing world are subjected to rigorous quality testing and are therefore quite reliable, especially if they are packaged in foil, the packet is intact, and they are within five years of manufacture.
- There is no evidence that spermicidally lubricated condoms offer greater protection against disease or pregnancy than other condoms. In fact, the spermicide may cause one or other partner irritation and may put users at a greater risk of developing an allergy to latex. Therefore, it is best to use a condom that is lubricated with silicone or water-based lubricant. Oil-based lubricants should not be used with latex condoms.
by Erin T. McNeill
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