Condoms: Fears of partner disapproval, less pleasure linked to teens' nonuse
Give teens accurate information regarding use of condoms
If your adolescent patients are not using condoms for protection, are you exploring the reasons behind such decisions? Results of a just-published survey of more than 1,400 adolescents and young adults indicate that teens who don't use condoms were significantly more likely to believe that condoms reduce sexual pleasure and also were more concerned that their partner would not approve of condom use.1
Adolescents might not be getting the information they need when it comes to condom use and negotiation skills. Commonly used abstinence-only curricula don't provide complete, current, or accurate medical knowledge about the effectiveness of condoms, states a 2008 review of current programs.2
The three programs assessed were Me, My World, My Future (published by Teen-Aid for use by middle school students), Sexuality, Commitment & Family (published by Teen-Aid for use by high school students), and Why kNOw (published by AAA Women's Services for sixth grade through high school). They often provide inaccurate medical information to adolescents, and this information including false or misleading statements about the effectiveness and safety of condoms, the review says. The programs inflate the actual failure rate of condoms, which suggests that using condoms is somewhat like playing "Russian roulette" with HIV, the report notes.2
How do abstinence-only and comprehensive sex education programs compare when it comes to adolescent sexual behavior? A current assessment of 56 such programs indicates that most abstinence-only programs did not delay initiation of sex. However, most comprehensive programs, which emphasize abstinence and the use of protection for those who do have sex, showed strong evidence of positive influence on teens' sexual behavior, including delaying initiation of sex and increasing condom and contraceptive use.3
Focus on condom use
To understand teens' use of condoms, take a look at the current research. Investigators from the Bradley Hasbro Children's Research Center in Providence, RI, and three other institutions surveyed more than 1,400 adolescents and young adults between the ages of 15 and 21 who had unprotected sex in the previous 90 days.1
Study participants in Atlanta, Miami, and Providence completed an audio computer-assisted interview to gather information about sexual risk behaviors including condom use. Questions included attitudes and perceptions about condom use, and communication and negotiation with partners about condom use. The study group included 797 females and 613 males. About half were African American. Almost one-fourth (24%) were Hispanic, and 19% were white.
Researchers found that two-thirds of adolescents did not use a condom the last time they had sex. Participants also reported an average of two partners and about 15 incidents of unprotected sexual activity within the 90-day period. In addition to concerns about reduced sexual pleasure and partner disapproval, teens who did not use condoms also were less likely to discuss condom use with their partners. Those findings held true across racial/ethnic groups, gender, and geographic locations, researchers report.
"It's clear that we have to address these attitudes, fears, and concerns that many teens have regarding condom use, if we want to reduce their risk for contracting a sexually transmitted infection," says Larry Brown, MD, professor in the Department of Psychiatry and Human Behavior in the Alpert School of Medicine at Brown University. "The good news is that these attitudes may be easily influenced and changed through clinical and community-based interventions."
What influences condom use?
What are some of the most common attitudes and concerns influencing condom use in adolescents? Consider these possibilities, says Brown, who served as lead author for the current research:
- Teens might have negative feelings about personal factors about condoms. They might see donning a condom as a hassle, something that will ruin the mood of sex, and make sex less pleasurable.
- Teens worry that their partners won't want to use condoms, says Brown. They might be suspicious about the reason for using a condom, or they might want to not use one as a sign of commitment.
- Teens might not use condoms when they have difficulty talking with their partners about condom use in the role of safer sex. Adolescents might not feel that they are able to refuse or delay sex until it is safer, says Brown.
"Two other reasons teenagers and older couples don't use condoms is that they think condoms don't work; one reason why they think that they don't work is because they frequently break," says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. "When used, condoms are effective in preventing both infection and pregnancy, and when used correctly, condoms break only 1% to 2% of the time."
What are some specific ways that health care providers can address those attitudes and concerns? Screen teens' sexual behavior, says Brown. Discuss whether they are having sex and whether condoms are used at all and with all partners. If consistent condom use is not in play, discuss what barriers impede such use.
Teach teens how to bring up discussions of sex and condoms in a mutually caring, respectful, and tactful manner, says Brown. Counsel that most partners won't refuse with this approach, he notes.
Reduce teens' discomfort with condoms by encouraging them to continue to try condoms and finding a brand that provides optimal fit, comfort, and sensation. Condom makers now are making condom use more pleasurable with freshening wipes, lubricants, ribbings, and even vibrating rings, reports Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
Refer teens to small group interventions with other teens, such as those offered at community-based organizations, that address those issues, offers Brown.
Continue to provide comprehensive sexuality education to adolescent patients, especially if your state accepts abstinence-only sexuality education funds. As of August 2008, the following states had opted out of Title V abstinence-only federal funding: Alaska, Arizona, California, Colorado, Connecticut, Delaware, District of Columbia, Idaho, Iowa, Maine, Massachusetts, Minnesota, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia, Washington, Wisconsin, and Wyoming.4
States that have rejected federal abstinence-only funds generally cite concerns about the efficacy and accuracy of abstinence-only curricula.4 Those states also tend to have progressive governments and strong advocates for comprehensive sexuality education, notes an overview of state trends.4
Give teens the facts about the condom's role in prevention of sexually transmitted diseases (STDs). When placed on the penis before any genital contact and used throughout intercourse, condoms prevent direct contact with semen; genital lesions and subclinical viral shedding on the glans and shaft of the penis; and penile, vaginal, and anal discharges or infectious fluids, according to Contraceptive Technology.5 Condoms thus greatly reduce the risk of STDs that are transmitted primarily to or from the penile urethra, such as gonorrhea, chlamydia, trichomoniasis, hepatitis B infection, and HIV, it advises. Condoms also provide protection against STDs that are transmitted primarily through skin-to-skin contact or mucosal surface contact, such as genital herpes, human papillomavirus, syphilis, and chancroid.5
- Brown LK, DiClemente R, Crosby R, et al. Condom use among high-risk adolescents: Anticipation of partner disapproval and less pleasure associated with not using condoms. Public Health Rep 2008; 123:601-607.
- Lin AJ, Santelli JS. The accuracy of condom information in three selected abstinence-only education curricula. Sex Res Social Policy 2008; 5:56-70.
- Kirby D. The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior. Sex Res Social Policy 2008; 5:18-27.
- Raymond M, Bogdanovich L, Brahmi D, et al. State refusal of federal funding for abstinence-only programs. Sex Res Social Policy 2008; 5:44-55.
- Warner L, Steiner MJ. "Male Condoms." In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 19th revised edition. New York City: Ardent Media; 2007, p. 302.