Ast the Experts

What's the evidence for using two condoms?

Question: What is the evidence that two condoms may be used at once? Who does this? What are their reasons for doing this? What are the other things that can do done to prevent condom breakage? Are there some men and some women who have sexual intercourse in a manner that predisposes them to have repeated condom breaks or repeated condom slippage?

Answer from Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta: Typical condom breakage rates range from 0.5% to 6.7%. Falling-off rates range from 0.6% to 5.4%. More recently, attention has focused on condoms that slip down the penis but not completely off, known as partial slippage.1,2

In Nevada, men going to legal brothels are required to use a condom during every sexual act. Many acts of intercourse are protected by two condoms. Legal prostitutes in Nevada are extraordinarily effective in preventing HIV and other infections. Do they use more than one condom? The answer is often "yes." Many of their acts of intercourse are protected by two condoms.

A 1995 study analyzed condom use among legal prostitutes in Nevada brothels.1 Here are some of the techniques these women used to prevent breakage: use of additional water-soluble lubricant (64%); monitoring the condition of the condom regularly throughout intercourse (20%); refraining from rough, vigorous sex (18%); using appropriately sized condoms (5%); and changing condoms during prolonged intercourse (5%).

Use of multiple condoms simultaneously also was a frequently reported method (9%) to prevent breakage. Twenty-nine women (66%) reported that at least one client had worn two condoms concurrently during intercourse in the previous year, for a total of more than 5,000 concurrent uses. Eight women reported doubling up condoms during every act of commercial intercourse in the previous year. Visual inspection of the used condoms from the prospective trial revealed that condoms were doubled up in 10.8% of the 372 sexual episodes. Condoms were doubled up primarily to prevent breakage when women had experienced a prior condom break, when the client's penis was very large, when the client presented with unidentifiable penile sores or track marks, when a thin condom was being used, and when the client requested it. To avoid friction, women reported applying additional lubricant between the condoms.1

Albert and fellow investigators reported a retrospective breakage rate much lower than other reported studies. There were 49 breaks reported in the course of 41,127 acts of intercourse (0.12%). This comes to a breakage rate of one condom break per 849 acts of intercourse.

In Albert's prospective study, 41 women used condoms during 353 acts of vaginal intercourse. A water-based lubricant was used 89% of the time, and oil-based lubricants were not used at all. There were no breaks at all (0/353), and lack of breakage was confirmed by visual inspection of all condoms by the senior author of the paper. (Condoms had been placed in zip-locked bags).

When women receive a license to be a prostitute in Nevada, they must be HIV-negative. Nevada law requires that registered brothel prostitutes be tested weekly for gonorrhea and chlamydia, and monthly for HIV and syphilis. Between July 1, 1988, and Dec. 31, 1993, more than 20,000 HIV tests were conducted on licensed prostitutes. None of the women employed in any Nevada brothel tested positive at the time of follow-up HIV testing. These rates are in sharp contrast to HIV prevalence rates in other female prostitutes in the United States and elsewhere.

Although the actual exposure level of brothel workers to clients with HIV and other sexually transmitted disease infections is not known, the absence of HIV and other sexually transmitted diseases might be explained by the fact that clients are required to use condoms during every sexual act.

Clearly, Albert has documented that use of two condoms in a high-risk group of women does not place them at risk for increased rates of condom breakage or increased rate of infection.

There is a final lesson to be learned from Albert's fascinating study. Condom mishaps are not evenly distributed among all condom users. In the retrospective phase of the study, the 44 women relating their experience with condom breakage, slippage, and falling off reported that of the 49 total breaks in the year prior to the study, 20 (41%) were reported by one woman. Fourteen of the 42 instances of slippage in the previous month (33%) were reported by another woman. Likewise, 48 of the 103 instances of slippage in the previous year (47%) were reported by only three women.1

In summary, use of two condoms is a common practice among legal prostitutes in Nevada. Condom breakage rates are extraordinarily low among these women. Therein lies an important practical lesson: When clinicians see women and men who have experienced multiple breaks or slippages, it would be wise to encourage them to use two condoms.

References

  1. Albert AE, Warner DL, Hatcher RA, et al. Condom use among female commercial sex workers in Nevada's legal brothels. Am J Publ Health 1995;85:1514-1520.
  2. Warner L, Steiner MJ. Male condoms. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. 19th ed. New York: Ardent Media; 2007.