Condoms as Primary Prevention in Sexually Active Women Condoms are lifesavers, not off-color jokes. The challenge is to get the focus on the former and forget the latter. By M. Kay Libbus
T
he simple condom has been present for many generations. Prior to the invention of oral contraceptives, the condom was regarded as the most accessible and practical form of contraception available. It also served to prevent sexuallytransmitted disease (STD). Before social tolerance of casual sexuality emerged, both functions were of particular importance in encounters where the participants were not married to one another. The appearance of acquired immune deficiency syndrome (AIDS) and the concomitant increase in other sexually-transmitted diseases have revived interest and enthusiasm for condom use. Nevertheless, health professionals' encouragement of condom use continues to carry a suggestion of a slightly off-color joke, a problem not noted with discussions of the diaphragm, IUD, or oral contraceptives. Several hypotheses have been proposed to explain this discomfiting response to discussions of condom use. Some propose that this reaction is a vestige of the attitudes behind the 1873 Comstock bill forbidding distribution of birth control information as that was thought to constitute frank obscenity (1). A second conjecture concerns the notion that condom use is synonymous with licentiousness; that promoting prophylaxis is seen as encouraging unsavory behavior. This attitude holds that the fear of punishment, as represented by pregnancy and infection, must play a major role in squelching illicit activity (2). The Condom: Past and Present Penile barriers have been used for centuries for purposes ranging from decoration to protection. The use of a linen sheath as a preventive measure for venereal disease was noted in the writings of Fallopius in 1564. The origin of the word condom is the subject of some debate. According to some sources, the "cunM. KAY UBBUS, DRPH, FNP, is an assistant professor of nursing at the University of Missouri-Columbia.
256
dum" was worn by men to prevent venereal infections and was invented by Colonel Cundum (2). Other sources claim that this device was named after Dr. Condom, a court physician who introduced the condom into the court of King Charles II of England in an attempt to both stem the overabundance of illegitimate royal children and protect the health of the king (3). Small-scale condom production was an important, if modest, cottage industry in 18th century London, with the product being marketed both by home manufacturers and prostitutes. However, condoms were not extensively available until after 1843, when rubber vulcanization made bulk production feasible. Unfortunately, inconsistencies in manufacturing methods and lack of quality control made the efficacy of condoms unreliable (3). Modern production of latex condoms is planned to ensure optimum reliability. Production is a relatively uncomplicated process: Cylindrical glass molds are dipped into vats of liquid latex, and when the rubber is dry, the condom is carefully rolled off. Glass is used as it is less likely to become damaged and subsequently to produce condoms with imperfections. Even minute blemishes may predispose a condom to rips and tears during use (3). Obviously, quality control is a critical aspect of manufacturing and distribution. The Food and Drug Administration (FDA) routinely collects and examines condoms, using a water stretch test for leakage. Leakage is defined as any moisture appearing on the outside of a condom filled with 10 ounces of water. If four or more condoms per 1,000 examined leak, the batch may be recalled or seized as a substandard lot. This standard also applies to foreign condoms shipped into the United States. Out of an estimated world production of approximately five billion condoms per annum, approximately 21 percent of foreign batches fail the test, compared to 12 percent of domestically manufactured condoms. If two or more MCN Volume 17 September/October 1992
lots of foreign condoms fail the leak tests, future imports can be banned (4). Greatest Increase in Condom Use Among Homosexual Men Since the majority of individuals and couples using condoms do so without consulting their health care providers, actual use patterns are difficult to delineate. Condom sales have increased, with the greatest increased use documented among male homosexuals. For example, in a sample of San Francisco men having anal intercourse, consistent condom use was reported to have increased from 26 to 79 percent between 1984 and 1987. In general, condom sales in drug stores increased by greater than 20 percent from 1986-1987, with women being responsible for an estimated 40-50 percent of U.S. purchases (5). Although it is possible to track condom sales, it is more difficult to accurately monitor use. An innovative project in Baltimore is attempting to estimate actual use by counting the number of condoms, presumably used, that appear at a wastewater treatment facility and in sewer lines (6). Although this investigation is ongoing, preliminary analysis has revealed a pattern of both weekly and seasonal use. The investigators commented on the difficulty condom use presented as a subject of scientific research. Not surprisingly, much derision has been heaped on the project by news media. Further attempts to educate the media of the importance of documenting and encouraging condom use has met with mixed success. Effectiveness Varies with Use Effectiveness of condoms must be considered in terms of both contraception and disease control. Effectiveness is as difficult to estimate as usage. Clinical observation and empirical studies suggest that for each 100 couples using condoms, between two and fifteen will experience unplanned pregnancy (3). For example, one source notes that failure rates for firstyear users average about 12 percent, but that consistent and correct condom use theoretically results in approximately a 2 percent failure rate. Concurrent spermicide use or use of spermicidal condoms have been shown to enhance effectiveness (5). Figures are also unavailable regarding incidence of condom breakage. Anecdotal information indicates that breakage tends to be relatively low in com-_| mercial sex (7). Investigations estimate that ratios of condom breaks to acts of intercourse range from 1:16 to 1:161, with a relatively low number of pregnancies MCN Volume 17 September/October 195
resulting (5). Few studies have examined the incidence of breakage occurring during vaginal intercourse. However, credible studies report mean breakage rates ranging from 0 to 13 percent (8). An important research project conducted by Family Health International (FHI) identified a cohort of individuals who consistently reported condom breakage. This study reported that several common denominators for breakage exist. These fall into four categories: 1) incorrect technique for putting on condoms, 2) use of any petroleum or oil-based lubricant, including specific medications, 3) reuse of condoms, and 4) unusually intense or lengthy coitus (8). Other distinctive risk factors for condom breakage, other than intrinsic flaws, include anal intercourse; rough handling, particularly by an individual with sharp or ragged fingernails; and exposure of the latex to heat, light, or air (5). When properly used, condoms significantly reduce the acquisition of sexually transmitted disease, although there is no assurance of total prevention. It must be emphasized that only latex condoms protect against disease. Natural membrane condoms, which are still made from the intestines of sheep, have greater permeability and allow passage of the human immunodeficiency virus (HIV) (4). Both epidemiological and laboratory studies have demonstrated that latex condoms are effective mechanical barriers to important viral transmissions including HIV, herpes simplex virus (HSV), hepatitis B virus (HBV), and cytomegalovirus (CMV), as well as bacteria such as Chlamydia trachomatis and Neisseria gonorrhoeae (9). Disease control is equally effective for both genders. However, the issue of the disease control may be especially germane to women for two important reasons: First, the bacterial agents typically do more damage to women's reproductive tracts; and second, many pregnant women are candidates for continued condom use due to the potential damage done by both bacterial and viral agents to the fetus and/or infant (5). The National Family Planning and Reproductive Health Association recommends consistent condom use throughout pregnancy in at least three specific sets of circumstances: 1) when a woman or her partner has a history of sexually transmitted disease; 2) when a woman has a partner
Lr
T
he simple condom has been present for many generations. Prior to the invention of oral contraceptives, the condom was regarded as the most accessible and practical form of contraception available. It also served to prevent sexuallytransmitted disease (STD). Before social tolerance of casual sexuality emerged, both functions were of particular importance in encounters where the participants were not married to one another. The appearance of acquired immune deficiency syndrome (AIDS) and the concomitant increase in other sexually-transmitted diseases have revived interest and enthusiasm for condom use. Nevertheless, health professionals' encouragement of condom use continues to carry a suggestion of a slightly off-color joke, a problem not noted with discussions of the diaphragm, IUD, or oral contraceptives. Several hypotheses have been proposed to explain this discomfiting response to discussions of condom use. Some propose that this reaction is a vestige of the attitudes behind the 1873 Comstock bill forbidding distribution of birth control information as that was thought to constitute frank obscenity (1). A second conjecture concerns the notion that condom use is synonymous with licentiousness; that promoting prophylaxis is seen as encouraging unsavory behavior. This attitude holds that the fear of punishment, as represented by pregnancy and infection, must play a major role in squelching illicit activity (2). The Condom: Past and Present Penile barriers have been used for centuries for purposes ranging from decoration to protection. The use of a linen sheath as a preventive measure for venereal disease was noted in the writings of Fallopius in 1564. The origin of the word condom is the subject of some debate. According to some sources, the "cunM. KAY UBBUS, DRPH, FNP, is an assistant professor of nursing at the University of Missouri-Columbia.
256
dum" was worn by men to prevent venereal infections and was invented by Colonel Cundum (2). Other sources claim that this device was named after Dr. Condom, a court physician who introduced the condom into the court of King Charles II of England in an attempt to both stem the overabundance of illegitimate royal children and protect the health of the king (3). Small-scale condom production was an important, if modest, cottage industry in 18th century London, with the product being marketed both by home manufacturers and prostitutes. However, condoms were not extensively available until after 1843, when rubber vulcanization made bulk production feasible. Unfortunately, inconsistencies in manufacturing methods and lack of quality control made the efficacy of condoms unreliable (3). Modern production of latex condoms is planned to ensure optimum reliability. Production is a relatively uncomplicated process: Cylindrical glass molds are dipped into vats of liquid latex, and when the rubber is dry, the condom is carefully rolled off. Glass is used as it is less likely to become damaged and subsequently to produce condoms with imperfections. Even minute blemishes may predispose a condom to rips and tears during use (3). Obviously, quality control is a critical aspect of manufacturing and distribution. The Food and Drug Administration (FDA) routinely collects and examines condoms, using a water stretch test for leakage. Leakage is defined as any moisture appearing on the outside of a condom filled with 10 ounces of water. If four or more condoms per 1,000 examined leak, the batch may be recalled or seized as a substandard lot. This standard also applies to foreign condoms shipped into the United States. Out of an estimated world production of approximately five billion condoms per annum, approximately 21 percent of foreign batches fail the test, compared to 12 percent of domestically manufactured condoms. If two or more MCN Volume 17 September/October 1992
lots of foreign condoms fail the leak tests, future imports can be banned (4). Greatest Increase in Condom Use Among Homosexual Men Since the majority of individuals and couples using condoms do so without consulting their health care providers, actual use patterns are difficult to delineate. Condom sales have increased, with the greatest increased use documented among male homosexuals. For example, in a sample of San Francisco men having anal intercourse, consistent condom use was reported to have increased from 26 to 79 percent between 1984 and 1987. In general, condom sales in drug stores increased by greater than 20 percent from 1986-1987, with women being responsible for an estimated 40-50 percent of U.S. purchases (5). Although it is possible to track condom sales, it is more difficult to accurately monitor use. An innovative project in Baltimore is attempting to estimate actual use by counting the number of condoms, presumably used, that appear at a wastewater treatment facility and in sewer lines (6). Although this investigation is ongoing, preliminary analysis has revealed a pattern of both weekly and seasonal use. The investigators commented on the difficulty condom use presented as a subject of scientific research. Not surprisingly, much derision has been heaped on the project by news media. Further attempts to educate the media of the importance of documenting and encouraging condom use has met with mixed success. Effectiveness Varies with Use Effectiveness of condoms must be considered in terms of both contraception and disease control. Effectiveness is as difficult to estimate as usage. Clinical observation and empirical studies suggest that for each 100 couples using condoms, between two and fifteen will experience unplanned pregnancy (3). For example, one source notes that failure rates for firstyear users average about 12 percent, but that consistent and correct condom use theoretically results in approximately a 2 percent failure rate. Concurrent spermicide use or use of spermicidal condoms have been shown to enhance effectiveness (5). Figures are also unavailable regarding incidence of condom breakage. Anecdotal information indicates that breakage tends to be relatively low in com-_| mercial sex (7). Investigations estimate that ratios of condom breaks to acts of intercourse range from 1:16 to 1:161, with a relatively low number of pregnancies MCN Volume 17 September/October 195
resulting (5). Few studies have examined the incidence of breakage occurring during vaginal intercourse. However, credible studies report mean breakage rates ranging from 0 to 13 percent (8). An important research project conducted by Family Health International (FHI) identified a cohort of individuals who consistently reported condom breakage. This study reported that several common denominators for breakage exist. These fall into four categories: 1) incorrect technique for putting on condoms, 2) use of any petroleum or oil-based lubricant, including specific medications, 3) reuse of condoms, and 4) unusually intense or lengthy coitus (8). Other distinctive risk factors for condom breakage, other than intrinsic flaws, include anal intercourse; rough handling, particularly by an individual with sharp or ragged fingernails; and exposure of the latex to heat, light, or air (5). When properly used, condoms significantly reduce the acquisition of sexually transmitted disease, although there is no assurance of total prevention. It must be emphasized that only latex condoms protect against disease. Natural membrane condoms, which are still made from the intestines of sheep, have greater permeability and allow passage of the human immunodeficiency virus (HIV) (4). Both epidemiological and laboratory studies have demonstrated that latex condoms are effective mechanical barriers to important viral transmissions including HIV, herpes simplex virus (HSV), hepatitis B virus (HBV), and cytomegalovirus (CMV), as well as bacteria such as Chlamydia trachomatis and Neisseria gonorrhoeae (9). Disease control is equally effective for both genders. However, the issue of the disease control may be especially germane to women for two important reasons: First, the bacterial agents typically do more damage to women's reproductive tracts; and second, many pregnant women are candidates for continued condom use due to the potential damage done by both bacterial and viral agents to the fetus and/or infant (5). The National Family Planning and Reproductive Health Association recommends consistent condom use throughout pregnancy in at least three specific sets of circumstances: 1) when a woman or her partner has a history of sexually transmitted disease; 2) when a woman has a partner
Lr
