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STI prevention and role of the male condom
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The adolescent population is at increased risk of exposure to, and development of, sexually transmitted infections.
Four million adolescents are diagnosed with an STI annually, and 25% of all adolescents will have contracted an STI by age 21 years. Of the 18.9 million new STIs that occur each year in the United States, 50% occur in 15- to 24-year-olds.
According to the CDC, most cases of gonorrhea and chlamydia occur in 15- to 24-year-olds (62% and 70%, respectively, 2011). Several methods are recommended to reduce the risk of STI exposure and development, including abstinence, vaccination, mutual monogamy, reduced number of sex partners, and use of the male condom. Although the male condom is not classified as a drug, it is commonly sold in pharmacies, and it is often used with various products (eg, lotions, spermicides) that are additionally sold in pharmacies. The male condom is classified as a medical device by the FDA and is regulated as such.
Edward A. Bell
Effective prevention of STIs
Condoms are the most commonly used contraceptive method, and when used consistently and correctly, they are highly effective. If used correctly, the condom is 98% effective as a contraceptive. The CDC states that when male condoms are used correctly, they “are highly effective in preventing the sexual transmission of HIV… and reducing the risk of other STIs …” When correctly used, male condoms reduce risk of exposure to genital herpes, syphilis and chancroid, when the infected area or site is covered and protected, and condoms may reduce the risk for HPV transmission and infection.
Although reported condom use has increased (70% to 80% for last vaginal intercourse among 14- to 17-year-olds in a national sample), many condom users more strongly associate condom use with contraception, as opposed to protection from STI. Thus, condom use among adolescents may decrease when other effective forms of contraception (eg, hormonal methods) are concomitantly used. Reduced rates of condom use have been observed in young males who did not receive formal sex education. Thus, counseling and education of adolescents on proper condom use by health care providers can prove beneficial.
Correct use of condoms
As with any medical device, it is reasonable to assess in users their appropriate use, as intended for maximal efficacy and safety. A recently published review of the literature addressed this question. Sanders and colleagues searched the peer-reviewed literature from 1995 to 2011 for studies evaluating condom use. Fifty papers from 14 countries (representing mostly North American-developed countries) were included, with the primary summary measure being the prevalence of problems or errors associated with condom use.
Subject populations in these studies varied, including college students, monogamous married couples, sex workers or attendees of STI clinics. The most commonly reported problems included condom breakage, slippage and leakage. Commonly reported errors in condom use included not using condoms throughout sex (ie, late application after intercourse began or early removal of the condom); not leaving space at the tip; putting on a condom upside down (ie, unrolled improperly); not using water-based lubricants; and incorrect withdrawal.
Six studies determined that late application occurred in 17% to 51% of users. Fifteen studies reported that breakage occurred in up to 40.7% of users. Oil-based lubricants were used inappropriately in 4.7% of users, and 3.3% of men reported re-use of a condom during the same sexual encounter. Some men (7.9%) reported incorrectly storing condoms (eg, not in a cool dry place, but carried in a wallet for an extended time). This useful study, representing a variety of participants in mostly developed countries, suggests that condoms often may not be correctly used. Many of the errors reported in this review can significantly increase risk of condom breakage, slippage, and leakage, and thus substantially increase risk of STI transmission.
Types of condoms and lubricants
Three types of condoms are commonly available: latex, synthetic and “natural” (natural membrane). Latex condoms are mostly commonly available and used. Synthetic condoms are mostly manufactured with polyurethane, and “natural” condoms are made from lamb cecum. There are important differences in these types of condoms. Latex condoms can be used by any male, with the exception of males with latex allergy (which can occur in 3% of the population). Synthetic condoms are likely to be equally effective as latex condoms with respect to prevention of STI transmission and pregnancy, if used correctly. However, several studies have demonstrated increased rates of breakage and slippage with synthetic condoms as compared with latex condoms. Synthetic condoms may be most appropriate for males with latex allergy or those who do not tolerate use of latex condoms.
Perhaps the most important difference among these types of condoms relates to STI prevention: Natural condoms contain pore openings that are substantially larger than some pathogens responsible for STI (more than 10 times greater than HIV and more than 25 times greater than hepatitis B virus). Thus, although natural condoms can prevent sperm transmission, they should not be used for STI prevention.
It is interesting to note the variety of condoms that are available, other than by the material they are manufactured with. A search on the Internet will find condoms that differ by: size, thickness, shape, texture (eg, with ridges), color (including glow-in-the-dark), lubricated/non-lubricated, smell (some reportedly do not smell good, as reviewed by users on Internet sites) and flavor (mint, banana, strawberry, chocolate, vanilla, among others). Some condoms are even available that are lined with a vasodilating gel.
Lubricants are often used with condoms to increase pleasure, and lubricants can play a substantial role to increase condom efficacy, as they can decrease condom breakage and cause the user to leave the condom on throughout intercourse (potentially decreasing early removal). It is important to note differences in lubricant availability and composition, and their effect upon condom efficacy. Lubricants are available as water-based and oil-based.
Only water-based lubricants should be used with latex condoms. Examples of water-based lubricants include K-Y Jelly (McNeil-PPC), Astroglide (Biofilm), AquaLube (Mayer Laboratories) and glycerin. Oil-based products, such as baby oil, body or massage oil, edible oils (eg, olive oil), petrolatum, and vaginal creams should not be used with latex condoms, as they may degrade latex structure. An advantage of synthetic condom use is their safe use with either water-based or oil-based lubricants.
Spermicidal products available in the United States all contain nonoxinol-9 (N-9). It is not generally recommended to use condoms with products containing N-9 as a primary lubricant, as several studies have demonstrated that N-9 can disrupt vaginal and rectal epithelial tissue, and thus may increase STI transmission, including HIV. As well, no data exist to demonstrate that condoms lubricated with N-9 decrease pregnancy rates.
Role of the health care professional
As condoms are the most commonly available and effective device to prevent contraception and STI transmission, a pediatrician plays an important role for the adolescent population. Health care providers can help maximize condom use and efficacy by not only promoting their use when appropriate, but also by simply providing condoms to adolescent patients, and by discussing their proper use, including avoidance of commonly reported errors. Recent evidence indicates that many pediatricians do not provide condoms to adolescents, nor do they adequately counsel on proper condom technique of use.
References:
Sanders SA. Sex Health. 2012;9:81-95.
Williams RL. Curr Opin Obstet Gynecol. 2011;23:350-354.
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Disclosure: Bell reports no relevant financial disclosures.