By Michael R. (Bob) MacDonald, MS, CHES Manager, Sexual Health and Responsibility Program (SHARP), Navy and Marine Corps Public Health Center
A good friend of mine (a retired Sailor) laughs at me and says he can’t believe I actually get paid to run around telling Sailors and Marines to wear a condom. He’s got a point. Don’t they already know about condoms and use them? Well…if only that was true. The fact is that only half of unmarried male Sailors and Marines and only one-third of unmarried female Sailors and Marines say a condom was used the last time they had sex.
Do Sailors actually even need condoms? Well, in 2012, there were 5,000 Sailors and Marines diagnosed with chlamydia, gonorrhea or syphilis, and another Sailor or Marine was diagnosed with human immunodeficiency virus (HIV) about every four days. About one in five enlisted female Sailors and Marines aged 21-35 say they had an unplanned pregnancy in the last 12 months. Condoms might have helped prevent many of these outcomes.
Do condoms work? Well…in general, yes – condoms reduce, but don’t eliminate risk. Correct use (before any penetration) and consistent use (every time) of male latex condoms reduce the risk of sexually transmitted infections (STI) including HIV. How effective are they? Condoms provide different levels of protection for various STIs, They are likely to provide greater protection against infections transmitted only by genital fluids (like gonorrhea, chlamydia, trichomoniasis, and HIV infection) than against infections that are transmitted primarily by skin-to-skin contact, which may or may not infect areas covered by a condom (like genital herpes, human papillomavirus [HPV] infection, syphilis, and chancroid). So although there is a range of effectiveness, clearly sex with a condom is much less risky than sex with no condom.
There are three challenges to using a condom: (1) know how to use them; (2) be comfortable and confident negotiating condom use with a partner; and (3) have easy access to condoms. With any given Sailor or Marine, we should not take for granted that any of these conditions has been met.
1. Some people have never actually been shown how to use a condom. Although 99% of Americans are aware of condoms, about one in three unmarried young American adults say they know little or nothing about condoms. It may depend on where they went to high school and the extent to which parents discussed condoms with them. I speak in many Navy medicine settings and I am continually surprised by how many Navy doctors seem to have never demonstrated this skill for anyone in their life.
2. And using condoms is the easy part. Negotiating condoms is actually the more difficult skill they need. What should a person say? What if they reject me? What if my partner says no? Many young people do not know how to initiate this conversation. Women worry about asking men to use a condom. Yet, among American male 20-somethings, when asked “What would your reaction be if a girl asked you to use a condom”, 83% would “gladly do it” and only 6% would not. In 2010, the largest national survey of Americans and their sexual behavior found that adults using a condom for intercourse were just as likely to rate the sexual event positively in terms of arousal, pleasure and orgasm than when having intercourse without one.
3. Condom access. Condom access is an evidence-based structural intervention. Condom distribution programs have been shown to reduce STIs in many settings. Remember – some adults are embarrassed about using condoms. While men report less embarrassment than women, studies have found that both groups often used like strategies when making their purchase. For example, they sought out a clerk of the same sex. Both men and women report trying to conceal the condoms or buying additional items to distract attention. Men and women alike said they scanned the store for other customers while purchasing the condoms; women were more likely to wait for other customers to leave. We must thoughtfully devise a strategy, in coordination with our stakeholders, which targets the segment of our population we believe to be at risk. Any effective strategies for condom access should include the aspect of inconspicuous access – in which people may discreetly access condoms without asking for permission and without being observed. For example, some preventive medicine offices, health promotion offices, shipboard medical spaces, and adult-patient clinical settings have condoms available in a place from which patients may help themselves inconspicuously. Retail stores can make condom access inconspicuous by positioning condoms in a place where the customer does not need to ask for assistance to select them. Restroom dispensers are another example of inconspicuous access.
Condoms are not the whole solution to the silent epidemics of STIs and unplanned pregnancies in our country. Abstinence, mutual monogamy and long-acting reversible contraceptives must also be part of our public health and individual solution set. But on both individual and societal levels, condoms remain the quickest, least expensive, most easily implemented intervention available to us for people who decide to have sex outside of long-term, mutual monogamy.
Some general suggestions:
• Sexual health promotion efforts should not be perceived as just “pushing condoms.” Wherever you make condoms accessible, include a comprehensive prevention message that includes the fact that abstinence and monogamy can eliminate risk, and condoms reduce risk.
• Every clinician, counselor or educator tasked to speak with patients about sexual health, should have condoms available for people who say they want to try them. Stock these clinical settings with a variety of condoms for patient education. Just having samples visible may generate patient questions and generate productive risk reduction discussions.
• Teach health care providers to speak with their patients about correct and consistent condom use. Many clinicians are not comfortable or experienced in this skill. Consider making this an in-service training for providers.
• Be prepared for occasional misuse of “free” condoms. For example, a bowl of free condoms may disappear from a clinic and reappear as “balloons” taped to the ceiling of a barracks hallway. Help leaders understand that these occasional events are expected, and each may be used as another opportunity to educate. Rather than focusing on preventing a recurrence by limiting access and punishing perpetrators, consider maintaining the same level of inconspicuous access and engaging perpetrators as partners in promoting sexual health among their peers.
• Don’t forget that many military members acquire their STI (including HIV) while in the U.S. – condom access and sexual health education isn’t just a “deployment” concern.
• For females who decide to have sex, help them know it is OK for them to get and carry condoms and insist on their use. It is their right and responsibility to protect their health.
My Vision: For people who are not in a long-term, mutually-monogamous relationship, I believe we need to achieve a new cultural norm in which sex without a condom is as crazy an idea as driving without a seat belt. We can help – help them know how to use a condom, how to negotiate condom-use with a partner, and we can make it easier to get a condoms.
Really, it’s a wrap. Condoms reduce risk. So let’s all get to work making condom use normal and easy. Check out our condom page at NMCPHC: http://www.med.navy.mil/sites/nmcphc/health-promotion/reproductive-sexual-health/Pages/condoms.aspx
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, nor the U.S. Government.