BMJ  2008;336:185 (26 January), doi:10.1136/bmj.39402.527766.AD

Head to Head

Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No

¹ University of Alberta, 2935-66 Street, Edmonton, AB, Canada T6K 4C1

Related article: doi: 10.1136/bmj.39402.488727.AD

Consistent condom use can reduce the spread of HIV, and Markus Steiner and Willard Cates believe condoms are the answer to other sexually transmitted infections. But Stephen Genuis argues that a more comprehensive approach is needed

Clinical considerations surrounding the science of sexuality and reproductive health have routinely been hijacked by philosophical perspectives, economic interests, religious bias, and sexual ideology. Rather than dialogue about evidence based outcomes and credible health policy, most talk about prevention of sexually transmitted infections involves debate over mutually exclusive perspectives on sexual morality.

Proponents of approaches encouraging safe sex (or safer sex) are accused of corrupting youth with amoral values, and opponents are perceived as zealots who disregard scientific fact in imposing their fanaticism on society. We need to look beyond vested interests to focus on clinical science and public health evidence.

A fundamental tenet of medicine is adherence to scientific fact and experiential evidence to develop treatments and programmes that maximise and sustain health. That evidence shows that effective population control of non-HIV sexually transmitted infections requires more than condom focused approaches.

Scope of protection

Firstly, condoms cannot be the definitive answer to sexually transmitted infection because they provide insufficient protection against transmission of many common diseases. "Skin to skin" and "skin to sore" infections such as human papillomavirus, herpes simplex virus, syphilis, lymphomagranuloma venereum, or chancroid often transmit despite barrier protection.^{1 2} Although condoms prevent contact between the skin of the penis and the vaginal mucosa, intercourse generally involves skin to skin contact in the external genital area; the condom gives limited protection against pathogens found throughout the external genital tract.

As barriers only protect the area they cover, clinical and subclinical lesions on the mons pubis or on the woman’s vulva or the male scrotum, for example, are not covered and readily transmit despite condom use. Rather than remaining contained within the vagina, some communicable pathogens are routinely encountered on the vulva and perineum of women. The most common sexually transmitted pathogens, human papillomavirus and herpes simplex virus, are often dispersed on infected genitalia and transmit through skin to skin contact. As the sequelae of these common infections may include various cancers,^{2 3} chronic sexual dysfunction,^{2 4} as well as vertical transmission,^{2 5} contracting such organisms is not inconsequential.

Practical effectiveness

The main problem with condoms is that average people, particularly aroused youth, do not use them consistently, regardless of knowledge or education.^{2 6} Although condoms offer some protection against discharge related infections such as chlamydia and gonorrhoea, protection is usually compromised by compliance issues, incorrect use, or mechanical failure.²

In theory, condoms offer some protection against sexually transmitted infection; practically, however, epidemiological research repeatedly shows that condom familiarity and risk awareness do not result in sustained safer sex choices in real life. Only a minority of people engaging in risky sexual behaviour use condoms consistently.^{2 6 7} A recent study found that less than 8% of couples discordant for herpes used condoms for each sex act, despite ongoing counselling.⁷ Even among stable, adult couples who were HIV discordant and received extensive ongoing counselling about HIV risk and condom use, only 48.4% used condoms consistently.⁸ Irregular use of condoms will not provide sustained protection against sexually transmitted infection.⁹

The relentless rise of sexually transmitted infection in the face of unprecedented education about and promotion of condoms is testament to the lack of success of this approach. In numerous large studies, concerted efforts to promote use of condoms has consistently failed to control rates of sexually transmitted infection—even in countries with advanced sex education programmes such as Canada, Sweden, and Switzerland.¹⁰ In my home province of Alberta, rates of chlamydia and gonorrhoea have tripled since 1998 despite ubiquitous "safer sex" education. The ongoing assertion that condoms are "the" answer to this escalating pandemic reminds me of Einstein’s words, "The definition of insanity is doing the same thing over and over again and expecting different results."

Reports of diminished rates of sexually transmitted infection as a result of widespread condom use in countries such as Thailand and Cambodia are reinforcing the focus on condoms as the primary strategy. Careful scrutiny of the data, however, suggests that changes in sexual behaviour (fewer partners, less casual sex, and less use of sex workers) after mass educational campaigns rather than widespread condom use by ordinary citizens was instrumental in reducing infection rates.^{2 11}

Tackling the root cause

The World Health Organization estimates that two thirds of sexually transmitted infections worldwide occur in teenagers and young adults.¹² Extensive research shows that, not unlike other high risk behaviour in young people, risky sexual activity is often an expression of non-sexual need and associated with fundamental problems and difficulties.^{2 13}

Promoting condoms as ‘the’ answer disregards the complex nature of human sexuality and fails to tackle the underlying social and emotional needs of young people, who are often trapped in high risk sexual behaviour as a consequence of difficult life circumstances. Innumerable adolescents saturated with condom focused sex education fail to have their fundamental human needs met and end up contracting sexually transmitted infections. For some, risky sex is one component of self destructive behaviour that includes substance misuse and delinquency.

Political correctness and ideological interests need to be usurped by sound science. After repeated failure, the altar of safe sex needs to be dismantled in favour of credible public health policy. Although factual information about barrier protection should be included in any discussion of sexually transmitted infections, narrow condom focused initiatives should be replaced with comprehensive programmes discussed in the medical literature that have evidence-based success at reducing rates of infection.²

Related article: doi: 10.1136/bmj.39402.488727.AD

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Competing interests: None declared.

References

1. Workowski KA, Levine WC. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.[Medline]
2. Genuis SJ, Genuis SK. Managing the sexually transmitted disease pandemic: a time for re-evaluation. Am J Obstet Gynecol 2004;191:1103-12.[CrossRef][ISI][Medline]
3. Gillison ML, Koch WM, Capone RB, Spafford M, Westra WH, Wu L, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst 2000;92:709-20.[Abstract/Free Full Text]
4. Vezina C, Steben M. Psychosexual impacts of human papillomavirus. Can J Cont Med Ed 2001;13:139-53.
5. Buka SL, Tsuang MT, Torrey EF, Klebanoff MA, Bernstein D, Yolken RH. Maternal infections and subsequent psychosis among offspring. Arch Gen Psychiatry 2001;58:1032-7.[Abstract/Free Full Text]
6. Madhok R, McCallum AK, McEwan R, Bhopal RS. Students’ knowledge and behavior concerning safer sex: a UK study. J Am Coll Health. 1993;42:121-5.[Medline]
7. Wald A, Langenberg AG, Link K, Izu AE, Ashley R, Warren T, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA 2001;285:3100-6.[Abstract/Free Full Text]
8. De Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med 1994;331:341-6.[Abstract/Free Full Text]
9. Ahmed S, Lutalo T, Wawer M, Serwadda D, Sewankambo NK, Nalugoda F, et al. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS 2001;15:2171-9.[CrossRef][ISI][Medline]
10. Genuis SJ, Genuis SK. Adolescent sexual involvement: time for primary prevention. Lancet 1995;345:240-1.[CrossRef][ISI][Medline]
11. Thato S, Charron-Prochownik D, Dorn LD, Albrecht SA, Stone CA. Predictors of condom use among adolescent Thai vocational students. J Nurs Scholarsh 2003;35:157-63.[CrossRef][ISI][Medline]
12. Dehne KL, Riedner G. Sexually transmitted infections among adolescents: the need for adequate health services. Reprod Health Matters 2001;17:170-83.
13. Cohen MW. Adolescent sexual activity as an expression of nonsexual needs. Pediatr Ann 1995;24:324-9.[ISI][Medline]

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