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Approximately 15 million incident cases of sexually transmitted infections (STIs) occur in the United States each year.1 These figures are troubling given the availability of primary prevention measures that sexually active people can use to avoid unprotected intercourse, including latex condoms.2 Although considerable attention has focused on making condoms widely available, surprisingly little research3,4 has examined whether condom availability is sufficient to ensure condom use.
We recruited a convenience sample of 98 male students through advertisements posted on two Georgia university campuses to evaluate sexual risk taking behaviour. Men were required to be aged 18–29 years, full time students, and to have used condoms for ≥5 episodes of vaginal intercourse. After providing written informed consent, eligible men participated in a standardised interview about their experiences with condoms. The study was approved by the institutional review board of Emory University.
The 98 respondents averaged 22 years of age (SD 3). Sixty four (65%) were white, 27 (28%) were African-American, five (5%) were Asian American, and two (2%) were of mixed race. Men reported a mean of 18 lifetime sex partners (median 8 partners, range 1–150); most (96%) reported having vaginal intercourse during the previous year. Eighty five men (87%) used condoms because of concern about acquiring STIs; of these, most men were also concerned about pregnancy.
However, 73 men (74%) reported having vaginal sex without a condom when they “felt one should have been used” to protect against pregnancy and/or infection (median lifetime number of times without condom 8; range 1–450). Among men acknowledging unsafe sex, 42 (58%) admitted ever having unprotected intercourse despite ready access to condoms “within the same room” (median 5 times; range 1–300). Overall, condoms, although readily accessible, were not used in more than one third (37%) of lifetime acts of intercourse where risk of pregnancy or infection was perceived (832 of 2254 acts). Reasons for men's most recent failure to use condoms, despite accessibility, included unwillingness to interrupt foreplay (48%), fear of loss of sensation or erection (17%), and inebriation (17%).
Among all 98 participants, 58 men (59%) also reported occasions in which they intended to use a condom, only to find that they did not have a condom with them. At the most recent occasion when condoms were not available, 34 men (58%) chose to have unprotected intercourse. The remaining 24 men (42%) elected to abstain from intercourse and instead participated in non-penetrative sexual activities posing less risk for STI acquisition, or waited until a condom could be obtained.
Despite the small size and self selected nature of our population, these findings point to formidable barriers to ”safer sex,” at least in this heterosexual setting. Condom availability did not ensure condom use, even when condoms were needed. Similarly, the lack of availability of condoms did not deter most men from having intercourse. Avoiding sexual intercourse with an infected partner is the most effective way to prevent STIs.2 However, for sexually active people, condoms can only reduce the risk of infection when they are both readily available and actually put on.5,6
Support for this work was provided in part with funds from the Society of the Scientific Study of Sexuality.
IRB approval: obtained from Emory University, October, 1993.
Conflict of interest: Neither author has a conflict of interest regarding publication of this work due to financial involvements or specific affiliations. All financial and material support for this research and work are clearly identified in the manuscript.
Contributors Both authors have made substantial contributions to the intellectual content of the paper. LW was responsible for the conception and design of the study, locating funding for the study, acquisition of study data, data analysis and interpretation, and drafting and revision of the research letter; MS was involved with the conception and design of the analysis and interpretation and drafting and revision of the research letter.