‘I didn’t like that when they started talking about the condoms in prison because I thought that most people would be using them for rape that wouldn’t leave any forensic evidence … You get raped and someone is wearing a frenchie.’ (Australian prisoner before condoms were introduced)

In 1991, the World Health Organization reported that 23 of 52 prison systems surveyed allowed condoms in correctional facilities.¹ In 2006, prison jurisdictions in many countries, including most Australian states, still did not allow prison inmates access to condoms, despite evidence that HIV prevalence and transmission risks are higher within prisoner populations than within the general community.² Condoms, if used correctly and consistently, can prevent HIV and other sexually transmitted infections (STIs).^3,4

Despite Australia’s success in containing the HIV epidemic in the general population and within specific high-risk groups,⁵ it took the better part of a decade, between 1987 and 1996, of political and legal controversy before condoms were allowed into New South Wales (NSW) prisons. Opponents argued that: (1) condoms would encourage prisoners to have sex; (2) condoms would lead to an increase in sexual assaults among prisoners; (3) prisoners would use condoms to hide and store drugs and other contraband items; (4) prisoners would use condoms as weapons against nurses, prison officers and fellow inmates (Christensen A, personal communication, 2006); and (5) prisons would be perceived as “homo” gaols, as stated by Mr Armstrong, then president of the Prison Officers’ Association, in the Sydney Morning Herald, 3 February 1988.^6,7,8,9,10

These arguments have rarely been examined using objective evidence. We examine whether the concerns raised by opponents to condoms in NSW prisons were realised after their introduction in 1996.

In 1993, 52 prisoners instituted legal action in the NSW Supreme Court, Prisoners A–XX Inclusive v. State of NSW, against the State government’s policy of denying access to condoms in prisons.^11,12 Following legal advice on the likely adverse outcome of the case, the NSW Department of Corrective Services implemented a pilot condom distribution programme in three men’s prisons.

The 6-month condom pilot was conducted between March and August 1996 using condom-vending machines that dispensed a small cardboard box containing one condom, a sachet of lubricant, information on the correct use of condoms and a plastic zip-lock disposal bag. Beginning in September 1996, the condom programme was expanded across NSW and included dental dams in women’s prisons. By 2005, the condom programme was distributing approximately 30 000 condoms and dental dams per month to prisoners in NSW. Condoms are freely available from both dispensing machines and the prison clinics.

METHODS

We examined various sources of data, including the NSW Inmate Health Survey (IHS) from 1996 and 2001 and official reports from the NSW Department of Corrective Services.

The methodology for the 1996 and 2001 IHS has been described elsewhere.^13–18 It involved 657 men and 132 women randomly selected from all prisons, with a 90% response rate in 1996. The 2001 survey involved 747 men and 167 women inmates, with an 85% response rate.

Several days before the survey, the NSW Department of Corrective Services provided a list of all detainees in the State’s 29 correctional centres. Inmates were selected randomly from this list, with stratification for age and indigenous status. The sample size was selected to enable a range of physical health, mental health and risk behaviours to be described for men and women and for Aboriginal and non-Aboriginal prisoners. Potential participants received verbal and written information about the study; those agreeing to participate were required to provide written consent. Respondents in the 1996 and 2001 surveys were paid $A10 each. Nurse interviewers collected the health information by face-to-face interview. The screening instrument covered a broad range of physical and mental health issues and risk behaviours. Blood and urine specimens were collected to screen for a range of infectious diseases and STIs.

Questions were also included on attitudes to the provision of condoms or dental dams in prison (1996), experiences of consensual and non-consensual sex in prison, injecting drugs in prisons, awareness of sexual assaults by others (1996 and 2001) and personal use of condoms or dental dams for purposes other than sex (2001).

Indirect questioning about awareness of sexual assaults was judged to be less personally threatening for the prisoners to answer. Respondents were also asked to list up to three ways in which they were aware of condoms or dental dams being used in prison. Neither the 1996 nor the 2001 IHS enquired about prisoners’ own use of condoms or dental dams for sexual purposes.

Sexual behavioural data were excluded from the three (of 29) prisons in 1996 that were involved in the condom pilot study, so as to prevent possible contamination of the results by those exposed to condoms at the pilot sites. Open responses were categorised and coded for tabulation and χ² tests were used to test for differences across surveys.

Reports on sexual assaults among inmates and misdemeanours related to the unauthorised possession or misuse of condoms between 1996 and 2005 were obtained from the NSW Department of Corrective Services.¹⁸ Under the 1996 prison policy, condoms and dental dams were not to be used for any purpose other than sexual activity with another consenting prisoner within a prison cell. Penalties apply for the unauthorised possession, use and disposal of condoms. The punishment provisions were regulated in the Crimes (Administration of Sentences) Regulation 2001 (NSW) (http://www.austlii.edu.au/au/legis/nsw/consol_reg/cosr2001439/).

RESULTS

Prisoner attitudes to condoms and dental dams in prison (1996)

According to the 1996 IHS, 32% of men opposed condoms and 5% of women opposed dental dams in prison. Around 10% of men feared that condoms, and 1% of women believed that dental dams, would lead to an increase in sexual assaults in prison, while 4% of men believed that condom provision was unacceptable on the grounds that it would lead to an increase in sexual activity among prisoners. In all, 6% of men believed that homosexual activity in prisons was unacceptable and 1% was concerned that condoms would give people the impression that prisoners were homosexuals. Nevertheless, 27% of men approved of condoms and 54% of women favoured dental dams in prison.¹⁶

Prison sex (1996 and 2001)

In 1996, most male prisoners reported that, in their lifetime, they had never had a male sexual partner (94.5% female partners only, 0.7% male only, 4.8% both; n = 603). Female inmates were more likely to report same-sex partners (68.1% male partners only, 12.9% female only, 19.0% both; n = 116).¹⁶

Few inmates reported having sex in prison (table 1). Between the 1996 IHS (excluding the three pilot sites) and the 2001 IHS, there was a reported decrease in the proportions engaging in either consensual (p<0.001) or non-consensual (p<0.001) sex between men. There was no significant change for women.

In 1996, 30% of men and 17% of women reported being aware of a sexual assault taking place in their prison in the past 12 months or since they came into prison within the past year (table 1). Fewer male inmates reported awareness of sexual assaults in 2001 (13%) than in 1996 (p<0.001), but there was no significant change among female inmates. About half the respondents said the most recent assault that they were aware of had occurred within the past 6 months.

Official records of sexual assaults in NSW prisons revealed that the incidence of notifications did not change significantly between 1996 (0.3/100 inmates) and 2001 (0.2/100 inmates).¹⁸

Condoms and dams used for purposes other than sex (2001)

The 2001 IHS asked prisoners whether they were aware of the use of condoms or dental dam kits for purposes other than sex. The prisoners (38% of men and 46% of women) offered at least one purpose (table 2). The most common use of condoms and the condom disposal bags was for the storage of contraband items and tobacco (prisoners generally smoked “roll-your-owns” rather than manufactured cigarettes). Lubricant was used as hair gel. Flavoured lubricant enjoyed a brief fashion as flavouring (banana and strawberry) for milk before being withdrawn. Condoms were also used as water bombs for throwing. The main non-sexual use of dental dams by women prisoners was for hair ties and sometimes as placemats or doilies.

While the contents of condom kits were used to store drugs, there was no difference in the proportion of prisoners who reported injecting drugs while in prison in 1996 and 2001 (21.5% vs 24.2% in men, 31.8% vs 33.5% in women).^16,17

Statistical data from the NSW Department of Corrective Services showed that condom misdemeanours were rare, and that incidents involving the unauthorised possession or misuse of condoms in 1996 and 2001 amounted to 0.0/100 inmates and 0.1/100 inmates, respectively.¹⁸ These incidents may have included three reports of condoms being used as weapons against prison officers recorded on prison charge sheets between 1996 and 2005. One incident involved a prisoner throwing a condom filled with shampoo at a prison officer and the other two incidents were similar, using liquids resembling ejaculate (Ropp FA and Vumbaca GA, personal communication, June 2006).

DISCUSSION

Condoms are a simple but effective means of preventing the spread of HIV and other STIs in the community, and the prison setting should be no exception to this. Despite their widespread acceptance in the community, their introduction in NSW prisons was controversial. Interestingly, the sentiments expressed by opponents to condoms in prisons, including government ministers, prison officers and their unions, and prison nurses, were also echoed by the prisoners. Most of these concerns were not realised. In fact, we found evidence of a decrease in both male-to-male consensual sex and sexual assaults between 1996 and 2001.

The decline in both consensual and non-consensual sex among men may be because of other factors. In 1996, the NSW Department of Corrective Services and Justice Health introduced health education programmes focusing on inmate education about HIV/AIDS and hepatitis, and established HIV/AIDS committees that included inmates.¹⁹ However, the presence of condoms and dispensing machines in NSW prisons may have also raised awareness and continued to reinforce HIV/AIDS prevention messages for prisoners.

Prison officers’ concerns that condoms would be used for concealing contraband items were justified. However, this did not appear to have led to an increase in the use of drugs in prison. Prisoners would undoubtedly find any means of storing contraband even if condoms were unavailable. In a controlled and resource-poor setting, inmates display great inventiveness in employing any new resources for a variety of purposes, and safe sex kits are no exception. A limitation of our study design is that we were unable to determine the proportions of the 30 000 condoms and dental dams issued per month that are used for various purposes.

There were three reports of minor incidents of condoms being used against prison officers. Such incidents were rare compared with the number of more serious assault charges recorded against prisoners each year, and were mainly of a mischievous nature.

Although the condom programme included the provision of dental dams for women’s prisons, this was presumably for political reasons rather than out of genuine concern about the spread of STIs that might be prevented by use of dental dams.²⁰ There was little controversy about dental dams before their introduction.

While these data are based on self-report and are subject to the insensitivity of official reporting, they highlight the benefit to correctional services of undertaking periodic surveys of prisoners’ health and behaviour to assess the outcomes of policy initiatives. Although there was initially strong opposition to condoms in prison, this soon dissipated as most of the anticipated adverse consequences did not eventuate. At least in NSW, condoms did not cause rape and mayhem.