What About the Condom?

Over the last few years, the condom has been promoted as the method of choice for preventing STDs. It has been described as the "vaccine" against such afflictions, and condom use has been the mainstay of the so-called "Safe Sex" and "Safer Sex" campaigns. This inanimate object has received astounding notoriety and has been advertised on television and radio; it has been carried and promoted in elementary schools through to universities; and has been advocated by certain church groups, government institutions, and many experts in the medical profession.

There have been a variety of clever and witty advertisements with such catchy phrases as "Don't go out without your rubbers" and pictures of condom dresswear with the jingle "Evening wear for lovers that care." The condomania mentality is increasingly pervasive to the extent that I recently saw a novelty store advertising "Used Rubbers for Real Cheap Lovers!" As cute and shrewd ads have not met with the desired result, condom advocates have pushed for more explicit and direct ads with the hope that people will understand and identify with this more realistic presentation. As a result there have been a variety of forthright messages using crude profanities to discuss sexual activity. It appears that many groups, with influential sponsorship, are putting all their hopes into the condom basket.

Amid all the excitement, controversy and hysteria, it appears that a cold sobering look at the usefulness and success of this "panacea" has been neglected. To do so, let us consider the failure rate of the condom, the usefulness of this device in the teenage population, and the scope of protection provided.

In order to appreciate the real value of the rubber condom, it is first necessary to assess its performance in relation to preventing unwanted pregnancy. To define the success of any contraceptive method, the medical community has established a definition and standard by which each method is evaluated. The effectiveness of a given form of birth control can be discussed in terms of its `Theoretical Effectiveness, and its `Practical' or `Actual Effectiveness'. The Theoretical Value is the potency under so-called ideal conditions with no defects, omissions, or improper use. The Practical Value is the success achieved at preventing pregnancy in real life with real people. As our current world is made up of real people, we will deal with the Practical Effectiveness.

The effectiveness of a contraceptive method is defined in terms of the phrase "number per 100 woman-years." This definition is designed to complete the sentence:

"Of 100 typical users who start out the year
employing a given method of contraception,
the number who will be pregnant by the end
of that year will be _________."

After reviewing the extensive literature on contraception, some variation in results is found. Reported failure rates for condom use vary from about 2 to 35 unplanned pregnancies per year, but a conservative consensus reveals a rate in the range of 8 failures per 100 users each year in the general population. Simple mathematics would conclude that after five years, the number pregnant with this method would be five times the yearly rate. Thus, after five years of condom use, there would be about 40 pregnancies in this group of 100 real people; after 10 years there would be 80 pregnancies. The two tables (8-1 & 8-2) are examples of charts depicting failure rates of various forms of family planning.²

Table 8-1 First Year Failure Rates of Birth Control Users

Method

Failure Rate in Typical Users

___________________________________________________________________________

Tubal Ligation Vasectomy Combined Birth control pills IUD Condom

0.04 0.15 2 4 10

______________________________________________________________________________


Table 8-2

Percent of Couples Who Experience Contraceptive Failure within the First Year of Contraceptive Use

Method

Failure

______________________________________________________________________________

Oral Contraceptive IUD Condom Diaphragm

2.0 4.2 10.1 13.1

______________________________________________________________________________

Despite much effort and money directly aimed at educating teens about birth control, there is a dramatically higher failure rate in this population. For example, the oral contraceptive medication has a Practical failure rate of about 1-2% per year in the general population, but a major study on contraceptive failure reported that in single woman under 18 years of age, using the birth control pill to prevent pregnancy, the first year failure rate was 11%!³ The failure rate of condoms is also seriously higher in the adolescent age group. For example, an article in the journal, Family Planning Perspectives, quotes an annual Practical failure rate of 18.4 percent in teenage girls under 18 years of age who are using condoms to prevent pregnancy. According to these figures, over half of the teenage users will be pregnant within three years. The authors further qualify this failure rate by stating that "these rates are understated because of the substantial under-reporting of abortion among single women; if abortion reporting was complete, failure rates would be 1.4 times as high as they appear here..."⁴

In an attempt to defend the usefulness of the condom, some have suggested that it might be easier to get pregnant than to catch a STD. How valid is this claim? In the normal reproductive cycle, which lasts about four weeks on average, the human egg is fertilizable for only 12-24 hours.⁵ Sperm generally retain their ability to fertilize for 24-49 hours,⁶, ⁷, although they may live for a longer period. There are thus, on average, only three to four days per cycle when sexual intercourse may result in conception. Conversely stated, normal physiology dictates that it is usually not possible to conceive a pregnancy for 85% of the year regardless of the sexual practices of those involved. Furthermore, in any given month, intercourse during this fertile time results in a viable pregnancy only about 20% of the time on average. This illustration would suggest that the high failure rate of condoms, with such a short available time for conception to occur, places this rubber saviour in a poor light in preventing unplanned pregnancy. The concerning point is that sexually transmitted diseases can be contacted at any time of the year and at any time of the menstrual cycle.

This limited effectiveness in preventing infection has been addressed in an article in the New England journal of Medicine entitled "What is Safe Sex?"The author comments in reference to AIDS, "It is clear that the use of condoms will not eliminate the risk of transmission and must be viewed as a secondary strategy."⁸

Some have tried to support the condom mentality to prevent the spread of AIDS by pointing to a transient reduction in the very significant incidence of gonorrhea in certain groups after encouraging condom usage. This is a rather tenuous premise as HIV and gonorrhea are totally different. "Unlike gonorrhea, HIV infection cannot be cured, is certain to be carried for a long time (possibly for life), and is highly likely to cause death. The risk of transmitting HIV must therefore be eliminated, since there is no acceptable level for this risk."⁹ Furthermore, there is mounting evidence that since 1988, the incidence of gonorrhea has been rising.¹⁰

Another very significant shortcoming of the condom is illustrated by two of the common viral STDs. Both the human papilloma virus (HPV) (which has recently been closely linked with genital tract cancers), and the herpes simplex virus, are not confined to the localized areas under the often-thought omnipotent protection of the condom. They are frequently found in various locations of the external genital tract (e.g. vulva, clitoris, anal and groin areas). As intercourse generally involves contact in these regions, it is apparent that condom usage would provide little, if any, protection against these types of organisms. As has been mentioned, this is particularly disturbing when one considers that there is at least a 50% chance of transmission of HPV with a single sexual encounter with an infected person.¹¹ The abysmal failure of condoms in this regard can be witnessed by the recent explosion in human papilloma and herpes simplex viral infections despite increased condom use.

In order to justify the continuous funding and promotion of condom education, it has been suggested that the high failure rate with condoms is most frequently due to improper use rather than condom malfunction. The Theoretical failure rate, or the rate which minimizes human error, has been stated as 2% per year. Accordingly, the dramatically higher Practical, or Real failure rate, is felt to be due to some element of human imperfection. The prevailing "pro condom" lobby emphasizes that if we "educate, educate, educate!", people will feel more comfortable and adept at using condoms and thus the rate of failure, and consequently the rates of unwanted pregnancy and STDs, will diminish. To address this claim let us consider a few points.

An extensive review of the medical literature reveals a particularly noteworthy study which attempts to assess practical condom effectiveness in a select and " condom- educated" population. In order to be eligible for the study, the participants had to be highly motivated towards family planning, aged 25-39 years, married, and British subjects. After education by the British Family Planning Association, contact was maintained with the couples to determine results and propose conclusions. Even in this very select group of married couples, the failure rate was 4% per year, or 20 pregnancies per 100 women every five years.¹² With such a dubious success rate in this motivated, informed group, it appears naively optimistic to expect greater success with condoms in a vulnerable, adolescent population. This study supports my own experience in medical practice over the last number of years; I have seen hundreds of couples who have conceived a pregnancy despite meticulous condom use.

In addition, there is no consistent evidence that the condom propaganda blitz has resulted in a decrease in STDs. I noted with interest that an article written in the Reproductive Health Digest was titled: "STDs: They're ALL still going up".¹³ When one listens to statistics presented about any apparent difference that the condoms are making, it is once again very important to remember that statistics can often be interpreted in a variety of ways and require careful and close scrutiny of the overall situation. For example, I was recently told that the rate of rise of one infection has declined in a specific localized population. On careful examination, however, it became apparent that a significant proportion of the population in that area had already been infected, leaving a smaller pool available for new infection. The numbers alone might, in this example, suggest that the rate of infection is diminishing, but the total picture reveals that the infection has already markedly infiltrated the population studied, leaving fewer persons available for an initial infection. The conclusions drawn would obviously differ depending on how this scenario was viewed and presented.

It is interesting to note that in areas with relatively high rates of known HIV infection, there has been a particular emphasis placed on the dissemination of information about condoms. Yet, even in these areas, evidence supporting the effectiveness of this educational strategy has not been produced. In fact, an abstract from the American Journal of Public Health highlights this concern.

Over a year when public health information regarding AIDS intensified, changes in perceptions and use of condoms in a sample of sexually active adolescents in San Francisco were examined. Although perception that condoms prevent sexually transmitted diseases and the value and importance placed on avoiding STDs remained high, these were neither reflected in increased intentions to use condoms nor in increased use.¹⁴

Fourthly, as has been discussed, condoms do not offer protection for diseases that are transmitted by skin to skin contact such as human papilloma virus and herpes simplex virus, frequently found throughout the genital area in infected individuals. No degree of condom education will curb the transmission of these organisms.

Finally on this point, I would like to consider an analogy as it pertains to this idea of securing results by improved and omnipresent condom education. In the general scholastic realm, despite the efforts of teachers to "educate, educate, educate!" the performance and examination results do not approximate 98-100% in most students. Even with excellent teachers, with researched and refined instruction methods, and with available extra tutorials and assistance, rarely do students achieve perfection. A few students score highly, most do average, and unfortunately a few fail. With condoms, however, anything less than perfection frequently results in the devastation of an unwanted pregnancy or a serious STD. One cannot help but question the expectation that with condom education most people will score near perfection. Yet, after a comprehensive review of the available literature on condoms, it is evident that the practical failure rate does not even come close to approximating perfection. To expect condom performance perfection, especially in teenagers where sexual activity is often unplanned, is grossly unrealistic-and this claim is supported by the disturbing escalation of STDs rates despite condom advertising.

An additional precaution that some have recommended to shield against STDs has been the "Coat of Armour" or the use of a spermicide in combination with a condom. While this supplement certainly decreases the rate of pregnancy, the toxic agents used to destroy the sperm may also have localized toxic effects on the body's own natural defense mechanisms. A concern was recently expressed that spermicide use may alter the protective lining of the vagina to perhaps more easily facilitate entry of HIV into the body.¹⁵

Over the last few years, there has been significant and increasing pressure to provide teenagers with easy access to condoms by placing dispensers in school washrooms. Let us consider two of the messages this undertaking provides to the students in schools harboring these machines:

1. There is a serious problem with STDs and something has to be done to diminish this problem.
   
   
2. Condoms provide effective protection against STDs.

Although the first message is absolutely true, the second suggestion is both dangerous and misleading. it provides people with a false sense of security-the mistaken notion that sex, utilizing a condom, is "safe". (The phrase "safe sex" has almost become synonymous with "using a condom during sexual activity".) If a condom is used, it is often assumed that sexual involvement carries no significant risk. As a result couples may engage in certain types of sexual activity that they otherwise might reconsider if the real hazards were known.

In general, it is important that inherent in any policy or program, there should be a mechanism to continually verify the real impact being made on people. This would ensure that programs based on hopes and projections would be monitored to assess actual results. In other words, programs should be evaluated by achievements and results, not promises and dreams. Thus far, I am not aware of any conclusive evidence revealing that increasing access to condoms actually decreases pregnancy or STD rates. Furthermore, there have now been anecdotal findings in some smaller communities that unwanted pregnancy rates have in fact increased since the placement of condom dispensers in the educational institutions. One explanation offered for this phenomenon has been the "kill two birds with one stone" mentality where users assume that the condom will prevent both STDs and pregnancy. As a result, the condom has replaced more effective forms of pregnancy prevention with a resultant increase in the number of unexpected pregnancies.

Although it is undeniably true that with any given sexual encounter, a participant is at less risk of contacting some types of infection with the proper use of a condom, it is equally true that over time, the sustained success at avoiding STDs by condom use is doomed to failure for many unsuspecting victims.

Many groups have been intrigued as to the evolution of AIDS prevention programs. Some critics, recognizing the limited effectiveness of the condom plan, have puzzled as to the persistent emphasis on this strategy. With reference to AIDS prevention programs, it has been explained that "The urgent nature of the epidemic is such that we have been recommending and implementing a variety of prevention programs based more on a reasoned hope than an established efficacy."¹⁶ Although it is understandable that an epidemic such as AIDS, with all the serious ramifications, would result in formulation of prevention strategies based on "...a reasoned hope...", enough time has elapsed to recognize the failure of the condom propaganda blitz despite previous hopes along this line.

With the phenomenon of global media coverage, world attention is being directed at the horrendous numbers of AIDS fatalities and the explosion of HIV in Africa, Asia and South America. As in other locations world wide, condoms are generally presented as the best and the only realistic prevention against transmission of this lethal virus. Addressing this matter at the Seventh International Conference on AIDS in Florence in 1991, President Yoweri Museveni of Uganda stated, "In countries like ours, where a mother often has to walk twenty miles to get an aspirin for her sick child, or five miles to get any water at all, the practical questions of getting a constant supply of condoms or using them properly may never be resolved." According to this national leader, the answer for his disease stricken country lies in "a return to our time-tested cultural practices which emphasized fidelity and condemnation of premarital or extramarital sex."¹⁷

It has often been expressed that most, though not all, of the STDs are sexist in nature. HIV is an example which appears to have serious complications in both men and women. Yet, with many of the other types of sexually transmitted infections, it is frequently the woman who is victimized by the serious complications, including infertility, cancer of the cervix, and other chronic pelvic problems. A female family physician recently commented to me that if the male partner suffered the majority of the complications, "...the pseudo-protection strategy of condom promotion would not be in place" and that "more effective strategies and types of prevention would have been implemented years ago!" One evening, a short while ago, my wife and I attended an outdoor theater festival. While listening to a string quartet perform Vivaldi, I stood close by a kiosk where volunteers were distributing free "information" about AIDS. The little booth was adorned with posters, in an assortment of languages and styles, pushing the message of safe sex through condom usage. A young male volunteer attempted to inspire the passers-by on the need to be "comfortable and familiar" with condoms as the only protection against AIDS. One gentleman, walking by with his pre-teen son, was stopped by the volunteer and an information pack and a free condom were offered. The father responded that these types of diseases had nothing to do with him or his son because they were "straight". It concerned me that condoms were being presented as the solution to the AIDS crisis, but of equal concern was the fact that many individuals do not recognize that STDs are a threat, regardless of sexual preference.

To put the problem in perspective, the rate of increase of new AIDS cases in the United States, went from 9 percent in 1989 to 23 percent in 1990. Over this same time period, the rate of increase of new AIDS cases tripled in women! Without exception, every population group, including men, women, newborns, individuals involved in high risk activities, and those with no known risk factors showed an increase in the rate of new AIDS cases.¹⁸, ¹⁹ The World Health Organization recently estimated that up to 5,000 people are newly infected with the lethal AIDS virus every single day!²⁰ Furthermore, it has been suggested that in the very near future, the second leading cause of death in many North American cities for men in their twenties, and the leading cause of death for women between the ages of twenty and forty will be AIDS. As the length of time from infection to death is frequently in excess of seven years, it is apparent that many people succumbing to this disease contracted it during their teenage years. A presentation in the New England Journal of Medicine states that in couples where one partner was HIV positive "...condoms failed to prevent HIV transmission in 3 of 18 couples, suggesting that the rate of condom failure with HIV may be as high as 17 percent."²¹ As it is now evident that many people have been infected with the lethal AIDS virus despite meticulous condom use, and that condoms do not provide protection against some other STDs, it is clearly of utmost importance that all people have access to truthful and complete information so that they can make appropriate health decisions. Access to full information and responsible personal choice within the law are, after all, important elements of a free society.

In conclusion, we are in the midst of a profound crisis and the situation is deteriorating. It is imperative that people be fully informed and educated about the facts and the issues. The strategy of encouraging condom use is not meeting its objectives. Yet, despite this lack of success, many continue to not only support the condom as the major warrior against STDs, but vociferously deny and oppose education which includes the serious shortcomings of condom use for so-called "safe sex". It is time to critically assess the effectiveness of this type of protection and to implement an alternate plan of prevention to curb the ongoing devastation in the lives of young and old alike.

Endnotes:

1. Adapted from Hatcher R. A. et al: Contraceptive Technology 1982-1983 (ed. 11 ) New York Irvington Publishers Inc., 1982, p.5. Back to text.
2. From Vaughan B et al Contraceptive failure among married women in the United States, 1970-1973 Family Planning Perspectives 9:251, 1977.
   
3. Grady WR, Hayward MD, Yagi J: Contraceptive failure in United States estimates from the 1982National Survey of Family Growth. Family Planning Perspectives 18(5): 200-209, 1986.
4. Speroff L, Glass R, Kase N: Clinical Gynecologic Endocrinology and Infertility 2nd ed. Baltimore, Williams and Wilkins,1982, p 327.
5. Speroff L Glass R, Kase N: Clinical Gynecologic Endocrinology and Infertility 2nd ed. Baltimore, Williams and Wilkins, 1982 p.327.
6. Austin CR, Human Embryos, The debate on Assisted Reproduction, Oxford University Press, p.6 1989.
7. Goedert, J J What is safe sex? New England Journal of Medicine 316(21) 1339-1341, 1987.
8. Goedert, J J What is safe sex? New England Journal of Medicine 316(21) 1339-1341, 1987.
9. Hewens FE, (Ed): Gonorrhea total-like its antibiotic-resistant variety-goes up. Reproductive Health Quarterly Fall 1990, p 1.
10. Beutner RR: Human papillouma virus infection. Journal of the American Academy of Dermatology 20:114-123, 1989.
11. Glass R, Vessey M, Wiggins P: Use effectiveness of the condom in a selected family planning clinic population in the United Kingdom. Contraception 10(6):591-598, 1974.
12. Hewens FE.(Ed) STDS: They're ALL still going up, Reproductive Health Digest, 1(4) 1 1988.
13. Kegeles SM, Adler NE Irwin CE: Sexually active adolescents and condoms: changes over one year in knowledge, attitudes and use American Journal of Public Health 78(4) 460-461, 1988.
14. Kreiss et al, Efficacy of nonoxynol-9 in preventing human immunodeficiency virus transmission, V International Conference on AIDS, Abstract, p.54, 1989.
15. Cates W Jr: Reviews and commentary Acquired immunodeficiency syndrome, sexually transmited diseases , and epidemiology. American Journal of Epidemiology 131(5) 755. 1990.
16. McConnell H: Africa, Asia, S. America, facing HIV explosion. The Medical Post, 27 (27)24, 1991.
17. Steel E, Haverkos HW: Increasing incidence of reported cases of AIDS. New England Journal of Medicine. 325(1):65-66, 1991.
18. Centers for Disease Control. HIV/AIDS Surveillance Report. Year-end ed. January 1991.
19. Heterosexual sex listed a cause in 75% of world's AIDS cases, Globe and Mail, Nov 12. 1991, pA8.
20. Goedert, J J: What is safe sex? New England Journal of Medicine 316(21) 1339-1341. 1987.