Zenilman, Jonathan M. MD
From Johns Hopkins University, Baltimore, Maryland
Received for publication November 2, 2005, and accepted November 8, 2005.
Condom promotion is a core component of sexually transmitted disease (STD) prevention. The efficacy of condom use has been recently questioned, primarily by political groups affiliated with an abstinence-only political agenda. A focus of these criticisms, which was crystallized in the 2002 DHHS report on condom use and STD prevention,1 was for most STDs; there were little clinical data to support an efficacy claim.
In response, over the past 3 years, we have seen innovative epidemiologic approaches to address the problem without the need to perform randomized, prospective, controlled trials, which would be expensive, unethical, and impractical. Since 2002, consistent condom use has been shown to be effective in preventing herpes simplex infection,2,3 gonorrhea and chlamydia from partners known to be infected,4 and human papillomavirus infection.5
Condom efficacy requires both consistent use and proper use. Condom use is actually a complex, multistep process, including having a condom available, being able to interrupt sexual activity or foreplay to obtain it, putting it on correctly, using it correctly, taking it off correctly, and disposing of it after use. Correct and consistent condom use requires training in both behavioral/negotiating skills as well as technical skills. Although the public health community has been aggressively promoting condoms, training in proper condom use is not systematic. Condom use training is often provided as part of patient care and counseling in STD and family planning clinics. Proactive condom use training is included in progressive comprehensive sex education programs, which are currently used by only a minority of school systems.
The accompanying paper by Bortot et al,6 and its focus on high-risk adolescents, provides an important window for us to view a very high-risk population. The backdrop is Texas, a state that has aggressively promoted abstinence only in its schools, pronouncements, and policies. However, the state of reproductive health in Texas is dismal. In 2003, the Texas pregnancy rate for girls age 15 to 19 was 62.9 per 1000, which was the worst rate of all 50 states and which compares with the national rate of 41 per 1000,7 and rates for the bacterial STDs are well above the national means.8
In their article describing incarcerated youth, Bortot et al present a number of intriguing results suggesting that a more progressive approach in Texas, even in marginalized youth, would yield results. Abstinence only has clearly failed here. High-risk youth are sexually active, with 87% of the subjects reporting having had intercourse, 81% within the previous 3 months. Nevertheless, prevention messages are getting through, with 73% of those sexually active reported using a condom, although there were high rates of use errors. I was fascinated by the source of training; only 23% received training in school, and an additional 27% received some level of training at home. Forty-five percent of detainees had read the package insert, and for 23%, this was the only training received. A number of detainees had only seen condom use demonstrated in pornographic films!
Societies ultimately are judged by how we treat our children. My reading of these data is that adolescents, even those who are at the fringe of society, are desperate for the knowledge and means to protect themselves. Many of our communities have embarked on a road to certain failure. Promoting ineffective abstinence-only interventions, railing against condom efficacy, eliminating comprehensive reproductive health education, and not providing our children with the skills to protect themselves is public health malpractice.
1. Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. Washington, DC: US Department of Health and Human Services; 2001.
2. Wald A, Langenberg AG, Link K, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA 2001; 285:3100–3106.
3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ 2004; 82:454–461.
4. Warner L, Newman DR, Austin HD, et al. Condom effectiveness for reducing transmission of gonorrhea and chlamydia: The importance of assessing partner infection status. Am J Epidemiol 2004; 159:242–251.
5. Winer RL, Hughes JP, Feng Q, O’Reilly S, Kiviat NB, Koutsky LA. The effect of consistent condom use on the risk of genital HPV infection among newly sexually active young women. 16th Biennial Meeting of the International Society of Sexually Transmitted Disease Research; Amsterdam; 2005.
6. Bortot, et al. Sex Transm Dis 2006; 33:2–4.
7. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker M, Munson ML. Division of Vital Statistics. Births, Final Data for 2003. National Vital Statistics Reports 2005;54. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_02.pdf
. Accessed October 31, 2005.
8. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2003. Atlanta: US Department of Health and Human Services; September 2004.