The Real Reasons Why People Don't Use Condoms

Condoms work. They remain the cornerstone of safer sex practices and a major contributor to the reduction of HIV infections worldwide.

So why, then, do only 65% of men use condoms on a consistent basis, according to a survey by the Centers for Disease Control and Prevention? And how is it that more than 20% of HIV-negative men who have sex with men (MSM) are willing to put themselves at risk by engaging condomless sex?

Women fare no better in these statistics. Of females who engage in high-risk,unprotected anal sex, a mere 11% report ever using a condom. Worse yet, women are far less likely overall to use condoms (including fem-doms) than their heterosexual male counterparts.

The Blame Game
Ignorance, apathy and irresponsibility may be the standard knee-jerk response, but that's a far too simplistic judgment for what is, in fact, an incredibly complex psychosocial issue.

In truth, there are a number of intersecting reasons for the decreased use of condoms among adults and young people. They include everything from how we feel about condoms, what we believe about HIV, how we negotiate sex in relationships, how \vulnerable we believe ourselves to be to infection, and even how adept we are at actually using condoms.

Dissecting these issues can be a dizzying process, made worse by the cultural tendency to assign blame to those we see as "vectors" (or the sources) of HIV infection.

Rather than opening up the conversation, we tend to shut it down—potentiating risk behavior in those who would rather remain silent than face public derision or disapproval.

At Risk Before We Even Start
Knowledge and power are the two factors that can affect genders and at-risk populations considerably, often in very different forms.

They not only direct why we make the decisions we do, but they also help explain why we sometimes put ourselves at risk against our otherwise better judgment.

Knowledge is not simply about our understanding of HIV as a disease, but our personal belief as to how susceptible we are to infection as individuals. This is called a perceived risk (a component of the so-called Health Belief Model).

Perceived risk is oftentimes based on misconceptions about who is "most at risk" for infection, either by group or behavior. Those, for instance, who believe thatunprotected oral sex between a man and a woman is "only a fraction" as risky as unprotected anal sex between high-risk MSM will likely forego discussions about condoms altogether. The same applies to misconceptions about age, race, education and income.
Perceived risk can vary considerably from one population to the next. While optimism about HIV sciences (including increased life expectancy and the efficacy ofpre-exposure prevention) generally correlates to higher condom use among heterosexuals, the same optimism has an inverse effect among many MSM, who believe that the consequences of an infection have now largely been minimized due to the ever-advancing medical sciences.

The Real Reasons Why People Don't Use Condoms

Conversely, pessimism about treatment or the effectiveness of safer sex generally translates to lower condom use. Oftentimes, these attitudes are fueled by an underlying distrust of public health authorities, specifically within poorer communities where infection rates are high and a lack of infrastructure hampers an effective community response. These factors can contribute to perceptions by which HIV is seen to be unavoidable—or even inevitable—to those most at risk.

Condom Bias
The same Emory University study revealed that nearly a third of the men surveyed reported that they had lost an erection after having put on a condom.

Negative associations and attitudes about condoms, known as condom bias, have long muted the safer sex message. They reflect both real and perceived barriers that can prevent people from using condoms, even when the risk of transmission is known. As a result, many decide to "trade off" between the potential risk and the "consequences" they associate with condom use.

Examples include:

• Lack of sexual spontaneity
• Unpleasant taste and smell
• Reduction of sexual pleasure for both men and women
• Loss of erection
• Condom use may be seen as a declaration of distrust or infidelity
• Condom use may be seen as a sign of sexual promiscuity
• Fear of being identified as "high risk," or as part of a stigmatized population (e.g., MSM, injecting drug users)

Condom Fatigue
By contrast, condom fatigue (also known as "prevention fatigue") is a term used to describe the general weariness felt by those who have tired of condom use. It reflects the decreased effectiveness of prevention messages, and is often associated with the increased transmission rates in MSM populations (although it directly impacts all population groups).

An increasing awareness of the benefits of antiretroviral therapy has led many to seek alternatives to condoms. Chief among these is the issue of Treatment as Prevention (TasP), a principle by which an HIV-positive person is less likely to transmit HIV if the viral load is undetectable.

A survey conducted by the Terrence Higgins Trust in London showed that, of a cohort of HIV-positive MSM, respondents largely failed to consider their viral in relation to transmission risk when making sexual decisions. Another reported that selective condom use was often based on the presumed HIV status of a sexual partner, rather than on an informed discuss about serostatus, therapy or viral load.

This seems to suggest that condom fatigue contributes to how a person uses anecdotal information to either make or validate personal belief, as opposed to making an informed choice will full, unbiased information.

Possible Strategies to Reinforce Condom Use

• If you are unaware of your HIV status and sexually active, get tested today. Research has shown that knowing one's status generally increases the sense of responsibility.
• Rather than addressing HIV in general terms, find information in plain language on the specific HIV risk in women, African Americans, MSM, etc. This can often be found at your nearest women's health facility, LGBT center or public clinic.
• Sexual education interventions (including instructions on the proper use of condoms and avoidance of common mistakes) have been shown to overcome many of the perceived barriers to condom use. In one study, condom use increased from 29% to 71% in a group of at-risk, heterosexual men after a single educational intervention.
• Don't count out the female condom, which Planned Parenthood stated "may enhance sex play (since) the external ring may stimulate the clitoris during vaginal intercourse." Female condoms also provide proactive controls to women who might be less able to negotiate safer sex.
• By and large, reducing the numbers of sex partners correlates to higher condom use. Studies suggest that this also reduces the likelihood of anonymous sexual encounters, while encouraging greater discussion about sexual health and HIV prevention.
• Finally, recruiting sexual contacts online often results in the practice ofserosortin" (using online information to make decisions or assumptions about a person's HIV status). Instead of relying on profile information, take the opportunity to actively discuss HIV and other health issues before meeting.

Sources:

• Anderson, J. "Condom Use and HIV Risk Among US Adults." American Journal of Public Health.June 2003; 93(6):912-914.
• Jacobs, R.; Kane. M.; and Ownby, R. "Condom Use, Disclosure, and Risk for Unprotected Sex in HIV-Negative Midlife and Older Men Who Have Sex With Men." American Journal of Men's Health. May 2013; 7(3):186-197.
• New York Department of Health and Mental Hygiene. "Women, Unprotected Anal Sex and HIV Risk" New York Vital Signs. February 2010; 9(2):1-4.
• Milam, J; Richardson, J.; Espinoza, A.; et al. "Correlates of Unprotected Sex Among Adult Heterosexual Men Living with HIV." Journal of Urban Health. July 2006; 83(4):669-681.
• Pulerwitz, J.; Amaro, J.; De Jong, W.; et al. "Relationship power, condom use and HIV risk among women in the USA." AIDS Care. December 2002; 14(6):789-800.
• Crosby, R.; Sanders, S.; Yarber, W.; et al. "Condom use problems and errors among college men." Sexually Transmitted Diseases. September 2002; 29(9); 552-557.
• Rietmeijer, C.; Lloyd, L.; and McLean, C. "Discussing HIV serostatus with prospective sex partners: a potential HIV prevention strategy among high-risk men who have sex with men."Sexually Transmitted Diseases. April 2007, 34(4):215-219.
• Suzan-Monti, J.; Préau, M.; Blanche, J.; et al. "The burden of HIV experience and care among MSM having an HIV-positive seroconcordant steady partner." Sexually Transmitted Infections. August 2011; 87(5):396-398.
• Bourne, A.; Dodd, C.; Keogh, P.; et al. "Relative safety II: Risk and unprotected anal intercourse among gay men with diagnosed HIV." London: Sigma Research/CHAPS/Terrance Higgins Trust, 2009.
• Crosby,R.; Diclemente, R.; Yarber, Y.; et al. "Refining self-reported condom use among young men at risk of HIV acquisition." Sexual Health. September 2007; 4(3):211-2.
• Gollub, E. "Choice Is Empowering: Getting Strategic About Preventing HIV Infection in Women." International Family Planning Perspectives. December 2006; 32(4): 209-212.
• Higgins, A.; Hoffman, S.; and Dworkin, S. "Rethinking Gender, Heterosexual Men, and Women's Vulnerability to HIV/AIDS." American Journal of Public Health. March 2010; 100(3):435-445.

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