Condoms

A condom is a device, usually made of latex, or more recently polyurethane, that is used during sexual intercourse. It is put on a male partner's penis, for the purpose of preventing pregnancy and/or transmission of sexually transmitted diseases (STDs) such as gonorrhea, syphilis and HIV.

Overview

Male condoms are packaged in a rolled-up form, and are designed to be applied to the tip of the penis and then rolled over the erect penis. They are most commonly made from latex, but are also available in other materials. As a method of contraception, condoms have the advantage of being easy to use, having few side-effects, and of offering protection against sexually transmitted diseases. With proper knowledge and application technique - and use at every act of intercourse - condom users experience a 2% per-year pregnancy rate. Condoms may be combined with other forms of contraception (such as spermicide) for greater protection.

Some couples find that putting on a male condom interrupts sex, although others incorporate condom application as part of their foreplay. Some men and women find the physical barrier of a condom dulls sensation. Advantages of dulled sensation can include prolonged erection and delayed ejaculation.

Materials

Latex

Most modern condoms are made of latex. This material has outstanding elastic properties. Tensile strength exceeds 30 MPa. Condoms may be stretched in excess of 800% before breaking. Natural latex condoms have a minimum thickness of 0.046 mm.

Some latex condoms are lubricated at the manufacturer with a small amount of nonoxynyl-9, a spermicidal chemical. According to Consumer Reports, spermicidally lubricated condoms have no additional benefit in preventing pregnancy, have a shorter shelf life, and may cause urinary-tract infections in women. nonoxynyl-9 was once believed to offer additional protection against STDs (including HIV) but recent studies have shown the opposite to be the case. The World Health Organization says that spermicidally lubricated condoms should no longer be promoted. However, they recommend using a nonoxynol-9 lubricated condom over no condom at all. In contrast, application of separately packaged spermicide is believed to increase the contraceptive efficacy of condoms.

Polyurethane

Polyurethane condoms can be thinner than latex condoms, with some polyurethane condoms only 0.02 mm thick. Polyurethane is also the material of many female condoms.

Polyurethane can be considered better than latex in several ways: it conducts heat better than latex, is not as sensitive to temperature and ultraviolet light (and so has less rigid storage requirements and a longer shelf life), can be used with oil-based lubricants, is less allergenic than latex, and does not have an odor.

However, polyurethane condoms are more likely to slip or break than latex, are more expensive, and may not be as effective in protecting against STDs (large clinical trials have not been performed).

Lambskin

Condoms made from one of the oldest condom materials, labeled "lambskin" (made from lamb intestines) are still available. They have a greater ability to transmit body warmth and tactile sensation, when compared to synthetic condoms, and are less allergenic than latex. However, there is a great risk of transmitting STDs because of pores in the material. While the pores are not large enough to allow sperm through, much smaller bacteria and viruses may easily slip in and out between the condom.

Invisible

The Invisible Condom, developed at Université Laval in Québec, Canada, is a gel that hardens upon increased temperature after insertion into the vagina or rectum. In the lab, it has been shown to effectively block HIV and herpes simplex virus. The barrier breaks down and liquefies after several hours. The invisible condom is in the clinical trial phase, and has not yet been approved for use.

Spray-on

As reported on Swiss television news Schweizer Fernsehen on November 29, 2006, the German scientist Jan Vinzenz Krause of the Institut für Kondom-Beratung ("Institute for Condom Consultation") in Germany recently developed a spray-on condom and is test-marketing it. Krause says the advantages to his spray-on condom, which is reported to dry in about 5 seconds, is that it is perfectly formed to each penis.

Form

In recent decades, condom makers have diversified in colors, shapes, and thicknesses. Flavors or designs thought to have stimulating properties are sometimes added. Such stimulating properties include enlarged tips or pouches to fit the glans penis better and textured surfaces such as ribbing or studs (small bumps). Many condoms have spermicidal lubricant added, but it is not an effective substitute for separate spermicide use. Most condoms have a reservoir tip, making it easier to leave space for the man's ejaculate. Condoms also come in different sizes, from magnum to snug.

Testing

In 1990 the ISO set standards for production (ISO 4074, Natural latex rubber condoms) and the EU followed suit with its CEN standard (Directive 93/42/EEC concerning medical devices).

Condoms are tested for holes with an electrical current. If the condom passes, it is rolled and packaged. Batches of condoms are tested for breakage with air inflation tests.

Effectiveness

In preventing pregnancy

The effectiveness of condoms, as of most forms of contraception, can be assessed two ways: method effectiveness and actual effectiveness. The method effectiveness is the proportion of couples correctly and consistently using the method who do not become pregnant. Actual effectiveness is the proportion of couples who intended that method as their sole form of birth control and do not become pregnant; it includes couples who sometimes use the method incorrectly, or sometimes not at all. Rates are generally presented for the first year of use. Most commonly the Pearl Index is used to calculate effectiveness rates, but some studies use decrement tables.

For all forms of contraception, actual effectiveness is lower than method effectiveness, due to several factors:

  • mistakes on the part of those providing instructions on how to use the method
  • mistakes on the part of the method's users
  • conscious user non-compliance with method.

For instance, someone using oral forms of hormonal birth control might be given incorrect information by a health care provider as to the frequency of intake, or by mistake not take the pill one day, or simply not bother to go to the pharmacy on time to renew the prescription.

The method pregnancy rate of condoms is 2% per year. The actual pregnancy rates among condoms users vary depending on the population being studied, with rates of 10-18% per year being reported.

In preventing STDs

According to a 2006 report by the National Institutes of Health, correct and consistent use of latex condoms:

  • reduces the risk of HIV/AIDS transmission by approximately 85% relative to risk when unprotected. See overall HIV transmission rates.
  • reduces the risk of gonorrhea for men by approximately 71% relative to risk when unprotected.

A University of Washington study published in the New England Journal of Medicine in June 2006 reports that proper condom use decreases the risk of transmission for human papilloma virus by approximately 70%.

Other studies have shown that the proper and consistent use of condoms prevented HIV from spreading from an infected partner to a non-infected partner in every case.

While different studies show a wide range of results, every scientific study verifies that engaging in sex with a STD positive partner without a condom increases the chances of transmitting an STD when compared to sex with a condom.

Other sexually transmitted infections may be affected as well, but they could not draw definite conclusions from the research they were working with. In particular, these include STDs associated with ulcerative lesions that may be present on body surfaces where the condom doesn't cover, such as genital herpes simplex (HSV), chancroid, and syphilis. If contact is made with uncovered lesions, transmission of these STIs may still occur despite appropriate condom use. Additionally, the absence of visible lesions or symptoms cannot be used to decide whether caution is needed.

An article in The American Journal of Gynecologic Health showed that "all women who correctly and consistently used Reality® were protected from Trichomonas vaginalis" (referring to a particular brand of female condom).

Causes of failure

Condom users may experience breakage or slippage of the condom due to faulty methods of application or physical damage (such as tears caused when opening the package), latex degradation (typically from being past the expiration date or being stored improperly), and from slipping off the penis after ejaculation.

While standard condoms will fit almost any penis, some men may find that use of 'snug' or 'magnum' condoms decreases the risk of slippage, leaking, and bursting. Ethnic differences may play a role in correct sizing; a small exploratory portion of a 2006 Indian Council of Medical Research study concluded that standard condom sizes were too large for many among India's men.

Experienced condom users are significantly less likely to have a condom slip or break compared to first-time users, although users who experience one slippage or breakage are at increased risk of a second such failure. An article in Population Reports suggests that education on condom use reduces behaviors that increase the risk of breakage and slippage. A Family Health International publication also offers the view that education can reduce the risk of breakage and slippage, but emphasizes that more research needs to be done to determine all of the causes of breakage and slippage.

Among couples that intend condoms to be their form of birth control, pregnancy may occur when the couple does not use a condom. The couple may have run out of condoms, or be traveling and not have a condom with them, or simply dislike the feel of condoms and decide to "take a chance." This type of behavior is the primary cause of "typical use" failure (as opposed to "method" or "perfect use" failure).

Another possible cause of condom failure is sabotage. One motive is to have a child against a partner's wishes or consent , known to be done by men and women alike. Saboteurs usually pierce the condom's tip multiple times before intercourse.

Health issues

Carcinogenic nitrosamines have been discovered in 29 out of 32 condom brands tested by the Chemical and Veterinary Investigation Institute in Stuttgart. However, there have been no studies linking the use of condoms to an increased risk of cancer and a 2001 study from the University of Kiel concluded that humans regularly receive 1,000 to 10,000 times greater nitrosamine exposure from food and tobacco than from condom use and concluded that the risk of cancer from condom use is very low.

Some lubricated condoms are produced with dusting powders, such as talc, which aren't recommended by the University of Virginia School of Medicine for surgery because of "acute & chronic problems" that may arise if the powders find their way into the abdominal cavity (i.e. via the vagina).

Condoms lubricated with the spermicide Nonoxynol-9 may increase the user's risk of contracting HIV and other sexually transmitted diseases. For this reason, Planned Parenthood has discontinued the distribution of condoms so lubricated, and the Food and Drug Administration has proposed a warning regarding this issue.

Latex condoms used with oil-based lubricants (e.g. vaseline) are likely to break due to rapid deterioration caused by the oils.

Female condoms

Recently "female condoms" or "femidoms" (not to be confused with femdoms) have become available. They are larger and wider than male condoms but equivalent in length. Female condoms have a flexible ring-shaped opening, and are designed to be inserted into the vagina. The female condom also contains an inner ring which aids insertion and helps keep the condom in place inside the vagina. This type of condom was first made from polyurethane, though newer iterations are made of nitrile (this material change was announced in September 2005).

Currently, 14 million female condoms are distributed to women in the developing world on an annual basis. By comparison, between 6 and 9 billion male condoms are distributed per annum.

Sales of female condoms have been disappointing in developed countries, though developing countries are increasingly using them to complement already existing family planning and HIV/AIDS programming. Probable causes for poor sales are that inserting the female condom is a skill that has to be learned and that female condoms can be significantly more expensive than male condoms (upwards of 2 or 3 times the cost). Also, reported "rustling" sounds during intercourse turn off some potential users, as does the visibility of the outer ring which remains outside the vagina.

The newer nitrile condoms are less likely to make these potentially distracting noises. It is hoped the nitrile condoms will also allow for significant reductions in female condom pricing.

Female condoms have the advantage of being compatible with oil-based lubricants as they are not made of latex. The external genitals of the wearer and the base of the penis of the inserting partner are more protected than when the male condom is used. Inserting a female condom does not require male erection.

Although marketed only for vaginal sex, some researchers promote use of the "female" condoms for anal sex between men.

In November 2005, the World YWCA called on national health ministries and international donors to commit to purchasing 180 million female condoms for global distribution in 2006. Their statement stated that "Female condoms remain the only tool for HIV prevention that women can initiate and control", but that they remain virtually inaccessible to women in the developing world due to their high cost of 72 cents per piece. If 180 million female condoms were ordered, the price of the female condom was projected to decline to 22 cents per female condom.

Effectiveness and risks of female condoms

The typical use failure rate for the first-generation female condoms lies at 21%. This means that of the women who intend to use female condoms as their only form of birth control, 21 out of 100 will become pregnant within one year. Among women who use the condom correctly at every act of intercourse, 5% will become pregnant after one year.

The effectiveness of the female condom at preventing STDs has not been studied to the same extent as male condoms, however it has been put forth that it should have similar effectiveness. They are also dangerous for those who have polyurethane allergies.

Role in sex education

Condoms are often used in sexual education programs, because they have the capability to reduce the chances of pregnancy and the spread of some sexually transmitted diseases when used correctly. A recent American Psychological Association (APA) press release supported the inclusion of information about condoms in sex education, saying "comprehensive sexuality education programs... discuss the appropriate use of condoms", and "promote condom use for those who are sexually active."

In the United States, teaching about condoms in public schools is opposed by various religious organizations, primarily some Protestant denominations and the Roman Catholic Church. Opposition may be based on the belief that teaching about contraception encourages premarital sex, or that only parents have the moral authority to teach children about sex. Some religions also consider the use of contraception to be immoral - the Catholic Church, for example, teaches that only total abstinence, or periodic abstinence (using Natural family planning), are moral ways to prevent pregnancy. The Protestant Quiverfull movement opposes all methods of family planning, including NFP. The Heritage Foundation, which opposes comprehensive sex education, believes that any sex education program should teach that "sexual happiness is inherently linked to... marriage," a moral message that is not found in comprehensive sex ed programs.

Groups such as Planned Parenthood, which advocate family planning and sexual education, argue that religious opposition to teaching about condoms results in increased number of unwanted pregnancies and the spread of STDs.

It should be noted that the Catholic Church directly condemns only artificial birth control, and sexual acts aside from intercourse between married heterosexual partners. The use of condoms to combat STDs is not specifically addressed by Catholic doctrine, and is currently a topic of debate among high-ranking Catholic authorities. A few, such as Belgian Cardinal Godfried Danneels, believe the Catholic Church should actively support condoms used to prevent disease, especially serious diseases such as AIDS. However, to date statements from the Vatican have argued that condom-promotion programs encourage promiscuity, thereby actually increasing STD transmission. Papal study of the issue is ongoing, and a 200-page document on the use of condoms to combat AIDS is being prepared for Pope Benedict's review.

Use in infertility treatment

Common procedures in infertility treatment such as semen analysis and intrauterine insemination (IUI) require collection of semen samples. These are most commonly obtained through masturbation, but an alternative to masturbation is use of a special collection condom.

Collection condoms are made from silicone or polyurethane, as latex is somewhat harmful to sperm. Many men prefer collection condoms to masturbation. Also, compared to samples obtained from masturbation, semen samples from collection condoms have higher total sperm counts, sperm motility, and percentage of sperm with normal morphology. For this reason, they are believed to give more accurate results when used for semen analysis, and to improve the chances of pregnancy when used in procedures such as IUI.

The Catholic Church teaches that masturbation is immoral. For observant Catholics, collection condoms are the only morally permissible way to obtain semen samples. Although detrimental to the purpose, most Catholics put two or three pinholes in the collection condom to avoid violating the Catholic prohibition on artificial birth control.

Condom therapy is sometimes prescribed to infertile couples when the female has high levels of antisperm antibodies. The theory is that preventing exposure to her partner's semen will lower her level of antisperm antibodies, and thus increase her chances of pregnancy when condom therapy is discontinued. However, condom therapy has not been shown to increase subsequent pregnancy rates.

Prevalence

Condoms are more accessible in developed countries. In various cultures, a number of social or economic factors make access to condoms prohibitive. In some cases, cultural beliefs may cause some persons to shun condoms deliberately even when they are available.

Furthermore, regardless of culture and availability, many men shun condoms simply because they dislike using them. This dislike may be due to reduced sexual pleasure or to practical problems, e.g. difficulty in sustaining an erection hard enough for effective condom use.

Because they are generally available without a prescription, and because they are very effective in reducing the spread of sexually transmitted disease, condoms tend to be especially popular among younger men, those who are not in exclusive partnerships, and newly-formed monogamous couples. Often, once a steady relationship has deepened, the woman may begin to use hormonal or some other type of highly effective contraceptive, at which time condom use typically (though not always) comes to an end. Ideally, however, this should not occur until blood tests have shown both partners to be free of infection.

Most research has revealed, through survey, four factors which establish the minimal use of condoms: various encumbering beliefs, reduced sexual pleasure, adverse experiences, and fears related to gender and tensions. New technology and beneficial studies have come forth that combat these various factors, however only a small proportion of individuals world-wide actually practice safe sex. This noticeable gap has lead several investigators to analyze whether social factors might be involved such as a residual social stigma attached to condoms.

In broad detail, social factors range from geographical location to race, and become as specified as methamphetamine versus non-drug users, so correlations within this research are not always strong and accurate, but it does establish that correlations do exist.

Geographic location

Several regions provide examples of social factors influencing the use of condoms within their populace. Two examples which contrast the effects of similar problems are South Africa and rural Lebanon.

South Africa has some of the highest HIV rates in the world, so there the statistics on condom use are being studied heavily. As of 2001, the 21-25 year age group has the peak rate of infection at 43.1%. These studies became more specified and it was discovered that despite all the information known today about HIV and the spread of infection, many young people of the study did not feel that they were in danger of contracting this disease. In fact, only 30% of people, males and females, felt they had any risk of contracting HIV at all. Of those that said they felt there was any chance of contracting HIV, only 12.9% thought there was a moderate chance, and 17.6% thought they had a good chance of infection. It seems that even though the youth of South Africa do have a relatively high level of knowledge concerning the risk factors of getting HIV, many feel that it simply won't happen to them. Many of the factors found in South Africa apply to well developed countries of the world and these new findings hopefully will help shape future campaigns against decreased condom use in the future.

Another end of the spectrum are the rural areas of Lebanon in the Middle East. Generally, the use of condoms and other forms of contraceptives in the Middle East is low even though there is a growing awareness of sexually transmitted diseases and HIV/AIDS. A study revealed that only twenty-four percent of the women in the regions ever used a condom. A household survey was also done on condom use which found that ninety-eight percent of women had indeed heard of contraceptive methods, but only eighty-five percent of the women had heard of condoms. Some things to keep in mind also are that women in this culture are not expected to have knowledge or express openly knowledge of contraceptives or even sexuality. Also some background that is needed on the group surveyed is that the marital fertility rate of the surveyed women were about five children per woman, and each of the women had a different level of education. About sixty-one percent had intermediate-level education, twenty percent had a primary education, and eighteen percent had trouble reading or could not read at all. This provides evidence that condom use varies dependent on social factors like the area’s cultural background and education.

It should be noted that largely the variances in geographical location are highly affected by culture and cultural beliefs, as well as class and race, but also have dynamic influences resounding from economic yield for the area, use and expansion of communication, and other criteria. These social factors can again be examined in South Africa and rural Lebanon:

An example is that in South Africa, it was discovered that condom availability is a problem for young adults. Although condoms are given away by local clinics, many participants stated that there are instances when they found themselves without condoms because they never know when they are going to need one. Thus, this higher economic region has properly developed health services; they are just not being properly utilized by the public.

Opposing in the lower economic region of rural Lebanon, another reason for the lack of condom use is that public health services and family planning services are very inadequately developed. A health service that is trying to help is the Lebanese Family Planning Association but their funding is very limited and recently they have not been able to increase its budget to promote more complete reproductive health service.

Despite these specific social factors contributing to the differences between these regions and others, most research has identified issues such as trust and gender power in relationships and others as socially relevant to almost all countries worldwide.

Drug use

Condom use among intravenous drug users is low. One study found that only 99 of 699 male Out-of-Treatment Injection Drug Users (OTIDUs) participating in the study reported always using a condom. Of the 232 women OTIDUs, 22 claimed their male partner always used a condom. Methamphetamine in particular has been associated with even lower use of condoms. When the same study was restricted to methamphetamine users only, condom use rates dropped to a mere one third and one fourth of the above statistics, respectively.

Anti-condom trends

Studies have shown baby boomers are increasingly contracting sexually transmitted diseases because they choose not to wear condoms. Many have been married, and separated, and now have random sexual partners. Several reasons for this choice are given. Since the women are no longer capable of conceiving children, they do not see the large risk in not protecting themselves, and thus the importance of a condom becomes minimal. Also, since many of them have just come out of a long term relationship, they are starting over and they are too uncomfortable with their new partner to ask them to use a condom.

The practice of barebacking in Western gay culture is another example of a trend away from condoms. Barebacking partners often know that they could reduce their risk of sexually transmitted infection by using a condom, but choose not to.

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