British Medical Journal - Are condoms the answer to non-HIV STDs?

By Ruben Obregon

In a "head to head" debate in the British Medical Journal, Researchers Markus Steiner and Stephen Genuis tackle the question "Are Condoms the answer to rising rates of non-HIV sexually transmitted infection?"

While Markus Steiner argues that condoms are indeed the answer, Stephen Genuis argues that condoms are not the answer to non-HIV STDs, and that a more comprehensive approach is needed. While I disagree with the idea that comprehensive sexuality programs are the answer, he does raise some valid points of reliance on condoms alone to control disease.

Genuis points out the obvious; that condoms do not prevent skin to skin infections, which was brought to light recently with the outbreaks of USA300 MRSA among homosexual men in certain locales.

He also details that inconsistent use, mechanical failure, and compliance issues pose significant problems.

The main problem with condoms is that average people, particularly aroused youth, do not use them consistently, regardless of knowledge or education. Although condoms offer some protection against discharge related infections such as chlamydia and gonorrhoea, protection is usually compromised by compliance issues, incorrect use, or mechanical failure. (emphasis added)

Genuis also points out that only a small amount of people use condoms consistently:

In theory, condoms offer some protection against sexually transmitted infection; practically, however, epidemiological research repeatedly shows that condom familiarity and risk awareness do not result in sustained safer sex choices in real life. Only a minority of people engaging in risky sexual behaviour use condoms consistently. A recent study found that less than 8% of couples discordant for herpes used condoms for each sex act, despite ongoing counselling. Even among stable, adult couples who were HIV discordant and received extensive ongoing counselling about HIV risk and condom use, only 48.4% used condoms consistently. Irregular use of condoms will not provide sustained protection against sexually transmitted infection.

He goes on to say that behavioral changes, rather than widespread condom use, was instrumental in reducing the rates of STDs in Thailand and Cambodia:

Reports of diminished rates of sexually transmitted infection as a result of widespread condom use in countries such as Thailand and Cambodia are reinforcing the focus on condoms as the primary strategy. Careful scrutiny of the data, however, suggests that changes in sexual behaviour (fewer partners, less casual sex, and less use of sex workers) after mass educational campaigns rather than widespread condom use by ordinary citizens was instrumental in reducing infection rates.

While vilifying behavior based prevention programs is all the rage here in the US, programs which encouraged behavioral changes have been successful in reducing STD rates in Uganda, Cambodia, and Thailand.

But even the behavioral changes these programs promote have limitations - having fewer partners, instead of only having one partner, and using sex workers less often is still risky sexual activity. To improve these programs, emphasis should be placed on monogamous sexual relationships that are confined to marriage. Such programs also need to emphasize that sex has two purposes - bonding and reproduction - so that the culture of casual sex can be laid to rest along side its millions of victims.