By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director, School-Based Health Centers
New York–Presbyterian Hospital
Columbia University Medical Center
New York City
According to the 2015 Youth Risk Behavior Surveillance (YRBS) Survey, the percentage of sexually active high school students reporting condom use at last intercourse has declined from a peak of 63% in 2003 to 57% in 2015.1 The 2015 YRBS found that just 57% reported using a condom at last intercourse. Overall, the percentage of students reporting condom use has increased since the YRBS started collecting data in 1991, when only 46% reported condom use at last intercourse. The decline in reported condom use at last intercourse in recent years serves as a reminder that discussing condom use with adolescents should remain a priority for healthcare professionals.
Condoms provide excellent protection from STIs, and they have the added benefit of acting as a method of pregnancy prevention. As a contraceptive, latex male condoms have just a 2% failure rate with perfect use, but the failure rate for typical use is estimated to be as high as 18%.2
The American Academy of Pediatrics Committee on Adolescence statement on condoms encourages clinicians to actively support consistent, correct condom use. The statement also suggests providing condoms in healthcare providers’ offices as well as in community settings, such as schools.3
It is appropriate and essential to discuss condom use with adolescents of all genders. Research suggests primary care providers are twice as likely to counsel female adolescents about condom use and are three times more likely to take sexual histories from females compared to male adolescent patients.4
When taking sexual histories or discussing sexual health with adolescent patients, providers should ask not just “if” adolescents are using condoms, but how often. If adolescents are not consistently using condoms, explore and listen to the reasons, and respect concerns for such complaints such as sizing and comfort, as well as availability, impact on spontaneity, and perceptions of condom use as representing a lack of trust or infidelity. Explore each reason to use or not to use condoms, and use open-ended questions. Offer a variety of sizes of condoms.
Reproductive coercion, birth control sabotage, or pressure to become pregnant also may be present in an adolescent’s relationship. Ask each adolescent who decides if or how often to use condoms in their relationships as part of a larger discussion of healthy relationships. Adolescents of all genders and sexual orientations and identities may need support in considering condom discussions and negotiation with sexual partners.
One tool for helping adolescents and young adults initiate a behavior change is motivational interviewing (MI). Motivational interviewing is a collaborative, goal-oriented style of communication, with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the adolescent’s own reasons for change within an atmosphere of acceptance and compassion. (More information on MI can be found at motivationalinterviewing.org.)
In a recent randomized controlled trial, an MI-based intervention was shown to decrease unprotected sex among young men who have sex with men living with HIV.5 Another randomized controlled trial found a computer-assisted MI intervention reduced unprotected sex among 572 predominantly minority female adolescents at risk for unintended pregnancy and STIs compared to didactic counseling.6
Outside of large studies, MI can be an effective method to facilitate condom use and enhance acquisition of other protective sexual health behaviors.
Many sexually active adolescents use condoms. When an adolescent reports condom use, an opportunity arises to affirm and applaud this behavior and also offer support, with positive feedback, for making healthy sexual decisions. Those using condoms also can benefit from discussing ways to practice consistent and correct usage by exploring potential barriers to use and solutions to these barriers. Most individuals do not use condoms consistently and correctly, which results in a much higher risk of failure with typical use.
When condoms are not used correctly, the likelihood of breakage or slippage increases, as does the risk for pregnancy and transmission of STIs. Several factors contribute to condom breakage and slippage, but one issue to consider when counseling adolescents is that breakage and slippage decrease significantly with condom use experience. In one study that focused on condom failures, breakage rates were 7% for first-time users and just 2% for those who had used the method at least 15 times. Slippage rates had a similar drop from 3% to less than 1% after 15 or more uses.7
Most breakage and slippage is caused by user-side errors and problems, rather than device-side or structural problems, so better education about correct condom use has the potential to increase efficacy for individual users. A 2012 systematic review of more than 50 studies from 14 countries reported that the most common errors users make are putting the condom on too late; removing the condom early; not leaving room at the tip for ejaculate; not squeezing out air from the tip, which leads to condom rupture; putting it on inside out; and using lubricants that are not water-based, which leads to breakage.8 These points are all ones to review when instructing patients on correct usage.
For tips on starting conversations about birth control methods, bedsider.org offers resources for adolescent and young adult patients, as well as for providers. Visitors can read about how to correctly and consistently use various birth control methods and watch testimonials about young people’s experiences using these methods.
REFERENCES
- Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2015. MMWR Surveill Summ 2016; 65(No. SS-6):1-174.
- Trussell J. Contraceptive failure in the United States. Contraception 2011; 83(5):397-404.
- Committee on Adolescence. American Academy of Pediatrics. Policy Statement — Condom Use and Adolescents. Pediatrics 2013; 132(5):973-981.
- Lafferty WE, Downey L, Holan CM, et al. Provision of sexual health services to adolescent enrollees in Medicaid managed care. Am J Public Health 2002; 92(11):1779-1783.
- Chen X, Murphy DA, Naar-King S, et al. A clinic-based motivational intervention improves condom use among subgroups of youth living with HIV — A multicenter randomized controlled trial. J Adolesc Health 2011; 49(2):193-198.
- Gold MA, Tzilos GK, Stein LAR, et al. A randomized controlled trial to compare computer-assisted motivational intervention with didactic educational counseling to reduce unprotected sex in female adolescents. J Pediatr Adolesc Gynecol 2016; 29(1):26-32.
- Vallapil T, Kelaghan J, Macaluso M, et al. Female condom and male condom failure among women at high risk of sexually transmitted disease. Sex Trans Dis 2005; 32(1):35-43.
- Sanders SA, Yarber WL, Kaufman EL, et al. Condom use errors and problems: A global view. Sex Health 2012; 9(1):81-95.
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