Overcome barriers to correct condom use
Check the responses of the last three patients in your office when it comes to questions on condom use. Did you hear these answers? "Last time we used one, my partner took it off during sex because it was too uncomfortable." "The condom broke." "My boyfriend had one on, but he realized it was inside out and reversed it."
In most circumstances, family planning providers are offering double counseling. Not only are they talking directly to their female patients, they are providing information women can share with their partners about correct condom use. Although providers can offer female condoms, they also need to cover proper male condom use as well.
How do you address condom use in your counseling? If you start out with, "Do you use condoms every time you use sex?," you are liable to close the conversation before it has even started, suggests Nicolas Sheon, a PhD candidate in the University of California at Berkeley medical anthropology program and an HIV test counselor at the Berkeley Free Clinic. Sheon also serves as prevention editor of the University of California at San Francisco’s HIV InSite Web site (http://hivinsite.ucsf.edu/) and creator of www.managingdesire.org, an HIV prevention resource for medical providers, researchers, and laypersons.
Eliminate any judgmental air about condoms and give the patient a "safe space" to explain why condoms aren’t used consistently or correctly, says Sheon. By opening with "When was the last time you used condoms?" you can start to assess where the patient is in condom use.
Follow up with some open-ended questions such as these:
• Have you had any problems with condoms feeling uncomfortable, breaking, or any other problem? Have any of your partners complained about using condoms?
• What was it specifically about condoms that you didn’t like?
• Which partners do you use condoms with?
The responses will be in narrative form, rather than "yes" or "no," and you will begin to gather information about experiences, attitudes, and beliefs regarding condom use.
A recent study of condom use behaviors among male college students identifies common condom problems that result in a definite exposure to pregnancy and/or a sexually transmitted disease:1
• failure to start intercourse with a condom, then stopping to put it on;
• initiating intercourse with a condom, then removing it midway due to uncomfortable fit;
• breakage;
• slippage.
Patients need to understand that condoms must be put on — and kept on — throughout intercourse to obtain the protection afforded by the barrier device, says Lee Warner, MPH, the study’s lead author and an epidemiologist with the Atlanta-based Centers for Disease Control and Prevention’s Division of HIV/AIDS Prevention. (See patient handout inserted in in this issue for facts about correct condom use.)
Patients who report frequent breaks may benefit from larger condoms and use of water-based lubricants. For those who note that the condom "fell off," remind them of the need to hold the rim of the condom at the base of the penis and withdraw soon after ejaculation.
Experience plays a large role when it comes to condom problems. An international study recently reported on approximately 130 male condom users who were given five condoms for vaginal intercourse over a three-week period. Those with a history of one or more condoms that broke or slipped off reported about twice as many condom failures as those not in this at-risk group.
These data suggest that a history of condom failure predicts future failure, a finding that may be useful for targeted intervention.2
Tips for condom use
Condom counseling involves a type of salesmanship, Sheon reflects. Not only is the counselor offering the advantages and benefits of condom use, but he or she is helping the patient learn the same techniques to use with partners.
Assess the patient’s comfort level in discussing and demonstrating condom use. Sheon likes to open two sizes of condoms, then blow a little bit of air into them so patients can see the shape. Put condoms of different thickness on the table so patients can touch them to feel the difference.
Give patients trial sizes of water-based lubricants to take home along with their condoms. All of these techniques will help spark interest in condoms and help patients leave with a more open view toward using them in the future.
"I think it is really important for people to leave with the message that maybe the condom they used didn’t work because they weren’t using a good quality condom, or there’s a better condom out there," says Sheon. "They shouldn’t give up on condoms completely." (Learn how communities are getting the word out about condom use in the next issue of Contraceptive Technology Update.)
References
1. Warner L, Clay-Warner J, Boles J, et al. Assessing condom use practices. Implications for evaluating method and user effectiveness. Sex Transm Dis 1998; 25:273-277.
2. Spruyt A, Steiner MJ, Joanis C, et al. Identifying condom users at risk for breakage and slippage: findings from three international sites. Am J Public Health 1998; 88:239-244.
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