Condoms can reduce your risk of contracting sexually transmitted diseases, but just how effective are they? On “Today’s Woman,” we take a look at condoms. Dr. Judith Reichman, a “Today” contributor and gynecologist, was invited on the show to share the latest information on STDs and tips on how to prevent getting one.
Condoms have a fascinating history. In 1000 B.C., Egyptian men used a linen sheath for protection against disease. By the 1700s, condoms were made from animal intestines and described as “a cobweb against infection.” In the 1800s, rubber became the condom material of choice. Natural rubber latex was introduced in the early 1900s, and by the 1950s lubricated condoms were widely marketed. Since then, we have seen the advent of polyurethane condoms. Currently, condoms have become thinner and strongerm and they come in various sizes, shapes, colors and, yes, even flavors. Clearly, we’ve come a long way from using Egyptian linen penis wraps for disease protection. But do modern condoms prevent the transmission of STDs? Here are a few common questions about them and the latest information on them.
Do condoms reduce the risk of STDs, including HIV?
Not always. Even though it makes sense that preventing direct skin-to-skin (or vaginal mucosa) contact during intercourse would prevent viruses, bacteria and sperm from passing between partners, warnings about condom effectiveness prevail. Condoms are certainly not foolproof when it comes to contraception. If 100 women and their partners use condoms for a year in what is described as “perfect use,” two will become pregnant. With “typical use” (not used consistently or correctly) 15 women will become pregnant. This “typical use” failure rate is rarely due to a faulty condom, but rather to faulty application or no application. (Note, condoms in the U.S. are electronically tested for holes and defects and serial lots are tested for strength.)
When it comes to STD information and labeling, condoms have come under social, religious, political and medical scrutiny. Absolute standards for STD protection have been strongly advocated and, of course, are correct: The best way to ensure 100 percent protection against STDs is for both partners to abstain from sexual intercourse until marriage and then to refrain from extramarital sex. But as we know, this has not been applicable or practical for many (if not a majority) of individuals both in the U.S. and the developing world. In 2001, a law was passed that required the Food and Drug Administration to reexamine condom labels to determine the “medical accuracy” of their description of condoms’ effectiveness in preventing human papillomavirus (HPV) infections as well as other STDs. Since then, there has subsequently been considerable effort to pressure the FDA to add a warning to condoms about their lack of protection.
But in the past six years, further studies have supplied evidence that should set the condom issue straight. Medical evidence now shows that consistent use of condoms reduces the risk of transmission in men and women of
- HIV (by 80 percent)
- Gonorrhea
- Chlamydia
- Herpes simplex virus
(Note: The prevention of the last three STDs has not been absolutely quantified, because no one is suggesting that a person known to have one of these treatable infections have regular intercourse with an unaffected partner, unless they use condoms and/or are appropriately treated. Condom protection against HIV has been studied, especially in countries where therapies are often unavailable or unaffordable.)
We now have a new study published in the New England Journal of Medicine that convincingly demonstrates that condom use also reduces the risk of HPV infection in women.
What was novel or important about this HPV study?
HPV transmission is extraordinarily common. Genital HPV has now been shown to occur at some point in up to 80 percent of sexually active young women within five years of becoming sexually active. If the virus is not killed by a woman’s immune system (which is what usually happens), it goes on to cause pre-cancers and cancers in the cervix, vagina, vulva skin and anus, as well as benign but physically disturbing warts.
This three-year study followed 82 female university students who had previously never had intercourse with a male partner. For three years, they answered simple questions on their computer every two weeks about their sexual behavior (whether they used condoms, how often they had intercourse, whether their partners had had previous partners, and if there was skin-to-skin contact without condom use). They were also tested every four months for HPV and had a Pap test. The women whose partners always wore a condom during sex were 70 percent less likely to become infected with HPV than those whose partners used protection less than 5 percent of the time. And even women whose partners used condoms just more than half of the time had a 50 percent reduction in their development of HPV.
None of the women whose partners always used condoms developed pre-cancerous lesions (called cervical squamous intraepithelial lesions) during the three-year period. But 14 women whose partners did not use condoms or used them inconsistently developed these lesions, which were detected on their Pap smears. The FDA is currently revising rules for claims that manufacturers can make on how well condoms prevent STDs and HPV, and this study may influence their final recommendations.
Does promoting condom use lead to an increase in promiscuous sex?
Let me first point out that according to data published by the Guttmacher Institute (as well as the Youth Risk Surveillance Survey of 2003), over 50 percent of high school girls have begun having intercourse between the ages of 15 and 18. The Institute has also published well accepted data that shows that contraceptive education does not encourage sexual activity. Of interest is the fact that only 15 percent of Americans want abstinence-only education taught in classrooms, but four in 10 sex education teachers don’t teach about contraceptive methods or teach that it is ineffective. We still have the highest rate of teen pregnancy in the developed world! Lack of contraceptive education is certainly not helping.
Moreover, analysis on the use of condoms to reduce the risk of HIV in 174 studies (with over 100,000 participants) did not show that condom use increased unsafe sexual behavior. Most major health institutions now support an ABC approach for prevention of HIV and other STDs. ABC stands for
- Abstinence
- Be faithful
- Use Condoms
For those who choose to be sexually active, there is medically sound reassurance that condom use can reduce the risk of STDs, but only when used consistently and correctly. Condoms, the “c” in this all important acronym can help attain safer sex.
Will the new HPV vaccine make condom use less important?
No. The vaccine that was recently approved by the FDA for HPV and cervical cancer protection (Gardasil, manufactured by Merck & Co.) specifically targets four types of HPV viruses, which cause 70 percent of cervical cancers and 90 percent of genital warts as well as pre-cancerous lesions of the cervix and vagina. This vaccine is effective in preventing cancers and active infections from these four types of HPV in women who have not yet been infected. It doesn’t protect those who have already been infected with these viruses. Gardasil is therefore slated for use in adolescent girls and young women between the ages of 9 and 26. The vaccine is given through three injections over a course of six months. Each shot costs $120. Within one month of finishing the last injection, immunity is present. In essence, this is a “before you have sex” or “before you are infected” vaccine. It will probably be given (like the hepatitis vaccine) by pediatricians or by gynecologists who see adolescent girls and young women.
(Note: The new recommendation by the American College of Obstetricians and Gynecologists is that 13- to 15-year old girls have an initial ob-gyn visit to discuss their development, periods and future reproductive health issues. A pelvic exam is not felt to be necessary at this time ... but it certainly would be an appropriate time to discuss and provide immunization.)
Clearly a lot of issues need to be resolved about this new vaccine. How long is it protective? (So far data has shown efficacy continues for at least five years.) Will booster shots be necessary? Who will pay? Should we immunize young women who have already had sex but whose previous HPV status is unknown ? And let’s not forget that as good as this vaccine may be in preventing cervical cancer, there are other types of HPV infections that can potentially cause cancer. The vaccine will not protect against all the other STDs and, of course, is not a contraceptive.
Condoms remain an important tool in our ongoing efforts to achieve sexual and reproductive health. We now have additional evidence that when it comes to the horrifically prevalent and transmittable HPV, condom protection is effective.
Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.