My London medical practice has seen a huge rise in sexually transmitted infections (STIs) over the past few years. Genitourinary medicine clinics are struggling with the increasing workload and the Medical Society for the Study of Venereal Diseases is promoting training courses to help GPs cope. Despite well-funded Government initiatives, sexual health is actually declining.

The importance of condoms

Condoms are considered to be 'the only products that offer protection against both pregnancy and infections '.[1] As such, they are the major priority in most sexual health improvement strategies. Half of girls under 16 attending family planning clinics in 2000-2001 chose male condoms as their main contraception method. The proportion of those of all ages using condoms rose from 6% in 1975 to 35% in 2001; use of the contraceptive pill declined from 70% to 42%.[2,3]

Of course, choosing condoms does not equate with using them. A large survey found that only 40% of unmarried 18-59 year olds used them at last intercourse. Even when this contact was casual, still only 62% used them.[4] Another study of 8,500 American undergraduates found that only 43% always used condoms and 24% never did. Men with the most partners reported lower condom use. Men who only had homosexual sex were less likely to use condoms than those who only had heterosexual sex.[5]

With UK STI rates soaring, condoms' effectiveness is increasingly questioned. Their use has been equated with playing Russian roulette.[6] Leading experts are asking 'why condom promotion is apparently not having much effect in most developing countries and whether we have the right balance between messages about condom promotion and partner reduction and selection?'[7] Others question, 'have we as health care professionals been co-conspirators in propagating the erroneous belief that using condoms makes sexual activity safe?'[8]

Effectiveness and failure

Contraceptive failure rates (CFR) are calculated in relation to resulting pregnancies. As infection can be transmitted during both fertile and non-fertile phases of the menstrual cycle, STI rates are very much higher than failure rates.

Condom method failure rate is 3% but user failure rate is 14%.[9] So, at least one in seven condom users become pregnant each year. CFR does vary greatly and depends more upon experience in correct condom use rather than the user's age per se. A study of 4,600 cumulative use attempts in monogamous couples found that condom breakage was only 0.4% and the CFR was 1%.[10] However, a third of heterosexual students said that they delayed putting on condoms until after initial penetration.[11]

Approximately 80% of emergency pill requests arise from contraceptive failure, mostly of condoms.[12] Reliance upon condom use alone will not reduce teenage pregnancy rates if a false sense of security in their effectiveness results in more acts of intercourse taking place.[13]

Using probability theory and assuming an average 14% per annum CFR, girls using only condoms for contraception have a 53% chance of becoming pregnant over five years.[14]

Risk displacement

The principle of risk displacement is well recognised in public health.Reliance on condoms leads to an increased frequency of sexual intercourse with either the same or a number of partners.[15] Given their 14% CFR and failure to address changes in consequent sexual behaviour, condom promotion may well result in increased STI transmission and unplanned pregnancies.

Protection provided for individual sex acts is not the only factor when considering a population's sexual health. If over-confidence in condoms' 'safety' leads to increased intercourse rates, the actual number of acts of unprotected sex within the population may actually increase.

Sexually transmitted infections

Even without considering incorrect use and risk displacement, condoms' protection against STI transmission varies considerably with each particular STI.

HIV

The risk of contracting HIV from one unprotected act of penile-vaginal sex with an infected partner is around one in 1,000; receptive penile-anal sex is thirty times riskier, ie.one in 33.[16] Condoms give substantial protection against the vaginal transmission of HIV, though none are specifically approved as safe for anal sex.[17]

Theoretical concerns about the 'holes' in latex being larger than HIV virus particles are not born out in practice. Most semen HIV is found within potentially infectious lymphocytes that can't pass through an intact condom.[18] In a multinational study of 378 seronegative partners of HIV-infected heterosexual men and women, no seroconversions occurred among the half of the sample who used condoms consistently. The 121 couples who used condoms inconsistently had a seroconversion rate of 4.8 per 100 person-years.[19]

Condoms offer substantial protection against HIV if used consistently and correctly but inconsistent use carries considerable risks of transmission. The recent USA Department of Health and Human Services report concludes that consistent condom use is 85% effective in reducing the risk of HIV transmission.[20]

Human papilloma virus

The UK 's commonest STI, HPV is probably transmitted by both skin-to-skin contact and genital fluids. The high -risk types are associated with cervical and anal cancers. Other, lower-risk types cause genital warts and/or dysplasia. There is no evidence that condom use reduces the transmission of HPV.[21]

Herpes simplex virus

Genital herpes infection results in multiple, painful blisters that shed virus particles. It is often recurrent and remains incurable. There is no conclusive evidence that condoms offer substantial protection from HSV, though one recent paper has proposed some protection to women.[22,23]

Chlamydia

Chlamydia is the UK's commonest bacterial STI with a 10% prevelance in sexually active women. It frequently causes asymptomatic tubal damage and subsequent infertility. Though theoretically they should, there is no convincing evidence that condoms protect against chlamydia.[24]

Safe sex or saved sex?

Condoms do provide good protection against HIV, but this has a very low prevalence in the UK and USA in comparison to other STIs. They also provide good protection against gonorrhea but the degree of protection against other, more common diseases is less clear.[25]

Condoms also reduce sexual sensitivity and interfere with spontaneous sex. Overall, consistent condom use rates are very low. What then is an effective alternative to the inadequacies of 'safer sex'? Saved sex is being widely suggested by many sexual-healthcare workers.[26,27,28,29,30,31] This concept is that sex is saved for a time when the relationship between the partners is at such a level of intimacy and commitment that they are able to make a reasoned decision that, once having made love, they will go on making it together exclusively with each other for the rest of their lives.

This of course is the biblical model of monogamy.[32] Whilst we cannot expect our non- Christian patients to live this way just because 'the Bible tells me so', there is every reason why we can promote 'saved sex 'as a reliable and practical sexual health strategy. God taught this because it works and even if our patients are not prepared to live fully by its principles, we can and should encourage them to live as close to it as possible.[33]

As the failure of the 'safer-sex 'message becomes increasingly apparent, it is time for sex education policy-makers in the UK to take the saved-sex message as a serious alternative.

This article is adapted from 'The Condom Controversy', a leaflet published by Family Education Trust. Copies can be obtained from FET, Mezzanine Floor, Elizabeth House, 39 York Road, London. SE1 7NQ or downloaded from www.famyouth.org.uk