- Email: [email protected]
Condom-use errors and problems
Brief Reports
Condom-Use Errors and Problems A Neglected Aspect of Studies Assessing Condom Effectiveness Richard Crosby, PhD, Stephanie Sanders, PhD, William L. Yarber, HSD, Cynthia A. Graham, PhD Objective:
To assess and compare condom-use errors and problems among condom-using university males and females.
Methods:
A convenience sample of 260 undergraduates was utilized. Males (n⫽118) and females (n⫽142) reported using condoms in the past 3 months for at least one episode of sex (penis in the mouth, vagina, or rectum) with a partner of the other sex. A questionnaire assessed 15 errors and problems associated with condom use that could be observed or experienced by females as well as males.
Results:
About 44% reported lack of condom availability. Errors that could contribute to failure included using sharp instruments to open condom packages (11%), storing condoms in wallets (19%), and not using a new condom when switching from one form of sex to another (83%). Thirty-eight percent reported that condoms were applied after sex had begun, and nearly 14% indicated they removed condoms before sex was concluded. Problems included loss of erection during condom application (15%) or during sex (10%). About 28% reported that condoms had either slipped off or broken. Nearly 19% perceived, at least once, that their condom problems necessitated the use of a new condom. Few differences were observed in errors and problems between males and females.
Conclusions: Findings suggest that condom-use errors and problems may be quite common and that assessment of errors and problems do not necessarily need to be gender specific. Findings also suggest that correcting “user failure” may represent an important challenge in the practice of preventive medicine. (Am J Prev Med 2003;24(4):367–370) © 2003 American Journal of Preventive Medicine
Introduction
R
ecently the U.S. Department of Health and Human Services issued a review regarding the effectiveness of male condoms for the prevention of sexually transmitted infections (STIs).1 Although the report noted the existence of strong evidence suggesting that condoms prevent transmission of the human immunodeficiency virus and female-to-male transmission of gonorrhea, it concluded that evidence was insufficient to evaluate the effectiveness of condoms against chlamydia, syphilis, chancroid, trichomo-
From the Rollins School of Public Health, Department of Behavioral Sciences & Health Education, Atlanta, Georgia (Crosby); Rural Center for AIDS/STD Prevention, Bloomington, Indiana (Crosby, Sanders, Yarber); Emory Center for AIDS Research, Atlanta, Georgia (Crosby); The Kinsey Institute for Research in Sex, Gender, and Reproduction, Bloomington, Indiana (Sanders, Yarber); Department of Applied Health Science at Indiana University, Bloomington, Indiana (Yarber); and Gender Studies at Indiana University, Bloomington, Indiana (Sanders, Yarber, Graham) Address correspondence to: Richard Crosby, PhD, Rollins School of Public Health of Emory University, Department of Behavioral Sciences and Health Education, 1518 Clifton Road, NE, Room 542, Atlanta GA 30322. E-mail: [email protected].
niasis, genital herpes, and human papillomavirus. One important recommendation called for substantially more research addressing condom effectiveness against STIs. To test hypotheses about condom effectiveness, several design issues must be addressed: measurement of condom use, protocols for establishing infection-free cohorts, and measurement of incident infections. A neglected issue is whether study participants reporting condom use actually used condoms correctly.2– 4 For example, a recent clinic-based study of women suggested that condom failure was primarily a function of user errors.5 Other clinic-based investigations of condom use errors and problems have been reported4 –7; however, it is important to acknowledge that studies of persons attending clinics may not generalize to the majority of condom users. Although two studies investigating condom-use errors and problems sampled university undergraduates, each included only males.8,9 To date, studies have not been published that report condom-use errors and problems in a nonclinic male and female sample. Given that questions about condom effectiveness apply to both males and females, studies
Am J Prev Med 2003;24(4) © 2003 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(03)00015-1
367
Table 1. Condom-use errors and problems reported by university undergraduates Errors/problems Errors Condoms not available when neededa Used condoms stored in wallet ⬎1 monthb Used condoms that were not lubricated Opened package with sharp tool Sharp object contacted condom after opening Applied condom after sex had begun Removed condom before sex was concluded Did not change condoms when switching from one form of sex to another Problems Erection lost during condom application Erection lost during sexc Condom broke Condom slipped off during sex Condom slipped off during withdrawal Condom problems required use of new condom Condom ejaculate dripped onto genitals or mouth
n/valid n
%
100/228 43/225 36/225 25/223 15/222 84/221 30/221 30/36*
43.9 19.1 16.0 11.2 6.8 38.0 13.6 83.3
34/225 22/222 31/220 32/216 25/216 40/215 14/214
15.1 9.9 14.1 14.8 11.6 18.6 6.5
*36 undergraduates who indicated they had recently changed from engaging in one form of sex to another (e.g., from penile–vaginal sex to oral sex) during the same sexual session provided responses to this item. a Reported more often by males (p⫽0.01) b Reported more often by females (p⫽0.003) c Reported more often by males (p⫽0.02)
that address similarities (or differences) in condom errors and problems between males and females are warranted. Accordingly, this study assessed and compared the occurrence of condom use errors and problems among a sample of condom-using males and females attending a large midwestern university.
Methods Study Sample From September 2001 through April 2002, research assistants enrolled 483 Indiana University undergraduates in an anonymous, cross-sectional survey of condom-use errors and problems. Undergraduates were solicited from courses that had not included instruction regarding correct condom use; other eligibility criteria were not applied. The Institutional Review Board approved the study protocol, and no incentives for participation were provided. For analyses, only those undergraduates who reported using condoms in the past 3 months for at least one episode of sex (defined as putting the penis in the mouth, vagina, or rectum) with a partner of the other sex were selected. Among 212 males, 169 reported having sex in the past 3 months; 118 reported condom use. Among 271 females, 203 reported having sex in the past 3 months; 142 reported condom use. Thus, the sample was comprised of 118 males and 142 females (N⫽260).
Measures The questionnaire assessed 15 condom-use errors and problems that could be observed or experienced by female as well as male condom users. Questions were based, in part, on two previously reported pilot studies of condom-use errors and
368
problems among undergraduate males8,9 and on widely cited condom-use guidelines.10,11 On the basis of previous research, a 3-month recall period was used.12,13 Errors were conceptualized as technically incorrect use of condoms and, in one instance, whether condoms were available when needed. Alternatively, problems were conceptualized as various events (e.g., loss of erection) that could lead to condom failure.
Data Analysis The proportion of undergraduates reporting that an error or problem occurred at least once in the past 3 months was calculated. Chi-square tests assessed differences between males and females relative to these proportions. Significance was defined by alpha ⬍0.05.
Results Average age of the sample (N⫽260) was aged 19.5 years (range ⫽ 18 –29; standard deviation [SD]⫽1.6 years). The majority (88.0%) self-identified as white, 6.6% self-identified as black or African American, and the remainder self-identified as members of other racial or ethnic minorities. Fifty-five percent were female. Most (85.7%) had received some form of instruction about correct condom use (e.g., from clinic brochures, friends, high school health classes). Table 1 displays the observed prevalence of errors and problems among study participants. Table 1 also indicates significant differences that were observed between males and females.
American Journal of Preventive Medicine, Volume 24, Number 4
Errors As shown, 44% of participants indicated they had recently needed a condom but did not have one available. Remaining errors listed constitute forms of user failure that could lead to condom failure. For example, opening condom packages with sharp instruments (11%) or subsequently allowing condoms to contact sharp objects (7%) may lead to breakage. Another striking example was that 38% reported that the condom was applied after sex had begun, and 14% reported that condoms were removed before sex was concluded. Males (53%) were significantly more likely than females (37%) to report that condoms were not available when needed. Females (26%) were significantly more likely than males (10%) to report that the condoms being used had been stored in a wallet for at least 1 month.
Problems About 15% and 10% reported erection problems during condom application or during sex, respectively. About 14% reported that a condom had broken, and about 15% and 12% reported that condoms had slipped off during sex or during withdrawal, respectively. Twenty-eight percent reported that condoms had either slipped off or broken on at least one occasion (data not shown). Nearly 20% experienced problems that they felt warranted the need for changing to a new condom during the same sexual session. Nearly 7% indicated problems involving dripping ejaculate during removal of the condom. Males (15%) were significantly more likely than females (6%) to report that erections were lost during sex; other differences were not observed.
Discussion Findings suggest that condom use errors and problems may be quite common, even among well-educated individuals who were not recruited through clinicbased venues. Indeed, errors and problems were common, even though most undergraduates reported receiving some form of instruction about correct condom use. Also, few differences between males and females were found. Thus, these findings support the idea that prevention messages should emphasize the correct use of condoms in addition to the current emphasis on the importance of always using condoms. The findings also have implications for researchers. Clearly, studies that do not account for whether participants used condoms correctly may underestimate condom effectiveness. That is, various forms of incorrect use would suggest that user failure, rather than product failure, may contribute to observed lack of condom effectiveness. Moreover, studies that assess the protec-
tive value of condoms may yield more precise findings if statistical analyses account for the mean number of condom use errors and problems occurring during acts of sexual intercourse included in the recall period. The results also suggest that clinicians and other health professionals may benefit men and women by providing them with carefully delivered instruction regarding correct condom use. In fact, the questionnaire used in this study could easily be adapted as a brief needs-assessment tool that could pinpoint gaps in clients’ knowledge and skills required for correct use. Such an approach could become interactive, much like the strategy used in a widely known approach to counseling patients about STI prevention.14 One particular objective of these interactive exchanges could be to help place negative condom-associated experiences into an appropriate perspective. For example, by learning that erection problems occur quite commonly with condom use, clients may be less likely to personalize this negative experience and, therefore, less likely to decide against subsequent condom use. Findings are limited by the use of a convenience sample and the inherent limitations of retrospective self-report measures. In addition, a fair portion of the undergraduates did not complete every item in the assessment (Table 1). Whether these missing data represent a form of response bias cannot be determined. The cross-sectional nature of the study also precluded determination of whether condom use errors and problems diminish with practice and maturation. Prospective studies are needed to test the hypothesis that a learning curve may apply to condom use practices. Finally, it should be noted that the observed prevalence of condom use errors and problems might be quite different in other populations. For example, more-experienced populations (e.g., commercial sex workers) may experience substantially fewer condom-use errors and problems. Clearly, further research among diverse populations of males and females is warranted. Within these limitations, this study provides some initial evidence supporting comprehensive assessment of condom use errors and problems in any study designed to test condom effectiveness. Because these findings suggest that females are quite aware of errors and problems occurring in conjunction with male condom use, assessments do not necessarily need to be gender specific. Findings also suggest that correcting “user failure” may represent an important challenge in the practice of preventive medicine.
References 1. United States Department of Health and Human Services. Workshop Summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention. Available at: www.niaid.nih.gov/dmid/ stdscondomreport.pdf. Accessed July 5, 2002. 2. Crosby RA. Condom use as a dependent variable: measurement issues relevant to HIV prevention programs. AIDS Educ Prev 1998;10:448 –57. 3. Crosby RA, DiClemente RJ, Wingood GM, et al. Correct condom application among African American adolescent females: the relationship to
Am J Prev Med 2003;24(4)
369
4.
5.
6.
7.
8.
perceived self-efficacy and the association to confirmed STDs. J Adolesc Health 2001;29:194 –9. Fishbein M, Peguegnat W. Evaluating AIDS prevention interventions using behavioral and biological outcome measures. Sex Transm Dis 2000;27:101– 10. Macaluso M, Kelaghan J, Artz L, et al. Mechanical failure of the latex condom in a cohort of women at high STD risk. Sex Transm Dis 1999;26:450 –7. Mertz KJ, Finelli L, Levine WC, et al. Gonorrhea in male adolescents and young adults in Newark, New Jersey: implications of risk factors and patient preferences for prevention strategies. Sex Transm Dis 2000;27:201–7. 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 –44. Warner L, Clay-Warner J, Boles J, Williamson J. Assessing condom use practices: implications for evaluating method and user effectiveness. Sex Transm Dis 1998;6:273–7.
370
9. Crosby RA, Sanders S, Yarber WL, Graham C, Dodge B. . Condom use errors and problems among college men. Sex Transm 2002;29:552–7. 10. Centers for Disease Control and Prevention. Facts about condoms and their use in preventing HIV infection and other STDs. Atlanta, GA: U.S. Department of Health and Human Resources, 1998. 11. Warner DL, Hatcher RA. Male condoms. In: Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive technology, 17th edition. New York: Irvington Publishers, 1999;325–52. 12. Kelly JA, Murphy DA, Washington CD, et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health 1994;84:1918 –22. 13. Orr DP, Fortenberry JD, Blythe MJ. Validity of self-reported sexual behaviors in adolescent women using biomarker outcomes. Sex Transm Dis 1997;24:261–6. 14. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;280:1161–7.
American Journal of Preventive Medicine, Volume 24, Number 4
Condom-Use Errors and Problems A Neglected Aspect of Studies Assessing Condom Effectiveness Richard Crosby, PhD, Stephanie Sanders, PhD, William L. Yarber, HSD, Cynthia A. Graham, PhD Objective:
To assess and compare condom-use errors and problems among condom-using university males and females.
Methods:
A convenience sample of 260 undergraduates was utilized. Males (n⫽118) and females (n⫽142) reported using condoms in the past 3 months for at least one episode of sex (penis in the mouth, vagina, or rectum) with a partner of the other sex. A questionnaire assessed 15 errors and problems associated with condom use that could be observed or experienced by females as well as males.
Results:
About 44% reported lack of condom availability. Errors that could contribute to failure included using sharp instruments to open condom packages (11%), storing condoms in wallets (19%), and not using a new condom when switching from one form of sex to another (83%). Thirty-eight percent reported that condoms were applied after sex had begun, and nearly 14% indicated they removed condoms before sex was concluded. Problems included loss of erection during condom application (15%) or during sex (10%). About 28% reported that condoms had either slipped off or broken. Nearly 19% perceived, at least once, that their condom problems necessitated the use of a new condom. Few differences were observed in errors and problems between males and females.
Conclusions: Findings suggest that condom-use errors and problems may be quite common and that assessment of errors and problems do not necessarily need to be gender specific. Findings also suggest that correcting “user failure” may represent an important challenge in the practice of preventive medicine. (Am J Prev Med 2003;24(4):367–370) © 2003 American Journal of Preventive Medicine
Introduction
R
ecently the U.S. Department of Health and Human Services issued a review regarding the effectiveness of male condoms for the prevention of sexually transmitted infections (STIs).1 Although the report noted the existence of strong evidence suggesting that condoms prevent transmission of the human immunodeficiency virus and female-to-male transmission of gonorrhea, it concluded that evidence was insufficient to evaluate the effectiveness of condoms against chlamydia, syphilis, chancroid, trichomo-
From the Rollins School of Public Health, Department of Behavioral Sciences & Health Education, Atlanta, Georgia (Crosby); Rural Center for AIDS/STD Prevention, Bloomington, Indiana (Crosby, Sanders, Yarber); Emory Center for AIDS Research, Atlanta, Georgia (Crosby); The Kinsey Institute for Research in Sex, Gender, and Reproduction, Bloomington, Indiana (Sanders, Yarber); Department of Applied Health Science at Indiana University, Bloomington, Indiana (Yarber); and Gender Studies at Indiana University, Bloomington, Indiana (Sanders, Yarber, Graham) Address correspondence to: Richard Crosby, PhD, Rollins School of Public Health of Emory University, Department of Behavioral Sciences and Health Education, 1518 Clifton Road, NE, Room 542, Atlanta GA 30322. E-mail: [email protected].
niasis, genital herpes, and human papillomavirus. One important recommendation called for substantially more research addressing condom effectiveness against STIs. To test hypotheses about condom effectiveness, several design issues must be addressed: measurement of condom use, protocols for establishing infection-free cohorts, and measurement of incident infections. A neglected issue is whether study participants reporting condom use actually used condoms correctly.2– 4 For example, a recent clinic-based study of women suggested that condom failure was primarily a function of user errors.5 Other clinic-based investigations of condom use errors and problems have been reported4 –7; however, it is important to acknowledge that studies of persons attending clinics may not generalize to the majority of condom users. Although two studies investigating condom-use errors and problems sampled university undergraduates, each included only males.8,9 To date, studies have not been published that report condom-use errors and problems in a nonclinic male and female sample. Given that questions about condom effectiveness apply to both males and females, studies
Am J Prev Med 2003;24(4) © 2003 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(03)00015-1
367
Table 1. Condom-use errors and problems reported by university undergraduates Errors/problems Errors Condoms not available when neededa Used condoms stored in wallet ⬎1 monthb Used condoms that were not lubricated Opened package with sharp tool Sharp object contacted condom after opening Applied condom after sex had begun Removed condom before sex was concluded Did not change condoms when switching from one form of sex to another Problems Erection lost during condom application Erection lost during sexc Condom broke Condom slipped off during sex Condom slipped off during withdrawal Condom problems required use of new condom Condom ejaculate dripped onto genitals or mouth
n/valid n
%
100/228 43/225 36/225 25/223 15/222 84/221 30/221 30/36*
43.9 19.1 16.0 11.2 6.8 38.0 13.6 83.3
34/225 22/222 31/220 32/216 25/216 40/215 14/214
15.1 9.9 14.1 14.8 11.6 18.6 6.5
*36 undergraduates who indicated they had recently changed from engaging in one form of sex to another (e.g., from penile–vaginal sex to oral sex) during the same sexual session provided responses to this item. a Reported more often by males (p⫽0.01) b Reported more often by females (p⫽0.003) c Reported more often by males (p⫽0.02)
that address similarities (or differences) in condom errors and problems between males and females are warranted. Accordingly, this study assessed and compared the occurrence of condom use errors and problems among a sample of condom-using males and females attending a large midwestern university.
Methods Study Sample From September 2001 through April 2002, research assistants enrolled 483 Indiana University undergraduates in an anonymous, cross-sectional survey of condom-use errors and problems. Undergraduates were solicited from courses that had not included instruction regarding correct condom use; other eligibility criteria were not applied. The Institutional Review Board approved the study protocol, and no incentives for participation were provided. For analyses, only those undergraduates who reported using condoms in the past 3 months for at least one episode of sex (defined as putting the penis in the mouth, vagina, or rectum) with a partner of the other sex were selected. Among 212 males, 169 reported having sex in the past 3 months; 118 reported condom use. Among 271 females, 203 reported having sex in the past 3 months; 142 reported condom use. Thus, the sample was comprised of 118 males and 142 females (N⫽260).
Measures The questionnaire assessed 15 condom-use errors and problems that could be observed or experienced by female as well as male condom users. Questions were based, in part, on two previously reported pilot studies of condom-use errors and
368
problems among undergraduate males8,9 and on widely cited condom-use guidelines.10,11 On the basis of previous research, a 3-month recall period was used.12,13 Errors were conceptualized as technically incorrect use of condoms and, in one instance, whether condoms were available when needed. Alternatively, problems were conceptualized as various events (e.g., loss of erection) that could lead to condom failure.
Data Analysis The proportion of undergraduates reporting that an error or problem occurred at least once in the past 3 months was calculated. Chi-square tests assessed differences between males and females relative to these proportions. Significance was defined by alpha ⬍0.05.
Results Average age of the sample (N⫽260) was aged 19.5 years (range ⫽ 18 –29; standard deviation [SD]⫽1.6 years). The majority (88.0%) self-identified as white, 6.6% self-identified as black or African American, and the remainder self-identified as members of other racial or ethnic minorities. Fifty-five percent were female. Most (85.7%) had received some form of instruction about correct condom use (e.g., from clinic brochures, friends, high school health classes). Table 1 displays the observed prevalence of errors and problems among study participants. Table 1 also indicates significant differences that were observed between males and females.
American Journal of Preventive Medicine, Volume 24, Number 4
Errors As shown, 44% of participants indicated they had recently needed a condom but did not have one available. Remaining errors listed constitute forms of user failure that could lead to condom failure. For example, opening condom packages with sharp instruments (11%) or subsequently allowing condoms to contact sharp objects (7%) may lead to breakage. Another striking example was that 38% reported that the condom was applied after sex had begun, and 14% reported that condoms were removed before sex was concluded. Males (53%) were significantly more likely than females (37%) to report that condoms were not available when needed. Females (26%) were significantly more likely than males (10%) to report that the condoms being used had been stored in a wallet for at least 1 month.
Problems About 15% and 10% reported erection problems during condom application or during sex, respectively. About 14% reported that a condom had broken, and about 15% and 12% reported that condoms had slipped off during sex or during withdrawal, respectively. Twenty-eight percent reported that condoms had either slipped off or broken on at least one occasion (data not shown). Nearly 20% experienced problems that they felt warranted the need for changing to a new condom during the same sexual session. Nearly 7% indicated problems involving dripping ejaculate during removal of the condom. Males (15%) were significantly more likely than females (6%) to report that erections were lost during sex; other differences were not observed.
Discussion Findings suggest that condom use errors and problems may be quite common, even among well-educated individuals who were not recruited through clinicbased venues. Indeed, errors and problems were common, even though most undergraduates reported receiving some form of instruction about correct condom use. Also, few differences between males and females were found. Thus, these findings support the idea that prevention messages should emphasize the correct use of condoms in addition to the current emphasis on the importance of always using condoms. The findings also have implications for researchers. Clearly, studies that do not account for whether participants used condoms correctly may underestimate condom effectiveness. That is, various forms of incorrect use would suggest that user failure, rather than product failure, may contribute to observed lack of condom effectiveness. Moreover, studies that assess the protec-
tive value of condoms may yield more precise findings if statistical analyses account for the mean number of condom use errors and problems occurring during acts of sexual intercourse included in the recall period. The results also suggest that clinicians and other health professionals may benefit men and women by providing them with carefully delivered instruction regarding correct condom use. In fact, the questionnaire used in this study could easily be adapted as a brief needs-assessment tool that could pinpoint gaps in clients’ knowledge and skills required for correct use. Such an approach could become interactive, much like the strategy used in a widely known approach to counseling patients about STI prevention.14 One particular objective of these interactive exchanges could be to help place negative condom-associated experiences into an appropriate perspective. For example, by learning that erection problems occur quite commonly with condom use, clients may be less likely to personalize this negative experience and, therefore, less likely to decide against subsequent condom use. Findings are limited by the use of a convenience sample and the inherent limitations of retrospective self-report measures. In addition, a fair portion of the undergraduates did not complete every item in the assessment (Table 1). Whether these missing data represent a form of response bias cannot be determined. The cross-sectional nature of the study also precluded determination of whether condom use errors and problems diminish with practice and maturation. Prospective studies are needed to test the hypothesis that a learning curve may apply to condom use practices. Finally, it should be noted that the observed prevalence of condom use errors and problems might be quite different in other populations. For example, more-experienced populations (e.g., commercial sex workers) may experience substantially fewer condom-use errors and problems. Clearly, further research among diverse populations of males and females is warranted. Within these limitations, this study provides some initial evidence supporting comprehensive assessment of condom use errors and problems in any study designed to test condom effectiveness. Because these findings suggest that females are quite aware of errors and problems occurring in conjunction with male condom use, assessments do not necessarily need to be gender specific. Findings also suggest that correcting “user failure” may represent an important challenge in the practice of preventive medicine.
References 1. United States Department of Health and Human Services. Workshop Summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention. Available at: www.niaid.nih.gov/dmid/ stdscondomreport.pdf. Accessed July 5, 2002. 2. Crosby RA. Condom use as a dependent variable: measurement issues relevant to HIV prevention programs. AIDS Educ Prev 1998;10:448 –57. 3. Crosby RA, DiClemente RJ, Wingood GM, et al. Correct condom application among African American adolescent females: the relationship to
Am J Prev Med 2003;24(4)
369
4.
5.
6.
7.
8.
perceived self-efficacy and the association to confirmed STDs. J Adolesc Health 2001;29:194 –9. Fishbein M, Peguegnat W. Evaluating AIDS prevention interventions using behavioral and biological outcome measures. Sex Transm Dis 2000;27:101– 10. Macaluso M, Kelaghan J, Artz L, et al. Mechanical failure of the latex condom in a cohort of women at high STD risk. Sex Transm Dis 1999;26:450 –7. Mertz KJ, Finelli L, Levine WC, et al. Gonorrhea in male adolescents and young adults in Newark, New Jersey: implications of risk factors and patient preferences for prevention strategies. Sex Transm Dis 2000;27:201–7. 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 –44. Warner L, Clay-Warner J, Boles J, Williamson J. Assessing condom use practices: implications for evaluating method and user effectiveness. Sex Transm Dis 1998;6:273–7.
370
9. Crosby RA, Sanders S, Yarber WL, Graham C, Dodge B. . Condom use errors and problems among college men. Sex Transm 2002;29:552–7. 10. Centers for Disease Control and Prevention. Facts about condoms and their use in preventing HIV infection and other STDs. Atlanta, GA: U.S. Department of Health and Human Resources, 1998. 11. Warner DL, Hatcher RA. Male condoms. In: Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive technology, 17th edition. New York: Irvington Publishers, 1999;325–52. 12. Kelly JA, Murphy DA, Washington CD, et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health 1994;84:1918 –22. 13. Orr DP, Fortenberry JD, Blythe MJ. Validity of self-reported sexual behaviors in adolescent women using biomarker outcomes. Sex Transm Dis 1997;24:261–6. 14. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;280:1161–7.
American Journal of Preventive Medicine, Volume 24, Number 4