- Email: [email protected]
Researching condoms: The laboratory and the bedroom
Reproductive Health Matters, No 3, May 1994
% s r hingC0n 0ms: Juliet Richters INTRODUCTION INCE the mid- to late 1980s t h e r e has b e e n g e n e r o u s r e s e a r c h f u n d i n g available f r o m g o v e r n m e n t s keen to 'do s o m e t h i n g ' a b o u t AIDS for t h e i r horrified electorates. T h e r e have b e e n excellent analyses by sociologists and cultural studies p e o p l e of t h e w a y in w h i c h AIDS, with its p o t e n t m i x t u r e of sex a n d death, has inflamed t h e p o p u l a r i m a g i n a t i o n , and t h e w a y s it has b e e n u s e d by t h e media. Death as a potential o u t c o m e of h a v i n g sex has b e e n so familiar to w o m e n for m o s t of t h e h i s t o r y o f t h e h u m a n r a c e that I find t h e s u d d e n h o r r o r displayed by m e n s o m e w h a t tactless, to say the least. Be that as it may, the result of m a l e fear was funding, in l a r g e a m o u n t s . T h e r e is o f c o u r s e a lot of basic scientific and applied m e d i c a l w o r k b e i n g d o n e on t h e virus a n d on i m m u n e r e s p o n s e s to c h a l l e n g e s by the virus. T h e r e has also b e e n m o n e y for w o r k on the physical p r o p e r t i e s of c o n d o m s a n d for h e a l t h p r o m o t i o n w o r k e n c o u r a g i n g p e o p l e to p r a c t i s e 'safe sex', or 'safer sex" as it was later called by health p r o m o t i o n i s t s anxious n o t to oversell it. The effectiveness of any b e h a v i o u r a l m o d i f i c a t i o n i n t e n d e d to p r o t e c t s o m e o n e f r o m c a t c h i n g HIV f r o m an infected p a r t n e r can n e v e r be total and of c o u r s e t h e m o r a l majority, often cloaked in professional w h i t e coats, w e r e only t o o h a p p y to have it scientifically p r o v e d that sin c a u s e d disease and that c o n d o m use w a s h i g h l y suspect, if n o t c o m p l e t e l y ineffective, as a p r e v e n t i v e measure. I was one of the people w h o benefited from this sudden infusion of funding. I was working for the Family Planning Association in Sydney as the e d i t o r o f .their j o u r n a l Healthright, and I w a n t e d to do a h i g h e r d e g r e e in public health. So I t e a m e d up w i t h an e n g i n e e r I h a d m e t socially w h o w a s i n t e r e s t e d in c o n d o m t e s t i n g a n d a d o c t o r he knew, a v e n e r e o l o g i s t , to put in an
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I
AIDS g r a n t application for a p r o j e c t e x a m i n i n g t h e a d e q u a c y o f c o n d o m s to m e e t the d e m a n d s n o w b e i n g p l a c e d o n t h e m to p r e v e n t HIV t r a n s m i s s i o n . In fact, I w a s at least as i n t e r e s t e d in the c o n t r a c e p t i v e use o f c o n d o m s , b u t b e c a u s e o f the f u n d i n g s o u r c e o u r attention, at least in theory, h a d to b e on STD p r e v e n t i o n . The funding body, an o f f s h o o t of t h e National Health and Medical R e s e a r c h Council, c o m b i n e d us with a n o t h e r p r o j e c t w h i c h p r o p o s e d to test c o n d o m s a l r e a d y o n t h e m a r k e t against t h e existing A u s t r a l i a n S t a n d a r d . As I had e x p e r i e n c e w o r k ing on p r o d u c t - t e s t i n g r e p o r t s for the C o n s u m e r s ' A s s o c i a t i o n I was e m p l o y e d to do both. Thus t h e t e a m a c q u i r e d a n o t h e r ' i n v e s t i g a t o r ' , a gay rights activist and l e c t u r e r in G o v e r n m e n t f r o m the U n i v e r s i t y of Sydney. As a r e s e a r c h t e a m w e w e r e a m o t l e y crew. This h a d d i s a d v a n t a g e s in the t w o and a bit y e a r s ' w o r k that followed. At o n e p o i n t it r e s u l t e d in the i n v e s t i g a t o r s n o t b e i n g on speaki n g t e r m s with e a c h other, but it was also extrao r d i n a r i l y p r o d u c t i v e b e c a u s e of o u r quite different points of view. It is unusual for a r e s e a r c h t e a m to i n c l u d e p e o p l e w i t h such diff e r e n t t r a i n i n g and a p p r o a c h e s , e v e n if w e w e r e all w h i t e a n d m i d d l e class. W h a t was v e r y usual w a s that the t h r e e "investigators' w e r e m a l e and I, t h e u n d e r l i n g ' r e s e a r c h assistant' (they kindly a l l o w e d m e to call m y s e l f c o o r d i n ator), a m female. A f t e r w o r k i n g for t h e Family P l a n n i n g Association, w h i c h is r u n by w o m e n , I was s u r p r i s e d ( t h o u g h I s h o u l d n ' t h a v e been) to find m y s e l f w o r k i n g w i t h p e o p l e w h o did n o t h a v e the s a m e s e l f - a w a r e n e s s of w h a t h a p p e n s w h e n sexual p r a c t i c e is the topic of y o u r w o r k as well as a p e r s o n a l i n t e r e s t and leisure activity. I learnt that not e v e r y o n e w h o p r o f e s s e s c o m f o r t a n d lack of e m b a r r a s s m e n t w i t h sexual topics is really c a p a b l e of d i s t i n g u i s h i n g t h e g e n e r a l i s e d a r o u s a l
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that can come from talking about sexual practice, from the shared and negotiated arousal of an intimate sexual encounter between two individuals. P e r h a p s this is m o r e difficult f o r m e n , w h o s e s e x u a l i t y is s o c o n s t r u c t e d in o u r c u l t u r e t h a t t h e y a r e m o r e likely t o l o c a t e t h e s o u r c e o f a r o u s a l in a n o b j e c t t h a n in t h e m s e l v e s .
W H A T W E R E W E T R Y I N G T O F I N D OUT."? T h e r e followed, off a n d on, w e e k s a n d m o n t h s o f d i s c u s s i o n s a b o u t w h a t it r e a l l y w a s w e w e r e t r y i n g t o find o u t a n d h o w w e s h o u l d g o a b o u t it. A s well as t e s t i n g c o n d o m s a g a i n s t t h e e x i s t i n g S t a n d a r d t h e e n g i n e e r w a n t e d to i n v e n t a k i n d o f ' l u c k m a c h i n e ' to s i m u l a t e in t h e l a b o r a t o r y t h e stresses and strains of intercourse. Something s i m i l a r to t h i s h a d b e e n d o n e in s o m e o f t h e v i r u s - t r a n s f e r e x p e r i m e n t s in t h e U n i t e d States. T h e r e s t of us w e r e s c e p t i c a l t h a t t h i s w o u l d address the real problem. What was the real problem with condoms? T h e m o s t o b v i o u s o n e is t h a t t h e y d o n ' t w o r k w h e n y o u d o n ' t p u t t h e m on. T h i s is b y f a r t h e m o s t c o m m o n r e a s o n f o r t h e i r failure as a c o n t r a c e p t i v e m e t h o d a n d as a n STD p r e v e n t i v e . Lots o f o t h e r h e a l t h p r o m o t i o n r e s e a r c h w a s c o n c e n t r a t i n g o n t h i s p r o b l e m , m o s t o f it f o c u s e d on the pre-existing attitudes towards condoms held by the potential user. We wanted to be more p r a c t i c a l a n d look at t h e p r o b l e m s t h a t c o n d o m u s e r s h a v e if t h e y d o at l e a s t t r y to u s e t h e c o n d o m s . F u r t h e r , w e c o n s i d e r e d t h a t if p e o p l e h a d n e g a t i v e a t t i t u d e s t o w a r d s c o n d o m s as a result of their own experiences, health education or "behaviour change interventions' would not b e likely to c o n v i n c e t h e m o t h e r w i s e . After a few months, during which we were already doing Standards testing, we focused our i n q u i r i e s o n t h e s e five q u e s t i o n s : • Do t h e c o n d o m s c u r r e n t l y o n t h e m a r k e t m e e t the present Australian Standard? • W h a t is t h e a c t u a l r a t e o f b r e a k a g e in u s e ? • Is a n y t h i n g in t h e c o n d i t i o n s o r m e t h o d o f u s e r e l a t e d to h i g h e r risk o f b r e a k a g e ? • Is p e r f o r m a n c e o n S t a n d a r d t e s t s f o r p i n h o l e s a n d b u r s t v o l u m e r e l a t e d to f a i l u r e r a t e s in use? • W h a t is t h e a c t u a l size r a n g e o f A u s t r a l i a n e r e c t p e n i s e s ? A r e t h e size r e q u i r e m e n t s o f the current Standard adequate?
L o o k i n g b a c k o n t h e s e q u e s t i o n s n o w , I find t h e i r language and approach very revealing. Although we were researching what happens when people h a v e sex, specifically a n a l o r v a g i n a l i n t e r c o u r s e , p e o p l e h a v i n g sex o c c u r n o w h e r e in t h e summary of our endeavours. We had managed as I w a s l e a r n i n g to d o w h i l e s t u d y i n g e p i d e m i o l o g y a n d b i o s t a t i s t i c s f o r m y M a s t e r of Public H e a l t h d e g r e e in t h e e v e n i n g s - to r e d u c e t h e t e r m s o f t h e i n q u i r y to w h a t w a s c o u n t a b l e . W e l o o k e d at q u e s t i o n s o f m e e t i n g a S t a n d a r d , statistical c o m p l i a n c e w i t h a p h y s i c a l test, t h e r a t e o f b r e a k a g e a n d f a c t o r s r e l a t e d to h i g h e r rates. We looked for a relationship between t h e s e t w o a b s t r a c t t h i n g s a n d a g r a p h o f t h e dist r i b u t i o n o f t h e size o f a p a r t o f t h e b o d y (in a n a d e q u a t e s a m p l e , o f c o u r s e ) d i v o r c e d f r o m its o w n e r , i n t h e e r e c t s t a t e b u t w i t h o u t social o r emotional meaning. What happened when we t r i e d to d o t h i s t a u g h t m e f a r m o r e t h a n t h e a n s w e r s to t h e q u e s t i o n s w e asked.
CONDOM STANDARDS TESTING W e d i d a s u r v e y o f t h e c o n d o m m a r k e t in A u s t r a lia, b o u g h t s a m p l e s of all t h e m a j o r b r a n d s , a n d t e s t e d t h e m to t h e A u s t r a l i a n S t a n d a r d . T h e s e r e s u l t s w e r e p u b l i s h e d a n d a t t r a c t e d q u i t e a lot o f m e d i a a t t e n t i o n . 1, 2 W h a t d o e s all t h i s m e a n n o w ? I w o u l d s a y t h a t a n y c o n d o m legally o n sale in A u s t r a l i a is as g o o d as c u r r e n t s t a n d a r d s t e s t i n g c a n m a k e it. T h e only e x c e p t i o n m i g h t b e if a s h o p s t o r e d t h e m f o r y e a r s u n d e r h o t l i g h t s a n d sold t h e m o n l y w e e k s b e f o r e t h e i r f i v e - y e a r e x p i r y date. If y o u ' r e b u y i n g c o n d o m s , c h e c k t h e u s e - b y date. T h e f u r t h e r a h e a d it is, t h e b e t t e r . I n t e r e s t i n g l y , I find m a n y p e o p l e d o n o t like t h i s g o o d n e w s . T h e r e is a n e t e r n a l f a s c i n a t i o n w i t h t h e f a i l i n g s o f c o n d o m s , I s u s p e c t as a justification or rationalisation of disliking them f o r o t h e r m o r e e m o t i o n a l r e a s o n s , i.e. t h e y d o n ' t w o r k a n y w a y , w h y b o t h e r ? Or, t h e y ' v e all g o t h o l e s in, y o u k n o w - j u s t like t h e o l d s t o r y a b o u t t h e P o p e e m p l o y i n g p e o p l e in t h e f a c t o r i e s to p i e r c e t h e m w i t h pins. N o t t h a t I d o n ' t s y m p a t h i s e w i t h t h e s e o t h e r r e a s o n s f o r disliking t h e m . T h e o t h e r o b s e s s i o n m e n h a v e is w i t h c o n d o m sizes. A u s t r a l i a n c o n d o m s all h a v e to m e e t t h e S t a n d a r d , w h i c h allows for s o m e t o l e r a n c e in length and width, but none are labelled with sizes. T h e y d o differ a bit in s h a p e a n d size
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between brands and lines, h o w e v e r . W e r e c o m m e n d e d that m a n u f a c t u r e r s offer m o r e than one size and that the S t a n d a r d be altered to allow l o w e r b u r s t v o l u m e limits for smaller c o n d o m s , but this has not yet h a p p e n e d . I think it was Gloria S t e i n e m w h o o n c e s u g g e s t e d that c o n d o m s s h o u l d be m a d e in t h r e e sizes (small, medium, large) but to salve m e n ' s egos, labelled like olives (large, j u m b o and colossal). This q u e s t i o n is c o m p l i c a t e d f u r t h e r b y the fact that m e n ' s p e r c e p t i o n of their o w n p e n i s size relative to o t h e r m e n is v e r y p o o r unless t h e y h a v e sex with o t h e r men. Also m o s t m e n w o r r y only a b o u t length. Not only m a n y w o m e n , but also c o n doms, are m o r e affected b y d i f f e r e n c e s in width. Just like fat legs in stockings, a fat penis n e e d s a l o n g e r c o n d o m . The A u s t r a l i a n i m p o r t e r s of c o n d o m s , all a p p a r e n t l y straight, find this topic so difficult that t h e y j o k e a b o u t it and n e v e r g e n u i n e l y a t t e m p t to do a n y t h i n g a b o u t it. I f o u n d the s a m e r e l u c t a n c e f r o m t h e m to discuss the taste o f c o n d o m s , a l t h o u g h t h e y w e r e all
asking us to give f e e d b a c k t h a t m i g h t be useful for p r o d u c t d e v e l o p m e n t o r m a r k e t i n g . People in g e n e r a l are often s u r p r i s e d to h e a r that c o n d o m testing a n d S t a n d a r d s a p p r o v a l h a v e no c o n n e c t i o n w i t h the p e r f o r m a n c e o f cond o m s in use. V e r y f e w studies h a v e b e e n d o n e on this. W e w e r e t e m p t e d to try to get p e o p l e to use s u b - s t a n d a r d c o n d o m s and c o r r e l a t e m i s h a p s w i t h lab test results, b u t ethically w e w o u l d h a v e h a d to use m o n o g a m o u s u n i n f e c t e d couples ( p r o t e c t e d against p r e g n a n c y by o t h e r m e a n s if t h e y w e r e heterosexual), and w e d i d n ' t think w e ' d b e able to r e c r u i t e n o u g h of them. So w e c o n c e n t r a t e d o n the q u e s t i o n of w h y s o m e people using adequate condoms have constant p r o b l e m s while o t h e r p e o p l e n e v e r do.
INTERVIEWS I conducted telephone interviews with women and m e n w h o r a n g m e in r e s p o n s e to advertisem e n t s put up in STD clinics. I w a s mainly t r y i n g
u: ~3 > z
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to f i n d o u t w h a t it w a s a b o u t p e o p l e w h o h a d t r o u b l e w i t h c o n d o m s , p a r t i c u l a r l y if t h e y frequently found the condom broke during i n t e r c o u r s e o r s l i p p e d off. In fact, f o r m o n t h s I t a l k e d to a n y o n e w h o w o u l d talk to m e a b o u t c o n d o m s - s e x w o r k e r s , a d u l t e r e r s , p e o p l e at p a r t i e s . I l e a r n e d a lot a b o u t sex c o u n s e l l i n g d u r i n g t h a t p e r i o d , j u s t as I h a d d u r i n g m y t i m e at t h e FPA. I m a y n o t h a v e t h e c r e d e n t i a l s , b u t I h a v e t h e flying h o u r s
BROTHEL STUDY Then we ran a prospective study of breakage and s l i p p a g e in t h r e e b r o t h e l s , t w o m a l e a n d o n e female. W e s u p p l i e d t h e f r e s h c o n d o m s , t o g e t h e r w i t h f o r m s t o fill in if t h e r e w a s a n a c c i d e n t a n d little p l a s t i c b a g s to p u t t h e t o r n c o n d o m s in. W e h o p e d to collect e n o u g h t o r n c o n d o m s to a n a l y s e in t h e l a b h o w a n d w h e r e t h e y t o r e , b u t o f t h e 1,269 c o n d o m s t h e w o r k e r s used, only 8 w e r e r e p o r t e d b r o k e n , a n d t w o o f t h e m t u r n e d o u t to b e i n t a c t w h e n w e l o o k e d at t h e m carefully. ( B r e a k a g e r a t e = 0.6 p e r cent.) This p r o d u c e d a nice little r e s e a r c h r e p o r t w i t h a c c u r a t e f i g u r e s and tight confidence intervals, just the kind of t h i n g t h e m e d i c a l j o u r n a l s like, a n d it w a s i n d e e d p u b l i s h e d i m m e d i a t e l y as a l e t t e r in t h e L a n c e t . 3 W h a t I f o u n d so f a s c i n a t i n g , t h o u g h , w e r e t h e discussions I had with the workers each week o v e r t h e t h r e e o r f o u r m o n t h s I w a s visiting t h e m to collect t h e i r f o r m s a n d d e l i v e r f r e s h c o n d o m s . Today, I w o u l d call t h a t f o c u s g r o u p w o r k a n d w r i t e it u p as f o r m a l q u a l i t a t i v e r e s e a r c h . T h e n , it w a s j u s t q u a l i t a t i v e pilot s t u f f - d e f i n e d b y e p i d e m i o l o g i s t s a l m o s t as n o n - w o r k . T h e f e m a l e sex w o r k e r s w e r e u n a n i m o u s t h a t if y o u d o n ' t w a n t t h e c o n d o m to b r e a k y o u d o n ' t let t h e c l i e n t t o u c h it. B u t t h e m a l e w o r k e r s also h a d v e r y f e w breakages, once they had a few weeks' experi e n c e in t h e j o b . W h a t w e still d i d n ' t k n o w , though, was whether the things the workers said t h e y d i d o r d i d n ' t d o w e r e really w h a t distinguished successful and unsuccessful condom u s e r s f r o m e a c h o t h e r in t e r m s o f b r e a k a g e a n d slippage.
QUESTIONNAIRE STUDY So w e d i d a q u e s t i o n n a i r e s t u d y to e x p l o r e t h e u s e r - r e l a t e d r e a s o n s f o r c o n d o m failure a m o n g ' a m a t e u r ' u s e r s . T h e m a i n a i m w a s to s e e
w h e t h e r t h e r e p o r t e d r a t e s o f t w o physical, observable phenomena (condom breakage and slippage) could be related to users' physical features and behaviours. We designed questionnaires asking men whether they used condoms. If not, w h y not. If so, h o w m a n y c o n d o m s t h e y ' d used during the past year and a whole string of questions about their age and ethnic group, what lubricant they used, how they put the condom on, w h a t t h e y t h o u g h t o f c o n d o m s , a n d w h a t their attitudes were. Five h u n d r e d a n d f o r t y - f o u r m e n a t t e n d i n g STD clinics a n d t h e U n i v e r s i t y H e a l t h S e r v i c e filled in initial q u e s t i o n n a i r e s w i t h t h e b a s i c i n f o r m a t i o n a n d 120 a n s w e r e d t h e a d d i t i o n a l q u e s t i o n n a i r e s w i t h all t h e a t t i t u d e a n d u s e details. F o r t h e 402 w h o h a d u s e d c o n d o m s in t h e p r e v i o u s year, t h e b r e a k a g e r a t e s w e r e f a r h i g h e r t h a n f o r t h e sex w o r k e r s , a r o u n d 7 p e r cent, t h o u g h t h i s f i g u r e i n c l u d e s b r e a k a g e s d u r i n g a p p l i c a t i o n . 4 F o r t h e 108 m e n f o r w h o m w e h a d full r e s u l t s , w e f o u n d t h e y w e r e likely to b r e a k m o r e c o n d o m s if they: • • •
•
had male partners didn't use condoms often s i m p l y r o l l e d t h e c o n d o m o n ( a c c o r d i n g to t h e i n s t r u c t i o n s ) r a t h e r t h a n p u l l i n g it o n like a s t o c k i n g w i t h t h e i r f i n g e r s inside, o r d o i n g a combination of these things had trouble with condoms slipping up but not
off; a n d to h a v e m o r e c o n d o m s slip off if t h e y : • • • •
were young were circumcised hadless condom experience s i m p l y r o l l e d t h e c o n d o m on.
A t t i t u d e s t o w a r d s c o n d o m s w e r e n o t r e l a t e d to s u c c e s s in use. 5 W e d i d e l a b o r a t e iogistic r e g r e s s i o n a n a l y s e s to c o m e u p w i t h t h e s e results. H o w e v e r , a p r i c e w a s p a i d f o r t h i s strictly q u a n t i t a t i v e a p p r o a c h to w h a t w a s l a r g e l y a n e x p l o r a t o r y p i e c e of r e s e a r c h . It is p o s s i b l e t h a t a c o n c e p t u a l ( r a t h e r than merely numerical) analysis of the experiences and attitudes of successful and unsuccessful u s e r s w o u l d h a v e y i e l d e d useful i n s i g h t s i n t o t h e b e h a v i o u r o f u s e r s . If w e h a d h a d t h e o p p o r t u n i t y to i n t e r v i e w s e l e c t e d r e s p o n d e n t s about their experiences with condoms, we might h a v e b e e n a b l e t o t h r o w m o r e l i g h t o n s o m e of
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<
z
o u r f i n d i n g s . F o r e x a m p l e , a b o u t 60 p e r c e n t o f r e s p o n d e n t s e x p e r i e n c e d loss o f e r e c t i o n d u r i n g i n t e r c o u r s e w i t h a c o n d o m , at l e a s t o c c a s i o n a l l y . Intuitively o n e w o u l d e x p e c t t h i s to m a k e slipp a g e m o r e likely. H o w d o s u c c e s s f u l u s e r s deal w i t h t h i s ? Do t h e y h o l d t h e c o n d o m o n until t h e i r erection returns? ARE THESE RESULTS GENERALISABLE. 9 It is o b v i o u s t h a t m e n a t t e n d i n g STD clinics a n d a u n i v e r s i t y h e a l t h s e r v i c e a r e n o t typical o f c o n d o m u s e r s at large. Still less a r e t h e 108 m e n who provided data, even though they may have b e e n r o u g h l y s i m i l a r to t h e n o n - r e s p o n d e n t c o n d o m u s e r s in age, s e x u a l p r e f e r e n c e a n d e t h n i c b a c k g r o u n d . It m a y b e r e a s o n a b l e t o a s s u m e t h a t t h e f a c t o r s r e l a t e d to h i g h e r c o n d o m b r e a k a g e r a t e s a m o n g m e m b e r s o f t h i s g r o u p w o u l d also b e r e l a t e d t o h i g h e r b r e a k a g e r a t e s in o t h e r g r o u p s , b u t o n l y if o t h e r e v i d e n c e f o r c a u s a l i t y c o u l d b e p r o d u c e d . T h e i n v e r s e , o f c o u r s e , is n o t t r u e . A m o n g o t h e r g r o u p s , e.g. n o n - c l i n i c a t t e n d e r s a n d p e o p l e w h o dislike filling in
questionnaires, there may be quite different reasons for condom breakage. T h e h u g e loss to f o l l o w - u p in this s t u d y d r a w s a t t e n t i o n to a p r o b l e m w h i c h a t t e n d s all s t u d i e s concerning sensitive or threatening issues'such as s e x u a l b e h a v i o u r , c h i l d r e a r i n g , c a n c e r , a n d u n e m p l o y m e n t , a W e n e e d e d to find c o n d o m u s e r s , as n o n - u s e r s c o u l d n o t tell u s a n y t h i n g helpful. W e t h e r e f o r e f a c e d s o m e o f t h e s a m e p r o b l e m s m e n t i o n e d b y C h a p m a n a n d Bray. 7 In c o n t r a s t to t h e i r e x p e r i e n c e , w e f o u n d eligible c o n d o m u s e r s - 353 m e n - b u t t h e n w e lost m o r e than two thirds of them. Presumably we scared t h e m off b y a s k i n g t h e m to d o s o m u c h . (As t h e y w e r e a n o n y m o u s w e c o u l d n o t follow u p d e f a u l t e r s to find o u t w h y t h e y h a d d r o p p e d out.) P a r t o f t h i s w a s t h e s h e e r a m b i t i o n o f t h e study. A s well as t h e q u e s t i o n n a i r e s , w e g a v e t h e m c o n d o m s t o u s e a n d a s k e d t h e m to d r o p off u s e d o n e s at t h e clinic. It r e q u i r e s a d e d i c a t e d r e s p o n d e n t i n d e e d w h o will u s e s p e c i a l l y s u p p l i e d c o n d o m s a n d r e p o r t o n t h e m a f t e r t h r e e m o n t h s , e v e n if h e h a s
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m o v e d h o u s e , lost his lover, e n t e r e d a r e l a t i o n s h i p in w h i c h c o n d o m s a r e n o t r e q u i r e d , o r b e c o m e t o o ill to u s e c o n d o m s . (This d i d h a p p e n to s o m e o f o u r m o s t d e d i c a t e d r e s p o n d e n t s , w h o r a n g t h e P r o j e c t office to s a y t h a t t h e y h a d n o t used the condoms or could not use any more b e c a u s e t h e y o r t h e i r p a r t n e r s w h o h a d AIDS w e r e t o o ill t o c o n t i n u e . ) I n a d d i t i o n to t h e m a n y d e m a n d s o f t h i s s t u d y w e u s e d t h e kits to m a k e further demands of the respondents for the sake of r e l a t e d s t u d i e s in t h e C o n d o m Project. It is likely t h a t m a n y r e s p o n d e n t s g a v e u p w h e n t h e y e x a m i n e d t h e i r kits a t h o m e a n d f o u n d t h a t w e were asking them to measure their penises and to d e l i v e r u s e d c o n d o m s t o t h e clinic. O n e res p o n d e n t e v e n p u b l i s h e d a n article a b o u t t h e g h a s t l i n e s s o f t h e study, vividly w a r n i n g his fellow s t u d e n t s to ' B e w a r e t h e C o n d o m Kit'. 8
IMPLICATIONS OF FINDINGS It is u n f o r t u n a t e t h a t t h e c l e a r e s t m e s s a g e f r o m t h i s s t u d y is t h a t m a n y o f t h e risk f a c t o r s f o r c o n d o m failure a r e t h i n g s t h a t t h e u s e r c a n n o t i n f l u e n c e o r m a y n o t w a n t to c h a n g e , s u c h as his age, his s e x u a l p r e f e r e n c e , w h e t h e r h e is circumcised and the amount of previous experie n c e h e h a s h a d . H o w e v e r , t h e f i n d i n g s p o i n t to s e v e r a l h i t h e r t o u n e x a m i n e d p r o b l e m s r e l a t e d to c o n d o m use. C o n d o m i n s t r u c t i o n s a r e b a s e d o n several assumptions: • t h a t t h e u s e r c a n m a i n t a i n a firm e r e c t i o n in o r d e r to roll t h e c o n d o m o n • that the user has three hands, or the manual d e x t e r i t y t o roll t h e c o n d o m d o w n w i t h o n e hand while holding the teat with the other, or the assistance of a cooperative partner • that penetrative intercourse occurs immediately a f t e r a p p l i c a t i o n • that the user maintains an erection througho u t i n t e r c o u r s e , w h i c h p r o c e e d s w i t h o u t int e r r u p t i o n a n d c u l m i n a t e s in e j a c u l a t i o n • t h a t t h e u s e r is n o t t o o e m o t i o n a l l y c a r r i e d away or sleepy or keen on continuin9 after o r g a s m a n d r e m e m b e r s to w i t h d r a w imm e d i a t e l y , w h i l e h o l d i n g o n to t h e r i m of t h e condom. O u r f i n d i n g s c h a l l e n g e s o m e of t h e s e a s s u m p t i o n s , w h i l e o t h e r s a r e intuitively u n s a t i s f a c t o r y . Even amon 9 this group of volunteer condom users, about two thirds of the men sometimes or
o f t e n lost t h e i r e r e c t i o n w h i l e p u t t i n g a c o n d o m on, a n d n e a r l y as m a n y lost t h e i r e r e c t i o n d u r i n g intercourse. One may hypothesise that this may b e o n e r e a s o n w h y m a n y m e n a r e u n w i l l i n g to use condoms, either because they prefer interc o u r s e n o t to b e c o n s t r a i n e d a n d s t r u c t u r e d in t h i s way, o r b e c a u s e t h e y feel t h e y ' o u g h t " to s t a y e r e c t , so t h a t w i l t i n g d u r i n g c o n d o m a p p l i c a t i o n d r a w s a t t e n t i o n to t h e i r failing. H e a l t h p r o m o tion messages which claim that 'putting on a condom need not interrupt love-making' are m i s s i n g t h e p o i n t . ( A n d n o t all sex is l o v e - m a k i n g anyway.) Those men who disobeyed instructions and p u l l e d t h e c o n d o m o n like a s t o c k i n g (or u s e d a combination method) had lower, not higher, failure r a t e s . T h i s f i n d i n g w a s u n e x p e c t e d . It may be that 'pullers' get the condom on more securely. We learnt from our discussions with sex workers that this method can be comfortable a n d c o n v e n i e n t . It is c e r t a i n l y e a s i e r to u s e if t h e p e n i s is n o t fully rigid, a n d it c a n b e d o n e w i t h o u t d a m a g i n g t h e c o n d o m . T h e r e a s o n it is g e n e r a l l y n o t r e c o m m e n d e d is p r e s u m a b l y b e c a u s e o f t h e possibility of users putting their fingers through the condom. We found no evidence that pinching the teat a f f e c t e d t h e risk o f b r e a k a g e o r s l i p p a g e . O n e c a n n o t p i n c h t h e t e a t a n d u s e t h e 'pull' m e t h o d of application simultaneously, though one can p i n c h t h e teat, roll t h e c o n d o m p a r t l y o n a n d t h e n pull. W e c o u l d s e e n o r e a s o n f r o m t h e m e c h a n ical p o i n t o f v i e w w h y failing to p i n c h t h e t e a t s h o u l d c a u s e p r o b l e m s . Air, if p r e s e n t in t h e teat, is s q u e e z e d d o w n to b e h i n d t h e g l a n s p e n i s o n insertion. Given the distensibility of the condom, t h e r e is n o r e a s o n w h y t h e p r e s e n c e o f I ml o r so o f air in a d d i t i o n to 3-5 m l o f s e m e n s h o u l d 'burst' the condom. 9
REFLECTIONS O f c o u r s e , t h e p l a y e r s in t h e c o n d o m a r e n a h a v e differing and sometimes conflicting interests. O n e c a n l o o k at t h e m a n u f a c t u r e r s , r e t a i l e r s a n d i m p o r t e r s , f o r e x a m p l e , in e c o n o m i c t e r m s as h a v i n g i n t e r e s t s in m a k i n g m o n e y o u t o f c o n d o m s . So t o o d o e n g i n e e r s w i t h c o n d o m - t e s t i n g laboratories. But there's a subtler kind of 'interest" t h a t I f i n d m o r e f a s c i n a t i n 9, w h i c h I t o u c h e d on when I mentioned the hegemonic form of 'sexual intercourse' that the condom instructions
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a s s u m e a n d t h a t c o n d o m use, in a s e n s e , enforces. I w a s n ' t s u r e w h e t h e r to b e w o r r i e d o r pleased that many young men who had never had intercourse and perhaps no experience of sexual r e l a t i o n s h i p s took o u r kits, p r e s u m a b l y out o f curiosity, to e x a m i n e t h e c o n d o m s a n d t h e i n s t r u c t i o n s . W a s this useful s e x e d u c a t i o n , t e a c h i n g t h e m h o w to u s e c o n d o m s b e f o r e t h e n e e d a r o s e , o r w a s it t r a n s m i t t i n g c u l t u r a l r u l e s a b o u t h o w t o h a v e i n t e r c o u r s e ? If t h e m a i n effect w a s t h e latter, I r e g r e t it. It w o r r i e s m e t h a t in t h e h e t e r o s e x u a l a r e n a c o n d o m s a r e p r e s e n t e d as t h e o n l y w a y of m a k i n g ' s e x ' safe. In leaflets f o r t h e g e n e r a l public, w h o a r e p r e s u m e d t o h a v e m o r e d e l i c a t e sensibilities t h a n g a y m e n , a l t e r n a t i v e s e x u a l practices to penis-vagina intercourse are rarely m e n t i o n e d . In c o n t r a s t , p a r t o f t h e s u c c e s s o f t h e safe sex c a m p a i g n s in t h e g a y c o m m u n i t y h a s been attributed to the eroticisation and promotion o f n o n - p e n e t r a t i v e p r a c t i c e s . 1° It m a y b e t h a t in p r o m o t i n g c o n d o m s in s c h o o l s , f o r e x a m p l e , w i t h o u t m e n t i o n i n g o t h e r w a y s o f h a v i n g safe sex, w e a r e r e i n f o r c i n g t h e m e s s a g e to y o u n g w o m e n t h a t p e n i l e i n t e r c o u r s e is t h e o n l y s o r t o f ' s e x ' to h a v e . It's n o s u r p r i s e t h a t p e o p l e in c o n d o m f a c t o r ies o r o n S t a n d a r d s c o m m i t t e e s , o r i n d e e d p e o p l e r e s e a r c h i n g c o n d o m failure, a r e m o r e c o m f o r t a b l e t a l k i n g a b o u t b u r s t v o l u m e s , leaka g e tests, t e n s i l e s t r e n g t h , s t o r a g e c o n d i t i o n s and batch numbers than about what actually h a p p e n s to t h e c o n d o m b e i n g u s e d b y people, especially d u r i n g a n a l i n t e r c o u r s e , a t o p i c w h i c h makes many straight men extremely uncomfortable. It's c l e a r also t h a t e v e n w h e n a t t e m p t i n g to d i s c u s s i s s u e s o f use, m a n y r e s e a r c h e r s a r e e n g a g i n g in m o r a l r a t h e r t h a n n e u t r a l d e s c r i p tive d i s c o u r s e - s o m e t h i n g w e p r o b a b l y o b j e c t to only w h e n t h e m o r a l p o i n t o f v i e w is d i f f e r e n t from our own. M a n y a u t h o r s , p a r t i c u l a r l y in t h e U n i t e d States, s e e m to feel t h e n e e d to m a k e s t a t e m e n t s a c k n o w l e d g i n g t h e v i r t u e s of a b s t i n e n c e b e f o r e d i s c u s s i n g c o n d o m s , p r e s u m a b l y to a p p e a s e t h e 'moral majority'. Then they write of intercourse and many other sexual practices, particularly w i t h s e x w o r k e r s , as if t h e y t h e m s e l v e s h a d n o e x p e r i e n c e o f t h e m . E v e n in a r t i c l e s w h e r e women are among the authors, women's sexual a r o u s a l o r lack o f it is o f t e n p r o b l e m a t i s e d in r e l a t i o n to c o n d o m u s e (e.g. it is s u g g e s t e d t h a t
b r e a k a g e is c a u s e d b y t h e w o m a n ' s d r y n e s s 11) b u t t h e i s s u e o f t h e m a n ' s a r o u s a l a n d e r e c t i o n is rarely mentioned. It's o b v i o u s f r o m t h e v e r y fact t h a t I d i d all t h i s work that I'm capable of thinking about anal or v a g i n a l i n t e r c o u r s e in r e d u c t i o n i s t , m e c h a n i c a l t e r m s , a n d I t h i n k t h e r e a r e s o m e useful i n s i g h t s t o b e g a i n e d f r o m t h e a t t e m p t to d o so. B u t t h e y are very limited insights. I have become more, n o t less, c o n v i n c e d t h a t t h e m a i n ' p r o b l e m s ' w i t h c o n d o m s a r e to d o w i t h h e a r t s a n d m i n d s , n o t j u s t l u b r i c a n t t y p e o r p e n i s size o r d u r a t i o n o f i n t e r c o u r s e . T h e c e n t r a l one, I believe, is to do with the meaning of intercourse within an affective r e l a t i o n s h i p . P e n e t r a t i v e i n t e r c o u r s e involves a blurring of body boundaries. For some p e o p l e a n d in s o m e s i t u a t i o n s t h i s c a n b e t h r e a t e n i n g a n d u n p l e a s a n t , b u t it c a n also h a v e a symbolic emotional meaning that validates the central role of intercourse within the practices t h a t g e t called s e x o r l o v e - m a k i n g in o u r c u l t u r e . T h e p r e s e n c e o f a c o n d o m s y m b o l i c a l l y - as well as b a c t e r i o l o g i c a l l y - m a i n t a i n s a b a r r i e r between the two bodies. W e a s k e d o n e q u e s t i o n t h a t , as f a r as I k n o w , h a s n o t b e e n a s k e d in c o n d o m r e s e a r c h b y a n y o n e else: H a v e y o u e v e r r e m o v e d a c o n d o m d u r i n g i n t e r c o u r s e a n d c o n t i n u e d w i t h o u t it? H a l f o f o u r r e s p o n d e n t s h a d d o n e t h i s at l e a s t o n c e . ( W e d i d n ' t ask w h e t h e r t h e y h a d h a d t h e i r p a r t n e r ' s p e r m i s s i o n to d o so.) T h e effecti v e n e s s o f C o n d o m u s e as a c o n t r a c e p t i v e o r STD preventive rests not so much on the physical a d e q u a c y o f t h e c o n d o m , as o n t h e h u m a n difficulty o f r e s p o n s i b l y c o n s i d e r i n g t h e c o n s e q u e n c e s o f o u r a c t i o n s , w h i l e in a s t a t e o f h i g h sexual excitement, and possibly emotionally transported and undifferentiated from our partn e r s . H o w a r e p e o p l e to p e r f o r m t h e e m o t i o n a l f e a t o f a c h i e v i n g at l e a s t m o m e n t a r y loss o f selfc o n s c i o u s n e s s - n e c e s s a r y f o r o r g a s m for s o m e p e o p l e - w h i l e at t h e s a m e t i m e c o n t i n u i n g to r e g a r d t h e p a r t n e r ' s b o d y fluids as "other" a n d potentially dangerous?
Note This paper is based on a talk given to the seminar "Making Bodies: Making Technologies" organised b y the W o m e n ' s Studies Centre, University o f Sydney, Australia, 29 May 1993.
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References 1. Condoms revisited. Choice (Australian Consumers' Association). January 1989, 42-45. 2. Donovan B, Richters, J and Gerofi, J, 1991. A pharmacopoeia of Australian condoms. Venereology. 4: 88-95. 3. Richters, J, Donovan, B, Gerofi, J and Watson, L, 1989. Low condom breakage rate in commercial sex [letter]. Lancet. 2:1487-88. 4. Richters, J, Donovan, B, and Gerofi, J, 1993. How often do condoms break or slip off in use? International Journal of STD and AIDS. 4:90-94.
5.
Richters, J. User-related predictors of condom failure in use. MPH treatise, Department of Public Health, University of Sydney, 1991. 6. Sudman, S and Bradburn, N M, 1982. Asking Questions. JosseyBass, San Francisco. 7. Chapman, S and Bray, F, 1989. Researching condom use: field notes from a failed project. British Medical Journal. 298: 682-83. 8. Lacey, S, 1989. B e w a r e t h e condom kit. Honi Soit (University of Sydney), 19 September, 23: 17. Reprinted as Lacey, S, 1989. Beware of the condom kit. Healthright.
RI~SUMI~ C e t e x p o s 6 d 6 c r i t et t r a d u i t m e s e x p @ i e n c e s d e t r a v a i l s u r u n p r o j e t d e r e c h e r c h e c o n c e r n a n t les e s s a i s et l ' u t i l i s a t i o n d e s p r 6 s e r v a t i f s . Le p r o j e t couvrait une 6tude de march6, des essais en l a b o r a t o i r e e n c o n f o r m i t 6 a v e c la n o r m e a u s t r a l i e n n e , d e s d i s c u s s i o n s et d e s e s s a i s d e p r ~ s e r v atifs a v e c d e s t r a v a i l l e u r s e n s a n t 6 s e x u e l l e ( h o m m e s et f e m m e s ) et d e s e n t r e t i e n s a v e c d ' a u t r e s utilisateurs. N o u s a v o n s 6 g a l e m e n t m e n 6 u n e enclu~te p a r q u e s t i o n n a i r e s u r les f a c t e u r s et les c o m p o r t e m e n t s d e s u t i l i s a t e u r s a s s o c i 6 s aux 6 c h e c s d e s p r 6 s e r v a t i f s tels qu'6valu6s & partir des nombres signal6s de p r 6 s e r v a t i f s q u i se d 6 c h i r e n t o u glissent. C e t e x p o s 6 a t t i r e l ' a t t e n t i o n SEErle fait q u ' a b o r d e r u n comportement sexuel complexe par des m6tho d e s r 6 d u c t i o n n i s t e s e s t d ' u n e utilit6 limit6e. C e r t a i n e s d e s q u e s t i o n s ' m a r g i n a l e s ' , d o n t les i n q u i 6 t u d e s d ' o r d r e 6 m o t i o n n e l et p r a t i q u e m a n i f e s t 6 e s p a r les u t i l i s a t e u r s , c o m m e la p e r t e d ' @ e c t i o n o u le g o 0 t d e s p r 6 s e r v a t i f s , ainsi q u e la s i g n i f i c a t i o n sociale et s y m b o l i c l u e d e s r a p p o r t s p o u r les p a r t i c i p a n t s , se s o n t a v 6 r 6 e s ~tre d e s sujets irnportants.
9(1):20-21. 9. Sherris, J D, Lewison, D and Fox, G, 1982. Update on condoms - products, protection, promotion. Population Reports. Series H, No 6:121. 10. Waldby, C, Kippax, S and Crawford, J, 1990. Theory in the bedroom: a report from the Macquarie University AIDS and heterosexuality project. Australian Journal of Social Issues. 25:177-85. 11. Albert, A E, Hatcher, R A and Graves, W, 1991. Condom use and breakage among women in a municipal hospital family planning clinic. Contraception. 43(2):167-76.
EXTRACTO E s t e e n s a y o es u n a d e s c r i p c i 6 n y r e f l e x i 6 n d e mi e x p e r i e n c i a l a b o r a l e n u n p r o y e c t o d e inv e s t i g a c i 6 n s o b r e las p r u e b a s clinicas d e los c o n d o n e s y el u s o d e los r n i s m o s . E1 p r o y e c t o i n c l u i a u n e s t u d i o d e r n e r c a d o , las p r u e b a s d e l a b o r a t o r i o del e s t f i n d a r d e c a l i d a d a u s t r a l i a n o , d i s c u s i o n e s y u s o s a p r u e b a d e los c o n d o n e s c o n t r a b a j a d o r e s del s e x o ( h o m b r e s y m u j e r e s ) , y entrevistas con otros usuarios. Realizarnos tarnbi6n un estudio encuesta sobre factores y c o n d u c t a s r e l a c i o n a d o s c o n los u s u a r i o s , vinc u l a d o s al u s o n o e x i t o s o del c o n d d n , m e d i d o d e a c u e r d o a l a s cifras r e p o r t a d a s d e c o n d o n e s clue se r o m p i a n o se salfan. Este e n s a y o l l a m a la a t e n c i d n s o b r e la lirnitada u t i l i d a d q u e o f r e c e n los m 6 t o d o s r e d u c c i o n i s t a s a la h o r a d e e n f r e n t a r c o n d u c t a s e x u a l c o m p l e j a . A l g u n o s d e los asp e c t o s 'al m a r g e n ' s u r g e n c o m o t e r n a s d e i r n p o r t a n c i a ; e n t r e ellos las p r e o c u p a c i o n e s e m o c i o n a l e s y prficticas d e los u s u a r i o s , c o m o la p 6 r d i d a d e la e r e c c i d n o el s a b o r d e los c o n d o n e s , y los s i g n i f i c a d o s s o c i a l e s y s i m b d l i c o s q u e t i e n e el c o i t o p a r a los p a r t i c i p a n t e s .
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% s r hingC0n 0ms: Juliet Richters INTRODUCTION INCE the mid- to late 1980s t h e r e has b e e n g e n e r o u s r e s e a r c h f u n d i n g available f r o m g o v e r n m e n t s keen to 'do s o m e t h i n g ' a b o u t AIDS for t h e i r horrified electorates. T h e r e have b e e n excellent analyses by sociologists and cultural studies p e o p l e of t h e w a y in w h i c h AIDS, with its p o t e n t m i x t u r e of sex a n d death, has inflamed t h e p o p u l a r i m a g i n a t i o n , and t h e w a y s it has b e e n u s e d by t h e media. Death as a potential o u t c o m e of h a v i n g sex has b e e n so familiar to w o m e n for m o s t of t h e h i s t o r y o f t h e h u m a n r a c e that I find t h e s u d d e n h o r r o r displayed by m e n s o m e w h a t tactless, to say the least. Be that as it may, the result of m a l e fear was funding, in l a r g e a m o u n t s . T h e r e is o f c o u r s e a lot of basic scientific and applied m e d i c a l w o r k b e i n g d o n e on t h e virus a n d on i m m u n e r e s p o n s e s to c h a l l e n g e s by the virus. T h e r e has also b e e n m o n e y for w o r k on the physical p r o p e r t i e s of c o n d o m s a n d for h e a l t h p r o m o t i o n w o r k e n c o u r a g i n g p e o p l e to p r a c t i s e 'safe sex', or 'safer sex" as it was later called by health p r o m o t i o n i s t s anxious n o t to oversell it. The effectiveness of any b e h a v i o u r a l m o d i f i c a t i o n i n t e n d e d to p r o t e c t s o m e o n e f r o m c a t c h i n g HIV f r o m an infected p a r t n e r can n e v e r be total and of c o u r s e t h e m o r a l majority, often cloaked in professional w h i t e coats, w e r e only t o o h a p p y to have it scientifically p r o v e d that sin c a u s e d disease and that c o n d o m use w a s h i g h l y suspect, if n o t c o m p l e t e l y ineffective, as a p r e v e n t i v e measure. I was one of the people w h o benefited from this sudden infusion of funding. I was working for the Family Planning Association in Sydney as the e d i t o r o f .their j o u r n a l Healthright, and I w a n t e d to do a h i g h e r d e g r e e in public health. So I t e a m e d up w i t h an e n g i n e e r I h a d m e t socially w h o w a s i n t e r e s t e d in c o n d o m t e s t i n g a n d a d o c t o r he knew, a v e n e r e o l o g i s t , to put in an
S
I
AIDS g r a n t application for a p r o j e c t e x a m i n i n g t h e a d e q u a c y o f c o n d o m s to m e e t the d e m a n d s n o w b e i n g p l a c e d o n t h e m to p r e v e n t HIV t r a n s m i s s i o n . In fact, I w a s at least as i n t e r e s t e d in the c o n t r a c e p t i v e use o f c o n d o m s , b u t b e c a u s e o f the f u n d i n g s o u r c e o u r attention, at least in theory, h a d to b e on STD p r e v e n t i o n . The funding body, an o f f s h o o t of t h e National Health and Medical R e s e a r c h Council, c o m b i n e d us with a n o t h e r p r o j e c t w h i c h p r o p o s e d to test c o n d o m s a l r e a d y o n t h e m a r k e t against t h e existing A u s t r a l i a n S t a n d a r d . As I had e x p e r i e n c e w o r k ing on p r o d u c t - t e s t i n g r e p o r t s for the C o n s u m e r s ' A s s o c i a t i o n I was e m p l o y e d to do both. Thus t h e t e a m a c q u i r e d a n o t h e r ' i n v e s t i g a t o r ' , a gay rights activist and l e c t u r e r in G o v e r n m e n t f r o m the U n i v e r s i t y of Sydney. As a r e s e a r c h t e a m w e w e r e a m o t l e y crew. This h a d d i s a d v a n t a g e s in the t w o and a bit y e a r s ' w o r k that followed. At o n e p o i n t it r e s u l t e d in the i n v e s t i g a t o r s n o t b e i n g on speaki n g t e r m s with e a c h other, but it was also extrao r d i n a r i l y p r o d u c t i v e b e c a u s e of o u r quite different points of view. It is unusual for a r e s e a r c h t e a m to i n c l u d e p e o p l e w i t h such diff e r e n t t r a i n i n g and a p p r o a c h e s , e v e n if w e w e r e all w h i t e a n d m i d d l e class. W h a t was v e r y usual w a s that the t h r e e "investigators' w e r e m a l e and I, t h e u n d e r l i n g ' r e s e a r c h assistant' (they kindly a l l o w e d m e to call m y s e l f c o o r d i n ator), a m female. A f t e r w o r k i n g for t h e Family P l a n n i n g Association, w h i c h is r u n by w o m e n , I was s u r p r i s e d ( t h o u g h I s h o u l d n ' t h a v e been) to find m y s e l f w o r k i n g w i t h p e o p l e w h o did n o t h a v e the s a m e s e l f - a w a r e n e s s of w h a t h a p p e n s w h e n sexual p r a c t i c e is the topic of y o u r w o r k as well as a p e r s o n a l i n t e r e s t and leisure activity. I learnt that not e v e r y o n e w h o p r o f e s s e s c o m f o r t a n d lack of e m b a r r a s s m e n t w i t h sexual topics is really c a p a b l e of d i s t i n g u i s h i n g t h e g e n e r a l i s e d a r o u s a l
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that can come from talking about sexual practice, from the shared and negotiated arousal of an intimate sexual encounter between two individuals. P e r h a p s this is m o r e difficult f o r m e n , w h o s e s e x u a l i t y is s o c o n s t r u c t e d in o u r c u l t u r e t h a t t h e y a r e m o r e likely t o l o c a t e t h e s o u r c e o f a r o u s a l in a n o b j e c t t h a n in t h e m s e l v e s .
W H A T W E R E W E T R Y I N G T O F I N D OUT."? T h e r e followed, off a n d on, w e e k s a n d m o n t h s o f d i s c u s s i o n s a b o u t w h a t it r e a l l y w a s w e w e r e t r y i n g t o find o u t a n d h o w w e s h o u l d g o a b o u t it. A s well as t e s t i n g c o n d o m s a g a i n s t t h e e x i s t i n g S t a n d a r d t h e e n g i n e e r w a n t e d to i n v e n t a k i n d o f ' l u c k m a c h i n e ' to s i m u l a t e in t h e l a b o r a t o r y t h e stresses and strains of intercourse. Something s i m i l a r to t h i s h a d b e e n d o n e in s o m e o f t h e v i r u s - t r a n s f e r e x p e r i m e n t s in t h e U n i t e d States. T h e r e s t of us w e r e s c e p t i c a l t h a t t h i s w o u l d address the real problem. What was the real problem with condoms? T h e m o s t o b v i o u s o n e is t h a t t h e y d o n ' t w o r k w h e n y o u d o n ' t p u t t h e m on. T h i s is b y f a r t h e m o s t c o m m o n r e a s o n f o r t h e i r failure as a c o n t r a c e p t i v e m e t h o d a n d as a n STD p r e v e n t i v e . Lots o f o t h e r h e a l t h p r o m o t i o n r e s e a r c h w a s c o n c e n t r a t i n g o n t h i s p r o b l e m , m o s t o f it f o c u s e d on the pre-existing attitudes towards condoms held by the potential user. We wanted to be more p r a c t i c a l a n d look at t h e p r o b l e m s t h a t c o n d o m u s e r s h a v e if t h e y d o at l e a s t t r y to u s e t h e c o n d o m s . F u r t h e r , w e c o n s i d e r e d t h a t if p e o p l e h a d n e g a t i v e a t t i t u d e s t o w a r d s c o n d o m s as a result of their own experiences, health education or "behaviour change interventions' would not b e likely to c o n v i n c e t h e m o t h e r w i s e . After a few months, during which we were already doing Standards testing, we focused our i n q u i r i e s o n t h e s e five q u e s t i o n s : • Do t h e c o n d o m s c u r r e n t l y o n t h e m a r k e t m e e t the present Australian Standard? • W h a t is t h e a c t u a l r a t e o f b r e a k a g e in u s e ? • Is a n y t h i n g in t h e c o n d i t i o n s o r m e t h o d o f u s e r e l a t e d to h i g h e r risk o f b r e a k a g e ? • Is p e r f o r m a n c e o n S t a n d a r d t e s t s f o r p i n h o l e s a n d b u r s t v o l u m e r e l a t e d to f a i l u r e r a t e s in use? • W h a t is t h e a c t u a l size r a n g e o f A u s t r a l i a n e r e c t p e n i s e s ? A r e t h e size r e q u i r e m e n t s o f the current Standard adequate?
L o o k i n g b a c k o n t h e s e q u e s t i o n s n o w , I find t h e i r language and approach very revealing. Although we were researching what happens when people h a v e sex, specifically a n a l o r v a g i n a l i n t e r c o u r s e , p e o p l e h a v i n g sex o c c u r n o w h e r e in t h e summary of our endeavours. We had managed as I w a s l e a r n i n g to d o w h i l e s t u d y i n g e p i d e m i o l o g y a n d b i o s t a t i s t i c s f o r m y M a s t e r of Public H e a l t h d e g r e e in t h e e v e n i n g s - to r e d u c e t h e t e r m s o f t h e i n q u i r y to w h a t w a s c o u n t a b l e . W e l o o k e d at q u e s t i o n s o f m e e t i n g a S t a n d a r d , statistical c o m p l i a n c e w i t h a p h y s i c a l test, t h e r a t e o f b r e a k a g e a n d f a c t o r s r e l a t e d to h i g h e r rates. We looked for a relationship between t h e s e t w o a b s t r a c t t h i n g s a n d a g r a p h o f t h e dist r i b u t i o n o f t h e size o f a p a r t o f t h e b o d y (in a n a d e q u a t e s a m p l e , o f c o u r s e ) d i v o r c e d f r o m its o w n e r , i n t h e e r e c t s t a t e b u t w i t h o u t social o r emotional meaning. What happened when we t r i e d to d o t h i s t a u g h t m e f a r m o r e t h a n t h e a n s w e r s to t h e q u e s t i o n s w e asked.
CONDOM STANDARDS TESTING W e d i d a s u r v e y o f t h e c o n d o m m a r k e t in A u s t r a lia, b o u g h t s a m p l e s of all t h e m a j o r b r a n d s , a n d t e s t e d t h e m to t h e A u s t r a l i a n S t a n d a r d . T h e s e r e s u l t s w e r e p u b l i s h e d a n d a t t r a c t e d q u i t e a lot o f m e d i a a t t e n t i o n . 1, 2 W h a t d o e s all t h i s m e a n n o w ? I w o u l d s a y t h a t a n y c o n d o m legally o n sale in A u s t r a l i a is as g o o d as c u r r e n t s t a n d a r d s t e s t i n g c a n m a k e it. T h e only e x c e p t i o n m i g h t b e if a s h o p s t o r e d t h e m f o r y e a r s u n d e r h o t l i g h t s a n d sold t h e m o n l y w e e k s b e f o r e t h e i r f i v e - y e a r e x p i r y date. If y o u ' r e b u y i n g c o n d o m s , c h e c k t h e u s e - b y date. T h e f u r t h e r a h e a d it is, t h e b e t t e r . I n t e r e s t i n g l y , I find m a n y p e o p l e d o n o t like t h i s g o o d n e w s . T h e r e is a n e t e r n a l f a s c i n a t i o n w i t h t h e f a i l i n g s o f c o n d o m s , I s u s p e c t as a justification or rationalisation of disliking them f o r o t h e r m o r e e m o t i o n a l r e a s o n s , i.e. t h e y d o n ' t w o r k a n y w a y , w h y b o t h e r ? Or, t h e y ' v e all g o t h o l e s in, y o u k n o w - j u s t like t h e o l d s t o r y a b o u t t h e P o p e e m p l o y i n g p e o p l e in t h e f a c t o r i e s to p i e r c e t h e m w i t h pins. N o t t h a t I d o n ' t s y m p a t h i s e w i t h t h e s e o t h e r r e a s o n s f o r disliking t h e m . T h e o t h e r o b s e s s i o n m e n h a v e is w i t h c o n d o m sizes. A u s t r a l i a n c o n d o m s all h a v e to m e e t t h e S t a n d a r d , w h i c h allows for s o m e t o l e r a n c e in length and width, but none are labelled with sizes. T h e y d o differ a bit in s h a p e a n d size
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between brands and lines, h o w e v e r . W e r e c o m m e n d e d that m a n u f a c t u r e r s offer m o r e than one size and that the S t a n d a r d be altered to allow l o w e r b u r s t v o l u m e limits for smaller c o n d o m s , but this has not yet h a p p e n e d . I think it was Gloria S t e i n e m w h o o n c e s u g g e s t e d that c o n d o m s s h o u l d be m a d e in t h r e e sizes (small, medium, large) but to salve m e n ' s egos, labelled like olives (large, j u m b o and colossal). This q u e s t i o n is c o m p l i c a t e d f u r t h e r b y the fact that m e n ' s p e r c e p t i o n of their o w n p e n i s size relative to o t h e r m e n is v e r y p o o r unless t h e y h a v e sex with o t h e r men. Also m o s t m e n w o r r y only a b o u t length. Not only m a n y w o m e n , but also c o n doms, are m o r e affected b y d i f f e r e n c e s in width. Just like fat legs in stockings, a fat penis n e e d s a l o n g e r c o n d o m . The A u s t r a l i a n i m p o r t e r s of c o n d o m s , all a p p a r e n t l y straight, find this topic so difficult that t h e y j o k e a b o u t it and n e v e r g e n u i n e l y a t t e m p t to do a n y t h i n g a b o u t it. I f o u n d the s a m e r e l u c t a n c e f r o m t h e m to discuss the taste o f c o n d o m s , a l t h o u g h t h e y w e r e all
asking us to give f e e d b a c k t h a t m i g h t be useful for p r o d u c t d e v e l o p m e n t o r m a r k e t i n g . People in g e n e r a l are often s u r p r i s e d to h e a r that c o n d o m testing a n d S t a n d a r d s a p p r o v a l h a v e no c o n n e c t i o n w i t h the p e r f o r m a n c e o f cond o m s in use. V e r y f e w studies h a v e b e e n d o n e on this. W e w e r e t e m p t e d to try to get p e o p l e to use s u b - s t a n d a r d c o n d o m s and c o r r e l a t e m i s h a p s w i t h lab test results, b u t ethically w e w o u l d h a v e h a d to use m o n o g a m o u s u n i n f e c t e d couples ( p r o t e c t e d against p r e g n a n c y by o t h e r m e a n s if t h e y w e r e heterosexual), and w e d i d n ' t think w e ' d b e able to r e c r u i t e n o u g h of them. So w e c o n c e n t r a t e d o n the q u e s t i o n of w h y s o m e people using adequate condoms have constant p r o b l e m s while o t h e r p e o p l e n e v e r do.
INTERVIEWS I conducted telephone interviews with women and m e n w h o r a n g m e in r e s p o n s e to advertisem e n t s put up in STD clinics. I w a s mainly t r y i n g
u: ~3 > z
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to f i n d o u t w h a t it w a s a b o u t p e o p l e w h o h a d t r o u b l e w i t h c o n d o m s , p a r t i c u l a r l y if t h e y frequently found the condom broke during i n t e r c o u r s e o r s l i p p e d off. In fact, f o r m o n t h s I t a l k e d to a n y o n e w h o w o u l d talk to m e a b o u t c o n d o m s - s e x w o r k e r s , a d u l t e r e r s , p e o p l e at p a r t i e s . I l e a r n e d a lot a b o u t sex c o u n s e l l i n g d u r i n g t h a t p e r i o d , j u s t as I h a d d u r i n g m y t i m e at t h e FPA. I m a y n o t h a v e t h e c r e d e n t i a l s , b u t I h a v e t h e flying h o u r s
BROTHEL STUDY Then we ran a prospective study of breakage and s l i p p a g e in t h r e e b r o t h e l s , t w o m a l e a n d o n e female. W e s u p p l i e d t h e f r e s h c o n d o m s , t o g e t h e r w i t h f o r m s t o fill in if t h e r e w a s a n a c c i d e n t a n d little p l a s t i c b a g s to p u t t h e t o r n c o n d o m s in. W e h o p e d to collect e n o u g h t o r n c o n d o m s to a n a l y s e in t h e l a b h o w a n d w h e r e t h e y t o r e , b u t o f t h e 1,269 c o n d o m s t h e w o r k e r s used, only 8 w e r e r e p o r t e d b r o k e n , a n d t w o o f t h e m t u r n e d o u t to b e i n t a c t w h e n w e l o o k e d at t h e m carefully. ( B r e a k a g e r a t e = 0.6 p e r cent.) This p r o d u c e d a nice little r e s e a r c h r e p o r t w i t h a c c u r a t e f i g u r e s and tight confidence intervals, just the kind of t h i n g t h e m e d i c a l j o u r n a l s like, a n d it w a s i n d e e d p u b l i s h e d i m m e d i a t e l y as a l e t t e r in t h e L a n c e t . 3 W h a t I f o u n d so f a s c i n a t i n g , t h o u g h , w e r e t h e discussions I had with the workers each week o v e r t h e t h r e e o r f o u r m o n t h s I w a s visiting t h e m to collect t h e i r f o r m s a n d d e l i v e r f r e s h c o n d o m s . Today, I w o u l d call t h a t f o c u s g r o u p w o r k a n d w r i t e it u p as f o r m a l q u a l i t a t i v e r e s e a r c h . T h e n , it w a s j u s t q u a l i t a t i v e pilot s t u f f - d e f i n e d b y e p i d e m i o l o g i s t s a l m o s t as n o n - w o r k . T h e f e m a l e sex w o r k e r s w e r e u n a n i m o u s t h a t if y o u d o n ' t w a n t t h e c o n d o m to b r e a k y o u d o n ' t let t h e c l i e n t t o u c h it. B u t t h e m a l e w o r k e r s also h a d v e r y f e w breakages, once they had a few weeks' experi e n c e in t h e j o b . W h a t w e still d i d n ' t k n o w , though, was whether the things the workers said t h e y d i d o r d i d n ' t d o w e r e really w h a t distinguished successful and unsuccessful condom u s e r s f r o m e a c h o t h e r in t e r m s o f b r e a k a g e a n d slippage.
QUESTIONNAIRE STUDY So w e d i d a q u e s t i o n n a i r e s t u d y to e x p l o r e t h e u s e r - r e l a t e d r e a s o n s f o r c o n d o m failure a m o n g ' a m a t e u r ' u s e r s . T h e m a i n a i m w a s to s e e
w h e t h e r t h e r e p o r t e d r a t e s o f t w o physical, observable phenomena (condom breakage and slippage) could be related to users' physical features and behaviours. We designed questionnaires asking men whether they used condoms. If not, w h y not. If so, h o w m a n y c o n d o m s t h e y ' d used during the past year and a whole string of questions about their age and ethnic group, what lubricant they used, how they put the condom on, w h a t t h e y t h o u g h t o f c o n d o m s , a n d w h a t their attitudes were. Five h u n d r e d a n d f o r t y - f o u r m e n a t t e n d i n g STD clinics a n d t h e U n i v e r s i t y H e a l t h S e r v i c e filled in initial q u e s t i o n n a i r e s w i t h t h e b a s i c i n f o r m a t i o n a n d 120 a n s w e r e d t h e a d d i t i o n a l q u e s t i o n n a i r e s w i t h all t h e a t t i t u d e a n d u s e details. F o r t h e 402 w h o h a d u s e d c o n d o m s in t h e p r e v i o u s year, t h e b r e a k a g e r a t e s w e r e f a r h i g h e r t h a n f o r t h e sex w o r k e r s , a r o u n d 7 p e r cent, t h o u g h t h i s f i g u r e i n c l u d e s b r e a k a g e s d u r i n g a p p l i c a t i o n . 4 F o r t h e 108 m e n f o r w h o m w e h a d full r e s u l t s , w e f o u n d t h e y w e r e likely to b r e a k m o r e c o n d o m s if they: • • •
•
had male partners didn't use condoms often s i m p l y r o l l e d t h e c o n d o m o n ( a c c o r d i n g to t h e i n s t r u c t i o n s ) r a t h e r t h a n p u l l i n g it o n like a s t o c k i n g w i t h t h e i r f i n g e r s inside, o r d o i n g a combination of these things had trouble with condoms slipping up but not
off; a n d to h a v e m o r e c o n d o m s slip off if t h e y : • • • •
were young were circumcised hadless condom experience s i m p l y r o l l e d t h e c o n d o m on.
A t t i t u d e s t o w a r d s c o n d o m s w e r e n o t r e l a t e d to s u c c e s s in use. 5 W e d i d e l a b o r a t e iogistic r e g r e s s i o n a n a l y s e s to c o m e u p w i t h t h e s e results. H o w e v e r , a p r i c e w a s p a i d f o r t h i s strictly q u a n t i t a t i v e a p p r o a c h to w h a t w a s l a r g e l y a n e x p l o r a t o r y p i e c e of r e s e a r c h . It is p o s s i b l e t h a t a c o n c e p t u a l ( r a t h e r than merely numerical) analysis of the experiences and attitudes of successful and unsuccessful u s e r s w o u l d h a v e y i e l d e d useful i n s i g h t s i n t o t h e b e h a v i o u r o f u s e r s . If w e h a d h a d t h e o p p o r t u n i t y to i n t e r v i e w s e l e c t e d r e s p o n d e n t s about their experiences with condoms, we might h a v e b e e n a b l e t o t h r o w m o r e l i g h t o n s o m e of
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<
z
o u r f i n d i n g s . F o r e x a m p l e , a b o u t 60 p e r c e n t o f r e s p o n d e n t s e x p e r i e n c e d loss o f e r e c t i o n d u r i n g i n t e r c o u r s e w i t h a c o n d o m , at l e a s t o c c a s i o n a l l y . Intuitively o n e w o u l d e x p e c t t h i s to m a k e slipp a g e m o r e likely. H o w d o s u c c e s s f u l u s e r s deal w i t h t h i s ? Do t h e y h o l d t h e c o n d o m o n until t h e i r erection returns? ARE THESE RESULTS GENERALISABLE. 9 It is o b v i o u s t h a t m e n a t t e n d i n g STD clinics a n d a u n i v e r s i t y h e a l t h s e r v i c e a r e n o t typical o f c o n d o m u s e r s at large. Still less a r e t h e 108 m e n who provided data, even though they may have b e e n r o u g h l y s i m i l a r to t h e n o n - r e s p o n d e n t c o n d o m u s e r s in age, s e x u a l p r e f e r e n c e a n d e t h n i c b a c k g r o u n d . It m a y b e r e a s o n a b l e t o a s s u m e t h a t t h e f a c t o r s r e l a t e d to h i g h e r c o n d o m b r e a k a g e r a t e s a m o n g m e m b e r s o f t h i s g r o u p w o u l d also b e r e l a t e d t o h i g h e r b r e a k a g e r a t e s in o t h e r g r o u p s , b u t o n l y if o t h e r e v i d e n c e f o r c a u s a l i t y c o u l d b e p r o d u c e d . T h e i n v e r s e , o f c o u r s e , is n o t t r u e . A m o n g o t h e r g r o u p s , e.g. n o n - c l i n i c a t t e n d e r s a n d p e o p l e w h o dislike filling in
questionnaires, there may be quite different reasons for condom breakage. T h e h u g e loss to f o l l o w - u p in this s t u d y d r a w s a t t e n t i o n to a p r o b l e m w h i c h a t t e n d s all s t u d i e s concerning sensitive or threatening issues'such as s e x u a l b e h a v i o u r , c h i l d r e a r i n g , c a n c e r , a n d u n e m p l o y m e n t , a W e n e e d e d to find c o n d o m u s e r s , as n o n - u s e r s c o u l d n o t tell u s a n y t h i n g helpful. W e t h e r e f o r e f a c e d s o m e o f t h e s a m e p r o b l e m s m e n t i o n e d b y C h a p m a n a n d Bray. 7 In c o n t r a s t to t h e i r e x p e r i e n c e , w e f o u n d eligible c o n d o m u s e r s - 353 m e n - b u t t h e n w e lost m o r e than two thirds of them. Presumably we scared t h e m off b y a s k i n g t h e m to d o s o m u c h . (As t h e y w e r e a n o n y m o u s w e c o u l d n o t follow u p d e f a u l t e r s to find o u t w h y t h e y h a d d r o p p e d out.) P a r t o f t h i s w a s t h e s h e e r a m b i t i o n o f t h e study. A s well as t h e q u e s t i o n n a i r e s , w e g a v e t h e m c o n d o m s t o u s e a n d a s k e d t h e m to d r o p off u s e d o n e s at t h e clinic. It r e q u i r e s a d e d i c a t e d r e s p o n d e n t i n d e e d w h o will u s e s p e c i a l l y s u p p l i e d c o n d o m s a n d r e p o r t o n t h e m a f t e r t h r e e m o n t h s , e v e n if h e h a s
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m o v e d h o u s e , lost his lover, e n t e r e d a r e l a t i o n s h i p in w h i c h c o n d o m s a r e n o t r e q u i r e d , o r b e c o m e t o o ill to u s e c o n d o m s . (This d i d h a p p e n to s o m e o f o u r m o s t d e d i c a t e d r e s p o n d e n t s , w h o r a n g t h e P r o j e c t office to s a y t h a t t h e y h a d n o t used the condoms or could not use any more b e c a u s e t h e y o r t h e i r p a r t n e r s w h o h a d AIDS w e r e t o o ill t o c o n t i n u e . ) I n a d d i t i o n to t h e m a n y d e m a n d s o f t h i s s t u d y w e u s e d t h e kits to m a k e further demands of the respondents for the sake of r e l a t e d s t u d i e s in t h e C o n d o m Project. It is likely t h a t m a n y r e s p o n d e n t s g a v e u p w h e n t h e y e x a m i n e d t h e i r kits a t h o m e a n d f o u n d t h a t w e were asking them to measure their penises and to d e l i v e r u s e d c o n d o m s t o t h e clinic. O n e res p o n d e n t e v e n p u b l i s h e d a n article a b o u t t h e g h a s t l i n e s s o f t h e study, vividly w a r n i n g his fellow s t u d e n t s to ' B e w a r e t h e C o n d o m Kit'. 8
IMPLICATIONS OF FINDINGS It is u n f o r t u n a t e t h a t t h e c l e a r e s t m e s s a g e f r o m t h i s s t u d y is t h a t m a n y o f t h e risk f a c t o r s f o r c o n d o m failure a r e t h i n g s t h a t t h e u s e r c a n n o t i n f l u e n c e o r m a y n o t w a n t to c h a n g e , s u c h as his age, his s e x u a l p r e f e r e n c e , w h e t h e r h e is circumcised and the amount of previous experie n c e h e h a s h a d . H o w e v e r , t h e f i n d i n g s p o i n t to s e v e r a l h i t h e r t o u n e x a m i n e d p r o b l e m s r e l a t e d to c o n d o m use. C o n d o m i n s t r u c t i o n s a r e b a s e d o n several assumptions: • t h a t t h e u s e r c a n m a i n t a i n a firm e r e c t i o n in o r d e r to roll t h e c o n d o m o n • that the user has three hands, or the manual d e x t e r i t y t o roll t h e c o n d o m d o w n w i t h o n e hand while holding the teat with the other, or the assistance of a cooperative partner • that penetrative intercourse occurs immediately a f t e r a p p l i c a t i o n • that the user maintains an erection througho u t i n t e r c o u r s e , w h i c h p r o c e e d s w i t h o u t int e r r u p t i o n a n d c u l m i n a t e s in e j a c u l a t i o n • t h a t t h e u s e r is n o t t o o e m o t i o n a l l y c a r r i e d away or sleepy or keen on continuin9 after o r g a s m a n d r e m e m b e r s to w i t h d r a w imm e d i a t e l y , w h i l e h o l d i n g o n to t h e r i m of t h e condom. O u r f i n d i n g s c h a l l e n g e s o m e of t h e s e a s s u m p t i o n s , w h i l e o t h e r s a r e intuitively u n s a t i s f a c t o r y . Even amon 9 this group of volunteer condom users, about two thirds of the men sometimes or
o f t e n lost t h e i r e r e c t i o n w h i l e p u t t i n g a c o n d o m on, a n d n e a r l y as m a n y lost t h e i r e r e c t i o n d u r i n g intercourse. One may hypothesise that this may b e o n e r e a s o n w h y m a n y m e n a r e u n w i l l i n g to use condoms, either because they prefer interc o u r s e n o t to b e c o n s t r a i n e d a n d s t r u c t u r e d in t h i s way, o r b e c a u s e t h e y feel t h e y ' o u g h t " to s t a y e r e c t , so t h a t w i l t i n g d u r i n g c o n d o m a p p l i c a t i o n d r a w s a t t e n t i o n to t h e i r failing. H e a l t h p r o m o tion messages which claim that 'putting on a condom need not interrupt love-making' are m i s s i n g t h e p o i n t . ( A n d n o t all sex is l o v e - m a k i n g anyway.) Those men who disobeyed instructions and p u l l e d t h e c o n d o m o n like a s t o c k i n g (or u s e d a combination method) had lower, not higher, failure r a t e s . T h i s f i n d i n g w a s u n e x p e c t e d . It may be that 'pullers' get the condom on more securely. We learnt from our discussions with sex workers that this method can be comfortable a n d c o n v e n i e n t . It is c e r t a i n l y e a s i e r to u s e if t h e p e n i s is n o t fully rigid, a n d it c a n b e d o n e w i t h o u t d a m a g i n g t h e c o n d o m . T h e r e a s o n it is g e n e r a l l y n o t r e c o m m e n d e d is p r e s u m a b l y b e c a u s e o f t h e possibility of users putting their fingers through the condom. We found no evidence that pinching the teat a f f e c t e d t h e risk o f b r e a k a g e o r s l i p p a g e . O n e c a n n o t p i n c h t h e t e a t a n d u s e t h e 'pull' m e t h o d of application simultaneously, though one can p i n c h t h e teat, roll t h e c o n d o m p a r t l y o n a n d t h e n pull. W e c o u l d s e e n o r e a s o n f r o m t h e m e c h a n ical p o i n t o f v i e w w h y failing to p i n c h t h e t e a t s h o u l d c a u s e p r o b l e m s . Air, if p r e s e n t in t h e teat, is s q u e e z e d d o w n to b e h i n d t h e g l a n s p e n i s o n insertion. Given the distensibility of the condom, t h e r e is n o r e a s o n w h y t h e p r e s e n c e o f I ml o r so o f air in a d d i t i o n to 3-5 m l o f s e m e n s h o u l d 'burst' the condom. 9
REFLECTIONS O f c o u r s e , t h e p l a y e r s in t h e c o n d o m a r e n a h a v e differing and sometimes conflicting interests. O n e c a n l o o k at t h e m a n u f a c t u r e r s , r e t a i l e r s a n d i m p o r t e r s , f o r e x a m p l e , in e c o n o m i c t e r m s as h a v i n g i n t e r e s t s in m a k i n g m o n e y o u t o f c o n d o m s . So t o o d o e n g i n e e r s w i t h c o n d o m - t e s t i n g laboratories. But there's a subtler kind of 'interest" t h a t I f i n d m o r e f a s c i n a t i n 9, w h i c h I t o u c h e d on when I mentioned the hegemonic form of 'sexual intercourse' that the condom instructions
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a s s u m e a n d t h a t c o n d o m use, in a s e n s e , enforces. I w a s n ' t s u r e w h e t h e r to b e w o r r i e d o r pleased that many young men who had never had intercourse and perhaps no experience of sexual r e l a t i o n s h i p s took o u r kits, p r e s u m a b l y out o f curiosity, to e x a m i n e t h e c o n d o m s a n d t h e i n s t r u c t i o n s . W a s this useful s e x e d u c a t i o n , t e a c h i n g t h e m h o w to u s e c o n d o m s b e f o r e t h e n e e d a r o s e , o r w a s it t r a n s m i t t i n g c u l t u r a l r u l e s a b o u t h o w t o h a v e i n t e r c o u r s e ? If t h e m a i n effect w a s t h e latter, I r e g r e t it. It w o r r i e s m e t h a t in t h e h e t e r o s e x u a l a r e n a c o n d o m s a r e p r e s e n t e d as t h e o n l y w a y of m a k i n g ' s e x ' safe. In leaflets f o r t h e g e n e r a l public, w h o a r e p r e s u m e d t o h a v e m o r e d e l i c a t e sensibilities t h a n g a y m e n , a l t e r n a t i v e s e x u a l practices to penis-vagina intercourse are rarely m e n t i o n e d . In c o n t r a s t , p a r t o f t h e s u c c e s s o f t h e safe sex c a m p a i g n s in t h e g a y c o m m u n i t y h a s been attributed to the eroticisation and promotion o f n o n - p e n e t r a t i v e p r a c t i c e s . 1° It m a y b e t h a t in p r o m o t i n g c o n d o m s in s c h o o l s , f o r e x a m p l e , w i t h o u t m e n t i o n i n g o t h e r w a y s o f h a v i n g safe sex, w e a r e r e i n f o r c i n g t h e m e s s a g e to y o u n g w o m e n t h a t p e n i l e i n t e r c o u r s e is t h e o n l y s o r t o f ' s e x ' to h a v e . It's n o s u r p r i s e t h a t p e o p l e in c o n d o m f a c t o r ies o r o n S t a n d a r d s c o m m i t t e e s , o r i n d e e d p e o p l e r e s e a r c h i n g c o n d o m failure, a r e m o r e c o m f o r t a b l e t a l k i n g a b o u t b u r s t v o l u m e s , leaka g e tests, t e n s i l e s t r e n g t h , s t o r a g e c o n d i t i o n s and batch numbers than about what actually h a p p e n s to t h e c o n d o m b e i n g u s e d b y people, especially d u r i n g a n a l i n t e r c o u r s e , a t o p i c w h i c h makes many straight men extremely uncomfortable. It's c l e a r also t h a t e v e n w h e n a t t e m p t i n g to d i s c u s s i s s u e s o f use, m a n y r e s e a r c h e r s a r e e n g a g i n g in m o r a l r a t h e r t h a n n e u t r a l d e s c r i p tive d i s c o u r s e - s o m e t h i n g w e p r o b a b l y o b j e c t to only w h e n t h e m o r a l p o i n t o f v i e w is d i f f e r e n t from our own. M a n y a u t h o r s , p a r t i c u l a r l y in t h e U n i t e d States, s e e m to feel t h e n e e d to m a k e s t a t e m e n t s a c k n o w l e d g i n g t h e v i r t u e s of a b s t i n e n c e b e f o r e d i s c u s s i n g c o n d o m s , p r e s u m a b l y to a p p e a s e t h e 'moral majority'. Then they write of intercourse and many other sexual practices, particularly w i t h s e x w o r k e r s , as if t h e y t h e m s e l v e s h a d n o e x p e r i e n c e o f t h e m . E v e n in a r t i c l e s w h e r e women are among the authors, women's sexual a r o u s a l o r lack o f it is o f t e n p r o b l e m a t i s e d in r e l a t i o n to c o n d o m u s e (e.g. it is s u g g e s t e d t h a t
b r e a k a g e is c a u s e d b y t h e w o m a n ' s d r y n e s s 11) b u t t h e i s s u e o f t h e m a n ' s a r o u s a l a n d e r e c t i o n is rarely mentioned. It's o b v i o u s f r o m t h e v e r y fact t h a t I d i d all t h i s work that I'm capable of thinking about anal or v a g i n a l i n t e r c o u r s e in r e d u c t i o n i s t , m e c h a n i c a l t e r m s , a n d I t h i n k t h e r e a r e s o m e useful i n s i g h t s t o b e g a i n e d f r o m t h e a t t e m p t to d o so. B u t t h e y are very limited insights. I have become more, n o t less, c o n v i n c e d t h a t t h e m a i n ' p r o b l e m s ' w i t h c o n d o m s a r e to d o w i t h h e a r t s a n d m i n d s , n o t j u s t l u b r i c a n t t y p e o r p e n i s size o r d u r a t i o n o f i n t e r c o u r s e . T h e c e n t r a l one, I believe, is to do with the meaning of intercourse within an affective r e l a t i o n s h i p . P e n e t r a t i v e i n t e r c o u r s e involves a blurring of body boundaries. For some p e o p l e a n d in s o m e s i t u a t i o n s t h i s c a n b e t h r e a t e n i n g a n d u n p l e a s a n t , b u t it c a n also h a v e a symbolic emotional meaning that validates the central role of intercourse within the practices t h a t g e t called s e x o r l o v e - m a k i n g in o u r c u l t u r e . T h e p r e s e n c e o f a c o n d o m s y m b o l i c a l l y - as well as b a c t e r i o l o g i c a l l y - m a i n t a i n s a b a r r i e r between the two bodies. W e a s k e d o n e q u e s t i o n t h a t , as f a r as I k n o w , h a s n o t b e e n a s k e d in c o n d o m r e s e a r c h b y a n y o n e else: H a v e y o u e v e r r e m o v e d a c o n d o m d u r i n g i n t e r c o u r s e a n d c o n t i n u e d w i t h o u t it? H a l f o f o u r r e s p o n d e n t s h a d d o n e t h i s at l e a s t o n c e . ( W e d i d n ' t ask w h e t h e r t h e y h a d h a d t h e i r p a r t n e r ' s p e r m i s s i o n to d o so.) T h e effecti v e n e s s o f C o n d o m u s e as a c o n t r a c e p t i v e o r STD preventive rests not so much on the physical a d e q u a c y o f t h e c o n d o m , as o n t h e h u m a n difficulty o f r e s p o n s i b l y c o n s i d e r i n g t h e c o n s e q u e n c e s o f o u r a c t i o n s , w h i l e in a s t a t e o f h i g h sexual excitement, and possibly emotionally transported and undifferentiated from our partn e r s . H o w a r e p e o p l e to p e r f o r m t h e e m o t i o n a l f e a t o f a c h i e v i n g at l e a s t m o m e n t a r y loss o f selfc o n s c i o u s n e s s - n e c e s s a r y f o r o r g a s m for s o m e p e o p l e - w h i l e at t h e s a m e t i m e c o n t i n u i n g to r e g a r d t h e p a r t n e r ' s b o d y fluids as "other" a n d potentially dangerous?
Note This paper is based on a talk given to the seminar "Making Bodies: Making Technologies" organised b y the W o m e n ' s Studies Centre, University o f Sydney, Australia, 29 May 1993.
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References 1. Condoms revisited. Choice (Australian Consumers' Association). January 1989, 42-45. 2. Donovan B, Richters, J and Gerofi, J, 1991. A pharmacopoeia of Australian condoms. Venereology. 4: 88-95. 3. Richters, J, Donovan, B, Gerofi, J and Watson, L, 1989. Low condom breakage rate in commercial sex [letter]. Lancet. 2:1487-88. 4. Richters, J, Donovan, B, and Gerofi, J, 1993. How often do condoms break or slip off in use? International Journal of STD and AIDS. 4:90-94.
5.
Richters, J. User-related predictors of condom failure in use. MPH treatise, Department of Public Health, University of Sydney, 1991. 6. Sudman, S and Bradburn, N M, 1982. Asking Questions. JosseyBass, San Francisco. 7. Chapman, S and Bray, F, 1989. Researching condom use: field notes from a failed project. British Medical Journal. 298: 682-83. 8. Lacey, S, 1989. B e w a r e t h e condom kit. Honi Soit (University of Sydney), 19 September, 23: 17. Reprinted as Lacey, S, 1989. Beware of the condom kit. Healthright.
RI~SUMI~ C e t e x p o s 6 d 6 c r i t et t r a d u i t m e s e x p @ i e n c e s d e t r a v a i l s u r u n p r o j e t d e r e c h e r c h e c o n c e r n a n t les e s s a i s et l ' u t i l i s a t i o n d e s p r 6 s e r v a t i f s . Le p r o j e t couvrait une 6tude de march6, des essais en l a b o r a t o i r e e n c o n f o r m i t 6 a v e c la n o r m e a u s t r a l i e n n e , d e s d i s c u s s i o n s et d e s e s s a i s d e p r ~ s e r v atifs a v e c d e s t r a v a i l l e u r s e n s a n t 6 s e x u e l l e ( h o m m e s et f e m m e s ) et d e s e n t r e t i e n s a v e c d ' a u t r e s utilisateurs. N o u s a v o n s 6 g a l e m e n t m e n 6 u n e enclu~te p a r q u e s t i o n n a i r e s u r les f a c t e u r s et les c o m p o r t e m e n t s d e s u t i l i s a t e u r s a s s o c i 6 s aux 6 c h e c s d e s p r 6 s e r v a t i f s tels qu'6valu6s & partir des nombres signal6s de p r 6 s e r v a t i f s q u i se d 6 c h i r e n t o u glissent. C e t e x p o s 6 a t t i r e l ' a t t e n t i o n SEErle fait q u ' a b o r d e r u n comportement sexuel complexe par des m6tho d e s r 6 d u c t i o n n i s t e s e s t d ' u n e utilit6 limit6e. C e r t a i n e s d e s q u e s t i o n s ' m a r g i n a l e s ' , d o n t les i n q u i 6 t u d e s d ' o r d r e 6 m o t i o n n e l et p r a t i q u e m a n i f e s t 6 e s p a r les u t i l i s a t e u r s , c o m m e la p e r t e d ' @ e c t i o n o u le g o 0 t d e s p r 6 s e r v a t i f s , ainsi q u e la s i g n i f i c a t i o n sociale et s y m b o l i c l u e d e s r a p p o r t s p o u r les p a r t i c i p a n t s , se s o n t a v 6 r 6 e s ~tre d e s sujets irnportants.
9(1):20-21. 9. Sherris, J D, Lewison, D and Fox, G, 1982. Update on condoms - products, protection, promotion. Population Reports. Series H, No 6:121. 10. Waldby, C, Kippax, S and Crawford, J, 1990. Theory in the bedroom: a report from the Macquarie University AIDS and heterosexuality project. Australian Journal of Social Issues. 25:177-85. 11. Albert, A E, Hatcher, R A and Graves, W, 1991. Condom use and breakage among women in a municipal hospital family planning clinic. Contraception. 43(2):167-76.
EXTRACTO E s t e e n s a y o es u n a d e s c r i p c i 6 n y r e f l e x i 6 n d e mi e x p e r i e n c i a l a b o r a l e n u n p r o y e c t o d e inv e s t i g a c i 6 n s o b r e las p r u e b a s clinicas d e los c o n d o n e s y el u s o d e los r n i s m o s . E1 p r o y e c t o i n c l u i a u n e s t u d i o d e r n e r c a d o , las p r u e b a s d e l a b o r a t o r i o del e s t f i n d a r d e c a l i d a d a u s t r a l i a n o , d i s c u s i o n e s y u s o s a p r u e b a d e los c o n d o n e s c o n t r a b a j a d o r e s del s e x o ( h o m b r e s y m u j e r e s ) , y entrevistas con otros usuarios. Realizarnos tarnbi6n un estudio encuesta sobre factores y c o n d u c t a s r e l a c i o n a d o s c o n los u s u a r i o s , vinc u l a d o s al u s o n o e x i t o s o del c o n d d n , m e d i d o d e a c u e r d o a l a s cifras r e p o r t a d a s d e c o n d o n e s clue se r o m p i a n o se salfan. Este e n s a y o l l a m a la a t e n c i d n s o b r e la lirnitada u t i l i d a d q u e o f r e c e n los m 6 t o d o s r e d u c c i o n i s t a s a la h o r a d e e n f r e n t a r c o n d u c t a s e x u a l c o m p l e j a . A l g u n o s d e los asp e c t o s 'al m a r g e n ' s u r g e n c o m o t e r n a s d e i r n p o r t a n c i a ; e n t r e ellos las p r e o c u p a c i o n e s e m o c i o n a l e s y prficticas d e los u s u a r i o s , c o m o la p 6 r d i d a d e la e r e c c i d n o el s a b o r d e los c o n d o n e s , y los s i g n i f i c a d o s s o c i a l e s y s i m b d l i c o s q u e t i e n e el c o i t o p a r a los p a r t i c i p a n t e s .
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