By David C. Holzman
David C. Holzman writes from Lexington, Mass., on science, medicine, energy, environment, and cars. He is Journal Highlights editor for the American Society for Microbiology and won a Plain Language Award last year from the National Institutes of Health. This essay began as a response to a CommonHealth post on why people have unsafe sex, and turned into much more.
Caution genes run in my family. My parents put seat belts in the ’57 Chevy in 1960, eight years before they became mandatory. In July, 1975, I bought Bell bicycle helmet serial number 7022. My cycling ensemble also includes one of those lime green jerseys that’s visible from the International Space Station.
And I was asking sex partners about Sexually Transmitted Diseases beginning in the early 1980s, when herpes — not HIV — was the main subject of such conversations. This despite the fact that the first time I did, the woman refused to discuss it, saying I could go to bed with her when I was ready to trust her. Condoms? Of course.
Now, in 2012, I still wouldn’t dream of leaving my seatbelt unbuckled, or biking without my helmet and jersey. I’ve never stopped asking new sex partners about STDs. But recent news reports have suggested that among the middle aged, rates of sexually transmitted diseases are rising while condom use is falling, and I have to confess:
At 59, I’ve worn condoms probably fewer than five times since the millennium, despite having been single for six of those years, during which time I’ve averaged one or two new partners a year, and despite the admonitions of my wonderful primary care doctor. The reason is simple: in my 20s and 30s, sex with a condom felt like getting massaged over a shirt. Now it feels like a massage through a winter overcoat.
I did don a condom last fall, when a new partner made a big deal of it. As a precaution, I took half a Viagra beforehand. (I don’t normally need the pharmaceutical pump; it was left over from earlier, when an antidepressant that I have long since discontinued had turned a Corvette into a Yugo.)
Despite my precaution, our effort to couple resulted in a deflationary event. I couldn’t feel a thing. Actually, I take that back. I did feel the condom squeezing me like a latex boa constrictor, then a softening like a leak in a bicycle tire. And then I felt lost. With that thing on, I would have needed a GPS to find my way in.
I’d like to note here that I take good care of my body. My diet is Michael Pollan-approved, my body mass index is 20, and I run more than 1,000 miles a year. But studies have shown that penile sensitivity declines steadily after the teens and 20s, so that by the 40s and 50s, men require more intense stimulation, says Culley C. Carson, III, Rhodes Distinguished Professor of Urology at the University of North Carolina. “And condoms add to the disability, if you will.”
I knew that there was an alternative — at least, there had been once. In 1993, I dated a woman who worked on reproductive issues at the National Institutes of Health. We initially used male condoms, but she soon introduced me to something called a female condom, which we used from then on. Then made of polyurethane, it fit inside the vagina, clinging snugly to the walls, held there by an inner and an outer ring. The sensation wasn’t quite as wonderful as using nothing, but for me, the sense of touch was like 20-20 vision rather than the somatosensory blurring that condoms induce. I marveled at the wonder of this device.
Nonetheless, for nearly the next two decades, I never even heard the phrase, “female condom,” nor did I read it, in the mainstream media or any health news outlet. It made few headlines at the major international AIDS conference this week.
Just prior to the date of the deflationary event, knowing that my hydraulics were not what they’d once been, I called a few drug stores to ask if they had female condoms. No one had heard of them.
Soon after, I began seeing news reports with titles like “Seniors’ sex lives are up — and so are STD cases,” and “Condom Use Lowest…Among Adults Over 40?”
In case you missed all that, there were two major sources. One was an editorial last winter in the Student British Medical Journal, written by Rachel von Simson, a medical student at King’s College London, and Ranjababu Kulasegaram, a consultant genitourinary physician at St. Thomas’ Hospital London. The two investigators found that in the UK, new HIV diagnoses in people over 50 had doubled from 2000 to 2009.
How much of that jump comes from unprotected sex? Not clear. They did not break it down by method of transmission, and von Simson says there are no data on condom use in older adults in the UK: “No one was interested in measuring rates until we already had a problem, making past comparison impossible, and still no one has got around to a large study.”
Data showing that condom use falls off with age comes from the National Survey of Sexual Health and Behavior, conducted by the Center for Sexual Health Promotion at Indiana University. Condom use among men plummets from 79.1 percent of males ages 14-17, down to 13.7 percent of 45-60 year olds, and just 5.1 percent of men over 60.
But the drop-off in condom use with age does not necessarily point to rampant risk-taking among older Americans. “The most common reasons for lack of condom use,” Michael Reece, co-director of the Indiana University’s Center for Sexual Health Promotion, wrote me in an email, are:
* in a monogamous relationship
* trying to get pregnant
* not worried about pregnancy (not planning to get pregnant but also not a big deal if it happens)
* using other forms of contraception.”
Nonetheless, while the risk of most STDs is real for my peers, it is probably far smaller than the risk for younger Americans. In the United States, unlike the UK, the rate of new HIV infections was stable from 2006 through 2009 among all ages and populations except for young African-American men who have sex with men, says Nikki Mayes, a spokesperson for the Centers for Disease Control and Prevention.
“Additionally, I do want to remind you that rates [of STDs generally] continue to be disproportionate among youth,” says Mayes, noting that the rate of new chlamydia infections was two orders of magnitude lower among 45-54 year olds than among 20-24 year olds: 36 cases per 100,000 people in the older group compared to 2,270 cases in the younger group.
Why female condoms haven’t caught on is a mystery to me. Women seem to love them as much as I do.
To assess your own risk of unprotected sex, it is important to note that these demographics are broadly sliced, and individual risks vary. There are discrete populations where STDs are much higher than average, and others where they are lower. For example, the CDC estimates that new cases of HIV among American women range from 2.9 per 100,000 among non-Hispanic white women to 56 per 100,000 among African American women.
For perspective, the annual death rate from car accidents in the United States is 12.9 per 100,000, according to the Kaiser Family Foundation (and lowest in Massachusetts among all states, at 5.6 per 100,000). In my subjective judgment, which is of course influenced by my own demographics, that risk is low. I can’t think of anyone I know, or have had any close connection with, who has died or been seriously injured in a car accident since the 1980s.
But that doesn’t compare directly to the risk of STDs. Since the risk of becoming infected with an STD is additive — you have to add up the risks of catching each of the different STDs — that risk can be much greater than that of death or serious injury by car crash. And the consequences of sexually transmitted infections vary greatly depending on the specific STD, from relatively inconsequential, to a world of trouble, to early death.
Anyway, why female condoms haven’t caught on is a mystery to me. Women seem to love them as much as I do. One user, 56-year-old Darence Wilson, who works at The Women’s Collective, a Washington, DC non-profit that provides HIV care management, prevention services, and policy and advocacy, calls it “the best thing since sliced bread.” (I am not making that up.) “I feel more like I’m not using anything,” she says, noting that in contrast, the male condom feels like the latex that it is.
All nine users who left reviews at a Walgreen’s pharmacy website — mostly women — gave the female condom five stars. “I really like them!” says MediaGal, from Waterbury, CT. “I put it in before dinner, and once in bed, my partner didn’t even notice it.” (The female condom can be inserted eight hours before sex.)
“This product exceeded my expecations (sic),” says Deb, of Pontiac, MI. “It is great to be in control of my protection.”
Mary Brewster, program coordinator for the Pediatric AIDS Chicago Prevention Initiative, says that her favorite aspect of the female condom is that lovers can remain in an intimate embrace after male orgasm. The female condom holds itself in place with its rings, unlike the male condom, which has slipped off many a post-coital penis, releasing sperm for a potential rendezvous with the egg. With the female condom, “It isn’t like, oh, my goodness, we’re using a [male] condom, you better remove yourself immediately after,” says Brewster. “It leads to more intimacy.”
Another advantage, the manufacturer notes, is that the female condom covers most of the external genitalia, making transmission of various viruses much less likely than with a male condom, which leaves plenty of opportunity for contact between male and female reproductive epithelium. (Unlike most of your skin, the areas around the genitalia are not impervious to viruses.)
For those with latex allergies, there’s more good news: the modern female condom, the FC2, is made of nitrile. An additional perk: The female condom can be used for anal sex.
Brewster, who promotes the female condom to clients, says that inserting it does take some getting used to. “We always tell clients that within three tries, you have it,” she says, adding that that was true in her case.
At $38.95 for a 15-pack on Amazon, some consider the female condom expensive, certainly compared to male condoms that tend to run about 50 cents each. But in the bigger picture, it has proven cost-effective for preventing HIV infection, according to researchers at the Johns Hopkins University Bloomberg School of Public Health.
Their study involved the “DC Females Condom Program,” in which half a million female condoms were distributed, along with education, to women in Washington DC neighborhoods with high rates of HIV. The Washington, DC Department of Public Health ran the program with support from various community groups. Every dollar spent on the program saved $20 in future health care costs, according to the study, which was just published this month in the journal AIDS and Behavior.
So why didn’t the female condom take off long ago? The polyurethane of the original female condom, which was not replaced until 2008, was harder than the male condom, says Brewster, and “they were kind of noisy, and got a bad rap.” (The noise was a faint crackling sound to which my brain quickly acclimated.)
Brewster also says that the word, “female” in the name of the condom turns off some men (not me!). Additionally, some women “don’t want to touch themselves down there,” she says, adding that it is taboo in some cultures. “In my work as a prevention counselor and HIV tester, I actually ran into this quite often, where women would be put off by the female condom because it required them to touch themselves.”
From my interactions with the Female Health Company, which makes the FC2, I suspect that marketing is not their forte and that they may be short-handed. I’ve phoned them on a handful of occasions, and I’ve usually had to leave a recorded message, which generally gets answered a couple of days later.
Mary Ann Leeper, senior strategic advisor and former president and COO of the Female Health Company, says that most of the interest, effort, and sales of female condoms has been abroad, in countries where big donors have taken an interest.
Meanwhile, the Female Health Company has had established FC2 marketing programs in New York, Houston, and San Francisco, where it is available through CVS stores, Walgreen’s and Planned Parenthood, and new programs are under way in another five jurisdictions. Boston, alas, is not among them. But female condoms can also be obtained on Amazon, for around $1.25 to $4 per unit, not including shipping.
If I were the Gates or the Clinton Foundation, I’d hire a really good public relations firm to get the word out. But I’m not, so I wrote this article.