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Just use a condom?

This article by guest contributor Melanie Lindwall Schaab MS RN was originally published on the Circumcision Facts and Science Facebook page on June 11, 2019. Reprinted by permission.

Anti-circumcision activists argue that you would be better off just teaching your son to use condoms. There are several flaws with this argument.

1. Men Don’t Use Condoms

The fact that we still have STIs even though condoms were invented thousands of years ago should be sufficient evidence that men - and especially boys - don’t use condoms like they should. Researchers have repeatedly found to their surprise that educating men about the dangers of other practices such as using prostitutes results in fewer men engaging in those practices (e.g., fewer men using prostitutes), but educating men about the importance of using condoms has no effect on condom use [1-4].

One study found that using condoms 100% correctly in 100% of sexual encounters reduced HIV risk by about 63% (i.e., equally as effective as circumcision), but only 4% of men used condoms 100% correctly in 100% of sexual encounters, even after being thoroughly educated to do so and given tons of free condoms. In men who used condoms less than 100% of the time, condoms had no effect on HIV risk. Furthermore, only the lowest-risk men used condoms like they were supposed to while the highest-risk men were least likely to use condoms. Overall, this meant there was no effect of condoms on HIV risk. [4]

2. It’s Easier to Use Condoms When Circumcised

In several studies, men reported that it was easier to use a condom after being circumcised. [5-7] So ironically, the option anti-circumcision activists favor instead of circumcision is more effective in men who are circumcised. Win, win!

3. Condom Programs Don’t Prevent HIV

A Cochrane Collaboration review of all research ever published in any language worldwide on the subject found that condom use did not reduce the risk of HIV, though condoms were at least somewhat effective against some other STIs. [8] In other words, they don’t necessarily work as advertised.

4. Telling People to Use Condoms Doesn’t Work

As mentioned above (see #1), men are notorious for not using condoms as they’re supposed to, even when they know they should, and even when they have access to free condoms. Not surprisingly, a study of all interventions designed to encourage people to use condoms found that the least influential factor was behavior change campaigns encouraging people to use condoms [9]. So much for just teaching your son to use condoms.

5. Condoms are More Expensive

Some anti-circumcision activists argue that condoms are less expensive than circumcision. However, when one considers that condoms must be supplied throughout the lifetime whereas circumcision generally happens just once and has many other benefits, the cost-effectiveness determination changes. Looking only at the issue of HIV-reduction, circumcision results in net cost-savings both in Africa [10-15] and in the U.S. [16-17] After adding in all the other cost-savings of circumcision and considering that condom programs don’t work to prevent HIV anyway (see #3 above), condoms may be more expensive than circumcision.

6. Circumcision Does Not Cause Behavioral Disinhibition

Behavioral disinhibition, also known as “risk compensation,” refers to people choosing to engage in higher risk activities because they perceive themselves to be at lower risk. For example, people who wear seat belts (are at lower risk) drive faster (engage in higher risk activities). Anti-circumcision activists have long argued that circumcision will make men engage in riskier sexual activities - i.e., circumcised men - knowing that they’re less likely to contract HIV - will be less afraid to sleep with prostitutes or have multiple sexual partners at once, and they will think they don’t need to use condoms. However, the research thus far has proven this fear false. Research shows that becoming circumcised does not cause men to engage in riskier sexual activities [18-19].

Ironically, however, other means of fighting STDs, such as pre-exposure prophylaxis (PrEP - a pill you can take before or shortly after having sex to lower your chances of contracting HIV), do contribute to risk compensation. Research has found that men who use PrEP are less likely to use condoms [20]. However, to our knowledge, researchers have yet to recommend against supplying PrEP to people at high risk of contracting HIV.

Conclusion

In short, as another critique of this argument asserts, “the argument to ‘just use condoms’ is a heartless and unscientific suggestion made by blind ideologues who apparently care nothing for people’s lives - only for their foreskins.” [21]

[1] D.L. Jackson et al; "Decreased Incidence of Sexually Transmitted Diseases Among Trucking Company Workers in Kenya: Results of a Behavioural Risk-Reduction Programme"; AIDS; June 1997). [2] Yadu Nath Singh MD, Anand Narayan Malaviya MD; "Long Distance Truck Drivers in India: HIV Infection and Their Possible Role in Disseminating HIV into Rural Areas"; International Journal of STD & AIDS; March 1, 1994 [3] Thomas C. Quinn MD et al; "Viral Load and Heterosexual Transmission of Human Immunodeficiency Virus Type 1"; North England Journal of Medicine; March 30, 2000 [4] S Ahmed et al; "HIV Incidence and Sexually Transmitted Disease Prevalence Associated With Condom Use: A Population Study in Rakai, Uganda"; AIDS; November 9, 2001 [5] R.C. Bailey et al; "The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya"; AIDS Care; April 26, 2010 [6] John N. Krieger MD et al; "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya"; National Institutes of Health; November 2008 [7] Thomas H. Riess et al; "'When I Was Circumcised I Was Taught Certain Things’':Risk Compensation and Protective Sexual Behavioramong Circumcised Men in Kisumu, Kenya"; PLoS ONE; August 2010 [8] Laureen M Lopez et al; "Behavioral Interventions for Improving Condom Use for Dual Protection"; Cochrane Library; July 24, 2013 [9] Irene Nekesa Opicho; "Influence of Male Circumcision on Sexual Behaviour of Luo Men in Relation to the Spread of HIV/AIDS: A Case of Maranda Sub-County, Kenya"; University of Nairobi; 2015 [10] Daniel T Halperin et al; Letter to the editor: "Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics"; Future HIV Therapy; September 19, 2008 [11] Ronald H. Gray et al; "The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda"; AIDS; April 2007 [12] James Kahn et al; "Cost-effectiveness of male circumcision for HIV prevention in a South African setting." PLoS Medicine; December 2006 [13] Katharine Kripke et al; "Impact and Cost of Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in the Context of the New 90-90-90 HIV Treatment Targets"; PLoS One; October 26, 2016 [14] Gayle Martin et al; "Costing male circumcision in Lesotho Swaziland and Zambia: Implications for the cost-effectiveness of circumcision as an HIV intervention"; United States Agency for International Development (USAID); September 2007 [15] Till W Bärnighausen et al; "Economics of antiretroviral treatment vs. circumcision for HIV prevention"; Proceedings of the National Academy of Sciences (PNAS); December 26, 2012 [16] Stephanie L. Sansom et al; "Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males"; PLoS One; January 18, 2010 [17] Annie L. Andrews et al; "The Cost of Medicaid Savings: The Potential Detrimental Public Health Impact of Neonatal Circumcision Defunding"; Infectious Diseases in Obstetrics and Gynecology; October 18, 2012 [18] Melanie Lindwall Schaab; "Circumcision and Risk Compensation - a Brief Summary"; Elephant in the Hospital; March 15, 2018 [19] Stephen Moreton PhD; "Risk Compensation – an Intactivist Half-Truth"; CircFacts; April 2020 [20] Julia L. Marcus, Ph.D., M.P.H et al; "Risk Compensation and Clinical Decision Making — The Case of HIV Preexposure Prophylaxis"; New England Journal of Medicine; February 7, 2019 [21] Melanie Lindwall Schaab; "Just Use Condoms"; Elephant in the Hospital; May 29, 2017

#Condom #Condoms #HIV #AIDS

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