The Real Reasons Why People Don't Use Condoms

Understanding Condom Bias and Condom Fatigue

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Condoms work. They remain the cornerstone of safer sex practices and a major contributor to the reduction of HIV infections worldwide. 

So why then do only 65 percent of men use condoms on a consistent basis, according to a survey by the Centers for Disease Control and Prevention? And how is it that more than 20 percent of HIV-negative men who have sex with men (MSM) are willing to put themselves at risk by engaging condomless sex?

Women fare no better in the statistics.

Of women who engage in high-risk, unprotected anal sex, a mere 11 percent report ever using a condom. Worse yet, women are far less likely overall to use condoms than their heterosexual male counterparts.

The Blame Game

Ignorance, apathy, and irresponsibility may be the standard knee-jerk response, but that's a far too simplistic judgment for what is, in fact, an incredibly complex psychosocial issue.

In truth, there are a number of intersecting reasons for the decreased use of condoms among adults and young people. They include everything from how we feel about condoms, what we believe about HIV, how we negotiate sex in relationships, how vulnerable we believe ourselves to be to infection, and even how adept we are at actually using condoms.

Dissecting these issues can be a dizzying process, made worse by the cultural tendency to assign blame to those we see as "vectors" (or sources) of HIV infection. Rather than opening up the conversation, we tend to shut it down—potentiating risk behavior in those who would rather remain silent than face public derision or disapproval.

Risk Perception

Knowledge and power are the two factors that can affect genders and at-risk populations considerably, often in very different forms. They not only direct why we make the decisions we do, but they also help explain why we sometimes put ourselves at risk against our otherwise better judgment.

Knowledge is not simply about our understanding of HIV as a disease but our personal belief as to how susceptible we are as individuals to infection. This is referred to as perceived risk.

Perceived risk is oftentimes based on misconceptions about who is "most at risk" for infection, either by group or behavior. Those, for instance, who believe that unprotected oral sex between a man and a woman is "only a fraction" as risky as unprotected anal sex between high-risk MSM will likely forego discussions about condoms altogether. The same applies to misconceptions about age, race, education, and income.

Perceived risk can vary considerably from one population to the next. While optimism about HIV therapy—including near-normal life expectancy and improved long-term health—generally correlates to higher condom use among heterosexuals, the same optimism has an inverse effect among many MSM, who believe that the need for condoms is all but erased due to advances in HIV therapy.

Conversely, pessimism about treatment or the effectiveness of safer sex generally translates to lower condom use. Oftentimes, these attitudes are fueled by an underlying distrust of public health authorities, specifically within poorer communities where infection rates are high and a lack of infrastructure hampers an effective community response.

These factors can contribute to perceptions by which HIV is seen to be unavoidable—or even inevitable—to those most at risk.

Condom Bias

The same Emory University study revealed that nearly a third of the men surveyed reported that they had lost an erection after having put on a condom.

Negative associations and attitudes about condoms, known as condom bias, have long muted the safer sex message. They reflect both real and perceived barriers that can prevent people from using condoms, even when the risk of transmission is known.

As a result, many decide to "trade-off" between the potential risk and the "consequences" they associate with condom use. Examples include:

  • Lack of sexual spontaneity
  • Unpleasant taste and smell
  • Reduction of sexual pleasure for both men and women
  • Loss of erection
  • Condom use may be seen as a declaration of distrust or infidelity
  • Condom use may be seen as a sign of sexual promiscuity
  • Fear of being identified as "high risk," or as part of a stigmatized population (e.g., MSM, injecting drug users)

Condom Fatigue

By contrast, condom fatigue (also known as "prevention fatigue") is a term used to describe the general weariness felt by those who have tired of condom use. It reflects the decreased effectiveness of prevention messages and is often associated with the increased transmission rates in MSM populations (although it can directly impact all population groups).

Increasing awareness about the benefits of antiretroviral therapy has led many to seek alternatives to condoms.

Treatment as prevention (TasP) is one such example. It is a strategy in which an undetectable viral load reduces your risk of transmission to zero, according to the landmark PARTNER1 and PARTNER2 trials.

A survey conducted by the Terrence Higgins Trust in London showed that, of a cohort of HIV-positive MSM, respondents largely failed to consider their viral in relation to transmission risk when making sexual decisions.

A similar study published in Sexually Transmitted Infections concluded that selective condom use was often based on the presumed HIV status of a sexual partner rather than on an informed discussion about serostatus, HIV therapy, or viral load status.

This seems to suggest that condom fatigue contributes to how a person uses anecdotal information to either make or validate personal beliefs, as opposed to making an informed choice will full unbiased information.

Strategies to Reinforce Condom Use

There are ways to reinforce condom use should you be at risk of getting HIV or infecting others:

  • If you are unaware of your HIV status and sexually active, get tested today. Research has shown that knowing one's status generally increases the sense of responsibility.
  • Rather than addressing HIV in general terms, find information in plain language on the specific HIV risk in women, African Americans, MSM, etc. This can often be found at your nearest women's health facility, LGBT community center, or a public clinic. 
  • Sexual education interventions (including instructions on the proper use of condoms and avoidance of common mistakes) have been shown to overcome many of the perceived barriers to condom use. In one study, condom use increased from 29 percent to 71 percent in a group of at-risk heterosexual men after a single educational intervention.
  • Don't count out the female condom which Planned Parenthood asserts can "enhance sex play (since) the external ring may stimulate the clitoris during vaginal intercourse." Female condoms also provide proactive controls to women who might be less able to negotiate safer sex.
  • By and large, reducing the numbers of sex partners correlates to higher condom use. Studies suggest that this also reduces the likelihood of anonymous sexual encounters while encouraging greater discussion about sexual health and HIV prevention.
  • Finally, recruiting sexual contacts online often results in the practice of serosorting (using online information to make decisions or assumptions about a person's HIV status). Instead of relying on profile information, take the opportunity to actively discuss HIV and other health issues before meeting.
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