Can We Afford to be Complacent About Teens’ Use of Condoms?

The publication of the article by Manlove and her colleagues about condom use and consistency among male teenagers in the U.S. is particularly timely [1]. Recent reports of the plateauing and possible reversal of what had been a remarkable improvement of teen sexual risk taking behavior across the last two decades suggests that the field needs to renew its vigilance in promoting safer behaviors. The most recent reports from the 2007 Youth Risk Behavior Survey conducted in high schools around the country suggest no change in the share of teens who are sexually experienced and no change in the proportion using a condom at last intercourse [2]. Further, for the first time in 15 years the National Center for Health Statistics recently reported an increase in birth rates among teenagers ages 15 to 19 [3]. These disturbing statistics may mean that we have become too complacent about expecting teenagers to do the right thing (a reference to my last editorial in this journal) [4]. The article published in this issue examines data from the 2002 National Survey of Family Growth and provides valuable information about the factors associated with higher rates of condom use among male teenagers. As such, the findings provide some guidance about potential strategies that might put us back on the right track as teenagers better protect themselves from the risks of STIs and unintended pregnancies.

What are these strategies? The analyses provide tantalizing evidence that male teenagers who report receiving sex education in school also report higher levels of condom use. Whether the sex education includes information about contraception and abstinence or one of these topics only does not seem to make a difference. It is the absence of information about any of these topics that is associated with lower condom use. There is much we do not know here about the quality of the educational program that the young men participate in, but at the broad brush level this evidence suggests that offering sex education to young men more broadly might lead to further use of condoms. One fifth of the sexually experienced male youth in the survey reported no education about either contraception or abstinence. Trend data indicate that nationally there has been a 19 percent decline in the proportion of youth receiving education about birth control methods in school since 1995 [5]. In light of the evidence in this article, restricting the information that teens receive in school about contraceptive methods can only be viewed as short sighted and poor public health policy.

The analyses also indicate that only one third of the sexually active male youth had ever received any reproductive health service—including advice about STDs, birth control, sterilization, or HIV/AIDS from a physician or reproductive health clinic. In the multivariate analyses there was no significant association between this measure and more condom use. Again, like the measures of sex education, there is no indication of the quality or depth of reproductive health services the young men have received. But the results describing the association between male teenagers’ attitudes and condom use do suggest that health care providers could better target their advice to their teenage male patients. Specifically providers could promote more positive attitudes among teenagers about condoms. When male teenagers believe that they will feel less physical pleasure when they use a condom, that they will be embarrassed discussing using a condom with a new partner or that a new partner would not appreciate using a condom, they are less likely to use condoms. These are issues that providers can and should address head on by suggesting the use of a drop of lubricant inside a condom or having teens role play discussions about condoms to make them feel more comfortable.

How is the U.S. doing in comparison to other developed countries in terms of condom use among teenagers? A recent comparison of 2002 data from many countries indicates that condom use at last intercourse among sexually active 15 year-old students varies considerably. In Sweden 44 percent used a condom at last intercourse in 2002 and in France the proportion was 59 percent, for example. Of course there are also substantial differences among countries in the share of 15 year old students who are sexually experienced [6]. While the US was not included in this comparison, data from a closely comparable year and age cohort ( the 2003 YRBS for 9th graders) indicate much higher levels of condom use here in the U.S. where 69 percent of sexually active 9th graders used a condom the last time they had sex [7]. Still, with the reproductive health indicators for teenagers appearing to move in the wrong direction for the first time in more than a decade, it is time to focus our attention on doing better. More, not fewer, health professionals and educators should emphasize that sexual intercourse should only occur when condoms are used. Teens need be trained to discuss condoms with their partners and to use them correctly and consistently.