The context of condom use among young adults in the Philippines: Implications for HIV prevention

Abstract

We examine current perceptions and constraints surrounding condom use among young adults in the Philippines to garner a deeper contextual understanding of this aspect of HIV prevention within Filipino society. Through thematic analysis of focus group data, we found three broad themes, all of which included societal and individual barriers to using condoms. The findings may provide insight for similar settings that have strong religious influences on society. To strengthen HIV prevention efforts in such settings, we suggest that the development of strategies to address these constraints in the cultural setting and promote sexual health of young adults is essential.

HIV continues to be a growing global health epidemic. While consistent condom use has been a primary component of primary prevention interventions, overall usage in many settings remains low. The contributing factors to this low usage have been explored in high-risk, high-prevalence settings, but not in high-risk, low-prevalence settings. We focus our research on the Philippines, a setting where current HIV prevalence is low, but societal risk factors are growing rapidly. Condom usage remains very low and has only been studied in a limited manner in this setting, yet the country stands at the precipice of a major potential HIV epidemic, according to UNAIDS. Through this study, we have provided contextual data on decisions regarding condom use among young adults in Cebu City, the second largest metropolitan area of the Philippines. We found that, as with many other settings around the world, religion plays an important role in society and is interwoven with many of the barriers to condom use and negotiation. Intervention efforts particularly focused on de-stigmatizing and increasing condom use must work jointly with religious bodies in order to effectively prevent the HIV epidemic from burgeoning in settings such as this.

Worldwide statistics on HIV/AIDS show that heterosexual transmission is steadily increasing and that each year over half of the new HIV infections worldwide are among 15 to 24 year olds (2008c). Southeast Asia is an area with growing numbers of those infected with HIV, but the reported HIV prevalence rate in the Philippines is still low, at less than one percent of a population of over 92 million (2008a). However, the 2008 Philippine Department of Health (DOH) showed a 54 % increase of total cases over the 2007 statistics, but the reported numbers of HIV infections may belie a more widespread rate, since testing is not widely available or practiced (Department of Health, National Epidemiology Center, 2008).

Young, heterosexual adults are increasingly at-risk for HIV/AIDS in the Philippines. In 2008, youth between 15 and 24 accounted for 21% of new HIV infections reported to the DOH registry that year (Department of Health, National Epidemiology Center, 2008). This rate may be attributed, in part, to sexual debut occurring at younger ages in the Philippines than in past generations (Upadhyay & Hindin, 2007). Nationally, more than 23% of Filipino adolescents have engaged in premarital sex, with 42% of them reporting consensual sex, 32.5% not wanting it but going along with it, and 2% being forced into the sexual encounter (Raymundo & Cruz, 2004). Nearly 40 % of young men have sex with another person other than their primary partner (Raymundo & Cruz, 2004), and over 20% of males 20–24 years old have visited a commercial sex worker (Xenos, 1997). In 2003, over three-fourths of sexually active young adults were not currently using any method of contraception, regardless of marital status. Researchers in the Philippines, funded through the Family Health International and USAID, found that up to 69% of sexually active young men between the ages of 15–24 have never used condoms (Ramos-Jimenez & Lee, 2007). According to the Philippines Demographic and Health Survey of 2003, only one to two percent of young adults reported using condoms in 2003 (Measure DHS, 2009).

Condom use remains an important mechanism for preventing the spread of HIV. In a setting where condoms are not commonly used, it is important to examine what barriers exist and what factors might facilitate more widespread adoption. We examine the beliefs surrounding condoms and condom use among young adults in Metro Cebu, the second largest metropolitan area in the Philippines. Through the presentation of findings from focus groups with young adults, we explore how condom use is viewed and how these views may form constraints to condom use in this age group. Limited data are currently available on the influencing factors of condom use among the general population in the Philippines. Therefore, we provide the first such analysis in this location. We present data that include both normative beliefs and those that challenge the norms. By understanding more of the social and personal meanings that are associated with condom use within sustained relationships, we may be able to enhance the processes that motivate people to use condoms and sustain their use. The authors conclude with discussion of the possible implications that condom use beliefs have for HIV prevention in the Philippines and possible strategies to work towards enhanced prevention efforts.

Background

Worldwide HIV risk reduction strategies for heterosexual transmission have begun to recognize the need for necessary changes. The ABC approach (abstinence, “be faithful”, and condoms) is now considered limited (Dworkin & Ehrhardt, 2007), as it overlooks the complexity of intimate relationships which can be shaped not only by the two individuals engaged in the partnership, but also by gender norms, societal and cultural mores, and other external influences (Ashburn, Oomman, Wendt, & Rosenzweig, 2009; Morisky, Stein, & Chiao, 2006; President's Emergency Plan for AIDS Relief (PEPFAR), 2009). In an effort to understand how the additional aspects influence condom use, researchers have begun to explore the reasons for persistently low usage of condoms despite recognition that it is an effective method of disease prevention.

Researchers in countries with varying levels of HIV prevalence have found that condom use is restricted by perceptions of the sexual relationships in which a person engages and the expectations of those encounters. In Russia, decisions depend on the type and duration of the sexual relationship, favoring use with casual or commercial sex partners (Gerber & Berman, 2008). Similarly, men in Cameroon reported using condoms with last sex if that sex was extramarital (Kongnyuy & Wiysonge, 2007). Condoms were not seen as appropriate or necessary with primary partners, as researchers have found that condoms in Malawi are considered “intruders” in marriages (Chimbiri, 2007), and they conflict with the couples' intentions to have children(Bhattacharya, 2004). Likewise, condoms are viewed as less necessary in settings where they are more commonly associated with contraception than with disease prevention (Bhattacharya, 2004; Bond & Dover, 1997; Simon & Paxton, 2004). To this end, religious teachings regarding condom use as a barrier for procreation and as a facilitator of promiscuity may influence social norms of sexuality and condom use among young adults.

In many settings, a woman's ability to negotiate condom use is highly influenced by the presence of traditional gender norms (MacPhail & Campbell, 2001; President's Emergency Plan for AIDS Relief (PEPFAR), 2009). For example, young men are often expected and even encouraged to have several partners while young women are often expected to be sexually inexperienced and naïve (Alesna-Llanto & Raymundo, 2005; Brown, Sorrell, & Raffaelli, 2005; MacPhail & Campbell, 2001; Molla, Berhane, & Lindtjorn, 2008). Even in settings where both young men and women are more sexually active, a clear delineation exists between “marriageable” women and those who are “casual” partners (Crosby et al., 2000; Meekers & Calves, 1997). Additionally, if a woman is in an economically dependent position, she has much less sexual negotiating power (Kabeer, 2001; Maganja, Maman, Groves, & Mbwambo, 2007; President's Emergency Plan for AIDS Relief (PEPFAR), 2009).

Current research has been conducted predominantly in areas where HIV is highly prevalent. The extent to which these previous findings apply to the general population in settings such as the Philippines, a low-prevalence, high-risk setting, is still unknown. The Philippines presents several contextual elements that, when combined, present a unique setting for exploring condom use when considering aspects of HIV prevention. On the one hand, over 85% of the population is Catholic. Of young adults, 9% consider themselves extremely religious, 29% very religious, and 49% somewhat religious, and 69% attend services at least once a week (Sandoval, Mangahas, & Guerrero, 1998). Secondly, gender roles are less traditional than in other Southeast Asian countries. For example, at the societal and community level in the Philippines, women enjoy a fair amount of autonomy, demonstrated through women holding positions of power, and girls having equal access to education. Yet, on the household and relationship level, traditional views of male and female roles are still present both in rural and in urban environments, although less so in the urban settings. In families, women are expected to look after the children while men are expected to be the primary breadwinners (Medina, 2001). In relationships, girls and women are expected to be more passive than the boys and men; women who are more aggressive are seen as being inappropriate (Medina, 2001). Premarital sex (particularly for women) has historically been discouraged since colonization by the Spanish in the 16^th century. Yet, today, young adults are beginning to change their views and practices. Many are moving away from their nuclear families before getting married, and many are experiencing sexual debut earlier than in previous generations with much higher prevalence occurring prior to marriage (Raymundo & Cruz, 2004). These changes can create a tension and discordance between individual practices and societal norms for young adults.

Per extant research, condom use is clearly constrained by several factors within settings of high HIV prevalence. The question remains whether these same constraints are present in the low-prevalence setting of the Philippines or if there are unique factors which influence young adults' sexual behaviors. We present data gathered during the qualitative phase of a mixed-methods study. We designed the larger study to investigate the dynamics between young couples with regards to HIV risk behaviors, considering aspects of relationship power and experiences of intimate partner violence (IPV). The purpose of the qualitative portion was to obtain further insight into factors that influence young adults' sexual decision-making in relationships, specifically pertaining to whether or not to use condoms and 2) how condom use was viewed among peers, families, and within the community. Here we examine the current perceptions and constraints surrounding condom use and use it to garner a deeper contextual understanding that may have implications for HIV prevention within Filipino society.

Methods

Setting

Metro Cebu is located on Cebu Island in the Central Visayas region of the Philippines. The metro area, comprised of Cebu City, Lapu-Lapu, Mandaue, and Talisay, is one of the largest metropolitan area in the country with a population of nearly 2 million as of 2009. It is the economic center of the southern part of the country. Although Tagolog and English are spoken, the predominant language is Cebuano. The metro area is divided into barangays, which are political subdivisions of the larger city. The qualitative portion of this study was conducted in 2009 in Metro Cebu, using data from eight focus group discussions (FGDs) conducted in four different barangays.

Sample

The target population was comprised of young, heterosexual adults between the ages of 21–30 who were in relationships and living in metro Cebu. Permission to conduct the study in the barangays was sought through meetings with the barangay captains. The barangay captains are the elected leading official for the neighborhoods, acting as liaisons between the people and higher government offices and facilitating services within the barangay. It was considered essential to have permission from these officials to conduct research in the neighborhoods.

Once permission was obtained, Cebuano-speaking research staff directly recruited participants within the communities. We purposively recruited FGD participants, attending to partnership status (either partnered but unmarried or married), age (between 21–30), gender (male and female groups held separately), and willingness to discuss the topic. The unmarried participants may or may not have been cohabitating with their partners, but they were all in sexually active relationships. Potential participants were approached, screened according to the eligibility criteria and asked if they would be interested in participating in and available for the FGDs.

Data collection

We obtained approval for the study procedures, recruitment scripts, discussion guides and consent forms from the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health. In the absence of an in-country IRB, an ethics panel at the University of San Carlos in Cebu reviewed the study protocols and upheld the IRB decision. Investigators worked closely with the in-country staff throughout the project.

We informed eligible young adults that the study was exploring topics of sexual health among couples, and we asked if they would be interested in participating. If they agreed, we provided them with the location and time of the FGDs for their barangay. At the time of the FGDs, we obtained informed consent individually for each participant. At the conclusion of the discussions, participants were provided 100 pesos ($2.50 US) compensation.

In an effort to establish homogeneity within groups and heterogeneity across groups, we held four FGDs for young men, two consisting of married men and two of unmarried men. We assigned the same protocol for the women. Two trained moderators, one male and one female fluent in Cebuano, were matched by gender to lead the respective focus groups. We also had two trained male and female note-takers who were matched by gender to the groups and who took notes on both the discussion and non-verbal communication within each of the groups. The entire team had debriefing sessions after each focus group.

We used a semi-structured discussion guide for the FGDs, including questions such as “How common is it for young couples to use condoms?”, “What are some of the reasons that they would use condoms?”, “What might influence a young couples' decision whether or not to use condoms?” and “What do you think about women/men your age who want to use condoms?”, allowing for clarification and probing. Natural conversation, including new thoughts and ideas, was also encouraged.

We implemented several measures to protect the study participants while maintaining confidentiality. The FGDs were conducted in private settings arranged by the barangay captains, including isolated conference rooms at community centers and unused classrooms at schools on the weekends. We informed participants that they could leave at any point and any necessary referrals would be provided. We asked all participants for permission to audiotape the interviews, and we did not collect personal identifiers from participants. Also, we reminded all participants prior to initiating the discussions that information shared amongst the group was to be held confidential. They were encouraged only to share what they felt comfortable discussing in front of others.

Data analysis

We present the findings of an analysis of the aforementioned study's transcripts. Trained research staff members who had been present in the FGDs and who were fluent in both languages transcribed the recordings from the focus groups verbatim in Cebuano and translated them into English. The first author and moderators reviewed the transcripts for accuracy.

We performed thematic analysis with all of the narratives, which were uploaded into NVivo 8 (QSR International Pty Ltd, 2008). We used inductive coding, thereby allowing the participants' experiences and thoughts to lead the categorization. Open coding of narratives used terminology of the participants. We examined these individual preliminary codes for initial impressions of commonalities and differences across focus groups. The final reading was done across transcripts and codes, making comparisons and identifying patterns that occurred within and across FGDs. We sought to determine areas of consensus across groups as well as to identify areas of disagreement between individuals.

We then combined these pieces of data into thematic areas. When selecting exemplars for the themes, we compared them with the other data that had been coded similarly to ensure representativeness. We used the following criteria when selecting exemplars: 1) logical fit with themes, 2) clarity and strength in message, 3) diversity in speakers, 4) ability to mirror subtle nuances in themes, and 5) singular usage to avoid using exemplars more than once. Names used in this article have been changed to maintain confidentiality. Numbers of the focus groups are noted and have not been changed.

Qualitative interpretation requires implementation of safeguards to assure credibility, confirmability, and authenticity (Tobin & Begley, 2004). The first author consulted with the focus group moderators and note takers for clarification of topics and verification of findings. We also utilized peer review and debriefing during the analysis process. We discussed our findings and interpretations as necessary during the analysis process to assure consistency in interpretation.

Presentation of Findings

Demographics

Table 1 presents demographics for each FGD. Cumulatively, twenty-six women (10 married, 16 unmarried) and 28 men (12 married, 16 unmarried) participated in the FGDs. The ages ranged from 21–30 years of age, with 25.7 years as the mean age for women and 25.9 years for men. Fifty percent of the women and 64% of the men had at least completed high school. Forty three percent of men in partnerships reported that both partners were not working, while only 12% of women reported the same.

Table 1.

Socio-demographics of the focus group participants from Metro Cebu, 2009.

Demographic Variable	Women				Men
	FGD1 (n=3)	FGD2 (n=9)	FGD3 (n=7)	FGD4 (n=7)	FGD1 (n=9)	FGD2 (n=7)	FGD3 (n=7)	FGD4 (n=5)
Age, years average (range)	28 (26–29)	24 (21–29)	26 (24–29)	25 (21–30)	25 (22–28)	25 (21–28)	27 (26–29)	28 (26–30)
Legally married	Yes	No	Yes	No	No	No	Yes	Yes
Employed, n (%)	0 (0)	3 (33)	3 (43)	0 (0)	1(11)	3 (43)	3 (43)	5(100)
Partner employed, n (%)	3 (100)	9 (100)	4 (57)	5 (71)	2 (22)	0 (0)	4 (57)	1 (20)
Education, Range (mode)	3 yrs high school (HS) – HS graduate (HS grad)	Grade 6 – some university (HS grad)	3 years HS – some university (HS Grad)	2years HS – some university (2yr HS)	1 year HS – HS graduate (HS Grad)	Grade 5 – HS graduate (2yr HS)	Gr 8 – College graduate (HS grad)	HS Grad – College graduate (HS Grad)
Length of relationship, mean (range) in years	6 (3–10)	4 (1–10)	6 (0.16–10)	4 (2–9)	2 (0.50–7)	3 (1–6)	5 (3–8)	3 (1–5)

Overview

We determined three overarching themes for the results of the focus group data regarding the perceptions and constraints of condom use among young adults: The Context of Condom Use, Condom Use for Married People, and Condom Use for Single People. Each of these themes has several subthemes which are detailed below.

The Context of Condom Use

The Church

Among focus group participants, condom use was still viewed primarily as a method of contraception rather than disease prevention. The Catholic Church's (heretofore referred to as “the Church”) teachings that the main purpose of sexual relations is procreation and thus should be limited to marital unions created a tension among young adults who are sexually active but not married. The need for unmarried young people to hide sexual activity by preventing pregnancy was pervasive in the groups. Unmarried young couples might use condoms because “they are afraid to get pregnant. They are hiding their relationship. They are afraid their parents will know,” said an unmarried woman (Honey, Women FGD2). There was little discussion of the importance of preventing sexually transmitted infections (STIs) and HIV in this context.

Once married, young adults can either embrace or disregard the Church's officially sanctioned natural methods of family planning. Participants felt that many couples their age used the rhythm method and withdrawal rather than synthetic methods like condoms. Several participants acknowledged the Church's influence on their decision regarding condom use, particularly as a form of contraception. Both male and female married participants indicated the teachings against condom use as the reason why they either stopped using or never started using condoms in their relationships and repeatedly referred to using condoms as “a sin.”

A few participants, both male and female, maintained a perspective that appeared to be more aligned with a philosophy of “trust, but verify.” Although the Church sets certain guidelines, a person makes an individual choice regardless of the teachings. Referring to whether or not to use condoms, one unmarried man (Sammy, Men FGD2) said, “The Church cannot help solve your problems. They are just there to tell you what to do. You decide for yourself.”

Several married participants said their decisions were influenced by more complex social issues, such as population control considering the country's limited resources, regardless of the Church's teachings. Participants were proponents of controlling family size during difficult economic times. Another married man, Richard (men FGD3), said, “It's difficult if you have many children and you don't have a stable work. And your wife too doesn't have stable work. What will you do? For me using condom is really better so that you can control your family.”

Condom-related Fears and Concerns

Certain health beliefs proved to be constraining against condom use. Misinformation about flaws in condoms is spread by word of mouth and through mainstream media alluding to functional problems and pitfalls. According to some participants, these defects would render condoms ineffective as birth control and disease prevention. Losing the condom inside the woman was a commonly cited fear in all FGDs. “For some, when the men use condoms, the woman is afraid that condoms get stuck inside,” said Susie (women FGD4). Popular news stories propagate this fear, as several participants mentioned hearing in the news about condoms being left inside of women. Others believed that rupturing occurs frequently with condoms, and they feared using them because of this. Frankie, an unmarried man (men FGD1) said, “There are instances that when you use the condom and it is not properly used. Then it erupts… Those incidences are based on other's stories. I just heard from other people.” Retelling stories of friends or acquaintances, men and women also spoke of holes in the condoms. “I only heard about it from someone. He told me that one time, they were using a condom and they noticed a hole in it when they were through having sex,” said Marissa (women FGD4). In the same FGD, Sarah stated that “somewhat deceitful men who don't like to control birth purposely put holes in the condoms.” Others spoke of “testing” for holes by blowing into the condoms before using them.

Participants also discussed physical constraints to condom use. Many participants voiced the concern that condoms inhibited the “heat of sex”, and several equated condom use to “wearing a sock on your penis” or “putting the penis in a wrapper.” Julie (women FGD2) said, “It's not a good feeling. It's different, really different with condom. It seems his drive is suppressed.” Other women said that men do not like to use condoms because it is as though they are not having sex at all, since the “skin-on-skin” feeling is diminished. Several men mentioned the lack of pleasure and satisfaction for men when using condoms, saying condoms were “irritating, especially if you really want to have sex. You can get frustrated because you have to wear the condom… You lose the excitement.” (Freddie, Men FGD1) Some participants thought that a woman's experience might be hindered as well. Some men thought that women do not like to use condoms during oral sex because it would be like eating “a banana with a peel on,” or like eating “candy with a plastic wrapper.” Several participants, both male and female, spoke of “the original” (sex without condoms) as being a better experience. Ki-Ki, a married woman (women FGD1) said, “The original is better because it is a little hot when touched. You won't feel anything [with a condom].”

Experiencing discomfort with condoms was also seen as inhibiting the pleasurable aspect of intercourse. “The women would say it is painful, that it's rough. That's what they say,” said Thomas (men FGD1). Others spoke of “itchiness” with condom use. Among the focus group participants, the itching was not thought of as limited to those with latex sensitivities, but rather a broadly occurring negative experience.

Being Judged While Purchasing Condoms

Some participants voiced concern over the cost of condoms (12 Philippine Pesos, equivalent to $0.24USD, for 3-pack), but many stated that cost was not an inhibiting factor. Overall, the majority of the participants felt that the real constraint was not scarcity or cost of condoms but rather the stigmatized process of purchasing them.

Free condoms are scarce. Condoms in Cebu can be purchased in large pharmacies and smaller street-based pharmacies. The smaller pharmacies are more easily accessible to lower socio-economic groups. They are often crowded with people from the neighborhoods in which they are located. Condoms are kept behind the counter in such stores.

Most participants used the small pharmacies as their reference point when discussing the process of purchasing condoms. An overall lack of privacy and anonymity was cited across all FGDs. The process involves asking the clerk for the condoms, and this publicly signals that the buyer may be intending to engage in sexual relations, which is seen as shameful to convey so overtly. Several male and female participants said they would never purchase condoms because it would be too embarrassing. Johnny, an unmarried man (men FGD1) said, “It's embarrassing especially if the sales clerk will ask, `Will you be the one to use the condom?'” A fellow participant, Frankie, in the same FGD continued, “There are some couples who will buy and [the clerk] will ask, `Will you use this with your wife or with your girlfriend?'” Several women (FGD 1, 3, 4) thought that men were embarrassed because they did not want the female clerks to “think of what they would do with the condom.”

There was also a feeling that a person could not purchase condoms unobserved by neighbors or acquaintances. This was perceived as a source of potential gossip in the community. “You will be ashamed of those who would overhear,” said Betty (women FGD3). A married man echoed similar sentiments, saying,

“In the pharmacy, you wait with other people. And there are some people who know you. You could not say to the pharmacy clerk that you want condoms. You would be laughed at by the people who knew you.” (Sandy, men FGD4)

Women said they also battled with the stigmatized purchase, but as one married woman explained, the long-term consequences can outweigh the momentary shame: “The shame to buy would prevent one to use. . . It can prevent one to buy, like one time when I bought (laughing), I was also hesitant. But for me, I would buy despite, because, Jesus, it's so hard to have children!” (Joyce, women FGD1)

Negotiating Condom Use

One of the factors that seemed to have a bearing on whether or not young adults would consider using condoms was the extent to which they felt comfortable communicating with their partners about sex in general and condom use specifically. On the one hand, some female participants felt strongly that discussing sex was inappropriate, claiming it was “repulsive” and they felt “revolted by it.” Discussions were often seen as being “lewd” and embarrassing, and as Maribel (women FGD2) said, “We are shy. It doesn't sound good, like we are loose or oversexed.” Men felt that talking about sex would give their primary partners the impression that the men were having affairs. Elwin (men FGD3) said, “[Talking about sex or condoms] would even be the cause of jealousy. Because the woman would think maybe you came from another woman.” In the same vein, men did not feel it appropriate to share with their partners if they were having sex with other women. “[Sex with other partners] should not be divulged. It should remain a secret. If you have sex with another partner, you should not tell.” (Ricky, men FGD2)

A minority of the participants said sex and condom use should be talked about between partners. One unmarried woman (Li-Li, women FGD 2) said, “It is really good that you talk about it, what you will use.” Joyce (women FGD1) said, “It's really okay to [talk about sex]. Ours is just understanding of each other; you talk about it. It's only discussing and agreeing about it.”

Perceptions of the repercussions of discussing condom use with partners varied among the participants. When given the scenario of a woman insisting on condom use but her partner disagreeing, many felt that it would result in a verbal argument. In these cases, many felt that the man's opinion would prevail. Women thought that men would not use condoms if they did not like them, and that the woman would agree so “that the family will not be broken. So she will consent to him not using a condom.” (Honey, women FGD2) She might also agree with his decision “to avoid trouble.”

If the woman did not concede, the threat of the man “walking out” was common. The emotional threat of seeking other partners was real for many participants. Jack, an unmarried man (men FGD1) said his approach would be, “I will tell her, `So you want me to use a condom. Okay. I will not have sex with you. I'll look for another woman.'” Men also believed that disagreements over condom use could lead to separation. The threat of separation can be emotionally frightening and places women in vulnerable positions, particularly if there are children involved.

A few participants thought disagreeing over condom use might lead to physical or sexual altercations such as hitting one another or the man forcing himself upon the woman. Maribel (women FGD2) said, “If you won't agree to have sex with him, there are some husbands who would rape you instead. [In that situation] You can't do anything.” However, this was a minority opinion.

Condom Use for Married People

Condoms in Marriage: “Waste of a Condom”

In accordance with teachings of the Church, several participants saw condom use within marriage as violating the reason for sex within marriage—that of procreation. One unmarried male participant (Paul, Men FGD2) voiced a sentiment that several echoed when he said, “It seems like they are joking with their married life.” Adam (men FGD2), who was cohabitating with, but not married to his partner believed that a married woman suggesting to use condoms “is not good behavior. She is playing with her husband”. Condoms were seen as violating the purpose of getting married. “If it's for a husband and wife, it is a waste of a condom,” said Thea, (women FGD3). Robbie (men FGD4) said, “You don't need to wear a condom [if you are married]. If you did not even wear one when you were still boyfriend-girlfriend, [there is] much less [need] now that she is already your wife!” implying there was no risk for illegitimate pregnancies.

Raising Suspicions

If a long-term partner suggested using condoms, several male and female participants felt this would raise suspicions. Sammy, an unmarried man (men FGD2), said, “I think [the woman] will feel bad. She might think, `My husband may have had sex with another woman because since the time we lived together, he has not use condom. It's just now.'” Women also felt condom initiation within the context of a marriage would arouse the wife's suspicions of her husband. Betty (women FGD3) said, “Once a married man uses condom, we can say that he might be using it with other women. He's doing something suspicious because with his wife he doesn't have to use condom.”

For other married women, however, a woman's tendency might not to be to suspect her partner, as others previously pointed out, but rather to internalize the request as a reflection of her own cleanliness, overlooking the other possibility. From the first women's FGD, participants said:

Woman 1: It will come to our mind that he thinks us as unclean. Why would he use condom when I am the wife?

Woman 2: Yes. [Why would he use a condom] when he has sex with only me …

Woman 1: And we wives don't have any idea that he is already having sex with others.

Sidelines

In line with the Church's stance that condom use encourages promiscuity and infidelity, both men and women in all focus groups felt that condoms might suggest the presence of a “sideline”, or secondary partner. Even within the socially conservative society, the idea of affairs and multiple partners appeared commonplace for both married couples. The majority of the focus group participants believed that condoms were more appropriately used for these sidelines and not between primary partners. These sidelines could be dalliances with prostitutes or sexual encounters with other partners, but they never took the place of the primary relationship. TJ, a married man from FGD4 stated, “Because you know the males. There are a lot of men who have extra marital affairs. They usually buy condoms…”

When asked why one uses a condom with a sideline, the men generally focused on avoiding unwanted pregnancies, with some attention paid to disease prevention. One unmarried man (Pol, Men FGD1) said, “There are only two reasons for [using a condom]. One is safety that you will not be able to acquire disease especially if your sideline also has another sideline with the others. Another is that you will avoid getting [the sideline] pregnant.” Women tended to concentrate more on the aspect of disease prevention, but again, with the underlying acceptance that it is primarily the men who have license to have these encounters.

Condom Use for Single People

Condoms Among the Unmarried: “Just Tasting”

Those who are not yet married or in a “committed” relationship are seen as using condoms because they are just “tasting” sex and they do not want to become encumbered with the “obligations” of parenthood. Women felt that, by using condoms, young men were able to avoid the commitment that would come from an unintended pregnancy. To that end, one young woman (FGD4) said,

“For the unmarried men, once they [use a condom to] have sex with the woman, they would no longer mind her [pay attention]. There are those who would leave the woman when they are through [having sex] with them.”

Marissa (women FGD4) said that unmarried couples who have sex “go where the wind blows,” indicating a lack of commitment on both sides. This lack of commitment arises from a desire to “taste `humba'[a local pork dish and a term that is often used as a euphemism for sex]. They say there's no dish more delicious,” according to Michelle (women FGD2). A married woman (Coco, Women FGD3) also alluded to the lack of commitment when she said, “They are not ready to marry that's why they will use condom. He is not sure if she's the one he would marry. And he is not sure if he's the first to have sex with the woman. That is why they will use condom.”

Playboys and Prostitutes

Across all eight FGDs, the perceptions of men and women who use condoms varied by gender. Women in the FGDs considered women who used condoms to be protecting themselves from pregnancy and to some extent, from sexually transmitted diseases. However, they believed men who used condoms to “have vices with women”, or to be “playboys” and “womanizers”. Betty (women FGD3) commented, “Men who have vices with women would always use condoms because they have several partners.”

Perceptions in the FGDs for men were rather negative regarding young women who suggested condom use with their partners. One married male participant (Marlon, men FGD4) directly evaluated the difference, saying, “[Using condoms] is okay for the man, but for the woman, it is not because it affects her morality.” These women were seen as prostitutes, “loose”, or “dirty.” If a young, unmarried woman proposes condom use, “she is [already] a prostitute. She would have sex to earn money,” said Ronnie (men FGD3). Another (Joe, Men FGD3) recognized that they may not be prostitutes, but “they love to have sex. They are maniacs.” His fellow participants agreed. “They love to have one night stands… They just think of it as a pastime,” said Ben (men FGD3). In another focus group of married men, young girls using condoms were seen as being promiscuous. “[Girls] like 15 years old. They are still in high school…They have partners left and right. Having sex with one partner, then another partner…If a woman uses a condom, she is seen as having a lot of sexual experience,” said Mike (men FGD4).

Discussion and Recommendations

In the Philippines, where condom use is reportedly so infrequent, it is imperative to gain a better understanding of the context that influences individual behaviors. The examination of these aspects is vital to developing programs that incorporate effective HIV prevention methods while considering and incorporating the larger contextual setting. While some of the themes discussed in this article are similar to findings from previous studies in other settings, others highlight contextual aspects that may be particular to the Philippines. These are important to consider when moving forward in HIV prevention efforts within the country.

In certain settings, condoms are now viewed as a mechanism of self-protection against HIV and other sexually transmitted diseases before they are seen as methods of contraception (Tapia-Aguirre et al., 2004). However, in areas where knowledge and prevalence of HIV is still relatively low or where demonstration of fertility is desired (Alesna-Llanto & Raymundo, 2005; Bond & Dover, 1997), condoms are seen primarily as mechanisms for preventing pregnancy. The latter appears to be the case among the young adults participating in this study. Their desire to limit unplanned pregnancies may increase the use of condoms for this purpose. However, viewing condoms primarily as contraception is limiting when considering more widespread use in disease prevention. These young adults may view condoms as unnecessary if they are using another form of birth control, thereby placing themselves at risk for STIs and HIV.

The participants' responses during these focus groups confirmed the latter view, which indicates that the shift in perceptions toward disease prevention has not yet occurred. This may be related to the general population not feeling at risk for HIV and other sexually transmitted infections (STIs), although prevalence of diagnosed STIs among young adults ranges from 3–28% (Raymundo & Cruz, 2004). The widespread belief among FGD participants that condoms are not necessary with primary partners implies an assumption that the primary partner is “safe,” confirming findings of research in a diverse number of settings, including among married couples in India and among migrant workers in Zambia (Bhattacharya, 2004; Bond & Dover, 1997). In addition, these participants felt that suggesting use in the context of primary relationships would send an undesirable message to the other partner and perhaps indicate a questioning of commitment. Researchers have found similar opinions in a range of populations, including inner-city African-Americans and rural Malawians (Chatterjee, Hosain, & Williams, 2006; Chimbiri, 2007).

Not surprisingly, the existing HIV prevention work in the Philippines has been sparse. The efforts have primarily focused on high risk behaviors such as commercial sex work and intravenous drug use (Congress of the Philippines, 1988)(Philippine National AIDS Council, 2000). Substantially lacking in both of these plans are prevention efforts in the general population, particularly among young adults. Many health clinics no longer offer free or subsidized condoms, following government ordinances prohibiting their distribution, the United States Agency for International Development's (USAID) withdrawal of support and supply of free condoms for distribution in 2002 and the Filipino government's withdrawal of funding for contraceptives in 2003 (Human Rights Watch, 2004). Such actions limit the opportunities to obtain condoms for the lower socio-economic groups and can contribute to the heavily stigmatized purchasing process about which the participants spoke.

With Filipino government support for HIV prevention work decreasing (Human Rights Watch, 2004), widespread knowledge of HIV risk factors and transmission methods has also been limited, even among those considered at highest risk (2008b). Several of the issues raised by the participants regarding condom use could be directly related to their lack of formalized sex education. The fears surrounding condoms stem from limited to no discussions regarding condom use. The aspect of diminished sexual pleasure, particularly for men, is a common constraint across settings (MacPhail & Campbell, 2001; Sarkar, 2008). The dislike of condoms because of physical discomfort and the diminished feelings of sexual pleasure may arise from the limited availability of condoms and lubricants as well as the hurried and embarrassed manner in which they are purchased without contemplation of type or fit. These constraints are not inconsequential when addressing readiness for behavior change.

Traditional gender norms on the household level were apparent in the sexual double standard voiced by several of the participants. This was particularly pronounced in the apparent acceptability for men to have secondary partners, as well as the unacceptability for women to be conversant regarding their sexual health and experiences. Although the Philippines has a proven track record of women holding positions of power on a societal level, women are still constrained in managing their sexual health by these more traditional views. The hesitancy to communicate with partners about sex and sexual decisions indicates that the environment for sex communication is also quite conservative. Yet, participants all voiced gratitude following the FGDs about being able to talk about these issues without judgment. This demonstrates that although there may be a general reticence to talk openly about sexual issues, this reticence does not mean a complete unwillingness.

It was encouraging that most participants did not feel that a disagreement over condoms would escalate to a physically or sexually violent altercation. There are two important considerations, however. The first is that the threat of abandonment which was voiced in the FGDs. While not as obviously injurious as a physical attack, it can make as strong an emotional mark and can be highly influential over a person's behavior. In addition, it is difficult to ascertain whether the one woman who mentioned marital rape as a result of the disagreement is an outlier or if this individual felt comfortable enough to voice something that is commonplace but rarely talked about. These considerations must be kept in mind when developing policies and programs to address HIV prevention in this context.

It is important to note that our findings are not generalizable to all young adults in the Philippines as this study represented the views of participants residing in Cebu, in the Central Visayas region of the country. In addition, there may have been self-selection bias on the part of the participants, as those who were more reticent to talk about sex and sexual health would have declined to participate.

At the present time, efforts in several segments of society can work towards mitigating HIV risk for the general population. Given that the Philippines is still at a place where primary prevention of an epidemic is still very possible, several steps can be taken. The first is ensuring access to accurate information. Currently, a great deal of misinformation is circulating. Sex education that acknowledges the Church's position yet provides adequate and sufficient information regarding disease prevention is crucial for men and women. To this end, there are several versions of a reproductive health bill in review in the Lower House and the Senate of the Congress of the Philippines that incorporate the need for age-appropriate sexual education and HIV prevention messages, but no final bill has been passed into law to date. Even so, professionals in health care settings and public health advocates in the communities can make a concerted effort to address the stigma associated with condom use and educate their clientele about safe sex. Small initiatives, such as the training of pharmacy clerks to improve their sensitivity towards the purchasing of condoms, can also begin to lessen certain constraints against more widespread acceptance of condoms. Additionally, including barangay leadership and community settings other than medical clinics in initiatives to break down the stigma associated with condom use could utilize pre-existing societal infrastructure to facilitate the transmission of health promotion information.

The second mechanism of primary prevention is to extend the access and availability of condoms to the general population. More widespread availability of free or discounted condoms is crucial, particularly in clinics and other locations that serve persons of lower socio-economic status. Lastly, but most importantly, involving the community members in the development and implementation of HIV prevention interventions, as demonstrated by Morisky and colleagues (Morisky, Ang, Coly, & Tiglao, 2004), can help to ensure acceptability and appropriateness of the messages. When considering how best to work with the Catholic church and other religious organizations in the country, a human-rights base approach to the promotion of HIV prevention might be appropriate. This has some promise in countries such as Brazil, where faith-based communities have been incorporated into HIV prevention on a smaller scale, although systemic initiatives on a federal level involving religious entities have not yet been achieved (Genrich & Brathwaite, 2005; Paiva et al., 2010). Researchers in Trinidad and Tobago have found that creating dialogue between religious leaders and persons living with HIV/AIDS is another route toward de-stigmatization of prevention measures and the disease itself (Genrich & Brathwaite, 2005). Although Trinidad and Tobago's and Brazil's cultures and religious environments are quite different than that of the Philippines, the approaches applied there may hold valuable lessons for going forward.

By calling attention to the perceptions surrounding condom use for young adults in this area, we provide a starting point towards the awareness of the constraints to widespread condom use and HIV prevention in general. This awareness can begin to inform the further development and implementation of comprehensive assessment and prevention strategies that best suit the needs of young adults in the Philippines.

Figure 1.

Visual Depiction of Contextual Themes