Condom Use by Adolescents - POLICY STATEMENT
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
Organizational Principles to Guide and Define the Child
Health Care System and/or Improve the Health of all Children
POLICY STATEMENT
Condom Use by Adolescents
COMMITTEE ON ADOLESCENCE
ABBREVIATIONS
abstract
CDC—Centers for Disease Control and Prevention Rates of sexual activity, pregnancies, and births among adolescents
FC—female condom
FDA—Food and Drug Administration have continued to decline during the past decade to historic lows. De-
HIV—human immunodeficiency virus spite these positive trends, many adolescents remain at risk for un-
HPV—human papillomavirus intended pregnancy and sexually transmitted infections (STIs). This
MSM—men who have sex with men
STI—sexually transmitted infection
policy statement has been developed to assist the pediatrician in un-
YRBS—Youth Risk Behavior Survey derstanding and supporting the use of condoms by their patients to
This document is copyrighted and is property of the American prevent unintended pregnancies and STIs and address barriers to their
Academy of Pediatrics and its Board of Directors. All authors use. When used consistently and correctly, male latex condoms reduce
have filed conflict of interest statements with the American the risk of pregnancy and many STIs, including HIV. Since the last policy
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American
statement published 12 years ago, there is an increased evidence base
Academy of Pediatrics has neither solicited nor accepted any supporting the protection provided by condoms against STIs. Rates of
commercial involvement in the development of the content of acquisition of STIs/HIV among adolescents remain unacceptably high.
this publication.
Interventions that increase availability or accessibility to condoms are
The guidance in this statement does not indicate an exclusive most efficacious when combined with additional individual, small-
course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be group, or community-level activities that include messages about safer
appropriate. sex. Continued research is needed to inform public health interven-
All policy statements from the American Academy of Pediatrics tions for adolescents that increase the consistent and correct use
automatically expire 5 years after publication unless reaffirmed, of condoms and promote dual protection of condoms for STI pre-
revised, or retired at or before that time.
vention with other effective methods of contraception. Pediatrics
2013;132:973–981
INTRODUCTION
This policy statement updates a previous statement from the American
Academy of Pediatrics published in 2001.1 The medical and societal
consequences of adolescent sexual activity, including sexually trans-
mitted infections (STIs) and unintended pregnancies, remain a signif-
www.pediatrics.org/cgi/doi/10.1542/peds.2013-2821 icant public health problem. Although abstinence of sexual activity is
doi:10.1542/peds.2013-2821 the most effective method for prevention of pregnancy and STIs,
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). young people should be prepared for the time when they will become
Copyright © 2013 by the American Academy of Pediatrics
sexually active. Prevention of STIs in adolescents involves safer sexual
practices by those who are sexually active or who no longer plan to
be abstinent. Since publication of the previous statement, there has
been increasing evidence supporting the effectiveness of condoms to
prevent many STIs, including HIV. Increased availability of condoms
has been shown to increase use, and widespread distribution pro-
grams have been recommended by the Centers for Disease Control
and Prevention (CDC).2
In this policy statement, the use of condoms as a method of preventing
STIs, including HIV and pregnancy will be reviewed including effective-
ness, factors that influence use, and the roles that schools, communities,
PEDIATRICS Volume 132, Number 5, November 2013 973
Downloaded from pediatrics.aappublications.org by guest on May 11, 2015and parents can play in improving use have all continued to increase in ad- women during 2010–2011. Adolescent
of condoms and increased availability olescent and young adults.9 A study and young adult men have also had
of condoms. that examined the prevalence of STIs increasing rates of gonorrhea, in-
among female adolescents 14 to 19 creasing 6% in those aged 20 to 24
TRENDS IN ADOLESCENT SEXUAL years of age in the United States from years during 2010–2011.9
ACTIVITY AND CONSEQUENCES the 2003–2004 NHANES reported Syphilis rates in both men and women
a 24.1% prevalence of any of 5 STIs
Despite recent data indicating that are highest in the 15- to 24-year old age
(Neisseria gonorrhea, Chlamydia tra-
sexual activity has declined among group and increased most dramati-
chomatis, Trichomonas vaginalis,
adolescents, the current rates of sex- cally during 2010–2011 in 20- to 24-
herpes simplex virus type 2, and hu-
ual activity and health consequences year-old men (5.2–21.9 cases/100 000),
man papilloma virus [HPV] infections)
of STIs and pregnancy remain a sig- particularly in men who have sex with
among all female adolescents and
nificant public health concern. The men (MSM).9
CDC, through its Youth Risk Behavior a prevalence of 37.7% among sexually
experienced females. Importantly, An estimated 10 065 young people
Survey (YRBS), reports sexual risk
even among those whose sexual aged 13 to 24 years received a di-
behaviors in a nationally representa-
tive sample of high school students partner was the same age or 1 year agnosis of HIV infection in 2011, ac-
surveyed biannually. In the most re- older, the prevalence was high counting for 20% of all new infections
cently available YRBS (2011), 47.4% of (25.6%), and among those with only 1 in the United States. Among adolescent/
students reported that they had ever lifetime partner, the prevalence was young adult males living with and
had sexual intercourse, 33.7% re- 19.7%.10 diagnosed with HIV, 77% acquired
ported that they were currently sex- For specific infections, in 2011 the infection from MSM, 4% from hetero-
ually active, and 15.3% had had sexual highest Chlamydia rates were seen in sexual transmission, and 13% were
intercourse with four or more part- 15- to 19-year-old (3.4%) and 20- to 24- perinatally acquired. Among females,
ners in their lifetime. Among sexually year-old women (3.7%). Of concern, 56% acquired infection by heterosexual
active students, 60.2% reported con- during 2010–2011, rates increased 4% transmission, and 34% were perinatally
dom use during their last sexual en- for those aged 15 to 19 years and 11% acquired.11,12 Anonymous HIV screening
counter. Of additional concern, by 12th for those aged 20 to 24 years. in locations where youth 12 to 24 years
grade, nearly two-thirds (63.1%) of Reported rates of Chlamydia are of age congregate in communities sur-
students reported ever being sexually lower among young men, likely be- rounding the Adolescent Trials Net-
active but reported lower use of cause of decreased screening efforts, work for HIV/AIDS interventions found
condoms than did sexually active 9th- but have increased 6% for those 15 to
a prevalence of HIV of 15.3% in 611
and 10th-graders.3 19 years of age and 12% for those 20
MSM tested, 60% of whom did not
In 2011, approximately 330 000 teen- to 24 years of age between 2010 and
know they were infected.13 In addition
agers gave birth,4 and in 2008, the 2011. In studies of higher-risk pop-
to patients with behaviorally acquired
most recently available estimates are ulations (for example, the National
HIV infections, an estimated 9038
that 750 000 teenagers became preg- Job Training Program, an educational
program for disadvantaged youth) at people with perinatally acquired HIV
nant.5 Despite the fact that US teen
entry, rates of Chlamydia for women are now in adolescence and young
birth rates are at the lowest level in
the past 70 years,6 the birth rate for and men 16 to 24 years of age were adulthood. These youth are generally
US teenagers remains higher than 10.3% and 8%, respectively. Similarly, receiving highly active antiretroviral
other developed nations, and marked in juvenile correctional facilities, therapy, and concern exists for ex-
disparities by race/ethnicity and geo- 13.5% of women and 6.5% of men tensive drug-resistant strains.14 In
graphic area persist.7 screened positively for Chlamydia.9 a prospective cohort study of the re-
Rates of STIs remain highest among Adolescent and young adult women productive health of sexually active
adolescents and young adults, with also have the highest rates of gonor- adolescent girls perinatally infected
estimates suggesting that 15- to 24- rhea compared with any other age and with HIV, the cumulative incidence of
year-olds, who represent 25% of the gender group and increased 1.4% in pregnancy at 19 years of age was 24%,
sexually experienced population, ac- 15- to 19-year-old women during 2009– and incidence of STIs was 26%,
quire nearly half of all new STIs.8 Rates 2010 (unchanged in 2011), and in- stressing the need for comprehensive
of Chlamydia, gonorrhea, and syphilis creased 5.4% in 20- to 24-year-old HIV/STI-prevention strategies.15
974 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on May 11, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
CONDOM USE associated with greater consistency of use include receiving comprehensive
Recent Trends in Adolescent condom use included African Ameri- sex and HIV education programs,28
Condom Use can race/ethnicity, more positive con- attending schools where condoms are
dom attitudes, and more discussion of available,29 and perceiving a risk of
The condom remains the most pop-
health topics with parents. Adoles- STIs.30
ularly used contraceptive method
cents who did not have formal sex The effect of the media on adolescent
among teenagers.3 An increased pro-
education were half as likely to use sexual behavior has been reviewed in
portion of sexually active adolescents
a condom at first intercourse and a recent American Academy of Pedi-
report using a condom at last in-
even less likely to use condoms con- atrics policy statement.31 Adolescents
tercourse, according to 2 CDC surveys.
sistently. Lower condom use at first are exposed to an increasing amount
In the YRBS, condom use increased
sex was associated with older age, an of sexual content in music, movies,
from 46.2% in 1991 to 60.2% in 2011.3
older or casual first sexual partner, magazines, television, and the Inter-
The prevalence of condom use was
and a partner using another method net, and this exposure plays an im-
higher among male (68.6%) than fe-
of contraception. These factors were portant role in adolescent initiation
male (53.9%) students and higher
also associated with lower condom of sexual activity. Despite the in-
among white (63.3%) and African
use at last sex, except for having creasingly sexually explicit material in
American (62.4%) than Hispanic stu-
a casual sexual partner, which was media and programming, there are
dents (54.9%).3 In the National Survey
associated with higher condom use.18 rare messages promoting responsible
of Family Growth, condom use at last
intercourse increased among females Higher rates of condom use are noted sexual activity, such as contraception,
from 31% in 1988 to 52% in 2006–2010 in youth who perceive their partners including condom use.31 On primetime
and males from 53% to 75%.16 Rates as wanting to use condoms and in television, 77% of programs have
of actual condom use in both surveys those able to communicate their de- sexual content but only 14% reference
may also be lower than thought be- sire to use condoms with their part- risks or responsibility of sexual be-
cause of the uncertain/questionable ners.19 Motivations for young people havior.32
validity of self-report of this and to have sex include the pursuit of Adults, especially parents, play an
other sexual behaviors that are prone fulfilling sexual experiences in addi- important role in promoting the sexual
to bias. For example, in a clinic-based tion to other motivations such as in- health of adolescents. Bright Futures
sample of African American females timacy, procreation, or in response to outlines how pediatricians and other
15 to 21 years of age in Atlanta, peer or partner pressure. However, health care providers can support
Georgia, 186 young women reported adolescents’ lack of condom use is parents in promoting healthy sexual
100% condom use via an audio associated with perceptions that con- development and sexuality, including
computer-assisted self-interviewing doms reduce sexual pleasure and/or the use of condoms to protect against
technique. In these young women, that partners disapprove of condom STIs including HIV.33 A number of
34% had a positive biologic marker use.20 Condom-promotion campaigns studies have examined the role of
for unprotected vaginal sex in the that include linking condom use to parent-adolescent communication about
past 14 days (a Y-chromosome poly- enhanced sensitivity and sensuality, sexual risk and association with in-
merase chain reaction assay). As and, thus, a more positive experience creased adolescent use of con-
a possible explanation of these find- as a motivating factor, have found in- doms.34–38 Parental communication
ings, condoms may have been used creased uptake of condoms and safer about sexual risk and condom use are
inconsistently or incorrectly, or youth sex behaviors.21–23 associated with increases in adoles-
might have provided socially desirable The influence of social networks that cents’ use of condoms.34–36,38 Timing
answers.17 encourage condom use is becoming of the discussion is important; in 1
increasingly recognized.24,25 However, study, the highest rates of condom
Factors That Influence Condom Use increased relationship intimacy and use at first and last sex, as well as for
A number of factors, including in- closeness to the partner’s family can regular use, were found among ado-
dividual, family, sociodemographic, be associated with less condom use.26 lescent girls who communicated with
attitude, education, relationship, and Condom use rates are higher in new their mothers about condom use be-
partner-related factors, influence relationships compared with estab- fore onset of sexual activity compared
condom use. For example, in a national lished relationships.27 Other factors with after initiation.34 In a recent lon-
study of adolescent males,18 factors associated with increased condom gitudinal study of parents and their
PEDIATRICS Volume 132, Number 5, November 2013 975
Downloaded from pediatrics.aappublications.org by guest on May 11, 2015children regarding the timing of parent 9-month follow-up survey, 36% repor- for unintended pregnancy is estimated
and child communication about sexual ted receipt of instruction.41 to be 2% in 12 months of use (ie, 2
behaviors, more than 40% of the chil- pregnancies per 100 woman-years
dren had intercourse before there EFFECTIVENESS OF CONDOM USE with perfect use), although with typi-
were discussions about STI symptoms, cal use, the failure rate (accounting for
Materials used for male condoms are
condom use, birth control, or partner inconsistent and incorrect use) is
of 3 types: most (>80%) are composed
condom refusal.39 This suggests in- 18%. 49 The most important non-
of latex (natural rubber), and a small
creased efforts are needed by pedia- contraceptive benefit of condom use
proportion (FROM THE AMERICAN ACADEMY OF PEDIATRICS
other STIs can be attributed to limi- FEMALE CONDOM effective user-independent methods of
tations in study design, because the contraception” defined as injectables,
The female condom 1 (FC1; Reality,
quality of studies historically tended to intrauterine devices, and implants,
Femy, Care Contraceptive Sheath,
be weaker than for studies of HIV.54 even lower than those who use oral
Femidom), a loose-fitting polyurethane
Recent studies have empirically doc- contraceptives.80
sheath with 2 flexible polyurethane
umented that the effectiveness of
rings, introduced in 1994, was the first Adolescents with main and regular
condom use against many STIs is un- partners tend to discontinue condom
condom marketed to women but is no
derestimated because of limitations use quickly, especially if other preg-
longer in production in the United
of study design.62–68 Even with these nancy prevention methods are used.27
States. The FC2 (similarly designed to
limitations, these and more recent Studies that have examined dual
the FC1 but made of nitrile and without
studies with improved methodologies method use among adolescents have
a seam) was approved for use in 2009
have found that condoms provide found that increased use is associated
protection against a variety of STIs, by the US FDA and is the only female-
initiated barrier method for STI pre- with perceived risks of pregnancy and
including gonorrhea, Chlamydia, STIs, communication with parents about
trichomoniasis, genital herpes, and vention currently available in the
United States. Data regarding contra- sexual risk, parental approval of birth
HPV.53,54,65,69–74 control, positive attitudes toward
ceptive effectiveness of female con-
Given the coital-dependent nature of condoms, increased use with casual
doms suggest estimated rates of
condoms, effectiveness against both un- partners versus main partners, part-
pregnancy during the first 12 months
intended pregnancy and STIs is closely ner support for condom use, and self-
of perfect use and typical use for FC1
tied to the degree of consistency or efficacy of condom negotiation.77,78,81–84
were 5% and 21%; these pregnancy
correctness of use. Factors associated In 1 clinic-based study of African
rates are slightly higher than those
with decreased condom effectiveness American and Hispanic female ado-
associated with use of the male
include failure to use a condom with lescents who received counseling and
condom.75
every act of intercourse; failure to use watched a video incorporating themes
condoms throughout intercourse, such Although laboratory and clinical stud- of condom use and nonuse, research-
as placing condoms on after initiating ies suggest that the female condom ers found that at 3-month follow-up,
intercourse or removing before ejacu- might be as effective as the male con- those who had the intervention were
lation; condom breakage and slippage; dom in preventing STIs, data are much more than twice as likely to have used
and improper lubricant use with latex more limited. Continued research is a condom at last intercourse than in
condoms (oil-based lubricants, such as needed to evaluate the effectiveness the usual care group. However, dif-
petroleum jelly, baby oil, hand lotions, and acceptability of female condoms, ferences did not persist at the
and some vaginal medications), which which currently account for less than 12-month follow-up.85
can reduce condom integrity and may 1% of US condom use overall.75,76
result in breakage.51 EFFORTS AIMED AT INCREASING
DUAL PROTECTION CONDOM USE
Five key condom instructions reached
by consensus at a World Health Or- Hormonal contraceptives and intra- Eighty-three studies of curriculum-
ganization Experts Meeting51 are as uterine devices offer pregnancy pro- based sex- and HIV-education pro-
follows: tection but no protection against STIs. grams among people younger than
1. Use a new condom for each act of Use of “dual methods” (the combined 25 years from all countries were
sexual intercourse. use of condoms and hormonal con- reviewed, finding that two-thirds of the
traceptives or an intrauterine device) programs significantly improved one
2. Before any genital contact, place
may be the optimal approach for pro- or more sexual behaviors. Of the 54
the condom on the tip of the erect
tection against both pregnancy and studies that evaluated effects on con-
penis with the rolled side out.
STIs for adolescents. Although dual dom use, nearly half (48%) demon-
3. Unroll the condom all the way to method use has been increasing over strated an increase in condom use,
the base of the erect penis. time, studies find that fewer than 25% and no studies found decreased con-
4. Immediately after ejaculation, hold of adolescents use dual methods77–79 dom use. Concern that these programs
the rim of the condom and with- According to data from the National might hasten the initiation of sex
draw the penis while it is still erect. Survey of Family Growth, condom use appears unfounded. In the 52 studies
5. Throw away the used condom safely. is lower in women who use “highly that measured timing of initiation of
PEDIATRICS Volume 132, Number 5, November 2013 977
Downloaded from pediatrics.aappublications.org by guest on May 11, 2015sex, 42% found that sexual initiation who are sexually active or contem- making condoms available to adoles-
was significantly delayed for at least 6 plating sexual activity. The respon- cents does not increase the onset or
months, and 55% found no effect.28 sibility of males as well as females frequency of adolescent sexual activ-
Condom availability programs have in preventing unintended pregnan- ity and that use of condoms can
been evaluated in a variety of settings. cies and STIs should be empha- help decrease rates of unintended
In a study of programs in Massachusetts sized. pregnancy and acquisition of STIs.
high schools, adolescents in schools 3. Pediatricians and other clinicians are 8. Pediatricians and other clinicians
where condoms were available were encouraged to implement the recom- should provide and support paren-
more likely to receive condom use mendations in Bright Futures promot- tal education programs that help
instruction and less likely to report ing communication between parents parents develop communications
lifetime or recent sexual intercourse, and adolescents about healthy sexual skills with their adolescent chil-
and adolescents who were sexually development and sexuality including dren around prevention of STIs
active were twice as likely to use the use and effectiveness of condoms. and proper use of condoms.
condoms at most recent sexual 4. Restrictions and barriers to condom 9. The American Academy of Pediat-
encounter. 29 Likewise, clinic-based availability should be removed, given rics should encourage additional
interventions have been shown to the research that demonstrates that research to identify strategies to
be effective in increasing condom increase continued condom use in
increased availability of condoms
use and decreasing STIs. 86,87 Clinic- established relationships and strat-
facilitates use. Beyond retail distri-
based safer sex interventions are egies for use of dual protection
bution of condoms, sexually active
endorsed by the CDC. 88 with condoms aimed at prevention
adolescents should have ready ac-
A recent meta-analysis of high-quality US cess to condoms at free or low cost of STIs and a second contraceptive
and international studies of structural- where possible. Pediatricians and method for the most effective pre-
level condom distribution interventions other clinicians are encouraged to vention of pregnancy.
found significant effects on increased provide condoms within their offices
condom use, condom acquisition, con- and to support availability within LEAD AUTHOR
dom carrying, delayed sexual initiation their communities. Rebecca F. O’Brien, MD
of youth, and reduced incidence of STIs.
5. Condom availability programs should CONSULTANT
The interventions that increase availability
be developed through a collaborative Lee Warner, PhD, Associate Director of Science
or accessibility to condoms are most ef-
community process and accompa- Centers for Disease Control and Prevention,
ficacious when combined with additional Division of Reproductive Health
nied by comprehensive sequential
individual, small-group, or community-
level activities. The intervention effects sexuality education to be most ef-
were significant across target partic- fective. This is ideally part of a COMMITTEE ON ADOLESCENCE
K–12 health education program, 2010–2011
ipant characteristics (youth, adults, Margaret J. Blythe, MD, Chairperson
commercial sex workers, STI clinic with parental involvement, counsel-
William P. Adelman, MD
populations, or males).89 ing, and positive peer support. Cora C. Breuner, MD, MPH
6. Schools should be considered ap- David A. Levine, MD
Arik V. Marcell, MD, MPH
propriate sites for the availability
Pamela J. Murray, MD, MPH
RECOMMENDATIONS of condoms because they contain Rebecca F. O’Brien, MD, MD
1. Abstaining from sexual intercourse large adolescent populations and
should be encouraged for adoles- may potentially provide a compre- LIAISONS
cents as the most effective way to hensive array of related educa- Loretta E. Gavin, PhD, MPH – Centers for Disease
prevent STIs, including HIV infec- tional and health care resources. Control and Prevention
Rachel J. Miller, MD – American College of
tion, and unintended pregnancy. Training of youth to improve com-
Obstetricians and Gynecologists
2. Pediatricians and other clinicians munication skills around condom Jorge L. Pinzon, MD – Canadian Pediatric Society
should actively support and encour- negotiation with partners can oc- Benjamin Shain, MD, PhD – American Academy
cur in school-based settings. of Child and Adolescent Psychiatry
age the consistent and correct use
of condoms as well as other reli- 7. Pediatricians and other clinicians STAFF
able contraception as part of antic- should actively help raise awareness Karen S. Smith
ipatory guidance with adolescents among parents and communities that Mark Del Monte, JD
978 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on May 11, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
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