The Condom Conundrum: What Good Are They Anyway?

Before you get the wrong idea, this is not a call for the abandonment of rubbers in favour of uninhibited sex. It's an attempt to place condoms in the context of a world where sexually transmitted infections (STIs) are out to get us at every turn.

God forbid we should have endless fun, so the gods invented unpleasant little bacteria and viruses to spoil the party and make sure we don't all have too good a time until we slide off this earth. Actually, the original intention behind STIs was probably to make sure we didn't procreate the earth so rapidly, that we would have starved ourselves into extinction years ago! I'm kidding, really, and I have no wish to bring the wrath of religion down on my head, but you do wonder at the sort of twist of natural fate that caused nature to bring STIs into the world! Why disease and sex for goodness sake? Keeping our bodies hale and hearty is hard enough without bringing the threat of disease into one of life's true pleasures. However, whatever the reason, STIs exist and are here to stay and the accepted truth is that a condom is a traditional and long-trusted method of keeping both them and unwanted children at bay.

That said, in the modern developed world, the Pill has pretty much removed the need for birth control prophylactics anyway, (unless your faith forbids birth control, too) so instead, the only thing standing in the way of lots of physical pleasure and procreation, apart from moral judgement, is sexually transmitted disease. And let's face it, since the Middle Ages, the accepted way of preventing both disease and babies, has been a protective sheath between egg and sperm.

But how efficient are condoms anyway?

For the purposes of this article and given that its target readership is LGBT, we can leave procreation out of the equation. How good are condoms in preventing sexually transmitted viruses and microbes?

The current hot potato is whether they are necessary to prevent the most deadly STI -- and that is HIV. Let nobody be under any illusion here; condoms still have a major part to play if you are HIV negative and sexually active and not on a strict daily PreP treatment. They are also important for HIV-positive people who do not have an undetectable viral load and a healthy immune system but arguably, less important for those who have achieved that Holy Grail and are healthy and undetectable ... but only as far as HIV is concerned! However for both groups, if you want to avoid a host of other STIs, plus hepatitis C and other viral problems, then a condom will go a long way to preserving your safety. For those very reasons, those who are questioning whether condoms are necessary any more, or have already abandoned them altogether, may need to look at the facts and ask themselves whether it's worth the risk.****

There is a tiny ray of light, side effect, for people living with HIV, in that recent research seems to prove that Truvada (the basis of many HIV combos) reduces the risk of herpes by about a third... who knew! But nobody in their right mind would abandon the condom for that reason alone.

So I seem to pushing the condom agenda pretty successfully here but many sexually active men are arguing that condoms are only a partial protection against disease and maybe they're right. After all, strictly speaking, if you use condoms for anal sex, you should also use them for oral sex. Why? Because STIs can be transmitted via the mouth and its fluids... and your fingers and hands. The truth is that apart from LGV (Lymphogranuloma venereum -- infection of the lymphatic system and lymph nodes) and Trichomoniasis (infection of the uro-genital tract and a cause of vaginitis), almost all other infections can be passed via the mouth, or skin to skin, or mucous to mucous. Are we suggesting using dental dams and rubber gloves every time we have sex? No of course not, that just isn't practical but remember, the vast majority of sexual activities do not end in penetration.

So is using a condom nothing more than harm-reduction, or damage limitation and do you still play the percentages game every time you go in for the clinch?

Well it's a fair assumption that if you use a condom with every new partner, you're reducing your risk of an STI considerably. However, a dangerous argument frequently heard in gay circles is, that if you assume that the risk of infection via the mouth is 100%, then adding anal sex to the mix doesn't increase that risk! The problem is, no STI can possibly have 100% risk of infection; it's a question of the circumstances you're in and what you're doing. For instance, if you meet someone and start off with heavy kissing, followed by heavy petting (sounds exactly what our parents warned us against eh!); then touching and exploring with fingers in every orifice and various fluids being excrete in the process; you're going to come in contact with an STI presence if it exists. Yet that behaviour is nothing short of normal, wouldn't you say? And we haven't even touched upon oral sex and penile penetration yet. Yet none of the above require a condom.

There are three major risk sites associated with sexual contact: the mouth, the penis or vagina and the anus and the more you expose your part to another's parts, the more risk there is of infection. It's a sort of cumulative risk and depends totally on the extent of your activity. Condoms actually only come into play in creating a barrier between the penis and the rectum or vagina and if you must, the penis and the mouth, so in that case, you can minimise risk by using them. I think you can see, though, that the condom only provides limited protection in the grand scale of things.

Another point is that STIs generally stay in the area where they took hold. For ulcerous infections like herpes, syphilis, HPV (human papillomavirus that causes anal warts and cancer), they will stay around the genitals, anus or mouth and unless you use a condom for blow jobs, you're only really protected around the anus, penis and vagina. For the other main STIs that are bacterial (things like gonorrhoea and chlamydia), the main infection sites are the urethra, rectum and throat. The point I'm making is that most sexual encounters involve a mixture of activities and although the condom will give you better odds of avoiding infection, it's by no means a universal protection. Someone with gonorrhoea or syphilis for example can pass that on via kissing, finger exploration and not only penile penetration.

It's also true that if you contract an STI from oral sex, it doesn't mean that you have it in other locations. The point being that you're at risk whether you use a condom or not. Reality however, means that many people end up contracting the same STIs in various locations, purely because your sexual play means you're addressing various sites in the same time span and possibly transferring the STI from one place to another. Again, a condom will limit the chances but only in certain areas and it's by no means fool-proof. Let's take this scenario for instance: you indulge in extensive foreplay and use your fingers and mouth to explore. During that process, you pick up an STI from say the mouth, the penis or the anus -- it's logical that while even just putting the condom on, you've already transferred it from your fingers to the urethra, thus defeating the object. Bacteria can live for a limited time outside the body. In the heat of the moment, disinfecting our body parts before, during and after foreplay is just not an option. Do you see how easy it is and how the condom is only playing one part in the whole process? Even with STIs of the skin, like genital warts, that particular virus can easily be passed on using the fingers, although theoretically, the condom protects you from genital wart transmission. It's so much more complex than it first seems. That said, when it comes to penetration, using a condom will prevent warts being transmitted to the internal parts of the partner but even rubbing the penis against the others skin in genital areas ... well you get the picture!

Where condoms best come into their own, is during penetration and they play a significant role in preventing gonorrhoea and chlamydia being internally deposited. In that case, foreplay is less risky because both those diseases are passed on via bodily fluids and mucous secretions. An active partner wearing a condom will significantly reduce the risk of introducing these two diseases into the anus or vagina (or mouth) but once again, it's by no means 100% safe.

Without spelling it out, I think you can see that STI transmission risks depend on the extent of what we do with a partner. Think of the last time you had full on sex, complete with foreplay and bathing in the afterglow. Think of everything you did with your mouth, penis, anus and fingers (never mind introducing foreign bodies into the equation!). Imagine you, or your partner already had an STI, can you see how the various permutations can all play a part in passing that on? Yes a condom will help and yes, it will reduce your chances of passing on or contracting a disease but it's far from the full story or the full protection that we're so often led to believe.

Terrified yet? Never going to have sex again?

I haven't even touched on the repercussions yet; or talked about trios, orgies, multiple partners in one evening! Exponential risk? You betcha!

The long term effects of STIs are still not fully understood but the neurological impact of syphilis for instance (several crowned heads have gone completely mad and also passed it on to their progeny!) has been understood for centuries. Some STIs are thought to be gateways to other STIs, increasing the likelihood that you're susceptible. Take HPV for instance (human papilloma virus). Some strains can lead to cancers of the throat, penis and anus. Condoms can't exclude the possibility completely but they can help.

There's not much point in listing every STI and its consequences; you get the picture and it's not pretty. In relation to condoms however, only one thing is 100% certain and that is that they will reduce your risk of contracting, or passing on an STI but as all the previous examples will have shown, they're only a tool and not a final solution. The problem with the publicity surrounding condoms both now and in the past, is that people are taught that if you use them, you're pretty much protected against everything. Unfortunately you're not but that's the popular belief and a measure of the success of decades of publicity. LGBT people should know better and see them for what they are, not what they're purported to be.

"So what if I get an STI: apart from HIV or Hep C, all I have to do is take a few pills for a short time then I can get back on the horse!"

It's true, that's a widely held belief but not a very sensible one. It's almost become a rite of passage, especially amongst heterosexual youth; that STIs are part of the game; irritating but easily resolved. What many people don't realise is that STIs are becoming increasingly resistant to current antibiotics and there are no replacements. We've seen what can happen with HIV, to an STI that gets out of control. Gonorrhoea is a current case in point -- it's not responding to antibiotics in many cases! It's no use assuming that new antibiotics and cures will quickly come onto the market -- it's an expensive process and the development of new antibiotics is not high on pharmaceutical companies' priority lists at the moment. It's going to have to be, very soon because the amount of antibiotics force fed into livestock, and therefore absorbed by us down the chain, is leading to even more resistance. It will be a crisis, it's just a question of when, so avoiding needing antibiotics should be on everybody's mind.

According to Robert Kirkcaldy, MD, a medical epidemiologist in the Centers for Disease Control and Preventions Division of STD Prevention:

"There is only one remaining treatment option that is recommended by CDC, and it is only a matter of time before gonorrhoea gains resistance to this treatment".

The problem is that when a bacteria becomes resistant to antibiotics, there is every chance that it will mutate into something considerable more dangerous.

Look at the alarming rise of the virus, hepatitis C (HCV), especially among gay men and more especially among men with HIV. Anal sex without a condom, rough sex, fisting, group sex, drug fuelled sex are all risk factors for hepatitis C and despite the new availability of new drugs, it's a horrible disease, very difficult and expensive to treat! The point being that although condoms will help prevent these things, there also has to be a behaviour shift because condoms alone are clearly not enough.

The moral of the story

I have argued recently that for men living with HIV, with an undetectable viral load, medication adherence and a healthy immune system, condoms are pretty much irrelevant and I've been accused of encouraging barebacking and spreading HIV even further. However, the relevance of using a condom for this group or not, is only in relation to HIV. These people cannot pass on the virus to others but they can pass on any number of other things, as I hope this article has shown. So no, I'm never going to advocate unsafe sex as the way to go -- the pitfalls are pretty obvious. On the other hand, I do take exception to an advertising industry and LGBT organisational policy that promotes condoms as the be all and end all of sexual protection. They are patently not! They are an aid to prevention and should be used in conjunction with risk assessment, to help us avoid other STIs.

What do I mean by "risk assessment"?

Look, when we have sex, it's rarely a question of bending the other over, never touching him or her and inserting the covered penis into the required cavity. If that were the case, then a condom (unless it breaks) is a sure-fire way to prevent disease. But we're complex human beings, whose sexual activity is varied and involves multi-tasking using the body parts that we have at our disposal. All those body parts are potential disease spreaders but we can't be expected to cover mouth, hands, fingers, genitals and anus with a thin coating of rubber -- never going to happen. So every time that we have sex, we indulge in risk assessment, in the knowledge that there is a potential risk with every activity we undertake. Condoms can help block disease in a limited way but for the rest we have to be aware and try to minimise those risks as best we can. We're told that certain activities carry less risk (blow jobs, kissing, fondling etc) but it's 'less' risk not 'no' risk and every time we move all around our partner's body, we increase that risk by bringing different body parts and potentially bacteria or viruses into contact with each other.

So what can we do apart from becoming celibate?

Nothing new is the answer. Use condoms where necessary to reduce risk but for the rest, we just have to act sensibly and take responsibility for our own bodies and those of our partners. Most sexually active LGBT people (mainly it has to be said, men) will probably come into contact with an STI (even if it's only crabs!) during their life time. It's a fact of life but you really have to use your common sense and try to make the best judgements at any given time or situation. Accept that you're not perfect but be aware of the reality of sex. Condoms were always a great invention but maybe we need to use them as part of an overall strategy and not just depend on them to save us from the sex bugs that haunt us.

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Read Dave's blog HIV, Neuropathy and More: Avoiding Becoming a Nervous Wreck.