EXECUTIVE SUMMARY
Women using long-acting reversible contraception (LARC) were less likely to use condoms than are women who use oral contraceptives, a new study shows.
- In the study, people using LARC were 40% to 60% less likely to use condoms than are people who use moderately effective contraceptives.
- Some LARC users might see condoms as backup contraception. People may believe that LARC’s extremely high effectiveness at preventing pregnancy means they do not need a backup contraceptive.
- Also, providers may not be counseling patients about sexually transmitted infections (STIs) and how condoms are effective at preventing STIs.
Women increasingly are using long-acting reversible contraception (LARC). But LARC users might also be forgoing condoms, the only contraceptive that protects against most sexually transmitted infections (STIs), the results of a recent study suggest.1
Investigators with the Centers for Disease Control and Prevention (CDC) found that LARC users have lower condom use when compared with users of oral contraceptives.1
“In this study, we compared published data on moderately effective contraceptive methods — [such as] pills and rings — and compared this to highly effective methods: IUDs [intrauterine devices], LARC,” says Riley J. Steiner, PhD, MPH, the study’s lead author and health scientist on the adolescent and young adult team with the CDC’s Division of Reproductive Health.
The investigators found that LARC users were 40% to 60% less likely to use condoms than those who use moderately effective contraception. “The other finding is that it’s unclear what that difference in condom use means for the risk of STIs,” Steiner says. “For chlamydia and/or gonorrhea, there was no difference in odds of infection between [users of] LARC and moderately effective contraceptive use.”
One potential reason for lower condom use among LARC users could be that condoms are seen primarily as backup contraception, and those with LARC find a backup contraceptive unnecessary because their birth control method is so highly effective, Steiner says.
Another possible explanation is that LARC users are less likely to have multiple sexual partners and contract STIs. “We’re still not certain, and it’s promising that we didn’t see a difference in chlamydia and gonorrhea infection among LARC users and moderately effective contraceptives users,” Steiner says.
STIs on the Rise
STIs cases are increasing — particularly among young people, says Kimberly R. McBride, PhD, MA, associate professor in the department of women’s and gender studies at the University of Toledo (OH).
“All of the money we’ve put into educational programming is missing the mark right now,” McBride says. “You have to conceptualize it within what else is happening within their lives.”
For instance, women with LARC might be more likely to perceive they are in monogamous relationships. “If they’re on LARC and in what they perceive as a consensual relationship, then condom use is going to be low,” McBride says. “The biggest reason you’re not seeing condom use is because of the relationship context.”
Providers should be aware of their clients’ STI risks when they do not use condoms regularly. “If [condoms used solely as backup contraceptives] is the underlying driver of the difference in condom use, we’d be concerned about the underlying risk of sexually transmitted infections,” Steiner says. “There is need for more research to get a better handle on what condom use is and to better understand the difference in condom use between LARC and moderately effective contraceptives users.”
Other research has shown that condom use with LARC has increased.2 “Recent analyses of the use of condoms with other methods of contraception — IUDs and implants — at last vaginal intercourse among women, aged 15-44, have shown that condom use with LARCs has increased from 11% in 2002 to 15% in 2011-2015,” says Casey Copen, PhD, MPH, behavioral scientist in the CDC’s Division of STD Prevention. “These increases in LARC use with condoms are related to increases in LARC use over time.”3
CDC data show a five-plus year trend of rising STI rates nationwide, despite a sharp decline in reported STIs after the COVID-19 pandemic emerged in the spring of 2020.4 (See the December 2021 issue of Contraceptive Technology Update on how the pandemic did not stop the trend of rising STIs.)
Other research shows that about one in five heterosexually active women who have anal sex use condoms, according to CDC data from the National HIV Behavioral Surveillance (NHBS) and estimates from the National Survey of Family Growth, Copen reports.2
“While we can’t directly correlate national trends in anal STIs among women to condom use, there have been a few trends in the use of condoms that could relate to overall STI increases among women,” Copen explains. “The National Survey of Family Growth [NSFG] estimates that 20% of women report condom use during anal sex. However, 4.2% have multiple opposite-sex anal sex partners in the past year.”
Over the past decade, NSFG historical data on condom use has shown a slight decline in condom use during vaginal sex among women age 15-44 years.5,6
“These declines could be due to several factors, including reports of less sexual activity — measured in past four weeks — and lower reported number of male sex partners in the past year,” Copen explains.
“One of the trends is fewer people, younger people, are sexually active than in the past,” McBride says. “Younger people are not having [as much] sex, and some of that is attributed to social media and people not being together in the same ways they have in the past.”
The collection of new data creates an interesting and contradictory picture. On one hand, overall sexual activity and condom use are declining. On the other hand, STI rates have risen.
“What’s going on there?” McBride asks. “We do see this trend of people exploring sexual behaviors other than penile-vaginal intercourse.”
For instance, there is a trend of penile-anal intercourse among heterosexual couples. “If they’re not well educated about STIs, they do not understand the risk,” McBride says.
McBride’s research shows that anal sex behavior, including oral-anal contact, is increasing.
“Even if they haven’t had penile-anal intercourse, they might have engaged in other things, like manual contact and use of sex toys,” McBride explains. “Women have had very little knowledge about sexually transmitted infections, generally, but particularly about anal intercourse.”
The HIV epidemic is one example. Most of the messaging involves sexual contact between men who have sex with men (MSM), and women often do not perceive themselves to be at risk. About 45% of the U.S. heterosexual population has tried penile-anal intercourse at least once, and this trend is increasing, McBride says.
HIV transmission risk is 18 times greater with anal intercourse than with vaginal intercourse, research has shown. Anal intercourse also raises the risk of other STIs because of the increased likelihood of mucosal disruption and trauma in the rectum’s lining vs. the vaginal lining.8,9
The chief takeaway message is that reproductive health providers need to counsel all women on using condoms during both vaginal and anal intercourse to reduce the risk of contracting an STI. (See story on how to improve messaging about condoms in this issue.)
Even as overall condom use has declined, evidence shows that condoms have become a more effective contraceptive. One study showed the failure rate of condoms as a contraceptive has declined from 18% in 1995 to 13% in 2010.7
The decrease in the failure rate of condoms suggests changes in the demographic and behavioral characteristics in who uses condom and in condom use consistency, Copen says.
REFERENCES
- Steiner RJ, Pampati S, Kortsmit KM, et al. Long-acting reversible contraception, condom use, and sexually transmitted infections: A systematic review and meta-analysis. Am J Prev Med 2021;61:750-760.
- Copen CE. Condom use during sexual intercourse among women and men aged 15-44 in the United States: 2011-2015 National Survey of Family Growth. National Health Statistics Reports. Aug. 10, 2017.
- Branum AM, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15-44. NCHS Data Brief 2015;188:1-7.
- Centers for Disease Control and Prevention. Reported STDs reach all-time high for 6th consecutive year. April 13, 2021.
- Daniels K, Daugherty J, Jones J. Current contraceptive status among women aged 15-44: United States, 2011-2013. NCHS Data Brief 2014;173:1-7.
- Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2017-2019. NCHS Data Brief 2020;388:1-8.
- Sundaram A, Vaughan B, Kost K, et al. Contraceptive failure in the United States: Estimates from the 2006-2010 National Survey of Family Growth. Perspect Sex Reprod Health 2017;49:7-16.
- Pebody R. HIV transmission risk during anal sex 18 times higher than during vaginal sex. AIDSmap. June 28, 2010.
- Jenness SM, Begier EM, Neaigus A, et al. Unprotected anal intercourse and sexually transmitted diseases in high-risk heterosexual women. Am J Public Health 2011;101:745-750.
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