Acceptance and use of condoms among school-aged young people in Australia

Introduction

Condoms are an affordable and effective means to prevent sexually transmissible infections (STIs) and have been at the forefront of safer sex campaigns for young people since the emergence of the HIV epidemic in the late 1980s. For most common STIs, including gonorrhoea and chlamydia, condoms are the most effective means of prevention.^1,2

Today, STI/HIV prevention encompasses multiple methods – condoms, vaccines, medical prophylaxis, testing and treatment – while holistic approaches to safer sex include a focus on consensual, respectful and pleasurable sex as necessary for STI prevention.³ However, in the late 1980s and 1990s, when HIV prevention, testing and treatment options were limited, condom use was the major component of safe sex practice. As a result, there are volumes of research on condom use among young people.⁴ Often informed by feminist or queer theory, much of this research explores the ways in which acceptability and use of condoms among young people is shaped by cultural perceptions of sex, the symbolism of condoms in the context romantic relationships, and gender-based inequalities.^2,5–8 Many young people view condoms as interrupting or negating what they perceive to be ‘natural’, ‘real’ or intimate sex, and condomless sex can symbolise trust or commitment to a partner.^5,9–13 Gender-based inequalities may also impact upon young women’s capacity to insist on condom use in heterosexual sexual encounters.^6,14 This body of research establishes an important framework for understanding condom use among young people in the context of gender, social and relational practices and the emotions and intimacies of sex.¹²

Recent research suggests that the number of young people in Australia who consistently use condoms is low and has declined over the past decade.¹⁵ In part, this is because young people tend to view condoms as contraception, rather than for STI prevention, and prefer hormonal contraceptives.¹⁵ Normative attitudes toward condoms are also significant in these trends. Many young people do not believe condom use is common among their peer group and are less likely to use condoms regularly as a result.^15–20

In this paper, we report findings from the 2021 iteration of a large, periodic survey of school-aged young people in Australia (14–18 years), the Secondary Students and Sexual Health (SSASH) survey.¹⁵ While a quantitative survey offers only limited insight into the nuance of condom use as it relates to contemporary sexual cultures, our aim was to explore condom use in the context of young people’s sexual and relationship experiences. With this in mind, we look at two aspects of condom use: (1) drawing on comprehensive definitions of safer sex that recognise the importance of pleasure,²¹ we look at whether condom use is associated with positive experiences of sex; and (2) we look at the relationship between condom use and social and relational variables, including perceptions of condom use among peers and whether young people feel confident talking about condoms with sexual partners.

Data were collected in 2021. The study is timely given recent decades have seen increasing STI rates among young people in Australia.^22–24 Young people, aged 15–29 years, are more likely than people in other age groups to contract common STIs (i.e. chlamydia and gonorrhoea) while syphilis is an increasing concern in some populations of young people.²³ As such, young people are recognised as a priority population in the Australian National STI strategy.¹

Materials and methods

The study was granted ethical approval by the La Trobe University Human Research Ethics Committee (HEC 20401).

Results

Demographic characteristics of the sample are shown in Table 1. The mean age of participants was 16.6 years (s.d. = 0.98). Most participants were female (n = 1311, 72.4%), and over one-third identified as lesbian, gay, bisexual, queer or other terms that described non-heterosexual sexual identity (LGBQ+; n = 692, 38.2%). The majority spoke English as their first language, with 14.3% (n = 246) from a non-English speaking background. There were 102 (5.8%) young people who identified as Aboriginal or Torres Strait Islander. The majority lived in major cities, with less than half (40.1%, n = 573) living in remote or regional areas in Australia rather than major cities.

Discussion

The findings from this large study of young people in Australia reveal the significance of communication and relational factors in supporting safe sex and condom use. Among participants, consistent condom use was more common among those who had discussed using condoms with a sexual partner, those who perceived condom use to be easy (a measure that included perceived ease of discussing condoms with a partner) and those who perceived condom use to offer social or relational benefits, including agreeing that condom use demonstrates care for a partner. Using a condom was not associated with young people reporting more positive feelings about their last sexual encounter. However, young people were more likely to report positive feelings about sex if it was with a regular partner, and people having sex with a regular partner were less likely to use condoms. Non-use of condoms was usually due to use of other contraception or a sense of trust in, or knowledge about, their partner. It is likely that these findings reveal young people’s attitudes toward condom use with non-regular or casual partners as well as the ways condom use (or non-use) may be connected with feelings of safety, pleasure and intimacy with regular partners. More research is needed to understand contemporary sexual cultures and the ways in which young people determine, or build, a sense of safety and trust in sexual partners. These findings support approaches to RSE that recognise condom use as a relational and social practice and focus on developing young people’s insight into the dynamics of sexual relationships and communication.³³ Such an approach would not just be about giving young people skills to negotiate use of a condom, but confidence and capacity to have meaningful conversations about sexual needs and wants with partners.^34,35

These findings reveal important differences in condom use and sexual experiences across different genders. Young heterosexual men were more likely to report positive feelings about sex and regular use of condoms than young women. Young women were less likely than young men or trans and non-binary young people to have used a condom when they last had sex or to report regular use of condoms. There may be many reasons why young women report less frequent condom use, including use of hormonal contraception. However, decades of research has drawn attention to the impact of unequal gendered power dynamics in sexual relationships and the ways that this can undermine young women’s confidence or capacity to understand, express or assert their desires (including a desire to use a condom) in sexual encounters.^6,14,36,37 The fact that young women were less likely to report positive feelings about sex than young men was not directly related to less regular condom use in these findings. However, it is worth considering the ways these experiences may both be related to more limited sexual agency among young women.³⁸ Waling’s³⁹ recent qualitative study with young men highlights the ways in which normative gendered and heterosexual social codes – including ideas that women are sexual gatekeepers – indirectly undermine young women’s sexual agency. In Waling’s study, young men, in their sexual encounters, were primarily focused on ensuring the sex (intercourse) happened; seeing the need to entice the ‘gatekeeper’. Conversations about condom use or contraception were often seen as interrupting this enticement (the ‘erotic moment’) and so were avoided (p. 351).³⁹ Few of Waling’s participants expressed awareness or concern that their lack of willingness, or capacity, to communicate about safe sex limited their partner’s agency, safety or pleasure. Waling advocates the importance of developing RSE content focused on building young men’s critical awareness of gender dynamics in sexual encounters.

The findings reported in this paper also reveal some important inconsistencies in young people’s perspectives on, and use of, condoms. Notably, most young people held positive attitudes toward condoms and agreed that young people should be using condoms. However, over half did not regularly use condoms and close to half were unsure or did not believe their peers were regular condom users. As noted above, among those who did not use a condom for their most recent sexual encounter, one in three reported this was because they trusted their partner, a finding that suggests condoms may be seen by young people as problematic for romantic relationships.⁵ HIV prevention research, particularly that done with communities of gay and bisexual men, has shown the importance of condom promotion efforts that aim to achieve collective mobilisation, community building and cultural acceptance of condoms.^40,41 Creative efforts to integrate condoms into young people’s sexual cultures and networks, and to change the image of condoms (e.g. from interrupting intimacy to supporting good sex) may be needed to revitalise condom promotion among young people. Results from previous iterations of the SSASH survey have shown a decrease, since the early 2000s, in the number of young people reporting condom use for their most recent sexual experience. This decrease has occurred despite a concurrent increase in the number of young people reporting they had a condom available¹⁵ and mirrors a decrease in use of condoms among gay and bisexual men in response to the introduction pre-exposure prophylaxis for HIV prevention.^42,43 It may be timely for new qualitative work to explore how young people perceive the risk or impact of STIs as the HIV prevention environment changes.

In this study, relational and communication factors were significantly more predictive of condom use than knowledge of STIs or understanding the efficacy of condoms for STI/pregnancy prevention. However, these findings still suggest that young people make decisions about whether or not to use a condom in the context of a range of factors, most notably unwanted pregnancy. Young people were less likely to use condoms if they were using hormonal contraception, and less likely to use condoms for anal sex than vaginal sex. While knowledge-based information on its own will not guarantee young people choose to use a condom,¹⁶ there is a still a need for young people to have access to information that allows them to make informed decisions about risks associated with STIs or unwanted pregnancy.^12,20

There are limitations to this study. While the sample is large, it is not representative and there are likely biases, including an over-representation of young women. While we have controlled for gender in our analyses, there may be less diversity in the views of young men and people of other genders due to the smaller sample. It is also likely that young people who were more motivated to respond to the survey advertising are over-represented in this study. It is also worth noting that the survey instrument did not differentiate between internal and external (or ‘male’/’female’) condoms and assumed young people were most likely to understand condoms to be the more commonly used external condom.

Conclusion

This study is timely and important given recent increases in common STIs among young people²⁴ and a reduced focus on condoms for HIV prevention in Australia.⁴⁴ The study shows the importance of supporting young people to build confidence to communicate about sex and relationships with partners, as well as with people who can provide support to them, including friends, parents, educators and healthcare professionals. This should occur as part of a comprehensive approach to supporting safe sex among young people, in which condom promotion initiatives are built on recognition of the complex ways in which public health concerns – STI prevention or unwanted pregnancy – are connected to sexual politics and the gendered cultures that shape young people’s experiences of sexual relationships, consent and pleasure. More work may be needed to reinvigorate condom use for STI prevention in Australia.