Patterns of Condom Acquisition by Condom-Using Men in the United States

Abstract

Condom-distribution programs have striven to make condoms more accessible to sexually active individuals, particularly adolescents and populations disproportionately affected by HIV and other STIs. Despite such programs, little is known about where condom-using men in the United States acquire their condoms. The purpose of this study was to document condom-access trends among a large sample of sexually active condom-using men in the United States. Data were collected from 1,832 men from all 50 U.S. states and the District of Columbia by using an Internet-based survey in which men provided details regarding the source of condoms that they had used within the past 30 days. Men reported acquiring their condoms from a variety of sources, including free condom-distribution programs (56.7%) and from venues where they had purchased condoms for themselves (75.7%). Bivariate analyses indicated that participants who reported using free condoms tended to be younger, self-identified as not heterosexual, or not currently in a monogamous relationship. Further, results indicated that those participants who accessed only free condoms did not differ from those who used only purchased condoms, indicating that perhaps efforts to make condoms more accessible through public health distribution campaigns are reaching a more general population of condom-using men than expected. Findings illustrate the importance of continuing free condom-distribution efforts but also suggest benefits of facilitating linkages between public health and a community's retail venues to increase access to the growing diversity of condoms in the marketplace.

Introduction

T he continued incidence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and unintended pregnancy remain among public health's most challenging issues and are those for which we continue to investigate opportunities for new and innovative tools for prevention. Rigorous studies have documented that among sexually active individuals, the male latex condom remains one of the most practical and effective devices for the prevention of infections such as HIV and other STIs.^1
–3 As a result, the adoption and maintenance of correct and consistent condom use by sexually active individuals remains a priority activity for sexual health–promotion professionals.³

In addition to promoting correct and consistent condom use, the public health community has also dedicated significant resources to making condoms more easily accessible. Such public condom-distribution programs have taken on many forms, with much discussion and debate, focused specifically on the distribution of condoms in public schools, particularly when in 1991, the New York City School District became the largest in the United States to make condoms available in its schools.⁴ Although condoms remain a source of controversy for some, studies in the recent past have demonstrated that most adults, including those who are parents, generally support the notion of condom-distribution programs for youth.^5

–8

In addition to programs focused on adolescents, for several decades, significant resources have been allocated to the distribution of condoms within communities disproportionately affected by HIV and other STIs.⁹ Expansive condom-distribution campaigns have been implemented by those typically leading HIV- and STI-prevention efforts in such communities, such as local health departments, STI and HIV treatment clinics, and other community-based agencies focused on sexual health.¹⁰ A recent study found that 69% of individuals who had received a condom during a city-led distribution program in New York reported having used the condom, providing evidence that condom-distribution and -marketing campaigns are effective mechanisms for driving actual condom use.¹¹

Condoms may be acquired, often at no cost, through these campaigns implemented by public health organizations. Condoms are often readily available for purchase in retail stores, such as drug stores and adult bookstores, which have primarily been considered a greater barrier because of cost than an integral component of public health's conceptualizations of condom accessibility.⁹ Retail store access has also, however, been a source of occasional public controversy and debate, with some community advocates recently calling for specific retail chains to make their condoms more accessible by removing locks, glass doors, or other barriers that make it necessary for a consumer to request assistance from a store employee before being able to select from a store's selection of condoms.

Although condoms are among our most-effective STI-prevention tools, significant resources have been allocated to their distribution, and condom-distribution programs have been the source of social debate, little is known about the manner in which individuals acquire condoms. Little is known particularly with regard to whether individuals who regularly use condoms for disease or pregnancy prevention are taking advantage of public distribution programs and to what extent the private retail sector represents venues for condom access.

Of the small number of existing studies on condom acquisition in the United States, one examined the issue among young (14- to 19-year-old) adolescents in New York.¹² The only study that has focused on condom acquisition among adult American men examined the issue among men who have sex with men (MSM), all of whom were recruited from a large gay-pride event in the southeastern United States.¹⁰ Other research on access to condoms has been conducted in other countries with high HIV prevalence that have more limited formal public health structures.¹³ Others have included concepts related to condom access in their research, such as those who have considered the nonacquisition of condoms before sexual activity to be a “condom error.”¹⁴ However, this research has not empirically assessed the patterns and preferences of condom access among men. Additionally, research has documented that male condom users often seek to access condoms that have specific structural properties, such as those that are larger, smaller, or made of a range of diverse textures.¹⁵

Although condom-distribution programs may reach those groups traditionally considered to be at increased risk for HIV and STI, knowledge regarding the condom-acquisition trends for the larger population remains undocumented. The purpose of this study was to document condom-access trends among a large national sample of adult men in the United States who had a recent history of using condoms during sexual interactions. A deeper understanding of the factors associated with men's condom acquisition will help to support public health through venue-specific interventions for condom distribution. Additionally, knowledge gained as to where men access condoms has the potential to engage the retail sector of the condom industry in the ongoing work of condom promotion in public health.

Methods

Data collection

In 2006, recruitment advertisements for a study on male sexual health were placed in newspapers (including community newspapers, campus newspapers, and varying forms of Gay Lesbian Bisexual Transgender (GLBT) community media) and in public information-distribution sites located within HIV/STI-focused community-based organizations. These printed recruitment materials were distributed specifically in seven U.S. states, selected to ensure geographic diversity across the United States and based on the extent to which the state had a history of high STI or HIV prevalence, or both. Advertisements (banner ads) were also placed on sexuality-related websites. To be eligible, men were required to be at least 18 years of age and to report recent sexual activity (at least one act of sexual intercourse with another person in the past 30 days) and the recent use of condoms.

Measures

By using an Internet-based survey, participants provided data related to their age, race/ethnicity, sexual orientation, geographic area of residence (state and size of actual area where they resided), sexual relationship status, past 30-day sexual behavior and condom use patterns, and other sociodemographic variables. Participants also provided histories of STI and HIV testing and diagnosis (whether they had ever been diagnosed with any of five commonly reported STIs and HIV). Participants also described the characteristics of the venues from which they had accessed the condoms that they had used within the past 30 days. Specifically, men were asked to report as to whether they had purchased condoms for themselves or had acquired free condoms. For each type of access (purchase or free), men provided descriptions of the specific types of venues where the condom had been acquired (e.g., for purchased condoms, men indicated yes/no to options such as drug store/pharmacy, large retail chain, grocery store, etc.; for free condoms, men indicated yes/no to options such as health clinic, sex club, friends, family members, bars, etc.).

Data analysis

Because of the nature of this study, the sample was restricted to men who had accessed and used condoms during the 30 days preceding their participation in the study. Based on this criterion, of the 1,864 completed online surveys, a subsample of 32 (1.7%) participants reported not using condoms within the past 30 days and were therefore removed from further analyses. With SPSS 17.0, descriptive statistics were derived (n = 1,832) to measure sociodemographics and frequencies of behavior. Pearson's χ² was used to assess the association between a series of sociodemographic variables (e.g., race/ethnicity) and source of condom acquisition.

Results

Participant characteristics

Of the 1,832 men who participated in this study, the average age was 26.96 years (SD = 8.69) with a range of 18–75 years. The sample was predominantly white (n = 1,475; 80.5%), with 161 (8.8%) self-identifying as Asian, and 196 (10.7%) as other ethnicities. Participants were located in all 50 U.S. states (and the District of Columbia) and resided in large cities (n = 445; 24.3%), medium cities (n = 723; 39.5%), small cities (n = 356; 19.4%), and rural areas (n = 110; 6.0%). Slightly more than half of the participants were currently enrolled as college students (n = 978; 53.4%). The sample was predominantly heterosexually identified (n = 1,598; 87.2%), with 78 (4.3%) self-identifying as bisexual, and 128 (7.0%) as homosexual. In terms of sexual relationship status, more than half of the men reported “dating or in a relationship with one person for longer than 6 months” (n = 1,156; 63.1%), 219 men were “dating or in a relationship with one person for less than 6 months” (12.0%), 228 men reported “currently dating or in a relationship with several different people” (12.4%), and 184 men were “currently not dating anyone” (10.0%). There were 110 (6.0%) men who had contracted an STI at some point in their lives, and 1,409 (76.9%) men who had never contracted an STI; 313 (17.1%) did not respond to this question.

Condom-acquisition source in the past 30 days

Men reported accessing condoms that they had used in the past 30 days from both free condom-distribution programs and from venues where they had purchased condoms. The majority of men reported that they had purchased condoms recently used (n = 1,386; 75.7%), a smaller proportion reported having used condoms that they acquired free (n = 1,039; 56.7%), and some reported having used both purchased and freely acquired condoms (n = 593; 32.4%). As seen in Table 1, the majority of participants who received free condoms acquired them through health fairs or clinics, and participants who reported purchasing condoms were likely to report purchasing them at a pharmacy or retail store.

Table 1.

Access Source of Condoms Used in the Past 30 Days

Condom acquisition source	n	%
Free	1,039	56.7
Health clinic	213	20.5
Health fair	139	13.4
Dorm/Student Group	88	8.5
Adult store	42	4.0
Sex club	40	3.8
Class	37	3.6
Other	110	10.6
Self-purchase	1,386	75.7
Pharmacy	850	61.0
Chain retail	555	40.0
Grocery store	392	28.3
Convenience store	151	10.9
Internet	123	8.9
Adult store	68	4.9
Health clinic	51	3.7
Vending machine	45	3.2
Sex club	7	0.5
In-home sex party	1	0.1
Other	2	0.1

Access trends for self-purchased condoms in the past 30 days

Of the 1,386 (75.7%) men who reported having purchased condoms for themselves that they had used in the past 30 days, the majority indicated that they had purchased such condoms in a drug store or pharmacy (n = 850; 46.4%). Other men reported purchasing their condoms at a chain retail store (n = 555; 30.3%), in the grocery store (n = 392; 21.4%), at a convenience store or gas station (n = 151; 8.2%), or on the Internet (n = 123; 6.7%). Few men reported purchasing their condoms in an adult store (n = 68; 3.7%), in the health clinic (n = 51; 2.8%), or from a vending machine (n = 45; 2.5%), at a sex club (n = 7; 0.4%).

Access trends for free condoms in the past 30 days

Of the 1,039 (56.7%) men who reported having received free condoms that they had used in the past 30 days, they reportedly came from a variety of sources, including a health clinic (n = 213; 20.5%), a health fair (n = 139; 13.4%), a dorm or frat house (n = 88; 8.4%), an adult store (n = 42; 4.0%), a sex club (n = 40; 3.8%), a college class (n = 37; 3.5%), or free from some other source (n = 110; 10.6%).

Sociodemographic categories and source of condom acquisition

Three characteristics were associated with self-reported self-purchased condom use and free condom use in the past 30 days, as presented in Table 2. Age, relationship status, and sexual orientation were found to be significantly associated with free condom use such that participants who reported using a free condom within the previous 30 days tended to be young, self-identified as not heterosexual, or not currently in a monogamous relationship. Age, geographic location, and relationship status were found to be significantly associated with self-purchased condom use, such that the highest percentage of participants who reported using a purchased condom within the previous 30 days were older than 40 years, resided in a small to medium-sized city, or were not currently in a monogamous relationship. In contrast to the significant differences between participants who reported having ever used a free or purchased condom within the past 30 days, sociodemographic variables were not a significant predictor (p > 0.05) of differences between participants who reported only using free or purchased condoms within the past 30 days (n = 1,832).

Table 2.

Association of Demographic Factors with Self-Reported Free and Purchased Condom Use During Past 30 Days

	Free condoms			Purchased condoms
Characteristic	n	%	p	n	%	p
Age in years			0.00			0.05
≤19	88	21.2		182	14.2
20–29	237	57.0		741	57.7
30–39	52	12.5		246	19.1
≥40	39	9.4		116	9.0
Race/Ethnicity			0.63			0.2
White	357	82.1		1128	83.4
All others	78	17.9		225	16.6
Geographic location			0.50			0.05
Large city	122	27.4		333	24.0
Medium city	175	39.2		562	40.6
Small city	83	18.6		271	19.6
Small town/Rural	39	8.7		134	9.7
Relationship status			0.00			0.00
Same relationship > 6	228	51.8		880	64.7
Same relationship < 6	73	16.6		164	12.1
Dating several people	78	17.7		191	14.0
Not dating	61	13.9		125	9.2
Sexual orientation			0.00			0.29
Heterosexual	352	79.5		1219	88.6
All others	91	20.5		157	11.4
STI Life contraction			0.43			0.19
Has contracted	31	8.2		81	6.8
Has not contracted	349	91.8		1112	93.2

Discussion

The data from this study are helpful in that they document trends in condom acquisition among a large sample of condom-using men from across the United States. Despite the significant investment of money and resources allocated to large-scale condom-distribution programs throughout the history of the HIV epidemic, and the mass availability of condoms in the retail sector, little is known about American men's patterns of, and preferences for, accessing condoms by those adult men who are sexually active and are using condoms. Data show that men in the United States who are using condoms access them from a range of sources, with more than half of men in the sample reporting having accessed free condoms that they had used within the past 30 days, and two thirds reporting having purchased condoms for themselves, mainly from retail outlets (51.7% at a retail or grocery store).

This sample varied significantly from the recent study by Rhodes and colleagues,¹⁰ in that ours primarily comprised heterosexually identified men, given that we collected data nationally rather than at GLBT events. However, consistent with that study's findings, men who identified as gay or bisexual were more likely to report that condoms they had used recently had been acquired only from free sources, although heterosexual men also reported frequently accessing free condoms. This may be an indication that efforts to make condoms more accessible through public health distribution campaigns are reaching not only men who are perceived to be at higher risk for HIV or other STIs, but perhaps the more general population of men who are using condoms as well.

The results must be interpreted while considering the study's limitations. By using a cross-sectional method, it is not possible to assess fully the complex and dynamic factors that are associated with the acquisition of condoms in the past 30 days. Additionally, recruitment via the Internet includes unique benefits and limitations, but was not able to sample individuals who were without Internet access (a minority of households in the United States). This study also included the collection of data only from men, and future studies should explore and seek to understand the condom-access trends of women. A strength of this study is that it included men from a diverse range of geographic areas throughout the country and therefore provides insights into trends across groups of men nationally who may have varying access to condoms through public distribution programs, depending on the extent to which they reside in areas of the country with active efforts to promote condom use.

As has been suggested in previous research, considering the potential to strengthen collaborative efforts between traditional public health providers and those who make sexuality related products available in retail spaces may facilitate our ability to include such private-sector venues as a component of our larger sexual health–promotion strategies.¹⁶ In particular, public health entities may want to continue to advocate changes to ensure that condoms are available within such venues in ways that remove barriers, such as locks or the need to interact with employees to access or view a venue's selection of condoms. Additionally, those who work in public health infrastructures to promote condoms may find other benefits of becoming more engaged with the retail sectors in their local communities. Previous research has documented that some men seek condoms that they perceive to be more pleasurable, better fitting, or better suited to their unique size, shape, or to the preferences of their sexual partners.^17

–21 Sexual health professionals may also encounter men who assert that their lack of correct and consistent condom use is related to their perceptions that condoms do not fit properly or feel comfortable, and research has demonstrated that men are able to discriminate between the points along the penis where they perceive discomfort or lack of fit.^15,22

In recent years, condom manufacturers have been more responsive to men's desires for a broader range of condoms with different structural properties, and today a great deal of condom diversity exists in the marketplace. However, offering such a wide variety of condoms may not be feasible for publicly funded outreach or condom-distribution programs. Although we should continue our efforts to distribute condoms through public health campaigns, particularly for men who remain condom resistant, considering innovative ways to facilitate men's (and their sexual partners') ability to acquire condoms in the retail environment may offer opportunities for increasing the likelihood that they will find condoms more suited to their and their sexual partner's desires.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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