Reasons for not Using Condoms among Heterosexual Men in Belgrade, Serbia.

Dear Editor, Proper and consistent use of male condoms can be a highly effective method of preventing the transmission of sexually transmitted infections (STIs) and HIV (1), but this method relies on men's willingness and ability to use condoms. In the United States of America, about 20% overall and less than 50% of adults with multiple partners used a condom at last intercourse (2). In Serbia in 2013 (3), 50.0% of women and 62.5% of men aged 15-49 who had more than one partner in the past year used a condom during their last intercourse. Heterosexual men often use condoms to prevent pregnancy rather than the transmission of venereal diseases (4). For better public promotion of condom use, it is necessary to know the reasons for its inconsistent or incorrect use. With this in mind, we asked 200 consecutive chlamydia-positive heterosexual men admitted to the City Institute for Skin and Venereal Diseases in Belgrade to complete an anonymous questionnaire, taken from a Danish study (5), about their attitudes to/or experience with condoms. Patients were divided into two groups; Group I consisted of 109 (54.5%) men who reported that they had never or sometimes used condoms during intercourse and Group II consisted of 91 (45.5%) men who had used a condom often or always. The majority of participants (68.5%) were ≤30 years old, while the rest were older. The analysis of differences between these two groups was performed using a chi-square test. Attitudes concerning use of condoms are presented in Table 1. The majority of our participants (43.5%) did not use a condom because they had sexual intercourse with regular partners. This may be explained by trust and misperception of risk of contracting STIs during sex with a regular partner or lack of discussion with the partner about condom use. The results of another study about condom use with a steady partner (6) have shown that 31% of participants reported using condoms consistently with steady partners. The second most frequent reason for not using a condom in our participants was the statement that condom decreased sexual pleasure. Several studies (7,8) have reported that this is one of the main reasons for not using a condom. In Randolph et al. (9), both women and men rated unprotected vaginal intercourse as more pleasurable than protected vaginal sex. In particular, men believe that condoms reduce sexual pleasure and they are less likely to use them in practice. Condom-associated erection problems or problems with condom fit were reported by 42% of our participants (items 1, 14, 15 in Table 1). Several studies have shown that men experiencing condom-associated erection problems practiced unprotected vaginal intercourse significantly more frequently than men who did not experience this problem (10,11). Although alcohol use has been found to be an independent and important risk factor for unprotected sex (5,12), only 5.5% of our participants reported that alcohol intake was the main reason for not using a condom. In the present study, participants who had never or sometimes used condoms reported significantly more frequently that they forgot to bring or even use a condom when it was available, which illustrates their risky behavior and unwillingness to use a condom. Patients who had often used a condom reported condom failure significantly more frequently because of their partners refusing to use it. Since men believe more frequently than women that condoms reduce sexual pleasure, the question is whether they could not persuade their partners or find a good excuse not to use it. In summary, the results of the present study indicate the main factors that should be considered when promoting condom use. Such promotion should include advice about using condoms, a demonstration of correct use, and provision of condoms to the patient.