Abstract
Promoting consistent and correct condom use remains a priority public health activity, although some HIV- and STI-related providers remain challenged by some men's resistance to condoms, which some claim do not fit properly or do not feel comfortable. Although these perceptions have been examined across multiple populations, they have not been documented among men living with HIV. During spring 2008, data were collected from 215 men living with HIV at HIV service organizations in the Midwestern and Southeastern United States. Participants completed the Condom Fit and Feel Scale and measures related to demographics and condom use during sexual interactions within the past 90 days. Men were primarily homosexual, African American, with a high school degree or higher, and unemployed. More than half of participants had used condoms for sexual intercourse within the previous 90 days. The majority of the men reported few problems with the fit and feel of condoms, with 63.1% reporting that condoms “fit my penis just fine,” and 80.9% reported being able consistently to find condoms that they perceived to be “sized appropriately for my penis.” Some men did report specific characteristics of condoms that challenged fit and feel, including 20.6% endorsing (always or often) that condoms feel too tight, 15.9% that condoms are too short, 17.8% or that condoms would not roll down far enough to cover their penis completely (15.6%). These data provide insights into mechanisms through which providers can help to increase men's access to the diverse range of condoms in the marketplace.
Introduction
T
While supporting the well-being of those living with HIV remains essential, public health is also charged with implementing programs that seek to reduce the likelihood that individuals will become infected with HIV or transmit HIV to another person if already infected. Over the past decade, HIV care programs and prevention programs have become more integrated, with a focus on both prevention and care seen as a necessary characteristic of a comprehensive public health response to HIV. Often referred to as “prevention for positives” programs, specific HIV-prevention activities designed for those already living with HIV have two purposes, to reduce the likelihood that an individual will transmit HIV to another person and that individuals will be exposed to comorbid conditions, including other sexually transmitted infections (STIs) that will further challenge their health and well-being.
A central component of most HIV-prevention programs has been, and continues to be, the promotion of latex condom use. The male latex condom remains one of the most practical and effective devices for the prevention of HIV and some other STIs. As a result, promoting correct and consistent condom use by sexually active individuals remains a public health priority and central element of most sexual health–promotion programs. 4 –8
Although the efficacy of condoms is well established, their promotion has sometimes been a challenge for those who run HIV care and prevention programs. Not only have sexual health–promotion providers described anecdotal reports in which some men have suggested that their lack of correct and consistent condom use is related to problems with their perceptions of the fit and feel of condoms, but this has also been documented empirically. 9 –12 Previous research demonstrated that although the majority of men find condoms to fit fine and feel comfortable, others have general complaints about the fit and feel of condoms, in which some men have expressed an interest in having access to condoms that come in a variety of textures, colors, and that are better fitting or better suited to their unique size, shape, or to the preferences of their sexual partners. 9,10,13 Although complaints of condom fit and feel may certainly be used by some men to rationalize a general dislike, and subsequent non-usage, of condoms, research has also demonstrated relations between a man's actual penile dimensions and his perceptions of condom fit and feel and also that men are able to discriminate between the points along the penis where they perceive discomfort or lack of fit. 11 Interestingly, across these reports, these complaints are reported by men who perceive condoms to be too small, as well as by those who perceive condoms to be too large. 9 –11 Some have called for new condom-manufacturing standards that are responsive to the need for condoms in more shapes and size. 14 –17 As a result, the condom industry has been rather innovative in attempts to expand the range of condoms in the marketplace to be responsive to men's desires and needs.
To date, research related to men's perceptions of condom fit and feel has focused on men from diverse sexual orientations, ages, ethnicities, and regions of the world but has not yet explored these issues among HIV-positive individuals. The purpose of this study was to assess condom fit and feel perceptions among men living with HIV, particularly those who are engaged with community-based HIV services. Given that condom use is an important behavior for men living with HIV to promote their health and the health of their partners and that, as a result, these programs often include an emphasis on the promotion of condoms, having an understanding about these men's perceptions of the fit and feel may provide valuable insights for HIV service providers. Not only might these insights help providers to understand the source of some men's resistance to condoms, but they might also help providers to identify mechanisms through which they can help to increase access to the diverse range of condoms in the marketplace. By doing so, providers may play a valuable role in helping to alleviate men's concerns about the fit and feel of condoms and also perhaps in helping men to find condoms that they are more likely to use consistently.
Methods
Participant recruitment
Participants were recruited from two HIV service organizations, one in a large Midwestern city and the other in a large Southeastern city during spring 2008. Both of these organizations are integral components of their city's HIV care and services infrastructure; both use an integrated model of HIV prevention and care that guides all services at each agency. Over a 1-month period, all men coming into these organizations for care and services were approached by a research assistant and offered the opportunity to participate in a study about sexual health and condoms. Men received an incentive of $5 for their participation in the study.
Data collection
All data were collected anonymously by using a 60-item paper-and-pencil instrument. Participants completed surveys in a private space within the agency and then returned completed surveys to an envelope, monitored by research assistants. Given the nature of the issues under study and to protect the confidentiality of participants, special care was taken to ensure that staff from the agencies were not involved in any recruitment or collection activity. All study protocols were approved by the institutional review board of Indiana University-Bloomington.
Measures
Demographics
Participants were asked to describe their gender, age, geographic area location, ethnicity, education background, employment status, and housing situation. Participant characteristics are summarized in Table 1.
Sexual characteristics and behaviors
Participants described their self-identified sexual orientation, relationship status, numbers of sexual encounters with male and female partners within the past 90 days, and condom use and sexual behaviors in past 90 days.
Sexual health characteristics
Participants described their history of being screened for, and diagnosed with, sexually transmitted infections including HIV.
Condom fit and feel
Participants completed the Condom Fit and Feel Scale, 9,11 a 14-item Likert-type scale with established reliability and validity and on which men indicate their experiences with the fit and feel of condoms. Items were developed by sexual health researchers in collaboration with sexual health practitioners, condom manufacturers, and condom distributors, based on the specific issues that men have presented during sexual health interventions and on the specific issues with condom fit and feel that men have expressed to condom companies and condom retailers when seeking condom recommendations. Given the potential for confounding that results from using words such as “large” or “small” when assessing perceptions so closely related to one's genitals, these constructs are instead conceptualized across five subscales, including condoms fitting fine, condoms feeling too loose, condoms feeling too tight, condoms being too long, and condoms being too short. Each item is assessed by using a 4-point response option (1, never applies; 2, sometimes applies; 3, often applies; 4, always applies). A mean score for each subscale is calculated by summing the scores on items within each subscale and dividing the total subscale score by the number of items in each subscale. The subscale mean scores can be used independently to assess men's experiences with specific aspects of condom fit and feel. One can also calculate an overall score of “condom fit and feel problems” by reverse scoring the two positive items in the “condoms fit fine” subscale and creating a summed score. The extent to which participants endorsed items on the Condom Fit and Feel Scale is summarized in Table 2.
Proportion of participants responding “often applies to me or always applies to me” when asked about the use of condoms over the course of their life (n = 215).
Condom seeking
Men described types of condoms used (e.g., condoms marketed for larger or smaller penises) and responded to questions related to whether they had purchased condoms used within the past year at specific types of public health (e.g., clinics) or retail (e.g., drugstore) venues.
Statistical analyses
Data were analyzed by using the Statistical Package for the Social Sciences, version 16.0. Descriptive analyses were used to describe the sample and the perceptions of men's condom fit and feel. Analyses were conducted to characterize relations between participant characteristics, condom fit and feel, and condom-seeking behaviors.
Results
Participant description
Participant characteristics
A total of 215 adult men completed this study, 100% of them indicating that they had received a diagnosis of HIV, and 100% being actively enrolled in one or more care and prevention programs at the agency from which they were recruited. The majority of the men self-identified as homosexual (59.1%, n = 127), 21.9% (n = 47) as bisexual, and 19.0% (n = 41) as heterosexual. More than two thirds (70.2%, n = 151) identified their ethnicity as African American or black, with the remaining men largely identifying as either white (14%, n = 30) or Latino/Hispanic (11.2%, n = 24). The majority of participants had completed a high school degree or higher (79.5%, n = 170). Consistent with the nature of publically funded HIV service programs, slightly more than half of the participants described themselves as being unemployed (60.5%, n = 130). In terms of differences between the samples from the two agencies, no significant differences were noted between them with regard to participant characteristics.
Health status
More than one third (36.6%, n = 78) of the men reported having received a diagnosis of AIDS. Most participants (85.7%, n = 180) of men reported having been tested for additional STI, with most (60.7%, n = 128) having been STI screened within the past 2 years.
Sexual behaviors
With regard to sexual relationship status, men described themselves as being “in a sexual relationship with only one person” (38.8%, n = 83), “currently not sexually active” (33.6%, n = 72), “having sexual relationships with more than one person” (14%, n = 30), and “sexually active, but do not consider myself in a sexual relationship” (13.1%, n = 28). In terms of sexual activity, 18.6% (n = 40) reported intercourse with a female partner within the past 3 months, 40.0% (n = 86) with a male partner, and a small number (4.2%, n = 3) with a transgendered partner. Of those reporting intercourse with women, most (57.5%) reported only one partner, whereas 37.5% of those with male partners reported more than one partner during the past 90 days.
Condom use
The majority of participants reported having used condoms consistently for sexual intercourse events over the previous 90 days, although 30.0% of those having female partners (n = 12) reported no condom use for vaginal intercourse events, and 20.0% (n = 8), no condoms for anal intercourse events with women. Of men having male sexual partners in the past 90 days, 44.4% (n = 55) reported at least one act of anal intercourse without a condom during which they were the insertive partner, and 40.2% (n = 50) reporting no condom use when they had been a receptive partner in anal intercourse.
Perceptions of condom fit and feel
The majority of the men reported few problems with the fit and feel of condoms, with 63.1% (n = 135) reporting that condoms “fit my penis just fine,” 80.9% (n = 169) reported being able consistently to find condoms that they perceived to be “sized appropriately for my penis.” Some men did report specific characteristics of condoms that challenged fit and feel, including 20.6% (n = 44) endorsing (always or often) that condoms feel too tight, 15.9% (n = 34) that condoms are too short, 17.8% (n = 38) or that condoms would not roll down far enough to cover their penis completely (15.6%, n = 33).
Some men indicated specific points along the penis where they had experienced discomfort with condoms. Most frequently endorsed (always or often) was that condoms felt too tight on the base of the penis (21.0%, n = 45), on the shaft (15.0%, n = 32) or on the glans (15.0%, n = 32). Of those describing condom looseness, men described condoms as being too loose on the penile shaft (10.3%, n = 22), glans (9.9%, n = 21), or base (9.4%, n = 20).
Relations between condom use and perceptions of condom fit and feel
Some significant associations existed between participants' perceptions of condom fit and feel and recent condom-use behaviors. These relations existed only for anal intercourse behaviors with both male and female partners. Specifically, men who reported having experienced condoms being too loose were more likely to report unprotected anal intercourse with female partners [X2 (2, 97) = 8.958; p = 0.011], whereas those with male partners were more likely to report being the insertive partner in unprotected anal intercourse with men when they reported perceptions of condoms being too tight [X2 (2, 168) = 10.157; p = .006]. No other significant interactions were found between other condom-use behaviors and perceptions of condom fit and feel.
Condom-seeking behaviors and condom access
Men who reported having used any condoms during the previous 90 days (n = 166) also indicated the source of those condoms. The majority of men reported that they had acquired free condoms from a health care provider or at a health clinic (51.2%, n = 85) or at a health fair of community event (28.3%, n = 47). Approximately one third of men also reported having purchased condoms for themselves (34.3%, n = 57). When asked about the types of condoms used in the past year, the vast majority (75.8%, n = 163) reported having used only latex condoms, with a small number (9.8%, n = 21) having used a polyurethane condom. Some men (12.6%, n = 27) had also sought condoms that they perceived would be better fitting or more comfortable, specifically having purchased condoms that they perceived to be designed for men with a larger penis or that were custom fitted to their particular penis size or shape.
Discussion
Previous research supports the notion not only that most men find condoms an efficacious option for preventing HIV and other STIs, but also that they find condoms to fit and feel comfortable. However, although the promotion of consistent and correct condom use remains a priority public health activity, some HIV- and STI-related providers remain challenged by some men's resistance to condoms, often described as being related to those men's perceptions that condoms do not fit properly or do not feel comfortable. Although these perceptions have been validated across multiple populations, these data represent the first that describe these perceptions among a group of men living with HIV who are actively engaged in HIV prevention and care programs in an HIV-focused community-based organization. Given that such organizations are among those charged with promoting the use of condoms, and that doing so is particularly important among individuals living with HIV, these unique data provide helpful insights for those who conduct such sexual health–promotion activities.
The limitations of this study must be considered while interpreting the results. Similar to other studies in this area, we used convenience sampling, and findings therefore have limited generalizability. It is also possible that men attending HIV service organizations may respond differently from those who are living with HIV but are not integrated into systems of care. The typical challenges of self-report questionnaires, particularly social desirability, should also be considered given the nature of this study.
Consistent with other research on this topic, 9 –11 the majority of men (63.1%) endorsed the notion that condoms fit just fine. However, also consistent with other research, smaller proportions of men are able to articulate specific challenges with the fit and feel of condoms. In this sample, men were most likely to report that they had used condoms that they perceived to be too tight. It is also important to note, however, that some men (∼10%) reported having used condoms that they thought were too loose. These data also suggest that men who most strongly have negative perceptions about condom fit are among those who were most likely to avoid condom use during recent sexual interactions, particularly when they were the insertive partner during anal intercourse (one of the highest-risk activities for their sexual partners). Perhaps more important is that these data provide some validation to the challenges experienced by those who provide services at community-based organizations who have encountered men who assert that condoms do not fit or feel comfortable. Additionally, these data provide insight into these men's assertions in that they may not always have a concern about condoms being too small or too tight and that men are able to articulate specific points along the penis where they have experienced discomfort with condoms.
Particularly in recent years, condom manufacturers have been more responsive to men's desires for a more-diverse 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 typical of HIV service agencies like those engaged in this study. Considering this, and knowing that men are able to express specific issues with condom fit and feel, however, does create a unique opportunity for HIV service providers. For example, given that new condom innovations are not always easily identifiable in the marketplace, an opportunity exists for better collaborations between service providers and condom manufacturers that would result in literature available in service agencies to helps consumers understand the differences between condom types.
Although we should certainly continue our efforts to distribute condoms through free distribution programs, 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. This may be particularly beneficial for men who remain condom resistant, regardless of the access to free condoms that they have through their engagement with HIV care and prevention programs. It is also important to note that some men, regardless of the options available, will remain resistant to condoms. Given this, it remains important for public health to continue exploring options beyond condoms (e.g., microbicides) that expand the tools available for HIV and STI prevention.
Until such additional tools become available, the Condom Fit and Feel Scale may be a helpful tool for providers who wish to initiate interactions with men who are condom resistant or who use condom discomfort as a reason for their lack of condom compliance. Combined with knowledge about the expanding range of condoms available, HIV service providers could make helpful recommendations about specific condoms that these men not only find more appealing, but also that, as a result, will increase the extent to which they use condoms consistently.
Footnotes
Author Disclosure Statement
No competing financial interests exist.