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February 2002, Vol 92, No. 2 | American Journal of Public Health 211-213
© 2002 American Public Health Association

RESEARCH AND PRACTICE

Condom Use as a Function of Time in New and Established Adolescent Sexual Relationships

J. Dennis Fortenberry, MD, MS, Wanzhu Tu, PhD, Jaroslaw Harezlak, MS, Barry P. Katz, PhD and Donald P. Orr, MD

The authors are with the Section of Adolescent Medicine, Division of Biostatistics, and the Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis.

Correspondence: Requests for reprints should be sent to J. Dennis Fortenberry, MD, MS, Riley Hospital Parking Garage, 575 N West Dr, Room 070, Indianapolis, IN 46202-5205 (e-mail: jfortenb{at}iupui.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

Objectives. This study sought to describe condom use over time in new and established adolescent relationships.

Methods. The outcome variable was time (in days) until first unprotected coital event. Analyses involved comparisons of Kaplan–Meier survival curves and Cox proportional hazards models.

Results. Survival functions for the 2 relationship groups were significantly different. However, by 21 days the curves had converged: 43% of new and 41% of established relationships involved no unprotected coital events. Time to first unprotected coital event was significantly longer in new than in established relationships.

Conclusions. Prolongation of condom use in ongoing relationships may be a useful intervention to prevent sexually transmitted diseases.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Relationship characteristics exert strong influences on condom use.1–4 Intimacy, mutual trust, and presumed fidelity are elements of sexual relationships that influence condom use,5–9 contributing to lower rates of use in established relationships than in new relationships.10,11

The time required for a "new" relationship to become an "established" relationship in terms of condom use is therefore an important issue for prevention of sexually transmitted diseases (STDs). The objective of this study was to establish the length of time required for adolescent women to fail to use condoms on a consistent basis.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Between the years 1995 and 1999, 172 women (age range = 13–22 years, mean = 17.6 years) were recruited from STD and primary care adolescent health clinics in Indianapolis, Ind. Participants were enrolled as a result of infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis or as a result of sexual contact with infected partners. Completion of diary forms was requested for each day in which coitus occurred. Codes were used to indicate coitus, partner initials, and condom use. Diaries were collected at scheduled clinic return visits over a 7-month period. Informed consent was obtained, and the study was approved by the Institutional Review Board of Indiana University/Purdue University at Indianapolis.

Coital events were analyzed on the basis of runs of sexual partners,12,13 defined as uninterrupted sequences of coital events (not necessarily on successive days) with a specific partner. A new run began each time a partner change occurred, even if the partner had been identified in an earlier run. Participants with one partner contributed one run. Number of runs did not necessarily equal number of partners, because multiple runs could be associated with the same partner. A "new" partner was defined as one not identified in any earlier run of a given participant. An "established" partner was defined as a partner associated with any previous run.

The sample consisted of 106 subjects with 359 runs (133 runs with established partners and 226 runs with new partners). The beginning of each run was used as the time origin. An unprotected coital event that occurred before the end of the run represented the "failure time." If the initial coital event of a run did not involve use of a condom, no additional events were contributed by that run. If no unprotected coital events occurred before the end of the run, the failure time for that run was censored. All observations were censored at 30 days because of the scarcity of data beyond that point.

Considering the first unprotected coitus in each run as a "failure," we calculated survival functions for new and established partners using Kaplan–Meier estimates.14 We compared survival curves using Wilcoxon tests.

Cox proportional hazard models for correlated survival data were used to control for multiple runs contributed by a single subject.15 Within-subject runs were treated as correlated with standard errors of parameter estimates obtained via a jackknife method. The robust version of the Wald test was used to assess differences in time elapsed before first unprotected coitus in new and established relationships.15 Level of statistical significance was set at P < .05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Data on participants' sexual behaviors at enrollment are shown in Table 1Go. The average diary length was 126 days (range: 25 to 266 days). Participants reported 3248 coital events, of which 1368 (42%) involved use of a condom.


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  		TABLE 1— —Sexual and Contraceptive Behaviors, at Enrollment and From Coital Diaries: Indianapolis, Ind, 1995–1999
 
More first coital events in runs associated with new partners (66%; 149/226) than in runs associated with established partners (54%; 72/133) involved use of a condom. Of runs involving new partners, 27% (61/226) were single sexual encounters. Protected coital events decreased in new relationships to the point that, by 21 days, condom use in new relationships was indistinguishable from that in established relationships (43% and 41%, respectively).

Kaplan–Meier survival curves showed that, in comparison with condom use rates in established relationships, rates in new relationships were initially higher and declined more rapidly (Wilcoxon test, P < .03; Figure 1Go). Similar results were obtained with a Cox regression model adjusted for clustered survival data (robust test statistic = 3.97, P < .05, with 1 degree of freedom).



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  		FIGURE 1— —Number of days to first condom nonuse: established and new relationships (Kaplan–Meier survival curves; P < .05 by Wilcoxon test).

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
The present results show that condom use rates were higher in new than in established relationships but declined to levels similar to those of established relationships over a 21-day period. In condom usage terms, a new relationship required somewhat less than a month to become an established relationship.

These data are in accord with other studies demonstrating the influence of relationship characteristics on adolescent condom use. Ku et al. proposed a "sawtooth" pattern of condom use within and across relationships.16 There are probably several reasons why condom use rates differ according to relationship characteristics. For example, higher levels of perceived STD risk are reported in new relationships.17 Perceived risk decreases because of increased knowledge about the partner, although perceptions regarding sex partner behaviors are often inaccurate.18

Passage of time may also reduce perceived risk and rates of condom use as a result of extrapolation of immediate past experience (i.e., because there are no signs of sexually transmitted infection, infection is not possible).19 Motivations for sex shift within relationships over time, with issues of trust and intimacy receiving greater priority in ongoing relationships.20

The present data should be evaluated in light of several caveats. The initial analysis may not have accounted fully for correlations among runs contributed by individuals with both new and established partners. However, we obtained similar results when we used a Cox regression model that adjusted for multiplicity of runs contributed by each participant.

Another consideration is the fact that only the initial occurrence of a nonprotected coital event was considered as an endpoint. Occasional condom nonuse may be interspersed in a pattern of consistent condom use, and such patterns may represent a degree of STD protection. In fact, commonly used ordinal measures of condom use almost certainly misclassify occasional nonuse, grouping such events in a category indicating that condoms are "always" used.21

Our results show that, typically, condom use is discontinued in relationships before the duration of infection of most STDs has elapsed. Practical interventions for adolescents might include advice to prolong consistent condom use beyond 3 weeks of a presumably sexually exclusive relationship and consideration of STD screening before cessation of condom use.


   Footnotes
 
J. D. Fortenberry and D. P. Orr contributed to all aspects of study design, data collection, and manuscript preparation. W. Tu, J. Harezlak, and B. P. Katz contributed to data analysis and manuscript preparation. All of the authors critically reviewed the manuscript for content and accuracy.

Peer Reviewed

Accepted for publication June 29, 2001.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Plichta SB, Weisman CS, Nathanson CA, Ensminger ME, Robinson JC. Partner-specific condom use among adolescent women clients of a family planning clinic. J Adolesc Health. 1992;13:506–511.[Medline]

2. Norris AE, Ford K. Sexual experiences and condom use of heterosexual, low-income African-American and Hispanic youth practicing relative monogamy, serial monogamy, and nonmonogamy. Sex Transm Dis. 1999;26:17–25.[Medline]

3. St. Lawrence JS, Eldridge GD, Reitman D, Little CE, Shelby MC, Brasfield TL. Factors influencing condom use among African American women: implications for risk reduction interventions. Am J Community Psychol. 1998;26:7–28.[Medline]

4. Forste R, Morgan J. How relationships of U.S. men affect contraceptive use and efforts to prevent sexually transmitted diseases. Fam Plann Perspect. 1998;30:56–62.[Medline]

5. Matricka-Tyndale E. Social construction of HIV transmission and prevention among heterosexual young adults. Soc Problems. 1992;39:238–252.

6. Bryan AD, Aiken LS, West SG. Young women's condom use: the influence of acceptance of sexuality, control over the sexual encounter, and perceived susceptibility to common STDs. Health Psychol. 1997;16:468–479.[Medline]

7. Marin BV, Gomez CA, Tschann JM, Gregorich SE. Condom use in unmarried Latino men: a test of cultural constructs. Health Psychol. 1997;16:458–467.[Medline]

8. Wingood GM, DiClemente RJ. Partner influences and gender-related factors associated with noncondom use among young adult African American women. Am J Community Psychol. 1998;26:29–51.[Medline]

9. Jadack RA, Fresia AF, Rompalo AM, Zenilman J. Reasons for not using condoms of clients at urban sexually transmitted diseases clinics. Sex Transm Dis. 1997;24:402–408.[Medline]

10. Cooper ML, Agocha VB, Powers AM. Motivations for condom use: do pregnancy prevention goals undermine disease prevention among heterosexual young adults? Health Psychol. 1999;18:464–474.[Medline]

11. Poppen PJ, Reisen CA. Women's use of dual methods of sexual self-protection. Women Health. 1999;30:53–66.

12. Koutsky L, Koutras MV. Distribution theory of runs: a Markov chain approach. J Am Stat Assoc. 1994;89:1050–1058.

13. Katz BP. A computer enhanced runs test for smoothed data. Stat Med. 1988;7:795–804.[Medline]

14. Lawless JF. Statistical Models and Methods for Lifetime Data. New York, NY: John Wiley & Sons Inc; 2000.

15. Therneau TM, Grambsch PM. Modeling Survival Data: Extending the Cox Model. New York, NY: Springer-Verlag; 2000.

16. Ku L, Sonenstein FL, Pleck JH. The dynamics of young men's condom use during and across relationships. Fam Plann Perspect. 1994;26:246–251.[Medline]

17. Ellen JM, Boyer CB, Tschann JM, Shafer M-A. Adolescents' perceived risk for STDs and HIV infection. J Adolesc Health. 1996;18:177–181.[Medline]

18. Ellen JM, Vittinghoff E, Bolan G, Boyer CB, Padian NS. Individuals' perceptions about their sex partners' risk behaviors. J Sex Res. 1998;35:328–332.

19. Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med. 1987;10:481–500.[Medline]

20. Cooper ML, Shapiro CM, Powers AM. Motivations for sex and risky sexual behavior among adolescents and young adults: a functional perspective. J Pers Soc Psychol. 1998;75:1528–1558.[Medline]

21. Fortenberry JD, Cecil H, Zimet GD, Orr DP. Concordance between self-report questionnaires and coital diaries for sexual behaviors of adolescent women with sexually transmitted diseases. In: Bancroft J, ed. Researching Sexual Behavior. Bloomington, Ind: Indiana University Press; 1997:237–249.





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Citing Articles
Right arrow Citing Articles via ISI Web of Science (35)
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Right arrow Articles by Fortenberry, J. D.
Right arrow Articles by Orr, D. P.
Related Collections
Right arrow Contraception
Right arrow Adolescent Health
Right arrow Prevention
Right arrow Sexual Health

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