Dual Protection: More Needed than Practised or Understood

Abstract

Although non-barrier contraceptive use has become a global norm, unprotected sex in relation to sexually transmitted infections remains the norm almost everywhere. Dual protection is protection from unwanted pregnancy, HIV and other sexually transmitted infections, and is a form of safer sex for heterosexual couples that is more needed than practised or understood. This paper draws on a review of the literature in family planning, obstetrics and gynaecology, and AIDS-related journals from 1998 to early 2005. Definitions of dual protection, found mainly in family planning literature, are very narrow. Condoms remain the mainstay of dual protection, but the aim of this paper is to provide an expanded list of dual protection methods to show that there is a range of options. These include non-penetrative sex and the increasing use of condoms with the back-up of emergency contraception on the part of young people. The fact that people may fail to use dual protection consistently and correctly is not a valid reason not to promote it. It is never too late for those providing family planning and STI/HIV prevention services to start promoting condoms and dual protection. In the long-term, the development of highly efficacious and highly acceptable methods of dual protection is an urgent research priority, starting with a wider range of condoms that will appeal to more people.

Résumé

Bien que l’emploi de contraceptifs non mécaniques se soit généralisé dans le monde, les relations sexuelles non protégées par rapport aux IST demeurent la norme presque partout. Une double protection permet d’éviter une grossesse, et la transmission du VIH et d’autres IST ; c’est une forme de sexualité sans risque pour les couples hétérosexuels trop peu pratiquée ou comprise. Cet article analyse des articles publiés dans les revues sur la planification familiale, l’obstétrique, la gynécologie et le SIDA, de 1998 au début de 2005. Les définitions de la double protection, trouvées essentiellement dans les revues sur la planification familiale, sont très étroites. La principale méthode de double protection demeure le préservatif, mais l’article souhaite donner une liste élargie afin de montrer qu’il existe une gamme d’options, notamment les relations sans pénétration et l’utilisation accrue de préservatifs complétée par une contraception d’urgence pour les jeunes. Que la double protection ne soit pas toujours utilisée de manière suivie et correcte n’est pas une raison valable pour ne pas l’encourager. Il n’est jamais trop tard pour que les responsables des services de planification familiale et de prévention des IST/du VIH commencent à promouvoir les préservatifs et la protection double. À long terme, le développement de méthodes très efficaces et acceptables de double protection est une priorité de la recherche, à commencer par un éventail plus large de préservatifs qui plairont à davantage de gens.

Resumen

Aunque el uso de anticonceptivos que no son de barrera se ha vuelto la norma mundial, el sexo sin protección en relación con las infecciones de transmisión sexual (ITS) continúa siendo la norma en casi todas partes. La doble protección –protección del embarazo no deseado, el VIH y otras ITS – es una forma de que las parejas heterosexuales tengan sexo más seguro, que es más necesitada que practicada o entendida. Este artículo se basa en una revisión de artículos sobre la planificación familiar, obstetricia y ginecología, en revistas relacionadas con el SIDA desde 1998 hasta principios de 2005. Las definiciones de la doble protección, encontradas principalmente en el material sobre la planificación familiar, son muy estrechas. El condón continúa siendo el pilar, pero el objetivo de este artículo es proporcionar una lista más amplia de los métodos de doble protección para mostrar que existe una variedad de opciones. Entre éstas figuran el sexo no penetrador y el uso en alza del condón con el respaldo de la anticoncepción de emergencia por parte de los jóvenes. El hecho de que las personas quizás no usen la doble protección de manera sistemática y correcta no es una razón válida para no promoverla. Nunca es muy tarde para que aquéllos que proporcionan servicios de planificación familiar y de prevención de ITS/VIH empiecen a promover el condón y la doble protección. A la larga, el desarrollo de métodos de doble protección de alta eficacia y aceptación es una urgente prioridad de investigación, comenzando por una mayor variedad de condones que atraerá a más personas.

Key Words:

• dual protection
• unwanted pregnancy
• sexually transmitted infections
• HIV
• condoms
• emergency contraception

Contraceptive use has become a global norm over the past 100 years following a highly successful global campaign promoting family planning. Yet unprotected sex in relation to sexually transmitted infections (STIs) remains the norm almost everywhere. This is the main reason why there are epidemics of HIV and other STIs globally that all the money in the world is not defeating.

Dual protection is protection from unwanted pregnancy, HIV and other sexually transmitted infections. It is a form of safer sex for heterosexual couples¹ and requires the agreement and involvement of both partners. The advent of the contraceptive pill and other methods of non-barrier contraception used by women in the 1960s created the belief that protection that interfered with sexual pleasure was no longer necessary; indeed, this was an important selling point of such methods. As a result, for more than four decades, men who have sex with women in most parts of the world left obtaining protection against unwanted pregnancy almost entirely up to women. Although the HIV/STI epidemic meant this was a short-lived dream, the message did not get through to the family planning world, who dismissed condoms as less effective and distanced themselves from people at risk of HIV as not being a target population for family planning services. In places where barrier methods had been the only means of contraception, condom use fell off steeply and diaphragm production and use all but disappeared. Withdrawal, a form of risk reduction, although still practised by millions of couples,²³ was ignored.

This paper discusses who needs dual protection and why. It looks at how limited definitions of dual protection and biases against condoms in the literature have served to make dual protection one of the most under-rated and under-promoted public health practices today, even after 25 years of the HIV epidemic and millions of deaths from AIDS. Condoms remain the mainstay of dual protection, but the aim of this paper is to provide an expanded list of dual protection methods to show that those who need it have a range of options and that the diverse needs of different population sub-groups in relation to safer sex can be met using different forms of dual protection. Lastly, it looks at the needs of young people, and increasing use among young people of condoms backed up with emergency contraception.

The paper draws on a review of the published literature on dual protection, mostly in family planning and sexual and reproductive health journals found on PubMed between 1998 and early 2005, in HIV-related journals, a few papers in PubMed from 1995–1997, journals on population issues indexed in the JSTOR web collection, and journals on the Lippincott, Williams & Wilkie website, including AIDS, Sexually Transmitted Diseases and several obstetrics and gynaecology journals. While it was not an exhaustive review, it covered the most widely read journals in the field.

The review found that even among those who are aware of the concept, definitions of dual protection are very narrow. As a result, neither family planning nor sexual health service providers have been trained or inspired to promote dual protection, mainly because they believe it would not suit the very people who need it most.

Who needs dual protection

A woman and man need dual protection if they are having sexual intercourse, if both of them are fertile and they do not want a pregnancy, and they may have been exposed to a sexually transmitted infection, including HIV, during unprotected sex with each other or with someone else.¹

Women having sex only with other women and men having sex only with other men do not need dual protection, as they are not at risk of pregnancy, though obviously they may need protection from STIs/HIV. Those who have sex with partners of both sexes may need dual protection with their opposite-sex partners.

One of the benefits of making safer sex the social norm is that protection would be accepted for the sake of sexual health and seen as a good thing in itself, independent of a person’s past or present relationships. Thus, trust would be generated by practising safer sex rather than the opposite. None of us knows what may happen tomorrow; hence, safer sex and protected sex, including dual protection, should be taught to everyone as part of sexuality and relationships education when they are young. The success with fertility regulation and other public health initiatives that require a change of entrenched practices, such as widescale smoking cessation, imply that this is a feasible goal.⁴ First, however, doubt and scepticism among the very people whose job it is to promote safer sex must cease to predominate.

Dual protection: more than family planning

In the literature reviewed, dual protection received more attention from family planning professionals than from HIV/STI professionals. Journals specialising in HIV-related topics were more concerned with treatment and clinical research related to HIV, or with analysing sexual practice rather than the use of protection in the context of sexual relations, and gave little attention to dual protection, if at all. Thus, on the Lippincott, Williams & Wilkie website, a search using the keyword “dual protection” brought up only 13 articles from 1998 to 2005, though highly relevant ones, and a search using the keywords “condoms” and “emergency contraception” brought up only two articles. This is in contrast to almost 1,200 articles on that same site that mention condoms, of which about 20 of the first 150 citations also referred to contraception in their titles in some form.

One of the biggest problems with defining dual protection primarily or only from a family planning point of view is that safer sex is more than protected vaginal–penile intercourse. Contact with infected semen or vaginal fluids through the mouth or anally as well as the vagina and penis, and oral or genital contact with external sores from STIs such as herpes simplex or genital warts, are also at issue. Thus, a barrier may be needed orally and/or anally as well as in the vagina and on the penis. This is what makes the use of condoms so important. It has been found that some young people, in the mistaken belief that anal sex was safe because it did not lead to pregnancy, were having unprotected anal sex and unknowingly putting themselves at risk of STIs/HIV.⁵

Research on contraceptive prevalence, even though it covers condoms from a family planning perspective, can actually obscure the extent of condom use and dual protection practised. One article from the US, for example, describes how data analysis reflects the priority given to contraception over STI/HIV protection. When the data indicated “dual use of both a hormonal method and a barrier method”:

“… for the analyses, if an individual used more than one method at last sex, they were categorized as hormonal-method users (the most effective method for pregnancy prevention), as this convention is commonly used in the analysis of national data sets such as the [US] National Survey of Family Growth.” ⁶

Similarly, in a Brazilian study of adolescent boys’ use of condoms at first intercourse, although half the boys in the study said they had used condoms for dual protection purposes, the concept itself was not discussed nor was the high level of awareness of dual risk among the boys, despite their young age.⁷ Thus, research can obscure or ignore dual protection because the researchers themselves do not consider it important.

Most of the literature that mentions dual protection does not attempt to analyse the concept or explain why it is defined one way or another. In fact, the family planning slant on dual protection in the literature contributes to the following misconceptions and omissions in the way dual protection is understood:

•	The need to use an effective contraceptive is emphasised over the importance of consistent and correct condom use, and is considered more feasible.
•	Condoms are primarily seen as a method of protection against infection and not equally as a form of contraception, and their promotion to married or stable couples is considered too problematic to attempt.8
•	The role of withdrawal as a means of risk reduction is not considered effective enough to mention or promote.
•	The use of two barrier methods, such as the diaphragm or cervical cap with condoms, if considered at all, is almost never suggested.
•	Biases of every possible ilk against condoms are constantly being expressed, particularly as regards condom use alone, even though the absence of condom use is far more risky.
•	The diverse dual protection needs of specific populations are rarely focused upon, and therefore the most appropriate forms of dual protection for them are not explored.

Limited definitions of dual protection and bias against condoms

Many of the definitions of dual protection found in the literature tend to be limited to only one type of dual protection, usually the use of condoms for disease prevention and birth control pills for contraception,⁹ or less often condoms with other contraceptives.¹⁰¹¹

Some authors assume that because use of the contraceptive pill is so common, it would be easiest just to add condoms. However, in addition to having to keep a supply and use a condom each time for sex, the pill must be taken every day at around the same time of day, making this combination one of the most demanding forms of dual protection possible. Longer-acting contraceptives such as contraceptive patches, injectables and implants, for example, do not require such constant attention. Other risk reduction practices such as non-penetrative sex are also not often mentioned.¹² Sterilisation with condoms is another option,¹³ but this form of dual protection is not commonly practised either.

In Brazil, where female sterilisation is one of the most common forms of fertility regulation, the use of condoms was rare among women who had been sterilised,¹⁴ and in the USA, hormonal contraception and surgical sterilisation were not significantly associated with the likelihood of consistent condom use in 18–45 year-old women previously diagnosed with an STI.¹⁵ Condom use with vasectomy was not mentioned as an option in the literature at all; perhaps the idea of asking most men to use two methods, let alone one, is not considered at all feasible.

Few clinicians advocate use of male or female condoms alone.¹⁶ An entrenched bias against condoms on their own is common in the family planning literature, often expressed as follows: “no single contraceptive, including the male condom, provides complete protection against both”¹⁷ or “although male condoms are the best form of protection against HIV/STDs, they are not the most effective method for preventing unintended pregnancy”.¹⁸ Ironically, HIV prevention messages often say just the opposite.

A more comprehensive list of dual protection methods

Dual protection can in fact be achieved in a number of ways, starting with using no method, or using one, two, three or even four methods, not necessarily simultaneously. The following is an expanded list of methods that achieve dual protection:

•	Not having sex at all.
•	Masturbation, mutual masturbation and other forms of non-penetrative sex (i.e. with no penetration of the vagina, anus or mouth by the penis).
•	Mutual monogamy between partners with no pre-existing infection, with the use of any effective contraceptive method and the back-up of induced abortion.
•	Use of male or female condoms alone, including for vaginal and anal sex and male condoms for oral sex.
•	Use of male or female condoms plus a diaphragm or cervical cap.
•	Use of male or female condoms plus a non-barrier contraceptive, i.e. the pill, implant, injectable, patch, vaginal ring or IUD (the latter in the absence of any STIs)* or male or female sterilisation.
•	Male or female condoms with the back-up of emergency contraception and/or induced abortion plus the back-up of post-exposure prophylaxis against HIV.
•	Breastfeeding on demand with condoms for the first months post-partum.

Withdrawal on its own or with other methods is a risk reduction method that is also protective against both pregnancy and HIV. However, with STIs that are not transmitted through semen, no risk reduction can be achieved using withdrawal alone.

•	Withdrawal alone.
•	Withdrawal plus male or female condoms during the ovulation period or in the presence of an STI.
•	Withdrawal with the back-up of emergency contraception and/or induced abortion plus the back-up of post-exposure prophylaxis against HIV.

These definitions move outside the narrow confines of previously mentioned definitions by acknowledging the possibility of using non-hormonal as well as hormonal contraceptives, other barrier methods, back-up methods, withdrawal and non-penetrative sex.

Microbicides will join this list if and when they come on the scene. Several papers mention the possibility of using the diaphragm lubricated with a microbicide in future.²⁰²¹ The acceptability and safety of the diaphragm for dual protection once a microbicide is available is currently being studied.²⁰ Indeed, the diaphragm with condoms harks back to the days before hormonal methods were developed; together they served as an effective form of dual protection long before the HIV epidemic began in several developed countries. Existing spermicides, especially nonoxynol-9, have been shown to be unsafe for STI/HIV protection, especially with frequent use,²² and cannot be promoted on their own or for dual protection.

Diverse forms of dual protection for diverse people and needs

From the above list, it becomes clear that for those who do not wish to have sex, saying no is completely safe, while for those who do wish to have sex, it is not necessary to abstain. Having sex less frequently or with fewer partners helps to reduce STI/HIV risk, though in high HIV or STI prevalence settings, it is far from risk-free. Not having intercourse if either partner has an STI is always recommended, and there are many people who practise safer sex by avoiding intercourse and exploring their bodies in other ways.

Condoms remain the mainstay of dual protection, however, and consistent condom use is highly effective. Data from two randomised, controlled trials of the contraceptive efficacy of condoms were combined, involving 800 couples who used three latex condom brands exclusively for up to six menstrual cycles. The combined, six-cycle, typical-use pregnancy rate was 7%. The combined, six-cycle, consistent-use pregnancy rate was only 1.0%. The combined clinical breakage rate for the first five condom uses was only 0.4% and the slippage rate only 1.1%. The study concludes that condoms rarely broke or slipped off during intercourse, and risk of semen leakage from intact condoms was very low. Condoms also provided high contraceptive efficacy, especially when used consistently.²³ Another study found that the male and female condom failure rate decreased among women at high risk of STIs from 20% at first use to 1.2% after 15 uses of the female condom and from 9% at first use to 2.3% after 15 uses for the male condom.²⁴ Thus, a bit of practice is the main thing that is needed. A number of studies among STI clinic patients comparing rates of STIs among condom users and non-condom users have found limited evidence of protection against specific STIs. However, consistent condom users in one study had statistically significantly lower rates of gonorrhoea and chlamydia in both men and women, and of trichomoniasis in women and genital herpes in men than inconsistent condom users.²⁵

Even so, negative attitudes towards condom use are constantly being rehashed, and an open or veiled dislike of condoms expressed in the literature.²⁶ Yet condoms can remove much of the anxiety about HIV and unplanned pregnancy that often accompanies unprotected sex.

Although withdrawal is a relatively effective contraceptive method used by millions of heterosexual couples and for HIV risk reduction by men who have sex with men,³ its value as part of dual protection has rarely received any attention from health professionals. Yet among couples in which the insertive male partner has HIV, avoidance of ejaculation has been reported in North America, Europe and Australia for vaginal, anal and oral sex. It is plausible that reducing exposure to (pre-)ejaculate through withdrawal should be an effective mode of HIV risk reduction as well as for avoidance of unwanted pregnancy,²⁷ but there is little research-based evidence available. A European study reported in 1993 among 122 heterosexual couples in which the man was HIV positive and the woman not, who used condoms irregularly, found that the rate of transmission of HIV was less the less the man ejaculated inside the woman, and was nil for those women whose partners never did so, compared to 30% among those whose partners always did so.²⁸

A little-explored form of dual protection for sex workers who want to avoid both pregnancy and infection is condoms with a long-acting hormonal method, such as patches, implants or injectables, as they require little attention and do not complicate condom use at all. A recent study in Cambodia among 632 sex workers visiting an STI clinic for the first time found that 87.3% were relying on condoms for dual protection while only 1.6% were using either the pill, an injectable or IUD. Abortion was widely practised. A major reason for this was that the women were not encouraged to attend family planning clinics and the National Centre for HIV/AIDS, Dermatology and STDs was worried that if the women started using contraceptives other than condoms, condom use might fall.²⁹ If sex workers are convinced of the value of a 100% condom policy, however, this might not be problematic.

What this study also brings out, however, is that women worldwide rely on induced abortion, safe or unsafe, when it is too late for contraception. The failure to include abortion as a necessary and legitimate component of fertility regulation, as well as a necessary and legitimate component of dual protection, flies in the face of reality and ignores women’s needs.

Young people: choosing condoms and emergency contraception

A study in France found that the use of condoms early in sexual life had risen from 10% in 1970–85 to 85% in 1995 in response to HIV prevention campaigns, and had led to increased use of other contraceptives, mainly the pill, later on.³⁰ This finding is reflected in many other countries as well.

Young people also increasingly appear to be using condoms with the back-up of emergency contraception, wherever the latter is available. Where both can be obtained from pharmacies or through social marketing outlets, family planning clinics that do not welcome the attendance of young people can be bypassed. The extent of use of this form of dual protection is unclear because in the literature the right questions have rarely been asked. Most research asks only what an individual respondent has used, or asks only about contraception or only about STI/HIV protection, rather than what both partners have used and for dual protection purposes. Two studies that did specifically ask young men about their own condom use and whether their female partner was also using a contraceptive³¹³² found that:

“Condoms were accessed by both sexes, but girls also requested emergency contraception.” ³³

“Experience with emergency contraception is associated with an increased probability of condom use.” ³⁴

A third study in the UK similarly reports that in a nurse-led condom club for adolescents, the majority of both young men and women who visited were given condoms and young women also asked for emergency contraception and pregnancy tests.³³

A recent study in a family planning clinic in Italy also found that 64% of 500 young women seeking emergency contraception who had used a contraceptive method had used condoms and a further 15% had used oral pills and condoms.³⁵ None of these papers discusses the use of these two methods as dual protection, however. In an Australian study reporting on the use of condoms and the pill among adolescents as dual protection, the use of the rhythm method and withdrawal by adolescents was also reported, but these were dismissed as ineffective and not considered to be worth discussing with young people, to help them use them effectively.³⁶

The following is a description of the contraceptive and dual protection practices of young women seeking abortions in New Zealand:

“Using condoms on every occasion, or condoms with another method (including safe time of the cycle, coitus interruptus, the pill, IUD, diaphragm, breastfeeding, or douching), followed by emergency contraception in cases of leakage of semen or non-use, followed by abortion if emergency contraception fails.” ³⁷

Programme staff, HIV testing and education centre, promote condoms and safe sex at gay pride parade, Corumba, Brazil, 2004

This description of actual practice comes closer to a comprehensive list of ways in which dual protection may be achieved (douching is never recommended) than any other paper referenced here.

Emergency contraception has not been considered an important component of dual protection and in many developing countries it is still hardly known and used. There are two ways in which the use of condoms backed-up with emergency contraception can be promoted and disseminated more effectively. The first is advanced provision of emergency contraception along with condoms by pharmacies, family planning and sexual health services, and HIV testing and counselling centres. Two recent studies, one among adolescent mothers and another among women contacted for STI partner notification, have found that women would welcome access to advanced provision.³⁸³⁹ The second is for social marketing organisations to package and distribute condoms and emergency pills together, e.g. a three-month supply of condoms together with three doses of emergency contraception.

Last but not least, non-penetrative sex is also highly appropriate for young people who want to explore sexual feelings, not only because it is very low or no risk but also because it is a way to explore sexuality and sexual pleasure without having to approach a service provider. And it costs nothing. Its more widespread promotion would seem to be highly rational if only the fact of youth having sex at all were not still being denied and frowned upon.

Recommendations

Promoting dual protection and safer sex as social norms requires a long-term strategy. Sexual health clinicians are often not trained to promote contraception. Family planning providers often do not promote condoms because of the priority placed on contraceptive efficacy, due to the reality of unsafe abortion and policies to reduce population growth. The fact that people may fail to use dual protection consistently and correctly is not a valid reason not to promote it, however.

Perhaps the most important recommendations arising from this paper are:

•	promote a wide range of forms of dual protection that people in diverse circumstances and with diverse sexual relationships and sexual practices are most likely to use;
•	make dual protection methods better known and more accessible;
•	train family planning and sexual health care providers as well as the range of NGOs providing these services in the importance of promoting dual protection, and to confront and overcome their biases against condoms.

Condoms are the mainstay of dual protection and will remain so until such time as other equally safe and effective methods that prove to be more user-friendly are developed. Meanwhile, condoms also protect against STI-related infertility and cervical cancer as well as unwanted pregnancy, STIs and HIV. They do not deserve the bad press they get.

Greatly increased access to existing methods of dual protection is needed. Those providing family planning and STI/HIV prevention services have a responsibility to promote dual protection far more than they have done in the past. In the long-term, the development of a greater range of efficacious and acceptable methods of dual protection is an urgent research priority, starting with a wider range of condoms that will appeal to more people.

Acknowledgements

A version of this paper was presented at Condoms: An International Workshop. London and Brighton, 21–23 June 2006.

Notes

* There are concerns about use of the IUD where there is a risk of untreated STIs. See Steen and Shapiro.¹⁹