The trade-off between hormonal contraceptives and condoms among adolescents. (Articles).

Healthy People 2010, the national health objectives set out by the Department of Health and Human Services, recommends that sexually active adolescents use both condoms and hormonal contraceptives to prevent pregnancy and sexually transmitted disease (STD). (1) Condoms and hormonal contraceptives carry different, complementary benefits and risks. For pregnancy prevention, condoms have a failure rate of 15% during one year of typical use. The two most common types of hormonal contraceptives, pills and injectables, have significantly better efficacy, with failure rates of 5% and 0.3%, respectively, during one year of typical use. (2) From the mid-1980s through the late 1990s, adolescent condom use increased and hormonal contraceptive use decreased) Unfortunately, rates of combined use of condoms and hormonal contraceptives remain low. In a nationally representative sample, only 7% of sexually active adolescent females and 5% of sexually active males reported having used the two methods in combination. (4)

An inverse association between condom and hormonal contraceptive use has been reproduced across many populations. (5) For example, a prospective study of adolescents receiving oral contraceptives at a family planning clinic found consistent condom use to be associated with inconsistent hormonal contraceptive use. (6) And in the National Survey of Adolescent Males, those who said that their partner used the pill had lower levels of condom use than others. (7)

In the past, contraceptive decisions involved balancing the efficacy of pregnancy prevention with obstacles to using a particular method. The focus on STDs over the past decade has introduced another motivation. For example, rates of condom use rise as adolescent males become more sure or suspicious that their partners have an STD. (8) Today, adolescents must make decisions about contraceptive methods on the basis of pregnancy concerns, STD concerns and method characteristics. Several studies have examined the influence of motivations to prevent pregnancy and STDs on condom use among adolescents) Yet little is known about the motivations underlying decisions to combine the use of condoms and hormonal contraceptives.

Given these interrelated motivations for method use, we reasoned that the apparent inverse correlation between condoms and hormonal contraceptives is an oversimplification, and that adolescents are actually making separate and independent decisions about condom and hormonal contraceptive use. For example, if adolescents are concerned only with pregnancy prevention, they may trade off the ease of condom use with the higher efficacy of hormonal contraceptives. But if adolescents have strong concerns about STDs, they may not be willing to stop using condoms. And those with strong concerns about both STD and pregnancy prevention might be motivated to use both condoms and hormonal contraceptives.

Further complicating decisions about the use of condoms or hormonal contraceptives, individuals may be making these choices with different types of sex partners. Among adults, contraceptive behaviors are specific to the type of sexual partner. (10) Among adolescents, studies examining differences in contraceptive behaviors and partner types have yielded mixed results, (11) perhaps in part because of methodological differences. The studies that have shown no differences in contraceptive use by partner type have tended to categorize the adolescent (for example, as monogamous, nonmonogamous or serially monogamous) rather than the nature of the sex partner or relationship. (12)

By contrast, studies that have categorized the type of sex partner (for example, as main or casual partner) have shown that adolescents may use different pregnancy and STD prevention methods with different partner types; some show that adolescents report less condom use with main partners than with casual partners. (13) In addition, adolescents report different contraceptive behaviors when sexual relationships have different characteristics. For example, young women are less likely to use condoms in sexual relationships of longer duration than in those of shorter duration. (14) And young men report more condom use and less hormonal contraceptive use by partners early in a sexual relationship than they do later in the same relationship. (15)

The concerns and motivations underlying contraceptive behaviors are also likely to be different with different types of sex partners. Condom and hormonal contraceptive use in general (not specific to a particular partner type) have been associated with concerns about STDs and pregnancy. In the National Survey of Adolescent Males, worry about STDs, including AIDS, differentiated young men who combined use of condoms and hormonal contraceptives from those whose partners used hormonal contraceptives alone. (16) Differences according to partner type in the use of condoms alone have been associated with differences in concerns about pregnancy and STDs. In a sample of black young women, perceived invulnerability to STDs and concerns about pregnancy were associated with not using condoms with steady partners. However, these concerns were not associated with unprotected sex with casual partners. (17) Although these studies have linked partner-specific concerns about pregnancy and STDs to condoms and hormonal contraception separately, little is known about how these concerns affect the inverse relationship between the two.

In this article, we examine whether there is an inverse relationship between adolescents' condom and hormonal contraceptive use; whether adolescents' concerns about pregnancy and STDs influence this association; and whether the relationship between condom and hormonal contraceptive use in casual sexual relationships is different from that in relationships with a main partner. Specifically, we looked at how hormonal contraceptive use, an independent variable, predicts condom use, the dependent variable.

When adolescents first begin using contraceptives, most start with condoms, then change to hormonal contraceptives. (18) We hypothesized that the inverse association between condoms and hormonal contraceptives would be strongest among adolescents with a high concern about preventing pregnancy, as these adolescents would be likely to give up condoms when they used hormonal contraceptives, a better pregnancy prevention method. We did not expect to see an inverse association between condoms and hormonal contraceptives among adolescents with a high concern for acquiring STDs, as this group needs condoms for STD protection in addition to pregnancy prevention. Finally, we hypothesized that the inverse association would occur with main partners, but not with casual partners.

METHODS

Sample Selection and Design

As part of a larger longitudinal study assessing adolescent sexual behavior, knowledge and attitudes, adolescents were recruited from a free municipal STD clinic and a large health maintenance organization (HMO) adolescent clinic in San Francisco. Adolescents recruited from the STD clinic were seeking reproductive health services, including STD checks (most without new symptoms), family planning services and yearly pelvic exams. Adolescents recruited at the HMO clinic were seeking either primary care, such as sports physicals, or reproductive health services. We recruited from these different sites so that we could study higher- and lower-risk adolescents.

From February 1997 through August 1998, all…