Have young people stopped fearing sexually transmitted infections?

The good news is that rates of teenage pregnancies are at record lows. In 2014 in England and Wales they were at the lowest rate since 1946, with only 15.6 pregnancies per 1,000 women younger than 20.

Unfortunately, rates of sexually transmitted infections (STIs) are still very high. There were 440,000 diagnoses in the UK in 2014, and the under 25s are one of the most high risk groups. STIs have a high financial cost for testing and treatment: diagnoses of chlamydia alone cost the NHS £620m in 2011.

Condoms provide effective protection against STIs but many people choose not to use them – around 15% of under-25s reported having unprotected sex with two or more partners in the last year. So why don’t young people use condoms? The most commonly given reason is the impact on sexual pleasureand intimacy. Pleasure is of course a very important part of sex, so anything that is perceived to interfere with it is bound to be viewed negatively.

Mixed evidence

Some also argue that young people don’t use condoms because they aren’t scared of contracting STIs anymore. Today, the majority of common STIs, including chlamydia and gonorrhoea, can be cured quickly with antibiotics, while HIV can be managed and those who contract it can expect to live 20 years longer than was the case in 2000.

While this idea makes sense, the evidence supporting it is mixed. Research has shown people’s beliefs about the seriousness of non-HIV STIs are not related to their behaviour, suggesting that it doesn’t make any difference whether people think STIs are serious or not: they’re still likely to put themselves at risk. This is despite the fact that, if left untreated, they can cause complications such as infertility.

Joint decisionShutterstock

Fear of HIV, on the other hand, may well influence behaviour. The problem is that many people may not feel at risk of catching it, particularly non-black-African heterosexual people, who are statistically at lower risk of HIV. One study showed heterosexual people who were at high risk of STIs and HIV underestimated that risk and many didn’t use condoms. This suggests that young people’s decision to use a condom or not may depend on whether they think they are at risk of an STI rather than how severe they think the consequences are.

We should also be aware that the decision to wear a condom isn’t always made by one person. Their partners may also be involved, and expectations about their reaction (or a lack of discussion altogether) may influence the choice. Getting caught in the “heat of the moment” is a commonly cited barrier to condom use and experiments have shown that sexual arousal in men reduces their ability to make decisions.

Sex-positive approach needed

So what can we do to change this situation? Previous educational programmes have often focused on the “dangers” of unprotected sex. But evidence suggests that scaring people, in particular those who feel unable to change their behaviour, can just cause them to become defensive.

The fact that perceived loss of sexual pleasure appears to be the fundamental reason most people don’t use condoms highlights how important it is to address the positive aspects of sex, rather than solely focusing on the negative consequences. Finding a way to enhance sexual pleasure with condoms, or at least change beliefs about pleasure, is important. This could be as simple as improving actual sensation with condoms, from recommending thinner designs to revolutionary new materials such as graphene. Alternatively, it could involve persuading people that safe sex can be good sex.

This sex-positive approach attempts to target an important driver of behaviour: motivation. We are primarily driven by our wants and needs in any particular moment. Therefore, we need to make people want to use condoms, rather than making them feel that they should. To do this, we should focus on outcomes that are important to people –- things that we know they want.

For example, when targeting smoking, focusing on appearance-related consequences may be more effective than focusing on health-related consequences, for people who value being attractive. Interventions to increase condom use should therefore focus on more immediate goals that young people care about, such as enjoying good sex or gaining social approval.

We certainly haven’t cracked the problem of getting people to use condoms yet. However, focusing on goals that are important to young people create an exciting new area for future investigation.

Rosie Webster receives funding from UK National Institute for Health Research, Health Technology Assessment Program, 10/131/01. Views are entirely of the author and do not reflect the views of the funder or of UCL eHealth unit.