Cuidado

The following flyer was found in a pharmacy by Marloes, the Fields Operation Manager of FIMRC in El Salvador. Once she read the flyer in question, she informed the pharmacist of the error in said flyer.

 It says the following:

"Careful! Inform yourself well!

Condoms do not protect 100%!

There are more than 65 sexually transmitted diseases (STDs) that one acquires even if condoms are utilized. Some of these STDs are deadly and others are incurable.

The condom fails in 47% of the time as an anticontraceptive in adolescents in the United States. (correct reference of this JAMA Article: Steiner MJ. Contraceptive Effectiveness. JAMA. 1999;282(15):1405-1407. doi:10.1001/jama.282.15.1405.)

The Human Papilloma Virus (HPV-incurable) is found in all genital areas, and can be transmitted by anyone from skin to skin contact. The condom does not protect against HPV. (According to the American Cancer Society).

 HPV causes 99.7% of cervical cancer cases.

Cervical cancer is the #1 cause of death in Salvadorian women.

Protect yourself with the only solution.
'Stay faithful to your partner all of your life."

Where to begin... Let's breakdown this flier line by line.

"Careful! Inform yourself well! Condoms do not protect 100%! There are more than 65 sexually transmitted diseases (STDs) that one acquires even if condoms are utilized. Some of those STDs are deadly and others are incurable," up until here everything is a true statement.

This next statement is problematic, "The condom fails 47% of the time as an anticontraceptive in adolescents in the United States." 47% of the time is not an accurate description of the facts. What are they quoting? If one pulls the JAMA article, the following statement is found, "for example, adolescent women who are not married but are cohabiting experience a failure rate of about 47% in the first year of contraception use, while the 12 month failure rate among married women aged 30 and older is only 8%."

Dr Steiner's article is a commentary paper and not the original or primary source of quoted research. The original paper by Fu et al goes on in the abstract to conclude that, "Levels of contraceptive failure vary widely by method as well as by personal and background characteristics. Income's strong influence on contraceptive failure suggests that access barriers and the general disadvantage associated with poverty seriously impede effective contraceptive practice in the United States." Here is the correct citation of the primary research paper: Haishan Fu, Jacqueline E. Darroch, Taylor Haas and Nalini Ranjit. Contraceptive Failure Rates: New Estimates from the 1995 National Survey of Family Growth Family Planning Perspectives , Vol. 31, No. 2 (Mar. - Apr., 1999), pp. 56-63. The correct failure rate is as follows, 18/100 will become pregnant if condoms are used incorrectly or inconsistently in the first year of use and 2/100 will become pregnant if used perfectly (James Trussell, Contraceptive failure in the United States, Contraception, Volume 83, Issue 5, May 2011, Pages 397-404).

Now the flyer jumps to a new topic about HPV: "The Human Papilloma Virus (HPV-incurable) is found in all genital areas. And can be transmitted by anyone from skin to skin contact. The condom does not protect against HPV. (According to the American Cancer Society)." Though it can be transmitted by contact, the condom does decrease the risk of transmitting the disease. The correct quote from the American Cancer Society is as follows:

"Condoms can help prevent HPV, but HPV may be on skin that’s not covered by the condom. And condoms must be used every time, from start to finish. The virus can spread during direct skin-to-skin contact before the condom is put on, and male condoms do not cover the entire genital area, especially in women. The female condom covers more of the vulva in women, but has not been studied as carefully for its ability to prevent HPV. Condoms are very helpful, though, in protecting against other infections that can be spread through sexual activity."

Skipping to this statement: "Cervical cancer is the #1 cause of death in Salvadorian women." This was a shocking statement for me to believe, because after being here for a few weeks, I have encountered many patients with diabetes and hypertension. I gathered from being in the clinic that the leading cause of death in the country was due to cardiovascular events. When I looked it up, cervical cancer is the leading cause of cancer death in Salvadorian women. Cardiovascular events are the leading cause of death for men and women. Cardiovascular event deaths count for 25% of death that are non-communicable, while all of cancers account for 12% of deaths. 

The last statement is the most confusing line: "Stay faithful to your partner all of your life." They are implying at this point that men should not cheat on their wives, because if they do cheat and use condoms, they can still cause their wife to have cervical cancer. The holy union of matrimony is symbolized by the wedding bands in the condom wrappers.

At one glance this flyer is about decreasing the rate of cervical cancers, but at another it is to discourage men from cheating on their wives. The CDC states the following about being faithful and cervical cancer:

"People can also lower their chances of getting HPV by being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity."

It is disheartening to see an advertisement against the use of condoms by twisting quotes from respected sources such as JAMA and ACS to support their cause. This flyer neglects to mention all the positives of condom use,  such as decreasing the risk of sexually transmitted diseases such as HIV, chlamydia and gonorrhea.

If the purpose of this flyer is to decrease mortality from HPV, it should first promote the vaccine against the deadly virus. The vaccine is one of the best preventative measures that one can take to decrease the risk of cervical cancer, but also warts. The article should represent condoms accurately, with both risks and benefits, so that patients can make an informed decision regarding their use. 

The flyer instead is an attempt to address another issue entirely - fidelity. This is a complicated issue, and condom use is tied to it, but we are having a hard time seeing that change will be affected by fear of condoms. Setting aside the issue of infidelity in a relationship, one should always use condoms with more than one sex partner.

Condom use is surrounded by myths:

Small holes exist in condoms that allow HIV to pass

Only prostitutes or those who sleep with prostitutes use condoms

Condoms cause cervical cancer

We can add a new one to the list, today - condoms are ineffective, so you might as well not use them, so you might as well not cheat.

Information can be twisted for an organization's agenda. As we continue our education sessions on Reproductive Health with adolescents (more on this later!), we need to keep in mind all of the cultural beliefs surrounding condoms, and the barriers to their use. It's a reminder of the importance of evidence-based medicine, focusing on giving best patient care, rather than allowing personal beliefs to influence how we advise patients.



--Nabil with edits by Angie