Male Contraception Without Prescription A Reevaluation of the and Coitus Interruptus

MICHAEL J. FREE, PhD, and NANCY J. ALEXANDER, PhD

CONTRACEPTIVE METHODS imple- the stigma of being associated with mented by the male were among promiscuity and venereal disease- the first procedures. an association stamped on them by Even today these methods have sig- the military services and the "old nificance for almost every sexually morality" and perpetuated until active person during some stage of life, and they constitute the main or only birth control methods prac- D Dr. Free is senior research scien- ticed by many couples. Therefore tist, biology department, Battelle physicians, in particular, should Pacific Northwest Laboratories, know the background, subtleties, Richland, Wash. Dr. Alexander, strengths, and shortcomings of these associate scientist in reproductive nonprescription methods for male physiology, Oregon Regional Pri- use. mate Research Center, Beaverton, is director, Infertility Laboratory The Condom at the University of Oregon Often denigrated by being cate- Health Sciences Center, Portland. gorized as a "traditional" contra- This paper is Oregon Regional ceptive method and accorded only Primate Research Center Publica- the cursory interest given to his- tion No. 836, whose preparation torical artifacts, the condom is was supported in part by National clearly not a symbol of our times. Institutes of Health grants Nos. HD Because must be used at 05969 and RR 00163. Tearsheet re- the time of coitus, in the past they quests to Dr. Michael J. Free, were perhaps too personally and Biology Department, Battelle Pacific graphically sexual for Western Northwest Laboratories, Battelle sensibilities. They have also retained Blvd., Richland, Wash. 99352.

September-October 1976, Vol. 91, No. 5 437 recently in the United States by the IUD. It therefore merits the 1. The Food and Drug Admin- anachronistic State and Federal attention and sanction of the medi- istration (FDA) had become in- laws requiring condom labels to cal profession and of married volved in the quality control of indicate that the devices were for couples as a highly effective, non- condoms under the Federal Food, disease prevention only. Condoms systemic method of long-range birth Drug, and Cosmetic Act of 1938. must be disposed of, and like empty control, devoid of side effects, The first formal regulatory program beer cans and cigarette butts, they which in some cases can prolong was introduced in 1949, and when can be painful reminders of mind- intercourse and prevent premature it was revised in 1957, stricter lim- less indulgence. Also, condoms do . For sexually active peo- itations were placed on defects. not easily meld into teenage fan- ple other than married couples, the These programs resulted in sta- tasies about sexual opportunity and condom is readily accessible and has tistically based sampling methods the unplanned encounter. They the distinctly separate advantage of and the testing of samples by water are not part of the family physi- affording protection against the filling. The tolerance for defective cian's repertoire, and by default transmission of venereal disease. condoms was lowered from 5 per- they do not receive his blessing. cent in the 1940s to 1 percent in clinics, whose The Condom as Contraceptive 1957. In 1968, FDA tolerance principal clients are women, do not Our general impressions of the levels were decreased still further often promote their use, apparently condom's effectiveness as a contra- to allow the seizure of shipments favoring the more sophisticated ceptive are based largely on surveys with more than 0.25 percent defec- chemical and surgical methods for and clinical records from the 1930s, tive units. birth control. The condom, being 1940s, and 1950s. These studies 2. Manufacturers mechanized and basically a contraceptive method (1,2) were usually of populations automated the dipping process, for the male, has been upstaged by in which one-half to two-thirds of controlling flows, viscosity, and the the emergence of the woman as the the condom users varied that use pH of the latex so that a much agent of contraception. The rela- with other contraceptive methods more uniform product of higher tive ease with which the female or with no method at all. The total quality was produced. reproductive system lends itself to pregnancy rates per 100 woman 3. Automatic drying in a dust- systemic contraception also has re- years of condom use, given as 6 to duced the emphasis on the condom. free and temperature- and humid- 30 pregnancies (Pearl formula), ity-controlled environment was in- Because of all these strikes have been repeated in handbook against them, it has been only with troduced, so that in the better after handbook. Thus, the condom grades of condoms, pinholes caused great difficulty that condoms have was assigned to an ever-lower rank been brought from behind the by dust settling on the drying latex on the list of effective contraceptive were virtually eliminated (3). pharmacist's barricade and dis- measures, while orally administered played as nonprescription nondrugs, drugs, modern intrauterine devices, 4. When automatic electronic advertised discreetly in a few maga- and surgical successive- testing of each condom became a zines, and given serious attention ly emerged to take the spotlight in part of the production process in by some contraceptive researchers. the birth control movement of the the 1950s, quality control was sig- In the absence of up-to-date infor- 1960s. Because the condom could nificantly improved. Upon recom- mation on their usefulness, the not be separated from sexual activ- mendation of the Food and Drug textbooks of contraception have ity and it was also an effective Administration, water or air infla- continued to pass on the results of prophylactic against venereal dis- tion tests also are now performed one or two limited studies done in ease, the condom became firmly on samples. the 1930s and 1950s, when mate- associated in the minds of the pub- 5. The introduction of semi-dry rials, testing procedures, and quality lic with promiscuity, prostitution, silicone lubrication around 1960 in- controls were so crude and disre- and venereal disease. creased the appeal of the lubricated gard for the consumer was so com- Moreover, during the early condom, since this material en- mon as to be unacceptable by 1960s, when the condom was held hanced sensitivity and reduced the present standards. When we com- in such low regard that there was probability of tearing. pare the figures from these old no support for its reevaluation as a 6. studies on the effectiveness of con- contraceptive device, contraceptive Sealed foil packages, which doms with the effectiveness figures measures for females were attract- slowed the degradation of the latex, from a vast array of up-to-date ing the attention of social scientists gave condoms a shelf life of up to studies on the pill and IUDs (intra- in the field of family planning. 5 years. uterine devices), the data in the During this period, however, sev- 7. In the United Kingdom in older studies lose by default. eral things happened to condoms 1964, the British Standards Insti- Actually, the efficacy of the con- that affected both method effective- tute published a set of quality dom is in the same range as that of ness and use effectiveness. standards for condoms and began

438 Public Health Reports Table 1. Effectiveness of the condom in 4 recent British studies

Years Total Method Author of study and method Total Method failure fallure yeatrofpubication People surveyed used to failures failures rate per rate per nearest year 100 years 100 years

Peel (6), 1969 ...... Group of highly fertile couples in Hull. 127 4 1 3.1 0.8 Peel (7), 1972 ...... Couples married in Hull, 1965-66. 308 12 5 3.9 1.6 John (8), 1973 ...... National Health Service patients of Shep- 248 12 1 4.8 0.4 shed practice. Glass, Vessey, and Wig- gins (9), 1974 ...... Married patients of British Family Planning 1,543 62 .. 4.0 Clinic who used oral contraceptives dia- phragm, or IUD before study. Aggregate of

above studies ...... 2,226 90 7 4.0 1.0 giving products conforming to them ginning at marriage, of contracep- The Condom as Prophylactic its seal of approval. tive use by urban couples (7). Even though in the history of the 3. A study of contraceptive usage condom, venereal disease preven- The Food and Drug Administra- in a small town medical practice tion estimated that 75 percent of tion and contraception became the condoms produced in the (8). inextricably interwoven, in previous 4. A large study of married pa- centuries use of the device was un- United States in 1939 were defec- tients of family planning clinics tive; between 1942 and 1960, this doubtedly a prerogative of rich men, who had substituted the condom who cared less about what they proportion declined to 4 percent for the pill, diaphragm, or IUD (3) and in 1961, to between 0.4 would leave behind than what they and 0.7 percent (4). Between 1969 (9). might bring home. Moreover, since and 1972, even with the new, more The results of these studies (table in recent times in the United States stringent standards that permitted 1) suggest combined use plus meth- the law permitted the condom no the FDA to seize condom shipments od failure rates of 3.1 to 4.8 per other image than that of a prophy- containing more than 0.24 percent 100 woman years and rates based lactic, this image of the condom of defective units, the proportion of on method alone of only 0.4 to 1.6 seems to have persisted in the minds promiscuous, who, questionable shipments was only per 100 woman years. In contrast, of all but the one-third that for the previous 3- for even the most successful intra- according to social studies of year period (3). Obviously, the uterine devices, pregnancy rates of venereal disease, are more inclined much quoted estimate of condom 1.5 to 3.0 per 100 women in the to rely on serendipity or the pill of 1 in 150 to 1 in 300 first year of use were reported (10), (13) for contraception. This disre- breakage gard of personal prophylaxis by the (1), based on studies carried out in and among women using combined the 1940s, is unlikely to have much progestin and estrogen oral contra- more promiscuous appears to stem ceptives, the failure rate from pills not from ignorance but from cer- meaning for U.S. and British con- attitudes that characterize dom users today. missed during the dosage cycle was tain effectiveness 1 pregnancy per 100 woman years their lifestyle (14). This fact, along The contraceptive (11). These figures on contracep- with the high incidence of asymp- of the modern condom is probably tive effectiveness, which reflect the tomatic infections, may unfortunate- the rate of 2.6 best represented by experience of well-motivated peo- ly limit the effectiveness of the failures per 100 woman years that tool. with ple, compare well with the figures condom as a public health was found among couples on the theoretical effectiveness of Nevertheless, the preponderance completed families (5) and the re- carried the condom (table 1). Presumably, of evidence seems to suggest that sults of a few British studies even with the best of intentions, it when used properly, the condom is out in the last 5 years. The four British studies is easier to forget an occasional pill a proven barrier against gonorrhea most recent of these than to forget a condom on the and other venereal infections have used diverse approaches: occasion! For poorly motivated or (14-16). Its effectiveness is re- 1. A longitudinal study of highly otherwise ineffective users of con- flected in the data on U.S. soldiers fertile couples (4 pregnancies in the traception, the failure rate with in Vietnam (table 2), whose con- previous 6 years) who used con- either the pill or condom can soar sistent use of the condom appears doms exclusively (6). to levels on the order of 11 to 28 to have afforded them adequate 2. A 5-year followup study, be- failures per 100 woman years (12). protection against venereal disease

September-October 1976, Vol. 91, No. 5 439 Condom imports into Sweden 1967-72 C ... and reported cases of gonorrhea 1968-72

cn 0L) C.)

I--, ') (I--c 'a O a o0 ._c ~0E c 0._ ._~~~~~~~~~~~~~~~~~~~~~~~~~~40 a) 0 Ct: 0. ._g 1967 1968 1969 1970 1971 1972 E 0E 0c0 0

1970 1971 1972 SOURCE: Reference 19.

(17). The results of studies of the growth of the condom program of their prophylactic effectiveness. The general population in the Scandi- the Swedish Association for Sex higher grades of condoms (that is, navian countries, where the public Education (19) (see chart). the more expensive) probably pro- is better informed about the con- According to the Food and Drug vide better prophylaxis than the dom and its proper use than in the Administration, pinholes in con- lower grades, but not better contra- United States, also show the pro- doms (caused by dust settling on ception. Sperm, being several times phylactic effectiveness of this de- the drying latex) allow the passage larger and many times longer than vice. The frequency of condom use of organisms the size of those caus- bacteria, are unlikely to penetrate by infected Danish teenagers was ing venereal disease (3). The in- pinholes. only 25 percent that of uninfected dustrial and regulatory develop- The segments of the population controls (18), and the statistics on ments that have reduced the pin- that need condoms for prophylaxis gonorrhea in Sweden showed a holes to practically zero in the best are clearly distinct from those that marked downward trend in re- grades of condoms have, by the need them for effective child spac- ported cases coincident with the same token, significantly improved ing or family limitations. Yet advice on use is limited and does not dif- ferentiate between the two types of users. Instructions for use are con- Table 2. Number of U.S. soldiers with and without venereal disease by number of exposures and prophylaxis used spicuously absent from most con- dom packages in the United States, even though the Food, Drug, and Group 2 Group 3 Group I prophylaxis condom Group 4 Cosmetic Act under which condoms no prophylaxis sometimes always wash always are regulated specifically requires Exposures V.D. No V.D. V.D. No V.D. No V.D. V.D. No V.D. that these devices be accompanied by adequate directions for their use. In the United Kingdom, also, in 1-5 ...... 14 53 10 24 48 8 16 6-10 ...... 7 9 9 14 5 4 1 all but the most imaginative family 11-20 ...... 3 6 4 0 1 0 0 planning projects (20), sparse and More than 20 ...... 2 2 5 0 1 0 0 obscure directions for the use of Total number ...... 26 70 28 38 55 12 17 condoms blur the significant dis- tinction between prophylaxis and Percent of group ...... 27 73 42 58 1100 41 59 contraception. These directions, like many others in handbooks of I Note that this is "No V.D." column. SOURCE: Table is based on data in reference 14. contraception, usually emphasize

440 Public Health Reports that the condom should be placed tural conditioning they have under- doms were always available from on the erect before genital gone, in which historically the con- barber shops, chemists, surgical contact. This procedure is necessary dom was associated with venereal stores, and discreet mail order com- only if the principal objective is to disease. Also, in the past, U.S. panies. Some of the embarrassment avoid the transmission of venereal condoms have been among the and subterfuge that sometimes disease organisms; this instruction thickest in the world, largely be- characterize the purchase of a puts unnecessary restrictions on the cause under Federal regulations condom have been eliminated by monogamous user. quality was measured by pinholes the Family Planning Association-'s (porosity). The. thickness of the initiation of a separate company to Other Considerations U.S. product is certainly the reason promote condom sales. High-quality Changing attitudes. Eighty percent for complaints that condoms dull condoms and combinations of con- of the men recently surveyed in the penile sensitivity and mute sensa- doms and spermicidal foam pes- eastern United States expressed the tion. The modern U.S. product, saries are packaged along with in- belief that males should share re- however, is less tactile than its structions in bright cartons bearing sponsibility for contraception (21). predecessor since it is thinner, more the titles "Forget-me-not" and Most, however, were not putting compliant, better lubricated, and in "Two's Company." As in Sweden, their belief into practice with much some cases, of a shape that permits the contraceptive image is kept sep- vigor and appeared to be waiting more movement of the glans within arate from the prop'hylactic, and no for a chemical answer that they the sheath. Many people who have brand names are associated with the could use. Although condoms are formed negative opinions based on advertising for venereal disease the only highly effective contracep- condom use in earlier years possibly campaigns (20). tive available for males, only 9 per- would respond more favorably to In Japan, the rapid rise in con- cent of the men in the sample pre- the modern product. dom use between 1962 and 1972 ferred them, and condoms appar- The lessons from Sweden are (from sales of 1.7 million gross to ently were the method of choice for legion. For example, negative atti- 4.3 million gross) was partly due to only 9 percent of the married couples tudes of Swedes toward condoms, door-to-door sales, the introduction in the general population (22). which had been similar to those of colored and shaped condoms, Reasons given by 2,325 patients of still prevalent in the United States, and the production of ultra-thin a venereal disease clinic for not have been changed by attractive (0.033 mm) ones (25). (In our using condoms related primarily and amusing advertising and youth- samples, the "ultra-thin" Japanese (60 percent) to interference with oriented marketing techniques that condoms were from 0.37 mm at the sexual spontaneity, unnaturalness, make condom-purchasing free of open end to a thin 0.05 mm over and lowered satisfaction (23). Rea- shame and even "trendy." Negative the glans. U.S., British, and the sons for not using condoms that attitudes have also been changed Japanese export latex condoms were reviewed by Hart (14) relat- by well-documented information ranged from 0.048 to 0.060 mm at ing to the consistency of use in- for physicians, pharmacists, and the open end and 0.06 to 0.09 mm cluded nonavailability (reason retailers, as well as by the careful over the glans. Natural skin con- given by 10 to 29 percent of the separation of the contraceptive doms were between 0.06 and 0.07 respondents) and the influence of image from the prophylactic one, mm throughout their length.) alcohol (reason given by 13 to 25 while at the same time the condom These heralded changes in condoms percent). Apparently few of the is promoted for both contraception in Japan have been accompanied respondents considered condoms and prophylaxis. Significant in- by (a) attractive packaging and ineffective, but presumably most of roads on venereal disease have been pleasure-oriented advertising that them were rating effectiveness for made in Sweden by large-scale is aimed at women as well as men, prophylaxis rather than for contra- candid advertising campaigns by (b) the availability of condoms of ception. nongovernment agencies and pri- different sizes and the inclusion of Despite the availability of the vate companies. This change in a clearly distinguished sample of more recently developed alterna- attitude has been achieved rapidly large and small sizes in each box tives to condoms (the pill, IUD, in an official and public environ- of medium-sized condoms, (c) clear and so forth) 40 percent of the ment that initially had been re- instructions for use, and (d) plastic fertile couples in Sweden, 40 per- sistant or even hostile to condoms, disposal bags packaged with the cent of those in the United King- where there had been legal restric- condoms. In Japan, the people's dom, and 70 percent of those in tions and where advertisements for aversion to medicines with unknown Japan use the condom for birth them had been refused or censored side effects may facilitate the pro- control (24). This widespread use (19). motion of condoms. In the West, suggests that some of the reasons In the United Kingdom, the however, the population more com- that U.S. couples reject the condom status of the condom never was as monly resorts to oral medicines. may result primarily from the cul- low as in the United States. Con- Physicians, pharmacists, and phar-

September-October 1976, Vol. 91, No. 5 441 maceutical firms are faced with an condom advertising has eroded also the only contraceptive method unprecedented demand by healthy substantially in the past 2 years. requiring the user to make a cash women for chronic doses of the The "personal" products that are outlay. Condoms are the only effec- powerful systemic drugs used in now edging into media advertising tive contraceptive method that does oral contraceptives over a signifi- may pave the way for condoms to not have the endorsement of the cant fraction of their life spans. be advertised informatively on a British medical profession. wide scale. Recent condom adver- In the United States, lubricated Obstacles to condom promotion. tisements in magazines and college rubber condoms require a recurring Legal, institutional, and cultural papers have generated 2 million re- cash outlay of $20 to $40 per year obstacles to the promotion and dis- quests for information and only 15 per couple (based on a frequency of semination of information about objections (27). intercourse of 100 per year) unless condoms exist in the United States. People choose their contraceptive they, can be obtained from family In the original Comstock Act of methods on the basis of input from planning clinics or other such 1873, condoms and the other then- friends, neighbors, physicians, clin- sources. This expense may be an current contraceptive procedures, ics, and the media, and unfortu- obstacle to condom use by some as well as information about them, nately, in the United States, the people, although cost has rarely were declaied to be obscene and condom is still denigrated by an been cited as a factor in nonuse. therefore illegal. The clandestine image that makes it unattractive, Oral contraceptives, by comparison, market in condoms that resulted by the physician who ignores it, and cost $20 to $35 per year per cou- was therefore without trademark by the family planning clinic, which ple, plus initial physician or clinic protection and subject to exploita- often downgrades it because it has fees and possibly the cost of peri- tion by unscrupulous manufactur- not been effectively used in the odic medical checks. The IUD and ers. In the 1930s, the prohibition on past. sterilization procedures can be con- the use of the mails to merchandise In the physician's office, the con- siderably cheaper if amortized over condoms was circumvented by de- dom is often overlooked because it several years. Condoms traditionally fining them as prophylactics for is a contraceptive that does not re- carry a high retail markup, pre- disease. Although legal restrictions quire the physician's signature. The sumably as an inducement for re- are gradually disappearing, as late physician can too easily assume that tailers to stock this "sensitive mer- as March 1973, 12 States still re- patients seeking birth control ad- chandise." stricted the advertising of condoms vice have already rejected such The insecurity and ill-will that as contraceptives, 9 States prohib- nonmedical options. Obviously, this can result from lack of proper in- ited their display, 9 States restricted is not always the case. The failure structions on condom use are also sales to pharmacies and physicians, of physicians to consider this meth- obstacles to the condom's wide ac- and 12 States prohibited their sale od can have far-reaching implica- ceptance. Given the inexplicable from vending machines (26). Some tions, even for people who for one absence of instructions in most con- State laws refer exclusively to pro- reason or another do not seek med- dom packages in the United States, phylactics, in which case they are ical advice on contraception. The the family planning clinic and the not applicable to condoms as con- emphasis that is placed or withheld physician's office are the only traceptives. Three States make it by physicians generates opinions in sources of information on proper difficult for sexually active young- the community that ultimately use available to most people. Mis- er persons to protect themselves affect laws, institutional sanctions, use of the condom is the major against venereal disease. One of and attitudes. An example is the cause of failure. If the user's pur- these States (New York) prohibits state of affairs that developed in pose is contraception, the condom the sale of prophylactics to persons the United Kingdom after the Na- need not be placed on the penis under 16 years, and the other two tional Health Service Reorganiza- before penetration of the , (Nebraska and Utah) prohibit the tion Act of 1974 was amended. only before ejaculation. The possi- sale of prophylactics to persons The British Medical Association bility is slight that pre-ejaculate under 18 years. declined to prescribe the condom sperm would be present in sufficient There are as many potential out- on the grounds that patients did not numbers to cause conception. Sam- lets for condoms as there are for need to consult their physicians ples of pre-ejaculatory fluid from aspirin. With active medical and about this method of contraception. 10 volunteers in our study revealed pharmaceutical endorsement, un- As a result, condoms are not avail- no sperm. (The lubricative pre- hampered advertising, and an im- able to many people under the Na- ejaculatory fluid is thought to ema- proved image of condom use, it is tional Health Service. They may nate from the bulbo-urethral and unlikely that any vested interest will therefore have become the most ex- urethral glands.) The user can in- suffer greatly from unlegislated sale pensive contraceptives in the coun- troduce the condom during foreplay of condoms. try, being not only more expensive or late in extended intercourse. Ob- The resistance of the media to than sterilization or but jections that intercourse must be

442 Public Health Reports interrupted to place the condom cated in the etiology of carcinoma user's motivation, character, and may disappear if the placement it- of the cervix. Some positive psycho- background as well as by the theo- self becomes a natural, even play- logical advantages of condoms in- retical effectiveness of the method. ful, part of the sexual exchange. clude the visual assurance of suc- Except for regulations governing Persons seeking protection from cessful contraception (28), the quality standards, the legislation on venereal disease must obviously put management of premature ejacula- condoms in the United States is the condom on before any genital tion, and the surmounting of anachronistic and serves no public contact and avoid genital contact esthetic objections to intercourse purpose. Health officials and after its removal. Even so, condom during menstruation (29). pharmacists, who play an important users need to be aware that syphilis The condom has been success- role in reassuring people, should be and herpes infections can be trans- fully used to reduce sperm antibody more active in promoting condom mitted to and from other areas of titers (especially sperm agglutinins) use, informing people of the avail- the body. in women. Such antibodies appear ability of this contraceptive, and The FDA regulations for preven- to be more common than generally correcting the erroneous image of tion of pinholes in condoms are the supposed; Karafin and Kendall re- it that many people have. Govern- most stringent in the world. Mini- ported that 36 of 50 prostitutes were ment testing standards for condoms mizing pinholes is thought to be found to have strongly positive re- should be changed after suitable necessary for venereal disease pro- sults on hemagglutination and research has been conducted to de- phylaxis. There is, however, some sperm immobilization tests (29). termine the relevance to contracep- doubt as to whether this criterion These same authors also reported tive efficacy and consumer accept- is relevant for condoms used as con- that among childless women with ance of pinholes and thinner con- traceptives (27). Relaxation of initially high sperm antibody titers doms. these regulations would almost cer- who were being treated for infer- Research is needed on every tainly permit thinner condoms, and tility, a period of condom use re- aspect of condoms, from the devel- thinner condoms, judging by the sulted in a fall in these antibody opment of synthetic polymers to the response to the ultra-thin condoms titers, which in 54 percent of the sensory nerve physiology of the in Japan and in its export market, patients was followed by pregnancy. penis and vagina. Research should would be attractive to the user. also be directed at the public's re- There is no obvious reason why Prescription for a New Image sponse to advertisements, packag- thinner condoms could not be mar- An editorial in a 1973 issue of the ing aimed at ease of opening, use- keted in this country except the American Journal of Public Health effectiveness in relation to attitudes obfuscation between disease prophy- (30), calling for a "massive in- or instructions, institutional atti- laxis and contraception. crease in attention to nonmedical tudes, and consumer preferences. birth control methods and delivery Modern users of contraceptives Clinical considerations. The con- in the United States," signaled a need effective alternatives to drug dom is suited to well-motivated significant change in the attitude of or surgical intervention as well as couples or individuals; it gives an the health community toward these the opportunity for both partners additional increment of control to methods. Such a change could help to share responsibility for birth the male and enables him to pro- rectify the distorted image of the control. long coitus if the couple so desires condom. Many changes also have (28). The contraceptive efficacy of taken place in the United States in Coitus Interruptus the condom becomes almost perfect the marketing of condoms with a Coitus interruptus, or withdrawal, if it is used in conjunction with view to making them more accept- is the only other male method of intravaginal . However, able to consumers-colored con- contraception not requiring inter- the trade-off in cost and conveni- doms, attractive packaging, infor- vention by a physician. In many so- ence may not be worth the small mative displays and advertising, cieties, it remains the most common increment of improvement. and a shift of emphasis from pro- contraceptive technique. Many peo- Karafin and Kendall (29) have phylaxis to contraception. An addi- ple who seek professional advice on discussed some other aspects of tional useful step might be for family planning have previously condom use that are of interest to manufacturers to include in con- practiced this method. a clinician. Advantages in the gen- dom packages some clear, simple, Coitus interruptus has its roots in eral category of disease control that illustrated instructions to promote antiquity, being by far the oldest they cite include the prevention of effective use. Physicians and clini- and most common method of con- reinfection during treatment for cal counselors should be prepared traception in use in the world. It is trichomoniasis and of the trans- to instruct on condom use and, as explicity described in Genesis 38: mission of the Herpes progenitialis for any contraceptive, should be 8-9: "Then Judah said to , virus, which is found in many un- guided in deciding whether to 'Go in to your brother's wife, circumcized males and is impli- recommend the condom by the perform the duty of a brother-in-

September-October 1976, Vol. 91, No. 5 443 law to her, and raise up offspring in some cases. Obviously, however, Additional disadvantages of coi- for your brother.' But Onan knew this procedure requires a good deal tus interruptus include possible ad- that the offspring would not be his; of self-control, especially consider- verse psychophysical consequences so when he went in to his brother's ing the strong desire to achieve for the woman if she repeatedly wife he spilled the on the deeper penetration at the time of fails to reach orgasm after sexual ground, lest he should give offspring impending orgasm (32). arousal (36). Masters and Johnson to his brother." Later Jewish think- Most authors on the subject of have pointed out that resolution of ing was influenced by this reference. coitus interruptus allude to the pos- the anatomical and physiological The Talmud refers to coitus inter- sibility of its failure as a contracep- changes associated with sexual ex- ruptus as "thrashing inside and tive due to the presence of sperma- citation, which usually occur rapid- winnowing outside." Historical de- tozoa in the lubricative pre-ejacula- ly and orderly after orgasm, become mographers have shown that in tory fluids that often ooze from the drawn out and less orderly if sexual some social groups in 17th and 18th penis in response to sexual stimula- arousal has not culminated in or- century France and England, mari- tion. Actual counts of sperm in gasm (37). The recurring failure tal fertility declined markedly, pre- these secretions do not appear in of the woman to obtain orgasmic sumably as a result of a growing the literature. As mentioned, our release following sexual stimulation use of coitus interruptus or possibly observations of samples of pre- may lead to difficulties, and this of coitus interruptus combined with ejaculatory fluid from 10 men re- subject is worthy of study. It has induced abortion (31). vealed no sperm. Since it is possible, been suggested that in some males, Its very obviousness is one reason however, that the lubricating fluid the psychological pressures of coitus for the popularity of coitus inter- may contain spermatozoa after a interruptus may result in impotence ruptus. It is often regarded as a recent ejaculation, it has been sug- -in particular, premature ejacula- natural method of birth prevention, gested that between multiple acts of tion (personal communication in even by some Roman Catholics. It intercourse there should be urina- 1974 from W. H. Masters). Fur- is referred to as "being careful." tion to flush out spermatozoa (33). thermore, many males are physio- Studies reported by Days and Potts Nevertheless, when coitus interrup- logically or psychologically unable (31) indicate that in France, Italy, tus fails to prevent conception, the to practice coitus interruptus, either and Hungary, all at least nominally reason usually is inadequate with- because they do not perceive the Catholic countries, it is the contra- drawal. imminence of ejaculation, or be- ceptive method of choice for two- Because coitus interruptus re- cause they cannot, or choose not, thirds of the population. Ironically quires little instruction or followup, to withdraw in time. Therefore enough, the influence of Christian- analysis of pregnancy rates among coitus interruptus cannot be con- ity in Latin America appears to users has been rare and only under- sidered a foolproof method of con- have fostered frequent use of coitus taken as part of a sample study on traception. interruptus. In Australia, it is prac- cross-sections of a community. In ticed by one-fifth of the married such a study in Indianapolis, Ind., Conclusion couples and in 1965 yielded only to a low rate of 10 pregnancies per 100 The condom deserves another look, the pill as the number one method woman years was found among both as a contraceptive and as of contraception. In England, it was users of coitus interruptus (34). a prophylactic. In view of recent outranked in 1972 both by the pill Undoubtedly this rate would be information about its efficacy and in second place and the condom much higher among inexperienced the more stringent manufacturing in first place. In the United States, and casual users. regulations that have increased coitus interruptus is less popular, For maximum effectiveness of quality assurance, the condom can and in the Orient it is rare (31). coitus interruptus, seminal emission serve both as an effective method Coitus interruptus has several must take place well away from the of birth control and as an efficient unique advantages. It costs nothing, vagina and external genitalia of the means of protection against vene- it cannot be forgotten when the woman. The man therefore has to real disease. Coitus interruptus, couple goes away from home, the be aware of the imminence of ejac- another common nonprescription children cannot find it, the govern- ulation, and the ejaculation has to method of birth control, is certainly ment cannot tax it, and it requires occur as a single climatic event. not a foolproof one. no medical supervision. The skilled However, more than 50 percent of use of coitus interruptus may im- males experience ejaculation as an References part to the man a sense of mastery intermittant or protracted emission 1. Tietze, C.: The condom as a con- and responsibility. The woman may of semen, at least on some occasions traceptive. National Committee on be relieved of some of the burden of (35). Furthermore, factors such as Maternal Health Publication No. 5. responsibility for contraception, but alcohol and fatigue may affect the New York, 1966. nevertheless she can facilitate effec- type of ejaculation or dull the 2. Dumm, J. J., Piotrow, P. T., and tive withdrawal or even initiate it awareness of its imminence. Daisimer, I. A.: The modern con-

444 Public Health Reports dom-a quality product for effec- Association in San Francisco, Nov. 25. Koyama, I., and Oato, N.: Condom tive contraception. Population re- 5, 1973. use in Japan. In The condom: in- port-barrier methods. Series H, 14. Hart, G.: Factors influencing creasing utilization in the United No. 2. George Washington Medi- venereal infection in a war environ- States. Edited by M. H. Redford, cal Center, Washington, D.C., ment. Br J Vener Dis 50: 68-72 G. W. Duncan, and D. J. Prager. 1974. (1974). San Francisco Press, San Francisco, 3. Butts, H. E.: Legal requirements 15. McCormack, W. W., Lee, Y., and Calif., 1974, p. 23. for condoms under the Federal Zinner, S. H: Sexual experience 26. Cook, R. J.: State laws regulating Food, Drug, and Cosmetic Act. In and urethral colonization with condoms. In The condom: increas- The condom: increasing utilization genital mycoplasma. Ann Intern ing utilization in the United States. in the United States. Edited by Med 78: 696-698 (1973). Edited by M. H. Redford, G. W. J. H. Redford, G. W. Duncan, 16. Darrow, W. W., and Wiesner, P. J.: Duncan, and D. J. Prager. San and D. J. Prager. San Francisco Personal prophylaxis for venereal Francisco Press, San Francisco, Press, San Francisco, Calif., 1974, disease. JAMA 233: 444-446 Calif., 1974, p. 59. p. 5. (1975). 27. Redford, M. H., Duncan, G. W., 4. Tietze, C.: The condom. In Man- 17. Hart, G.: The role of the condom and Prager, D. J., editors: The ual of family planning and contra- in venereal disease control. Paper condom: increasing utilization in ceptive practice. Edited by M. S. presented at First National Confer- the United States. San Francisco Calderone. Williams & Wilkins, ence on Methods of Venereal Press, San Francisco, Calif., 1974, Baltimore, 1970, p. 424. Disease Prevention, held at Uni- p. 9. 5. Westoff, C. F., Potter, R. G., and versity of Chicago, Nov. 16-17, 28. Decker, A.: Contraceptives for Sagi, P. C.: The third child: a 1974. men. Reprint from November 1973 study in the prediction of fertility. issue of Sexual Behavior. 18. Ekstrom, K.: Patterns of sexual be- 29. Karafin, L., and Kendall, A. R.: Princeton University Press, Prince- havior in relation to venereal ton, N.J., 1963. Advantages and disadvantages of disease. Br J Vener Dis 46: 93-95 the condom. Med Aspects Human male oriented fertility 6. Peel, J.: A (1970). Sexuality 3: 73-77 (1969). control experiment. Practitioner 19. Ajax, L.: How to market a non- 30. Nonmedical birth control-A ne- 202: 677-681 (1969). medical contraceptive. In The con- glected and promising field (Edi- 7. Peel, J.: The Hull family survey dom: increasing utilization in the torial). Am J Public Health 63: II. Family planning in the first 5 United States. Edited by M. H. 473 (1973). years of marriage. J Biosoc Sci 4: Redford, G. W. Duncan, and D. J. 31. Deys, C. M., and Potts, D. M.: 333-346 (1972). Prager. San Francisco Press, San Condoms and things. Adv Biosci 8. John, A. P. K.: Contraception in Francisco, Calif., 1974, pp. 5-21. 10: 287-297 (1973). a practice community. J R Coll Gen 20. Snow, F.: Condom marketing in 32. Hatcher, R. A., Kline, R. W., Pract 23: 665-675 (1973). the United Kingdom. In The con- Steward, G. K., and Moorhead, 9. Glass, R., Vessey, M., and Wig- dom: increasing utilization in the F. L.: Contraceptive technology gins, P.: Use-effectiveness of the United States. Edited by M. H. 1974-1975. Emory University Fam- condom in a selected family plan- Radford, G. W. Duncan, and D. J. ily Planning Program, Atlanta, Ga., ning clinic population in the Prager. San Francisco Press, San 1974, p. 13. United Kingdom. Contraception Francisco, Calif., 1974, p. 1. 33. Bryuere, R: Planification famili- 10: 591-598 (1974). 21. Kieth, L.: Contraception is job of ale; methods physiologiques. Union 10. Tietze, C.: Evaluation of intra- both partners. Fam Plann Digest Med Can 97: 1445-1447 (1969). uterine devices. Ninth progress re- 2: 12-13 (1973). 34. Westoff, D. F., Herrera, L. F., and 22. C. F.: The port of the Cooperative Statistical Westoff, modernization Herrera, P. E.: Social and psycho- Program. Stud Fam Plann 1: 1-40 of U.S. contraceptive practice. Fam logical factors affecting fertility. (No. 55) 1970. Plann Perspect 4: 9-12 (1972). Ch. XX. The use, effectiveness and 23. Darrow, W. W.: Attitudes toward acceptability of methods of fertility 11. Tietze, C.: Effectiveness, accept- condom use and the acceptance of control. Milbank Mem Fund Q 31: ability and safety of modern contra- venereal disease prophylactics. In 291-357 (1953). ceptive methods. In Proceedings of The condom: increasing utilization 35. Sjovall, E.: Coitus interruptus. In 2d World Population Conference, in the United States. Edited by Manual of family planning and Belgrade, 1967, vol. 2, p. 305. M. H. Redford, G. W. Duncan, contraceptive practice. 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