Which condom is safest?
Unfortunately we cannot give an easy answer to this question. There is no national watchdog agency overseeing the safety of all condoms sold in the UK. There is no independent comparative sampling and testing of condoms as actually sold in packets. And it is not illegal to market condoms which don't measure up to the British Standard BS EN600, which lays down requirements for good quality condoms.
Which condom should I choose?
The best advice is to choose a condom which carries the Kitemark. The Kitemark indicates that the condom brand is recognised under the British Standards Institution's (BSI) scheme. The BSI is responsible for drawing up the British Standard (known as BS3704:1989) and its testing division polices the scheme. A manufacturer who wants his brand to carry the Kitemark has to agree that BSI inspectors may regularly test samples of the brand and ensure that those samples will pass the tests laid down in the British Standard.
It's not compulsory for condoms to comply with the British Standard. What's more, any condom manufacturer can claim that his product conforms to the British Standard, but not sign up to the Kitemark scheme to have the claim checked by the BSI. Even if this claim appears to be backed up by a set of laboratory test results, the testing may not have been independent and may reflect only a one-off testing of a sample of condoms from one given batch at one given moment, rather than regular checking of multiple batches over time. So consumers can only be confident that a brand does meet the British Standard on an ongoing basis if it does carry the Kitemark.
During the 1990s, standards organisations throughout Europe have been working together to agree a pan-European condom standard. This was finally approved in early 1996, and European Union member states are obliged to replace their existing national standards with the new European one (known as EN600:1996).
In Britain, the pan-European standard formally came into effect in Autumn 1996, although it remains voluntary. It was introduced not by scrapping the British Standard, but by amending it to make it identical to the agreed European model. Thus, condoms can still carry the Kitemark, just as condoms in other countries may still carry the national certification marks in those countries. But for the first time, all those different marks will indicate that condoms are certified to an identical standard.
In practice, however, this makes little difference to British condom manufacturers or consumers. The British Standard was last amended in April 1995, at which stage many of the requirements in the European standard were incorporated even before the European standard had been finalised.
AIDS organisations usually recommend consumers to stick to Kitemarked brands, but this can cause confusion when they also endorse certain brands such as HT Special that don't have a Kitemark. That's because Kitemarking is a British scheme, and condoms that are not formally marketed by their manufacturer in the UK are unlikely to be submitted for Kitemarking regardless of their quality.
This symbol indicates that the condom brand has been independently tested and is certified to conform to the requirements of the British Standard EN600. Beware, however, of misleading claims which it is not illegal to make, but which are no guarantee of quality, such as `made to BS 3704' (the previous code-name for the Standard). Only the presence of the Kitemark guarantees that the condom brand has been independently tested and found to conform to the Standard. Alternatively choose a condom which can be shown to have met equivalent foreign standards, if it is imported.
Since Autumn 1996, European Union member states have all had harmonised condom standards; this means that the guidelines in the British Standard are the same as those elsewhere in Europe.
Another mark called the CE Mark is starting to appear on packets of condoms sold in Europe. Many people mistakenly assume that this symbol indicates that the product meets the European standard, just as the Kitemark indicates that the product meets the British Standard - but in fact this isn't true.
The CE Mark relates to an entirely separate piece of European legislation called the Medical Devices Directive. This came into force in the UK on 1st January 1995, with a transitional period extending until 1998. After 13th June 1998 all manufacturers of medical devices (including condoms) were expected meet the standards laid down in the Directive's Essential Requirements. Manufacturers must obtain official confirmation that their product meets the requirements of the Directive from a certification body, and then indicate certification by placing a mark called the CE mark on the packaging.
The problem with the CE Mark is that there are several routes to obtaining certification. One way is to conform with the European condom standard; if a manufacturer chooses this route, the CE Mark effectively is the equivalent of the Kitemark. But there are other, far less demanding routes to CE certification; for example, a manufacturer could simply submit information on its manufacturing processes, quality control systems and internal testing of the product once every four years, without any independent or ongoing testing of the product.
By contrast, to qualify for the Kitemark the manufacturer is subject to quarterly inspections of the manufacturing plant and random sampling of the product, and Kitemarked products have to be submitted every week for independent testing. For this reason, it is safest not to assume that the CE Mark and the Kitemark are equivalent, and to choose only brands that carry the Kitemark, with or without the CE Mark.
But despite this potential superiority of the Kitemark over the CE Mark, the British government isn't allowed to advise consumers to prefer Kitemarked products, as to do so would be seen as imposing a barrier to free trade. This restriction also applies to agencies funded by the Department of Health - most notably the Health Development Agency (HDA) - which has previously played a major role in advocating the use of Kitemarked products.
It is possible that the CEN will eventually introduce a new quality mark called the CEN/CENELEC European Mark, or the KeyMark, that will genuinely be a pan-European equivalent to the Kitemark, but this is still at the discussion stage.
In practice, this confusing situation means that people buying condoms are probably best advised to look for brands that carry the Kitemark, or both the Kitemark and the CE Mark, but not the CE Mark alone.
Don't be misled into thinking that the thickest condoms are always the best in the range. Without independent comparative testing there is no guarantee that the thickest condom of one manufacturer's range will necessarily be stronger or more reliable than a thinner one in another manufacturer's range. See Which condoms for anal sex? for further discussion.
The thickest condoms
ince the introduction of the harmonised European standard, condoms that claim to be extra strong have had to pass more a more stringent tensile breaking force test than those that do not make such a claim. There is no difference between the air-burst test requirements for standard versus strong condoms.
In early 1996 Rubberstuffers commissioned the British Standards Institution's laboratories to test condoms that claimed to be extra strong to the new standard. Over 200 condoms from each brand were subjected to tests for holes by filling with water, stretched until broken and inflated until they burst. In late 1996 the Consumers Association published in Health Which? the results of tests on a range of condom brands including some (but not all) of the brands tested by Rubberstuffers. Both sets of tests reached the same conclusions. There was little difference in strength between any of the following brands:
• CONDOMI STRONG: without spermicide
• EX S BOYS OWN: does not contain spermicide, but does have a teat, silicone lubricated
• EX S ULTRA STRONG: without spermicide
• DUREX ULTRA STRONG: without spermicide. This is marketed as the strongest of the Durex range and also carries the Kitemark. It is teatless
• DUREX AVANTI: non-allergenic, non-spermicidal polyurethane condom, which is much thinner than the latex condom.
• MATES SUPER STRONG: without spermicide or a teat. This is marketed as the strongest of the Mates range and also carries the Kitemark
• MONDOS YANTRA: no spermicide, but teated.
Another brand marketed to gay men in the UK is SAFEGUARD FORTE. In both sets of tests, these condoms just failed to meet the tensile breaking force requirements for condoms that claim to be extra strong, as defined in the British Standard. Safex Supplies claim that they have since improved their manufacturing processes, but there have not yet been any independent tests to verify this claim.
Notwithstanding their name, the Dutch GAY SAFE condoms performed poorly in both Rubberstuffers' and the Consumers Association's tests, and cannot be considered an extra-strong brand.
Both these brands were also thinner than the others, reinforcing the impression that the thicker condoms are generally the stronger.
Standard thickness condoms
The only difference between condoms listed in this section and the thicker condoms listed above is the thickness of the rubber. On average the condoms listed below are 30% thinner than the thickest brands such as HT Special and Durex Ultra Strong, and around 25% thinner than the other brands listed above.
The results of the Consumers Association's tests found that 19 out of the 20 brands tested passed. The only failure was Safex Sensitive condoms, which failed both airburst testing and tensile elongation testing.
Among the other brands, the best performers (those with no failures at all during airburst testing) were Boots Ultra Fine, Durex Extra Safe, Durex Fetherlite, Durex Gossamer, RFSU Okeido and RFSU Profil. The full list of brands tested was as follows:
• BOOTS ULTRA SAFE: Non-spermicidal lube, slightly thicker for extra reassurance.
• BOOTS MULTI-RIBBED: Textured to enhance stimulation for ultimate intensity, non- spermicidal lube with reservoir.
• CONDOMI NATURE:Lubricated with silicon-based lube, regular-sized.
• CONDOMI ULTRA THIN:Ultra thin, non-spermicidal, regular-sized condom.
• CONDOMI XXL: Longer and wider than the average condom, lubricated with a silicone-based lubricant.
• CONFIDENT CLASSIC: Non-spermicidal, slightly longer condom
• CONFIDENT FEELINGS: Non-spermicidal, slightly longer, ribbed and textured.
• DUREX CLOSE FIT: Narrower condoms designed for a closer fit for those who have problems with regular- sized condoms. Non-spermicidal.
• DUREX COMFORT FIT: Extra-long and wide, non-spermicidal.
• DUREX GOSSAMER: Hypoallergenic, non-spermicidal, regular-sized condom.
• DUREX SELECT: Non-spermicidal and ribbed.
• EX S NATURAL: Non-spermicidal, regular-sized.
• MATES CRYSTAL: Dermatologically tested, thinner, with a straight profile, and non-spermicidal lube. Mates Crystal condoms have undergone a unique treatment to reduce the risk of an allergic latex reaction and are thinner.
• MATES CONFORM: Non-spermicidal, one of the narrowest and shortest brands on the market.
• MATES LARGE: Flared shape at the closed end of the condom, to provide comfort for those who find condoms too tight. Non-spermicidal lube.
• RFSU OKEIDO: Non-spermicidal lubricant. One of the longest and widest brands on the market.
• RFSU PROFIL: Non-spermicidal lubricant, regular-sized.
• SAFEX SENSITIVE: Non-spermicidal lube, fine sheath for increased sensitivity.
• SAFEX NATURAL (non-spermicidal): Regular-sized, non-spermicidal lube (Available also with spemrmicidal lubricant)
• FEMIDOM: Made from polyurethane, femidom is a disposable, odourless sheath specially designed to protect women by lining the inside of the vagina.
Which strength condoms for anal sex?
At the 13th International AIDS Conference in Durban, a team of researchers from London's City University presented data from a study of 283 gay male couples who had been randomised to use either standard or thicker condoms for anal sex and additional water based lubricant. Each couple were provided with 9 condoms and completed a questionnaire after each sexual act.
The researchers found that condoms broke for the same reasons as previously identified in studies among heterosexual couples; unrolling the condom before fitting it to the penis, longer duration of intercourse (longer than 45 minutes), and absence of additional lubricant. Use of additional inappropriate, (oil-based lubricant or saliva) was also associated with condom breakage. Penis length was also associated with condom breakage, yet girth was not.
Interestingly, the study found no significant differences between the two types of condoms with respect to breakage or slippage. Condoms were more likely to slip if lubricant was placed on the penis under the condom. A low incidence of clinical breakage was reported for both condom types during appropriate use.
In order to use standard condoms most effectively, the researchers recommended that gay men be reminded of the following:
• unroll the condom after fitting it to the penis
• use additional lubricant
• apply the lubricant to the outside of the condom only
• apply the lubricant in and around the anus.
The findings of this study call into question the long-standing recommendation that gay men should use extra-strong or thicker condoms wherever possible. The researchers have proposed that gay men should be advised to use Kitemarked condoms, and note that inexperience in the use of condoms and use of inappropriate lubricants were far more important factors in explaining condom failure.
When published in the peer-reviewed journal AIDS in 2001 the study researchers criticised exisiting studies for lacking "operational definitions of failure" and for not separating participants "according to sexual orientation and behaviour".
Further, they argued that the reported methods used to measure condom reliabiity for gay men have been weak since they have almost entirely relied on retrospective self report-surveys of failure.
In North America and Australia (yet not in Europe) HIV prevention messages have always offered the alternative of standard condoms for anal sex. This trial has seemingly offered the first piece of evidence to confirm this approach to HIV health promotion.
The authors concluded that the data concerning the predictors of failure should be used in health promotion "to reduce the incidence of condom failure among gay men".
Mixed response from UK HIV prevention agencies
For the past 15 years one of the cornerstones of gay menís HIV prevention in the UK has been the recommendation to use extra-strong condoms for anal sex.
However, this view is not universally shared. Around the world, the UK is almost unique in recommending extra-strong condoms to gay men, with HIV prevention agencies in both the USA and Australia happy to say that itís okay for gay men to use standard strength condoms for anal sex. Only Germany and the Netherlands share the UK's insistence on extra-strong condoms.
HIV agencies in the UK are now starting to question the advice that extra-strong is best, not least because research conducted in 1999-2000, using a sample of almost 300 gay couples, found that standard strength condoms are no more likely to Ďfailí during anal sex than extra-strong condoms.
Based on this research GMFA designed and launched a mass media campaign which says that standard strength condoms are just as reliable for anal sex as extra-strength ones.
But, not everybody involved in UK HIV prevention agrees, most notably and vocally, Mark Maguire Team Leader of Camden and Islington's HIV and Sexual Health Promotion Service, who insists that thereís not enough evidence showing the reliability of standard strength condoms for anal sex. This means that gay men in the UK will be offered conflicting advice on condoms by two equally well respected HIV prevention agencies, who in theory, should cooperate to ensure the coordination of gay menís HIV and sexual health education across London.
In June 2002 the two sides came head-to-head to discuss the issues at a debate at the University of London Union. At the core of the discussion was the reliability of the research undertaken by a team the City University in London outlined above, which found no difference in the reliability of standard and extra-strong condoms when used by gay men for anal sex.
The researchers recruited 283 gay male couples who were split into two groups; one was given extra-strong condoms and the other standard condoms. They were asked to complete a questionnaire describing their use of the condoms and whether or not the condom split. The study showed that the failure rate of extra-strong condoms was 2.5% compared to 2.3% for standard strength condoms, leading the study authors to conclude that Ďour findings suggest that gay men no longer need to be encouraged to buy, or be provided with extra-strong condoms, as failure rates did not differ between the two different types of condoms.í
At the debate Richard Harding, on of the studyís authors, stood by his research, adding that in the majority of cases condom failure was the result of slippage rather than breakage.
In defence of the status quo
Whilst acknowledging that the City University team had produced a good piece of research, Mark Maguire did not believe that it provided a firm enough foundation for the advice on extra strong condoms to be changed. Hence the decision of the Camden and Islington gay menís team to produce the booklet, Condoms: everything a gay man needs to know, with the traditional advice about extra-strong condoms included. Maguire argues that the City University trial merely demonstrated that normal strength condoms were equally safe for anal sex when used by gay couples who had sexual experience of one another. The results of the trial would not necessarily be applicable to casual sexual encounters, particularly in public or semi-public environments. He noted however, that standard HIV prevention advice has always been to use a standard strength condom if a stronger condom was unavailable, under the principle that any condom is better than no condom at all. He therefore stood by the existing advice.,/p>
Supporters of the current stance on extra-strong condoms also quote epidemiological data. The UK has a much lower rate of HIV prevalence amongst gay men than, for instance, the USA, which has never recommended stronger condoms for gay anal sex. However, there may be other historical reasons for this, not least that the epidemic went undetected for longer in the USA. In addition, US gay men had a much more developed commercial sex scene offering more opportunities for multiple sexual contacts between gay men than the UK in the early years of the HIV epidemic.
The argument about prevalence rates is further undermined when Australia is considered. With only 15,000 cases of diagnosed HIV, Australia is regarded as an HIV prevention success. Indeed when the UK government first announced that it was to have a national HIV strategy Australia was held up as a model to follow. But Australia has never recommended extra-strong condoms to gay men.
The united front of HIV prevention agencies in the UK capital on the type of condoms to use for anal sex is going to be broken with GMFA and Camden and Islington gay men's team offering conflicting advice. Will it matter to UK gay men? Or will it simply reflect what gay men are doing already, two years after the research was first publicised, assuming that theyíre not one of the estimated 40% of UK gay men who will have unprotected anal sex this year.
Condoms containing spermicide
A spermicide is a chemical substance which is designed as a form of birth control by inactivating sperm to prevent conception. Some are also effective against HIV in some circumstances (see Uncertainty about spermicidal lubricants below). Spermicides may be introduced in lubricant on condoms, lubricating gels, pessaries etc. Condoms that contain nonoxynol-9 are no longer recommended as a safer alternative to condoms without nonoxynol-9 since evidence emerged in 2000 that nonoxynol-9 may actually facilitate HIV transmission rather than provide added protection. See the section on female condoms and spermicides for more detail. Condoms that don't contain spermicidal lubricant may contain other water-based lubricants such as Sensitol.
List of non-recommended, spermicide-contained condoms:
• CONDOMI Supersafe
• MATES Ultra Safe
• MATES Ribbed
• SAFEX Natural Spermicidal
• TROJAN Supra
Brands to use if you are allergic to rubber
The vast majority of condoms are made of latex. If you are allergic to latex:
• Try Durex Allergy: it contains less of what makes you allergic to rubber condoms
• Try Femidoms which are made of plastic rather than latex
• Try polyurethane condoms if they are available.
There is no evidence that lambskin condoms prevent the transmission of HIV.
Some condoms are manufactured without a teat at the end. In the past the teat has always been considered necessary to contain semen and prevent the condom from bursting under the force of ejaculation. However, there is no conclusive evidence that teatless condoms are more prone to bursting, and research in Holland during the development of a stronger condom suitable for anal sex showed that a teatless condom was more acceptable to gay men (it looked less artificial) and performed just as well in strength trials.,/p>
Larger and snugger fitting condoms
Men who have experienced difficulty in using condoms quite often complain that condoms split because they are not large enough, or that they slip off because they do not fit snugly enough. There are quite considerable variations in penis size amongst men in the UK which are related to some extent to ethnicity. It was recently estimated that a third of penises in the UK exceed the size designated as `average' in the UK condom standard. A London GUM clinic recently investigated this variation and found that black men experienced the problem of condoms splitting more frequently, whilst Asian men were more likely to report problems with condoms slipping off.,/p.
This list above notes differences between the length and width of the standard strength condoms tested by the Consumers Association.
It is one of the scandals of this epidemic that only in recent years have any of the condoms available in the UK been marketed for anything other than vaginal use. For example, only Boys Own and Safeguard Forte condoms are currently promoted by their manufacturers towards the gay community.
Naturally, they are regularly used in very large numbers for anal sex as well as for vaginal sex. But because there are no standards for anal sex condoms, nor any guidelines on how to use them for this purpose, those using `vaginal' condoms for anal fucking may not be using the best brands, or using them in the safest way.
It may be that in the same way the female condom will also serve as an anal condom, though the same issues that apply to women using female condom also apply to gay men being fucked with one. See the section on female condoms and spermicides for further detail.
If you cannot afford condoms
Free supplies are often available from:
• NHS Family Planning Clinics
• Brook Advisory Centres
• Needle exchanges and drugs agencies
• Some GUM clinics
• Some local HIV/AIDS services and self help groups
• And increasingly from some GPs
• Gay pubs and clubs in London participating in the health-authority funded free condom scheme Freedoms.