This question was originally posted on our website in 2005 and updated in 2008. 

                           

Q:  What is the evidence that 2 condoms may be used at once?  Who does this?  What are their reasons for doing this?  What are the other things that can do done to prevent condom breakage?  Are there some men and some women who have sexual intercourse in a manner that predisposes them to have repeated condom breaks or repeated condom slippage?

A:  In Nevada, men going to legal brothels are required to use a condom during every sexual act.  Many acts of intercourse are protected by 2 condoms.

Typical condom breakage rates range from 0.5% to 6.7%.  Falling-off rates range from 0.6% to 5.4%.  More recently, attention has focused on condoms that slip down the penis but not completely off (partial slippage). [Albert -1995] [Warner  2004]

Legal prostitutes in Nevada are extraordinarily effective in preventing HIV and other infections.  Do they use more than one condom?  The answer is often "yes".  Many of their acts of intercourse are protected by 2 condoms.

Here are the techniques prostitutes use to prevent breakage:

Among the most-cited techniques to prevent breakage were use of additional water-soluble lubricant (64%); monitoring the condition of the condom regularly throughout intercourse (20%); refraining from rough, vigorous sex (18%); using appropriately sized condoms (5%); and changing condoms during prolonged intercourse (5%).  Many of these tips have previously been suggested to prevent condom breakage.

Use of multiple condoms simultaneously was also a frequently reported method (9%) to prevent breakage.  Twenty-nine women (66%) reported that at least one client had worn two condoms concurrently during intercourse in the previous year, for a total of more than 5,000 concurrent uses.  Eight women reported doubling up condoms during every act of commercial intercourse in the previous year.  Visual inspection of the used condoms from the prospective trial revealed that condoms were doubled up in 10.8% of the 372 sexual episodes.  Condoms were doubled up primarily to prevent breakage when women had experienced a prior condom break, when the client's penis was very large, when the client presented with unidentifiable penile sores or track marks, when a thin condom was being used, and when the client requested it.  To avoid friction, women reported applying additional lubricant between the condoms. [Albert - 1995]

Albert reported a retrospective breakage rate much lower than other reported studies.  There were 49 breaks reported in the course of 41,127 acts of intercourse (0.12%).  This comes to a breakage rate of:

 1 condom break per 849 acts of intercourse.   SO LOW!

In her prospective study, 41 women used condoms during 353 acts of vaginal intercourse.  A water based lubricant was used 89% of the time and oil-based lubricants were not used at all.  There were no breaks at all (0/353) and lack of breakage was confirmed by visual inspection of all condoms by the senior author of the paper.  (Condoms had been placed in zip-locked bags).

When women receive a license to be a prostitute in Nevada, they must be HIV negative.  Between July 1, 1988 and December 31, 1993, more than 20,000 HIV tests were conducted on licensed prostitutes.  None of the women employed in any Nevada brothel tested positive at the time of follow-up HIV testing.  These are in sharp contrast to HIV prevalence rates in other female prostitutes in the United States and elsewhere.

A 1988 study found 5,000 cases of gonorrhea in Nevada, only 9 of which were detected in legal brothels.  More than 7,000 sexually transmitted disease tests conducted between 1982 and 1989 on 246 cases of syphilis and 19 cases of gonorrhea, all reportedly contracted before implementation of Nevada's mandatory condom law.

Although the actual exposure level of brothel workers to clients with HIV and other sexually transmitted disease infections is not known, the absence of HIV and other sexually transmitted diseases may be explained by the fact that clients are required to use condoms during every sexual act.

Clearly Albert has documented that use of 2 condoms in a high-risk group of women does not place them at risk for increased rates of condom breakage or increased rate of infection.

There is a final lesson to be learned from Albert's fascinating study.  Condom mishaps are not evenly distributed among all condom users.  In the retrospective phase of Dr. Alexa Albert's study, the 44 women relating their experience with condom breakage, slippage and falling off reported:

Of the 49 total breaks in the year prior to the study, 20 (41%) were reported by 1 woman.  Fourteen of the 42 instances of slippage in the previous month (33%) were reported by another woman.  Likewise, 48 of the 103 instances of slippage in the previous year (47%) were reported by only 3 women. [Albert-1995]  

Summary:  Use of two condoms is a common practice among legal prostitutes in Nevada.  Condom breakage rates are extraordinarily low among these women.  Here is an important practical lesson from Dr. Alexa Albert's work: When we see women and men who have experienced multiple breaks or slippages, we would be wise to encourage them to use 2 condoms.

References: 

Albert AE, Warner DL. Condom use among female commercial sex workers in Nevada's legal brothels American Journal of Public Health, Vol. 85, No. 11, November 1995.

Warner DL. IN Hatcher RA. et al. Contraceptive Technology 18^th edition: Ardent Media, 2004. Pages 343-347

To learn more about the advantages and disadvantages of all contraceptives, go to our website: www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.

Key Words:  period, unprotected sex, Postinor, emergency contraceptive pills, bleeding, protected, condom broke, pregnant, cycle, pregnancy test, IUD, Implanon implant, anxiety

Posted 11-16-2010, Upated 12-4-2010, Updated 12-11-2010