Condom use by Dutch men with commercial heterosexual contacts: determinants and considerations

Abstract

We report responses from 559 clients of female prostitutes, with a view to determining to what extent previously identified factors play a part in condom use. To increase the response rate to advertisements in daily and weekly newspapers, interviews were held by phone. This procedure had the advantage of ensuring the anonymity many clients demanded. Of those clients having vaginal or anal contact (91%), 14% had not always used condoms in the previous year. Compared with consistent condom users, these men were less highly educated, had twice as many commercial contacts, and had more contacts with "steady" prostitutes. They were either more emotionally motivated to visit prostitutes than were consistent condom users or exhibited a stronger need for sexual variation. They showed a more compulsive attitude toward visiting prostitutes, had a more negative attitude toward prostitution in general, evaluated condoms more negatively, had a higher personal efficacy to achieve unsafe contacts, and had a higher general risk assessment, commensurate with their behavior. Men with only safe contacts had either an intrinsic or an extrinsic motivation for condom use. Among extrinsically motivated men, their behavior change was more recent and had not yet taken root: They still envisioned unsafe commercial sex to be possible in the future. Education aimed at the small group of men practicing unsafe contacts will not easily and directly lead to behavior change. But these educational activities may support prostitutes to persist in (consistent) condom use, regardless of clients' pressure to do otherwise.

PIP: The determinants of condom use with commercial sex workers were investigated in the Netherlands in 1993 through phone interviews with 559 male clients who responded to newspaper advertisements for anonymous study respondents. The mean age of respondents was 41 years; 53% were married. Clients had an average of 22 commercial sex contacts in the year preceding the interview. 91% reported vaginal intercourse and 17% anal intercourse. 14% of men in both groups had not used condoms consistently in these encounters. Compared with consistent condom users, the multivariate analysis indicated inconsistent users were less educated, reported twice as many commercial contacts, were more likely to visit steady prostitutes, had a stronger need for sexual variation, viewed condoms more negatively, and considered their risk of HIV infection to be high. The most frequently cited reasons for consistent condom use were fear of infection with HIV (50%) or another sexually transmitted disease (67%) and sex workers' refusal to have unprotected sex (27%). Many clients who reported consistent condom use did not view safer sex as an intrinsic choice, but rather as something forced on them by the prostitute. Given the importance of extrinsic motivation to safer sex practices for HIV prevention, prostitutes must be supported in their insistence on condom use.