Commercial advertisements are needed to create a condom culture

EDITOR—Yamey highlighted the need for work on the sexual health of boys and men, and he identified education and service provision as the key factors in increasing condom use, among other outcomes.1 Both of these factors fail to address the underlying problem, that condoms are unpopular—they are far short of desired items among young men in particular.

A major factor influencing cultural attitudes is not education or services but the media. Global marketing, vast advertising budgets, and sexual imagery are used to sell items as diverse as chocolate bars and sanitary products on television. However, noticeably absent in the United Kingdom is any commercial television advertisement promoting particular condom brands or targeted to the growing market for condoms. Consequently, the promotion of condom use falls largely on public sector bodies. Education and health bodies have already made condoms more available to young people and developed an understanding of their health benefits. However, without a cultural move making condom use popular, such efforts have limited success as health promotion fights to convince people to use unpopular products. Partly as a result, sexually transmitted infections in young people are increasing in England, 2 and there are 90 000 teenage conceptions a year.3

Condoms are produced commercially and lend themselves to many images that are used to market other products successfully, so you would predict a deluge of television adverts promoting one brand above another. Antiquated advertising rules may explain why this has not happened. Those governing condom advertisements on UK television expressly forbid companies from showing the product unwrapped, and consequently the image of an unwrapped condom cannot be normalised or promoted.4 Advertising limitations also dictate social responsibility in advertisements and prohibit anything promoting promiscuity. How far these other measures limit advertisers seems to be unknown, but such restrictions should be measured against the numerous television hours showing promiscuity without any reference to condoms. Furthermore, these considerable restrictions on condom advertising may prevent movement of new producers into markets and consequently stifle the competition necessary to refine marketing and product development.

The government is pursuing strategies in communicable disease, sexual health, and HIV, as well as reductions in teenage pregnancy.3 Pragmatic revisions to existing rules on the commercial advertising of condoms may allow commercial interests to work with those of health to alter the image of condoms and increase markets (particularly among young people) in order to help reduce sexually transmitted infections and unwanted pregnancies.

Attitudes to adolescent boys' sexual and reproductive health urgently need changing

EDITOR—Yamey questions the appropriateness of ignoring sex differences in sexual and reproductive health, a grave omission in view of the obvious differences in boys' and girls' experiences of their culture, adolescence, and sex.1 The fact that the focus has been on girls is not surprising because, physically at least, they bear the burden of a pregnancy, delivery, or termination. However, as sex is a joint experience, research and clinical practice should recognise and address this. Last year's Our Healthier Nation consultation paper acknowledged the importance of individual differences in behaviour.2 Our study of 2018 adolescents confirmed significant differences in self efficacy: girls were more able to say no to sex (61.5%) than boys (38.5%) (P<0.0001).

The media, a powerful source of information, refer more to the consequences of sex for girls than for boys. Although results are divided about the usefulness of sex education, girls unequivocally benefit more than boys from sex education from school and the media.3 Our data show that, although more boys than girls had used contraceptives, paradoxically boys were more willing to have sex without contraceptives and were less unhappy with a pregnancy than were girls. Whether this is through ignorance or boys' unrecognised wish to be involved in the consequences of unsafe sex is not clear.

Yamey urges the nation to change its approach to adolescent sex.1 By recommending that safe sex services be made “more attractive,” he acknowledges that a shift in culture is imminent. Research and government echo this. The question now is: why can't we effectively implement the attitudinal change that is needed? If research continues to fail to have an impact on practice, perhaps the media could redress the covert sexual health equality imbalance for boys in the same way that they, rather than policy or health care, have impacted overtly on the sexual health of girls.