Contraception in Spain

This report analyzes various aspects of contraception in Spain. One notable finding is the wide socioeconomic, cultural and health variation among regions. Since 1975 a significant drop in the birth rate has been observed overall. Twenty per cent of the women studied at risk of pregnancy are using oral contraceptives. The most widespread contraceptive method is still coitus interruptus, followed by oral contraception and the condom, as well as the rhythm method. The highest use of oral contraceptive and IUDs is seen in Catalonia (20% and 26% respectively) followed by Andalusia, Madrid and Valencia. Although contraception has only recently become legal in Spain, it is widely available either without charge or very inexpensively; all methods including abortion are available. At present, priority is given to special interest groups such as women in special circumstances, teenagers, etc. and to special programs like "Integrated Care for Women" which includes contraception, STD, pregnancy monitoring, early diagnosis of gynaecologic cancer and menopause.     

Contraceptive behavior in the population of the Czech Republic: results of a national survey

Using an anonymous questionnaire the authors investigated in a representative group of the Czech population above 15 years of age (862 men and 857 women) the use of the main contraceptive methods. During the first intercourse more than half the respondents did not use any contraception, a condom was used only by 19% men and 14% women. In a steady partnership the most frequent method of contraception is coitus interruptus, whereby experience with hormonal contraception was reported by cca one third and with a condom by two thirds of respondents. Among younger men and women there are more users of hormonal contraception and condoms. Only 5% of the examined men and 4% of the women opposed any type of contraception, almost one quarter of respondents use only so-called "natural methods" and almost three quarters of the respondents consider them an essential part of sex life. The attitudes of atheists and junior and more educated women are more liberal.     

Attitudes toward condoms and experience with their use among sex education teachers

BACKGROUND: The sex education is influenced by knowledge and attitudes. The aim of presented study was to evaluate the attitudes toward condom among sex education teachers and their personal experience with its use. METHODS AND RESULTS: Attitudes toward condoms were measured by 10-items anonymous questionnaires according to Zv?rina and Lippert. Personal experience was subjectively assumed in 5-point scale. The samples consists of 230 sex education teachers, among them 193 (84%) women. The average age was 40.5 +/- 9.7 years, in the range from 19 to 60 years. 37 teachers (16%) assigned themselves as religious. Condom was evaluated as a good protection against HIV and other STD in almost all answers. Three fifths of teachers considered condom to be an excellent contraception. 48% teachers did not know if the majority of women dislike condom. One tenth respondents rejected the opinion that the men dislike condoms. One tenth of teachers has never experienced condom personally. 12 percent stated to use it regularly, among them are more represented men. The opinions about quality of condom and decreased sensitivity by condom differ believers from atheists and users from non-users. CONCLUSIONS: Attitudes toward condom are predominantly liberal among Czech sex education teachers. The personal experience with use is common but not regular. The religion has small influence toward the attitudes and use.     

Electrogenic cation transport across leech caecal epithelium

This paper is based on the analyses of data collected in the Tanzania Demographic and Health Survey (TDHS). The TDHS national sample was obtained by using 1988 population census list of enumeration areas. Information about sexual behaviour and condom use was obtained from sexually active women (N = 4620) and men (N = 1440) reporting sexual activity during the period of four weeks preceding the survey. Univariate and multivariate (using logistic regression model) analyses were done to identify predictors of condom use and highrisk sexual behaviour. About 6% of women and 31% of men reported to have more than one sexual partner during the study period. Compared to respondents married once and in monogamous union, the tendency to have multiple partners was increased among never married women [OR 10.9, 95% CI (7.1-16.9)] and men [2.6 (1 7-3.9)], formerly married women [11.5 (7.3-17.9)], and among men in monogamous marriage reporting more than one marriage [12.4 (8.3-18.4)]. Occupation, residence, ever use of contraceptives, and AIDS knowledge were not associated with history of multiple sexual partners. Only 134 (9.3%) men and 173 (3.7%) women reported to have used condoms during the study period. After adjusting for other predictors of condom use, respondents reporting multiple sexual partners were more likely to have used condom among both women [3.4 (2.2-5.4)] and men [3.3 (2.3-6.0)]. Condom use was common in urban areas than rural areas and among unmarried respondents. These results show that high-risk sexual behaviour is common among men. Condom use was very low indicating that efforts to promote condom use has been less successful in Tanzania. More efforts are needed to promote safer sexual practices and condom use in Tanzania.     

Why gender is a barrier to contraception advice

In the UK, the Contraceptive Education Service is attempting to place contraception services on the health care agenda for all health providers dealing with heterosexual and bisexual men. Contraceptive education can prompt men to take more responsibility for contraception. Recent surveys indicate that the taking of sexual histories varies not only from clinic to clinic but also among various practitioners working in the same clinic. An observational study revealed that contraceptive information was not displayed in a third of general practitioners' offices and 10% of family planning and sexual health clinics. While good reasons may exist for keeping the information under the counter, clients have expressed a desire for printed information that they can take home to read. Sexual health clinics (formerly called "genito-urinary" clinics) are being targeted as one of the best places to reach sexually active men. Currently inequalities exist between what female and male patients are asked. For example, men are not asked how many unwanted pregnancies they have caused. Nurses have a special role in health education because they are perceived to be more approachable than physicians. While nurses discuss condom use whenever they have the opportunity, most feel that schools are the best place for sexual health education. The nurses also felt that, whereas most men have no need for information about oral contraceptive usage, information on emergency contraception may prove valuable. One clinic is using new forms to take sexual histories and prompt providers to cover topics such as safer sex and risk reduction.     

High HIV prevalence, low condom use and gender differences in sexual behaviour among patients with STD-related complaints at a Nairobi primary health care clinic

Of 22,274 patients > or = 12 years old attending a Nairobi primary health care (PHC) clinic, 1076 (4.8%) had STD-related complaints, of whom 980 underwent assessment of risk factors for human immunodeficiency virus (HIV) infection and infrequent condom use. Gonorrhoea, chancroid, syphilis seroactivity, trichomoniasis, or objective signs of STD were found in 78%, and HIV seropositivity in 15% of men and 19% of women. Most women were married, living with a spouse; while most men were single, or married, but living separated from a spouse. Among married men, last sex was with a female sex worker (FSW) or casual partner for 60% not living with a spouse and 26% living with a spouse (P<0.005). Two or more partners during the past year were reported by 82% of men and 25% of women (P <0.001), and 55% of men and 11% of women reported the last partner was high risk. HIV seropositivity among both genders was associated with numbers of partners, and among women, with being widowed or divorced. Only 3% reported use of a condom with the last partner. Among men whose last sex was with a FSW, 74% said the reason for not using a condom was not having one. Thus, infrequent condom use, low condom availability, and gender differences in behaviour necessitate modifying development policies that separate families; and better coordination between family planning, PHC, and AIDS/STD programmes, with improved supply, social marketing and community-based distribution of condoms in high-risk settings for STD/HIV prevention.     

Durable effects of implementation intentions: Reduced rates of confirmed pregnancy at 2 years.

Objective: To assess the long-term impact of implementation intention formation in reducing consultations for emergency contraception and pregnancy testing among teenage women. Design: Teenage women visiting a family planning clinic were randomly assigned to implementation intention versus control conditions. Main outcome measures: Objective measures of consultation outcomes were obtained from clinic records at 2-year follow-up (N = 227). Results: Rates of consultation for emergency contraception and pregnancy testing in the implementation intentions condition were 19% and 33% lower, respectively, compared to the rates observed in the control condition. Pregnancy rates were 43% lower. Intervention participants who consulted for emergency contraception and pregnancy testing at baseline were more than twice as likely to change to consulting for contraceptive supplies over the follow-up period compared to equivalent control participants (19% vs. 9%). Conclusion: The impact of implementation intention formation on reducing pregnancy risk among teenagers is durable over 2 years. Implementation intentions were successful in changing behavior among precisely those participants who were at greatest risk of becoming pregnant. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Planned condom use among women undergoing tubal sterilization

BACKGROUND AND OBJECTIVES: Women who are undergoing tubal sterilization are at risk for various sexually transmitted diseases (STDs) if they do not use a barrier method of contraception. There is a paucity of data concerning dual use of condoms among sterilized women. GOAL: Planned use of condoms for protection against STDs was examined among 2,782 women undergoing surgical sterilization from 1991 to 1996. STUDY DESIGN: Cross-sectional survey. RESULTS: Planned condom use increased significantly over the 6-year study period. Of women who were using condoms before sterilization (n = 646), nearly half indicated no plans to do so after becoming sterilized. Thus, 11% of the total sample experienced an increased risk for exposure to human immunodeficiency virus or other STDs. Condom abandonment was significantly higher among Hispanic and married women. Multiple regression analysis was used to examine the association between condom use and various characteristics. Factors associated with future condom use were younger age, black ethnicity, being unmarried, previous STD, not having a steady partner, higher number of previous sexual partners, having used condoms for disease prevention in the past, and lack of partner involvement in the decision to undergo sterilization. CONCLUSIONS: Use of condoms among sterilized women appears to be on the rise, women at higher risk for disease are more likely than others to be using condoms, and only a small group of women experience an increased risk for exposure to disease as a result of selecting this permanent method of contraception.     

Young women's condom use: The influence of acceptance of sexuality, control over the sexual encounter, and perceived susceptibility to common STDs.

A comprehensive model of the determinants of condom use among young women was developed, tested, and replicated, with longitudinal follow-up to assess predictive utility of the model for condom use over time. Participants in Study 1 and Study 2 were 198 female undergraduates (mean age, 18.6 years) and 238 female undergraduates (mean age, 19.1 years), respectively. Acceptance of sexuality and control over the sexual encounter were related to a multidimensional measure of condom use self-efficacy, which predicted condom use intentions. Perceived susceptibility to STDs was both directly related to intentions and indirectly related through perceived benefits and attitudes about condom use. Intentions predicted subsequent reports of condom use. The model suggests foci for condom use interventions for young women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implementation intention formation reduces consultations for emergency contraception and pregnancy testing among teenage women.

Objective: This study examined the impact of implementation intention formation in reducing consultations for emergency contraception and pregnancy testing in young women. Design: Teenage girls (N = 261) visiting a family planning clinic were randomly assigned to implementation intention versus control conditions and completed questionnaires at recruitment. Main Outcome Measures: Objective measures of consultation outcomes were obtained from clinic records at baseline and 9-month follow-up (n = 200). Results: Forming implementation intentions significantly reduced consultations for emergency contraception and pregnancy testing at follow-up compared with the control group (38% vs. 55%). There were also differences between the groups in consultation outcomes over time. For instance, whereas 31% of implementation intention participants changed from consulting for emergency contraception and pregnancy testing at baseline to consulting for contraceptive supplies only at follow-up, only 16% of control participants did so. Conclusion: These results suggest that implementation intention formation is a simple yet effective means of promoting pregnancy prevention among teenagers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A rivalry of foulness: official and unofficial investigations of the London cholera epidemic of 1854

OBJECTIVE: To describe and explain sex differences in antihypertensive drug use. DESIGN AND METHODS: From 1987 to 1995, two cross-sectional population-based surveys of cardiovascular disease risk factors in The Netherlands were carried out among 56026 men and women aged 20-59 years. Polytomous logistic regression modelling was used to adjust for potential confounders of the association between sex and use of different antihypertensive drugs. RESULTS: The response rate was 40% for men and 46% for women. Of these respondents, 40% (1041) of the hypertensive men and 59% (1403) of the hypertensive women were being treated pharmacologically; 57% (595) of the treated men and 54% (760) of the treated women were on monotherapy for hypertension with a diuretic (men 14.8%, women 37.2%), a beta-blocker (men 59.0%, women 45.3%), a calcium antagonist (men 8.6%, women 5.0%) or an angiotensin converting enzyme inhibitor (men 17.7%, women 12.5%). Among those on monotherapy for hypertension, women were less likely than men to be using a beta-blocker [prevalence odds ratio (POR), female/male=0.34; 95% confidence interval (CI) 0.24-0.47], a calcium antagonist (POR=0.27, 95% CI 0.15-0.48) or an angiotensin converting enzyme inhibitor (POR=0.34, 95% CI 0.22-0.52) than a diuretic. These sex differences persisted after adjustment for all factors that could have influenced the choice of these antihypertensive drugs (indications and contra-indications for the four antihypertensive drug classes). The sex differences in antihypertensive drug use were smaller among hypertensives with a history of cardiovascular disease (adjusted PORs, female/male, for beta-blockers, calcium antagonists and ACE inhibitors, respectively, compared to diuretics were 0.80 with 95% CI 0.20-3.24, 0.40 with 95% CI 0.10-0.48 and 0.64 with 95% CI 0.12-3.39) than among those without such a history. CONCLUSIONS: The different patterns of antihypertensive drug use among hypertensive men and women seem irrational, and cannot be explained by factors known to influence antihypertensive drug choice. Among hypertensives with a history of cardiovascular disease, the sex differences were smaller than among those without such a history. Further research is required to explain the sex differences in the choice of antihypertensive drug by prescribers, and to investigate the consequences of these differences for long-term patient outcomes.     

Current status of the female condom in Africa

The female condom was developed in the 1980s. It is a contraceptive device used by women that protects against both pregnancy and sexually-transmitted diseases (STDs) including HIV infection. Two studies have investigated the contraceptive effectiveness of the female condom, and it was found to be as effective as other barrier methods. It has been shown to be effective against STD and HIV transmission in vitro but there is only limited evidence of its efficacy in vivo. No serious local side effects or allergies have been reported and the female condom can be used with any type of lubricant, spermicidal cream or foam. The female condom is the only device other than the male condom that has been shown to prevent HIV transmission. The female condom has been marketed in 13 countries since the summer of 1996. Most of these countries are industrialized and the selling price in these countries is too high for developing countries. Sub-Saharan Africa has very high prevalence rates for HIV infection, at least 30% of the general population in Eastern and Central regions. The epidemic is also spreading fast in some parts of the Western region. In Ivory Coast for example, 12 to 15% of pregnant women are infected. African women are subordinate to men in many aspects of their lives, politically, educationally, socially and sexually. This sexual inequality makes them highly vulnerable to STDs, including HIV, and unwanted pregnancies. This paper reviews 10 of the 15 studies carried out in sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization. Recruitment methods, education of subjects, methodology and assessment of acceptability differed between studies. Despite these limitations, most studies concluded that the women who participated in the trials generally found the female condom acceptable. Acceptability was established quicker among prostitutes than among other women and men found the female condom less acceptable than did women. However, the sample size is too small to draw any firm conclusions. Commercial sex workers in the studies reviewed were very interested in this new method because it gave them an additional method of safer protection during sex. However, they were occasionally faced with difficult negotiations with some clients, refusal to use the female condom and sexual violence. Reuse of the device was reported in four studies, but the term reuse is seldom defined. In cases where it was defined, the frequency of reuse, with washing of the device, accounted for no more than 1% of the total number of uses. The acceptability of the female condom among women other than prostitutes faces two obstacles, the reaction of the woman's regular partner and attitudes to the device itself (appearance, difficulties or uneasiness concerning its use). However, some women liked it because it provided dual protection against pregnancy and STDs and sexual pleasure. The moderate level of acceptability to male partners may be overestimated because women whose partners disliked the device would be more likely to discontinue its use. The studies of acceptability reviewed here show that use of the female condom in Africa is realistic and that it provides women with more independent protection. Initial negative perceptions of the device are often replaced with a more positive reaction after several uses. The experience gained with use reduces the technical problems. We need to overcome the stereotypes, simplifications and strong opinions that threaten to damage the acceptance of this new method and efforts to encourage women to adopt it. However, we still require further clinical data on the effectiveness of the female condom at preventing pregnancy and HIV transmission. Availability of the female condom is improving in Africa. Pilot marketing studies were launched in 1996 in Guinea, Zambia, South Africa, followed by Uganda and Tanzania. There are local initiatives in Ivory Coast and Zimbabwe. (ABSTRACT TRUNC     

Body mass and social class: a comparison of Finland and Sweden in the 1990s

High physical weight affects public health as well as people's social relations. This study seeks to examine the distribution of physical weight across the social structure in Finland and Sweden in the early 1990s. We compare physical weight, classified by overweight and obesity, 1) between men and women, 2) between different age groups, and 3) between social classes in these two countries. Comparable interview surveys were conducted in Finland 1994 (N = 8,650, response rate 73%) and in Sweden 1991 (N = 5,306, response rate 79%). Physical weight, overweight and obesity of populations are described in terms of body mass index (BMI = weight (kg)/height (m2)). The average BMI is higher in Finnish men (25.6) and women (24.6) than in their Swedish counterparts (24.6 and 23.2, respectively). In both countries, the average BMI is higher in men than in women below the age of about 55-64 years. In both countries and in both genders the average BMI is higher, the higher the age. The level of overweight as well as obesity is lower in Sweden than in Finland. Social class differences can be found in both countries. The odds ratio for overweight is higher in Finnish male and female farmers (OR = 1.57 and 1.94, respectively) as compared to upper white collars (OR = 1.0). In Sweden, high odds ratio for overweight can be found among male entrepreneurs (OR = 1.80) and female unskilled manuals (OR = 2.65). Obesity varies by social class in Swedish men and women as well as in Finnish women, but not in Finnish men. The results show that Finnish men and women are more often overweight and obese than their Swedish counterparts, but social class differences in overweight and obesity are larger in Sweden than in Finland.     

Gender discrepancies in living related renal transplant donors and recipients

Renal transplantation is the most successful treatment strategy for patients with ESRD to improve survival and quality of life. The study presented here examines the relationship of gender and living related (LR) transplantation donor and recipient rates in the United States. National data from the United States Renal Data System (USRDS) were used for this study. All LR transplants occurring between 1991 and 1993 among blacks and whites were included (N = 6193). Transplantation and donation rates for men and women were calculated. Poisson regression was used to calculate female/male transplantation and donation rate ratios. Overall, women were 10% less likely to receive a LR transplant than men (rate ratio [RR] = 0.90, P < 0.001). This gender difference increased over time from 1991 (Female/Male RR = 0.95, P = not significant [NS]) to 1993 (RR = 0.85, P < 0.001). In contrast, women were significantly more likely to donate a kidney than men (RR = 1.28, P < 0.001 and RR = 1.29, P < 0.001 among whites and blacks, respectively). Analyses by age subgroups revealed that only among ESRD patients aged 20 to 44 yr was the likelihood of receiving a LR kidney transplant equal for men and women. Higher donation rates among women compared with men were observed in all donor age and race subgroups except young blacks (aged 0 to 19 yr). Recipient gender appeared to influence donation rates. The female-to-male relative donation rates were higher when donations were to female, compared with male, recipients. This study of national data suggests an imbalance in LR donation and transplantation between men and women. Women are more likely to donate a kidney but are less likely to receive a LR transplant than men. Several potential explanatory factors are explored. These findings suggest a need for the development of gender-appropriate interventions to encourage donation among men and LR transplantation among women, to ultimately facilitate greater use of this ESRD treatment modality.     

Changes in sexual behavior and condom use among teenaged males: 1988 to 1995

OBJECTIVES: This study examines shifts in sexual experience and condom use among US teenaged males. METHODS: Results from the 1988 and 1995 National Surveys of Adolescent Males were compared. RESULTS: The proportion of never-married 15- to 19-year-old males who had had sex with a female declined from 60% to 55% (P = .06). The share of those sexually active using a condom at last intercourse rose from 57% to 67% (P < .01). Overall, the proportion of males who had sex without condoms last year declined from 37% to 27% (P < .001). CONCLUSIONS: Although protective behaviors among teenagers have increased, significant proportions of teenagers--especially Black and Hispanic males--remain unprotected.     

Age, gender, and non-modulation. A sexual dimorphism in essential hypertension

The angiotensinogen gene is one of the very few related by linkage analysis to human hypertension, but the linkage has been consistently shown only among males. Moreover, polymorphisms in this gene predict an abnormal renal responsiveness to angiotensin II, a feature of non-modulation, but again, only among males. To pursue these related bridges between genetics and physiology, we evaluated the effects of sex on a second feature of non-modulation, the aldosterone response to infused angiotensin II during low sodium balance. We tested the resultant hypothesis-that non-modulation would be less frequent in women-by conducting identical protocols on 225 hypertensive inpatients (70 women, 155 men). Non-modulation was strikingly less frequent among women (26%; 95% confidence interval, 16% to 37%) than men (49%; 95% confidence interval, 40% to 57% (P = .001). We tested the hypothesis that sex steroids play a role by comparing young, premenopausal women (< 35 years) with women who were perimenopausal (45 to 55 years) and postmenopausal (> 55 years). Among the youngest women, the frequency of non-modulation was only 7%, significantly less than in young men (41%, P = .02). A steady increase in non-modulation frequency accompanied advancing age in women, reaching 47% in those older than 55 years, equal to the fraction of men affected. Age influenced non-modulation frequency in men far less. We conclude that a striking sex difference underlies the non-modulation phenotype and that female sex hormones may confer protection against a genotypic predisposition in women. This "override" of genotype, manifest by a very low frequency of non-modulation in young women, may participate in their known protection against cardiovascular disease.     

Molecular features of primary MDS with cytogenetic changes

This article compares cross-sectional measures of condom use among 2,269 female sex workers in Cameroon randomly assigned to receive one of five different questionnaires measuring condom use. We found that the level of reported condom use varied depending on the type of survey questions used. Measures based on 2-week coital logs or the past 10 acts categorized more women as "100%" or "0%" users than always-to-never scales categorized women as "always" or "never" users. Consistency of use also varied by type of partner. Internal consistency of responses was high. Future studies should assess differences in prospective measures of condom use and the level of association between various measures and infection with sexually transmitted disease.     

Unplanned pregnancies in Harare, Zimbabwe: what is the contraceptive history and awareness of the mothers?

OBJECTIVES: The study aimed to estimate the proportion of unplanned pregnancies among mothers delivering at the referral Harare Hospital and to describe their levels of contraceptive use and awareness in relation to the planning of pregnancy. DESIGN: Systematic sample of mothers who had just delivered identified through maternity delivery, records. The study was analysed as a case-referent study where cases where mothers who had unintended pregnancies and those with intended or planned pregnancies served as referents. SETTING: Postnatal wards of Harare Maternity Hospital. SUBJECTS: 923 mothers following delivery. MAIN OUTCOME MEASURES: Socio-demographic characteristics, pregnancy planning, contraceptive history and contraceptive knowledge. RESULTS: Of the 923 deliveries studied, 377 (41%) were unintended (cases), of which 9% were unwanted. Mothers aged 19 years or below (Odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.6 to 3.7) and those aged 35 years or above (OR = 3.2, 95% CI = 1.8 to 5.5) were significantly more likely to report the index pregnancy as having been unintended. Nulliparous (OR = 2.4) and parity five or more (OR = 8.2) mothers were at significantly increased risk of unintended pregnancy. Mothers presenting with unintended pregnancies were also significantly more likely to be single (OR = 7.8), divorced/separated or widowed (OR = 6.0). Contraceptive ever use was 53% and 58% in cases and referents, respectively. The combined oral contraceptive pill was the most commonly known and used method of contraception. Contraceptive failure was reported by 23% of mothers with unplanned pregnancies. Previous use of the progesterone only pill (OR = 2.2), the condom (OR = 2.3) or the IUCD (OR = 6.3) were significantly associated with the likelihood of reporting with unplanned pregnancy. Mothers in both groups were concerned about contraceptive method failure, irregular menstruation and perceived subsequent infertility with contraception. Failure to discuss family planning with the male partner (OR = 2.3) or partner refusing use of contraception (OR = 2.8) constituted risk factors for unplanned pregnancy. CONCLUSION: Results point to the need for wider contraceptive counselling and provisions which encourage and involve the male partner. Programmes for reproductive health services and education should target women in identified high risk circumstances.     

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

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.