There are two principal strategies currently available for women to prevent sexually transmitted disease (STD): abstinence and condom use. Both strategies require negotiation and assertiveness with a partner. This necessity is perhaps the greatest impediment to protection against disease for women. As with pregnancy prevention, negative consequences for fail­ure to protect fall more heavily on women than men. Data suggest that women are more susceptible than men to infection as a result of unpro­tected sex with an infected partner by a factor of 12 to 1 (Padian, Shiboski, &. Jewell, 1990).

To determine whether condoms represent an effective method of dis­ease prevention for women, it is important to learn about how decisions related to condom use are made by couples. A study examining women’s role in decision making with respect to condom use (Osmond et al., 1993) revealed that 35% of women in the sample either never discussed condom use with a partner or had no role in deciding whether to use a condom. These data made it evident that the unwritten rule among couples was that intercourse occurs without condoms and that for condoms to be used, the couple must talk. For those couples who never discussed condom use, 100% were using condoms less than half the time. If the male partner made the decision concerning condom use, only 12% used condoms more than half the time. If the decision was made jointly, 32% reported using condoms more than half the time, and if the woman reported making the decision herself, condoms were used more than half the time by 49% of the couples. The importance of this research is that it demonstrates both that a substantial portion of women do not have input into a critical sexual health decision and that many men cannot be counted on (without women’s input) to make decisions that protect women.

Research supports the conclusion that when women control the use of an efficacious prevention method they will use it. The family planning literature indicates that when types of contraceptives that can be con­trolled by women are available, they are often used, whereas when types of contraception traditionally controlled by men are relied on, they are not used as much (Rosenberg &. Gollub, 1992). These authors reviewed 10 observational studies that compared the effect of condoms, diaphragms, or spermicides on the risk of STDs (not including HIV). Nine of the 10 studies found lower risk among users of female-controlled devices than among condom users. The largest study (Rosenberg, Davidson, Chen, Jud – son, & Douglas, 1992) found a significantly greater risk for male-controlled (condoms) than for female-controlled (spermicide or diaphragm) methods. Such evidence leads some to recommend the female-controlled methods as more effective (taking into account compliance) than more efficacious male-controlled methods that have a lower rate of compliance (Stein, 1990, 1993). Women’s reproductive freedoms over the past 20 years have relied on female-controlled contraceptives such as the IUD, oral contra­ceptives, and the diaphragm, as well as on abortion. The HIV/AIDS epi­demic has been particularly challenging for women because it has partially set back women’s reproductive health to a time when reproductive health was controlled by men.

Furthermore, research indicates that it is difficult to increase women’s assertiveness for condom use. For example, Gallagher, Morokoff, Quina, and Harlow (1991) reported an increase in condom use following a five – session small group intervention with college women compared to a control group. However, a follow-up study revealed that after one year condom use for the intervention group had decreased to a level below that of the con­trol group (Gallagher & Lang, 1993). Similarly, Deiter (1993) found no increase in sexual assertiveness as a result of a sexual assertiveness training intervention for college-age women, although the program was rated fa­vorably by women. Part of the problem in demonstrating effectiveness of the intervention was that scores on the sexual assertiveness scale declined for women in both intervention and control groups. This interesting find­ing suggests that young women may initially have an unrealistic appraisal of their own level of sexual assertiveness, which they revise on subsequent test administrations.

Gavey and McPhillips (1997) found that some women reported being unable to initiate condom use despite their stated intentions not to have intercourse without a condom and despite having condoms in their pos­session. The author interprets this experience in the context of a socially determind sexual passivity. It is unlikely that gender roles for sexuality and social pressures on women to sexually acquiesce will dramatically change in coming years. Therefore, real questions exist as to whether the best protection for women involves teaching them to be sexually assertive con­cerning condom use with male partners. Alternative approaches in­volve speeding up the development of a female-controlled microbicide as well as focusing on heterosexual men to teach them sexual responsibility.