Revisiting the condom riddle: solutions and implications.
Munoz, Karen ; Davtyan, Mariam ; Brown, Brandon 等
Introduction: Male Condoms
A male condom is a thin sheath worn over a the penis during sexual
intercourse to reduce the risk of acquirement and transmission of Human
Immunodeficiency Virus (HIV), Sexually Transmitted Infections (STIs),
and to prevent pregnancy. Since its first appearance in the 16th
century, the male condom, has evolved and as current paradigms suggest,
using them consistently and correctly provides protection against the
aforementioned conditions (World Health Organization, 2010).
Today, condom availability and use continue to be widespread,
especially in developed parts of the world, and play a significant role
in public health interventions and outreach efforts, as HIV and other
STIs continue to burden communities and societies (Moran et al., 1990).
This paper aims to critically examine the "condom riddle",
initially proposed in 1978, and provide alternative solutions with
existing paradigms in order to promote safe sexual practices through
condom use.
The Age Old Condom Riddle and Existing Solution
The condom riddle first appeared in an article entitled "An
Algorithm prevents the Propagation of Certain Diseases at Minimum
Cost". It was published in 1978 in conference proceedings
appropriately titled "Interfaces Between Computer Science and
Operations Research" (Lenstra, Rinnooy Kan, & van Emde Boas,
1978). The challenge in the riddle is as follows: If a man were to have
sexual intercourse with three women consecutively, but only has two
condoms, how would he do so without exposing himself or any of the women
to diseases. Dr. Ilan Vardi, a Professor of Computational and Applied
Mathematics at Stanford University, proposed a mathematical solution to
the problem and published it in his book "Computational Recreations
in Mathematica" in 1991(Vardi, 1991). His solution was later
translated into a non-mathematical module (Vardi, 1993). The proposed
and universal solution to this riddle is as follows: The man in question
uses condom "A" and "B" at the same time to have
sexual intercourse with woman #1. Then, he takes off condom
"B" to have sexual intercourse with woman #2 using condom
"A" only. Finally, the man turns condom "B" inside
out and places it back on top of condom "A" to have sexual
intercourse with woman #3. Through this process, he has sexual
intercourse with all three women with two condoms and reduces the risk
of exposing himself and the women to STIs as the exchange of bodily
fluids is theoretically less. To facilitate understanding of this
process, we have provided an illustration of the solution (Figure 1),
which has been discussed at length on message boards, blogs, forums,
personal websites, books, and University websites (OCF, 2004).
Public Health Implications of Posted Solution
The condom riddle may not be as unrealistic as many would think. A
study of sexual behaviors in Puerto Rico identified a 2% self-reported
prevalence of group sex activities, with this group possibly more
vulnerable to the acquisition and transmission of HIV and STIs (Ortize
et al., 2011). The current solution for the riddle does not provide the
most effective and safe method of reducing the spread of infection among
the four sexually active individuals. In this section, we examine some
of the problems associated with the proposed solution from a public
health perspective.
Condoms Are Not One-Hundred Percent Effective
As with any form of protection, condoms are not 100% effective. An
observational study carried out in the southern United States showed
that used condoms ripped during intercourse for 3% of participants, and
the rate of a condom ripping was found to be higher for first time users
(Hollander, 2005). Other studies indicate that slippage and condom
ripping during use may range from 1.0% to 3.6% (Fitch, Stine, Hager,
Mann, Adam, & McIlhaney, 2002). Thus, a condom cannot be regarded as
a flawless method of reducing the risk of acquisition and transmission
of STIs and pregnancy prevention. The solution to the riddle, therefore,
does not account for the margin of error in ripping, breakage, and other
mechanical problems.
Using Condom A and B Together
In order for condoms to be effective, they must be used correctly.
Utilizing the same condom for more than one episode of intercourse,
using two or more condoms simultaneously, or wearing a condom inside out
presents problems when trying to minimize exposure to bodily fluids.
First, a condom must never be used more than once, since this increases
the chances of ripping ("What care should be taken to ensure
correct male condom use?" 2013). Second, using more than one condom
at a time, a practice called "double-bagging", can lead to
increased friction thereby elevating the likelihood of ripping
("Condoms," 2013). Third, using a condom inside out makes it
difficult for a man to remove it after sexual intercourse, leading to an
increased risk of exposure to bodily fluids (Hollander, 2005).
Therefore, the solution proposed to the riddle fails to account for
issues that surface with improper condom use.
Skin-to-Skin Infection
Condoms are not 100% effective in reducing the risk of STI
transmission that may occur in areas of the skin that are not protected
by the condom (Male Latex Condom: Specification, Prequalification and
Guidelines for Procurement, 2010). Genital ulcer diseases such as
genital herpes, syphilis and cancroid are examples of such STIs.
Furthermore, HPV may also be transmitted from infected skin and lesions
not covered by condoms, and lead to genital warts or cancer (Fitch,
Stine, Hager, Mann, Adam, & McIlhaney, 2002). Consequently, the
riddle solution fails to recognize that STIs vary greatly in their
location and ability to spread. If any individual were to be a carrier
of an STI transmitted through areas not covered by a condom, all others
will be at an increased risk for infection.
Alternative Solutions to the Riddle and precautions
STI Testing
Before all four individuals decide to engage in sexual intercourse,
it should be recommended that they undergo STI testing. Screening for
common STIs such as Gonorrhea and Chlamydia entail a simple urine test.
Herpes, HIV, and Syphilis can be detected by serological testing to
determine presence of antibodies, and HIV testing is now less invasive
with oral swab testing. Trichomoniasis and HPV screening involve a
pelvic exam followed by microscopic visualization of genital specimens
(Greenwald, Burstein, Pincus, and Branson, 2006). Furthermore, it is
important for these individuals to get tested regularly as STIs have
different incubation periods before symptoms appear and some are
asymptomatic altogether, constituting a particular challenge. While STI
testing is now available in most countries, there are structural and
societal barriers to access for economically disadvantaged groups and
those living in the developing world (Kolman et al., 2011; Packel,
2012). It is important to note that although STI testing is an important
step towards achieving favorable health outcomes, each test carries
diagnostic limitations, some STIs are untreatable and correct diagnoses
and disease management will depend on the natural history of the disease
in question.
Reducing the Number of Lifetime Partners
Abstinence is the ideal method for preventing STIs, but may not be
a realistic solution due to societal standards. Fortunately, reducing
the number of lifetime sexual partners greatly reduces the acquisition
of STIs (Fitch, Stine, Hager, Mann, Adam, & McIlhaney, 2002). Thus,
the solution to the riddle needs to be modified to include a risk
analysis of having sexual intercourse with multiple partners in a short
period of time. If the man were to just have sexual intercourse with one
woman, his and her risk of acquiring STIs would be significantly
reduced. However, it is important to note that having sex with one
partner does not eliminate the risk of contracting an STI because the
partner in question may be infected with an STI and may have varying
levels of sexual experience that can significantly increase one's
risk. It is therefore in the best interest of involved parties to engage
in open, honest, and consistent dialogue about sexual behaviors and
histories, in order protect one another from venereal diseases.
Alternative condoms
For individuals with allergies to latex, non-latex condoms are
widely available. Polyurethane condoms are undoubtedly the best
alternative. In fact, studies indicate that polyurethane condoms are
comparable to latex condom in that they do not have excessively high
rates of slippage and breakage, and can be considered a safe-sex method
((Potter & de Villemeur, 2003). Additionally, study results indicate
that other non-latex condoms such as those from polyisoprene (approved
by the FDA in 2008), exhibit strong comparability to latex condoms in
terms of protection and durability ("Durex Synthetic Polyisoprene
Male Condom," 2008). Lambskin condoms, while effective in
preventing pregnancy, are not effective in reducing the likelihood of
contracting STIs because of their porous nature and should not be used
for that purpose ("Condoms: Barriers of Bad News," 2009). The
evolution of the condom has not ceased with latex and non-latex options.
A new innovative form of barrier protection called the Origami condom
has gained popularity and is expected to reach the market soon. They are
being referred to as the 21st century condom ("About the
condoms," 2013). The male and female Origami condoms provide users
with pleasure-oriented silicone without having problems associated with
rolling the condom on. The goal of Origami condoms is to increase
consumer use, while maintaining sexual pleasure. Female condoms are also
an effective tool to reduce the transmission of HIV and STIs. Studies
have found reductions in the prevalence of STIs among women who engaged
in sexual intercourse where both a female and male condom was present
(Fontanet et al., 1998; Macaluso, 2000).
However, condoms of all types and materials have the disadvantage
of not covering the entire genital area, leaving skin vulnerable to
exposure to particular STIs. To address the surface area limitation of
traditional condoms, we recommend a new condom design that would cover a
larger portion of the genitalia. The proposed condom design would cover
the testicles in order to reduce the risk of STIs that may be contracted
from bodily fluids and skin-to-skin contact. More research is needed to
examine the acceptability of such a condom.
Education
Another important component in addressing the posted condom riddle
solution is education focused on proper condom use (D'Anna, 2012).
As studies have shown, incorrect practices such as not withdrawing the
penis after ejaculation, improper holding of the condom as it is placed
on the penis, not pinching the tip of the condom before use, and coming
into contact with semen before the condom is put on can all elevate the
risk of infections. Thus, in-depth explanations are warranted to condom
users to maximize their self-efficacy of use and to minimize their
exposure to bodily fluids that could be carrying STIs (Duerr, 2011).
Treatment as Prevention
Recent findings have shown that Pre-Exposure Prophylaxis (PrEP),
one of the newest HIV prevention strategies, is an effective tool that
can be used to reduce the risk of HIV infection among men and women who
are at high risk of becoming infected. Those undergoing PrEP treatment
must take the pills consistently in order to maximize efficiency and
effectiveness (Centers for Disease Control, 2013). However, PrEP alone
cannot reduce acquisition of HIV. An intervention strategy that focuses
on behavioral modifications such as an increase in condom use and a
decrease in the number of sexual partners combined with PrEP may be the
most effective way to prevent HIV transmission among high risk
populations (Vissers, Voeten, Nagelkerke, Habbema, & De Vlas, 2008).
Limitations
The recommendations mentioned in this paper are a response to the
condom riddle which only mentions one man engaging in sexual intercourse
with three women. Yet, it is important to acknowledge that other
vulnerable groups can also benefit from all of the mentioned strategies.
A woman who engages in sexual intercourse with multiple partners and men
who have sex with men (MSM) should also follow similar suggestions to
reduce the acquisition of STIs and HIV transmission. Further discussions
are needed to analyze the factors within these populations that may need
an intervention to reduce the transmission and acquisition of STIs and
HIV.
Conclusion
The public health implications surrounding the proposed solution to
the condom riddle are important to examine in order to educate the
public and develop new and effective strategies to reduce the risk of
contracting STIs. The condom continues to be the most effective way for
reducing these risks after abstinence. We must propose new solutions to
the condom riddle that can educate the public on the importance of
proper condom use, prevention of STIs, regular testing, reduction of
lifetime sexual partners, and communication among partners.
[FIGURE 1 OMITTED]
Karen Munoz, B.S.
Program in Public Health, University of California, Irvine
Mariam Davtyan, MPH
Program in Public Health University of California, Irvine
Brandon Brown, MPH, Ph.D.
Program in Public Health Department of Population Health and
Disease Prevention University of California, Irvine
Contact and Additional Information to be addressed to: Brandon
Brown, 653 E. Peltason Drive, AIRB, Rm. 2024, Irvine, CA 92697-3957.
(949) 824-6996 phone (949) 824-0529 fax brandon.brown(at)uci.edu
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Caption: Figure 1. Condom riddle posted solution