In many cases, Duke students decline to use contraception or protection during sex, a recent study found.

According to data from an American College Health Association survey, in their last instance of vaginal intercourse, 58.5 percent of students reported not using a contraceptive method or stated that it was not applicable or they did not know. Similarly, nearly 40 percent did not use protective barriers when they had vaginal intercourse in the last thirty days.

In the preceding four years, the University experienced relatively little change in proportion of students using contraceptives and practicing safe sex, according to survey data. Some students and staff interested in sexual health said they believed new initiatives like the Peer Advocacy for Sexual Health Center can improve the outlook for contraception use and safe sex at Duke.

The numbers

Overall, 378 undergraduates and 508 graduate students at Duke responded to questions about their sexual behavior for the Fall 2016 survey. The questions on sexual health asked about two distinct behaviors: students’ usage of protective barriers, such as condoms—which prevent sexually transmitted infections—and usage of contraception—which prevent pregnancy, but do not necessarily prevent STIs.

In 2016, nearly 33 percent of students reported having oral sex, just more than 29 percent reported having vaginal sex and almost 4 percent reported having anal sex within the 30 days prior to taking the survey. Among these students, 66.1 percent of students reported using condoms or protective barriers for vaginal intercourse, although just three percent reported doing so for oral sex.

“Safe sex practices for oral and anal sex are just as important as those for vaginal sex, but are often overlooked because pregnancy is of little worry,” senior Adriana Parker, co-president of PASH, wrote in an email. “However, STIs can still be transmitted through oral and anal sex.”

For anal intercourse however, the usage of condoms and other protective barriers dropped heavily compared to the past—22.7 percent in 2016, down from 60 percent in 2012.

In their last instance of vaginal intercourse, 41.5 percent of students reported using contraception, lower than the national average of 51.8 percent. Despite this proportion, just 0.6 percent of students who had vaginal intercourse within the last 12 months reported experiencing an unintentional pregnancy or getting someone pregnant.

Interpreting the data

Cole Taylor and Eulena Jonsson, assistant directors of assessment and research for student affairs, said the survey was distributed to 2,200 undergraduates through Qualtrics, an online survey platform. The sample—which received a 17.2 percent response rate—was representative of undergraduate demographics across dimensions of sex, year of school, race and whether the student was international, Jonsson said.

“We have control over the 2,200 [students], but we don't have control over who responds,” she said. “When we look at the demographics for who actually responded, males and upperclassmen are slightly underrepresented.”

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Female respondents comprised 58 percent of the responses. Breaking down the classes, 31 percent of respondents were first-years, 32.2 percent were sophomores, 12.4 percent were juniors and 23.5 percent were seniors.

David Banks, professor of statistical science, advised heavy skepticism regarding survey data. One reason, he said, was that information about the questions’ wording or order are not always provided, which can affect the quality and type of responses.

“In general, I would not trust any survey on its own,” Banks said. “If you don't have complete information on how it was designed and administered, then it could be very deceiving.”

Several student affairs staff members spoke about how the office interpreted the survey data. Tom Szigethy, associate dean and director of Duke Student Wellness Center, warned against coming to "very quick conclusions" about the numbers rather than digging deeper.

“I see survey data like this as the beginning of a dialogue,” Taylor said. “Students' perspectives enrich the data by helping us learn more about where we can or perhaps shouldn't make an inference.”

'A learning process'

Even with limits on its applications, the results of the survey have caused concern among those tasked with sex education on Duke's campus. Parker wrote that one major task of sex education on campus includes distinguishing between prevention measures for pregnancy and STIs.

Parker noted that many people—not just students—focus on pregnancy prevention more than STI prevention. She added that while most forms of contraception—such as birth control pills and intrauterine devices—prevent pregnancy, they do not prevent STI transmission.

“Safe sex is important because it allows a person to exercise their own agency in regards to family planning and prevents possible long term damage to the reproductive system caused by untreated STIs,” Parker wrote. “Many STIs have few to no symptoms, so it is best to practice safe sex to decrease one’s chances of contracting one.”

Kathy Rudy, professor of gender, sexuality and feminist studies, recalled how the concept of safe sex was developing when she taught a large class on AIDS during the 1990s.

“Mostly everyone was worried about safe sex, but none of us really knew what safe sex was in 1990,” Rudy said. “[Many] of the girls were on the pill and I saw it as my job to persuade them that the pill was not safe sex. It was a learning process for all of us.”

What should students do?

In an email, Maralis Mercado, program coordinator for health and wellness, stressed that students should get tested for STIs regularly, use protection and maintain a dialogue with partners on "expectations, boundaries and protection."

Parker recommended that sexually active people get tested every three months or after every new partner, while individuals who are not sexually active should be tested at least once a year. Free testing is available under the Student Medical Insurance Plan, or at the Adult Health HIV/STD Clinic in downtown Durham. SMIP also covers a number of contraceptives for free.

“A lot of my own friends just didn't know that the injection existed on campus and that it was free,” junior Adair Necalli said. “The pill is also free through Duke.”

For oral sex, Parker recommended that dental dams be used on people with vaginas and external condoms on those with penises and that for anal sex, both external and internal condoms can be used, but the ring must be removed in the internal condom. For all methods, she emphasized using only water-based or silicone-based lubricant to prevent damaging the barrier.

Parker wrote that withdrawal—which 34.6 percent of Duke students surveyed in 2016 reported using as a contraceptive method—provides no protection against STIs and, used alone, is only about 78 percent effective against pregnancy. She also noted that timing ejaculation may not always be accurate and sperm can sometimes be present in pre-ejaculate.

Necalli noted that one barrier to using more effective methods could be social norms around communication between partners.

“For females in general, there's this pressure to be a pleasant partner,” Necalli said. “But some guys are like 'it feels better without the condom,' or 'just trust me, I know how to do this.’ A lot of that is male selfishness—not realizing how much pressure that puts on us and how much danger that puts us in.”

Sophomore Jay Zussman, a member of the Duke Men’s Project, wrote in an email that they viewed men's control in sexual situations as being bolstered by social norms. However, they noted that their perspective did not necessarily reflect the stance of all feminists or the Duke Men's Project.

“Social norms reward men for their sexual prowess; this can lead to circumstances of gender violence in some cases,” Zussman wrote.

Duke's next steps

In an effort to encourage greater sex education, sexual health workshops targeted at men are in the midst of development, Szigethy said, adding that the Student Wellness Center is also rolling out a poster campaign about communication in relationships and safe sex practices, including abstinence.

Several students also provided suggestions for how Duke might reform the way it approaches these conversations during orientation week.

Noting that many students enter Duke with little to no sexual health education, Parker suggested that education should target first-year students. Necalli criticized the current Orientation Week efforts at education.

“I don't think that anything during O-Week actually works in terms of prevention,” Necalli said, noting there is limited attendance at many events. “A lot more progress happens when you're [having discussions] with your own peers than when [Larry Moneta, vice president for student affairs] is telling you about consent.”

Parker also supported peer education groups as an effective method to address issues of safe sex and contraception use.

“Peer education groups like PASH are incredibly important because students are more likely to engage with these topics when there is no pre-conceived power dynamic in place,” Parker wrote. “In our experience, students are much more likely to be honest and open up to us because we experience the same things.”