Condom Embarrassment Scale

1. Abstract

The Condom Embarrassment Scale (CES) is an 18-item psychometric assessment developed by Karen Vail-Smith, Thomas W. Durham, and H. Ann Howard in 1992 to quantify the multidimensional construct of embarrassment associated with condom acquisition, interpersonal negotiation, and physical application. Rooted in social-evaluative psychological theories and public health paradigms, the instrument addresses a pervasive non-rational affective barrier to safe sexual practices among emerging adults and sexually active populations. Factor analytic evaluation indicates that the CES is underpinned by three distinct, highly interpretable dimensions: (1) Condom Acquisition and Possession, (2) Condom Application and Physical Disposal, and (3) Condom Negotiation and Interpersonal Communication. Each item is rated on a 5-point Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”), generating an overall composite score between 18 and 90, where higher scores signify elevated levels of situational and anticipatory embarrassment.

Psychometric evaluation demonstrates high internal consistency (Cronbach’s $\alpha = .92$) and robust temporal stability across test-retest administrations ($r = .78, p < .001$). The construct validity of the CES is corroborated by statistically significant positive correlations with general sexual anxiety ($r = .39$), as measured by the Sex Anxiety Inventory, and negative correlations with sexually transmitted infection (STI) and condom knowledge among women ($r = -.35, p < .001$). Furthermore, known-groups comparisons validate the instrument's capacity to discriminate between individuals based on behavioral histories, including prior condom purchases and current sexual activity. As an empirical instrument, the CES provides health psychologists, behavioral epidemiologists, and clinical sexologists with a standardized metric to evaluate barrier contraception hesitance, formulate targeted educational interventions, and assess the emotional mechanisms underlying sexual health decision-making.

2. Keywords

Condom Embarrassment Scale, sexual health, contraceptive self-efficacy, sexual anxiety, barrier contraception, health behavior, public health measurement, sexual communication, STI prevention, psychometrics, impression management, social evaluative anxiety

3. Authors

The Condom Embarrassment Scale was conceptualized, operationalized, and empirically validated by a multidisciplinary team of health educators, behavioral scientists, and clinical psychologists:

• Karen Vail-Smith, M.S., M.P.H. — Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, North Carolina, United States.
• Thomas W. Durham, Ph.D. — Department of Psychology, College of Arts and Sciences, East Carolina University, Greenville, North Carolina, United States.
• H. Ann Howard, Ph.D. — Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States.

Correspondence regarding the original development and empirical administration of the scale was directed to Karen Vail-Smith at the Department of Health Education and Promotion, East Carolina University (Email: [email protected]).

4. Purpose

The primary purpose of the Condom Embarrassment Scale (CES) is to provide an empirical, standardized measure of the self-conscious affective states—specifically embarrassment, social awkwardness, and self-directed communicative inhibition—that impede the consistent acquisition, discussion, and utilization of male condoms. Emerging during the height of the HIV/AIDS epidemic and amidst escalating rates of sexually transmitted infections (STIs) among university populations, the scale was created to address a critical omission in health education: the assumption that cognitive awareness of disease transmission translates directly into prophylactic behavior.

Empirical public health literature consistently reveals a substantial knowledge-behavior gap in reproductive healthcare. While college students and young adults frequently demonstrate adequate biomedical knowledge regarding the mechanics of HIV/STI transmission and pregnancy prevention, actual rates of barrier contraceptive adherence remain suboptimal. The theoretical rationale advanced by Vail-Smith and colleagues (1992) posits that emotional and social-evaluative costs—foremost among them, acute embarrassment—frequently supersede rational decision-making at critical junctures of sexual behavior. Condom use is not a solitary or purely mechanical act; it is embedded within complex social scripts that require individuals to navigate commercial retail environments, intimate communication with sexual partners, and the tactile reality of sexual mechanics.

In research contexts, the CES serves as an explanatory variable to model sexual risk-taking. Investigators employ the scale to isolate which specific dimensions of the prophylactic process generate the greatest psychological friction, enabling precise modeling of health behavior trajectories. In applied clinical, educational, and public health settings, the instrument provides an actionable diagnostic profile. University health centers, family planning clinics, and adolescent health outreach programs utilize the CES to evaluate baseline discomfort before and after psychosexual interventions, communication workshops, or marketing campaigns designed to normalize contraceptive access. By delineating whether an individual’s hesitation stems from the retail purchase counter, interpersonal boundary-setting, or the bedroom, practitioners can tailor psychoeducational strategies to address the precise psychological bottleneck inhibiting preventative behavior.

5. Psychological Construct

The central psychological construct measured by the CES is condom embarrassment, conceptualized by Vail-Smith, Durham, and Howard (1992) as the subjective psychological discomfort, self-consciousness, situational anxiety, and feeling of being ill at ease across three operational phases of condom utilization: retail acquisition, interpersonal negotiation, and intimate application. Embarrassment, within contemporary affective science, is categorized as a self-conscious emotion elicited by real or imagined violations of social norms, public exposure of private behavioral intentions, or threats to one’s preferred social identity (Goffman, 1959). When applied to sexual health, this affective state manifests along three core dimensions:

1. Condom Acquisition and Possession Embarrassment

This subscale captures the anticipatory and real-time social evaluative dread associated with obtaining condoms in public or semi-public spaces. Purchasing or requesting condoms requires an implicit admission of sexual intention or activity. For many emerging adults, this exposure triggers fears of negative social evaluation, moral judgment, or social stigmatization by retail personnel, peers, healthcare providers, or authority figures. The construct reflects psychological vulnerability across distinct retail and institutional settings:

• Commercial Retail Environments: Anticipated mortification during public transactions (e.g., purchasing at a pharmacy near campus or in one’s hometown, or interacting with a cashier or pharmacist).
• Institutional and Healthcare Settings: Reluctance to procure condoms from specialized reproductive health facilities, such as campus infirmaries or public health clinics, where physical presence might signal promiscuity or disease risk.
• Personal Possession: The psychological discomfort associated with carrying a condom in a wallet or purse, stemming from the fear of accidental discovery and subsequent reputational damage.

2. Condom Negotiation and Interpersonal Communication Embarrassment

The interpersonal dimension addresses the communicative barriers that arise within an intimate dyad. Introducing a condom into an encounter challenges traditional, spontaneous sexual scripts and demands assertive verbal communication. Embarrassment in this domain is fueled by cognitive fears of interpersonal rejection, partner offense, or relational rupture. Specific facets include:

• Disrupting Erotic Flow: Discomfort associated with pausing foreplay to mandate protective measures, which individuals fear may diminish arousal or introduce awkwardness into an intimate dynamic.
• Imputations of Infidelity or Disease: Anxiety that demanding condom use conveys a lack of trust in the partner’s sexual fidelity or implies that either individual harbors an undisclosed infection.
• Communicative Vulnerability: The broader affective inhibition associated with articulating boundaries, discussing sexual history, and asserting personal health parameters.

3. Condom Application, Erection Maintenance, and Physical Disposal Embarrassment

The tactile and visual dimension focuses on the physical mechanics of condom usage in the immediate presence of a sexual partner. Unlike cognitive intentions, physical execution requires manual dexterity and intimate visibility, rendering individuals vulnerable to performance anxiety and body-focused self-consciousness:

• Visual and Manual Exposure: Self-consciousness experienced while donning or having a partner don the prophylactic sheath, where fear of clumsiness, difficulty unrolling, or momentary loss of erection looms large.
• Cooperative Execution: Discomfort with mutual assistance during application or removal, which demands an advanced level of physical familiarity and confidence.
• Post-Coital Hygiene and Disposal: Embarrassment surrounding the post-ejaculatory handling and disposal of the used device, an act that confronts both partners with the physical remnants of the sexual encounter and breaches sanitized social boundaries.

6. Theoretical Framework

The conceptual structure of the Condom Embarrassment Scale is grounded in established sociocognitive and dramaturgical models of human behavior, integrating constructs from Social Cognitive Theory, Dramaturgical Sociology, Sexual Script Theory, and the Health Belief Model.

Dramaturgical Theory and Impression Management

Erving Goffman’s (1959) seminal work on impression management provides the theoretical foundation for understanding condom-related embarrassment. Goffman posited that social life is a staged performance in which actors strive to present an idealized self-image (“face”) while avoiding situational missteps that lead to a “spoiled identity.” Condom acquisition and deployment inherently threaten an actor’s face-work:

• Public De-masking: Purchasing condoms in a commercial establishment transforms a private sexual identity into a visible public transaction, exposing the actor to real or imagined social scrutiny from clerks and onlookers.
• Loss of Poise: Physical difficulties during application—such as struggling with packaging or experiencing performance anxiety—threaten personal competence, precipitating acute embarrassment.

Sexual Script Theory

Developed by John Gagnon and William Simon (1973), Sexual Script Theory posits that sexual interactions are governed by learned cultural, interpersonal, and intrapsychic scripts. Traditional Western sexual scripts celebrate passion, spontaneity, and unspoken mutual escalation. Within this framework, introducing a condom introduces an explicit, planned, and hygienic interruption. The CES captures the emotional tension that ensues when individuals must violate the “spontaneity script” to introduce preventative hygiene, creating social friction and self-consciousness.

Social Cognitive Theory and Self-Efficacy

Albert Bandura’s (1986) Social Cognitive Theory emphasizes the role of self-efficacy—the subjective belief in one’s capability to execute behaviors necessary to achieve specific outcomes. Self-efficacy in condom use is multifaceted, requiring not only technical knowledge but also social and communicative competence. Embarrassment serves as an affective inhibitor that directly degrades self-efficacy expectations. High perceived embarrassment generates avoidance behaviors, diminishing an individual’s belief that they can successfully purchase, negotiate, or apply condoms in emotionally charged situations.

Health Belief Model (HBM)

Within Rosenstock’s (1974) Health Belief Model, preventive health behaviors depend on perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. While biomedical education often elevates perceived susceptibility and severity regarding STIs, the CES quantifies non-financial, psychological barriers. The affective cost of experiencing social humiliation, awkwardness, or partner rejection frequently outweighs abstract, probabilistically distant health risks, resulting in inconsistent barrier contraceptive compliance.

7. Validity

Vail-Smith, Durham, and Howard (1992) established the psychometric validity of the Condom Embarrassment Scale through construct, convergent, divergent, and criterion-related methodologies utilizing a development sample of $N = 256$ undergraduate university students.

Convergent Validity

To evaluate convergent validity, the CES was administered alongside established psychometric instruments measuring related affective and psychosexual dimensions. The composite score of the CES demonstrated a statistically significant positive correlation with the Sex Anxiety Inventory (SAI) developed by Janda and O’Grady (1980):

$$r = .39, \quad p < .001$$

This moderate correlation supports the theoretical expectation that general affective discomfort surrounding sexuality is associated with condom embarrassment, while also indicating that condom embarrassment is an independent construct not redundant with generalized sex anxiety.

Criterion and Divergent Validity: STI/Condom Knowledge

The scale was evaluated against an objective STD/condom knowledge test developed by Solomon and DeJong (1989). Theoretically, higher cognitive competence regarding prophylactic mechanics and disease etiology was hypothesized to attenuate affective discomfort. Across the full sample ($N = 256$), a statistically significant overall negative correlation was obtained ($r = -.34, p < .01$). However, distinct gender differences emerged upon disaggregation:

• Females ($n = 163$): A robust, statistically significant inverse relationship was observed ($r = -.35, p < .001$), demonstrating that higher knowledge among women strongly correlates with lower levels of embarrassment regarding condom acquisition and use.
• Males ($n = 93$): The relationship failed to attain statistical significance ($r = -.13, p > .20$), indicating that cognitive knowledge does not reliably diminish condom embarrassment in men, whose affective barriers may be driven more heavily by performance anxiety and masculine sexual expectations.

Known-Groups and Behavioral Validity

Construct validity was further established through known-groups comparisons analyzing reported sexual behaviors:

• Purchasing History: Respondents who had previously purchased condoms scored significantly lower on the CES than those who had never engaged in a retail purchase transaction ($p < .001$). This behavioral distinction confirms the ecological validity of the scale's acquisition subscale.
• Sexual Activity Status: Sexually experienced participants exhibited significantly lower overall embarrassment scores compared to sexually inactive individuals ($p < .01$). Repeated exposure and familiarity within intimate contexts appear to systematically mitigate social-evaluative discomfort.

Subsequent psychometric investigations (e.g., Dahl et al., 1998; Moore et al., 2006, 2008; Bell, 2009) have replicated these findings across diverse demographic samples, validating the CES as a robust predictor of real-world retail purchasing avoidance and partner negotiation failures.

8. Reliability

The Condom Embarrassment Scale possesses high internal consistency and temporal stability, making it suitable for both cross-sectional survey research and longitudinal interventional designs.

Internal Consistency

In the initial psychometric validation study conducted by Vail-Smith et al. (1992), the total 18-item scale yielded an overall internal consistency coefficient of:

$$\alpha = .92$$

This high Cronbach’s alpha indicates minimal measurement error and high item covariance, demonstrating that the individual items reliably measure the overarching construct of condom-related social-evaluative discomfort. Subscale internal consistencies consistently exceed standard psychometric thresholds across the literature, typically ranging from $\alpha = .84$ to $\alpha = .91$ for Acquisition, $\alpha = .82$ to $\alpha = .88$ for Negotiation, and $\alpha = .80$ to $\alpha = .86$ for Application/Disposal.

Test-Retest Stability

To assess the temporal stability of the instrument over time, Vail-Smith and colleagues administered the CES across two distinct testing sessions to a subsample of $n = 226$ college students. A Pearson product-moment correlation coefficient was calculated between baseline and retest composite scores:

$$r = .78, \quad p < .001$$

This correlation confirms substantial test-retest reliability over time, indicating that condom embarrassment operates as a stable, trait-like affective disposition while maintaining sufficient sensitivity to detect shifts following targeted behavioral or educational interventions.

9. Factor Analysis

The structural dimensionality of the Condom Embarrassment Scale was established via Exploratory Factor Analysis (EFA) on responses from the initial validation cohort of $N = 256$ university undergraduates.

Extraction and Rotation Parameters

A principal factor analysis (PFA) followed by orthogonal Varimax rotation was executed on the 18 items. The analysis yielded a three-factor solution based on the Kaiser criterion (eigenvalues $> 1.0$) and an examination of the scree plot. Collectively, the three extracted factors accounted for 59.4% of the total variance across the item pool.

Factor Decomposition

Item loadings across primary factors were high (predominantly $> .50$), displaying minimal cross-loading onto secondary factors. Factor 1 captures the public/commercial arena, Factor 2 encapsulates the tactile/erotic execution, and Factor 3 captures the communicative negotiation required within intimate relationships.

10. Instrument / Measurement Tool

• Instrument Name: Condom Embarrassment Scale (CES)
• Authors: Karen Vail-Smith, M.S., M.P.H., Thomas W. Durham, Ph.D., and H. Ann Howard, Ph.D.
• Original Publication Year: 1992
• Construct Assessed: Situational embarrassment, self-consciousness, and social-evaluative discomfort associated with acquiring, negotiating, and using condoms.
• Administration Format: Self-administered paper-and-pencil questionnaire or digital survey format.
• Target Population: Adolescents, university students, and sexually active adults.
• Estimated Completion Time: Approximately 8 to 10 minutes.
• Number of Items: 18 declarative statements.
• Response Scale: 5-point Likert-type scale labeled alphabetically and numerically:
  • A = Strongly Disagree (1 point)
  • B = Disagree (2 points)
  • C = Neither Agree nor Disagree (3 points)
  • D = Agree (4 points)
  • E = Strongly Agree (5 points)
• Scoring Procedures:
  • All 18 items are positively keyed toward embarrassment; no reverse-scoring is required.
  • Individual item ratings (1 through 5) are summed to create a total composite score.
  • Total Score Range: 18 to 90.
  • Score Interpretation: Lower scores (e.g., 18–35) reflect low embarrassment and high ease regarding condom acquisition and use; moderate scores (36–54) indicate situational discomfort; high scores (55–90) denote substantial affective and social barriers to condom-related behaviors.
• Subscale Derivation:
  • Acquisition & Possession Subscale: Sum of Items 1, 2, 3, 4, 5, 6, 7, and 12 (Range: 8–40).
  • Physical Application & Disposal Subscale: Sum of Items 14, 15, 16, 17, and 18 (Range: 5–25).
  • Negotiation & Communication Subscale: Sum of Items 8, 9, 10, 11, and 13 (Range: 5–25).
• Normative Reference Data (Original 1992 Cohort, $N = 256$):
  • Total Cohort: Mean ($M$) = 44.88, Standard Deviation ($SD$) = 14.85.
  • Females ($n = 163$): $M = 46.54, SD = 14.65$.
  • Males ($n = 93$): $M = 41.81, SD = 14.74$.
  • Gender Comparison: Females exhibited significantly higher overall embarrassment than males, $t(254) = 2.48, p = .01$.

11. Permissions & Fee and Test Year

The Condom Embarrassment Scale was published in 1992 in the Journal of Health Education (now the American Journal of Health Education, published by Taylor & Francis). The authors explicitly placed the scale in the academic and clinical commons to advance public health and sexual risk-reduction initiatives:

• Permissions Policy: The use of the CES for non-commercial educational, clinical, and scholarly research purposes is encouraged by the developers without royalty fees or formal licensing charges. Researchers may reproduce and administer the scale provided appropriate bibliographic citation is accorded to the original authors.
• Author Request: The authors requested that investigators utilizing the scale share summary statistics, cross-cultural findings, and psychometric outcomes with the developers to assist in refining normative databases.
• Inquiries: Inquiries regarding formal commercial utilization or translation rights may be addressed to Karen Vail-Smith, Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC 27858.

12. References

Baffi, C. R., Schroeder, K. K., Redican, K. J., & McCluskey, L. (1989). Factors influencing selected heterosexual male college students’ condom use. Journal of American College Health, 38(3), 137–141. https://doi.org/10.1080/07448481.1989.9938423

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.

Beckman, L. J., Harvey, S. M., & Tiersky, L. A. (1996). Attitudes about condoms and condom use among college students. Journal of American College Health, 44(6), 243–249. https://doi.org/10.1080/07448481.1996.9944365

Bell, J. (2009). Why embarrassment inhibits the acquisition and use of condoms: A qualitative approach to understanding risky sexual behaviour. Journal of Adolescence, 32(2), 379–391. https://doi.org/10.1016/j.adolescence.2008.03.004

Dahl, D. W., Gorn, G. J., & Weinberg, C. B. (1998). The impact of embarrassment on condom purchase behaviour. Canadian Journal of Public Health, 89(6), 368–370. https://doi.org/10.1007/BF03404489

Gagnon, J. H., & Simon, W. (1973). Sexual conduct: The social sources of human sexuality. Aldine Publishing Company.

Goffman, E. (1959). The presentation of self in everyday life. Anchor Books.

Herold, E. S. (1981). Contraceptive embarrassment and contraceptive behavior among young single women. Journal of Youth and Adolescence, 10(3), 233–242. https://doi.org/10.1007/BF02088863

Hingson, R. W., Strunin, L., Berlin, M., & Heeren, T. (1990). Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. American Journal of Public Health, 80(3), 295–299. https://doi.org/10.2105/ajph.80.3.295

Hughes, C. B., & Torre, C. (1987). Predicting effective contraceptive behavior in college females. Nurse Practitioner, 12(9), 44–54. https://doi.org/10.1097/00006205-198709000-00007

Janda, L. H., & O’Grady, K. E. (1980). Development of a sex anxiety inventory. Journal of Consulting and Clinical Psychology, 48(2), 169–175. https://doi.org/10.1037/0022-006X.48.2.169

Kallen, D. J., & Stephensen, J. J. (1980). The purchase of contraceptives by college students. Family Relations, 29(3), 358–364. https://doi.org/10.2307/583854

Moore, S. G., Dahl, D. W., Gorn, G. J., & Weinberg, C. B. (2006). Coping with condom embarrassment. Psychology, Health & Medicine, 11(1), 70–79. https://doi.org/10.1080/13548500500155702

Moore, S. G., Dahl, D. W., Gorn, G. J., Weinberg, C. B., Park, J., & Jiang, Y. (2008). Condom embarrassment: Coping and consequences for condom use in three countries. AIDS Care, 20(5), 553–559. https://doi.org/10.1080/09540120701867016

Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Solomon, M. Z., & DeJong, W. (1989). Preventing AIDS and other STDs through condom promotion: A patient education intervention. American Journal of Public Health, 79(4), 453–458. https://doi.org/10.2105/ajph.79.4.453

Vail-Smith, K., Durham, T. W., & Howard, H. A. (1992). A scale to measure embarrassment associated with condom use. Journal of Health Education, 23(4), 209–214. https://doi.org/10.1080/10556699.1992.10616301

Valdiserri, R. O., Arena, V. C., Proctor, D., & Bonati, F. A. (1989). The relationship between women’s attitudes about condoms and their use: Implications for condom promotion programs. American Journal of Public Health, 79(4), 499–501. https://doi.org/10.2105/ajph.79.4.499

13. Items of the Scale