Condom Use Errors/Problems Survey

1. Abstract

The Condom Use Errors/Problems Survey (CUES), encompassing both the Men’s version (M-CUES) and the Women’s version (W-CUES), is an established, event-specific behavioral assessment instrument designed to measure technical execution errors and functional somatic difficulties encountered during male latex condom usage. Developed by Richard A. Crosby, Cynthia A. Graham, Robin R. Milhausen, Stephanie A. Sanders, and William L. Yarber, the scale emerged from public health recognition that consistent condom use alone is insufficient to prevent sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and unplanned pregnancy; optimal prophylactic efficacy requires technically correct execution. Comprising 16 core items, the instrument is bifurcated into two primary conceptual domains: Condom Use Errors (9 behavioral items assessing procedural violations such as late application, early removal, non-expulsion of air, lack of reservoir tip space, failure to inspect for damage, incorrect orientation rollover, and inappropriate lubricant selection) and Condom Use Problems (7 items measuring mechanical and psychophysiological complications including breakage, complete or partial slippage, erectile tumescence loss during application or intercourse, poor anatomical fit, and sensory discomfort).

The standard administrative protocol evaluates condom use behaviors across the preceding three sexual episodes within a three-month recall window, categorizing events as occurring on 0, 1, 2, or 3 occasions. Scoring frameworks accommodate either continuous cumulative error and problem counts (ranging from 0 to 27 for error frequency) or dichotomous categorization indicating any occurrence. Psychometric evaluation of the CUES highlights distinct methodological considerations inherent to behavioral inventories. Because the instrument reflects a formative index of heterogeneous mechanical errors and physiological events rather than a reflective latent trait, classical test theory metrics such as high internal consistency (Cronbach’s alpha) are neither theoretically anticipated nor psychometrically requisite. Content and face validity are supported through strict correspondence with clinical guidelines from the Centers for Disease Control and Prevention (CDC). Criterion, convergent, and predictive validities are supported across clinic and community cohorts, wherein elevated error and problem scores reliably predict prophylactic failure, acute condom breakage, condom-associated erection problems, and STI diagnosis.

2. Keywords

Condom Use Errors/Problems Survey, CUES, M-CUES, W-CUES, condom failure, STI prevention, HIV prophylaxis, psychosexual assessment, sexual health behavior, barrier contraception, psychometrics, condom-associated erection problems

3. Authors

The Condom Use Errors/Problems Survey was developed through an interdisciplinary collaboration among leading investigators in behavioral sexual health, psychometrics, and public health:

• Richard A. Crosby, Ph.D. — Department of Health Behavior, College of Public Health, University of Kentucky, Lexington, Kentucky, United States.
• Cynthia A. Graham, Ph.D. — Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; and The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, Indiana, United States.
• Robin R. Milhausen, Ph.D. — Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Ontario, Canada.
• Stephanie A. Sanders, Ph.D. — The Kinsey Institute for Research in Sex, Gender, and Reproduction, and Department of Gender Studies, Indiana University, Bloomington, Indiana, United States.
• William L. Yarber, H.S.D. (Corresponding Author) — Department of Applied Health Science, School of Public Health, and The Kinsey Institute, Indiana University, Bloomington, Indiana 47405, United States. (E-mail: [email protected]).

4. Purpose

The primary purpose of the Condom Use Errors/Problems Survey is to provide a standardized, empirically sensitive measurement tool for public health researchers, epidemiologists, and clinical sexologists to systematically identify, quantify, and intervene upon specific behavioral mechanics and psychophysiological complications that compromise male condom efficacy. For decades, epidemiological surveillance and public health interventions operationalized barrier contraception almost exclusively as a binary construct: whether a condom was used consistently (always versus not always) during penetrative sexual intercourse. However, extensive clinical trials and prospective observational investigations revealed an alarming discrepancy between theoretical efficacy and real-world user effectiveness, with epidemiological data demonstrating high transmission rates of STIs and unintended pregnancies among cohorts reporting 100% consistent condom use.

The CUES was engineered to resolve this measurement gap by shifting scientific inquiry from mere frequency of use to the quality and correctness of use. Epidemiological evidence shows that commercial condom structural failure due to manufacturing defects is exceptionally rare, approaching less than 0.1% under standardized mechanical burst-volume and tensile testing. Consequently, barrier degradation—manifesting as slippage, perforation, breakage, or biological leakage—originates overwhelmingly from user-dependent behavioral errors. These errors include opening the wrapper with shears or fingernails, failure to evacuate air from the reservoir tip, donning the prophylactic inside-out and subsequently flipping it over, applying oil-based lubricants that rapidly disintegrate latex matrices, or delaying application until after genital penetration has already occurred.

From an applied clinical perspective, the CUES serves as an indispensable diagnostic and educational intake tool within sexually transmitted disease (STD) clinics, adolescent health centers, family planning units, and clinical psychology practices addressing psychosexual disorders. In research settings, the tool enables precise behavioral phenotyping across randomized controlled trials (RCTs) evaluating sex education curricula, motivational interviewing protocols, digital sexual health interventions, and pharmacotherapy evaluations (e.g., investigating whether phosphodiesterase type 5 [PDE5] inhibitors reduce condom-associated erectile tumescence loss). Moreover, the modular design of the CUES permits explicit contextualization for penile-vaginal or penile-anal intercourse, making it a critical public health instrument across both heterosexual and men who have sex with men (MSM) populations.

5. Psychological Construct

The Condom Use Errors/Problems Survey evaluates two interconnected, yet structurally differentiated, dimensions of barrier contraceptive interaction: technical procedural execution (Condom Use Errors) and somatic/mechanical functional impairment (Condom Use Problems).

1. Condom Use Errors (Behavioral/Technical Dimension)

Condom errors represent volitional or non-volitional behavioral deviations from established clinical guidelines governing the donning, maintenance, lubrication, and removal of male latex condoms. The instrument captures nine discrete error indicators:

• Visual Inspection Omission (Item 1): Neglecting to examine the prophylactic wrapper and physical sheath for visible tears, dry rot, brittle latex, or packaging breaches prior to intercourse.
• Inverted Application Rollover (Item 2): Attempting to unroll the condom onto the glans penis in the inverted orientation, meeting resistance, flipping the condom over to the correct side, and continuing application. This procedural failure exposes the partner’s mucous membranes to pre-ejaculatory fluid that adhered to the exterior surface during initial contact.
• Absence of Reservoir Tip Clearance (Item 3): Failure to leave an adequate distal space (approximately 1 to 1.5 cm) at the receptacle tip to accommodate the volume of ejaculate under hydraulic pressure, markedly elevating the risk of lateral blowout.
• Air Trapping (Item 4): Failing to compress the reservoir bulb during application to evacuate trapped ambient air, creating pneumatic stress during active thrusting that precipitates latex rupture.
• Sub-Optimal Lubrication (Item 6): Deploying a non-lubricated condom without supplementary water-based or silicone-based lubrication, which increases frictional shearing forces along mucosal surfaces.
• Incompatible Lubricant Application (Item 7): Utilizing lipid-based compounds (e.g., petroleum jelly, mineral oil, vegetable oil, moisturizing lotions) on latex condoms. Such substances destabilize the polymer chain bonds of natural rubber within minutes, lowering burst volume and tear resistance.
• Sharp Surface Mechanical Abrasion (Item 9): Exposing the delicate latex sheath to sharp jewelry, fingernails, body piercings, or dental surfaces during unpacking, donning, or oral-genital foreplay.
• Delayed Application (Item 10): Initiating penetrative intercourse prior to condom donning and applying the sheath only prior to ejaculation, failing to protect against pre-ejaculatory pathogens or early biological fluid transmission.
• Premature Removal (Item 11): Donning the condom at initial penetration but discarding it mid-coitus and continuing unprotected intercourse.

2. Condom Use Problems (Somatic & Mechanical Dimension)

Condom problems represent undesirable mechanical, anatomical, or psychophysiological events occurring concomitantly with barrier usage, comprising seven specific parameters:

• Donning Erection Difficulties (Item 5): Experiencing partial or complete detumescence specifically during the interruption required to unpack and roll the sheath down the penile shaft.
• Coital Erection Difficulties (Item 8): Sustaining loss of erectile rigidity after penetration has commenced with the prophylactic in place, often driven by cognitive distraction, performance anxiety, or sensory attenuation.
• Complete Rupture/Breakage (Item 12): Overt failure of the latex barrier matrix during penetrative sexual friction.
• Intra-Coital Slippage (Item 13): Partial or complete displacement of the condom sheath off the penile shaft during active coital thrusting.
• Withdrawal Slippage (Item 14): Retention of the condom within the anatomical vault (vagina or rectum) as the penis is withdrawn post-ejaculation, frequently secondary to delayed post-climax withdrawal or failure to hold the base ring firmly against the penile root.
• Dimensional Mismatch / Fit Difficulties (Item 15): Experiencing adverse physical dimensions, wherein the condom is either excessively tight (inducing ischemic discomfort) or excessively loose (predisposing to rolling and mechanical slippage).
• Sensory and Tactile Dissatisfaction (Item 16): Dyadic reports of tactile numbing, decreased partner pleasure, mucosal dryness, or irritation resulting from condom material properties.

6. Theoretical Framework

The architectural foundation of the Condom Use Errors/Problems Survey is grounded at the convergence of behavioral psychology, health communication models, and human sexual physiology. Three primary theoretical paradigms explain the occurrence of condom errors and problems:

1. The Information-Motivation-Behavioral Skills (IMB) Model

Originally formulated by Fisher and Fisher, the Information-Motivation-Behavioral Skills model posits that risk-reduction behaviors are enacted when individuals are well-informed, highly motivated, and possess the requisite behavioral skills to execute complex technical actions under conditions of emotional and physiological arousal. The CUES directly operationalizes the “Behavioral Skills” deficit axis of this model. While an individual may possess high motivational drive to prevent HIV/STIs, they frequently lack accurate procedural information (e.g., awareness that petroleum jelly degrades latex) or the fine-motor self-efficacy required to evacuate air bubbles and maintain reservoir space during states of heightened sexual excitement.

2. Cognitive Distraction and Dual-Control Models of Sexual Response

The integration of erection loss items within the CUES is rooted in the Dual Control Model of Sexual Response proposed by Bancroft and Janssen at The Kinsey Institute. This framework conceptualizes human sexual arousal as a balance between neurochemical Sexual Excitation (SE) and Sexual Inhibition (SI). Condom donning represents a tactile and cognitive disruption during sexual escalation. For men susceptible to performance anxiety or hyper-monitoring, interrupting sexual activity to apply a prophylactic introduces performance demands and fear of failure, triggering sympathetic autonomic dominance and acute detumescence. This physiological reaction frequently prompts secondary behavioral errors, such as delaying condom application or removing the condom mid-coitus in an effort to restore penile rigidity.

3. Event-Level Cognitive Appraisal Theory and Recall Heuristics

From a psychometric perspective, the CUES incorporates cognitive-behavioral insights on self-report accuracy in human sexuality research. Classical global recall measures (e.g., asking respondents to estimate their percentage of correct use over the prior six months) are biased by social desirability and cognitive availability heuristics. By delimiting the cognitive recall horizon to the last three sexual encounters within the past three months, the CUES aligns with behavioral memory retrieval frameworks that minimize temporal decay, anchoring responses to specific, episodic coital encounters.

7. Validity

The CUES has undergone empirical validation across diverse epidemiological populations, including patients at municipal STI clinics, urban adolescent cohorts, university students, rural adults, and digital community samples.

1. Content and Face Validity

The CUES exhibits strong content and face validity. Scale items were derived directly from clinical barrier prophylactic guidelines issued by the Centers for Disease Control and Prevention (CDC, 1998, 2009) and clinical reproductive health protocols (Contraceptive Technology; Warner & Hatcher, 1999). Every item corresponds to an empirical mechanical failure risk factor identified in barrier contraception biomedical literature.

2. Known-Groups and Construct Validity

Known-groups validity was demonstrated by Crosby, Sanders, et al. (2002) in an investigation examining sexual health education history. Participants who reported receiving prior formal clinical instruction regarding step-by-step correct condom application demonstrated significantly lower cumulative error scores than peers without formal training. Furthermore, Sanders et al. (2003) demonstrated that female partners who actively applied condoms to their male partners experienced distinct, quantifiable error profiles (e.g., rolling difficulties, air entrapment) that mirrored anatomical familiarity patterns.

3. Criterion and Predictive Validity

Multiple investigations have demonstrated strong associations between specific behavioral errors and corresponding physical failure events:

• Breakage and Mechanical Abrasion: Yarber et al. (2004) identified that participants who reported using sharp objects to open packets or exposing prophylactics to sharp jewelry/fingernails demonstrated significantly higher rates of intra-coital condom breakage (Item 12; odds ratios exceeding 2.5 across models).
• Erection Loss and Interrupted Use: Graham et al. (2006) established a significant direct correlation between condom-associated erection loss (Items 5 and 8) and hazardous behavioral compensations, particularly delayed application (Item 10) and premature removal (Item 11).
• STI Transmission: Prospective epidemiological studies utilize CUES scores to account for apparent prophylactic failure, showing that high cumulative error scores predict incident bacterial STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae) even among individuals reporting 100% frequency of use.

8. Reliability

Evaluating the reliability of the Condom Use Errors/Problems Survey requires careful psychometric consideration of the difference between reflective psychological scales and formative behavioral indexes.

1. Formative Indexes Versus Reflective Trait Latency

In classical psychometrics, internal consistency metrics (e.g., Cronbach’s alpha, McDonald’s omega) presuppose a reflective model wherein all survey items are indicators of a single underlying latent psychological construct (such as neuroticism or self-esteem). Under this assumption, items are expected to intercorrelate substantially. However, as articulated by Crosby, Graham, and colleagues, the CUES operates as a formative behavioral inventory. An individual item reflects an independent mechanical or physiological incident. An individual who fails to check for visible damage (Item 1) has no logical or statistical necessity to use an oil-based lubricant (Item 7) or lose an erection during donning (Item 5). Consequently, calculating aggregate Cronbach’s alpha across all 16 disparate behavioral and somatic items yields modest coefficients that misrepresent instrument precision. Researchers are strongly advised to analyze individual error items as discrete risk parameters rather than relying on homogeneous latent composite scores.

2. Test-Retest Reliability and Episodic Variability

Test-retest stability assessments for event-specific sexual behaviors are complicated by natural behavioral variability. Human sexual interactions are dyadic, situational, and variable across time. If an individual experiences condom slippage during a coital event with high frictional resistance and poor lubrication, but uses adequate water-based lubricant during subsequent encounters, the scores will diverge. Longitudinal assessments by Milhausen et al. (2009) have shown that while trait-like behavioral habits (e.g., habitual non-expulsion of air) show moderate stability across brief windows, dynamic items (e.g., breakage, slippage) function primarily as situational event markers rather than fixed traits.

9. Factor Analysis

Although the CUES is primarily operationalized as a formative instrument, exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) conducted across empirical cohorts have validated the conceptual bifurcation of the scale into distinct structural domains.

1. Exploratory Factor Structures

Principal axis factoring with oblique rotations (promax) typically resolves the 16 items into two overarching dimensions, alongside minor empirical sub-clusters:

• Factor 1: Procedural & Donning Errors (The Error Subscale): High factor loadings are observed for Item 2 (flipped over), Item 3 (tip space), Item 4 (air squeezing), Item 6 (lack of water lubricant), Item 7 (oil lubricant), Item 9 (sharp contact), Item 10 (late application), and Item 11 (early removal). Factor loadings for these technical execution items range from 0.42 to 0.78 across published studies.
• Factor 2: Mechanical & Physiological Compromise (The Problem Subscale): High factor loadings emerge for Item 5 (donning erection loss), Item 8 (coital erection loss), Item 12 (breakage), Item 13 (thrusting slippage), Item 14 (withdrawal slippage), Item 15 (fit difficulties), and Item 16 (comfort/sensation problems), with loadings spanning 0.45 to 0.81.

2. Confirmatory Factor Analytic Fit

When modeling the CUES within structural equation modeling (SEM) frameworks, two-factor correlated models demonstrate acceptable fit indices when error items and physiological/mechanical items are treated as separate latent clusters, yielding Comparative Fit Index (CFI) values > 0.90, Root Mean Square Error of Approximation (RMSEA) < 0.06, and Standardized Root Mean Square Residual (SRMR) < 0.07. Cross-loadings occasionally manifest between erection loss items and delayed application/early removal, which aligns with theoretical expectations of performance compensation.

10. Instrument / Measurement Tool

The Condom Use Errors/Problems Survey exists in two parallel gender/role-specific formats:

• M-CUES: Condom Use Errors/Problems Survey — Men (for men who personally apply condoms to their own penises).
• W-CUES: Condom Use Errors/Problems Survey — Women (for women who apply male condoms to their male partners).

Structural Characteristics

• Total Item Count: 16 core behavioral and functional items.
• Subscale Allocation:
  • Error Items (9 items): Items 1, 2, 3, 4, 6, 7, 9, 10, and 11.
  • Problem Items (7 items): Items 5, 8, 12, 13, 14, 15, and 16.
• Recall Period: The last three occasions of male condom use within the preceding three months. (Can be modified by researchers to assess the last single encounter or all occasions over an alternate predefined interval).
• Intercourse Specificity: Contains adaptable field blanks enabling insertion of either “penile-vaginal” or “penile-anal” sexual intercourse.
• Administration Format: Paper-and-pencil questionnaire, computer-assisted self-interview (CASI), or digital online survey.
• Completion Duration: Approximately 8 to 10 minutes.

Response Mode and Scoring Rubrics

Each item utilizes a gated, two-stage response hierarchy:

1. Initial screening: “no” vs. “yes”.
2. Frequency quantification if “yes”:
   • I did it on 1 occasion (or “it did it / he did it / it happened on 1 occasion”)
   • I did it on 2 occasions (or “it did it / he did it / it happened on 2 occasions”)
   • I did it on all 3 occasions (or “it did it / he did it / it happened on all 3 occasions”)
3. Certain W-CUES items include an additional response option: “not sure”.

Scoring Methods:

• Method A (Summative Cumulative Error Count): For the recall period covering the last 3 occasions, the continuous cumulative error score reflects the total count of reported errors across events (theoretical range: 0 to 27; 9 error items × 3 occasions). In this system, protective behaviors are reverse-scored:
  • Items 1, 3, and 4 are phrased protectively (checking damage, leaving tip space, squeezing air). These are reverse scored such that: Response of “no” = 3 points; “1 occasion” = 2 points; “2 occasions” = 1 point; “all 3 occasions” = 0 points.
  • Items 2, 6, 7, 9, 10, and 11 are negative errors scored directly: Response of “no” = 0 points; “1 occasion” = 1 point; “2 occasions” = 2 points; “all 3 occasions” = 3 points.
• Method B (Dichotomous Indicator Scoring): Any occurrence of an error across the three occasions is assigned a score of 1, whereas correct/unproblematic execution across all three occasions is assigned 0.
• Method C (Individual Item Profiling): Public health and sexological research often examines each item independently to evaluate targeted intervention outcomes (e.g., measuring the prevalence of rollover inversion or late application as separate end-points).

11. Permissions & Fee and Test Year

The Condom Use Errors/Problems Survey was initially introduced in peer-reviewed scientific literature in 2002 (Crosby, Sanders, Yarber, Graham, & Dodge, 2002) and formally compiled as a standard instrument in psychometric handbooks in subsequent years. The instrument is considered an open-access public domain scale for educational, clinical, and non-commercial scientific research purposes. No commercial licensing fees or royalty payments are required for academic implementation.

Investigators and clinicians utilizing the CUES are requested to properly cite the foundational validation articles. Researchers intending to make formal structural, translational, or linguistic modifications are encouraged to communicate their research designs with the corresponding author, Dr. William L. Yarber, Department of Applied Health Science, Indiana University Bloomington ([email protected]).

12. References

• Centers for Disease Control and Prevention. (1998). Facts about condoms and their use in preventing HIV infection and other STDs. U.S. Department of Health and Human Services.
• Centers for Disease Control and Prevention. (2009). Condoms and STDs: Fact sheet for public health personnel. U.S. Department of Health and Human Services. https://www.cdc.gov/condomeffectiveness/latex.htm
• Crosby, R. A., DiClemente, R. J., Holtgrave, D. R., & Wingood, G. M. (2002). Design, measurement, and analytic considerations for testing hypotheses relative to condom effectiveness against nonviral STIs. Sexually Transmitted Infections, 78(4), 228–231. https://doi.org/10.1136/sti.78.4.228
• Crosby, R. A., Milhausen, R. R., Sanders, S. A., Graham, C. A., & Yarber, W. L. (2008). Two heads are better than one: The association between condom decision-making and condom use errors and problems. Sexually Transmitted Infections, 84(3), 196–201. https://doi.org/10.1136/sti.2007.028688
• Crosby, R. A., Sanders, S. A., Yarber, W. L., Graham, C. A., & Dodge, B. (2002). Condom use errors and problems among college men. Sexually Transmitted Diseases, 29(10), 552–557. https://doi.org/10.1097/00007435-200210000-00008
• Crosby, R. A., Yarber, W. L., Sanders, S. A., Graham, C. A., & Arno, J. N. (2008). Slips, breaks and “falls”: Condom errors and problems reported by men attending an STD clinic. International Journal of STD & AIDS, 19(2), 90–93. https://doi.org/10.1258/ijsa.2007.007137
• Graham, C. A., Crosby, R. A., Sanders, S. A., & Yarber, W. L. (2005). Assessment of condom use in men and women. Annual Review of Sex Research, 16(1), 1–33. https://doi.org/10.1080/10532528.2005.10559826
• Graham, C. A., Crosby, R. A., Yarber, W. L., Sanders, S. A., McBride, K., Milhausen, R. R., & Arno, J. N. (2006). Erection loss in association with condom use among young men attending a public STI clinic: Potential correlates and implications for risk behavior. Sexual Health, 3(4), 255–260. https://doi.org/10.1071/SH06031
• Holmes, K. K., Levine, R., & Weaver, M. (2004). Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization, 82(6), 454–461.
• Milhausen, R. R., Wood, J., Sanders, S. A., Crosby, R. A., Yarber, W. L., & Graham, C. A. (2009). A novel, self-guided home-based intervention to promote condom use among young men: A pilot study. Unpublished manuscript.
• Sanders, S. A., Graham, C. A., Yarber, W. L., Crosby, R. A., Dodge, B., & Milhausen, R. R. (2003). Condom use errors and problems among women who put condoms on their male partners. Journal of the American Medical Women’s Association, 58(2), 95–98.
• Sanders, S. A., Milhausen, R. R., Crosby, R. A., Graham, C. A., & Yarber, W. L. (2009). Do phosphodiesterase type 5 inhibitors protect against condom-associated erection loss and condom slippage? The Journal of Sexual Medicine, 6(5), 1451–1456. https://doi.org/10.1111/j.1743-6109.2009.01217.x
• Steiner, M. J., Cates, W., Jr., & Warner, L. (1999). The real problem with male condoms is nonuse. Sexually Transmitted Diseases, 26(8), 459–462. https://doi.org/10.1097/00007435-199909000-00007
• Warner, D. L., & Hatcher, R. A. (1999). Male condoms. In R. A. Hatcher, W. Cates, Jr., J. Trussell, F. Stewart, F. Guest, G. K. Stewart, et al. (Eds.), Contraceptive technology (17th rev. ed., pp. 325–352). Ardent Media.
• Yarber, W. L., Graham, C. A., Sanders, S. A., & Crosby, R. A. (2004). Correlates of condom breakage and slippage among university students. International Journal of STD & AIDS, 15(7), 467–472. https://doi.org/10.1258/0956462041211280
• Yarber, W. L., Kennedy, J., Sanders, S. A., Crosby, R. A., Graham, C. A., Heckman, T. G., & Arno, J. N. (2005). Prevalence of condom use errors and problems among Indiana rural men: An exploratory telephone survey. The Health Education Monograph, 22(3), 36–38.

13. Items of the Scale (Questionnaire)