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RESEARCH ARTICLE
Non-consensual condom removal, reported
by patients at a sexual health clinic in
Melbourne, Australia
Rosie L. LatimerID
1
*, Lenka A. Vodstrcil
1,2
, Christopher K. Fairley
1,2
, Vincent
J. CornelisseID
1,2
, Eric P. F. Chow
1,2
, Tim R. H. Read
1,2☯‡
, Catriona S. Bradshaw
1,2☯‡
1Central Clinical School, Monash University, Melbourne, Australia, 2Melbourne Sexual Health Centre,
Alfred Health, Melbourne, Australia
☯These authors contributed equally to this work.
‡ Joint Senior Authors
*rlatimer@mshc.org.au
Abstract
Background
Non-consensual removal of condoms, colloquially referred to as ‘stealthing’, is the removal
of a condom during sex by a sexual partner when consent has been given for sex with a con-
dom only.
Methods
We conducted a cross-sectional survey to determine how commonly women and men who
have sex with men (MSM) attending Melbourne Sexual Health Centre had experienced
stealthing, and analysed situational factors associated with the event. Responses were
linked to demographic information extracted from patient files.
Results
1189 of 2883 women (41.2%), and 1063 of 3439 MSM (30.9%) attending the clinic during
the study period completed the survey. Thirty-two percent of women (95% CI: 29%,35%)
and 19% of MSM (95% CI: 17%,22%) reported having ever experienced stealthing. Women
who had been stealthed were more likely to be a current sex worker (Adjusted Odds Ratio
[AOR] 2.87, 95% CI: 2.01,4.11, p <0.001). MSM who had experienced stealthing were more
likely to report anxiety or depression (AOR 2.13, 95% CI: 1.25,3.60, p = 0.005). Both female
and male participants who had experienced stealthing were three times less likely to con-
sider it to be sexual assault than participants who had not experienced it (OR 0.29, 95% CI:
0.22,0.4 and OR 0.31, 95% CI: 0.21,0.45 respectively).
Conclusions
A high proportion of women and MSM attending a sexual health service reported having
experienced stealthing. While further investigation is needed into the prevalence of steal-
thing in the general community, clinicians should be aware of this practice and consider
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 1 / 16
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OPEN ACCESS
Citation: Latimer RL, Vodstrcil LA, Fairley CK,
Cornelisse VJ, Chow EPF, Read TRH, et al. (2018)
Non-consensual condom removal, reported by
patients at a sexual health clinic in Melbourne,
Australia. PLoS ONE 13(12): e0209779. https://doi.
org/10.1371/journal.pone.0209779
Editor: Junjie Xu, China Medical University, CHINA
Received: August 22, 2018
Accepted: December 11, 2018
Published: December 26, 2018
Copyright: ©2018 Latimer et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Information obtained
in this survey is highly sensitive and confidential
and includes patient health record data.
Furthermore, we are unable to share data as it
would be in breach our ethics approval. Our
participant information and consent form
specifically states that individual participant
information will only be accessible to the study
team and will not be disseminated further in an
identifiable way, i.e. only presented as aggregated
data or statistics - "Information obtained in this
research project that can identify you will remain
confidential and will be stored securely indefinitely.
integrating this question into their sexual health consultation. Understanding situational fac-
tors would assist in the development of preventive strategies, particularly female sex work-
ers and MSM.
Introduction
Non-consensual removal of condoms, colloquially referred to as ‘stealthing’[1] or ‘stealth-
breeding’ [2], refers to the practice of a sexual partner covertly removing a condom, when con-
sent has been given for condom protected sex only [1]. Condoms are used as a primary pre-
ventative method of protecting against sexually transmitted infections (STI), human
immunodeficiency virus (HIV) and pregnancy, being 80 to 98.6% effective [3–5]. Stealthing
may result in the transmission of STIs, HIV, or unintended pregnancy, and could have signifi-
cant personal and public health implications.
Studies of undergraduate students have found consent for sexual intercourse to be mostly
communicated through non-verbal means [6,7], with consent for sexual intercourse often
implied in the process of asking for or applying a condom [6]. Brodsky has argued that con-
dom removal without mutual agreement violates consent to sex [1].
In young adult heterosexual relations, it is common for male partners to engage in condom
resistance tactics [8]. Several studies have identified stealthing as a method of birth control sab-
otage [9,10], as well as a means of intentional HIV transmission [11]. Anecdotal research by
Brodsky focusing on heterosexual and heteronormative relations, and theoretical research by
Brennan focusing on condom-less sex between men, argue these are not the primary motiva-
tors for this act [1,2].
In spite of public interest in stealthing, there are no scientific articles that investigate how
common it is, who is most at risk, and the outcomes for those who report being stealthed. We
aimed to investigate the proportion of sexual health centre patients reporting nonconsensual
removal of condoms: 1) among heterosexual women and 2) among men who have sex with
men, as well as associated risk factors. For the purpose of this study, ‘stealthing’ was defined as
condom removal without consent, where consent to sex was conditional upon use of a
condom.
Methods
Population and setting
This was a cross-sectional questionnaire-based study conducted amongst women and gay and
other men who have sex with men (MSM) attending the Melbourne Sexual Health Centre
(MSHC) in Victoria, Australia, between the 22
nd
December 2017 and the 22
nd
February 2018.
MSHC is the largest public sexual health service in Victoria, Australia. The centre provides
around 50,000 consultations every year, 37% with women and 36% with MSM [12]. Clinic
attendees routinely complete a computer assisted self-interview (CASI) about their sexual his-
tory prior to seeing a triage nurse.
Study measurement
Women and MSM presenting to MSHC, aged 18 or over, were invited to complete an elec-
tronic questionnaire containing questions about stealthing after completing CASI. Participants
read a patient information and consent form which detailed the nature of the survey, and
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 2 / 16
The database containing the questionnaires and the
code linking these to your name will remain at
Melbourne Sexual Health Centre, on password-
protected servers, and only the study team will
have access. Your information will only be used for
this research project, or future research at this
centre, and will not be disclosed except as required
by law. The results of this research will be
published and presented at conferences in such a
way that you are not identified." Therefore we have
presented all data collected in an aggregate way in
the paper so that it is non-identifiable, as approved
by our ethics committee. Data is required to be
securely stored in keeping with requirements from
Alfred Hospital Ethics Committee who can be
contacted through Angela Henjak at
research@alfred.org.au for queries regarding
accessing the data. Any questions regarding the
data itself should be directed to Rosie Latimer at
rlatimer@mshc.org.au or A/Professor Catriona
Bradshaw at cbradshaw@mshc.org.au.
Funding: RLL and VJC are supported by an
Australian Government Research Training Program
(RTP) Scholarship. TRHR and EPFC are supported
by NHMRC early career fellowship no.1091536,
1091226, respectively. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
patients could only commence the questionnaire after ticking a box stating ‘Yes- willing to
help’. Due to the potential of the questionnaire to cause distress when recalling the stealthing
event, the participant information included advertisement of free counselling services available
at MSHC and elsewhere. The Alfred Hospital Ethics Committee approved the study (number
494/17).
Age, number of sexual partners, and HIV status were extracted electronically from rou-
tinely collected clinic records for respondents and non-respondents, de-identified for non-
respondents, and linked to questionnaire responses for respondents (Fig 1).
The questionnaire asked whether the participant had ever had a condom removed during
sex with or without permission and at what point the participant noticed. Participants could
choose from a hierarchy of seven responses describing the circumstances. Multiple responses
were allowed for those reporting multiple occurrences, and there was no time limit applied to
the reported event. Participants were deemed not to have experienced stealthing if they
responded either: 1) they had never had a condom removed during sex, 2) that a condom had
been removed with permission, or 3) that a condom was removed without permission but they
willingly continued sex. Participants were deemed to have experienced stealthing if they
reported: 4) condom removal without permission and sex continued unwillingly, 5) condom
removal without permission and sex was discontinued, 6) condom removal during sex but they
did not realise until afterwards, or 7) the condom was never put on despite being requested. If a
participant only selected options between 1 and 3 they were classified as never having been
stealthed. If a participant selected any option between 4–7, regardless of whether they had also
selected options between 1 and 3, they were classified as ever having been stealthed (Fig 1).
Participants who reported stealthing were asked further questions about the specific event
(Fig 1). Participants who had selected multiple options were asked about the incident with the
highest assigned number. For instance if they reported several stealthing events with differing
scenarios and selected both response 4 and 5, then specific questions were asked about “event
5” only–i.e. condom removal without permission and sex was discontinued. Questions
included: when the incident occurred, how long they had known the partner, how they would
describe the relationship, where they had met, whether either person had been using drugs or
alcohol, whether the event was reported to the police, and what they perceived were the conse-
quences of the condom removal. All respondents were asked whether they considered the
removal of a condom without consent to be sexual assault.
Statistical analysis
All analyses were performed using Stata IC version 14. MSM who reported only insertive anal
sex and no receptive anal sex while completing CASI were excluded from the dataset prior to
analysis of questionnaire responses, as experiencing stealthing was considered unlikely if the
male was only the insertive partner. Risk factors for experiencing stealthing in women and
MSM were not compared to each other as they are different populations. Univariable and mul-
tivariate analyses were performed to determine the differences in demographics between non-
respondents and respondents, and the differences between those who had and had not experi-
enced stealthing. Variables were included in multivariate models if the p-value was 0.1; if
correlated, the variable most strongly associated with the outcome was used. Models were built
in a backward-stepwise fashion, using the likelihood ratio test to determine the significance of
the contribution of each variable. Ninety-five percent binomial confidence intervals (CIs) were
calculated for all proportions. We assumed 100 patients would complete the survey each week
and estimated 2% would report ever being stealthed. The 95% confidence interval around an
estimated 2% prevalence of stealthing after six weeks (600 responses) would be 1.0%, 3.5%.
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 3 / 16
Results
During the study period, 2883 women and 3439 MSM attended the clinic, of whom 1189
women (41%, 95%CI: 39%,43%) and 1063 MSM (31%, 95%CI: 29%,32%) completed the survey
(classified as respondents).
Female respondents were more likely than non-respondents to have had sex overseas in the
last twelve months (adjusted odds ratio [AOR] 1.49, 95% CI: 1.26,1.77, p<0.001) and were less
likely to be a current sex worker (AOR 0.78, 95% CI: 0.63,0.96, p = 0.02) (Table 1). Compared
to MSM non-respondents, the men who responded were more likely to have had sex overseas
in the last twelve months (AOR 1.70, 95% CI: 1.37,2.11, p<0.001), and were less likely to be
HIV positive (AOR 0.60, 95% CI: 0.38,0.95, p = 0.029) (Table 1).
Of the 1189 women and 1063 MSM who consented to the survey and answered the first
question: 60 (5%) women and 64 men (6%) declined to answer whether they had experienced
stealthing, 45 (4%) women and 37 (3%) men deemed the question to be not applicable to them
i.e. they never used condoms, or did not engage in penetrative sex with men and 90 (8%) men
were removed from the analysis, as they had only reported insertive anal sex and not reported
receptive anal sex in CASI (Table 2).
Three hundred and forty-six of the remaining 1084 women (32%, 95% CI: 29%,35%) and
168 of the remaining 872 MSM (19%, 95% CI: 17%,22%) reported having ever experienced
stealthing (Table 3). Of those who had experienced stealthing, forty-two women (12%, 95% CI:
9%,16%) and 23 MSM (14%, 95% CI: 9%,20%) presented to the clinic on the day of the ques-
tionnaire following a reported stealthing incident (Table 4).
Data missing from up to 5% of female respondents and up to 3% of male respondents; pro-
portions are calculated using available data.
On multivariate analysis, women who had been stealthed were more likely to be a current sex
worker than those who had never experienced stealthing (AOR 2.87, 95% CI: 2.01,4.11, p<0.001)
(Table 3), and MSM who had been stealthed were more likely to report ‘health issues, such as anx-
iety or depression which may have affected their decision to use condoms for anal sex’ than those
who had never experienced stealthing (AOR 2.13, 95% CI: 1.25,3.60, p = 0.005) (Table 3).
Most women met the male partner who had stealthed them through friends (29%, 95% CI:
24%,34%) or sex work (23%, 95% CI: 19%,28%). MSM reporting stealthing most commonly
described the partner as someone they “did not know well” (61%) and had predominantly met
them through geosocial dating applications or online (67%, 95% CI: 59%,74%) (Table 4).
At the time of the stealthing incident, 41% (95% CI: 36%,47%) of women and 54% (95% CI:
46%,62%) of MSM reported being sober, while 57% (95% CI: 51%,62%) of women and 41%
(95% CI: 33%,49%) of MSM had consumed alcohol. Twelve percent of women and 13% of
MSM had used other drugs either in addition to or without alcohol (Table 4). The majority of
women reported their partner had consumed alcohol (68%, 95% CI: 62%,73%) and/or other
drugs (19%), with only 27% (95% CI: 22%,33%) stating the partner had been sober when the
incident occurred. Many MSM believed their partner to be sober (53%, 95% CI: 44%,62%),
with 40% (95% CI: 31%,50%) of partners under the influence of alcohol, and 12% using addi-
tional/or other drugs (Table 4).
Fig 1. Possible pathways for patients offered the survey, and the classification for analysis of nonconsensual condom removal.
Abbreviations: MSM = men who have sex with men; CASI = computer assisted self-interviewing.
a
Participants were classified as never
having experienced stealthing if they responded either: 1) they had never had a condom removed during sex, 2) that a condom had been
removed with permission, or 3) that a condom was removed without permission but they willingly continued sex.
b
Participants were deemed
to have experienced stealthing if they reported: 4) condom removal without permission and sex continued unwillingly, 5) condom removal
without permission and sex was discontinued, 6) condom removal during sex but they did not realise until afterwards, or 7) the condom was
never put on despite being requested.
https://doi.org/10.1371/journal.pone.0209779.g001
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 5 / 16
Table 1. Demographics and epidemiological features of respondents versus non-respondents to survey on rates of non-consensual removal of condoms (stealthing)
in a STI clinic (N = 6322).
Female non-respondents
n = 1694 (%; 95% CI) or
median [range]
Female respondents
n = 1189 (%; 95% CI)
or median [range]
Unadjusted Odds
Ratio (95% CI)
p-value Adjusted Odds Ratio
a
(95% CI)
p-value
Age 27 [16–74] 26 [18–64]
Employment
Employed 958 (60; 57,62) 689 (60; 57,62) 1
Not in the labour force
b
641 (40; 38,43) 467 (40; 38,43) 1.01 (0.87,1.18) 0.87
Aboriginal and/or Torres Strait Islander
peoples
No 1479 (99; 98,99) 1074 (99; 98,99) 1
Yes 16 (1; 0,2) 14 (1; 1,2) 1.20 (0.59,2.48) 0.613
Sex overseas
No 817 (60; 57,62) 485 (48; 45,52) 1 1
Yes 552 (40; 38,43) 517 (52; 48,55) 1.58 (1.35,1.86) <0.001 1.49 (1.26,1.77) <0.001
Injecting drug use
Never injected 1420 (98; 97,99) 1023 (98; 97,99) 1
Ever injected 26 (2; 1,3) 22 (2; 1,3) 1.17 (0.66,2.08) 0.582
Current sex worker
No 1095 (76; 74,78) 856 (82; 79,84) 1 1
Yes 348 (24; 22,26) 191 (18; 16,21) 0.70 (0.58,0.86) <0.001 0.78 (0.63,0.96) 0.020
Condom Use in the last 3mo with male
partners
Not always 1014 (83; 81,85) 765 (82; 80,85) 1
Always 204 (17; 15,19) 163 (18; 15,20) 1.06 (0.84,1.33) 0.619
Number of male sexual partners
in the last 3mo
1 [0–50] 1 [0–15]
Male non-respondents
n = 2376 (%; 95% CI) or
median [range]
Male respondents
n = 1063 (%; 95% CI)
or median [range]
Unadjusted Odds
Ratio (95% CI)
p-value Adjusted Odds Ratio
c
(95% CI)
p-value
Age 30 [16–82] 30 [18–75]
Employment
Employed 1480 (67; 65,69) 644 (64; 61,67) 1
Not in the labour force
b
742 (33; 31,35) 361 (36; 33,39) 1.12 (0.96,1.31) 0.161
Aboriginal and/or Torres Strait Islander
peoples
No 2114 (99; 98,99) 978 (99; 99,100) 1 1
Yes 26 (1; 1,2) 5 (1; 0,1) 0.42 (0.16,1.09) 0.073 0.64 (0.21,1.97) 0.441
Sex overseas
No 1365 (70; 69,72) 542 (61; 58,64) 1 1
Yes 587 (30; 28,32) 345 (39; 36,42) 1.48 (1.25,1.75) <0.001 1.70 (1.37,2.11) <0.001
Injecting drug use
Never injected 2048 (96; 96,97) 914 (97; 96,98) 1
Ever injected 75 (4; 3,4) 28 (3; 2,4) 0.84 (0.55,1.3) 0.428
Current sex worker
No 2126 (>99; 99,100) 933 (99; 98,99) 1 1
Yes 9 (<1; 0,1) 10 (1; 1,2) 2.53 (1.03,6.25) 0.044 2.72 (0.97,7.59) 0.057
Condom Use in the last 3mo with male
partners
Not always 1379 (74; 72,76) 616 (71; 68,74) 1
Always 492 (26; 24,29) 246 (29; 26,32) 1.12 (0.93,1.34) 0.220
(Continued)
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 6 / 16
The majority of women (61%) and MSM (55%) discussed the removal of the condom with
their partners after the event. Over half of the participants reported being emotionally stressed
following the incident. Eight percent of women and five percent of MSM reported they
thought they had acquired an STI following the event. One percent of women and two percent
of MSM believed they had acquired HIV as a consequence of being stealthed (Table 4). Only
1% of people stealthed reported this experience to the police (Table 4).
Table 1. (Continued)
HIV status
Negative 1279 (91; 90,93) 558 (95; 92,96) 1 1
Positive 119 (9; 7,10) 32 (5; 4,8) 0.62 (0.41,0.92) 0.019 0.61 (0.38,0.97) 0.038
Use of prep
No 1844 (81; 79,82) 861 (83; 81,85) 1
Yes 436 (19; 18,21) 174 (17; 15,19) 0.85 (0.70,1.04) 0.112
Number of male sexual partners
in the last 3mo
3 [0–100] 3 [0–140]
Abbreviations: n = number; CI = confidence interval; mo = months; HIV = human immunodeficiency virus; PrEP = HIV pre-exposure prophylaxis
a
Adjusted model for females includes: sex overseas and current sex worker
b
Not in the labour force includes both those who are unemployed and/or students
c
Adjusted model for males includes: Aboriginal and/or Torres Strait Islander peoples, sex overseas, current sex worker and HIV status.
Data missing for: <5% of PrEP data; <5%-10% of employment data; 5–15% of Aboriginal and/or Torres Strait Islander peoples data; 10–15% of current sexworker data;
10%-20% of sex overseas data and injecting drug use data; 15- 20% of condom use data; and >20% of HIV data. Proportions are calculated using available data.
https://doi.org/10.1371/journal.pone.0209779.t001
Table 2. Reported events of non-consensual removal of condoms (stealthing) amongst patients presenting to a
STI clinic (N = 2252)
a
.
Female
respondents
n = 1189 (%; 95%
CI)
Male respondents
n = 1063 (%; 95%
CI)
Classified as not experiencing ‘stealthing’
Never stealthed 420 (35; 33,38) 496 (47; 44,50)
Condom removed w permission 455 (38; 35,41) 315 (30; 27,32)
Condom removed w/o permission but continued willingly 104 (9; 7,10) 77 (7; 6,9)
Classified as experiencing ‘stealthing’
Condom removed w/o permission, and continued unwillingly 108 (9; 8,11) 52 (5; 4,6)
Condom removed w/o permission, and stopped 135 (11; 10,13) 65 (6; 5,8)
Condom removed w/o permission, but didn’t realise until afterwards 147 (12; 11,14) 60 (6; 4,7)
Condom never put on but had been requested 84 (7; 6,9) 41 (4; 3,5)
Removed from further analysis
Not applicable
b
45 (4; 3,5) 127 (12; 10,14)
Decline answer 60 (5; 4,6) 64 (6; 5,8)
Abbreviations: n = number; CI = confidence interval; w = with; w/o = without.
a
Patients could select multiple options, to report multiple events occurring, i.e. events are not mutually exclusive,
therefore percentages do not sum to 100. Percentages represent the proportion of participants who have reported the
event. If reporting multiple events, patients were classified in the analysis based off the highest numbered event they
reported, if 1 is Never and 7 is ‘Condom never put on even though requested’.
b
Not applicable refers to patients who have not/do not engaged in penetrative penile sex, includes 97 MSM who
responded to survey but reported no receptive anal sex and 30 who selected not applicable.
https://doi.org/10.1371/journal.pone.0209779.t002
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 7 / 16
Table 3. Risk factors associated with non-consensual removal of condoms (stealthing) in patients presenting to a STI clinic (N = 2042).
Womenwho have not
had been stealthed
n = 738 (%; 95% CI) or
median [range]
Women who have
have been stealthed
n = 346 (%; 95% CI)
or median [range]
Unadjusted Odds
Ratio (95% CI)
p-value Adjusted Odds Ratio
(95% CI)
a
p-value
Age 26 [18–58] 26 [18–55]
Number of male sexual partners in the
last 3mo
2 [0–15] 1 [0–15]
Employment
b
Employed 439 (61; 57,65) 189 (56; 51,62) 1
Not in the labour force 281 (39; 35,43) 146 (44; 38,49) 1.21 (0.93,1.57) 0.161
Education level
Did not complete high school 18 (2; 1,4) 13 (4; 2,6) 1
High school/Certificate/Diploma 238 (33; 29,36) 134 (39; 34,45) 0.78 (0.37,1.64) 0.512
University degree 475 (65; 61,68) 195 (57; 52,62) 0.57 (0.35,1.47) 0.131
Aboriginal and/or Torres Strait Islander peoples
No 672 (99; 98,99) 319 (98; 96,99) 1
Yes 8 (1; 1,2) 5 (2; 1,4) 1.31 (0.43,4.06) 0.632
Australian/New Zealander
No 441 (63; 59,66) 166 (51; 45,56) 1
Yes 264 (37; 34,41) 160 (49; 44,55) 1.61 (1.23,2.09) <0.001 1.26 (0.94,1.70) 0.122
Current sex worker
No 573 (87; 85,90) 215 (71; 65,76) 1
Yes 83 (13; 10,15) 89 (29; 24,35) 2.86 (2.04,4.01) <0.001 2.87 (2.01,4.11) <0.001
Injecting drug use
Never injected 644 (98; 97,99) 295 (97; 95,99) 1
Ever injected 11 (2; 1,3) 8 (3; 1,5) 1.59 (0.63,3.99) 0.325
Sex overseas
No 303 (47; 44,51) 136 (47; 41,53) 1
Yes 335 (53; 49,56) 153 (53; 47,59) 1.02 (0.77,1.34) 0.903
Use other contraceptives in addition to
condoms
c
No 293 (46; 42,50) 112 (47; 40,53) 1
Yes 339 (54; 50,58) 128 (53; 47,60) 0.94 (0.733,1.33) 0.936
MSM who have not
been stealthed n = 704
(%; 95% CI) or
median [range]
MSM who have been
stealthed n = 168 (%,
95% CI) or median
[range]
Unadjusted Odds
Ratio (95% CI)
p-value Adjusted Odds
Ratio (95% CI)
d
p-value
Age 30 [18–75] 29 [18–58]
Number of male sexual partners in the
last 3mo
3 [0–140] 3 [0–100]
Employment
Employed 435 (65; 61,69) 98 (61; 53,68) 1
Not in the labour force 232 (35; 31,39) 63 (39; 32,47) 1.20 (0.85,1.72) 0.302
Education level
Did not complete high school 24 (3; 2,5) 7 (4; 2,8) 1
High school/Certificate/Diploma 183 (26; 23,30) 34 (20; 14,27) 0.64 (0.25,1.60) 0.336
University degree 494 (70; 67,74) 127 (76; 68,82) 0.88 (0.37,2.09) 0.775
Aboriginal and/or Torres Strait Islander peoples
No 701 (100; 99,100) 166 (99; 97,100) 1
Yes 2 (0; 0,1) 1 (1; 0,3) 2.11 (0.19,23.42) 0.543
(Continued)
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 8 / 16
Table 3. (Continued)
Womenwho have not
had been stealthed
n = 738 (%; 95% CI) or
median [range]
Women who have
have been stealthed
n = 346 (%; 95% CI)
or median [range]
Unadjusted Odds
Ratio (95% CI)
p-value Adjusted Odds Ratio
(95% CI)
a
p-value
Australian/New Zealander
No 343 (50; 46,54) 83 (49; 42,57) 1
Yes 342 (50; 46,54) 85 (51; 43,58) 1.03 (0.73,1.44) 0.877
Current sex worker
No 622 (99; 98,100) 151 (99; 95,100) 1
Yes 5 (1; 0,2) 2 (1; 0,5) 1.65 (0.32,8.57) 0.553
Injecting drug use
Never injected 611 (97; 96,98) 145 (96; 92,99) 1
Ever injected 18 (3; 2,4) 6 (4; 1,8) 1.4 (0.55,3.60) 0.480
Sex overseas
No 354 (60; 56,64) 82 (57; 49,66) 1
Yes 237 (40; 36,44) 61 (43; 34,51) 1.11 (0.77,1.61) 0.577
HIV status
No 375 (95; 93,97) 96 (2; 85,97) 1
Yes 19 (5; 3,7) 8 (8; 3,15) 1.64 (0.70,3.87) 0.255
Use of prep
No 582 (84; 81,87) 126 (78; 71,84) 1 1
Yes 110 (16; 13,19) 35 (22; 16,29) 1.47 (0.96,2.25) 0.077 1.16 (0.70,1.92) 0.567
Drugs use with anal sex w/o a condom in the last 12mo
e
No 222 (58; 53,63) 58 (55; 45,64) 1
Yes 162 (42; 37,47) 48 (45; 36,55) 1.13 (0.74,1.75) 0.569
Drunk during anal sex w/o a condom in the last 12mo
e
No 219 (57; 52,62) 53 (50; 41,60) 1
Yes 166 (43; 38,48) 52 (50; 40,59) 1.29 (0.84,1.99) 0.242
Anal sex w/o a condom with known HIV positive in the last 12mo
e
No 319 (83; 79,87) 83 (82; 73,89) 1
Yes 65 (17; 13,21) 18 (18; 11,27) 1.06 (0.60,1.89) 0.832
Anal sex w/o a condom with someone of unknown HIV status in the last 12mo
e
No 189 (50; 45,55) 39 (38; 29,48) 1 1
Yes 190 (50; 45,55) 63 (62; 52,71) 1.61 (1.03,2.51) 0.038 1.51 (0.96,2.39) 0.075
Self-reported health issues, such as anxiety or depression, which may have affected your decision to use condoms for anal
sex?
e
No 318 (85; 81,89) 74 (73; 63,81) 1 1
Yes 55 (15; 11,19) 28 (27; 19,37) 2.19 (1.30,3.68) 0.003 2.13 (1.25,3.6) 0.005
Abbreviations: n = number; CI = confidence interval; mo = months; MSM = men who have sex with men; HIV = human immunodeficiency virus; PrEP = HIV pre-
exposure prophylaxis; w/o = without
a
Adjusted model for females includes: Australian and current sex worker
b
Not in the labour force includes both those who are unemployed and/or students
c
Women who reported not using contraception due to pregnancy were excluded (2 females who did not have condoms removed, and 10 who did).
d
Adjusted model for males includes: use of prep, condom use with someone of uncertain HIV status, health issues (anxiety & depression) affecting decisions to use
condoms.
e
These questions were asked only to patients who had reported unprotected anal sex since their last HIV test as part of their routine computer assisted self-interviewing
(CASI).
Data missing for: <5% of employment data, education data and PrEP data; <5%-10% of Aboriginal and/or Torres Strait Islander peoples data and Australian data; 10%-
15% of injecting drug use data and current sex worker data, 10%-20% sex overseas data; 10- 20% contraception data; and 20% of HIV status and questions on issues
affecting decisions to use condoms. Proportions are calculated using available data.
https://doi.org/10.1371/journal.pone.0209779.t003
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Table 4. Situational factors surrounding non-consensual removal of condoms (stealthing) reported by patients presenting to a STI clinic (N = 523).
Women
n = 346 (%; 95% CI)
MSM
n = 168 (%; 95% CI)
When the incident occurred
Here today for this reason 42 (12; 9,16) 23 (14; 9,20)
In the last 3mo 59 (17; 13,22) 20 (12; 7,18)
3–12 mo ago 78 (23; 18,28) 35 (21; 15,28)
More than 12 months ago 120 (35; 30,40) 78 (46; 39,54)
More than 1 occasion 43 (13; 9,17) 12 (7; 4,12)
Relationship
Did not know him well 101 (30; 25,36) 102 (61; 54,69)
Friend 33 (10; 7,14) 10 (6; 3,11)
Friend with benefits/ Sex buddy 51 (15; 12,20) 30 (18;13,25)
Casually dating 54 (16; 12,21) 22 (13; 8,19)
Relationship 25 (8; 5,11) 2 (1; 0,4)
Client (of sex worker) 69 (21; 16,25) 0 (0; 0,2)
a
Relationship duration
Less than a day (<24hrs) 126 (38; 33,44) 85 (52; 44,59)
One day to one month 95 (29; 24,34) 39 (24; 17,31)
More than one month 107 (33; 28,28) 41 (25; 18,32)
Met through
Smartphone dating app/Internet 64 (20; 15,24) 110 (67; 59,74)
(Gay) bar or party 50 (15; 12,20) 20 (12; 8,18)
Gay sauna, beats of SOPV, sex party 2 (1; 0,2) 24 (15; 10,21)
Friend, or friend of friend 94 (29; 24,34) 6 (4; 1,8)
Co-workers 22 (7; 4,10) 3 (2; 0,5)
Sex work 76 (23; 19,28) 0 (0; 0,2)
a
Travel 15 (5; 3,7) 0 (0; 0,2)
a
Other (cafe
´, park etc.) 4 (1; 0,3) 1 (1; 0,3)
Drugs used by partner
bc
None 75 (27; 22,33) 63 (53; 44,62)
Alcohol 188 (68; 62,73) 48 (40; 31,50)
Cannabis/marijuana/hash 28 (10; 7,14) 4 (3; 1,8)
Ecstasy 12 (4; 2,7) 4 (3; 1,8)
Speed/ice/meth 5 (2; 1,4) 6 (5; 2,11)
GHB 2 (1; 0,3) 3 (2; 1,7)
Cocaine 10 (4; 2,7) 3 (2; 1,7)
Heroin 1 (<1; 0,2) 0 (0; 0,3)
a
Other 1 (<1; 0,2) 3 (2; 1,7)
Drugs used by respondent
bd
None 135 (41; 36,47) 87 (54; 46,62)
Alcohol 186 (57; 51,62) 65 (41; 33,49)
Cannabis/marijuana/hash 21 (6; 4,10) 3 (2; 0,5)
Ecstasy 9 (3; 1,5) 4 (3; 1,6)
Speed/ice/meth 5 (2; 0,4) 8 (5; 2,9)
GHB 2 (1; 0,2) 3 (2; 0,5)
Cocaine 8 (2; 1,5) 4 (3; 1,6)
Heroin 1 (<1; 0,2) 0 (0; 0,2)
a
Other 0 (0; 0,1)
a
4 (3; 1,6)
(Continued)
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Both female and MSM participants who had experienced stealthing were less likely to con-
sider it to be sexual assault than participants who had not experienced stealthing. Amongst
women, 62% (95% CI: 56%,67%) of those stealthed considered it to be assault, compared to
85% (95% CI: 82%,87%) of those not stealthed (OR 0.29, 95%CI: 0.22,0.4, p<0.001). Amongst
men, 61% (95% CI: 53%,69%) of those stealthed considered it to be assault versus 84% (95%
CI: 81%,86%) of those not stealthed (OR 0.31, 95%CI: 0.21,0.45, p<0.001).
Discussion
Although increasingly discussed in international media, there is little scientific research on
non-consensual removal of condoms, popularly termed ‘stealthing’. To our knowledge this is
the first study investigating how common stealthing is, the context in which it occurred, the
impact on individuals, and how those stealthed perceive the event. A surprising proportion of
clients attending a sexual health centre in Melbourne (32% of women and 19% of MSM)
reported removal of a condom in a situation where they would not have willingly engaged in
sexual intercourse without one—in other words, a violation of their consent [1].
These data need to be interpreted in the context of a STI clinic population which is gener-
ally a higher risk group than the general population. Our data show that 4% of women and 3%
of MSM presenting to our clinic during the study period were attending following a stealthing
incident. This equates to over 1200 consultations per year [12]. These data suggest that steal-
thing is common and should be considered when assessing patients in STI services.
Female respondents were less likely to be a current sex worker and MSM respondents were
less likely to be HIV positive, compared to non-respondents. It is possible that both sex work-
ers and HIV positive men were less likely to complete the survey due to privacy concerns,
Table 4. (Continued)
Women
n = 346 (%; 95% CI)
MSM
n = 168 (%; 95% CI)
Condom removal discussed with partner
No 128 (39; 33,44) 74 (45; 37,52)
Yes 204 (61; 56,67) 92 (55; 48,63)
Consequences of condom removal
b
None 85 (25; 21,30) 62 (38; 30,46)
Emotional stress 190 (56; 51,62) 86 (52; 45,60)
Caught an STI 26 (8; 5,11) 9 (5; 3,10)
Contracted HIV 2 (1; 0,2) 3 (2; 0,5)
Fight 49 (14; 11,19) 15 (9; 5,15)
Relationship broke up 30 (9; 6,12) 6 (4; 1,8)
Other 42 (12; 9,16) 12 (7; 4,12)
Reported to the police
No 336 (99; 97,100) 163 (98; 95,100)
Yes 3 (1; 0,3) 3 (2; 0,5)
Abbreviations: n = number; CI = confidence interval; MSM = men who have sex with men; mo = months; SOPV = sex on premises venue; GHB = Gamma-
hydroxybutyrate; STI = sexually transmitted infection; HIV = human immunodeficiency virus
a
one-sided, 97.5% confidence interval
b
Patients could select multiple options, to report multiple events occurring, i.e. events are not mutually exclusive, therefore percentages do not sum to 100. Percentages
represent the proportion of participants who have reported the event.
c
64 women (19%) and 47 MSM (28%) were unsure as to whether or not their partner had used any alcohol and/or other drugs and were removed from the analysis.
d
11 women (3%) and 6 MSM (4%) were unsure as to whether or not they had used any alcohol and/or other drugs and were removed from the analysis.
https://doi.org/10.1371/journal.pone.0209779.t004
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especially with regards to condom use and their legal obligations, which vary state by state in
Australia. In Victoria, sex workers are legally required to use condoms with clients[13], and
while those who are HIV positive are not legally required to disclose their HIV status, they
must take reasonable precautions to prevent HIV transmission to those they are engaging in
penetrative sex with[14]. Reasonable precaution refers to correct use of condoms and lube dur-
ing intercourse. While female sex workers were less represented in respondents than non-
respondents, 18% of participants were sex workers and we still observed an association
between being a sex worker and being more likely to be stealthed. Low numbers of HIV posi-
tive men participating may have limited our ability to examine any association between steal-
thing and HIV status. Lastly, both women and MSM who had been overseas recently were
more likely to respond to our survey. This may bias our findings towards individuals who may
have participated due to recent high risk sexual encounters, in the context of overseas travel
[15].
Women who experienced stealthing were three times more likely to be sex workers com-
pared to those who had not. In the Law and Sex Worker Health (LASH) Survey conducted in
Australia, 8% of respondents reported assault by clients [16]. However the LASH survey did
not compare rates of assault to the general population or differentiate between physical and
sexual assault, and only examined assault in the workplace. Perkins’ (1991) research with Syd-
ney-based brothel workers found that 20% of sex workers experienced rape while working.
Outside the workplace sex workers experienced higher levels of sexual assault compared with
non-sex workers, with 46.9% reporting rape, compared to 21.9% of health workers and 12.7%
of students [17]. Our data are consistent with these findings that sex workers are at increased
risk of non-consensual sex acts.
Sixty-seven percent of MSM who had experienced stealthing met the partner via geosocial
dating applications, for example Grindr, Tinder or Scruff. This is comparable to the number of
MSM meeting partners through dating applications (70%) [18]. Sexual encounters initiated
online are more likely to include unprotected anal intercourse [19], however it has also been
found that meeting partners online increases the likelihood of discussion between partners of
preferred sexual practices compared to meeting partners offline [19,20]. MSM who had been
stealthed were twice as likely to report having anxiety or depression. Depressive symptoms
and anxiety are predictive of condom non-use [21] and higher levels of depression are related
to lower levels of self-efficacy for sexual safety [22]. MSM who have anxiety or depression may
be vulnerable to stealthing for this reason.
In this study, the majority of women (73%) believed the partner who had stealthed them to
be under the influence of alcohol and/or other drugs. In heterosexual relations, the link
between alcohol consumption and committal of sexual assault is well documented [23,24].
Condom resistance tactics and sexual aggression with female partners are more commonly
employed by men with history of sexual aggression and alcohol intoxication [25,26]. Addi-
tionally, both alcohol consumption [27] and condom use [28,29] have been associated with
erectile dysfunction. Men with erection issues are more likely to engage in unprotected sex,
misuse condoms [28,29], and are more likely to remove condoms before sex is over
(p = 0.001) [29]. Literature supports our finding that heterosexual men who have consumed
alcohol may be at increased risk of committing nonconsensual sex acts, and may be removing
the condom to maintain an erection.
Whilst the majority of those reporting stealthing considered it sexual assault, they were
three times less likely to consider stealthing sexual assault than those who had never experi-
enced it. The US National Crime Victimization Survey found 20% of female victim narratives
contained excuses for offenders’ behaviour, denials of injury, or justification of the incident as
the victims’ fault [30]. This allowed the women to avoid the distress of labelling themselves
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 12 / 16
victims of a crime, or their partners as criminals [30]. Victims of stealthing may also not yet
view themselves as sexual assault victims as stealthing is a relatively new topic. Sexual assault is
a term with many connotations and there are cultural myths as to who is a ‘real’ sexual victim
[31], with the type of violence experienced influencing society’s view as to whether a woman is
a victim [32]. Our current language around sexual assault (and in this case, stealthing) may
require expansion- until an act is named as assault it cannot be viewed as such, and cannot be
reported or legislated against [33]. A limitation of this study is that we did not ask respondents
why they did not consider stealthing to be sexual assault.
Stealthing has potentially serious consequences. The majority of patients reported conse-
quences following the stealthing incident, with over half experiencing emotional stress. Although
literature contains estimates as to the rate of STI and HIV transmission during sexual assault, it is
difficult to establish if an STI has been acquired from a specific event. The Centers for Disease
Control and Prevention (CDC) guidelines recommend testing all people for STIs following sexual
assault [34], with the caveat that many positive tests will be from a pre-existing STI [35]. MSM
patients with condom malfunction or condom-less sex presenting in a 72 hour window fulfil crite-
ria for HIV Non-Occupational Post Exposure Prophylaxis (nPEP) [36,37], and therefore MSM
who present reporting non-consensual condom removal should be prescribed it.
This study has several limitations. Firstly, this study was offered in English only, which
means it cannot be generalised to attendees who are not fluent in English. Secondly, this study
may be subject to responder bias, as those who have experienced stealthing may have been
more likely to answer the survey. Given this is a retrospective survey, participant responses
may be subject to recall bias, and specific contextual situational factors and outcomes were
asked about one event only for those stating it had happened on more than one occasion.
While some participants within our study attributed the acquisition of STIs to being stealthed,
this cannot be verified. According to attribution theory [38] following an adverse event people
will make attributions to understand and control their environment[39], with situational fac-
tors often exaggerated when there is a negative outcome [40], and thus patients could be incor-
rectly attributing contracting a STI to the stealthing event.
Despite these limitations, this study has a large sample size with over two thousand
responses. Accurate statistics describing the prevalence and incidence of sexual assault are dif-
ficult to obtain since the majority of assaults are not reported to authorities and victims often
do not access services [31]. Only 1% of patients reporting stealthing in this study reported the
event to the police. Although this study may be subject to recall bias, population surveys are
the best means of learning the true extent and nature of these crimes, rather than relying on
crime statistics. This is the first study to describe how commonly this practice is occurring.
In summary, stealthing was commonly experienced by our clinic population, with a third of
women and a fifth of MSM reporting it, with situational contexts often involving alcohol and/
or drugs in women, and geosocial networking applications in MSM. Sex work was a clear risk
factor identified among women, and risk factors for MSM included anxiety and depression.
Knowledge of these risk factors can enable services to ask about stealthing in target groups and
offer specific support and counselling. Further community-based research would help deter-
mine the prevalence in the broader population and studies that link behavioural measures to
biological outcomes would help to quantify the STI risk associated with this practice.
Acknowledgments
We would like to acknowledge Jun Kit Sze and Afrizal for technical assistance and assistance
with data collection for this project, and Melbourne Sexual Health Centre counsellors Jocelyn
Verry and Peter Hayes for their support of this project.
Non-consensual condom removal or ’stealthing’
PLOS ONE | https://doi.org/10.1371/journal.pone.0209779 December 26, 2018 13 / 16
Author Contributions
Conceptualization: Rosie L. Latimer.
Data curation: Rosie L. Latimer.
Formal analysis: Rosie L. Latimer.
Investigation: Rosie L. Latimer.
Methodology: Rosie L. Latimer, Lenka A. Vodstrcil, Vincent J. Cornelisse, Tim R. H. Read,
Catriona S. Bradshaw.
Project administration: Rosie L. Latimer, Tim R. H. Read, Catriona S. Bradshaw.
Resources: Christopher K. Fairley.
Supervision: Lenka A. Vodstrcil, Christopher K. Fairley, Tim R. H. Read, Catriona S.
Bradshaw.
Validation: Lenka A. Vodstrcil, Tim R. H. Read, Catriona S. Bradshaw.
Visualization: Rosie L. Latimer.
Writing – original draft: Rosie L. Latimer.
Writing – review & editing: Rosie L. Latimer, Lenka A. Vodstrcil, Christopher K. Fairley, Vin-
cent J. Cornelisse, Eric P. F. Chow, Tim R. H. Read, Catriona S. Bradshaw.
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