Acceptability and usage

In 2005, Susie Hoffman¹ reviewed studies of female condoms (primarily the FC1) and said that acceptability rates in studies had varied hugely from 37 to 96%.

Positive aspects of the female condom cited in various studies by Hoffman include the fact that it enhanced women’s ability to negotiate and ensure safer sex, the strength and hypoallergenic nature of polyurethane, and that for some couples it enhanced sexual pleasure: for the men, it felt less restrictive and dulled sensitivity less than male condoms. For the women, it could be inserted well before sex and so increased spontaneity, and for both it conducted heat better so that sex felt more ‘natural’.

However, for a majority of women and couples the overall impression was negative. It was criticised aesthetically for looking ‘weird’ especially in the way the outer ring protruded from the vulva; many women and some men found it uncomfortable; men had insertion difficulties, and one of the most frequent causes of failure was that men ‘aimed wrong’ and inserted their penis between the condom and the vaginal wall rather than inside the condom. It was also noisy: polyurethane is slightly stiffer than latex and makes a crinkling sound.

In a US study of 1159 female STI clinic attendees in Alabama² who were offered female condoms as an additional method of contraception and STI protection, 79% used the female condom at least once and often multiple times and more than a third of the women used female condoms throughout the follow-up period of 12 months.

Two months after they were introduced, about 40% of protected sex acts involved female condom use, but this settled down to about 25% after four months. The proportion of sex acts that were protected by any condoms, male or female, jumped from 38% at baseline to 78% at two months (thus illustrating the powerful effect of condom provision and safer sex support in general), and then settled down to about 68%.

Initially, therefore, female condoms were used in about half of protected sex acts and, although this proportion declined as time went on, it was still used in over one-third of sex acts by 12 months.

Of the women who used female condoms, 75% also used male condoms, showing that female condoms are generally used to increase choice and flexibility rather than as a total substitute for male condoms.

Initially, 25% of women using female condoms reported difficulties in inserting them properly, but with training and the opportunity to practise insertion, the proportion reporting difficulties decreased to 3%.

Patterns of use vary according to the geographical area of studies. In US studies, female condoms tended to be used in long-term relationships; in casual sex situations, male condom use was more common. In a US study, for instance, 77% of women tried the female condom with their spouse or boyfriend, 42% with other ‘friends’, and only 28% with new or casual partners.³

In the majority of the developing-world studies, the opposite pattern held true; if condoms were used at all in primary relationships they tended to be male condoms, but female condoms might be used in casual and commercial sex situations – and least when women had the power of decision over what kind of protection to use, if any.

In one Tanzanian study, for instance,⁴ which interviewed 2712 men and women about their actual or intended use of the female condom after a mass-marketing campaign, about a quarter of all women interviewed said they would use the female condom in a casual-sex situation, one in eight with regular partners, but only one in 14 with husbands. There was an interesting disconnect here with men’s views: one–in-eight men said they would use the female condom with a spouse or regular partner but only one in ten in a casual sex situation. This disconnect was not investigated further but may reflect both women’s comparatively greater control over sex in casual situations than in marriage in poorer counties, and men’s concern about HIV and sexual pleasure in casual sex.

A number of studies have included provision of the female condom and training on its use in a ‘safer-sex hierarchy’ model for female STI clinic attendees. This ranks safer-sex methods according to their safety.

For instance, in a Philadelphia study,⁵ 292 female STI clinic attendees were provided with both male and female condoms when requested, but were randomised into three groups according to the advice they were given. One group was only given advice on using the male condom (62 women), and the second was only advised on using the female condom (112 women). The final group (118 women) was given advice on the following safer-sex hierarchy:

1. Abstinence

2. Male condom

3. Female condom

4. Diaphragm with spermicide

5. Spermicide alone

Abstinence and male condom (1 and 2) were cited as the two best ways of avoiding infection.

The female condom (3) was cited as the next-best method if male condoms could not be used.

Diaphragm with spermicide (4) was cited as risky but better than nothing.

Spermicide alone (5) was cited as a ‘last resort’ use, offering significant protection only if coupled with withdrawal before ejaculation.

There had been concerns before these and similar studies that the introduction of hierarchical messages would have a counterproductive effect, in that women would feel safe to move down the hierarchy and start using the less safe methods. However this did not happen. The hierarchical method appeared to be popular, with higher rates of study retention and follow-up amongst women receiving the hierarchy counselling: 74% of those given hierarchy counselling returned for their six-month follow up, compared with 56% given male-condom instruction alone and 49% given female-condom instruction alone.

The proportion of sex acts that were protected were slightly higher at six months amongst women given female-condoms alone (74%, versus 66% given hierarchy counselling and 62% given male condoms), but then there was a higher drop-out rate seen in the female-condom arm. If this was taken into account, it was estimated that in all study subjects including those who did not return for follow-up, 59% of sex acts in subjects given hierarchy counselling were protected versus 50% in those given female condoms and 40% in those given male condoms.

The relative power women have over sex in different cultures is just as important for the female as for the male condom. While the female condom may be designed to be a female-initiated method, it cannot be used (unlike PrEP and possibly some envisaged microbicides) without a partner’s knowledge. Men’s consent for use therefore remains crucial.

In the US, qualitative interviews with women and their partners⁶ showed that women used a number of different strategies to persuade men to use condoms. They emphasised the additional degree of protection female condoms gave, either as an added choice, or as additional protection against pregnancy if oral contraception was being used. They emphasised the more ‘natural’ feeling female condom use conferred, both because condom use did not interrupt the process of sexual stimulation and erection, and because of the better heat conductivity of polyurethane; and they eroticised female condom use by involving the man in the process of insertion.

Studies from Kenya and Brazil⁷ have found that women in developing countries use similar strategies. In these countries focusing on pregnancy as opposed to STI prevention was even more important in order to win male acceptance, both for negative reasons (the lower availability of oral contraception) and for positive ones (emphasising pregnancy as opposed to STI avoidance builds trust and avoids accusations of infidelity). Women used a variety of non-confrontational persuasion methods, including leaving the female condom on the bed to stimulate discussion and, as in the developed world, asking the man to help insert it.