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The Female Condom and Sexually Transmitted Infections -- May 10, 2000

NAIROBI, KENYA--In rural Kenya, more than 1,900 women recently participated in an effort to introduce the female condom — a device that offers protection against unplanned pregnancies and sexually transmitted infections (STIs).

A majority of women said they like the new method, and as many as half the women surveyed said they tried the method from time to time. In addition, women said their male partners generally liked the method.

Yet, in spite of these positive reactions to the female condom, STI rates did not decline as researchers had hoped. The reason: Women used the female condom but not often enough to cause a significant drop in STIs.

"Studies show the female condom can protect against the spread of several types of sexually transmitted diseases," said Dr. Paul Feldblum, a scientist at Family Health International (FHI). "And because STIs can be a risk factor that leads to HIV/AIDS, it’s important to help women find new ways to protect themselves and their partners.

"In this study, we provided the female condom, thinking that with the availability of this new method, more couples might protect themselves from STIs more often," he said. "At the end of the day, too few women were able to use the female condom often enough to make a real difference in STI rates."

These findings come from a study recently completed by the Family Planning Association of Kenya (FPAK), the Department of Medical Microbiology at the University of Nairobi, and FHI. A meeting was held May 9 in Nairobi to discuss study findings with high-level policy-makers, physicians, representatives of nongovernmental organizations (NGOs) and others interested in reproductive health.

Approximately 1,930 women working at flower, coffee and tea plantations throughout Kenya participated in the study. The mean age of women in the study was 33, and participants had a mean number of three to four children.

Women were divided into two groups. One group of 969 women received information about the female condom, instructions on how to use the method, and free female condoms. The group also received information on the benefits of male condoms in STI and pregnancy prevention, and participants received free male condoms. The second group of 961 women received free male condoms only, with information on how to use them correctly. Researchers conducted extensive activities at study sites to educate and motivate study participants to use both types of condoms.

"We succeeded in reducing STI prevalence overall at both intervention and control sites," Dr. Feldblum noted. "The entire multi-faceted intervention campaign did work. We simply did not get any additional benefit from the female condom introduction and availability."

In addition to the survey of 1,930 women, researchers also held focus group discussions with approximately two dozen men and 48 women to learn more about their views of the female condom. Researchers also interviewed a group of depot holders and held in-depth interviews with local opinion leaders, teachers, employers, health workers and religious leaders. These interviews were conducted when the study began and again eight months later.

At the beginning of the study, women were screened for gonorrhea, chlamydia and trichomoniasis. The two groups of women had similar STI rates — approximately 22 percent for the group that received information on both female and male condoms and 26 percent for the group that received male condom information only. Twelve months after the study began, the STI rates had dropped slightly. However, they remained similar for both groups — 18 percent.

During the study, researchers learned:

• Overall, women had a favorable opinion of the female condom. Among those who used the method, four out of five said they liked the device "very much" or "fairly well" when they were interviewed six months after the study began. At one year, the number was slightly higher. Among women who had tried both female and male condoms, women generally preferred the female condom. One study participant said the female condom "is better because when you feel it, it is strong and does not break easily. … In my opinion, it is more effective in protecting somebody." Another said the female condom "does not ‘choke’ the penis." And another said, "The [female] condom is light and, therefore, just like the skin."

• Some women said they liked the female condom because it is a method they can control. Others complained that men tamper with the male condom, deliberately tearing it or punching holes in it; the female condom gave them a sense of security. One study participant said, "For women, you insert it yourself. Women have control. They [men] cannot tear the tip [of the female condom], and theirs they tear, and the disease you were protecting yourself [from] still catches you."

• Approval of the female condom did not always translate into actual use. When women were interviewed six months after the study began, only 12 percent said they used the female condom every time they had sex. One year after the study began, that percentage had dropped to 7.

• The number of women who said they had not used the female condom since the previous clinic visit increased from 39 percent during the first six months of the study to 58 percent during the last six months of the study.

• When asked if they had used the female condom the last time they had sex, 26 percent of the women said yes at the six-month interview. At 12 months, 16 percent of the women said yes.

• Some women said they experienced difficulties when they first began using the female condom. At six months, 10 percent of women said they had trouble inserting the device; at 12 months, the percentage dropped to 3. In describing difficulties in using the female condom, one study participant explained: "It is hard work holding the female condom in place, but it is not for the male condom." In general, problems with insertion diminished over time, as women gained more experience using the female condom.

• Women’s negative comments about the female condom were that it contained too much lubricant, it made noise during sex, it was too big and it reduced sexual pleasure. Some women incorrectly believed the female condom could disappear inside their bodies. "I feared that it might be pushed into my stomach," one woman said. "I went to the nurse who explained how to insert it and even how to remove it if it is pushed inside."

• Generally, study participants believed men should initiate sex, and women should initiate family planning.

• When asked their male partners’ opinions, 58 percent of women who used the female condom said at the six-month interview that their partners liked the device. At the 12-month interview, 63 percent said their partners approved.

• However, more than one-fourth of the women said their male partners refused to let them use the female condom, and more than one-third said their partners would not use male condoms. "Some of the factors that limit male condom use — discomfort, the need to use the device during each act of sexual intercourse, the disruption of sexual intercourse — also appear to limit female condom use," said Dr. Theresa Hatzell, an FHI researcher. "Additionally, there are rumors about possible negative health effects. And there are issues of trust and power that affect both female and male condom use."

• Some women said it was difficult to discuss female condom use with their husbands because men would think they were unfaithful. Some men said they feared women would re-use the device and transmit disease. One man said, "She cannot insert it when I’m not near because I may not trust it was just for me. … She could have used it with somebody else. She should insert [it] in my presence."

• Some men opposed any type of family planning, believing it promotes promiscuity among women. One female study participant explained, "They feel that when you have a child who is breastfeeding, you will not move with other men. But if you have no baby, you are a ‘manyanga,’[an unmarried woman], and they want you pregnant all the time."

• In spite of some men’s reluctance to use any type of condom, male condom use actually increased. When research began, only 2 percent of study participants said they always used male condoms. Twelve months later, the percentage had jumped to 22 for the group that received information about male and female condoms and 24 percent for the group that received information about male condoms only. The percentage of men who used condoms the last time they had sex increased substantially — from 6 percent when the study began to 38 percent at the 12-month interview."The increase in male condom use indicates that men and women are listening to messages that male condoms can prevent STIs," said Ms. Maureen Kuyoh of FHI’s Nairobi office. "While couples like the female condom, it appears the male condom is the method they use more often."

The female condom is a long sheath, made from polyurethane plastic, which fits inside the woman's vagina. It has several advantages. It is made of a material stronger than latex, the material used for most male condoms, so it can withstand heat in tropical climates and is less likely to break or tear. Many men and women say the female condom feels more natural than the male condom, and its use does not reduce sexual pleasure. And many women like the ability to protect themselves against STIs if their partner will not or cannot use male latex condoms. "Some women told us that men intentionally damage male condoms," said Dr. Hatzell of FHI. "Using the female condom gives the woman more confidence her contraceptive will be effective and free from these type of problems."

In the coming months, researchers will be discussing study results with health policy-makers and health workers in Kenya. They will discuss ways to reduce STI rates.

"In spite of greater awareness of STIs among the study participants, in spite of increases in male condom use, and in spite of improvements in the way we treat and prevent STIs, the incidence of gonorrhea, chlamydia and trichomoniasis remains distressingly high," explained Dr. Job Bwayo of the University of Nairobi, a co-principal investigator for the study.

"Male latex condoms still offer the best protection against STIs and HIV/AIDS, but the female condom is an important option for women whose partners will not or cannot use male condoms," said Dr. Michael Welsh of FHI’s Nairobi office. "We need to look at every possible way to reduce STI rates, including treatment for people who already have STIs and prevention for those who are not infected.

"If we can reduce the prevalence of STIs, we can reduce the risks of acquiring HIV," said Dr. Welsh. "That will be good news, not only for participants in this study, but for all of Kenya