FHI Research Briefs on the Female Condom — No. 4:

Female Condom Acceptability and Sustained Use

Women may be able to negotiate use of the female condom more easily than the male condom, giving them potentially more power to protect themselves in a sexual relationship. But the female condom must be acceptable to both men and women in order to be used consistently and correctly, thus providing effective protection against sexually transmitted infections (STIs) and pregnancy.

Studies conducted in more than 40 countries in Africa, Asia, Latin America, Europe and North America have found good initial acceptability of the device by people with varying sexual histories, ages, social situations and economic status. Acceptance rates in these studies varied widely, from 37 percent to 96 percent of study participants.¹ Determining which initial acceptors sustain female condom use over time requires more research. Research indicates:

• counseling helps overcome women's initial difficulties in using the device,
• directing promotion campaigns to men and providing women with negotiation skills are important to overcome men's resistance to use, and
• over time, use tends to become concentrated among a subset of women or couples with high motivation to use it.

Initial acceptability

Since the female condom is a new method in many settings, initial interest and demand has to be generated. Various aspects of the method attract potential users. Women and men report that, compared to a male condom, the female condom is less likely to slip or break, more durable, and less disruptive of sexual spontaneity and intimacy. A woman can put it in place well before intercourse occurs, which can give her more personal control. After ejaculation, the male partner need not hurry to withdraw fearing that the condom will slip off inside the vagina. Men report that the female condom is more comfortable than the male condom, neither diminishing sexual sensation nor constricting the penis. Some men like female condoms because women take responsibility for their use.

On the other hand, some women say that the device is too long — its outer ring hangs outside of the body. Some report that the rings are uncomfortable and that it is unattractive. Men and women have complained about noise during use and excessive lubrication. Like the male condom, the female condom may carry the stigma of being used only in short-term, casual relationships for disease prevention, and hence be associated with promiscuity. While some women report initial trouble correctly placing the device, having a clinician, counselor or peer educator train people to use it can increase acceptability, and difficulties with insertions and use decline with practice.²

Among the many acceptability studies, UNAIDS-supported research in Costa Rica, Indonesia, Mexico and Senegal found that women who introduced the female condom into a relationship reported that it allowed them to communicate more successfully about safer sex.³ In a study involving 377 women in the Dominican Republic, Mexico and United States, about four of every five women liked the device and said that they would recommend it to others.⁴

Sustained use

Researchers are seeking to understand which types of users are most likely to continue using the female condom. In Zambia and Zimbabwe, mass marketing campaigns and some educational support have made the female condom available in urban areas. A year after the Zimbabwe campaign began, a survey of more than 1,600 people at retail outlets concluded that single women and men with partners outside of marriage seemed to benefit most from the female condom introduction.⁵ After six months in the Zambia campaign, a random sample of 1,570 persons at 52 retail outlets found that those who had already discussed the female condom with a partner were more likely to use it in the future.⁶

Among 900 women provided with both male and female condoms at STI clinics in the U.S., after six months, 8 percent had used only the female condom. Another 73 percent had used both the male and female condom; about a third of those used 10 or more female condoms. The researchers concluded that women at risk of STIs find the female condom acceptable, with many using either the male or female condom consistently over time.⁷ Likewise, a study in Brazil involving 255 women and 29 men who had used female condoms for at least four months found that while most of them alternated between male and female condoms, about one-third of respondents preferred female condoms.⁸

Several studies among women at high risk of HIV infection indicated successful sustained use. A study in Zambia found that the devices were used in one-quarter of coital acts at three, six and 12 months.⁹ In a study among sex workers in Thailand, some 250 women offered both male and female condoms used female condoms in 12 percent of all sexual acts, a level that continued for the entire six-month study period.¹⁰ One year after the introduction of female condoms in a study among 1,000 sex workers in Madagascar, 20 percent of all sex acts with clients were protected by female condoms, and the overall proportion of sex acts that were protected had risen by 10 percent over 18 months.¹¹

Endnotes

1. UNDP/UNFPA/WHO/World Bank Special Programme of Research on Human Reproduction. The Female Condom: A Review. Geneva: World Health Organization, 1997; Cecil H, Perry MH, Seal DW, et al. The female condom: what we have learned thus far. AIDS and Behavior 1998:2(3):241-56.
2. Snyder K. Reality' check: female condom use supported by research. Drug Topics 1996;140:73; Artz L, Macaluso M, Brill I, et al. Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics. Am J Public Health 2000;90(2):237-44; Valappil T, Kelaghan J, Macaluso M, et al., Female condom and male condom failure among women at high risk of sexually transmitted disease. Sex Transm Dis 2005;32(1):35–43.
3. Rivers K, Aggleton P, Elizondo J, et al. Gender relations, sexual communication and the female condom. Critical Public Health 1998;8(4):273-90.
4. Farr G, Gabelnick H, Sturgen K, et al. Contraceptive efficacy and acceptability of the female condom. Am J Public Health 1994;84(12):1960-64.
5. Kerrigan D, Mobley S, Rutenberg N, et al. The Female Condom: Dynamics of Use in Urban Zimbabwe. New York: The Population Council, 2000.
6. Agha S. Intention to use the female condom following a mass-marketing campaign in Lusaka, Zambia. Am J Public Health 2001;91(2):307-10.
7. Macaluso M, Demand M, Artz L, et al. Female condom use among women at high risk for sexually transmitted disease. Fam Plann Perspect 2000;32(3):138-44.
8. Telles Dias PR, Souto K, Page-Shafer K. Long-term female condom use among vulnerable populations in Brazil. AIDS Behav 2006; 10(4 Suppl 7):67-75.
9. Musaba E, Morrison CS, Sunkutu MR, et al. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia. Sex Trans Dis 1998;25(5):260-64.
10. Fontanet AL, Saba J, Chandelying V, et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial. AIDS 1998;12(14):1851-59.
11. Deperthes B, Hatzell-Hoke T. Effectiveness of female condoms in the prevention of pregnancy and sexually transmitted infections. Global Consultation on the Female Condom, September 26-29, 2005.

FHI produced these research briefs as part of an information dissemination effort supported by the Bureau for Africa/Office of Sustainable Development, U.S. Agency for International Development.