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At a time when AIDS has become a devastating public health problem,
the role of female barrier methods to prevent sexually transmitted
diseases (STDs) has taken on new importance. To give women more options
in pregnancy and STD prevention, researchers are developing new types of
female barrier methods while refining existing methods.
In spite of the dual-role advantage female barrier methods provide,
offering both contraception as well as protection against some STDs, use
of female barrier methods remains low in many countries. The reason:
Barrier method use is not practical for many women.
For some women, barrier methods are messy, inconvenient,
uncomfortable and costly. For others, barrier method use is complicated
by cultural norms that discourage couples from talking about sexual
matters, including contraception. And for many women, successful use of
female barrier methods frequently depends upon the cooperation of their
male partners.
Male latex condoms offer the best protection against STDs, including
HIV, and are more effective contraceptives than other barrier methods.
Many couples, however, do not use condoms, believing they reduce sexual
pleasure or that condoms are used only with casual partners or
prostitutes.
Because of their economic dependence on men, women often find
themselves unable to suggest condoms or refuse sex if condoms are not
used. In Haiti, for example, researchers from the Institut Haïtien de
l'Enfance and FHI found women refer to their sexual organs as
mammanlajan-m or "my capital" and negotiate sex to promote
their economic welfare. Yet, while women typically negotiate sex, they
rarely negotiate protection. Asking a man to use condoms was viewed as a
sign of infidelity, and refusal to have sex could provoke anger or
violence. Both women and men agreed that if a woman refused sex, she
jeopardized her own health and that of her partner. According to one
man, "If I tell the woman that I feel like making love, and she
does not agree, well! I will go out! Then who is responsible that I get
AIDS? She is."1
In Thailand, a government program to promote male condom use in
brothels has been very successful. However, condom use within marriage
remains low. Although 74 percent of Thai couples use contraception, only
2 percent use condoms.2 In focus group discussions and
in-depth interviews, couples said they viewed condoms as a means to
prevent disease among men who engage in premarital and extramarital
visits to prostitutes. Condoms were used within marriage only as a
temporary or backup contraceptive. To suggest condom use for any other
reason would arouse suspicions of infidelity or would be demeaning. One
woman explained, "He said it would seem like I am not his
wife."3
Scientists are examining these and many other human behavioral
factors that affect barrier method use — how and why women use barrier
methods, what they like or do not like about these devices, how partner
attitudes are likely to influence use, and the gap between acceptability
and use.
Female condom appeal
Women like the female condom because it can be woman-initiated and
many report increased sexual pleasure for both the woman and man
compared with the male condom. For these and other reasons, some users
prefer it to the male condom.
In Zimbabwe, where the female condom is relatively new, users said
they were pleased with the method, according to research conducted by
Population Services International. "If your partner refuses to use
the male condom, you just insert yours quietly," one woman told
researchers. Men also approved of the method, saying it enhanced their
sexual pleasure. "It allows me to be aroused more quickly,"
one man said.
A study of commercial sex workers in Costa Rica, conducted by the
Instituto Latinoamericano de Prevención y Educación en Salud with
support from FHI, found that approximately two-thirds of the 50 women
interviewed preferred the female condom to the male condom.4
Women who initially reported difficulty with insertion, discomfort, or
problems with the penis entering incorrectly — between the device and
the vagina — said those problems diminished over time. Women reported
that their partners were less likely to refuse female condom use than
male condom use.
In Thailand, a study among 56 sex workers in Songkla province found
that a majority of women were satisfied with the female condom and 80
percent said they were willing to use it in the future. However, 98
percent said they would prefer to use the male condom, believing the
client would refuse to use the female condom, that it would not be
effective and that it would be uncomfortable.5
A study in Kenya, conducted by the University of Nairobi and FHI,
found that three-fourths of the women said they liked the female condom
very much, and 39 percent said they preferred it to the male condom.
Women said the device was comfortable, made sex more pleasurable,
offered STD protection and was under their control. However, other women
(24 percent) said they would not use the device in the future. Many said
their partners would object.6
An FHI study in São Paulo, Brazil, and Nairobi, Kenya, also found
that some women prefer the female condom over the male condom. Forty-two
percent of the 103 women interviewed in Brazil said they preferred the
female condom, and 21 percent said they liked it as much as the male
condom.
Men said they were glad that it did not interfere with their sexual
pleasure, relieved that the burden of STD protection was not theirs
alone and less concerned that the female condom would tear or dislodge.7
As this research indicates, partner approval is critical for
successful use of the female condom and other female barrier methods.
Diaphragm and spermicides
A study in Colombia, Turkey and the Philippines found that among 550
diaphragm users, some women liked this method because it was free from
side effects, while others said it gave them more control over their
contraceptive use. "I like it because I can manipulate it,"
said one woman. "I do not need to ask my husband. I am
responsible." They also were more likely to have used a
contraceptive method previously and were more likely to be dissatisfied
with intrauterine devices (IUDs) or hormonal methods, such as oral
contraceptives and injectables.
However, partner attitude was important. While continuation rates
were comparable to those of IUDs and hormonal contraceptives, women who
reported their partners were unaware of method use or who liked the
method were almost three times more likely to continue than other women.8
Convenience and ease of use are important factors. In São Paulo,
Brazil, 11 percent of 1,723 low-income women selected the diaphragm as
their contraceptive method. However, 46 percent of diaphragm users
discontinued the method within three months, compared with 29 percent of
male condom users and 16 percent of oral contraceptive users.
The most common reasons women gave for initially choosing the
diaphragm were concerns for health (35 percent), ease of use (16.3
percent), efficacy (15.2 percent), and woman-control (5 percent). Among
women's reasons for discontinuation were that they no longer need
contraception (15.2 percent), they had difficulty in handling the
diaphragm (15.2 percent), they suffered side effects such as urinary
tract infections (11.6 percent), the method was uncomfortable (10.7
percent), and their partner complained (10.7 percent). Researchers
recommended that providers receive additional training to help new
barrier method users adapt to their method and resolve any problems.9
Spermicides can be used in conjunction with a diaphragm or alone.
These female-initiated methods come in a variety of formulations,
including foam, vaginal suppository, gel or cream, and film. An FHI
study in the Dominican Republic, Mexico and Kenya found that women did
not prefer foaming contraceptive tablets to contraceptive film,
believing tablets to be too wet or messy. While women did like
contraceptive film, citing ease of use and lack of side effects, Latin
American women complained film stuck to the fingers during insertion.10
New methods
In designing new methods for pregnancy or disease prevention,
researchers are taking a closer look at what women want.
In Brazil, a study conducted by the Universidade Estadual de Campinas
and the Program for the Topical Prevention of Conception and Disease
found that women's ideal new contraceptive would be a gel or cream
rather than a film, with no taste, color or odor. More than 600
adolescent and older adult women also said they wanted a barrier method
they could insert with a pre-filled single-dose applicator. They said
the method should not be messy, should be easy to store, and should last
for eight hours or longer so that reapplication for other sexual acts
would not be necessary. And women wanted one method that would perform
two functions — disease and pregnancy prevention.
However, older adult women said they would be willing to use a new
barrier method in conjunction with another contraceptive, even if the
barrier method were messy, as long as it protected them from STDs,
including HIV. Adolescents said they would not tolerate messiness. All
women said they would not accept a method that caused vaginal burning,
irritation or swelling.11
The Program for Appropriate Technology in Health (PATH) has solicited
women's opinions in designing a new type of barrier method, the SILCS
intravaginal barrier contraceptive. Made of silicone, the device
resembles a diaphragm.
PATH interviewed diaphragm users in the United States about their
likes and dislikes in using barrier methods, then recruited consumers
and family planning providers to test prototypes of a new device. PATH
learned that women wanted a barrier method that is less messy than those
currently available, that is not inserted immediately before intercourse
and that will not cause urinary tract infections, a side effect among
some diaphragm users. Providers had a slightly different perspective,
believing women would place a high priority on a device that was easy to
insert, that was effective and that was comfortable during sex.
With comments from these groups, PATH developed the SILCS device. In
a small acceptability study, 18 couples in the United States said they
liked the device and found it comfortable, easy to insert and easy to
remove. The SILCS device is undergoing clinical trials to evaluate
barrier properties.
PATH also has conducted research on prototype devices similar to the
female condom. "We are not asking 'Is this acceptable?' but 'How
can it be improved?'" says Maggie Kilbourne-Brook, PATH program
associate. "What we are hearing is that couples want skin-to-skin
contact. If something we introduce is going to take that away, then we
can try to develop a device that is minimally intrusive or if we take
something away, maybe we can offer something back in return."
In its work to develop new products called microbicides, the
Population Council invited women's health advocates to advise
researchers on many aspects of product development, including
characteristics that will make a new method acceptable. Women's groups
have emphasized the urgent need for a method that is highly effective
and free from side effects, says Elizabeth McGrory, a program associate
with the Population Council. The ideal microbicide would be
female-controlled and convenient.
Women also want a microbicide that is not messy (although the
importance of this factor varies from country to country), that could be
inserted well in advance of intercourse, and that does not stain
clothing. While some women want a method that can be used secretly,
others say they want their partner to know and to be involved.
In working with the Population Council to develop a microbicide, the
Women's Health Advocates on Microbicides (WHAM) suggested that
researchers explore multiple formulations to meet women's diverse needs
— microbicides in gels, films, foams or sponges; microbicides with or
without applicators; microbicides with and without contraceptive
effects; and microbicides with or without a prescription. WHAM members
said that a desirable microbicide would be one that was effective, not
messy and could be inserted several hours before sex.12
If an effective microbicide were developed, its introduction would
require more than providing information about the new product itself.
Women and men would need education about method use, support to
encourage method use, and skills in how to negotiate with partners.
"In the long run, reducing women's vulnerability will require
more than a new technology," says a report by women's advocates and
the Population Council. "Ultimately, empowering women to have
control over their sexual lives requires a fundamental change in
male-female relations and a concerted effort to eliminate the inequities
that leave women economically and socially dependent on men."13
— Barbara Barnett
References
- Ulin PR, Cayemittes M, Gringle R. Bargaining for
life: women and the AIDS epidemic in Haiti. In Long LD, Ankrah ME,
eds. Women's Experiences with HIV/AIDS. (New York: Columbia
University Press, 1997)91-111.
- World Contraceptive Use 1998,
poster. New York: United Nations Department of Economic and Social
Affairs, 1999.
- Knodel J, Pramualratana A. Prospects for increased
condom use within marriage in Thailand. Int Fam Plann Perspect
1996;22(3):97-102.
- Madrigal J, Schifter J, Feldblum PJ. Female condom
acceptability. AIDS Educ Prev 1998;10(2):105-13.
- Sinpisut P, Chandeying V, Skov S, et al.
Perceptions and acceptability of the female condom (Femidom) amongst
commercial sex workers in Songkla province, Thailand. Int J STD
AIDS 1998;9(3):168-72.
- Ruminjo JK, Steiner M, Joanis C, et al.
Preliminary comparison of the polyurethane female condom with the
male condom in Kenya. East Afr Med J 1996;73(2):101-06.
- Ankrah EM, Attika SA. Adopting the Female
Condom in Kenya and Brazil: Perspectives of Women and Men. A
Synthesis. Arlington, VA: Family Health International, 1997.
- Brady M, Díaz J, Bulut N, et al. Assessing the
acceptability, service delivery requirements and use-effectiveness
of the diaphragm in three developing countries. Unpublished paper.
The Population Council, World Health Organization, and Family Health
International, 1999.
- Di Giacomo de Logo T, Barbosa M, Klackmann S, et
al. Acceptability of the diaphragm among low-income women in São
Paulo, Brazil. Int Fam Plann Perspect 1995;21(3):114-18.
- Steiner M, Spruyt A, Joanis C, et al.
Acceptability of spermicidal film and foaming tablets among women in
three countries. Int Fam Plann Perspect 1995;21(3):104-7.
- Hardy E, de Pádua KS, Jiménez AL, et al. Women's
preferences for vaginal antimicrobial contraceptives II, preferred
characteristics according to women's age and socioeconomic status. Contraception
1998;58(4):239-44; Hardy E, de Pádua KS, Jiménez AL, et al.
Women's preferences for vaginal antimicrobial contraceptives III,
choice of a formulation, applicator and packaging. Contraception
1998;58(4):245-49; Hardy E, de Pádua KS, Osis MJD, et al. Women's
preferences for vaginal antimicrobial contraceptives IV, attributes
of a formulation that would protect from STD/AIDS. Contraception
1998;58(4):251-55.
- Heise LL, McGrory CE, Wood SY. Practical and
Ethical Dilemmas in the Clinical Testing of Microbicides, a Report
on a Symposium. New York: International Women's Health
Coalition, 1998.
- Heise.
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Promoting
Partner Communication |
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In many cultures, men and women do not typically discuss sexual
issues. If they do, the man initiates discussion and the use of
family planning begins after several births, when the desired
family size has been achieved.
For many women, introduction of the female condom has given
them a chance to communicate with their partner about sex,
pregnancy, sexually transmitted diseases (STDs) and family size.
Women in Costa Rica, Indonesia, Mexico and Senegal said the
female condom gave them an opportunity to talk with their partners
about safer sex.1 Some women in a U.S. study said they
initiated discussions about contraception and STD protection by
leaving the female condom in a place for their partner to see.2
In Kenya, where men typically are responsible for sexual
decision-making and women are responsible for contraception, women
said female condom use enabled them to talk with their partners
about a broad range of topics, including intimacy and sexual
pleasure. In Brazil, women said they felt female condom use gave
them some control over their bodies and their sexuality, as well
as knowledge about reproductive anatomy. "Ultimately, the
women valued the fact that the female condom encouraged dialogue
with their partners that went beyond sex to other issues,"
wrote the authors of a summary report.3
In Zimbabwe, Population Services International (PSI) has
conducted a nationwide marketing campaign of a female condom under
the brand name "care." Through this effort, PSI is also
emphasizing the need for couples to talk with each other about
sex. In order to reach couples with established relationships,
where better communication is more likely to occur, PSI promotes
the condom as a "contraceptive sheath" offering dual
protection from both pregnancy and sexually transmitted diseases,
including HIV.
PSI advertisements show a man and woman smiling and talking,
with the message "for women & men who care." The
emphasis is on joint decision-making about reproductive health.
"You can design an intervention that helps women negotiate
condom use, but unless you address what goes on beyond the closed
door, between those two people, programs will have limited
impact," says Josselyn Neukom, program analyst for PSI.
"The challenge is reaching the couple."
PSI campaigns are directed at both women and men because both
are involved in the decision to use the female condom. "With
the female condom, the man knows the woman is using it, and may
have played some role in the decision to use it — he may even
have introduced it. To say it is an exclusively female-controlled
method is misleading," says Neukom. "PSI programs
promote products, but also promote a behavior — two people
talking together about prevention. And we are promoting condom use
as a joint decision."
But couple communication is not the only type of interaction
needed to make female condom use successful. PSI also encourages
potential users to talk with health providers.
"One of the things we knew from the outset is that this
product requires different strategies. Unlike the male condom, it
is not something you put on the shelf, you advertise with a few
billboards, and sales pick up," says Neukom. "Having
confidence in one's ability to negotiate and use this product
correctly are important issues. Clients need face-to-face
interaction with a provider or someone else they trust, such as a
peer educator or outreach worker, for information and counseling
about how to use this method."
— Barbara Barnett
References
- More Evidence on Female Condom: Increased
Protection against Sexually Transmitted Diseases, Including
HIV/AIDS, press release. Geneva:
Joint United Nations Programme on HIV/AIDS, 15 July 1997.
- El-Bassel N, Krishnan SP, Schilling RF, et
al. Acceptability of the female condom among STD clinic
patients. AIDS Educ Prev 1998;10(5):465-80.
- Ankrah EM, Attika SA. Adopting the Female
Condom in Kenya and Brazil: Perspectives of Women and Men. A
Synthesis. Arlington, VA: Family Health International,
1997.
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