|The Female Condom: a guide for planning and programming under (UNAIDS, 2000, 81 p.)|
Source: Mark Schlossman / Panos Pictures
Source: J.C. Tordai / Panos Pictures
Source: Piers Benatar/Panos
Source: Anders Gunnartz / Panos Pictures
The female condom is the first and only female-controlled contraceptive barrier method with the advantage of also providing protection from STIs. The female condom is safe and effective if used correctly and consistently and has high acceptability among both women and men in many countries. Because it is a new method, though, the way the product is presented to potential users is critical. Many people will be seeing the female condom for the first time and, at first glance, the female condom may look strange or hard to use.
Introducing the female condom can be done in groups or in one-to-one sessions. Group sessions offer a friendly environment where women (and/or men) can share information, ideas and experiences. In one-to-one sessions, messages can be tailored to fit the specific needs of a user. In either case, the following are essential ingredients to successful introduction:
· Maintaining a non-judgmental attitude
· Covering basic concepts
· Using plain language
· Encouraging interaction
The following is an outline of the way the female condom can be introduced. It is meant to be adapted and modified depending on the setting.
1. Describe the social context of HIV/AIDS and STIs in the community/country and dynamics of sexual relationships.
2. Establish how much the person or group knows about safer sex, anatomy and the female condom.
3. Provide a brief overview of disease transmission.
4. Provide an overview of the reproductive system.
5. Discuss personal vulnerability and risk.
6. Explain protection, especially the idea of dual protection protection from STIs/HIV/AIDS and unintended pregnancy.
7. Highlight major anatomy points that relate to the female condom:
· The difference between the vaginal canal and the urethra.
· The vagina is a closed pouch.
· The location of the pubic bone and cervix.
· Explain that the female condom will not interfere with normal bodily functions.
8. Let each person touch the female condom.
9. Describe the female condom and compare it to the male condom and other contraceptive methods.
10. Demonstrate proper use and disposal.
11. Discuss partner negotiation skills and techniques.
12. Emphasize practice and patience.
The information on the following pages is meant to help people understand the female condom and related issues. These pages can be photocopied for users; be used in brochures with visual examples; and/or be developed as flip chart materials. FHC is currently developing this material as a flipchart for wide distribution.
Disease transmission and safer sex
Personal vulnerability and risk
Many men and woman may not believe that they are at risk of STIs. Therefore, the following messages should be delivered in introduction programmes:
· Good, reliable data should be presented about the realities and risks of STI and HIV infection and the fact that women are also at risk of contracting HIV/AIDS.
· A person can become infected through having sexual relations with someone who is infected.
· An HIV-infected person may or may not have any symptoms or signs of the infection and may not know that he or she is infected.
· A person with an STI is at increased risk of contracting HIV, the virus that causes AIDS.
· An STI may affect a persons fertility.
· Protection against STIs is also protection against infections that can cause cervical cancer.
· An infected pregnant woman can infect her baby in the womb or during childbirth.
· Infections such as syphilis can cause permanent heart and brain damage if untreated.
· Infections such as HIV can kill the infected person.
· Counsellors should encourage clients with signs and symptoms of common STIs to see a health care provider immediately, as most STIs can be treated. They should be advised also to inform their partners to seek out a health care provider to ensure that they are not also infected.
Only barrier method contraceptives provide protection against both unwanted pregnancy and the transmission of some STIs.
Other methods, such as oral contraceptive pills, injectables, implants and IUDs reduce the risk of pregnancy only, but provide no protection against STIs.
· It is important to be familiar with both your body and your partners.
· Show the vagina, explaining that this is where the penis goes during sex.
· Show the urethra, explaining that inserting a female condom will not interfere with normal bodily functions such as urination.
· Show the location of the pubic bone and cervix on a diagram or plastic model, explaining that the female condom covers the cervix and protects it from both sperm and diseases that can enter the cervix.
· Point to the uterus, explaining that this is where the fetus grows, and to the fallopian tubes, stating that each month an egg is released, it goes into the uterus, and the outcome is either pregnancy or a period.
· The vagina is a closed pouch; the female condom will not float up and become lost in a womans body.
The female condom is a relatively new method and requires practice and patience. Think about developing a mechanism to provide support to new users through drop-in weekly groups and one-to-one counselling sessions.
The Female Reproductive System from the Reproductive Health Research Unit's contraceptive methods flip charts in South Africa
How to use a female condom is explained in the Reproductive Health Research Unit's contraceptive methods flip chart in South Africa
The female condom
· A strong, loose-fitting polyurethane sheath that is 17 centimetres long (about 6.5 inches) with a flexible ring at each end.
· Polyurethane is a soft, thin plastic that is stronger than the latex, used to make most male condoms.
· Polyurethane conducts heat efficiently, so sex can feel very sensitive and natural with the female condom.
· Polyurethane is odourless.
· The inner ring is used to insert the female condom and helps keep the female condom in place. The inner ring slides in place behind the pubic bone.
· The outer ring is soft and remains on the outside of the vagina during sexual intercourse. It covers the area around the opening of the vagina (the vulva). It can prove pleasurable for men as well as for women.
· There are no serious side-effects associated with use of the female condom; less than 10% of users report mild irritations.
· It can be inserted up to eight hours in advance so it will not interrupt sexual spontaneity.
· It does not require an erect penis to insert the female condom into the vagina.
· It need not be removed immediately after ejaculation.
· It comes pre-lubricated with a non-spermicidal, silicone-based lubricant that is needed for ease of insertion and for easy movement during intercourse.
· Lubrication reduces noise during sexual intercourse and makes sex smoother.
· Additional lubricant, either oil-based or water-based, can be used.
· It is not tight or constricting.
· Its larger size makes the female condom easier for ejaculation.
· It does not require a prescription or the intervention of a health care provider.
· Male and female condoms should not be used together as friction between the plastic and the latex rubber can result in either product failing.
How to use a female condom
The female condom is a new method and requires practice and patience. Practice putting it in and removing it before using it for the first time during sexual intercourse. Insertion becomes easier with time, and it may take several tries before you are comfortable with inserting the female condom. Try it at least three times before making any decisions about continuing to try it or not.
1. Open the package carefully; tear at the notch on the top right of the package. Do not use scissors or a knife to open.
2. Choose a position that is comfortable for insertion squat, raise one leg, sit or lie down.
3. Look at the condom and make sure it is lubricated.
4. While holding the sheath at the closed end, grasp the flexible inner ring and squeeze it with the thumb and second or middle finger so it becomes long and narrow.
5. With the other hand, separate the outer lips of the vagina.
6. Gently insert the inner ring into the vagina. Feel the inner ring go up and move into place.
7. Place the index finger on the inside of the condom, and push the inner ring up as far as it will go. Be sure the sheath is not twisted. The outer ring should remain on the outside of the vagina.
8. The female condom is now in place and ready for use with your partner.
9. When you are ready, gently guide your partners penis into the sheaths opening with your hand to make sure that it enters properly be sure that the penis is not entering on the side, between the sheath and the vaginal wall. Use enough lubricant so that the condom stays in place during sex. If the condom is pulled out or pushed in, there is not enough lubricant add more to either the inside of the condom or the outside of the penis.
10. To remove the condom, twist the outer ring and gently pull the condom out. Try to do this before standing up.
11. Wrap the condom in the package or in tissue, and throw it in the garbage. Do not put it into the toilet.
The female condom may be unfamiliar at first. It is lubricated and may be slippery to insert. Be patient with time, using the female condom becomes easier and easier. You will become more and more comfortable with it each time you use it, and so will your partner.
It is essential to provide good, visual instructions on how to use the female condom. These are examples from The Female Health Company and from Contrasida in Venezuela.
The Female Health Company supplies pads of the instructional sheets with text in English, French and Spanish as part of every shipment of female condoms.
Comparison between a female condom and a male condom
Both the female condom and male condom are barrier methods that provide dual protection against pregnancy and STIs. The female condom is the same length as the male condom and somewhat wider. They also differ in the following ways:
Rolled on the mans penis
Inserted into the womans vagina
Made from latex; some also from polyurethane
Made from polyurethane
Fits on the penis
Loosely lines the vagina.
Requires erect penis
Does not require erect penis
Condom must be put on an erect penis
Can be inserted prior to sexual intercourse, not dependent on erect penis
Must be removed immediately after ejaculation
Does not need to be removed immediately after ejaculation
Covers most of the penis and protects the womans internal genitalia
Covers both the womans internal and external genitalia and the base of the penis
Latex condoms can decay if not stored properly; polyurethane condoms are not susceptible to deterioration from temperature or humidity
Polyurethane is not susceptible to deterioration from temperature or humidity
Recommended as one-time use product
Recommended as one-time use product.
Male and female condoms should not be used together as friction between the plastic and the latex rubber can result in either product failing.
Talk to your partner about the female condom
Safer sex depends on the ability to convince partners that it is in their mutual best interest to use a condom, without changing the basis of the relationship or the intimacy of the moment. However, negotiation for safer sex is not always easy. Because it may be difficult to discuss the subject, practising safer sex may be very limited or just not done.
The female condom provides women with an extended choice to protect themselves from unwanted pregnancy and STIs. Extending choice and enhancing womens options increases the number of protected sexual encounters. In addition, the female condom may provide women with a device that can increase their ability to negotiate safer sex.
Role plays and real-life testimonials successfully incorporated into counselling, along with printed materials, videos, face-to-face education, peer education and promotional events, can all help men and women to negotiate female condom use.
Some lessons learned about negotiating safer sex includes:
· Cultural norms can be used to help with promotion and persuasion. For example, women in Senegal are sometimes able to work together with their husband's other wives to persuade men to use the female condom.
· In some cases it can be useful to incorporate the female condom into sexual play by allowing the male partner to insert the device.
· To encourage continued use, many women who had problems with insertion asked their partners to help.
· In places of strong community spirit, women often negotiated the female condom by arguing that most local women now use the device. More often than not, partners felt obliged to comply.
· In South Africa and Zimbabwe, brochures were developed that women could give to their partners that could be used as a "discussion starter" for women and men. They emphasized the novelty of the new product and the key attributes that other men really liked about the female condom.
· In Birmingham, Alabama, USA a video for male partners was used as a motivation strategy.
· In the area of sex work, it has been reported that some sex workers impose the female condom on the clients rather than negotiate its use. Some sex workers did not even tell their clients that they were wearing the female condom prior to sex and found that men either did not notice or were happy not to use the male condom. Others felt more confident about introducing and persuading clients to use the female condom after the client had refused to use the male condom.
Addressing common questions, problems and concerns
1. Is the female condom difficult to use?
The female condom is not difficult to use, but it may take some practice to get used to it. Supportive and positive counselling for new users is very useful to encourage women not to abandon the female condom until they have tried it several times. Research has indicated that the female condom may need to be tried at least three times before users become confident about inserting the device.
Counsellors need to explain that the female condom requires practise and patience. Women should be advised to practise putting it in and removing it before using it for the first time during sexual intercourse. They should try to place the device several times, and each time with the body in a different position (e.g. lying down, crouching, sitting) to find the most comfortable one. Encouragement should be given that insertion becomes easier with time, and that it may take several tries before the user becomes comfortable with inserting the female condom. They should be encouraged to try it at least three times before making any decisions about continuing to use it or not.
While individual counselling and personal fitting may help to reassure women, group sessions and peer groups may overcome early abandonment as women can share anxieties, ideas and laughter with each other.
2. What happens if the penis doesnt enter correctly?
It is important that the penis is guided into the centre of the female condom and not between the vaginal wall and the outer side of the female condom. Diagrams and/or anatomical models should be used to illustrate this problem at introduction. Women and men should be instructed that the penis must be guided to ensure no errors occur. If the penis does enter incorrectly, the man should withdraw his penis and the couple should start again using the same female condom with additional lubrication, if necessary.
3. What kind of lubricant should be used with the female condom?
The female condom comes pre-lubricated with a silicone-based, non-spermicidal lubricant. This lubrication is necessary to assist in the insertion of the device and to allow easy movement during intercourse. The lubricant may make the female condom a little slippery at first.
If the outer ring of the female condom gets pushed in or the condom pulled out of the vagina, more lubricant may be needed. Also, if the female condom makes noise during sex, simply add more lubricant.
The female condom can be used with both water-based and oil-based lubricants, whereas male latex condoms can only be used with water-based lubricants.
4. Can the female condom be used more than once?
At present the female condom is intended for a single use only. However, researchers are currently exploring the safety of re-use of the female condom. It is anticipated that by mid-2000, the results of the ongoing research will provide adequate information and data to recommend clear guidelines on the re-use of the female condom. The current research is examining the following properties of the female condom during re-use and after repeated washing, drying and relubrication procedures:
· structural integrity;
· microbial retention;
· safety; and
· potential cleaning, storage and relubrication practices.
The practice of re-use has been documented in several countries; therefore, clear guidelines based on scientific evidence are urgently needed.
5. Is the inner ring uncomfortable for me or my partner?
Some women do report that the inner ring is uncomfortable. If it is, you can try to place the female condom differently (i.e. reinsert or re-position the device) so that the inner ring is tucked back behind the cervix and out of way. On the other hand, some people report that the inner ring adds to both a mans and a womans sexual pleasure.
6. Is the female condom big?
There may be an initial negative reaction to the female condom because of its size, but this feeling diminishes with use. To avoid this misperception of size, it is useful to compare the female condom to an unrolled male condom to highlight that the female condom is the same length but wider than the male condom. It is also important to note that the female condom provides added protection because the base of the penis and the external female genitalia are partly covered during use.
Some strategies that have been used to reduce the possible negative reaction of the womans sexual partner include introducing the female condom rolled up, to minimize its size (Mexico), and inserting the female condom before the initiation of sexual activity (Zimbabwe). In Zimbabwe, counselling stressed the advantages of the wider diameter, as many men complain about the constricting nature of male condoms.
7. How do I dispose of the female condom?
The proper removal and disposal of the female condom should be included with the packaging of the female condom as well in introductory training programmes:
· The female condom does not need to be removed immediately after a mans ejaculation, like the male condom. But it should be taken out before the woman stands up to avoid the semen spilling out.
· The outer ring should be twisted to seal the condom so that no semen comes out.
· The female condom can be pulled out.
· It is important to stress that the female condom should be disposed of in waste containers and not, for example, in the toilet.
· Also, since in many countries women dispose of sanitary napkins in a clean and private way, the same procedures can be promoted for the disposal of the female condom.
8. Can I use the female condom in different sexual positions?
The female condom can be used in any sexual position; however, additional lubricant may be needed. But some women may feel more comfortable learning to use the female condom in the missionary position, and then adding other positions after that. Group counselling sessions are often ideal for women to learn from each other how to use the device while having sex in different positions.
9. Can we use a female condom and a male condom at the same time?
You should not use both condoms at the same time. Using the condoms simultaneously may cause friction due to inadequate lubrication resulting in either or both condoms slipping or tearing, and/or the outer ring of the female condom being pushed inside the vagina.
10. How long will the female condom last?
The United States Food and Drug Administration has approved the female condom for a shelf-life of five years from the date of manufacture. Because of the properties of polyurethane, the female condom is not affected by differences in temperature and humidity, so no special storage conditions are required.
11. How can the risk of unintended pregnancy be minimized?
Where the female condom has been approved, it is recommended both as a contraceptive and as a method to prevent STI and HIV transmission. It is, therefore, understandable that women may regard the female condom as a contraceptive alternative. If a woman stops using her previous method of contraception when she first tries the female condom, there is a risk that, should she soon reject the female condom, she may not be cove red for pregnancy prevention. One counselling strategy that recognizes both the contraceptive and disease prevention capabilities of the female condom, as well as the novelty of a new method, is to define a period where overlap in contraceptive methods can be encouraged. This type of trial period will provide a few months for users to become comfortable with the new method and avoid unintended pregnancy during any switch - over period between contraceptive methods. Following this period, the woman can choose to continue with the female condom as her main contraceptive method, to return to her previous method, or to integrate (where appropriate) the female condom into her contraceptive/disease prevention mix.
Where available, it is important to also discuss the possibility of using emergency contraception as a back-up for the prevention of conception in the case of non-use or failure of the female condom (for example if the condom is removed before ejaculation) during any specific act of sexual intercourse. A female condom client should be given information about where emergency contraception can be obtained, and when and how it should be used.
12. Who can use the female condom?
· People who want to protect themselves and their partners, and show their partners that they care.
· People who are concerned about unintended pregnancy and STIs, including HIV/AIDS.
· People whose partners cannot or will not use the male latex condom.
· Women who are menstruating.
· Women who have recently given birth.
· Women who have had a hysterectomy.
· Women who are peri-and post-menopausal.
· People who are allergic or sensitive to latex.
· People who are allergic to nonoxynol-9 spermicide.
· People who are HIV+ or have HIV+ partners.