Shades of Grey: Ephimeral Sexualities - Alvin S. Concha
Do Female Condoms Matter?
All is not black and white… and we want to explore the shades of grey. Feminism is diverse and we don’t always agree totally with one another, though we may share a similar perspective. While we don’t want to silence other viewpoints, we want to focus on the finer distinctions between arguments used by people who are on the same side of the table. The issue of the efficacy and availability of the female condom has been coming up repeatedly in the last few years. As the only female controlled barrier method, the use of the female condom has huge potential to prevent unwanted pregnancies as well as HIV infection. However, it is not freely available and many argue that it is not user friendly and will not be accepted. These for and against arguments will continue, and it is not the purpose of this column to resolve them, so let’s see what Rupsa Mallik has to say.
Condoms are one of the three anchors of the ABC approach – Abstinence from sexual activity/delayed sexual debut, Be faithful/mutual monogamy/reduce number of sexual partners, and, Correct and consistent condom use – for HIV/AIDS prevention. Till date, male condoms remain the only option through which sexually active persons can protect themselves from sexually-transmitted infections (STIs) including HIV. However, in many situations women, in particular, are often unable to negotiate condom use with their partners. This is often a result of lack of access to condoms, and various socio-cultural factors including masculine notions of pleasure and ‘fidelity’.
Female condoms (FC) are the only female initiated barrier method for dual protection – allowing women to protect themselves from both unintended pregnancies as well as infections including HIV and AIDS. The most widely available FC is produced by the US-based Female Health Company (FHC).
Preliminary evidence from India where an acceptability study of the FHC female condoms was conducted (2003) as well as other countries where the FC has been introduced, shows that when male and female condoms are both made available, the rate of unprotected sex declines and there is a decrease in the rate of sexually transmitted infections (UNAIDS, 2002).
The Female Condom as a Gender and Rights Based Approach
A gender and rights based approach integrates human rights with public health principles in HIV prevention by:
Assuming the right to bodily integrity, freedom from coercion, of choice and to attain the highest standard of health
Addressing the realities of power disparities in determining risk
Promoting equitable partnerships between men and women
Expanding beyond changing individual ‘risk behaviour’ to address their `vulnerability’
Emphasising participatory processes as much as outcomes
Positioning the Female Condom
The female condom needs to be positioned as a commodity that enables dual protection. Dual protection means the ability of individuals particularly women to prevent unwanted pregnancies and protect themselves from sexually-transmitted infections including HIV and AIDS. There are a number of ways this can be attained. One way is for mutually monogamous, uninfected partners to practice effective contraception. Other dual protection methods include abstinence and/or delay of sexual debut, correct and consistent condom use, correct and consistent condom use along with another effective family planning method (USAID, 2003: 20).
In the past ten years, FC acceptability studies have been conducted in over 45 countries, trial introductions have taken place in approximately 25 countries and large-scale introduction campaigns are underway in 15. However, for a number of reasons FC continues to be viewed cautiously by most, including donors. The problems that are cited include – high cost (reuse of FC can help bring down the cost but is still not recommended), effectiveness during typical use and the impact of FC on male condom use.
However, there is a substantial body of scientific evidence that confirms the efficacy and effectiveness of the FC for preventing pregnancy as well as reduction in STI rates. One study among sex workers in Thailand found that STI rates were lower among women who had been given the option of using both the female and male condom compared to women who have only been instructed to consistently use the male condom (Fontanet, et al, 196, cited in FHI Research Brief No. 2). While there is no population based research that shows that FC use leads to reduction in HIV rates, an overall increase in the total number of protected sexual acts will likely lead to the lowering of rates of infection of HIV.
In India, the Female Health Company has entered into an agreement with Hindustan Latex Limited (HLL) to be the exclusive marketer and distributor of the female condom. HLL is the largest male condom manufacturer in the country. A Memorandum of Understanding between the two companies was signed in 2001 and regulatory approval to import and market the FC was granted in September, 2003. Acceptability studies have been conducted by the Hindustan Latex Family Planning Promotion Trust and the Female Health Foundation in three States in 2003.
Some of the key findings of the study include low awareness of the FC at the time of the baseline study particularly among married women. Sex workers reported slightly higher levels of awareness. Some of the findings with regard to qualities liked about the product include the fact that it is a female-initiated method.
Particularly in the case of sex workers this is important in circumstances when clients refuse to use male condoms (65 percent). The other quality liked was that it is well lubricated (50 percent). Sex workers also cited the need for disease prevention as the primary reason for participating in a trial for a new barrier method. While a majority of the respondents used the FC consistently during the trial period there is still a gap in evidence with regard to FC use over a longer period of time. It has been noted in the study report that part of the reason for high rates of consistent use was a result of regular and timely counselling. With regard to barriers for FC acceptability the two important reasons that have been cited include the physical features of the FC and the difficulty of insertion. This finding is not unique to India and has also been one of the key findings of most acceptability studies in other countries. The other constraint reported was partner perception. This again is not unique to FC acceptability and has for decades remained an important barrier in the promotion of male condoms.
Cost also remains a constraining factor with regard to FC use. In the acceptability study respondents were asked how much they would be willing to pay for the product. Respondents said they would be willing to pay up to Rupees Five for a FC. However, a substantial percentage of the married couples who were part of the study said they would consider using the FC only if it was distributed free. By comparison, almost all sex workers said they would be willing to buy the FC and stock them to use in instances where clients refused to use male condoms (HLFPPT and FHF; 2004:13).
While the issue of cost is indeed an important factor in enabling acceptability and use, it is important to note that willingness to pay hinges as much on risk perception. While sex workers are aware of the life threatening consequences of unprotected sex and the importance of condom use, risk perception is low among married couples (especially women). As a result they assign less importance to condom use in general and the FC in particular.
Feedback from sex workers about the female condom
‘First I got scared, but after using I liked it… I will not lose customer, no matter how drunk.’
‘It got set within my body, I didn’t feel there was anything inside. Feels so natural. Even I enjoyed it.’
‘There was a problem, customer got to know from the outside bangle.’
‘He asked me what have you put and got furious… accused me of wearing some rubber inside, left in a huff and never came back.’
‘I have not used LC [ladies condom], but I suppose it is good as you can earn money with it.’
‘My aadmi (man) laughed at it.’
Reference: Population Services International. 2004. Project Aurat: A Presentation of Findings. Mumbai:PSI.
Male condom promotion – What are the lessons?
The history of male condom programming in India provides important lessons, highlights challenges and in turn can help guide efforts to effectively introduce a new barrier method i.e female condoms as part of a new and expanded prevention strategy.
The current scenario with regard to awareness of male condoms is a varied one. A high level of awareness of the product has been noted as part of the National AIDS Control Organisation (NACO) Behavioral Surveillance Survey (BSS), 2001. Four out of every five respondents who took part in the survey stated that they had either heard of or seen a condom. However, this number declines with regard to the rural population (76.9 percent) and in particular with regard to rural women (69.5 percent). The same level of knowledge and awareness of the condom is not found in the family planning programme in spite of it being a longer running programme. Knowledge is much less widespread with 71% of married women aged 15-49 years saying they had heard of the condom. The variation in knowledge in the two surveys, one administered by the AIDS control programme and the other as part of the family planning programme, is to a large extent the outcome of the conflicting objectives of the two programmes. Actual use of the method is abysmally low currently placed at less than 3%.
Serious gaps continue to exist with regard to both availability and accessibility of male condoms In a NACO survey respondents identified pharmacy (91% females), clinic/hospital (88.5% females); family planning clinic (72% females) as places where condoms can be procured. This statistic demonstrates that in India the availability of condoms is linked to the private sector (pharmacy) or at best social marketing Two important conclusions the study made was the importance of integrating the FC as part of a broader programmatic intervention and second, the need to not just introduce a new barrier method into the existing method mix but to simultaneously raise awareness of risk of infections including HIV and AIDS among women and eligible couples. programmes that often use pharmacies as a conduit to distribute condoms at subsidised prices and not the government sponsored family planning programme. The government too has recently endorsed the view that social marketing represents the best route to distribute condoms instead of the long-standing free distribution program (NACO, 2005; MOHFW,).
While the effectiveness of social marketing programmes to reach certain segments of the population cannot be contested it is really the needs of the poorest section of the population in particular poor women that remains a concern.
With regard to access, more than a third of the respondents of the NACO BSS, 2001 stated that it took them more than 30 minutes of travel time to procure a condom. In rural areas, close to half of the women surveyed reported poor access. In these areas the public health delivery system remains the main source for condoms. Social marketing currently caters to 47% of the unmet need of the population in the lower-middle and middle income groups. Given the stated tilt in government policies towards greater public-private partnerships mainly social marketing and other community based models through private voluntary organisations (PVOs) and non-governmental organisations (NGOs) it remains unclear how gaps in condom programming for the poorest segments of the Indian population particularly women will be effectively addressed.
Integrating FC as part of on-going prevention efforts is not only important but evidence also suggests that it is the only viable strategy. Evidence collected from across the world suggests that if the goal is to reduce the number of unprotected sexual acts making both male and female condoms available serves that goal better than an either/or approach. It is important to reiterate this as a basic and fundamental premise from which any advocacy on FC needs to be undertaken. It is also important to reiterate that there is sufficient evidence that demonstrates that FC inclusion in no way affects or reduces male condom use. In fact in some instances FC introduction and the accompanying communication and counselling that go with it have served to enable women to better negotiate male condom use and not necessarily substitute male condom use with female condoms.
Secondly, there is a critical need to assess self-risk perceptions among sexually-active individuals, how that varies across relationships, and to develop adequate and effective communication and outreach strategies that can address risk. Enhancing risk perception lies at the heart of any good prevention effort. However, this cannot be done without understanding what determines the way individuals assess risk and the cost of taking risks. Once risk perception is assessed interventions can develop locally relevant communication and outreach strategies that can address the same. In the absence of the above just the introduction of a new barrier method will not result in any dramatic change with regard to overall condom use and protected sexual acts.
Currently, the best methodology to make the FC available at the community level could be based on a two-pronged approach – programme-based interventions in combination with social marketing – to help offset the high cost of the product.
As part of a spectrum of choices, female condoms can dramatically increase women’s agency and ability to make informed choices regarding pregnancy and disease prevention. As with other methods, real access to female condoms will be determined only in part by the efforts the government and donor agencies to increase supplies and services. Deep rooted biases including those of providers, stark gender-based disparities with regard to reproductive decision-making, the stigma associated with using condoms all remain thorny issues that require long-term programme strategies. However, the current context of the HIV and AIDS epidemic and the particular vulnerabilities and risks that women face demands a commitment on the part of the government to identify ways of designing and effectively implementing a gender-based HIV prevention strategy. The FC – as the only female controlled, barrier method – should be viewed both as an additional prevention method as well as an important if not the only cornerstone to help shape a more gender and rights oriented approach.
FHI. Research Briefs on the Female Condom. No. 2:
Rupsa Mallik, currently works as a consultant on gender and reproductive health issues. Prior to this she was with the Center for Health and Gender Equity (2001- 2007) where she worked on US policies in the area of reproductive health and HIV and AIDS.