Option of Covert Use Is an "Important" Advantage of the Diaphragm in Africa

P. Doskoch

First published online:

One in 11 women who used a diaphragm as part of an HIV prevention trial conducted in South Africa and Zimbabwe never told their partner that they were using the method, and 41% said that covert use was a "very important" advantage of the diaphragm.1 Focus group discussions conducted with trial participants revealed that disclosure of dia-phragm use occurred along a continuum: While some women told their partner about their diaphragm use immediately, others did so only after using the method for a period, and others reported occasional covert use, particularly when their partner refused to use a condom.

The findings come from the Methods for Improving Reproductive Health in Africa study, a randomized controlled trial that examined whether the combination of the dia-phragm (used with a lubricant gel) and condoms was more effective than condoms alone for preventing HIV. The trial, which included 5,039 women, was conducted in 2003–2007 at five clinics—two near Durban, South Africa; one in Johannesburg, South Africa; and two near Harare, Zimbabwe. Participants were randomized to one of the two groups and followed quarterly for 12–24 months; analyses showed that the incidence of HIV infection did not differ between the two groups.

In a secondary analysis, the investigators explored disclosure of diaphragm use among the 2,316 women in the intervention group who had been 49 or younger at baseline, had completed a survey on diaphragm acceptability at their last follow-up visit and had responded to a question about whether they had told their primary partner that they were using the diaphragm. The researchers used logistic regression to examine relationships among women's covert diaphragm use and demographic characteristics, STI risk factors, experiences of domestic abuse, fertility and partner characteristics.

In addition, the researchers conducted focus groups with a systematically selected sample of trial participants and their male partners. For this analysis, they examined transcripts from 14 focus groups involving 105 women from the intervention group and seven focus groups involving 31 male partners. Because the focus group participation rate was much lower for male partners than for female study participants (14% vs. 60%), the researchers also conducted in-depth interviews with 10 men. Focus group and interview participants were asked in detail about their experiences with the trial and their perceptions and use of the diaphragm, gel and condoms.

Women who took part in the trial were aged 28 at baseline, on average, and their mean length of participation was 21 months. Eighty-eight percent of women revealed their diaphragm use to their primary partner during the first three months of the trial; only 9%, or one in 11 women, concealed their use for the entire trial.

Among respondents who did not disclose their diaphragm use, the most common reason for concealment was that the woman thought her partner would disapprove of or be upset about her diaphragm use (60%); smaller proportions said that their partner would insist on not using the method (18%), believed that the matter was not their partner's business (15%) or gave other reasons (7%). Even though the vast majority of women told their partner that they were using the diaphragm, the ability to conceal its use was widely considered an important advantage of the method: Eighty-eight percent of participants agreed or strongly agreed that women like the diaphragm because they can use it without their partner's knowledge, and 41% said that they themselves considered it "very important" that the method could be used covertly.

In logistic regression analyses, study site was the factor most strongly associated with concealment: Women in South Africa were much more likely than their counterparts in Zimbabwe to report covert use (odds ratios, 8.8 and 12.4 for Durban and Johannesburg, respectively). In addition, women aged 35–49 at baseline were more likely than 18–24-year-olds to report covert use (1.7), and the odds of concealment were also elevated among women who were not living with their primary partner (1.6), had used male condoms during the study (4.1) or knew, suspected or weren't sure whether their regular partner had had other partners in the past three months (1.7–1.8). In addition, women who had had sex 1–3 times per week were less likely than those who had had sex at least four times a week to conceal their diaphragm use (0.6).

In focus group discussions and interviews, most women and their partners said that diaphragm use should be a joint decision, and that covert use, if discovered, would likely result in "serious fights" between husband and wife and possibly lead to violence or divorce. However, findings also suggested that disclosure of diaphragm use occurred along a continuum that, while bookended by full disclosure and complete concealment, included several intermediate approaches. For example, some women initially hid their diaphragm use to test whether their partner could feel the device. Others did not tell their partner for a long time; used the diaphragm covertly when their partner did not want to use a condom; or adopted a "don't ask, don't tell" approach in which they mentioned the diaphragm once but did not discuss it again. Covert use was higher in South Africa than in Zimbabwe, interview results suggested, because women placed greater emphasis on individual rights in the former country and had greater fear about the consequences of being caught in the latter.

The researchers suggest that the rate of covert use among study participants may have been lower than would occur under real-world conditions, because the frequent clinic visits required for the trial made it difficult for women to conceal their participation. Nonetheless, the qualitative findings suggest that "occasional and circumstantial covert use was strategically important for many women." The issue may be particularly relevant for disempowered women, who lack the ability to request or insist that their partner use a condom; for these women, the investigators note, the decision to use a diaphragm covertly involves weighing the risk of becoming infected with HIV (if they don't use the method) against the risk of being beaten or divorced (if their covert use is discovered). They add that research on the relationship between gender dynamics and disclosure of diaphragm use should shed light on "the need and preference for covert use across different populations."

—P. Doskoch


1. Sahin-Hodoglugil NN et al., Degrees of disclosure: a study of women's covert use of the diaphragm in an HIV prevention trial in Sub-Saharan Africa, Social Science & Medicine, 2009, 69(10):1547–1555.