Usage rates of female condoms are low throughout Sub-Saharan Africa. Programs have traditionally presented female condoms as a means of women’s empowerment. However, prevailing gender norms in Sub-Saharan Africa assign sexual decision making to men, suggesting that male acceptance is imperative for increased use.
In 2011, data on perceptions of and experiences with female condom use were collected from 336 men in Zimbabwe, Nigeria and Cameroon through 37 focus group discussions and six in-depth interviews; participants also completed pre–focus group discussion questionnaires. The data were analyzed by country, using thematic content analysis. Results were stratified by marital status and regularity of female condom use.
Perceived advantages of female condoms over other protection methods were enhanced pleasure, effectiveness and lack of side effects. Single and married men preferred using female condoms with stable rather than casual partners, and for purposes of contraception rather than protection from infections. In Cameroon and Nigeria, where contraceptive rates are lower than in Zimbabwe, men favored female condoms as a contraceptive device. Its acceptability as a method of protection from HIV infection is greater in highly AIDS-affected Zimbabwe than in the other two countries. In Cameroon, some men did report regular use of female condoms in casual encounters. Initiation of female condom use by men’s stable partners was not acceptable in any of the countries.
The findings suggest the importance of accounting for local contexts and targeting both men and women in campaigns to promote female condom use.
International Perspectives on Sexual and Reproductive Health, 2015, 41(3):126–135, doi: 10.1363/4112615
The female condom is the only available female-initiated contraceptive method that offers dual protection against pregnancy and STIs, including HIV. It is as effective as the male condom,1,2 and possesses unique features that make it a potentially valuable addition to the array of modern protection methods. The female condom can be inserted several hours before sexual intercourse,3 its use does not require an erect penis4 and users report greater pleasure than with the male condom.5 Moreover, because the female condom is worn by women instead of men, its use may increase women’s control over their reproductive health.6 Nevertheless, use of female condoms remains low all over the world, including Sub-Saharan Africa. The promotion of the female condom as a female-initiated method without including male-sensitive messages may in fact contribute to the low rates of use.
Low usage has been explained by the female condom’s limited availability and high price,7 its unattractive appearance, and the considerable practice required for easy and confident use.6,8,9 An additional reason for low usage mentioned in the female condom literature is the lack of male acceptance.6,10 Male authority in sexual and reproductive decision making prevents women from introducing condoms (male or female) into their relationship.11,12 The literature therefore stresses the importance of male involvement in female condom programming.6,10 However, men have been neglected as subjects in female condom studies and are rarely targeted by female condom programs.13
Our study focuses exclusively on men. To our knowledge, this is the first study that explores perceptions of and experiences with the second-generation female condom in a relatively large sample of male users. Three other female condom studies in the Sub-Saharan region have included men. Pool et al. conducted 50 in-depth interviews and seven focus group discussions in Uganda.14 None of their study participants had used a female condom; the study mainly explored male attitudes toward the potential use of female-controlled methods. Masvawure et al. conducted in-depth interviews in South Africa with 38 men whose partners were enrolled in a female condom intervention trial.13 Twenty-one participants had used the first-generation female condom and 17 had not. These studies showed that men want to protect their partner, but worry about losing control over the method and sexual encounters. Unfamiliarity with the product, limited awareness of the benefits for men13,14 and user-related problems13 were mentioned as the main barriers to use. These barriers were also found by Mantell et al., who conducted focus group discussions in South Africa with 74 male tertiary school students.15 Although the majority of these young men (95%) had heard about the female condom, only eight had ever used them; unfortunately, the study does not elaborate on their experiences with the female condom. In comparison with the other two studies, the male respondents in the Mantell study seemed more accepting of women’s initiation of female condoms. Four other studies on first-generation female condoms were conducted with men in the United States and are therefore less relevant to gaining an understanding of the low usage rates in Sub-Saharan Africa.16–19
The objective of our study is to explore male perceptions of and experiences with use of female condoms and to provide recommendations to female condom programs on how to involve men. The analysis distinguishes explicitly among men’s different types of sexual partners, thereby contributing to the limited number of studies on female condom use by partner type, which have yielded varying results. For example, two studies among U.S. women suggest that female condoms are used mainly within stable relationships,20,21 whereas a study among Zimbabwean sex workers finds that they were less likely to use female condoms with their stable partners than with their clients.8
Our study took place in Zimbabwe, Nigeria and Cameroon. Zimbabwe was selected because of its long history of female condom programming, which began in 1997. Nigeria and Cameroon were included because of their participation in the Universal Access to Female Condom Joint Programme since 2008 and 2009, respectively. The inclusion of three countries allows for a comparison of female condom acceptability and use in contexts that are similar in terms of gender power relations, but vary in HIV prevalence and levels of contraceptive use.
Method Use and HIV Prevalence
Current modern contraceptive use among women aged 15–49 years is substantially more common in Zimbabwe (41%) than in Nigeria (11%) or Cameroon (14%).22–24 At 15%, the HIV prevalence in the adult population in Zimbabwe is considerably higher than in Nigeria and Cameroon (4% and 5% respectively).22,25,26 Nevertheless, only 3% of married women and 30% of sexually active single women in Zimbabwe use male condoms,22 comparable to rates of 2% and 35%, respectively, in Nigeria.23 Use of the male condom is highest in Cameroon, at 8% of married women and 41% of sexually active single women.24 The use of female condoms among women is negligible in all three countries: 0.3% in Zimbabwe, 0.2% in Nigeria and 0.1% in Cameroon.22–24
The patriarchal traditions in the three countries yield comparable gender power relations,27–35 in which men are the dominant decision makers concerning household resources, sexual relationships and family planning.27–35 Women are generally positioned as subservient to their partner, lacking bargaining power to take control of their sexual and reproductive health.27–35 However, the literature also states that women are not completely powerless; they have subtle ways to exercise choice within their relationships, such as covertly using contraceptives.27–35
Research Design and Sampling
Between May and August 2011, data were collected through 37 focus group discussions—14 in Zimbabwe, 11 in Nigeria and 12 in Cameroon—and six in-depth interviews, two in each country. Before the start of a focus group discussion, we conducted semistructured interviews to collect background characteristics of participants, including age, education level and employment, as well as information on their sexual partners and contraceptive use.
The study was conducted in urban and semiurban areas where female condom promotion activities had taken place recently. Eight research sites were selected in greater Harare in Zimbabwe; four in Lagos city in Nigeria; and one each in the cities of Yaoundé, Douala and Bamenda in Cameroon.
Focus group participants were recruited through purposeful sampling by our local partners, organizations that conduct female condom promotion activities, from their networks. Men who were at least 18 years old, who had commenced sexual activity and who were aware of the existence of female condoms were eligible to participate. The sample was stratified by marital status and frequency of female condom use (never, once or twice, and regular). Regular users were defined as having used female condoms three or more times and still using, or having used female condoms at least 10 times. In keeping with the study objective to explore the experiences of users, regular users were oversampled. The stratification resulted in the following design and sample: 21 focus groups with regular users, nine with men who had used the device once or twice, and seven with never-users. The number of focus groups for each given user type did not vary substantially across countries, nor did the number of participants in those groups. On average, each focus group had about nine participants, for a total of 336 participants. We selected two regular users in each country who were particularly outspoken during the group discussion to participate in the in-depth interviews.
The focus groups took place in schools, community centers, clinics and a church compound. They were conducted in the local language, moderated by experienced local researchers and held in the presence of at least one of the authors. Each session lasted approximately three hours. As a token of appreciation, participants received a drink and snack in addition to financial compensation for transportation (about US$5–10 per participant in total).
All focus group discussions and in-depth interviews were audio-recorded; they were then translated and transcribed verbatim by the focus group moderators, who retained concepts and expressions unique to the local languages. The authors analyzed the focus group data by country, using thematic content analysis, comparing findings by marital status and frequency of female condom use. Findings from the in-depth interviews were used to complement and validate the findings from the focus group discussions. Stata 12 software assessed heterogeneity in background characteristics by user group with data from the semistructured interviews.
Findings were subsequently compared across countries, taking into consideration the contextual differences in terms of national contraceptive use and HIV prevalence rates. The discussion of the results will focus on the similarities between countries, but will note any major differences. Country-specific details have been published elsewhere.36–38
Ethical approval for the studies was obtained from the National Health Research Ethics Committee of Nigeria and the National Ethics Committee of Cameroon. In Zimbabwe, ethical clearance was not required because the data were collected for operational research purposes for three nongovernmental organizations among their network members. Focus group participants signed an informed consent form prior to the discussions and were informed that they could leave at any time. Participant-chosen nicknames were used during the discussions and interviews to ensure the anonymity of the participants in the recordings and transcriptions.
Our study sample was not representative of the population in the selected areas because of purposeful sampling and overrepresentation of regular users of the female condom. Since all participants had heard of the female condom, they were probably better informed and perhaps more open to various contraceptive and protection methods than the average male population. In Zimbabwe, additional selectivity was introduced because one of the mobilizing organizations was a network of people living with HIV and AIDS. To increase external validity, focus groups were organized in diverse environments and findings were discussed and validated during a workshop with representatives from the three countries.
Participants’ ages ranged from 18 to 66 years; in each of the three countries, the majority of men were 20–39 years old (76% overall). The Zimbabwean participants were older (37 on average) than the participants in Nigeria (30) and Cameroon (29). The participants were relatively well educated. The majority (59%) had completed secondary education, and 32% had pursued a tertiary education or were doing so at the time of the study. The Zimbabwean participants were the least educated; 87% had completed secondary education and only 3% had continued to tertiary education. In Nigeria, these figures were, respectively, 53% and 39%. The Cameroonian participants were most educated, with 36% who had completed secondary education and 55% who had pursued a higher education. Within countries, no systematic differences were found in terms of age, employment or educational attainment across user types.
Men’s Sexual Partners
In the focus group ice-breaker sessions, participants were asked to name and describe the different types of sexual partners that men in their area generally have. In all three countries, participants described similar partner types, which differed in terms of purpose, exclusivity and trust, power relations and decision making, and acceptability of contraceptives and of HIV and STI protection methods (Table 1, page 15).
Men generally decide whether a protection method is used and, if so, which type. A woman’s negotiating power depends on the type of relationship as well as her degree of financial dependence; it is generally lowest in marriage, especially when a bride-price has been paid. In all relationships, except within marriage, male condoms are accepted to prevent pregnancies and STIs. Trust between spouses is breached when male condom use is suggested because of its connotations of infidelity and HIV. Outside marriage, trust and exclusivity are not guaranteed, which renders male condom use more acceptable. However, when the relationship of single men with their special stable girlfriend—called the "marriage type" in Zimbabwe, "fiancée" or "mother of my unborn child" in Nigeria, and la titulaire in Cameroon—progresses toward marriage, acceptability of male condom use decreases.
Pre–focus group discussion questionnaire data showed that many participants had had multiple partners in the year prior to the study. One-quarter (24%) of married men reported a stable extramarital partner, and one-third (33%) reported at least one casual partner. Among single men, 84% reported a stable partner and 46% a casual partner. Fourteen percent of single men and 6% of married men reported sex with a sex worker.
First-Time Female Condom Use
•Motivation. In all three countries, curiosity about how sex would feel with a female condom was the main reason for using a female condom for the first time. Many men wanted to find out whether it is really "next to natural" (referred to as nyoro in Zimbabwe and "skin-to-skin" in Nigeria), or to know how it would feel inside "such a big shape." Participants heard about it in advertisements, on TV, in workshops or from peer educators. A married regular user in Cameroon said, "It was a comparative study. I am someone who loves adventures, so when I heard about the female condom, I decided to use it."
Participants also mentioned the apparent effectiveness of the female condom for protection against pregnancy and disease as a motivation for first-time use. Nigerian married men in particular reported that they had tried the female condom because they had heard that it is an effective family planning method without negative side effects on the menstrual cycle and fertility. A few participants mentioned that female condoms are not as strongly associated with casual sex, sex work, and HIV and STIs as male condoms.
The main reason for never having used a female condom was poor knowledge about it. Most of the nonusers in the three countries had never seen one. An unmarried nonuser in Cameroon said, "I do not know where to get it, while [the] male condom is everywhere."
•Partners and decision making. Because of the physical characteristics of the female condom, its use generally has to be negotiated. Users commented that a woman can use a female condom secretly only when the man is drunk or very aroused and she has inserted it beforehand. Indeed, a few men shared that they had had no say in using female condoms for the first time, because their sexual partner had one already inserted without their knowledge.
Most married participants had used the female condom for the first time with their wife or stable girlfriend, and had been the one to introduce it to their partner. They would not have liked her to initiate use (for the first time), particularly if they had no prior knowledge of female condoms. Married men mentioned three main reasons for this. First, husbands—not wives—should make such decisions and introduce new items. Second, women are not supposed to talk about sex, let alone condom use. Third, a husband would suspect his wife of having an extramarital affair in which she had learned about the female condom. A married nonuser in Zimbabwe commented:
"My wife could do so [introduce female condoms] only by encouraging me to go with her to the clinic for advice on family planning. If she is to bring such information to me at home and not link it to a formal teaching from the clinic, I am likely to take it negatively and accuse her of infidelity or having used the female condom outside the home."
Single participants were more often introduced to the female condom by their stable girlfriend, but felt ambivalent about this. On the one hand, they wanted to please her and would thus accept it if she proposed trying a female condom. On the other hand, it would make them doubt her fidelity, because she might have learned about the female condom from another partner. Most single men would accept initiation by a "sugar mommy" because she has economic power over her lover.
In Nigeria, participants were more adamant than in other countries that wives and stable girlfriends could not initiate female condom use because this would indicate that they were loose or a prostitute. A married regular user reacted, "She does not have the right to do such a thing." A single man who was a regular user, speaking about his stable girlfriend, said, "The day she does that, she will have to go back to her parents’ house."
In all countries, neither single nor married participants liked female condom initiation by casual partners or sex workers, but said they might sometimes accept it because they were keen to have sex. A married regular user in Cameroon said, "I cannot refuse because the desire is there." Men also believed that a casual partner would be experienced in using female condoms, knowing that she has other partners. Most men said that they would first try to convince the woman to use a male condom, but would agree to the female condom if she insisted.
After each of the focus group discussions with non- users, the research team gave information and a demonstration and handed out female condoms. At the end of these sessions, there was quite a bit of excitement and laughter when the men shared their intention to try it that evening with their wife or special girlfriend. None of them mentioned trying it with a casual partner.
•First-time experiences. First-time experiences with the female condom varied. Men were much more likely to have had a positive first experience when the female condom was inserted quickly and well by their partner and she did not show feelings of discomfort or pain. Men with a positive first experience generally said that using the female condom felt as if they were having natural, unprotected sex. Cameroonian men talked about extra pleasure and feeling heat, greater excitement, sweet ejaculation and a "feeling beyond your experience," compared with the tight-fitting male condom. Men with a negative first experience encountered problems such as inserting the penis outside of the condom or pushing the condom inside the vagina, which disturbed the sex and caused pain. Some men found that insertion took too long, and thereby lost momentum. A single man in Cameroon who had used the female condom once or twice noted, "Before she was able to put it on, I was already dead." Psychological factors also played a role in the perception of female condoms. Men with a positive first experience reported feeling safe and protected by the female condom, while men with a negative first experience mentioned fear of the female condom disappearing in their partner’s vagina or womb.
•Discontinuation. A negative first experience was the main reason for discontinued use of the female condom in each country. However, a good first experience was no guarantee of sustained use. Some participants who used the female condom once or twice considered the trial just an experiment, and kept using male condoms. An unmarried man in this group in Zimbabwe said, "We stay loyal to our male condom."
The low availability and high price of female condoms were other deterrents to use: Some participants who had used free female condoms did not buy or get new ones when their samples ran out. A single man in Nigeria explained:
"I stopped because it’s scarce. Second, because it’s expensive … like if you have 30 naira, you can buy the male condom. But if you want to buy the female condom, they sell it [for] 150 naira in my area. That 30-naira one has four inside but the 150-naira one has only two inside."
Some married men stopped using the female condom because their partner refused to use them again. Others said they objected to condoms in general because they prevent the exchange of bodily fluids and flesh-to-flesh contact. For some Zimbabwean men, using condoms (male or female) felt morally wrong because of their religion.
Regular Female Condom Use
•Motivations for regular use. When explaining why they had become regular users of female condom, most participants compared female condoms to male condoms, emphasizing the enhanced sexual pleasure and perceived effectiveness. A Nigerian single man remarked, "The thing that makes me continue to use it is that when my girlfriend puts it on, it is like flesh-to-flesh. When I meet her, it is as I used to meet her before when I did not use any condom." In addition, men liked the female condom because it does not smell bad, does not necessarily interrupt foreplay and does not require an erection before it can be used. According to a married man in Zimbabwe:
"A male condom can only be worn when the penis is erect, so psychologically it is disturbing … with the female condom, you are not disturbed and when you are erect, you just enter and enjoy."
Furthermore, the men noted that they can leave the protection up to the woman, and not have to dispose of the female condom themselves.
Married regular users considered the female condom to be the best contraceptive method because it combines effectiveness with a lack of side effects. The latter was particularly important for participants in Nigeria. A married Nigerian user explained:
"The main reason why I decided to continue to use female condoms is that it is affordable in the sense that it does not have the side crises [effects] that the other family planning methods like injectables have. For instance, if my wife should take any method, she keeps complaining. Sometimes, she will menstruate twice or thrice in a month, which is dangerous to her health, but with female condoms, we discovered that there [are] not any side effects. The benefits [are] just to have fun with it and after it, you throw it away and everyone in the home is happy and just like that."
Some single men explained that they had become regular users because their stable girlfriend had insisted. They also liked the fact that their girlfriend was fully involved when using female condoms, creating sexual excitement and pleasure for both. They reasoned that women who use them want to have sex, which arouses them. According to a single man in Zimbabwe:
"It changes the whole setup of things. Under normal circumstances, it is the man who wears the condom. With the female condom, the female has to put it on prior to the act. So seeing it on her basically makes it nicer. So I can say it is exciting to watch her put it on, and the fact that I am not wearing anything whilst she is in charge of the protection is exciting."
Other reported motivations for regular use include the fact that the female condom allows a man to have sex whenever he feels like it, since it can be used during menstruation. Some older men mentioned that it makes sex with postmenopausal partners more pleasurable because of the lubrication.
•Pros and cons of preinsertion. Programs promote the possibility of preinsertion, enabling the condom to take on body temperature, because it increases the feeling of having unprotected sex. Opinions on the advantage of preinsertion were, however, ambivalent. Some men liked it because it is a sign of their partner being in the mood for sex, and the feel is more like unprotected sex. However, most men were suspicious of it because their partner might be wearing it for sex with another man or may even already have had sex with it. As a single man in Cameroon said:
"I will condemn the act immediately.… We don’t have to prepare for [sex] in the absence of your partner.… It means if I am not at home or not able to get home from work in time and someone else comes before myself, he could have sex with my partner."
•Patterns of use. All regular users alternated female condoms with male condoms. When asked about the relative proportions of female and male condom use, they reported percentages such as "25% female condoms, 50% male condoms and 25% free [without a condom]." Men said they alternate for several reasons: They do not use female condoms with every sexual partner, they want variation in sex, and it depends on the availability of one or the other condom.
First, and most important, men appeared to strategically choose a method with different types of partners. An unmarried regular user in Zimbabwe explained his use pattern as follows:
"Myself, I am torn in between the two condoms in that I will rather use the female condom on my trusted partner because I trust that she is going to insert it properly and that she is not going to cheat on me, but the male one, I trust to use it with casual sex partners and proper commercial sex workers."
Participants reported using female condoms mainly with their wife or stable partner. Only a few men, mostly in Cameroon, said that they also regularly used female condoms with casual partners or sex workers. The most important reason men used them primarily in stable relationships was related to trust. An additional reason for using female condoms primarily with stable partners was that inserting a female condom may take some time and requires a certain level of intimacy, both of which are often lacking in casual encounters. A married man in Cameroon explained:
"For about two or three years now, I have been using the male condom out of my home each time I am on mission. So I esteem the female condom in my home … I think it should be used on someone we esteem, someone we love. The male condom, on the other hand, is used to protect oneself against another."
Men feared that casual partners and sex workers would use the same female condom with more than one man. Therefore, they felt that male condoms offer better protection when having sex with these partners, even though they were of the opinion that female condoms are more effective and pleasurable. Some men found a solution to this dilemma by making sure that they see the woman open the package, insert the fresh female condom and dispose of it afterward. A married man in Zimbabwe said:
"With such partners [casual], I would only accept if it is opened and worn in my presence. To find her wearing it might pose a risk of my penis entering into a condom with some semen already disposed by another man."
With the exception of HIV-positive men in Zimbabwe, married men said that they did not alternate between male and female condoms with their wife but only used female condoms because male condoms imply a lack of trust in spousal fidelity. They used the female condom as a contraceptive during the "unsafe" period, and some also used it during menstruation. Thus, they did not stress the dual protection qualities. With their stable extramarital partners, married men were more likely to consider the female condom’s effectiveness as a dual protection method, alternating female with male condoms. These patterns of regular use are similar for single men.
Second, participants said that alternation between the two condoms brings variation to their protected sex lives. Many men complained that female condoms restrict the positions one can use during intercourse to the "missionary type," while male condoms allow for variation. Variation was an important consideration particularly for HIV-positive or serodiscordant married couples in Zimbabwe, who acknowledged that always using a condom is essential to prevent infection or reinfection. As a married man in Zimbabwe stated:
"The education we got on positive living and avoiding reinfection has made us continue using the female condom and also the option of the male condom or the female condom has made sex more enjoyable."
The third reason for alternation was that female condoms are not always available and are expensive, in contrast to male condoms. Participants calculated that female condoms are at least twice as expensive as male condoms. Nigerian and Zimbabwean participants reported that the price difference is often much greater, because female condom prices vary. Limited affordability was a constraint, particularly for participants in Cameroon and Nigeria; many participants in Zimbabwe had access to free female condoms at public health clinics or support groups for people living with HIV.
Despite the variety in contexts, there are strong commonalities in male attitudes and experiences across Zimbabwe, Nigeria and Cameroon. Female condom acceptance varies by type of partner. Generally, participants appreciated female condoms because of their pleasant feel, effectiveness and lack of side effects. They agreed that female condoms would be an acceptable method of contraception within marriage and other stable relationships. This stands in contrast to the connotations attached to the male condom, which cannot be introduced within intimate, trusting relationships without shedding doubt on partners’ fidelity.39,40 Compared with the male condom, the female condom was not as strongly associated with HIV, STIs, promiscuity and sex work. This makes it a potentially viable alternative to other modern contraceptives.
When female exclusivity is not guaranteed in a relationship, female condoms are acceptable as a double protection method to prevent both unwanted pregnancy and HIV or STI infection. In casual encounters and with sex workers, most men would rather use male condoms, either because sex with a female condom requires a greater level of intimacy and more time for insertion, or because they fear a female condom might have been used previously with another partner.
These findings suggest that female condom promotion campaigns should be careful in their messages. To enhance uptake within marriage and other stable relationships, the emphasis should be on contraception, albeit with the additional advantage of HIV and STI protection, to avoid creating the stigma that is currently attached to male condoms.
To stimulate use in casual sex encounters, programs should encourage women to practice inserting the female condom before use, to open the package and insert the female condom in front of their partner and to jointly dispose of it afterward.
Comparison of the three countries shows that male motivations for female condom use are both comparable and context-specific. In Zimbabwe, where the HIV prevalence rate is high, female condoms are acceptable within marriage for protection against HIV infection or reinfection, because of a greater sense of necessity and the welcome diversion they offer from male condoms. We note, however, that Zimbabwean respondents were partly mobilized through a network of people living with HIV and AIDS, who were strongly aware of the risk of unprotected sex. In Cameroon and Nigeria, where contraceptive use within marriage is low and the perceived need for HIV protection is minimal, the potential of the female condom centers on its attractiveness as a contraceptive method without side effects. These differences emphasize the need to take into account local contexts when designing female condom promotion campaigns.
Nevertheless, the similarities between countries were far greater than the discrepancies. We hypothesize that this is to a large extent driven by the similarity in traditional norms of masculinity and femininity in the region. We therefore consider the study findings to be meaningful indications of male views on female condoms in Sub-Saharan African countries with similar gender norms and sexual decision-making patterns.
The prevailing atmosphere in all focus group discussions was one of openness to new methods, and curiosity and eagerness to experiment and introduce variation when having protected sex. The advantages and disadvantages identified by male users were in line with female perceptions.6,9,41 The pleasure aspect in particular seems worthy of further exploration in the development of marketing strategies aimed at men. Pleasure and excitement are a major reason for having sex, but they are all too often overlooked in sexual and reproductive health messages, which are mainly problem-focused.42
A concern among program managers is that female condoms would merely replace male condoms, leaving the total number of fully protected sex acts unchanged. An even less favorable outcome would arise if a preference for female condoms would reduce overall condom use because, for example, female condoms are not always available or accessible because of supply-side factors or financial constraints.
Our data do not provide grounds for such fears. Although regular users indeed indicate that they alternate between female and male condoms, men perceive the value of female condoms precisely for sex acts that would otherwise remain unprotected, such as within marriage. Existing quantitative evidence is in line with these qualitative insights, showing the potential of female condoms for improving reproductive health outcomes. A number of studies argue that female condoms may enhance the overall uptake of contraceptives just by expanding the choice of available methods,43–45 and may decrease the total number of unprotected sex acts and STI incidence.46–49
To fully benefit from the female condom’s complementarity and to avoid substitution for the less expensive and widely available male condom, programs could especially target men and women in stable relationships who are most in need of reliable, acceptable, temporary contraception.
Our findings corroborate the results from other studies that sexual decision making in marital and other stable relationships rests predominantly with the male partner.6,10 The common practice of targeting women and promoting the female condom as a female-initiated method may be largely ineffective in settings where unequal gender relations prevail. It may even be counterproductive if men feel threatened in their traditional role as the primary decision maker. The initiation of first-time female condom use by a woman in a marital or other stable relationship is often met with great suspicion by her male partner. Enhancing female condom use within stable relationships thus requires the active involvement of men in awareness and information campaigns.
On the other hand, a too-strong emphasis on men and the benefits and pleasures that men can derive from female condoms may reinforce existing gender imbalances instead of enhancing women’s sexual and reproductive health and rights, as ratified at the 1994 International Conference on Population and Development in Cairo. According to Molyneux, any resulting increase in female condom use would promote women’s practical gender needs because it enhances their protection against unintended pregnancy and HIV and STI infection; however, women’s strategic gender needs will remain unmet as long as there is no fundamental change in gender power relations and bargaining processes.50
Our recommendation to female condom programs is therefore to involve both male and female partners in promotion campaigns, and to emphasize the importance of a dialogue between sexual partners, encouraging communication and mutual decision making. Once both partners are willing to experiment with the female condom, the number of acceptable methods increases, which provides women with an additional negotiation tool for the use of any kind of protection. In the longer term, these discussions may effectuate a change in decision-making processes, and so lead to women’s empowerment. Promotional messages could stress the advantages for men who take responsibility for protecting their wives or girlfriends—men will also personally benefit when the health, the pleasure associated with intimacy, and the feelings of safety and protection increase for both partners. Thus, female condoms have the potential to both empower women and please men.
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12. Cecil H et al., The female condom: what we have learned thus far, AIDS and Behavior, 1998, 2(3):241–256.
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Winny Koster is senior researcher, Amsterdam Institute of Global Health and Development. Marije Groot Bruinderink is researcher, Amsterdam Institute for International Development. Wendy Janssens is associate professor, VU University Amsterdam and senior researcher, Amsterdam Institute for International Development.
The authors would like to thank Development Data in Harare, Population Services International Zimbabwe, Zimbabwe National Network of HIV Positive Persons, African Regional Youth Initiative Zimbabwe, Society for Family Health Nigeria and Association Camerounaise pour le Marketing Social for their excellent research assistance; and Marie Christine Siemerink, Ciska Kuijper and other participants at the Universal Access to Female Condoms (UAFC) Joint Programme Conference in November 2011 for their insightful discussions on the preliminary study findings. This study has been funded by the UAFC Joint Programme under grant 4500030757 as part of a larger research project to evaluate the impact of female condoms on rates of unintended pregnancy and HIV and STIs.
Author contact: [email protected]