Female Condom Forum Summary
The online forum was cosponsored by PATH, WHO/RHR and The INFO Project. The audiences for the forum included donors, researchers, women's health advocates, program planners, product procurement specialists, and ministry of health officials.
The Implementing Best Practices in Reproductive Health (IBP) Female Condom Community completed its month-long forum on the access and acceptability of the female condom in late November, 2005. 359 members signed up for the forum, many of them new to the IBP. This report pulls together the discussion items that were submitted.
Background Information:
The Global Consultation on the Female Condom, held September 26 to 29, 2005 in Baltimore, MD, brought together experts from around the world to review evidence of the female condom’s effectiveness in preventing pregnancy and sexually transmitted infections (STIs) and to learn about countries’ program experiences. This discussion was planned to take place after the Global Consultation so that participants could benefit from the issues raised there. For more information on the Global Consultation, see http://www.path.org/projects/womans_condom_gcfc2005.php
The Forum: Areas of Discussion
1. Acceptability of the Female Condom
2. Access to female condoms
3. Commercial sex workers and the female condom
4. Reuse and cleaning
5. Male and female condoms used together
6. Country activities
7. Available resources
8. Lessons learned
1. Acceptability of the Female Condom
Early in the forum, the discussion centered on issues related to male/female relationships, social norms and how to include men.
Mags Beksinska from South Africa wrote, “I attended the Baltimore meeting (and) I just wanted to highlight one of the key issues that was raised and that was to target men.” Barry Farkas from Tanzania thought this was important because “men dictate the terms of the heterosexual encounter in (at least) sub-Saharan Africa.”. Zeguela Gala from Cote d’Ivoire noted that “Speaking about female condom is consider(ed) as doing the promotion of sex.” Maxwell Madzikanga in Belgium states that “In most instances it is the man who controls and moderates the sexual interaction process. (A man) would be offended if a woman informs a sex partner that she has a condom in her handbag. In most cases the woman would be negatively labeled and most women have either been divorced or beaten up.” Emilia Emomotimi states “taking Nigeria (my country) as a case study, many women feel carr(y)ing condoms make them look promiscuous, when they feel they are not.”
Dr. Siddhartha Sankar Datta states the “Issue of female condom will bear with it the same stigma of CONDOM in a country like India.” Lucy Kinavi Nguma from Tanzania states “I come from a Maasai community in Arusha where by they really don't know what is about the FC.” Jennifer Nsubuga works with African women in the UK and she finds that, “Although women are keen to try this out, it is not always available free of charge from most local services that we publicize as part of health promotion. Free male condoms on the other hand are more readily available.”
Jully Chilambwe in Zambia believes that other problems with the female condom exist. She reports that
* It is too big
* It is ugly
* It makes noise during sex
* It can dislodge and get lost in the abdomen
* It is meant for prostitutes
* It is smeared with HI(V)
Several replies to this suggested that the female condom needs to be redesigned to eliminate some of these problems.
Speaking about gender equity, Mary Drake in the USA, noted that “social norms are operational zed in relationships between men and women.” Ishtiag Bashir from the Sudan said that “to make about a change in the society on the women's position as a whole, their involvement in the income generating activities (microfinance as a good example) is essential.”
One participant noted that “the marriage bed is now more risky as an avenue for the transmission of HIV/AIDS and unless we change our attitudes as men and as policymakers we are committing a silent genocide against our women.” Heidi Worley from the USA wants to reinforce “the importance of the female condom for married women, where HIV is spreading most rapidly.”
Barry Farkas eloquently says, “Until men are directly brought on board with an appeal to their own selfish interests, we will continue to unwittingly but no less powerfully undercut the survival of women and children.”
2. Access to female condoms
Access to female condoms seemed to be the major problem in most areas we heard from. Chinazo Nkechi wrote, “I don't actually believe it exi(s)t”. Dr. Chidi V. Nweneka, in Bangladesh told us that when he “carried out a study of microbicides and the female condom among doctors and nurses, knowledge of the female condom was very poor with only a handful having seen one.” Monica Taiwo in Nigeria wrote that the female condom is “not available in FP clinics.” “When John Gozie also from Nigeria, spoke to students about the female condom he found “95% of the student hear about it but they have not seen it.”
Dr. Salwa Sh. Abdulwahid says that “in my country, Iraq, generally and in Diyala province especially, female condoms are unfamiliar to women, or the women had not heard about it, and it is unavailable in the markets and pharmacies. Also the health education about it is nil.”
Victor Olaore Omoshehin in Nigeria reports, “The issue now is that, the female condom was not given much awareness like the male condom, and there is no accessibility to it, another issue is cost. So to ensure a good acceleration of the female condom, its knowledge has to be created along the male condom, whether in the workplace, school, Community and every where we talk about condom.” Wadem Asogbo also in Nigeria, tells us that after 2 years of work in his community “acceptability is encouraging, but more has to be done in the area of availability.”
“Ms Jesmin Jesmin from Malasia notes that she was not able to find female condoms while in New York, USA , she asks “if it is not readily available in a normal drug store where regular people would go, why would people be interested on 'female condoms?” “Here in Malawi it is quite difficult to access the female condoms,” states Andrew Machine Namakhoma. He told us they are “also too expensive.” The issue of cost came up frequently.
Emilia Emomotimi in Nigeria wrote that “The entire budget of a person will be used up in less than 2 months just in the cost of providing condoms.” He went on to say that “The distribution difficulties are even greater.”
3. Commercial Sex Workers and the Female Condom
Roselini Murota in Zimbabwe notes another problem is “it is also prone to abuse. Commercial sex workers confess that they use one condom through out the night.” The female condom in many areas has been introduced to and is being used in commercial sex work. This reinforces the perception that using the female condom is a sign of a promiscuous woman.
Patricia Weisenfeld in Thailand reported that “This past weekend twenty-five people gathered in Chiang Mai, Thailand to share our experiences with introducing female condoms and to examine some of the lessons we've learned in Asia about female condom programming. This was the very first time a group of highly committed program, field based staff, users, and advocates from a small part of a big region gathered together to examine programming FC to high risk groups and how to be more inclusive of high risk groups when we think of who is in our "mainstream.”
Commercial sex workers seem to be strongly linked to the female condom, but even in that arena there is a lack of access. Margaret Onah in Nigeria works with commercial sex workers and she finds, “I have seen a female condom only once and I did not under stand its application. A lot of advocacy must be put into it to gain the women’s acceptability of it.”
4. Reuse and cleaning
There is also concern that when the female condom is used and then reused by commercial sex workers, and it is not cleaned at all, or not cleaned appropriately, it leads to a higher rate of STD exposure for their clients. The issues of reuse and whether or not adequate cleansing is possible got some attention.
Dr Mathew H.N.Tambukwa in the USA notes that “men who relied on women putting on female condom tended to re-use the same. In this act men were exposed to more risk”.
Carol Joanis, also in the USA says “More information about female condom reuse can be found on the WHO Web site at http://www.who.int/reproductive-health/rtis/female_condom.en.html
FHI's Female Condom Research Briefs series includes a two-page update on reuse research, available at
http://www.fhi.org/en/RH/Pubs/Briefs/fcbriefs/reuse.htm”.
Anne Philpott in the United Kingdom sent information about another web site about reuse, www.reusefemalecondom.org
This did not ease the concerns of some of the participants. The WHO web site recommends using a ratio of one to twenty parts of bleach and water for cleaning. “Bleach is not always available, dilution requirement are not always that easy to follow, not everyone has access to running water,” says Ms. Bidia Deperthes from the USA .
“What do we say about access to bleach itself then to be diluted to 1:20 is it feasible and practical to the real people we are talking about?” asks Mathew Tambukwa. From FHI,
Theresa Hartzell Hoke in the USA replied, “In response to Mathew Tambukwa's message, FHI shares the concern about the feasibility of widespread implementation of the re-use protocol relying on bleach. Many women may not have access to bleach, and arriving at a 1:20 dilution could be an overly complex task for many people.”
Jully Chilambwe of Zambia suggests that the, “manufacturers scrape this information (about reuse) off the instructions because people know very little about the FC and misuse will put them more at risk than protection.”
But, Chipo Mbanje in the USA says, “I am concerned that we are worrying about reuse of the FC. I think the CRITICAL issue is making the FC available and accessible FIRST.”
Concerned about this problem of reuse, Suman Mehta from Switzerland says we need a “reuse policy that is feasible taking in to account the ground realities.”
5. Male and female condoms used together
He continues by suggesting that, “Male condoms to be used along with female condom where possible”. This suggestion brought this reply, from Carol Joanis “It is never advisable to use a male condom and a female condom at the same time. The two devices are made with materials that are not compatible.” Failure of one or both is possible when they are used together.
6. Country Activities
Some respondents reported on activities related to the female condom in their countries. “Include men and make a part of FP not just STI. That is why in Tanzania there are high sales of female to Institutions than to commercial outlets,” came from Ukende Shalla.
Inon Schenker, in Israel told us about “The Jerusalem AIDS Project, an international NGO based in Israel has tried to promote FC in Israel by:
* Inclusion in information and curricula on HIV/AIDS provided in schools.
* Training. JAIP is providing training for health and education (teachers) professionals
* Targeted campaign with men and women in uniform
* Advocacy in parliament
* Contacts with private sector to develop a market strategy failed (too expensive, little revenue, no demand).
Supriya Pillai in the USA tells us “in trainings if the participants actually practice wearing the female condom, this increases the likelihood that they will be able to adopt it and use it correctly. Further research points out that correctly practicing insertion at least 3 times increases the likelihood of proper use.”
Ukende Shalla in Tanzania found that when the “female condom was primarily for high risk group, the acceptance was very low but when we started to incorporate with FP the acceptance increased and has been accepted by all people.”
T. Sethna in India works with an organization called TRUE. He reports that “TRUE is working in the promotion of the female condoms in Tamilnadu state with the support of UNAIDS. We have conducted one feasibility study and some demonstrative programmes from 1998. Our study about the female condoms indicates that the acceptance of female condoms is good especially the commercial sex workers.”
Barry Farkas reported on some of his efforts. “Despite dozens of attempts to enlist the interest and research expertise of colleagues within South Africa and internationally, no one working for any institution I contacted was interested, neither governmental nor para-statal, nor NGO, nor religious, nor academic were interested in it.”
He asks “As UNAIDS publicized it a few years ago, if we truly mean it when we argue for *Men Making the Difference*, where is the fearless institutional advocacy and applied intellect when many of the most important vectors of the pandemic are interested in an approach that is culturally consonant for some but that is universally ignored by those entrusted with stewardship on their behalf!”
Wadem Osogbo reports, “My organization has been working on female condom use for over two years in Osun State, Nigeria. Though the acceptability is encouraging, but more has to be done in the area of availability.”
On the practical side from Kenya, Nicholas Patel told us, “We have just finished developing a coin activated female condom machine. We hope to begin installing by end of November 2005. These will be installed alongside our male condom vending machines which have already made quite an impact.”
Many, including Dr. Chidi V. Nweneka in Bangladesh and Dr. Siddhartha Sankar Datta in India advised that more studies are needed. However, Dr Suman Mehta at UNAIDS says “while cost and reuse issues must get resolved - we should not await but should charge ahead for women's voices and for their needs to be heard.”
7. Available resources
For the question about whether the female condom really exists, Okuns Ohiosimuan answered, “There is really a female condom. Follow this link to see lots of pictures of the FC: http://images.google.com/images?svnum=10&hl=en&lr=&q=The+female+condom&btnG=Search
All you need to know about it and a picture of it are available at the link: http://www.femalehealth.com/theproduct.html
Maggie Kilbourne-Brook at PATH suggested the following list of issues to be addressed:
*Importance of ensuring political support at the local and country level;
* Introducing female condoms while acknowledging the social context of women's lives (need for empowerment, negotiation skills, income-generating options);
* Additional need for product awareness, adequate information, and reliable product supply at an appropriate cost; and
* Need to mainstream female condoms for regular couples not just for FSW.
* better support women in introducing and continuing use of the female condom, especially in married relationships;
* reach out to men more effectively, as partners in using the female condom;
* introduce female condoms among populations such as young women who are most at risk of infection, and may have even less social power than other women.
She also sent in information on how to access the documents from the original Female Condom Consultation held in Baltimore, MD, USA and provided these other references as well. Presentations from the Global Consultation are available online at http://www.path.org/projects/womans_condom_gcfc2005.php
Effectiveness of Female Condoms in the Prevention of Pregnancy and Sexually Transmitted Infections, by Bidia Deperthes, Technical Advisor, Condom Programming, UNFPA and Theresa Hatzell Hoke, Senior Research Associate, Family Health International. http://www.path.org/files/gcfc2005/THERESA_BIDIAFCGS_effectiveness_sept_22_THH.pdf
The Female Condom: Acceptability and Patterns of Use by Susie Hoffman, DrPH, HIV Center for Clinical & Behavioral Studies at the NYS Psychiatric Institute. http://www.path.org/files/gcfc2005/FC_consultation_SH_10_3_05.pdf
Models of Female Condom Introduction and Distribution: Associated Uptake and Sustained Use, by Erica L. Gollub, DrPH, University of Bordeaux, Bordeaux, France. http://www.path.org/files/gcfc2005/GOLLUB_x007E_1.pdf
Men's attitudes to condoms and female controlled means of protection against HIV and STDs in south-western Uganda by Pool R.; Hart G.; Green G.; Harrison S.; Nyanzi S.; Whitworth J. Culture, Health & Sexuality, Vol 2, Number 2, 1 April 2000, pp. 197-211(15)
"Acceptability of the female condom among STD clinic patients" el-Bassel, N; Krishnan, S. P.; Schilling, R. F. ;Witte, S. ;Gilbert, L. AIDS Educ Prev; 1998 Oct Vol 10 pp 465-80
You can also use the POPLINE database at the INFO Project to search for additional information on the female condom. POPLINE is available on the Internet at http://www.POPLINE.org and use is free of charge. Developing country users can also request free copies of documents less than 100 pages in length from POPLINE
8. Lessons learned
Ms. Artidevi Jagnarain in Suriname brings up a point that the forum allowed her to realize, “after reading the messages from our members in Iraq, India and Nigeria I realised that we aren't so different in our experiences.”
“We do not expect any single solution to address this enormous challenge”, says Maggie Kilbourne-Brook. Manju Chatani in Ghana sums up, “For me, it was an indication of how much work there is still to be done in FC advocacy and social marketing, that price continues to be a huge barrier, but also that we may not be really listening to what people are saying, nor recognizing that women's empowerment is still not an easy concept for many to come to terms with”. Lastly, one participant reminds us that there is a “generalized lack of political commitment on the part of national leaders to support the procurement, distribution and promotion of female condoms”.
You can read the entire discussion on the Implementing Best Practices in Reproductive Health Electronic Communication System at www.ibpinitiative.org . If you are not a member of the IBP, send a request for membership to info@ibpinitiative.org indicating that you would like to have access to the Female Condom discussion.
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