Perceptions around second generation female condoms: Reporting on women's experiences
Maheshvari Naidu
University of KwaZulu-Natal, naiduu@ukzn.ac.za
Abstract
This empirical study on the knowledge and perceptions of the female condom was cast against the assumption that the female condom could potentially be a powerful contraceptive tool whose use women could initiate and use against sexually transmitted diseases, and in so doing, allow them to exercise control over their bodies and sexuality, more especially within the context of the high prevalence rates of HIV/AIDS in the country. Many African women in rural spaces are faced with the situation when the male condom cannot always be comfortably demanded due to gendered power imbalances. This is where the promoting of female condoms may come into play. Against this background, we embarked on a large scale study that included 1,290 women in the greater KwaZulu-Natal (KZN) province in South Africa. The findings revealed that a staggeringly high number of African women surveyed and interviewed, who are potentially the beneficiaries that stand the most to gain from female-initiated contraception, have very little exposure and knowledge of the female condom.
KEYWORDS: female condoms, HIV/AIDS, women, empowerment Introduction
In 1997, the first generation of the female condom (or FC1) was introduced in South Africa and initially piloted in 32 sites across the country; about 31.6 million FC1 have been distributed.1 In 2010. FC2 or the second generation of female condoms (Reality polyurethane female condom) were distributed (Hlatshawo 2012). These were claimed to be cheaper, softer and more user-friendly.
There has been some scholarly work done on FC and sub Saharan women in Zambia, Zimbabwe, Kenya (see Musaba, Morrison, Sunkutu & Wong 1998; Kerrigan et al. 2000; Feldblum, Kuyoh and Bwayo 2001) and work in South Africa (see Mantell et al. 2000 and Marseille, Elliot & Kahn 2001). Some work by groups such as Swaziland, Population Services International or in Swaziland, and the Durban Lesbian and
1 http://www. supportworldwide.org/country-programs/africa/south-africa/
ANTHROPOLOGICAL NOTEBOOKS 19 (1): 25-34. ISSN 1408-032X
© Slovene Anthropological Society 2013
Gay Community & Health Centre indicate that while many women are uncertain about the use and reliability of FCs, other women are open to learn about female condoms. PSI Swaziland, an organisation that focuses on providing low cost, high quality HIV/AIDS prevention products and that introduced the Care female condom in Swaziland, claims that the condom has been a new option for HIV/STD prevention and contraception.
However, these are relatively old studies and the Marseille study was based on the viability of FC use amongst female sex workers. There is thus an urgent need for more recent studies around female condoms (FC2, henceforth: FC) and female condom acceptance and actual use that take into account the epidemiological, economic and socio-cultural realities that confront women in the South African context. These women are assumed to be in greater vulnerable socio-economic contexts of exclusion and marginalisation (Morrell 2001), and thus form greater numbers in the high risk categories as shown by provincial and national statistics. Our concern was also from a social science and gender perspective, and was directly interested in the efficacy of a female oriented intervention in the female condom.
Figure 1: In the waiting room (photograph by K. Ngqila)
Methodology
For this study to reach a projected number of 1,000 to 1,400 women in approximately three to four months, five female fieldworkers (between the ages of 30 and 45) were purposely recruited. These fieldworkers were selected due to their familiarity with FCs, as four had previously worked on educative projects around women, HIV/AIDS and other female health related issues. The advantage of recruiting such fieldworkers was that they were familiar with issues around the female body and had been involved in conducting interviews for various NGOS around wider women's health aspects. The fieldworkers were bi-lingual and fluent English and isiZulu speakers. However, all interviews were conducted in isiZulu, which is the language the participants were comfortable with, as the aim was to minimise barriers between fieldworkers and informants. The field assistants were reminded throughout of ethical considerations and to be cognisant of the sensitive nature of some of the questions and to be alert to the fact that they were to be non-judgmental and neutral as possible in their recording of responses that the women were willing to share.
The study focused on women from the groups classified as African. This did not assume that women from other race groups are immune to STD and HIV infection, but that statistics place these women as showing higher prevalence rates in KZN. Additionally, women were selectively sampled so that the study identified peri-urban women who are seen to be more vulnerable to HIV/AIDS through their socio-economic backgrounds and known histories of being in abusive sexual relationships, etc. (as identified by some of the NGO women's groups and clinics). The rationale reflects an understanding of where the female condom could most likely prevent new cases of HIV. The clinics sites (in Inanda, Umlazi and Durban Central) that were eventually chosen, although not having on-going programmes dedicated to FCs, had NGOs such as the Durban Lesbian and Community and Health Centre render periodic programmes about FCs and health related issues.
There is not much extant literature on the use and perception of female condoms in the African context or amongst South African women. Instead, there are organisational reports and references from groups such as the Swaziland Population Services International (PSI) and their work in Swaziland and The Gay and Lesbian Community Centre and their work with many women's clinics and organisations in KZN. The challenges around lack of literature were thus recognised, but this challenge provided the very premise for the necessity for a study of this nature. Anthropological and ethnographic work in any event demands not just access to published work, but access to the narratives and case studies of women, which this study aimed to collect.
The study sampled approximately 1,290 sexually active women participants (18-52 years) in heterosexual relationships, who answered a structured open-ended interview. A total number of 1,220 interview sheets were deemed usable out of the 1,290, with others being in a few instances illegible or in the larger instances incomplete due to the participants withdrawing and choosing not to continue. This was not a problem in itself as the field assistants had been reminded to make clear to the women that participation was voluntary and could be withdrawn at any point without any fear. The data generated
from the remaining 1,220 interviews was in any event substantial. Nvivo 9 software was used to assist in handling and helping to thematically classify the large amount of data in the 1220 interview sheets.
It emerged that the total number of participants could be categorised into the following groups: 1) those who used male condoms only; 2) those who knew about female condoms and used these interchangeably with male condoms; 3) those who knew enough about the female condoms and thought them a good idea (although had yet to use them); 4) those women who were sexually active but who did not use condoms at all. These groups were not necessarily mutually exclusive. For example the women in Group 2 and Group 3 overlapped, as both had heard of FCs. From these two groups, one group was distilled, and these participants represented women who were familiar with female condoms and either: a) used these at times in the times they did not use a male condom; b) were familiar with the female condoms, did not use them, but were open to learning more about them, and possibly begin using them.
This yielded approximately 111 participants and 111 interview sheets and 10% of the total participants.
Figure 2: Advertising for free HIV testing (photograph by K. Ngqila)
Findings
The responses to a series of questions of this group of 111 women were analysed through thematic and narrative analysis. From the 111 women interviewed, and whose responses were captured on the interview schedule, 43 women were using female condoms consistently, and interchangeably, in some instances as a "fall back" when the partner did not have his own condom, and in other instances as a personal choice to use the female condom over that of the male condom. The findings of this study have revealed that this small number of women viewed female condoms as an empowerment tool. These women (who form a subgroup) within the sample of 111 see FCs as a positive intervention and empowering tool against sexually transmitted diseases and unwanted pregnancies. However a disconcertingly high percentage of these women, who were open to the freedom and agency potentially offered by the female condoms, also raised problems around the design of FCs, sharing that it is not compatible with their bodies, raising concerns and appealing for a change in design, shape and size.
The main reason for the poor usage of FCs, aside from issues around inaccessibility2 thus appeared to be, judging from the responses of the women themselves, substantial dissatisfaction with their design. Out of the 111 women interviewed, 63 felt that FCs were discernibly "uncomfortable" in their bodies. Some felt that this discomfort experienced most in the first few times that FCs were used. However, this discomfort also persisted with repeated use: 'FCs are not comfortable but I use them because my partner sometimes refuses to wear his,' stated Informant 1, and Informant 2 explained: 'I prefer male condoms as they are more comfortable, but if he doesn't want to protect himself it's his problem I still want to protect myself'.
The responses above, which were fairly similar to many other responses, indicated that women were aware of the importance of protecting themselves, and to a large extent were willing to use FCs. However, there appeared to be major issues around poor design and experiences of high discomfort that severely inhibited this possibility. Not much extant literature is available on the actual design of FCs. The empirical data gathered however, illustrated that informants felt that FCs are too big and that they have an undesirable scent. These concerns and issues regarding the design speak to more than the issue of the external design of these condoms, and more to the fact that women are of course intimately knowledgeable and aware of their own bodies.
The FCs are designed to go into the female body, as opposed to male condoms which are externally used (on the male body). The popular and commonly seen visual media depicts FCs as being tubular in shape, almost similar to that of male condoms, but the FC's width is bigger. However, once out of the package the FC opens into a large shapeless "bag". Thus the aesthetics of the female condom are different from that of the male. While it may appear speculative to claim that this is, in a sense "off putting", or dissuasive, there are responses from the participants themselves, that gives credence to the assertion. Such aesthetics appears to feed thinking and imagining female sexual organs as being big (and loose) and being likewise undesirable.
2 Some informants who were keen on using FCs shared that due to poor access to FCs, they used male condoms.
The introduction of FCs with a design that goes into the vagina thus appeared to pose many concerns and uncertainties for women. Urban women and women in so-called modern contexts (and women in developed nations) are perhaps comfortable with feminine products such as tampons that are inserted into the body.
However, among the categories or peri-urban women that this study dealt with, there was substantial unfamiliarity with products such as tampons. One is able to thus appreciate fears that may otherwise appear unfounded and irrational. For some informants shared that they feared FCs getting lost in their bodies. Additionally, these women felt FCs are uncomfortable and painful, and feared that the outer ring of the FC would not be able to stay in their bodies during intercourse and to avoid this, some shared that they had to 'hold it [the FC] while having sex'. This of course has substantial impact on how the sexual act can be experienced as pleasurable by the women. The understanding is that these women do not only hold onto FCs only physically, but psychologically, as during the intercourse they may be thinking and concerned about the condoms slipping off. This would also minimise their enjoyment and fulfilment during sex as they would be preoccupied about the state of the condom. One informant shared that she felt that 'FCs are not strong and tight enough,' and she felt that 'it was the size that made them feel uncomfortable.'
Sexual intercourse is about mutual pleasure. However, again the very real and experienced design flaws around FCs, appears to substantially inhibit pleasure for the woman. Feminist anthropologists have shown how women's bodies, and especially the bodies of African women have been appropriated and rendered "docile" by so called cultural or traditional practices, as well as by discourse. On some levels, practices around condom design, that appeared blind to the contours and realities of women's bodies appear to be perpetuating this docility. Some informants shared that using FCs was undesirable as 'female condoms are noisy.' This "noise" whether tangibly discernible, or "white noise" as some kind of background lowly discernible noise is nevertheless "off-putting". Such white noise also holds a clutch of preconceptions, most commonly that of the (mis)perception of women as being expected to have "tight vaginas". The masculinized assumption amongst many women (in turn fuelled by their male partners) is that if the vagina is tight enough and the penis fits snugly into it during penetration, there should be no noise.
Hence, the study found that some women avoid using FCs because they have been experienced as noisy in previous instances. The lack of knowledge regarding the correct usage of FCs is also a concern. While some women know that FCs are protective, some feel that FCs are not suitable for them as they are all the same size, hence the FCs appear to be are too big for them and their particular bodily size and shape. Visually "seeing" the size of FCs poses questions for these women, the main being whether their bodies have such a huge hollow space that fits it, or is capable of holding such a "big condom". As indicated by informants, FCs appeared bigger compared to male condoms.
Several informants using FCs commented on the outer ring as being too big and shared that this ring can send negative impressions to their sexual partners about their vaginas. Since the ring rests on the outside of the female sexual organ, it is the object that sexual partners see as they prepare to penetrate. Because of its big size, informants shared that it could give their partners the idea that their vaginas are big as well. Many women shared that this was far from desirable.
One 29-year-old informant shared: 'They should make FCs more comfortable, they should change the shape and the size. They should fit nicely and the ring should not be so big and uncomfortable.'
Such responses, as feminist writers like Patricia Collins, bell hooks, Margaret Locke, Judith Butler, et al., point out, speak directly to the politics that cohere around how women are represented in both popular discourses, as well as within medical and health interventions assembled for women. The praxis of engagement at the level of design and even government policy and urgency and agency around these vital issues that affect women in a very literal sense, appears largely absent. The FC is literally, unlike the male condom, a very generic "one size fits all". Although there are currently small pilot productions and promotions around a new model, the bulk of the purchased FCs that are being distributed to clinics and NGOs are the second generation FC. Such a generic constructionist view of the generic woman/female body in turn retards the wider possible success of the FC and its acceptance by the women. While there has been an improvement in the actual material being used to make the condom, there still appears very little involvement on the part of the government to attempt to understand the needs of the women. Most campaigns around FC are intermittent and tied to already high-profile events such as women's months when there is a huge barrage of information disseminated etc., only to have very little follow up or ongoing educative programs.
As with many other products, FCs come in a packet that has "directions to use" insert in it. This pamphlet is written in English and has images to demonstrate how these FCs are meant to be used. However, the majority of the informants shared that it was difficult to use FCs, their main reason being the outer ring. This lack of understanding cannot be resolved by the simple insert, which is also in a language not fully accessible to many of the African women. Many informants shared their uncertainties about when to put on FCs. The most prevailing understanding shared by informants, was that FCs have to be worn long before engaging in sexual activities. Most informants shared that they wore FCs thirty minutes before sex and even eight hours before. One informant shared that the reason she puts it on hours before sex is 'to absorb the moisture inside [her].' This difference in the length of times raises many issues with regard to the women's understanding. A 32-year-old informant shared that she would rather use male condoms as they are 'easy to use' as she felt that she did not have to wear it and wait before having sex. This indicates that for some women, FCs are major inconveniences. Unlike male condoms, to wear FCs, women have to assume a certain position which will better enable them to wear the condom. For this reason, FCs cannot be worn at any moment and at any place. Informants shared that they fear not wearing FCs properly, as this may cause irritation because the outer ring may cause discomfort. A 23-year-old student shared that it is not easy to use FCs especially for the first time. She also shared that it becomes easier and less painful if women are accustomed to inserting tampons into their vaginas. Not knowing how to properly use FCs is of critical concern, not only to women's health activists as they realize that this intervention strategy may not be useful for the majority of women, but to the social scientists who work with feminist discourse and women's issues. Both realize that the individuals who stand to lose the most are the women who are meant to be the main beneficiaries.
The large selection of male condoms are a strong indication that the choice to use a condom is sometimes further expressed in which type to use, and is further entangled
with notions of sexual pleasure. The study was thus interested in the women's awareness and sense of sexual pleasure while using the female condom. The sense is that using a condom for the prevention of pregnancy or infections or HIV/AIDS should not mean that the women are not free to enjoy her sexuality or sexual pleasure. For those participants using the female condom, it was thus important to explore what their comments were about the experience of sex when wearing a female condom.
Comments such as 'Female condoms ... yes this is good ... why do men always have privilege in our lives and over our bodies' reveal that although a small number, for some women self-empowerment is of great importance. As stated earlier, for some informants within the sample of 111 women, regardless of dissatisfaction around design issues, condoms served as an empowering tool on some level. These women shared that FCs were important especially as one informant shyly put it: 'since you are more comfortable knowing that you have your protection as some boys want the lights off and you never know if the condom is on or not.'
There was a small percentage of women who had had positive experiences around FCs, and thus considered these a desirable alternative to male condoms. Some women shared that they did feel empowered and that these condoms made them, feel 'more protected' and 'relaxed'. Some added that in comparison to male condoms, the FCs are 'flexible, long lasting and safe enough to protect them from contracting HIV/AIDS.'
One informant shared; 'I use female condoms as often as possible. I prefer them over male condoms. They are nice and big, impossible to burst and break like it always happens with male condoms.'
Closing comments: Some thoughts on the way forward
There is overwhelming evidence from various studies (Barker & Ricardo 2005; Marseille, Elliot & Khan 2008; Mekgwe 2008) that in Africa, more females are affected and infected by HIV/AIDS. The global disease burden of HIV/AIDS is staggering, accounting for 39.5 million infections and 2.8 million deaths worldwide in 2006 (UNAIDS 2006).
What is clear from this study is that a staggeringly high number of African women surveyed and interviewed, who are potentially the beneficiaries that stand the most to gain from a female initiated contraception, have very little exposure and knowledge of the female condom. This was startling, considering that the research sites or clinics where the interviews were conducted, were sites where some sort of periodic female condom programming had taken place. Thus although a large number, 1,220 usable responses from 1,290 peri-urban women were elicited, only 111 respondents could specifically comment on the knowledge and perception of FCs, with an even smaller number (43) indicating that they had actually used the condoms. The female condom thus emerges as a possible tool whose use the women can initiate and control against also sexually transmitted diseases. However, as pointed out in an international impact study (Marseille Elliot & Kahn 2008) and certainly true within the context of South Africa as our empirical study revealed, the female condom field lacks a consistent definition of success across the different groups of women in the study.3 Thus, a much
3 Additionally the female condom is at present still much less cost-effective than the male condom based on analytical modelling and based on inherent design flaws that severely inhabit the success of their use.
more sophisticated approach or 'smarter programming' (see Marseille, Elliot & Kahn 2008) is needed, and one that pays special attention to the experiences of the women themselves and the exegetics of women's bodies. Thus, within the context of the female condom, what is needed is a two pronged approach that is cognisant of situated social realities; one that engages at a theoretical level and at the level of policy and interventionist strategy and design, to lobby for a better product, and another level simultaneously targeting women who derive immediate benefit, while the policy and practice catches up. Such a smarter, gendered and contextually relevant (Dosekun 2007) approach that responds to African woman in sub-Saharan Africa would: 1) lobby at the level of policy for a better product that speaks to the needs of the women, and 2) work at the grassroots level with women that might gain immediate benefit from negotiating and using a female controlled prevention method within the context of sexual relations with their male partners.
References
Barker, Gary & Ricardo Christina. 2005. Young Men and the Construction of Masculinity in Sub-Saharan Africa: Implications for HIV/AIDS, Conflict and Violence. Washington: The World Bank. Dosekun, Simidele. 2007. Defending Feminism in Africa: Post amble 3(1): 40-7.
pathonline. Expanding Access to Female Condoms in Africa, a Fact Sheet. http://www.global-campaign.org/
clientfiles/FS-EastAfricaFemaleCondom-action. Accessed on 15 September 2012. Feldblum, Paul J., Maureen A. Kuyoh, Job J. Bwayo, Mohamedb Omari, Emelita L.Wong, Kathryn G. Tweedy & Michael J. Welsch. 2001. Female Condom Introduction and Sexually Transmitted Infection Prevalence: Results of a Community Intervention Trial in Kenya. AIDS 15(8): 1037-44. Kerrigan, Deanna, Steve Mobley, Naomi Rutenberg, Andrew Fisher & Ellen Weiss. 2000. The Female Condom:
Dynamics of Use in Urban Zimbabwe. Washington: Horizons Project. Mantell Joanne, Susie Hoffman, Eugene Weiss, Lawrence Adeokun, Grace Delano, Temple Jagha, Theresa Exner, Zena Stein, Quarriaisha Abdool Karim, Elma Scheepers, Kim Atkins & Ellen Weiss. 2001. The acceptability of the female condom: Perspectives of family planning providers in New York City, South Africa, and Nigeria. Journal of Health 78(4) 658-68. Marseille, Elliot & James G. Kahn. 2008. Smarter Programming of the Female Condom: Increasing Its Impact
on HIV Prevention in the Developing World. www.fsg-impact.org. Accessed on 29 March 2012. Mekgwe, Pinkie. 2008. Theorizing African Feminism(s) the 'Colonial' Question. QUEST: An African Journal
of Philosophy /Revue Africaine de Philosophie XX: 11-22. Morrell, Robert (ed.). 2001. Changing Men in Africa. University of Natal Press: Scottsville. SA. Mikell, Gwendolyn (ed.). 1997. African Feminism: The Politics of Survival in Sub-Saharan Africa. Philadelphia: University of Pennsylvania Press. Musaba, Elizabeth, Charles S. Morrison, Musonda Roremary Sunkutu & Emelita L. Wong. 1998. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia. Sexually Transmitted Diseases 25(5): 260-4. Hlatshawo, Sthembile. 2012. The female condom: Slowly becoming popular. Swaziland Times Online 16 March 2012.
UNADIS. 2006. AIDS Epidemic Update - December 2006. Geneva: UNAIDS.
Povzetek
Empirična študija vednosti in zaznav ženskega kondoma je bila zasnovana na predpostavki, da bi ženski kondom lahko bil močno kotracepcijsko sredstvo, s katerim bi se ženske lahko borile proti spolno prenosljivimi boleznimi. Na ta način bi ženske lahko nadzorovale svoja telesa in spolnost, kar je še posebej pomembno v kontekstu visoke pojavnosti okužb virusom HIV v južnoafriški province KwaZulu Natal. Številne afriške ženske, še posebej v ruralnih področjih, se soočajo s težavo, ko zaradi spolno neuravnoteženih oblastnih odnosov od moških ne morejo vedno udobno zahtevati uporabo kondoma. V takšnih primerih je promocija ženskega kondoma izjemno pomembna in na podlagi takšnih pogojev je bila izvedena tudi obsežna raziskava, v kateri smo intervjuvali 1290 žensk v širši regiji KwaZulu Natal v Južni Afriki. Izsledki so pokazali, da ima veliko število afriških žensk, ki so bile vključene v raziskavo, intervjuvane in so potencialne uporabnice ženske kontracepcije, zelo malo stika in znanja o ženskem kondomu.
KLJUČNE BESEDE: ženski kondomi, HIV/AIDS, ženske, emancipacija
CORRESPONDENCE: MAHESHVARI NAIDU, University of KwaZulu-Natal, School of Social Sciences, Howard College, Private Bag X54001, Durban, South Africa. E-mail: naiduu@ukzn.ac.za.