The European Journal of Contraception & Reproductive Health Care
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Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa Nomsa Brightness Mahlalela & Pranitha Maharaj To cite this article: Nomsa Brightness Mahlalela & Pranitha Maharaj (2015) Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa, The European Journal of Contraception & Reproductive Health Care, 20:5, 379-386, DOI: 10.3109/13625187.2015.1036415 To link to this article: http://dx.doi.org/10.3109/13625187.2015.1036415
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Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa Nomsa Brightness Mahlalela and Pranitha Maharaj School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
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ABSTRACT
Objectives The study aimed to explore the factors facilitating and inhibiting female condom use among female university students in South Africa. Methods This qualitative study drew on 15 individual, in-depth interviews with female university students in Durban, South Africa. Results The results of the study highlight several factors that facilitate and inhibit female condom use. Protection from sexually transmitted infections (including HIV/AIDS) and prevention of pregnancy facilitated use of the device among female students. In addition, students expressed positive attitudes towards the female condom and preferred it to hormonal contraceptives because it offered them dual protection. Absence of side effects and greater power and autonomy to initiate safer sex were other factors that facilitated use. Inadequate availability, partner objection, stigma, insertion difficulties and lack of awareness served as significant barriers to consistent female condom use. Conclusions Although the female condom can protect female students from infections and pregnancy, there are several barriers to its use. Interventions should aim to increase availability of the female condom, and male involvement should be increased to facilitate consistent use of the method.
K E Y WO R D S
Durban; South Africa; Female condoms; University students
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I N T RO D U C T I O N
A growing body of literature indicates that South Africa has a high prevalence of HIV and continues to have the largest number of people living with HIV/AIDS in the world1. In 2012, South Africa had a national HIV prevalence of 12%, indicating an increase from
the estimated prevalence of 10.6% in 20082. There are significant gender differences in the level of infection between males and females, with women more likely to be infected compared with their male counterparts3. Most distressing is the high incidence of HIV infections among young women in particular. More
Correspondence: Nomsa Brightness Mahlalela, School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban 4041, South Africa. Tel: ⫹ 27 12 816 9218. E-mail: [email protected]
© 2015 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2015.1036415
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Use of female condoms in South African students
Mahlalela and Maharaj
than half of all infected adults acquired the virus before the age of 254. The reasons behind such differences in vulnerability include factors such as unequal gender relations, economic dependence of women on their male partners, structural and cultural factors, and the biological make-up of women. High levels of unwanted pregnancy also remain a huge public health concern among young women in South Africa. The number of unwanted pregnancies in women between the ages of 15 and 24 remains high. At the national level, more than one-third of women have their first child before the age of 203. The high level of unwanted pregnancies among young women in South Africa underscores the need for effective options to protect women’s health. These options include interventions such as the female condom that aim to empower women in sexual relationships to initiate safer sex with their male partners. The female condom was first introduced to the South African community in 1998 and is still the only female-initiated tool available that provides a strong dual protection method for women5.There are various types of female condoms available in the public sector in South Africa including the FC2 (Female Health company, Chicago, USA) and the Cupid female condom (Cupid Ltd, Mumbai, India). Female condoms offer women and men a wide range of benefits. Among these benefits, evidence suggests that, when promoted alongside the male condom, female condoms increase the total number of protected sex acts6,7. A review of studies of female condom use has also shown that the female condom empowers diverse populations of women, helping them to negotiate protection with their male partners, promoting healthy behaviours and increasing self-efficacy8–10. Thus, the female condom increases women’s sense of control over their sexual and reproductive health. Since its first introduction, knowledge about, support and demand for female condoms have increased dramatically in South Africa. Today, the majority of primary health care facilities, together with hundreds of non-governmental organisations and other informal distribution sites, receive female condom supplies for distribution11. In South Africa, the distribution of the female condom formed part of the national strategic plan of South Africa’s health ministry to combat the scourge of HIV/AIDS. This underscores the importance of the female condom in addressing the challenges of the HIV pandemic in the country. The aim 380
of this study was to explore female condom use among female university students in order to provide insights into factors facilitating and inhibiting the use of the female condom.
METHODS
This study was conducted among female university students who were ever-users of the female condom. Ever-users of the female condom included current and former users. Current users were defined as those who reported using the female condom and had used it at least in their last sexual encounter; former users were defined as those who reported using the female condom but were no longer using it at the time of the study. It should be noted, however, that some current users were not using the female condom consistently in all sexual encounters. Contact was made with the local campus clinic to help identify and recruit potential participants, because the clinic holds the records of all students requesting the female condom. The campus clinic nurses contacted students whom they knew used the female condom and informed them about the study. Interested female condom users were then contacted by the researcher to arrange an interview. The study was restricted to ever-users of the female condom, because they had experience with the method and would be able to provide meaningful information on factors facilitating and inhibiting female condom use. This study draws on qualitative data derived from 15 in-depth individual interviews with female condom users. Due to the complex and sensitive nature of sexual behaviour and the stigma associated with condoms in general, qualitative methods were used to gather information on various factors that shape the sexual behaviour of female students. Prior to the interviews, permission was obtained from the university authorities. Informed consent was obtained from all participants prior to the interview, explaining that all the responses would be kept strictly confidential and the researcher would maintain participants’ anonymity. The interviews collected detailed information including participant demographics, reasons for using the female condom and barriers to use. The duration of each interview was approximately 45 min. All the interviews were conducted in English and participants’ quotes were tidied into correct
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sentences rather than transcribed word for word. The interviews were tape-recorded with the permission of the participants. The recorded interviews were transcribed by the researcher and analysed using thematic analysis, which involves categorising the data according to themes. Themes refer to recurrent ideas or topics that are detected in the material and that usually arise on more than one occasion in a particular set of data12. Parts of the transcribed interviews are highlighted in terms of direct quotes to substantiate the theme. Ethics approval for the study was obtained from the University of KwaZulu-Natal, Durban, South Africa.
R E S U LT S
Participants in the study included ever-users of the female condom. Eleven of the participants currently used female condoms and four were former users.
Mahlalela and Maharaj
They said that they wanted to see how sex feels when using the female condom: To be honest, the main reason why I used the female condom was for sexual experimenting to see what this thing is about, because when we think about condoms, we only think about the male condom. It is difficult to imagine how the female condom could work when you actually need to use it. [P7] The majority of the participants who currently used the female condom further viewed it as a way of empowering themselves, as they got to decide on its use. The female condom increased their power over their sexual health. They had greater control over their bodies and sexual life, and they could protect themselves if their partner was not willing to use a male condom: It is empowering to know that as a woman I get to decide to use the condom, as normally it is men who use the condom. For me personally, I also believe that the female condom gives power to young women like me regarding my sexual health. It gives control over my own body and a sense of control over my sexual life. [P2]
Reasons for female condom use Almost all the participants indicated that they perceived themselves as being at high risk of contracting a sexually transmitted infection (STI) or having an unwanted pregnancy. They felt they were more at risk because of their lack of power in sexual relationships. Protection from STIs including HIV and prevention of unwanted pregnancy were the initial reasons given by the majority of the participants for using the female condom: The main reason for using the female condom is for protection, obviously, so that I would not have an unplanned pregnancy and I would not get STIs. [P5] Although I love my boyfriend, I cannot write it in blood that I know what he is doing with his life. So, it is just important for me to be on the safe side. Also, with the lack of power we have as women in relationships it is important for us women to protect ourselves. [P12]
I think the main reason for me was that sometimes my boyfriend does not want to use protection. So I just wanted to have that sense of control and power that I can do things to protect myself in the relationship. Also, to have that sense of control that, since he does not want to use the condom, I can do something about it, meaning that I can use the female condom. [P3] Although the majority of the participants found the female condom to be empowering to women, one of the participants highlighted that female condoms alone did not empower women, but that male partner involvement in its use remained as significant:
Although most of the participants in the study used the female condom for protection from STIs and pregnancy, for some the opportunity for sexual experimentation with the device was the main reason for using it.
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We are made to believe that female condoms are developed to empower women, but most women still do not have the power to initiate female condom use. Most women always find it difficult to negotiate female condom use with their male partners. As women, we cannot be empowered by female condoms alone, but I believe that men’s
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participation in female condom use is a key to empowerment. [P11] The majority of the participants reported that although they wanted to protect themselves, they required the cooperation of their male partners to use the female condom. They further reported men’s reluctance to use it, highlighting that men believed that the female condom interfered with sexual pleasure, and for that reason they did not approve its use. They reported using certain strategies to negotiate female condom use with their partners, such as suggesting the use of the female condom for pregnancy prevention or telling them about the side effects they had experienced with hormonal contraceptives: Although I want to protect myself, I cannot use the female condom without my partner. He needs to agree. Most men do not like using condoms and they will never approve of its use.They believe that it interferes with sexual pleasure. It is easy to use the female condom with my partner if I discuss it is for pregnancy prevention. [P15]
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I do not use the female condom only; I also use the injection. I feel safer using both.They are both effective and it is a double protection against pregnancy and HIV infection. [P15]
Inadequate availability is one of the most significant barriers to the consistent use of female condoms. The majority of the participants reported that female condoms were not easily accessible; they were very rare and hard to obtain compared with male condoms, which were readily available in public places such as public toilets and clinics:
More than half of the participants who were current users liked the female condom and preferred it to hormonal contraceptives. They repeatedly cited that the female condom provided double protection for women against infections and unwanted pregnancy. They also articulated that hormonal contraceptives had side effects and that they were not used for prevention of STIs (including HIV/AIDS). Female condoms were effective in preventing infection and pregnancy, if used consistently and correctly. There was also an (incorrect) belief that female condoms were more effective at pregnancy prevention than other contraceptive methods:
Well, you can use contraceptives, like pills, but they will never protect you from contracting HIV and other STIs.They do not work 100%.You find
One of the participants mentioned that she used dual methods – the female condom and injectable contraceptives, and both methods were effective. She highlighted that she felt safer using both methods because they gave her double protection from pregnancy and infections:
Barriers to female condom use
I talked to my partner about the side effects I had experienced with the injection and the pill and I asked to use the female condom. [P2]
Injections have side effects; I have seen my friends gaining weight after using injections. Of course, as I mentioned, you cannot prevent HIV with the other contraceptive methods, so a condom is at least 99% guaranteed. [P1]
that there are people who use pills but they still get pregnant. But with the female condom you are sure that there would not be any pregnancy and you would not contract any STIs if it is used consistently and correctly. [P5]
I do not think the supply of the female condom is much these days like the male condom. In the clinic, as in the university clinic for instance, I assure you that you will find not just one or two male condoms; you will find boxes of male condoms. But rarely will you find a female condom. If you do, maybe you will find one or two on display just so that women will know that it exists.You cannot even find female condoms in the toilets. Even here in the university you can only find the male condom but not the female condom. [P5] Many of the participants felt that there was a lack of awareness about the female condom. They reported that in most cases the majority of women were not well informed about its availability. They highlighted that it was hardly advertised compared with the male condom and they felt that there was not sufficient promotion of the female condom in the media: I feel like there is not enough awareness, because many women are not well informed about the female condom. If you go to the nearest toilet you will find adverts or pamphlets on the male condom
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and you will find the male condom in the toilet. But with regard to the female condom, you will hardly find it in public toilets and you hardly come across pamphlets advertising it. I also do not think that there is much communication about the female condom from the media to the people. [P6]
To be honest, injection works better for me because I do not have to take it every time I have sex, as I would with the female condom. I tried to use the female condom twice and that was it. I could not use it again. It is one of those things that are not for me and I am not very comfortable with it. I am using injections at the moment and they are more effective for me in preventing pregnancy. [P9]
One participant reported stigma as a significant barrier to the use of the female condom. She highlighted that there was stigma attached to female condoms in general and this in turn influenced its use. She further reported that female condoms were associated with promiscuity, and women who used the device were considered to be promiscuous: There is stigma attached to the female condom. As a woman, if you talk about it or discuss it with your partner – that is with regard to the women I have spoken to – you will find that they are seen as a bit forward when it comes to sexual orientation. Some women are assumed to be promiscuous if they tell other people that they are using the female condom. [P6] Many participants reported difficulties in inserting and properly positioning the female condom when they started using it, even though it came with instructions: The major problem was actually at the beginning when I first started to use the female condom. I experienced difficulties when I tried to insert it. I read the instructions but it was not easy. The practical part of actually applying it was a nightmare. I was not really sure how much you need at the bottom and how far to push it up. I had to do it over and over again. [P6] There were some concerns expressed by both current and former users about female condoms. They stated that they preferred hormonal methods such as injections, pills and implants because they were more effective at preventing pregnancy. They felt that with hormonal methods they did not have to worry about condom rupture. In addition, hormonal contraceptives were more easily accessible than female condoms. They also indicated that they found female condoms uncomfortable to use and that they used a hormonal method because they did not have to use it at every sexual encounter and it was more effective in preventing pregnancy over a longer period of time.
I use female condoms but I prefer contraceptive pills because they are effective and easily accessible. With pills I do not have to worry about pregnancy and condom breakage. [P4] I used female condoms before and I find them not very comfortable. I decided to use implants because they are more effective and protect me from getting pregnant for years. [P6]
DISCUSSION
Findings and interpretation In general, perception of personal vulnerability is regarded as a prerequisite to undertaking modifications in behaviour to prevent a disease13. Participants in this study perceived themselves to be at risk of STIs and pregnancy and this motivated them to use the female condom. They believed that lack of power in sexual relationships increases women’s susceptibility to infections. However, we also need to acknowledge that one’s perception of risk to a health threat alone is not sufficient to change behaviour13. Knowing one’s susceptibility to infections does not automatically translate into using the female condom. This suggests that we need to take into account other important external and internal factors that prevent the uptake of preventative measures despite one’s perception of risk. The female condom provides women with an opportunity to protect themselves and enhances their ability to ensure healthy sexual behaviours14. The importance of the female condom in empowering women in sexual relationships was evidenced in the current study. Participants repeatedly observed that the female condom increased their sense of independence and their control over their sexual health. Participants also reported that the availability of the female condom
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allowed them to provide their partner with an option between a male or female condom, which gave them the opportunity to participate actively in reinforcing safer sex in relationships. Although some participants found the female condom to be empowering by allowing women greater control in sexual relationships, others found that the female condom was not empowering because it remained under men’s control. One of the key findings of this study is that the female condom was preferred by most of the current users over hormonal methods, because it provided dual protection against infections and pregnancy. These users reported that they preferred the female condom due to the negative side effects of hormonal methods. Other participants were satisfied with hormonal methods, reporting that they were highly effective at pregnancy prevention. Participants indicated that hormonal methods were easily accessible; some of the methods, for instance implants, prevented them from getting pregnant in the long term. They further raised concerns about the female condom, indicating that they tried the device but found it to be uncomfortable and that it could rupture in some instances, which might put them at risk of pregnancy. In this study, inadequate availability was reported to be the greatest barrier to consistent use of the female condom. Almost all participants complained of insufficient distribution of the female condom compared with the male condom, and the majority felt that the device was not well promoted. One was unlikely to come across pamphlets on the female condom and it was hard to find it in public places where you might find male condoms, for instance in public toilets, clinics and shops. Participants also mentioned that there was not enough communication about the female condom in the media. Like any other contraceptive method, the female condom is not without challenges. Difficulties in inserting the female condom properly when using it for the first time were reported in the study.The major concern was that even though the female condom came with instructions, the practical part of inserting it for the first time was difficult. Nevertheless, participants in this study also acknowledged that with practise the female condom became easier to use. Stigma associated with female condom use was also highlighted as a barrier to the use of the device. Stigmas that were mentioned by the participants included the association between condom use and promiscuity, the 384
result of a lack of trust in relationships, and that people are told that condoms are used for casual sexual relationships or by sex workers. Therefore, participants in the study found that it was fairly difficult for women to use female condoms when they were confronted by such negative perceptions. The male partner’s response to female condom use is also a significant barrier despite the woman’s interest in using the female condom15. The participants in this study mentioned that although they wanted to protect themselves, they first had to negotiate female condom use with their partners. They reported that men did not like using condoms and they did not approve of its use because they thought that it interfered with their own sexual pleasure. This emphasises the extent of the unequal power in sexual decision-making, particularly the extent of women’s disempowerment in sexual decision-making, which further increases their susceptibility to infections. As a result, participants reported using various strategies to facilitate female condom use with their partners. For instance, they reported introducing female condom use for pregnancy prevention and communicating to their partners the negative side effects of hormonal methods. Strengths and weaknesses of the study This study provides some interesting insights into female condom use among female university students. Not only did it look at factors facilitating female condom use, it also focused on inhibiting factors. It is important, however, to note some of the limitations of the study. The study findings cannot be generalised to the entire population because of the relatively small sample size. Furthermore, the study was carried out among university students with higher levels of knowledge, whereas low levels of education are common in South Africa. Men have a huge influence on female condom use; thus, using only women to understand factors facilitating and inhibiting use created some bias within the study. This qualitative study is suitable for eliciting possible reasons for and against use, but it does not tell us how many women find these reasons important. Differences in results and conclusions in relation to other studies Previous studies have been conducted on female condom use in order to understand various factors
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that influence its use4,16,17. The findings of the present study are consistent with those of previous studies which found that the female condom played a role in improving women’s self-efficacy and independency9,10,18. First-time users, however, may experience difficulty inserting the device5,16,19,20. Participants in the current study reported introducing female condom use for pregnancy prevention to convince their partners to use the method, a finding consistent with that of another study21. Furthermore, in one report by the Program for Appropriate Technology in Health (PATH) and the United Nations Population Fund (UNFPA)3, hormonal implants and injectables, as well as intrauterine devices and sterilisation, were found to be highly effective in preventing pregnancy, consistent with the current study’s findings. Participants in the present study highlighted the stigma attached to female condoms as a barrier to their use. This finding corresponds with results from previous studies which found that residual social stigma attached to condom use was associated with less frequent female condom use17,22. Moreover, the study participants preferred the female condom because of its dual protection against infections and pregnancy. The importance of the female condom in reducing the risk of infections has been observed in previous trial research5,23,24.
Relevance of the findings: Implications for clinicians and policy-makers The female condom is one of the government’s strategies to fight the HIV pandemic in South Africa. The study findings suggest that female university students are using female condoms for protection against the dual risk of infections and pregnancy. However, there is an urgent need for the government to increase the availability of female condoms and make them widely accessible to the entire population. Providing adequate information and increasing male involvement in female condom use are essential to women’s empowerment.
Mahlalela and Maharaj
Unanswered questions and future research Male involvement in female condom use is important in facilitating consistent use of the device and in empowering women. More research is needed on female condom use, especially among larger groups of female condom users and their male partners, in order to get a holistic picture of factors facilitating and inhibiting its use, and to identify strategies to increase its consistent use. There is a need also for research on never-users of the female condom to understand barriers to use.
CONCLUSIONS
The female condom is important for female university students, because it protects them from infections and unwanted pregnancy. Female students feel empowered by the female condom, because they decide on its use and it gives them control over their sexual and reproductive health. However, some feel they are not empowered by the female condom, as its use remains under men’s control and they have to use communicative strategies to convince their partner to use it. The lack of availability of the female condom remains a major stumbling block to consistent use. The study findings suggest that providing adequate information, educating both men and women, increasing availability and making the device easily accessible to the population are important strategies to facilitate consistent use of the female condom.
AC K N OW L E D G E M E N T S
We thank all the female students who participated in this research, as well as the university clinic staff who assisted in identifying the study participants. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
REFERENCES
1. Shisana O, Rehle T, Simbayi LC, et al. South African national HIV prevalence. Incidence and communication survey 2008. A turning tide among teenagers. Cape Town: HSRC Press 2009.
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2. Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence. Incidence and behaviour survey, 2012. Cape Town: HSRC Press 2014. 3. PATH, United Nations Population Fund. Female condom: A powerful tool for protection. Seattle, WA: UNFPA, PATH 2006.
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4. Maharaj P. Reasons for condom use among young people in KwaZulu-Natal: Prevention of HIV, pregnancy or both? Int Fam Plan Perspect 2006;32:28–34. 5. Hoffman S, Mantell J, Exner T, et al. The future of the female condom. Perspect Sex Reprod Health 2004;36:120–6. 6. Center for Health and Gender Equity. Female condoms and U.S foreign assistance: An unfinished imperative for women’s health. Washington, DC: Center for Health and Gender Equity 2011. 7. Witte SS, El-Bassel N, Wada T, et al. Acceptability of female condom use among women exchanging street sex in New York City. Int J STD AIDS 1999;10:162–8. 8. Kalckmann S, Farias N, Carvaiheiro J. Evaluation of continuity of use of female condoms among users of the Brazilian national health system (SUS): longitudinal analysis in units in the metropolitan region of São Paulo, Brazil. Rev Bras Epidemiol 2009;12:1–12. 9. Ankrah M, Attika S. Adopting the female condom in Kenya and Brazil: Perspectives of women and men. A synthesis. 1997. Accessed 15 July 2014 from: www. popline.org/node/275766 10. Rivers K, Aggleton P, Elizondo J, et al. Gender relations, sexual communication and the female condom. Critic Public Health 1998;8:273–90. 11. Mash R, Mash B, de Villiers P. Why don’t you just use a condom? Understanding the motivational tensions in the minds of South African women. Afr J Primary Health Care Fam Med 2010;2:1–4. 12. Hayes N. Framework for qualitative analysis in doing psychological research. Buckingham, UK: Open University Press 2000. 13. Darrow WW, Siegel K. Preventive health behavior and STD. In: Holmes KK (ed), Sexually Transmitted
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ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage: http://www.tandfonline.com/loi/iejc20
Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa Nomsa Brightness Mahlalela & Pranitha Maharaj To cite this article: Nomsa Brightness Mahlalela & Pranitha Maharaj (2015) Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa, The European Journal of Contraception & Reproductive Health Care, 20:5, 379-386, DOI: 10.3109/13625187.2015.1036415 To link to this article: http://dx.doi.org/10.3109/13625187.2015.1036415
Published online: 17 Apr 2015.
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Article views: 71
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Date: 12 November 2015, At: 17:35
The European Journal of Contraception and Reproductive Health Care, 2015; 20: 379–386
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Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu–Natal, South Africa Nomsa Brightness Mahlalela and Pranitha Maharaj School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
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ABSTRACT
Objectives The study aimed to explore the factors facilitating and inhibiting female condom use among female university students in South Africa. Methods This qualitative study drew on 15 individual, in-depth interviews with female university students in Durban, South Africa. Results The results of the study highlight several factors that facilitate and inhibit female condom use. Protection from sexually transmitted infections (including HIV/AIDS) and prevention of pregnancy facilitated use of the device among female students. In addition, students expressed positive attitudes towards the female condom and preferred it to hormonal contraceptives because it offered them dual protection. Absence of side effects and greater power and autonomy to initiate safer sex were other factors that facilitated use. Inadequate availability, partner objection, stigma, insertion difficulties and lack of awareness served as significant barriers to consistent female condom use. Conclusions Although the female condom can protect female students from infections and pregnancy, there are several barriers to its use. Interventions should aim to increase availability of the female condom, and male involvement should be increased to facilitate consistent use of the method.
K E Y WO R D S
Durban; South Africa; Female condoms; University students
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I N T RO D U C T I O N
A growing body of literature indicates that South Africa has a high prevalence of HIV and continues to have the largest number of people living with HIV/AIDS in the world1. In 2012, South Africa had a national HIV prevalence of 12%, indicating an increase from
the estimated prevalence of 10.6% in 20082. There are significant gender differences in the level of infection between males and females, with women more likely to be infected compared with their male counterparts3. Most distressing is the high incidence of HIV infections among young women in particular. More
Correspondence: Nomsa Brightness Mahlalela, School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban 4041, South Africa. Tel: ⫹ 27 12 816 9218. E-mail: [email protected]
© 2015 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2015.1036415
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Use of female condoms in South African students
Mahlalela and Maharaj
than half of all infected adults acquired the virus before the age of 254. The reasons behind such differences in vulnerability include factors such as unequal gender relations, economic dependence of women on their male partners, structural and cultural factors, and the biological make-up of women. High levels of unwanted pregnancy also remain a huge public health concern among young women in South Africa. The number of unwanted pregnancies in women between the ages of 15 and 24 remains high. At the national level, more than one-third of women have their first child before the age of 203. The high level of unwanted pregnancies among young women in South Africa underscores the need for effective options to protect women’s health. These options include interventions such as the female condom that aim to empower women in sexual relationships to initiate safer sex with their male partners. The female condom was first introduced to the South African community in 1998 and is still the only female-initiated tool available that provides a strong dual protection method for women5.There are various types of female condoms available in the public sector in South Africa including the FC2 (Female Health company, Chicago, USA) and the Cupid female condom (Cupid Ltd, Mumbai, India). Female condoms offer women and men a wide range of benefits. Among these benefits, evidence suggests that, when promoted alongside the male condom, female condoms increase the total number of protected sex acts6,7. A review of studies of female condom use has also shown that the female condom empowers diverse populations of women, helping them to negotiate protection with their male partners, promoting healthy behaviours and increasing self-efficacy8–10. Thus, the female condom increases women’s sense of control over their sexual and reproductive health. Since its first introduction, knowledge about, support and demand for female condoms have increased dramatically in South Africa. Today, the majority of primary health care facilities, together with hundreds of non-governmental organisations and other informal distribution sites, receive female condom supplies for distribution11. In South Africa, the distribution of the female condom formed part of the national strategic plan of South Africa’s health ministry to combat the scourge of HIV/AIDS. This underscores the importance of the female condom in addressing the challenges of the HIV pandemic in the country. The aim 380
of this study was to explore female condom use among female university students in order to provide insights into factors facilitating and inhibiting the use of the female condom.
METHODS
This study was conducted among female university students who were ever-users of the female condom. Ever-users of the female condom included current and former users. Current users were defined as those who reported using the female condom and had used it at least in their last sexual encounter; former users were defined as those who reported using the female condom but were no longer using it at the time of the study. It should be noted, however, that some current users were not using the female condom consistently in all sexual encounters. Contact was made with the local campus clinic to help identify and recruit potential participants, because the clinic holds the records of all students requesting the female condom. The campus clinic nurses contacted students whom they knew used the female condom and informed them about the study. Interested female condom users were then contacted by the researcher to arrange an interview. The study was restricted to ever-users of the female condom, because they had experience with the method and would be able to provide meaningful information on factors facilitating and inhibiting female condom use. This study draws on qualitative data derived from 15 in-depth individual interviews with female condom users. Due to the complex and sensitive nature of sexual behaviour and the stigma associated with condoms in general, qualitative methods were used to gather information on various factors that shape the sexual behaviour of female students. Prior to the interviews, permission was obtained from the university authorities. Informed consent was obtained from all participants prior to the interview, explaining that all the responses would be kept strictly confidential and the researcher would maintain participants’ anonymity. The interviews collected detailed information including participant demographics, reasons for using the female condom and barriers to use. The duration of each interview was approximately 45 min. All the interviews were conducted in English and participants’ quotes were tidied into correct
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Use of female condoms in South African students
sentences rather than transcribed word for word. The interviews were tape-recorded with the permission of the participants. The recorded interviews were transcribed by the researcher and analysed using thematic analysis, which involves categorising the data according to themes. Themes refer to recurrent ideas or topics that are detected in the material and that usually arise on more than one occasion in a particular set of data12. Parts of the transcribed interviews are highlighted in terms of direct quotes to substantiate the theme. Ethics approval for the study was obtained from the University of KwaZulu-Natal, Durban, South Africa.
R E S U LT S
Participants in the study included ever-users of the female condom. Eleven of the participants currently used female condoms and four were former users.
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They said that they wanted to see how sex feels when using the female condom: To be honest, the main reason why I used the female condom was for sexual experimenting to see what this thing is about, because when we think about condoms, we only think about the male condom. It is difficult to imagine how the female condom could work when you actually need to use it. [P7] The majority of the participants who currently used the female condom further viewed it as a way of empowering themselves, as they got to decide on its use. The female condom increased their power over their sexual health. They had greater control over their bodies and sexual life, and they could protect themselves if their partner was not willing to use a male condom: It is empowering to know that as a woman I get to decide to use the condom, as normally it is men who use the condom. For me personally, I also believe that the female condom gives power to young women like me regarding my sexual health. It gives control over my own body and a sense of control over my sexual life. [P2]
Reasons for female condom use Almost all the participants indicated that they perceived themselves as being at high risk of contracting a sexually transmitted infection (STI) or having an unwanted pregnancy. They felt they were more at risk because of their lack of power in sexual relationships. Protection from STIs including HIV and prevention of unwanted pregnancy were the initial reasons given by the majority of the participants for using the female condom: The main reason for using the female condom is for protection, obviously, so that I would not have an unplanned pregnancy and I would not get STIs. [P5] Although I love my boyfriend, I cannot write it in blood that I know what he is doing with his life. So, it is just important for me to be on the safe side. Also, with the lack of power we have as women in relationships it is important for us women to protect ourselves. [P12]
I think the main reason for me was that sometimes my boyfriend does not want to use protection. So I just wanted to have that sense of control and power that I can do things to protect myself in the relationship. Also, to have that sense of control that, since he does not want to use the condom, I can do something about it, meaning that I can use the female condom. [P3] Although the majority of the participants found the female condom to be empowering to women, one of the participants highlighted that female condoms alone did not empower women, but that male partner involvement in its use remained as significant:
Although most of the participants in the study used the female condom for protection from STIs and pregnancy, for some the opportunity for sexual experimentation with the device was the main reason for using it.
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We are made to believe that female condoms are developed to empower women, but most women still do not have the power to initiate female condom use. Most women always find it difficult to negotiate female condom use with their male partners. As women, we cannot be empowered by female condoms alone, but I believe that men’s
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participation in female condom use is a key to empowerment. [P11] The majority of the participants reported that although they wanted to protect themselves, they required the cooperation of their male partners to use the female condom. They further reported men’s reluctance to use it, highlighting that men believed that the female condom interfered with sexual pleasure, and for that reason they did not approve its use. They reported using certain strategies to negotiate female condom use with their partners, such as suggesting the use of the female condom for pregnancy prevention or telling them about the side effects they had experienced with hormonal contraceptives: Although I want to protect myself, I cannot use the female condom without my partner. He needs to agree. Most men do not like using condoms and they will never approve of its use.They believe that it interferes with sexual pleasure. It is easy to use the female condom with my partner if I discuss it is for pregnancy prevention. [P15]
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I do not use the female condom only; I also use the injection. I feel safer using both.They are both effective and it is a double protection against pregnancy and HIV infection. [P15]
Inadequate availability is one of the most significant barriers to the consistent use of female condoms. The majority of the participants reported that female condoms were not easily accessible; they were very rare and hard to obtain compared with male condoms, which were readily available in public places such as public toilets and clinics:
More than half of the participants who were current users liked the female condom and preferred it to hormonal contraceptives. They repeatedly cited that the female condom provided double protection for women against infections and unwanted pregnancy. They also articulated that hormonal contraceptives had side effects and that they were not used for prevention of STIs (including HIV/AIDS). Female condoms were effective in preventing infection and pregnancy, if used consistently and correctly. There was also an (incorrect) belief that female condoms were more effective at pregnancy prevention than other contraceptive methods:
Well, you can use contraceptives, like pills, but they will never protect you from contracting HIV and other STIs.They do not work 100%.You find
One of the participants mentioned that she used dual methods – the female condom and injectable contraceptives, and both methods were effective. She highlighted that she felt safer using both methods because they gave her double protection from pregnancy and infections:
Barriers to female condom use
I talked to my partner about the side effects I had experienced with the injection and the pill and I asked to use the female condom. [P2]
Injections have side effects; I have seen my friends gaining weight after using injections. Of course, as I mentioned, you cannot prevent HIV with the other contraceptive methods, so a condom is at least 99% guaranteed. [P1]
that there are people who use pills but they still get pregnant. But with the female condom you are sure that there would not be any pregnancy and you would not contract any STIs if it is used consistently and correctly. [P5]
I do not think the supply of the female condom is much these days like the male condom. In the clinic, as in the university clinic for instance, I assure you that you will find not just one or two male condoms; you will find boxes of male condoms. But rarely will you find a female condom. If you do, maybe you will find one or two on display just so that women will know that it exists.You cannot even find female condoms in the toilets. Even here in the university you can only find the male condom but not the female condom. [P5] Many of the participants felt that there was a lack of awareness about the female condom. They reported that in most cases the majority of women were not well informed about its availability. They highlighted that it was hardly advertised compared with the male condom and they felt that there was not sufficient promotion of the female condom in the media: I feel like there is not enough awareness, because many women are not well informed about the female condom. If you go to the nearest toilet you will find adverts or pamphlets on the male condom
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Use of female condoms in South African students
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and you will find the male condom in the toilet. But with regard to the female condom, you will hardly find it in public toilets and you hardly come across pamphlets advertising it. I also do not think that there is much communication about the female condom from the media to the people. [P6]
To be honest, injection works better for me because I do not have to take it every time I have sex, as I would with the female condom. I tried to use the female condom twice and that was it. I could not use it again. It is one of those things that are not for me and I am not very comfortable with it. I am using injections at the moment and they are more effective for me in preventing pregnancy. [P9]
One participant reported stigma as a significant barrier to the use of the female condom. She highlighted that there was stigma attached to female condoms in general and this in turn influenced its use. She further reported that female condoms were associated with promiscuity, and women who used the device were considered to be promiscuous: There is stigma attached to the female condom. As a woman, if you talk about it or discuss it with your partner – that is with regard to the women I have spoken to – you will find that they are seen as a bit forward when it comes to sexual orientation. Some women are assumed to be promiscuous if they tell other people that they are using the female condom. [P6] Many participants reported difficulties in inserting and properly positioning the female condom when they started using it, even though it came with instructions: The major problem was actually at the beginning when I first started to use the female condom. I experienced difficulties when I tried to insert it. I read the instructions but it was not easy. The practical part of actually applying it was a nightmare. I was not really sure how much you need at the bottom and how far to push it up. I had to do it over and over again. [P6] There were some concerns expressed by both current and former users about female condoms. They stated that they preferred hormonal methods such as injections, pills and implants because they were more effective at preventing pregnancy. They felt that with hormonal methods they did not have to worry about condom rupture. In addition, hormonal contraceptives were more easily accessible than female condoms. They also indicated that they found female condoms uncomfortable to use and that they used a hormonal method because they did not have to use it at every sexual encounter and it was more effective in preventing pregnancy over a longer period of time.
I use female condoms but I prefer contraceptive pills because they are effective and easily accessible. With pills I do not have to worry about pregnancy and condom breakage. [P4] I used female condoms before and I find them not very comfortable. I decided to use implants because they are more effective and protect me from getting pregnant for years. [P6]
DISCUSSION
Findings and interpretation In general, perception of personal vulnerability is regarded as a prerequisite to undertaking modifications in behaviour to prevent a disease13. Participants in this study perceived themselves to be at risk of STIs and pregnancy and this motivated them to use the female condom. They believed that lack of power in sexual relationships increases women’s susceptibility to infections. However, we also need to acknowledge that one’s perception of risk to a health threat alone is not sufficient to change behaviour13. Knowing one’s susceptibility to infections does not automatically translate into using the female condom. This suggests that we need to take into account other important external and internal factors that prevent the uptake of preventative measures despite one’s perception of risk. The female condom provides women with an opportunity to protect themselves and enhances their ability to ensure healthy sexual behaviours14. The importance of the female condom in empowering women in sexual relationships was evidenced in the current study. Participants repeatedly observed that the female condom increased their sense of independence and their control over their sexual health. Participants also reported that the availability of the female condom
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allowed them to provide their partner with an option between a male or female condom, which gave them the opportunity to participate actively in reinforcing safer sex in relationships. Although some participants found the female condom to be empowering by allowing women greater control in sexual relationships, others found that the female condom was not empowering because it remained under men’s control. One of the key findings of this study is that the female condom was preferred by most of the current users over hormonal methods, because it provided dual protection against infections and pregnancy. These users reported that they preferred the female condom due to the negative side effects of hormonal methods. Other participants were satisfied with hormonal methods, reporting that they were highly effective at pregnancy prevention. Participants indicated that hormonal methods were easily accessible; some of the methods, for instance implants, prevented them from getting pregnant in the long term. They further raised concerns about the female condom, indicating that they tried the device but found it to be uncomfortable and that it could rupture in some instances, which might put them at risk of pregnancy. In this study, inadequate availability was reported to be the greatest barrier to consistent use of the female condom. Almost all participants complained of insufficient distribution of the female condom compared with the male condom, and the majority felt that the device was not well promoted. One was unlikely to come across pamphlets on the female condom and it was hard to find it in public places where you might find male condoms, for instance in public toilets, clinics and shops. Participants also mentioned that there was not enough communication about the female condom in the media. Like any other contraceptive method, the female condom is not without challenges. Difficulties in inserting the female condom properly when using it for the first time were reported in the study.The major concern was that even though the female condom came with instructions, the practical part of inserting it for the first time was difficult. Nevertheless, participants in this study also acknowledged that with practise the female condom became easier to use. Stigma associated with female condom use was also highlighted as a barrier to the use of the device. Stigmas that were mentioned by the participants included the association between condom use and promiscuity, the 384
result of a lack of trust in relationships, and that people are told that condoms are used for casual sexual relationships or by sex workers. Therefore, participants in the study found that it was fairly difficult for women to use female condoms when they were confronted by such negative perceptions. The male partner’s response to female condom use is also a significant barrier despite the woman’s interest in using the female condom15. The participants in this study mentioned that although they wanted to protect themselves, they first had to negotiate female condom use with their partners. They reported that men did not like using condoms and they did not approve of its use because they thought that it interfered with their own sexual pleasure. This emphasises the extent of the unequal power in sexual decision-making, particularly the extent of women’s disempowerment in sexual decision-making, which further increases their susceptibility to infections. As a result, participants reported using various strategies to facilitate female condom use with their partners. For instance, they reported introducing female condom use for pregnancy prevention and communicating to their partners the negative side effects of hormonal methods. Strengths and weaknesses of the study This study provides some interesting insights into female condom use among female university students. Not only did it look at factors facilitating female condom use, it also focused on inhibiting factors. It is important, however, to note some of the limitations of the study. The study findings cannot be generalised to the entire population because of the relatively small sample size. Furthermore, the study was carried out among university students with higher levels of knowledge, whereas low levels of education are common in South Africa. Men have a huge influence on female condom use; thus, using only women to understand factors facilitating and inhibiting use created some bias within the study. This qualitative study is suitable for eliciting possible reasons for and against use, but it does not tell us how many women find these reasons important. Differences in results and conclusions in relation to other studies Previous studies have been conducted on female condom use in order to understand various factors
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that influence its use4,16,17. The findings of the present study are consistent with those of previous studies which found that the female condom played a role in improving women’s self-efficacy and independency9,10,18. First-time users, however, may experience difficulty inserting the device5,16,19,20. Participants in the current study reported introducing female condom use for pregnancy prevention to convince their partners to use the method, a finding consistent with that of another study21. Furthermore, in one report by the Program for Appropriate Technology in Health (PATH) and the United Nations Population Fund (UNFPA)3, hormonal implants and injectables, as well as intrauterine devices and sterilisation, were found to be highly effective in preventing pregnancy, consistent with the current study’s findings. Participants in the present study highlighted the stigma attached to female condoms as a barrier to their use. This finding corresponds with results from previous studies which found that residual social stigma attached to condom use was associated with less frequent female condom use17,22. Moreover, the study participants preferred the female condom because of its dual protection against infections and pregnancy. The importance of the female condom in reducing the risk of infections has been observed in previous trial research5,23,24.
Relevance of the findings: Implications for clinicians and policy-makers The female condom is one of the government’s strategies to fight the HIV pandemic in South Africa. The study findings suggest that female university students are using female condoms for protection against the dual risk of infections and pregnancy. However, there is an urgent need for the government to increase the availability of female condoms and make them widely accessible to the entire population. Providing adequate information and increasing male involvement in female condom use are essential to women’s empowerment.
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Unanswered questions and future research Male involvement in female condom use is important in facilitating consistent use of the device and in empowering women. More research is needed on female condom use, especially among larger groups of female condom users and their male partners, in order to get a holistic picture of factors facilitating and inhibiting its use, and to identify strategies to increase its consistent use. There is a need also for research on never-users of the female condom to understand barriers to use.
CONCLUSIONS
The female condom is important for female university students, because it protects them from infections and unwanted pregnancy. Female students feel empowered by the female condom, because they decide on its use and it gives them control over their sexual and reproductive health. However, some feel they are not empowered by the female condom, as its use remains under men’s control and they have to use communicative strategies to convince their partner to use it. The lack of availability of the female condom remains a major stumbling block to consistent use. The study findings suggest that providing adequate information, educating both men and women, increasing availability and making the device easily accessible to the population are important strategies to facilitate consistent use of the female condom.
AC K N OW L E D G E M E N T S
We thank all the female students who participated in this research, as well as the university clinic staff who assisted in identifying the study participants. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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