Can the Female Condom Go Mainstream?

By Cari Romm

To understand the plight of the female condom, says sociologist Amy Kaler, it’s helpful to look at the old story of the blind men and the elephant.

There are several versions of this particular piece of folklore, but they all more or less go as follows: A group of blind men encounters an elephant. Putting their hands on the animal, each one attempts to explain to his companions what’s in front of them: An elephant is a snake, declares the man touching the trunk. No, it’s a fan, says the one touching the ear. No, a rope, counters the one at the tail.

An elephant, of course, is none of these things. An elephant is an elephant—but try telling that to the men whose hands have just told them otherwise. For better or worse, direct experience defines reality.

So what does this have to do with the device that, in its short history in the U.S., has been promoted as a contraceptive breakthrough, mocked with a host of unflattering comparisons and, most recently, allowed to fade into relative obscurity?

Plenty.

When it was first introduced to the American market by the Female Health Company (then called the Wisconsin Pharmacal Company) in 1993, the female condom seemed, on paper at least, like it ought to have been a hit. Like male condoms, it prevented both pregnancy and sexually transmitted infections. Unlike male condoms, it could be put in place hours before sex to avoid ruining the mood in the moment. And most significantly, it was woman-controlled, meaning that safe sex was still possible even if a male partner refused to wear a condom—a major boon in a time when public awareness of AIDS had only just become widespread.

But as with the elephant in the fable, some of the female condom’s less appealing attributes quickly outweighed and obscured the whole, explains Kaler, a professor at the University of Edmonton who’s authored several studies on the subject. “The concept of the female condom has enormous appeal,” she says, but it came to be defined in the U.S. by a collection of its flaws: an awkward appearance, a tendency to rustle, the public distrust that often affixes itself to the unfamiliar.

“Everyone,” Kaler adds, “will tell you [about] a different part of the whole beast.”

Lately, though, that beast is having something of a moment, thanks to a few female condom optimists who think its reputation may be salvageable after all.

The Gates Foundation, which last month announced its second round of grants for the “next generation condom,” includes two female condom projects among the 11 winners, each of which will receive $100,000 in funding (a third bills itself as a “non-gender specific internal condom” intended for both anal and vaginal sex). Both projects focus on the foundation’s call for a design meant to make condoms fun rather than burdensome: The “Air-Infused Female Condom,” from Massachusetts physician Mache Seibel, “is inflated and positioned using air pressure and provides additional stimulation,” while the “Female Pleasure Condom,” from Indiana University professor Debby Herbenick, “will be ribbed on one side to provide directed internal stimulation for the female, making it potentially more enjoyable than no condom.”

Current designs “haven’t been sized or shaped in ways that fit really comfortably or pleasurably inside women’s bodies,” Herbenick says (earlier this month, she told Bloomberg News that their bulkiness drew comparisons to “a sandwich bag”).

“It’s still a problem for both male and female condom companies to say, ‘You can use our product and have safer sex but also feel great,’” she continues. With her project, which will be tested in both the U.S. and India, “I hope that adding more features that are directed at pleasure will help people see it as something they can use for good sex.”

To make it happen, though, Herbenick, Seibel and other advocates for the female condom will have to overcome a bias as old as the device itself.

In the developing world, women have considered female condoms an essential tool in the fight against HIV/AIDS since they were invented (notably, Zimbabwe’s Ministry of Health received a petition in 1996 from 30,000 women who wanted it to be brought into the country). In 2012, the United Nations Population Fund distributed some 32 million female condoms worldwide. Designs have proliferated to keep up with demand: PATH created the Woman’s Condom, while an Indian company has developed the Cupid.

But in the U.S., where innovation for female condoms has languished by comparison, the reputation struggle began right at the beginning. When the Food and Drug Administration approved the first version, marketed under the brand name Reality, in 1993, the agency’s press release announcing the approval was less than confidence-inspiring:

“The female condom is not all we would wish for, but it is better than no protection at all," FDA Commissioner David A. Kessler, M.D., said. "I have to stress that the male latex condom remains the best shield against AIDS and other sexually transmitted diseases. Couples should go on using the male latex condom.”

The media treated the female condom with much the same disdain as the FDA, though with much more creative metaphors. In a 2004 survey of news reports on the female condom leading up to and immediately after approval, Kaler wrote, it was compared to:

“a jellyfish, a windsock, a fire hose, a colostomy bag, a Baggie, gumboots, a concertina, a plastic freezer bag, something to line Boston’s Inner Harbor with, a cross between a test tube and a rubber glove, Edvard Munch’s The Scream, something designed for a female elephant, something out of the science-fiction cartoon The Jetsons, a raincoat for a slinky toy or ‘a contraption used to punish fallen virgins in the Dark Ages.’”

A similar study, published in 2012 by University of Texas at Arlington researchers Karishma Chatterjee and Charla Markham Shaw, found that that even when the American media treated the female condom in a positive light, it tended to focus on non-American users. “The positive portrayals centered on the developing world and on contexts where the female condom was positioned as offering protection for women who had no control and few options,” they wrote, and were often “followed or preceded by a discussion of its inferiority as a second-class medical device.”

And for those women who did give it a shot, the female condom presented another issue: They knew what it was supposed to do, but actually figuring out how to properly use the thing was another story.  A 2005 study from the Guttmacher Institute found that 11 percent of women had the condom slip off the first time they used it. “It fell steadily to less than 1 percent if the method had been used 15 times or more,” the study notes—but experiencing that kind of snafu the first time presumably turns some off from a second time, let alone a 15th. And while the female condom’s failure rate was 5 percent when used perfectly, its actual failure rate was closer to 21 percent.

In an effort to salvage the image of its product, the Female Health Company launched another version of the female condom in 2009 under the brand name FC2 (Reality, the first iteration, is no longer produced in the U.S.). Currently the only FDA-approved female condom available in the U.S., the FC2 is made of the synthetic rubber nitrile rather than polyurethane, a change meant to cut down on the noisiness so many had complained about, and comes pre-lubricated.

Even with the launch of the FC2, though, the female condom was still plagued by the image of its predecessor. Jezebel’s Tracey Eagan Morrissey, in a 2013 piece titled “Stop Trying to Make Female Condoms Happen,” declared them to be “just ew.” Bedsider, a birth control website geared towards young women, offers this disclaimer: “It's not the prettiest thing in the world (it looks a bit like a floppy, clear elephant trunk) but it is a method that gives you lots of control.”

But for those looking to bring the female condom into the American mainstream, there may be an upside to the backlash of the earlier years. A bad reputation and low uptake have left the female condom largely excluded from public discourse about safe sex (“Many of my college students—most of them—have never seen a female condom,” Herbenick says), meaning that as a new generation experiences its sexual coming-of-age, it does so without the prejudice of the female condom’s earlier years.

A new paper published earlier this month lends support to the notion that ignorance, rather than negative attitudes, is what’s now keeping young people from using female condoms. Chatterjee and Shaw, the same team that had conducted the 2012 media study, surveyed a group of college students before and after an educational session on female condoms. They found that while many had heard of it, most knew little to nothing about it before the sessions; after, the majority said they would use it.

“What we know about sexual behavior suggests that what people start out with is what they stick with for the long term,” Kaler explains. The key to the female condom’s success, in other words, may be getting devotees to adopt it early in their adult lives.

And the key to that may be not only remaking the parts of the female condom—the shape, the material—but redefining the whole elephant, so to speak, as something it’s never been: sexy.

This article available online at:

http://www.theatlantic.com/health/archive/2014/07/can-the-female-condom-go-mainstream/375325/