The Enduring Unpopularity of the Female Condom
The internal condom saves lives, but it has been criticized from the start. An Object Lesson.
A tubular sheath with rings on both ends—that’s how the United Nations describes “the only female initiated dual protection device that is believed to be effective at preventing STIs and pregnancy.” After being inserted vaginally or anally, it prevents the passage of fluids from one person to another. It feels much like a conventional condom, even if it looks much more ungainly at first.
Given their simple design, it’s likely that internal condoms, more commonly known as female condoms, have been used in some form for ages. In fact, the first recorded condom use refers to a female condom. The poisoned semen of King Minos, who lived around 3000 BCE, supposedly led to the deaths of multiple mistresses. Therefore, according to legend, Minos fashioned an internal condom out of a goat’s bladder to protect his sexual partners. Little has changed but the lore: In the place of scorpions, snakes, and woodlice—the reported sources of Minos’s poison—today we fear the viruses that might lurk in bodily fluids.
As a modern commodity, the female condom was the brainchild of Lasse Hessel, a Danish public health celebrity and prolific inventor. Hessel’s other creations include diet pills, a comic strip, an indoor waterfall system, a breast cancer test, an early version of Viagra for women, and a TV show. He has earned the nickname “The Health Millionaire” in Denmark.
In the early 1980s, Hessel heard the Danish gynecologist Fritz Fuchs speak about the new scourge AIDS, and the barriers women faced in protecting themselves from infection. During the talk, Fuchs challenged Hessel to develop a female condom. That day, Hessel made the first prototype by cutting apart some hospital gloves and, with an iron, fusing the palm-covering areas together. The invention hit stores in Europe in 1990. In the U.S., the Food and Drug Administration finally approved the internal condom for domestic sales in 1993.
The product was heavily politicized from the start. One of the first mainstream publications to mention the internal condom, Forbes, didn’t paint a very flattering picture. Criticizing the FDA in 1993, Peter Brimelow and Leslie Spencer noted, “The same agency that holds up potentially useful drugs tends to become lax when politically fashionable products come before it. Thus the agency has responded to feminist pressure to approve the very failure-prone female condom.”
It’s peculiar that the FDA’s rigorous regulatory process was termed lax by certain media outlets, and that feminist support was seen as a drawback for a health product. But the internal condom was greeted with suspicion and dismissiveness in the United States—a country in the throes of a war over political correctness. In a demonstration of the internal condom played for laughs on his TV show, Rush Limbaugh suggested that the device was impossible to use. This mocking attitude would come to define media attitudes toward internal condoms for a long time.
The heyday of the female condom was short-lived. A Google Ngram graph shows that in books, the term only came into semi-regular use in the mid-1980s. Its usage peaked in the late 1990s and has been declining steadily ever since. “Femidom”, which is not the name of an anarcha-feminist punk band but a synonym for a female condom, trails behind slightly, with its usage reaching an apex in 2003 but also falling precipitously immediately afterward.
The fact that “female” prefixes the product suggests that it is seen as a lesser, or at least less standard, version of a contraceptive mainstay. It is also a misnomer, as the “female” condom can be used during anal (male and female) as well as vaginal sex.
In the U.S. and Europe, the female condom continued to be seen as faddish and ineffective. Therefore, attention turned from consumer markets to international development. In 2002, the Female Health Company won a Queen’s Award for Enterprise, an honor recognizing U.K. companies’ achievements. The award was conferred not in the sustainable development or innovation category, but as part of the international trade category, reinforcing the idea that the female condom had largely become a developing-world export.
The Female Health Company holds patents for the most widespread form of the internal condom, the FC2, which is the only form of the internal condom approved by the FDA. This may change in the future, as the National Female Condom Coalition in the U.S. is advocating for an FDA reclassification of the female condom into the same category as the male condom. This would allow more entrants into the market. In the U.S., the bulk of the Female Health Company’s sales go to the U.S. Agency for International Development, the Brazilian and South African health ministries, and the UN.
The FC2 has evolved from Hessel’s original design. When it made its 1990 market debut, the device was 17 centimeters long and ill-fitting for many. It sold poorly. Since then, costs have been reduced, and the polyurethane used for the FC1, the precursor to the FC2, has been replaced with nitrile, a substance with a number of medical applications. A major advantage is that nitrile has reduced the distracting squeaking or rustling that was often reported with the FC1 (many reported the noise to be a turn-off).
Since the FC2, the product has evolved and diversified. “Normal” condoms—the ones meant for penises—come in thousands of varieties, from glow-in-the-dark to ribbed-in-different-thicknesses, so the range of vaginal/anal condoms is extremely limited by comparison. Internal condoms offer fewer customization options, but some current devices are scented, and others come with applicators (like tampons). “Panty condoms” even come packaged with underwear. These are marketed as being especially convenient, discreet, and reusable, although large-scale regulatory approval has not validated these claims.
A controversial innovation appeared in 2005. A South African doctor, Sonnet Ehlers, announced the invention of a female condom that doubled as an anti-rape device. The Rape-aXe, planned for distribution during the South Africa-hosted 2010 World Cup, was intended to keep women safe in a country with staggering rates of sexual assault (the South African Medical Research Council found that 1 in 4 men surveyed in 2009 admitted to having committed rape).
The Rape-aXe is designed for precautionary insertion by a woman. It has tiny internal barbs that attach to a penis on penetration, making it difficult for anyone but a medical professional to remove. Despite the furor—on both logistical and ethical grounds—that surrounded the announcement of this anti-rape device, Ehlers continues to seek investors. As she explained to me by email regarding recent tests, “It worked very well—the guy that tested it was in excruciating pain. He could not walk, let alone run, after his victim.”
While the technology of the internal condom continues to evolve, its financials remain an obstacle. Planned Parenthood states that the price of a single female condom varies from two to four dollars in the U.S.—about two- to three-times the cost of a traditional condom. Bulk purchases by aid agencies bring the price down to 55 cents per condom (ordinary condoms purchased in quantity cost as little as 2 cents each).
The price disparity comes in part from the limited production of female condoms. Economies of scale are difficult to achieve when there’s little demand in wealthy markets, and one company essentially holds a monopoly in the U.S. This lack of demand is a persistent phenomenon. And the reasoning is circular. Female condoms are unpopular because they’re not widely discussed or available. And they’re not widely discussed or available because they’re unpopular. Costs could be driven down further if they were more popular.
Likewise, their unpopularity seems to arise from unfamiliarity more than concern. The Internet doesn’t lack for personal essays by women who have tried internal condoms once and decided, never again. Sex education in schools provides training on how to use the external condom, and there are plenty of pop culture touchstones about external condoms. No one is an expert on external condom use after their first time using one, after all.
The bar for the internal condom seems to be set higher: Some expect it to be intuitive and comfortable from the first time, despite the much sparser information available about its correct use. Female sex workers interviewed in El Salvador and Nicaragua reported that it took them two to 10 tries to feel comfortable using an internal condom. These aren’t unreasonable figures given the learning curve that also comes with other prophylactics.
Other reasons cited for disliking internal condoms include associations of partner mistrust, perceptions of promiscuity, a lack of spontaneity, a decrease in sensation, discomfort, lack of knowledge, technical difficulties, inconvenience, religious or cultural stigma, and cost. All of these factors have at some point been associated with the male condom as well. Loss of pleasure, in particular, is associated with the unpopularity of external condoms in North America as well as in Africa.
However, if women and gay men were to demand internal condoms, aid agencies and governments might supply them in greater quantities. Zimbabwe, which has one of the highest usage rates of female condoms, offers an example. Zimbabwean women’s and health organizations campaigned to bring female condoms to the country. After 30,000 petition signatures, the Zimbabwean government rolled out female condoms in 1997. The products have subsequently been made available on both a for-profit (branded) and a non-profit (unbranded) basis.
Social marketing has been key to their success in the country. Internal condoms are distributed in Zimbabwe not only through health facilities, universities, and pharmacists, but also through hair salons. Stylists in over 1,500 salons have been trained in sharing information about female condoms, helping to promote correct use as well as normalize the products.
Health organizations often promote female condom use because of its ostensibly transformative potential to allow women and girls to protect themselves sexually. A device managed by females and inserted vaginally is meant to be empowering for those whose partners disapprove of contraception. Of course, such responsibility still requires that the woman’s partner agree to safe sex. And unlike the traditional condom, the internal condom never really disappears during intercourse. Most internal condoms hang out of the vagina or anus, making them highly visible.
Internal condom distribution has also been stigmatizing in some contexts. For a time, the Brazilian government would mainly buy internal condoms for female sex workers and drug users. Thus, policymakers, along with the media and the public, have contributed to a perception that this is a niche product—and one made for “unseemly” users, besides. The stigma has been partly diminished by the UN, which considers the female condom one of 13 essential, overlooked commodities for saving the lives of women and children. Together, these items (including zinc tablets and emergency contraception) are expected to save over six million lives over a five-year period.
One reason to encourage the internal condom is that increased choice benefits sexual health generally; what works well for one woman (or man) might be inappropriate for another. A key advantage is that the internal condom can be inserted up to eight hours before sex. And some surveys find that, with sufficient training, users become comfortable with internal condoms and even come to prefer them to external ones. However, this is not the norm, and context is extremely important in determining acceptability. It’s important to note too that the failure rate of a female condom, in terms of unintended pregnancy, is slightly higher than that of a male condom. This is highly dependent on users’ experience with the devices.
The persistent myths around female condoms highlight the danger of searching for panaceas in global development. One object alone isn’t sufficient to solve an issue with complex social and cultural meanings, particularly if the recurring costs of these objects aren’t factored in. And as noted in a scoping study on female condom use in developing countries, increasing the availability of new methods for contraception does not necessarily result in broader choices in practice. “Uptake,” the study explains, “depends on the perceptions and experiences of potential users and the socioeconomic context, with culture and gender relations often having greater impact on acceptability than actual attributes of the method.”
It’s clear that female condoms save lives, but over a quarter-century since their introduction, the apparatus remains unappealing and unpopular. The female condom may have a future if aid organizations, governments, health care providers, educational institutions, and other groups that advocate for safe sex increase their commitment to the awareness of contraceptive choice. The internal condom may not be for everyone, but it would help those who would prefer it to other mechanisms of STD prevention and contraception—particularly those who might choose to practice safe sex as a result.
This article appears courtesy of Object Lessons.