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The future of sex:  can the female condom catch on second time around?

Once mocked as having the erotic appeal of a jellyfish, the female condom is being reinvented as the next big thing in protective sex. In the first article from new digital publication Mosaic, Emily Anthes takes an in-depth investigation to see what chance it has of catching on this time around.

Male condoms (top) make up more than 98% of the market at the moment (Science Photo Library)

These requests became the guiding principles for the designers and engineers working at Path’s product development laboratory in Seattle. The team ran an iterative, multi-step design process, building prototypes of potential new condoms in the lab and then sending them out to heterosexual volunteers in each of the four countries. These women and men handled and examined each model, sharing their impressions with researchers, and couples received samples of some of the more advanced prototypes to try out in their bedrooms. The product designers used the feedback to refine – and sometimes utterly rethink – their designs and then sent new, tweaked models back for further testing.

Early generations of female condoms had relied on a ring-based design. One of Path’s first prototypes was similar, with a polyurethane pouch anchored between two fixed rings. But some women reported that it was difficult to push the inner ring into the vagina – the same complaint often made about the FC1 and FC2 – and that it was painful once inside. “Device is stable but uncomfortable,” one Mexican tester reported. So Path decided to scrap the rings entirely. They briefly tested a prototype that could be inserted using a tampon tube applicator, but the condom didn’t deploy reliably.

They spent a lot of time talking about how to improve insertion. “We know from a user perspective, if you have a difficult time the very first time you try to use a device, a woman may never come back,” says Kilbourne-Brook. “We wanted this to be not only easy to use, but it needed to be easy to use for someone who’s never used it before.”
According to Kilbourne-Brook, the ultimate breakthrough was inspired by feedback from testers and researchers in Thailand, who said, “Wouldn’t it be wonderful if you had some kind of insertion device that helped you insert it and then it got out of the way?”

Radical redesign
By 2003, they had hit on the solution: a dissolving applicator. The engineers created a condom that looked like a funnel, with a thin sheet of polyurethane that narrowed into a rounded tip. This tip contained the main pouch of the condom, collapsed inside a dissolving capsule. To insert the condom, women would simply push the capsule inside, much the same way they’d insert a tampon. Once it came into contact with the moisture of the vagina, the capsule would melt away – often within 30-60 seconds – releasing the full condom pouch.
The product designers gave the condom stability by attaching four small, thin pieces of polyurethane foam to the outside of the condom. Once the pouch expanded, these foam pieces nestled up against the vaginal wall, keeping the condom in place. Like other female condoms, the model also featured a flexible outer ring to cover the external genitalia.

Between November 2003 and January 2004, 60 couples received samples of this prototype to try at home. They were impressed. Eighty-eight per cent of the women said it was easy to insert and 97% said the pouch was stable during sex. The vast majority of men and women asked said the condom was comfortable, and 98% of women and 100% of men said it allowed for satisfactory sensation during sex.
It had taken six years and more than 300 unique prototypes, but by early 2004, Path had found its female condom.

The final product, which Path named the Woman’s Condom, is “just a brilliant design,” says Kaler, who was not involved in its creation. “When you look at it visually, it isn’t huge. It’s clear what you do with it. And the way that it’s been designed with these foam pads means that it doesn’t move around.”

A series of larger clinical trials – conducted in Mexico, South Africa, Thailand, China and the US – has reinforced what Path found in its initial testing, with users reporting that the Woman’s Condom is comfortable, stable and easy to insert. Several studies have found that both men and women tend to like the Woman’s Condom better than the FC1 and FC2. Users’ main complaint was that it does not come pre-lubricated, as the FC2 does. Instead, each condom comes with a packet of lubricant that users can apply themselves.

In 2011, the Woman’s Condom received the stamp of approval from the Shanghai Food and Drug Administration and is currently under review by the UNFPA; approval is expected in 2014. In the meantime, limited quantities are already being sold in China and South Africa.
“Low-stress solution”

The Woman’s Condom isn’t the only new female condom on the scene. In 2012, the UNFPA pre-qualified the Cupid, which is manufactured by an Indian condom company. The Cupid relies on a ring-shaped foam sponge tucked into the closed end of the condom pouch for internal stability. Made of natural latex, the Cupid may be the cheapest female condom yet, and is now available for purchase in both the public and private sectors.

Several other condoms, each slightly different in design, are currently under UNFPA review. For instance, the Phoenurse, which is currently sold in China, comes with an optional insertion stick. Then there’s the panty condom, in which a condom pouch is affixed to a pair of reusable panties with an opening over the vagina. Before sex, a woman can push the condom inside with her finger – or a man can with his penis – without her having to take off the undergarment.

Promoting the female condom in poorer countries has had more effect than in the US (Getty Images)

And there are still more designs in the early stages of development. Origami Condoms, based in Los Angeles, California, has developed a silicone female condom that unfolds like an accordion as it’s pushed into the vagina. The company just completed a small phase I acceptability study – overall, participants preferred the Origami condom to the FC2, though they said the FC2 felt more stable during sex. The company plans to conduct a larger clinical trial this year.
Not every product will be right for every woman or couple, but that’s precisely the point. “In the studies we’ve done, we’ve found that some women will say, ‘I really love this one and I don’t like this one at all’,” says Mags Beksinska, research director at the division of maternal, adolescent and child health at the University of the Witwatersrand, South Africa. “There are different aspects that appeal to different women in the different designs. So it would be good if there was a wider choice.”

Krissy Ferris, the woman who was initially turned off by the cost of female condoms, came to see their advantages while dating a man who had trouble maintaining an erection with a male condom. “It was definitely a barrier to male condom use, and I was not ready to compromise on using a barrier method,” she says. The female condom was a “low-stress” solution.

Over the years, Ferris has tried several different products, including the FC1, the FC2 and the VA w.o.w., which, like the Cupid, uses an internal sponge to hold the condom pouch in place. Ferris found that she preferred the VA w.o.w. because the sponge made it feel more secure during sex. “If you’re using something with this desire for safety, having this extra measure of security was definitely a positive for me,” she says. But the FC1 and FC2 felt more natural, she acknowledged, and for some women, that may be more important.
There is some evidence to suggest that women are more likely to have safe sex – and less likely to become pregnant or contract sexually transmitted infections – when a larger selection of contraceptive and barrier products is available. Giving women a greater choice in female condoms may increase the odds that they choose any female condom at all.

Meanwhile, male condoms are also getting a redesign. In November 2013, the Gates Foundation awarded 11 grants of $100,000 to designers, engineers and scientists with ideas for a “next-generation condom’”– male or female – that would be easier and more pleasurable to use. The winning proposals include a male condom that is packaged with a built-in applicator, allowing the condom to be removed from its foil wrapper and donned in a single smooth motion, and a one-size-fits-all male condom designed to tighten during sex.

Practice makes perfect
Of course, upgrading a product is merely a first step. While the FC1 certainly had its flaws, they weren’t the only reason that female condoms didn’t take off. “Some technologies are harder than others,” says Laura Frost, a partner at Global Health Insights, a research and consulting firm. “Compared to other products where there’s one huge issue, like affordability or awareness, this one had those barriers at every stage.”

That’s why, for the female condom to truly break through, advocates will need to invest in comprehensive marketing and education campaigns at the local, national and global levels. “It takes more than just putting it on the shelf,” says Susie Hoffman, an associate professor of epidemiology at Columbia University in New York.

The Origami Condom unfurls like an accordion – and some users prefer it (Origami Condom)

Female condoms remain less straightforward than male condoms, and one of the major lessons of the last two decades is that women often need a little bit of training to use them correctly. That means that clinicians and counselors may have to do more than simply tell women that female condoms exist – they’ll need to give them the opportunity to practice inserting one, either on a pelvic model or on themselves.

In addition, women may need help figuring out how to broach the subject with their male partners. Though the condoms have won praise for being female-initiated, they’re not entirely invisible, and most men will notice if their partners are wearing them. “In many cases, she’s probably going to want to mention to her partner before having sex that this is a new product that she’s going to try,” Hoffman says. “Ideally there’s going to be some kind of a conversation about it, and women need help in figuring out how to do that.”

Male partners are also a potential market. “Men probably feel, when it’s called the ‘female condom’, that it’s not something that’s for them,” Mags Beksinska says. But “there’s no reason that a man shouldn’t take one and bring it home and introduce it to his partner”. In fact, she adds, once men get used to the female condom, they often prefer it to the more constricting male version. Female condoms even enhance sex for some people: the outer ring can be used to stimulate the clitoris, while the inner ring of some designs can bump up pleasurably against the tip of the penis.

The female condom may remain a tough sell, but the good news, experts say, is that there are now more organizations trying to make the pitch. “Now we’re seeing a much bigger coalition of advocates, which is what we need,” Frost says. Some existing agencies, most notably the UNFPA, have stepped up their support, while champions have created a variety of new advocacy and awareness groups, including the National Female Condom Coalition in the US, and the Universal Access to Female Condoms Joint Programme, based in the Netherlands.

New support
Alongside this, the condom’s supporters are getting more creative in their promotion efforts, establishing Global Female Condom Day – the first one was held on 12 September 2012 – and holding female-condom-themed fashion shows and film festivals. Several organizations have turned salons and barbershops in Zimbabwe, Malawi, Cameroon and elsewhere into female condom distribution centers, training hairdressers to promote and sell the product to both male and female clients. And all-out media blitzes in Africa – in which the condoms are promoted on billboards, television and the radio – have fed a sharp increase in demand.

“I think people had kind of written off the female condom,” says Beth Skorochod, a senior technical adviser at Population Service International. “But now people are beginning to say, ‘Ok, with more competition and more interest, maybe this deserves another look’.”
There may even be hope for the hard-to-crack private sector in higher-income countries. After winning FDA approval for the FC2 in 2009, the Female Health Company relaunched the female condom in the US, creating female condom campaigns and programmes in a handful of major American cities, including New York, San Francisco and Washington, DC.

Female condoms may be more expensive, but they have a role to play in sexual health, supporters say (Getty Images)

Some local US groups are also beginning to lay the groundwork for the future. Staff members at the Chicago Female Condom Campaign now show off samples of some of the newest products – including the Cupid and the Woman’s Condom – in their training and education sessions. The goal is to make sure that healthcare providers and consumers will be familiar with the products if and when they appear in the US. But there’s an added benefit. “Frankly what this also does is it helps to cultivate new female condom advocates,” says Jessica Terlikowski, who coordinates the Chicago Female Condom Campaign and the National Female Condom Coalition. Seeing other products, she says, can prompt women to ask, “‘How can I get that?’ ‘Why don’t we have that here?’ People can’t ask for or demand what they don’t know about.”

Women may soon have choices beyond the conventional condom. Scientists have been developing interventions that would be truly invisible to women’s partners: oral antiretroviral pills and vaginal gels that prevent HIV. Despite the enormous excitement surrounding these drugs, they won’t be magic bullets either, and the public-health community will still have to grapple with the thorny issues of education, access and adherence. Earlier this year, for instance, researchers announced that a clinical trial of two different HIV prevention pills and one vaginal gel, conducted among women in three African nations, failed because women weren’t using the medications regularly.

Such outcomes are making it increasingly obvious that the global fight against HIV and other sexually transmitted infections is unlikely to be won with any one technology, no matter how elegantly designed. Instead, it will require an arsenal of weapons, a diverse array of tools that allow women and men to protect themselves. The female condom may never be as cheap or as popular as the male condom, but that doesn’t mean it has no role to play.

Among those optimistic about the female condom’s future is Lasse Hessel, the Danish doctor who started it all. The condom’s champions made some mistakes in the early years, Hessel says, but he’s encouraged by the recent resurgence of interest and the new products that are hitting the shelves. In fact, he wishes other inventors had redesigned his condom sooner, especially because there was so much room for improvement: “How can my ugly, clumsy female condom get any worse?” Hessel says. “It can only get much better.”

This article was originally commissioned by Mosaic, and reproduced under a Creative Commons license.

I remain hopeful that the day will come when there is a female condom that women can use that is very effective at preventing both infection and pregnancy. A female condom that is moderately well accepted by women and men remains an important priority because it is controlled by women and women, for all their inventiveness, sometimes cannot get a man to use a male condom and may be treated violently if the push too hard to get the man to agree.  Remember that most violence happening is happening in sexual relationships that have been ongoing for a long while.  Worldwide that means in marriages.  Women clearly want such an option and I am appreciative of the individuals, companies and foundations that are working to make an acceptable female condom available, particularly for those women who have insensitive male partners who really care little about the consequences of sexual intercourse for the woman in their life. Their long term sexual partner or a one night date.     

To learn more about the advantages and disadvantages of female condoms; go to: www.managingcontraception.com and click on Choices 2013 edition.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?  It is now available in English and Spanish.   

Key Words:  female condoms, effective, infection, pregnancy, male condoms, sexual relationship, options, insensitive partners, intercourse, Mosaic, ring-based design, dissolving applicator, funnel, polyurethane, capsule, vagina, tampon, flexible  


Posted on

May 4, 2014