Did you know that…?
Female condoms are safe and effective.
People often find them a lot more pleasurable than male condoms.
They can be used for vaginal or anal sex.
I recently sat down with advocate extraordinaire Jessica Terlikowski to talk about female condoms. Despite being around for 20 years, they are not well known, understood or used. But that is quickly changing, especially with the more recent FC2 design.
Jessica works for AIDS Foundation of Chicago (AFC) and is the coordinator of the National Female Condom Coalition in the US. AFC is the secretariat of the Coalition, whose goal is to increase awareness, access and use of female condoms throughout the US. They do that by partnering with local health departments as well as community-based organizations, researchers, advocates, and national organizations.
Marc-André: Hi Jessica. I thought we would start with the basics. Tell us about female condoms. What are they made of? How much do they cost? Where can people find them?
Jessica: The answer varies depending on where you are. In the US and Canada, the only one that we have is the FC2, which is manufactured by the Female Health Company. It’s the only one that has been approved by the FDA. It’s made of a synthetic latex called nitrile. Nitrile is stronger than latex. And compared to the original female condom, it no longer has a seam, it’s softer and it doesn’t make the same noise!
Then there are products that are available in a handful of other countries. That includes the PATH Women’s Condom, which is made of polyurethane. Then there’s the Cupid, which is made out of latex. There is one that is worn like a panty, which is only available in Columbia. There’s one that looks just like the FC1. It’s made out of polyurethane, same construction and everything, but it has an applicator that helps with insertion. Then there’s the VA w.o.w that’s available in a few countries. Then there are a number of other ones in development. Some are further along than others. There’s one called Origami being developed that would be available in two designs, one for vaginal sex and the other one for anal sex. That would be made out of silicone. So the ones that are most widely accessible and available are the FC2, the Cupid and the PATH Women’s Condom.
So why is it that we only have one available in North America?
The cost of moving through the regulatory process is really high. The developers of female condoms don’t actually have a lot of resources. So that’s been part of it. They have been prioritizing making them available through international aid organizations like the World Health Organization (WHO) as opposed to going through the US because the US and Canada are not been as a market for their products. However for US organizations to make them available, they require US FDA approval. So it’s important to get that approval if female condoms are going to be made available in the US and through US funded programs.
It’s also interesting because we’re used to having the greatest access to the greatest number of products generally in our context. So it’s interesting that in this case, for the reasons that you outlined, that we actually have fewer options than other parts of the world. And in terms of our context, what’s the typical cost? What can someone expect to pay to get their hands on one of these condoms?
There’s a range. If you walk into a drug store, you should be able to get three of them for about $7. They come in a pack of three. But they’re also covered by insurance, at least in the US. But you’d have to get a prescription for them to be covered. It’s great that it’s covered as a preventative measure. The complexity comes in when you try to get that prescription filled because not all stores stock them. So it’s not something that you can just go anywhere and get them. So even with the FC2 approved and available, walking into a store and getting them can be a real challenge. People can access them online and also through public health entities, Planned Parenthoods, and health departments.
How long have female condoms been around? Have they gained in popularity over the last few years?
The female condom just had its 20th anniversary. The new FC2 has been approved since 2009 and has been on the market since 2010. One thing is that public health departments are buying them more and distributing them more, particularly where there is programming. So that’s in several of the larger urban centers. That’s where you’re seeing greater programming that’s going alongside the distribution. That’s facilitating and increasing the acceptability and popularity of them. Because if people don’t know about them, then they can’t use them or decide if they want to try them. So a big thing is awareness.
But the other thing in terms of popularity and acceptance, going into meetings, you would hear one or two voices, and I was usually one of those voices… ‘The lone female advocate is in this room’. And then we started seeing more people raising this issue, people we didn’t know, which was very exciting.
The other thing is that when we would do trainings, we would have to dedicate a really significant amount of time to really get at people’s biases and create the space to say everything you don’t like about the female condom so folks could get out any negative feelings. And the wall would fill up with flipchart paper. What we’ve seen from when we started those trainings a few years ago is that the list of negative responses has gotten so small that what we hear is primarily positive things that come from providers. So a lot of the bias that we had to address and for people to get over has really minimized significantly, which I think is really important.
What do you think caused that shift? Was it just a question of time? People needed to get familiar with it? We hear that long list of provider biases today around things like PrEP for example. So was there a shift at some point that you saw in terms of attitudes towards female condoms on the part of service providers?
What we’d seen is during the provider training. The stories with PrEP are so similar, and the approaches to addressing those issues are so similar. Frankly a lot of the PrEP training programme that we developed for service providers was inspired and informed by what we did for female condoms. In terms of the attitudes, in terms of the biases, recognizing where people stand in terms of coming with their own baggage. Very, very similar. Dedicating that time and space for building provider knowledge in that training, and the skills on how to talk about female condoms so that they feel comfortable. Because people were not even comfortable taking the female condom out of its packaging. So they didn’t know what to do with them. “Oh we have these. We have about 30 that we put out on tables at times. But we really don’t want anyone to ask us questions about them because we can’t answer them.” So that’s really changed. We have agencies calling us telling us “We really want female condoms. Can you help us get them?” That’s been really exciting to see that demand going up. And that request coming both from agencies serving women as well as serving gay men.
We were just talking about PrEP. Obviously in the last few years the prevention landscape had changed quite a bit with the introduction of PrEP and what we know about undetectable viral load and treatment-as-prevention and a whole slew of other things that are in the pipeline as well. So where do you see female condoms fitting within that rapidly evolving HIV prevention landscape?
Female condoms are definitely still relevant and matter. Condoms are the only option that provides dual protection in terms of pregnancy protection and STI prevention, including HIV.
Even as the landscape is evolving, it’s important to have a range of options for different people at different times. Just like with PrEP, we’re not expecting people to use it for their entire life for every type of situation that they have. We look at the female condom in the same way. There’s times when people would want to use this and we want to make sure that they have the ability to do that. It’s like contraception. We have everything from IUDs to the pill to the patch to the shot. All these different things. We want the same thing for HIV and STI prevention. Female condoms fit there for pregnancy prevention as well. We want to make sure that they fit with HIV prevention. And they do!
The other thing is to look at the lessons from PrEP and female condoms and making sure that we’re talking about access and talking about comfort using this, whether it’s about PrEP or female condoms or microbicides. That all of these things are really linked. And I think that the lessons learned from female condom programming are relevant for PrEP programming and will be relevant for microbicide programming as well.
You alluded to some of the advantages of female condoms, including being effective against HIV, STIs and pregnancy, as well as some of the advantages of the material. What are some of the other advantages of female condoms?
One of them is pleasure! That is one of the biggest things. We always get bogged down in all the disease prevention pieces. And that’s great and important and matters. But people have sex because it feels good. And we want to be able to help them enjoy that even more. One of the ways in which we talk about female condoms is that the material conducts heat so it feels more like a natural environment, which is a good thing. It doesn’t feel like an unnatural material.
The other thing is that for vaginal sex the outer ring can stimulate the clitoris so that’s obviously enjoyable for the female partner. And then also the fact that for men who don’t want to wear a male condom and feel constricted, this gives another option for them. And then similar to PrEP, one of the things that feels good is that you’re able to do more for yourself and to take the initiative to protect yourself and not just rely on someone else to protect your health. That piece plays a role as well.
You mentioned the difference with where the condom goes and not wearing it on the penis. Is there evidence showing that it causes less problems in terms of loss of erection than a male condom?
I don’t recall if there’s specific data around that but it has been cited as a benefit. So you don’t have to fear losing an erection, because it’s not erection dependent. And that’s one of the pieces that’s really positive.
Right. It’s not going to fall off if you go soft.
Exactly. That’s exactly right. And you know, the fact that this is something that can be used for anal sex as well is really important, for women and for men.
That was actually the next question I wanted to ask you. Tell me about using them for anal sex. But also they’re sometimes called internal condoms. I know there are different names. I assume that’s part of the reason why. I was wondering if you could tell us a bit about that.
We don’t have data on safety and efficacy for using female condoms for anal sex. However, the National Female Condom Coalition and a number of other organizations promote it as a harm reduction strategy. It’s better to use something as opposed to nothing.
Simultaneously we’re seeking to advance a research agenda that says we need to look at the safety and efficacy of using this. But in the absence of that, we think it’d better to use something rather than nothing.
The FDA has not approved female condoms for anal sex. But then again the FDA has also not approved male condoms for anal sex either, which is important to keep in mind. There are a couple of things in terms of looking at the language used to describe female condoms. You pointed out some people use the term internal. Some also use the term receptive, partner-initiative, bottom condom… It’s an important conversation and one that is challenging.
There are two needs that we’re trying to meet here. One is that no matter the gender of the person you’re talking to, as you’re trying to make them aware of different options to reduce their risk, you want to make sure that they’re going to feel comfortable with whatever you’re talking to them about. You want them to see that the tool you put before them is something for them and not be turned off by any language that you’d use. That really matters and is really important for that purpose to use language like internal condom, receptive partner, bottom condom… whatever is going to resonate with them.
The other need is that we have the reality of the classification of this tool as a female condom. So if someone goes into a store or a clinic or a pharmacy where many of them don’t even know that there are female condoms to start, let alone if you’re asking for a bottom condom or an internal condom. I don’t know what the language solution is, but think as advocates we must continue to work to figure it out. We want to talk about this in a non-judgmental way, but then at the same time there’s the reality that if you’re going in to buy something, you need to know what it’s called by the name that’s known.
I think there’s also a marketing question there for the company, which obviously is not a very large company compared to many others, like male condom companies. But the very same product could be packaged to target different audiences. So if you’re reaching for something called the female condom and it’s pink packaging with pink flowy lettering, maybe that will appeal to some people, but not to others who might otherwise have used it.
Right. And one of the things is that in the US they have rebranded the product. So it’s purple with orange and yellow. The packaging is warmer, more appealing, and much more gender neutral. It doesn’t have a big women’s symbol on it that’s pink. It says FC2 and then in small print it says female condom, which I think is helpful. But the thing is that the FDA classification of this device is that of a female condom. So because of that the company has some limitations. Having them change the packaging so it’s not so gendered was a huge feat.
One last question I had and I know this is the cause of much debate and controversy, but can they be re-used?
No. They should not be re-used. They’re a single use product. They are not to be washed out. There was guidance that was released several years ago that yes you can, but really you shouldn’t. They are approved for one use. Do not re-use it. It does not hold up.
That’s it for my questions. Anything else you think we should add?
The other thing is advocacy work. There’s a Global Female Condom Day on September 16, a dedicated day of action People taking to the street to make female condoms more visible. It’s really taken off. We had more than 50 countries across the world participate this year, and we only launched it 3 years ago. People can also stay up to date on female condom research and development though the National Female Condom Coalition website and newsletter.
And hopefully we’ll have a National Female Condom Coalition in Canada as well. Thanks so much for talking to me. For more information, please check out: US National Female Condom Coalition How to use female condoms /