RESEARCH ARTICLES

Female condoms: difficulties regarding adaptation and strategies to make their routine use easier

Jaqueline do Espírito Santo Costa^I; Camila Daiane Silva^II; Vera Lúcia de Oliveira Gomes^III; Adriana Dora da Fonseca^IV; Daniele Acosta Ferreira^V

^INurse. Master's Graduate in Health Sciences Program, Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: jaqueline.costa@live.com.
^IINurse. Master in Nursing. Doctorate student of the Post-Graduation Program in Nursing. Member of the Group of Studies and Research on Gender and Society Nursing. Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: camilad.silva@yahoo.com.br.
^IIINursing. Doctorate in Nursing. Professor. Study group and Research Leader on Gender and Society Nursing. Tutor Program of the Tutorial Nursing Education Program. School of Nursing. Federal Ubiversity of Rio Grande. Rio Grande do Sul, Brazil. E-mail: vlogomes@terra.com.br.
^IVNurse. Doctorate in Nursing. Professor. Study group and Research Leader on Gender and Society Nursing. School of Nursing, Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail:adriana@vetorial.net.
^VNurse. Master in Nursing. Doctorate of the Post-Graduation Program in Nursing. Member of the Group of Studies and Research on Gender and Society Nursing, Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: daniele_acosta@hotmail.com.

ABSTRACT: This study aimed at investigating strategies to make the routine use of female condoms (FC) easier. Descriptive research among post-graduate students, senior Nursing and their partners, the Federal University of Rio Grande/RS. Data were collected from October 2012 to March 2013 by questionnaires that were answered anonymously. The analysis and the interpretation were carried out through the discourse of the collective subject. Respondents pointed out that woman’s autonomy and double protection were advantages of using female condoms whereas their high cost, little advertisement and difficulty in handling were obstacles. Main strategies were the manufacture of an applicator in order to make the FC easier to use, more advertisement, more knowledge on how to use it and the involvement of the couple in its use. Conclusions of the study highlighted that nurses must be able to problematize its use and spread information on this method so that this alternative can be applied to face issues of sexual and reproductive health.

Keywords: Safe sex; female condoms; health education; nursing.

INTRODUCTION

Data released by the Ministry of Health reveal the feminization of Acquired Immunodeficiency Syndrome (AIDS) epidemic. While the sex ratio in 1986 was 15 men for every woman, in 2002 this indicator amounted to 15 men to 10 women¹. One of the probable reasons which justify the new profile of the epidemic is gender inequality, that due to patriarchal patterns, triggers the lack of autonomy and the control of female sexuality, possibly resulting in serious implications for the negotiation of safe sex². Thus, although it is known that the condomVI is the only way to avoid transmission of Human Immunodeficiency Virus (HIV), their use goes far beyond the issues of protection. Focusing specifically on the male condom, it is a controlled method by men, it is difficult for women to negotiate their use³.

Despite these impasss the female condom (FC) presents clear advantages with regard to the freedom it provides to the woman to choose safe sex. Nevertheless, adherence to FC still remains low. In this sense, it is questioning the lack of familiarity of health professionals, both in use as a measure of personal protection and for the discussion of strategies to facilitate the adaptation of women to the routine use of the method.

Enfermeiros e demais profissionais de saúde possuem condições privilegiadas para advogar em favor do PF, auxiliando clientes na tomada de decisão sobre anticoncepção e métodos preventivos de IST’s⁴. No entanto, o pouco preparo para abordagem desse método representa mais um impasse⁵.

Nurses and other health professionals have a privileged position to advocate on behalf of PF, assisting clients in making decisions about contraception and preventive methods IST's⁴. However, little preparation to approach this method represents a deadlock⁵.

It is known that the repeated use and practice of the female condom reduces the problems encountered by women using it. Accordingly, when professionals have knowledge and feel comfortable in approaching the use of FC, they can increase the promotion of the method, contributing to their membership⁴.

We assume that nurses have practical knowledge about FC deficit, and therefore difficult to display it in the health education programs. Even assuming that familiarity with a method provides greater security and argumentative ability, this study took place in order to investigate the strategies that can be adopted to facilitate the routine use of FC.

LITERATURE REVIEW

The FC, also called female condom is a protective alternative that gives women freedom, autonomy and decision making power. It has the form of a cylindrical bag with two flexible rings, one fits the cervix and the other protects the vulva. It was originally released in polyurethane, but currently there is made ​​of nitrile rubber, a material that conducts heat better and emits less noise during lovemaking^6.7.

This method provides double protection, i.e. against Sexually Transmitted Infections (STIs), HIV and pregnancy⁷ and reduces the risk of allergic reactions, because it is produced with hypoallergenic material and dispose penile erection for placement. The female condom can even increase the pleasure of the user by the outer ring contact with the clitoris². These aspects highlight the potential use of the product and represent real advantages.

Concerning effectiveness, comparative study between male and female versions shows that the risk of seminal exposure are similar between them. The flaws with the FC usually are related to incorrect use. In this sense, the increase in frequency of use results in improving the ability of users⁸.

On the other hand, many can be barriers to the use of this method, including its appearance, sometimes described as grotesque; restricted dissemination; the high price that hinders the acquisition; and ignorance, that many women have about anatomical and functional aspects of the organism itself and the difficulty in touching their body². Likewise, the sparse distribution remains an obstacle to the routine use of the female condom. Comparing the distribution of the male version, it is evident that while in 2005 were made available worldwide six billion male condoms, the number of FC reached only 14 million units⁹.

Thus, strategies must be devised to both discuss prejudice, as to facilitate the accessibility of it, including the implementation of sexual and reproductive health programs and policies².

METHODOLOGY

This is a descriptive study with a qualitative approach. Informants were students of the Graduate Program in Nursing (PPGEnf) and graduates of the Undergraduate Nursing, School of Nursing (CGEEnf) of the Federal University of Rio Grande (FURG) and their partners.

For the development of the instrument, two pilot studies were conducted. In both informants were students of the fifth semester of the CGEEnf, together with their partners. In the first, couples fill out forms and set out to discuss the issues and suggest more clear and objective forms of writing. After adjusting, the new pilot study was conducted with two other couples. At this stage, the instrument was adequate to the collection.

After release of the coordination of both courses, we performed, in the classroom, the invitation to participate in the research. The agreement was expressed by signing the Informed Consent Form (ICF), when receiving an envelope containing another ICF to be signed by the partner, two FC and two semi-structured forms that should be answered individually, one for them and one for each partner.

The forms were divided into three stages, corresponding to different times. At first we tried to grasp the opinions of the couples about FC, even though they had never used it. The second and third steps were fulfilled after intercourse protected by FC. It was requested that the placement of the FC in the second stage, occurred immediately before the sexual act and third with at least one hour in advance. In them, it aimed to investigate the facilities, difficulties and strategies adopted to facilitate the use of FC.

After completing the instruments, they were delivered in sealed envelopes to the researcher. To derail the identification of the informants, envelopes were opened only after the completion of all data collection. This lasted five months, starting in October 2012 and ending in March 2013. 50 envelopes were distributed, getting back only¹⁶.

The collective subject discourse was the technique adopted for the analysis and interpretation of data. This method, like a puzzle, tries to reconstruct, with chunks of individual speeches, speeches synthesis necessary to express a certain way of thinking or specific imagery about a phenomenon¹⁰. Fictitious names were given to the interviewees' speeches, feminine speech (FS) and male speech (MS). The Research Ethics Committee of the Health FURG area under Opinion No. 36 /2012 approved the study.

RESULTS AND DISCUSSION

Informants were 16 couples, aged 21 to 43 years OLD, where in eleven of them, one partner was student of Graduate and five, one of them was a nurse. All study subjects had sexual intercourse with steady partners. Only one man had used FC before participating in this study and among women, no one used it before. The lack of familiarity with the method was also evident among nursing students of Fortaleza, Ceará, where over 90% of the subjects had never used FC¹¹.

The results were grouped into three categories contemplated that the opinions about the FC, the difficulties associated with their use and strategies to facilitate its routine use.

Opinions about FC and its placement

In this category we tried to grasp the perceptions and impressions of the informants' experiences and prior knowledge, i.e., before the first intended use in research. Thus, theoretically speaking FC, the participants show positives and negatives point of view.

I never used it, but I know that is a safe, practical and effective method that provides greater autonomy and decision-making about the use of condoms. It prevents STIs and prevent unwanted pregnancies. It has advantages such as the ability to be placed up to eight hours before intercourse, without diminishing the effectiveness and gives opportunity go prepared for the meeting. However FC is more expensive than the male and seems to be uncomfortable mainly because I still have no practice for the placement. Also, I think it should be weird to be with one of the hanging rings, covering the vulva. I believe that condoms come loose and this should reduce the sensitivity. (FS)

Also, participants recognize that although this is a practical, efficient, safe and feasible method, there is a certain bias.

I think it's more practical and would be a great choice for protection because it seems to be an efficient, safe and feasible contraceptive method facilitating a woman to exert its protection against HIV and STIs with more autonomy. However, I have the impression that their use should be uncomfortable, being strange and perhaps lessen the pleasure. I actually have some prejudice about female condoms, as well as be aesthetically something that does not call attention to the use, I think its use should not be complicated. (MS)

It is noticed that men and women share similar views regarding FC. They have theoretical knowledge on the subject, mention the advantages described in the literature¹² as that provided security, increasing the capacity of women to negotiate a method of protection against HIV, other STI's and unplanned pregnancy. Moreover, they mentioned erroneously as an advantage, the possibility of placing the FC up to eight hours prior to sexual intercourse, which was shown to polyurethane condom, manufactured previously to the current condom nitrile no indication of time.

However, the disadvantages are also evident, including aesthetics, focusing on the size and structure of the FC, which could influence negatively the appearance of female genitalia and even repel sexual desire. Lack of practice for placement and high cost are also cited as drawbacks. These perceptions reflect a lack of familiarity with the FC that was also shown in other studies through expressions of estrangement with respect to the method^2,3.

The advantages described by the couples were centered in sexual intercourse. Thus, ten men reported higher sensitivity, protection, comfort compared to the male condom and autonomy afforded to women. Thirteen women mentioned as benefits of using FC protection conferred by the outer ring to cover the vulva, increased sensitivity and female autonomy given by the method. In this sense, the participants admit that FC is an effective method and brings comfort to the man when compared to the male condom and can also provide pleasure and protection to women.

The FC is more pleasurable compared to the male version, and provide comfort and sensitivity during sexual intercourse. It is an effective means of protection that allows independence to women to decide about their use. (MS)

I realized advantages as the possibility of putting an hour before the intercourse, so it does not break the “climate” and also it gives greater autonomy to the woman, who can decide on the use of condoms. In addition, FC stimulates the clitoris, enhancing the feeling of pleasure and also it highlight the protection afforded by the external ring against sexually transmitted diseases, as the vulva is covered during intercourse. (FS)

Difficulties were divided in placed it and in sexual intercourse. Difficulties in placing the FC were observed both when the women introduced immediately before the sexual act, as when introduced with at least one hour in advance. In addition, it was analyzed the difficulties related to the protected sexual intercourse with the FC. Regarding the placement of FC opinions were quite diverse, while eight women found difficulties, one did not answer and seven did not report any difficulty, on the other hand, they did not explain the facilities. At this stage, seven partners were involved. Only one informant reported difficulties in removing the condom, but she did not described it.

Specifically regarding the placement of the FC immediately before intercourse, women said it was a difficult task and the men were not involved in placing the FC, but they believe to be easy.

I had trouble inserting it, the excess lubricant in the condom slipped between the fingers, beyond the inner ring is slightly malleable. Because it was the first time I used, I felt a little pain and discomfort. I had some doubts about the correct position, I did not know if the part that is inside the vagina was well positioned, I confused the way is explained the placement of the inner ring on the packaging. (FS)

I only watched the placement, did not participate. Consider this factor an advantage because it does not need to worry about this step, which was performed by my partner. (MS)

The men who participated in the placement of the FC had very similar reports to those of women reports, so we opted to bring only the speech of those who did not participate in this phase.

It is noticed that one of the main obstacles highlighted during placement, was the lack of familiarity with the method. This factor led to insecurity and discomfort during placement of FC. The excess lubricant on the outside, touted as a benefit by improving vaginal lubrication in menopausal women², was described in this study, as an obstacle to hinder the handling. Study conducted in the Dominican Republic also cites excessive lubrication as a factor that increases the difficulty of placing the FC¹³. The instructions on the package, as well as its illustrations were described as inadequate or little enlightening. It also indicates that the safe handling increases with continued use of barrier methods. This was evidenced in a study with a group of women. In it, the number who did not feel confident in the insertion of FC decreased from 5% to 0% over 5 months¹³.

Regarding the placement of FC at least one hour before sex, women admit feeling uncomfortable with it.

I felt strange, it was uncomfortable to sit on the couch or chair using the FC, it was horrible because the outer ring is large and causes discomfort in touch with the panties. After placing it bad to move around and at the time of intercourse noticed that the lubrication of the condom was impaired. However with the passage of time it was greater adaptation condom vaginal canal. (FS)

It was evident that the difficulties encountered when putting the FC, with a minimum of one hour before the sexual act, are mainly related to structural aspects such as the size of the outer ring, a fact that makes the use of nasty and uncomfortable. It is cited also the reduction in lubrication arising from longer advance in the placement. The use of a method routinely debunks taboos related to its use, since with continuous management women feel safer and gradually find fewer difficulties in their practice¹⁴.

During intercourse protected by FC, 13 men and 10 women reported difficulties related to the use of condoms, one participant did not answer the question. The highlights issues were difficulties in penetration, positioning restrictions, feeling of discomfort and feelings of shame and insecurity.

I felt quite uncomfortable and pain at times. During penetration I was afraid she left little to be lubricated in part that is in contact with the penis. To position change is sometimes difficult to hold the outer ring and the fear is that this is internalize the vaginal canal, or is misplaced. I found it difficult to restrain it during sex and shame felt by the unattractive appearance. (FC)

I had difficulties in penetrating therefore I had to be careful and hold the outer ring, to not let it penetrate together. I felt that the FC does not bring security in use and can leave at any time, as actually occurred. Moreover, the small internal lubrication, it decreases sexual pleasure. (MS)

It was evident in the speeches that using the FC, the relationship lost spontaneity, because there was concern about the position of the outer ring, with the correct penetration inside the FC, in addition to feelings of shame and embarrassment about the appearance of genitalia covered by the condom. Contrary to the opinion of the informants, in Ceará study concluded that there are no restrictions to sexual positions while using FC³. Statistically proved the reduction of 7% to 2.5% in the number of failures as internalization into the vaginal canal and rupture displacement with increasing frequency of use¹⁴.

Strategies to facilitate the routine use of FC

It was asked to the couples to suggest strategies to solve or alleviate the difficulties encountered with the use of FC. Among the suggestions obtained the importance of increasing the release of FC were highlighted, providing greater familiarity with the method, besides the complicity between couples, i.e. the involvement of both in all stages, including the placement of FC.

First we need to know all the steps of the placement, i.e., to know how to use it. Then ask your partner to help, including the placing of condoms during foreplay and creating an atmosphere of seduction. I think that would solve this issue creating a applier, like those used for tampon. It also would aid the inner ring were smaller and more flexible, and the amount of lubricant on the outside of the condom is reduced. Their placement should be taken just before sexual intercourse, since the prior sexual stimulation vaginal lubrication that also generates placement assistance. Also, I think it facilitates if standing with one leg resting in bed or in front of a mirror. (FS)

The stimulus partner was present in female speech as a tool facilitating the placement of FC, providing close contact and making it more enjoyable. Of the 16 partners, subjects in this study, only seven participated in the placement of the FC. In a study published in 2009, the size of the FC is also cited as a negative aspect of their use¹³.

Concerning the strategies to remedy the perceived difficulties in sexual intercourse, men and women expressed similar views, so we chose to illustrate this category with a single speech to contemplate the opinions of both.

I believe that the routine use becomes more familiar appearance, ease handling and reduce the insecurity generated face of new situations. FC could be narrower and lubricated on the inside. Also, I think the manufacturer should increase disclosure of FC and improve its appearance making it more enjoyable. During the relationship would help if the condom would remain in place without the need to hold it. (FC) (MC)

During the sexual act, the main difficulties reported were related to lack of familiarity with the method and causes estrangement, although at least one of the components of the couple belong to healthcare. It is noticed that about desire, sexual intimacy, new contraceptive alternatives, regardless of profession or education, there are obstacles that end up inhibiting the acceptance of something new in the relationship. In this sense, a study conducted in the metropolitan region of São Paulo found that the lowest rate of adherence to FC occurred among women with high education¹⁵.

Another study with university professors concluded that they did not perceive themselves vulnerable to STIs, and so they adopted risk behaviors such as infrequent condom use and multiple partners¹⁶.

One of the strategies cited most frequently by subjects was related to increased use and disclosure of FC, expanding, therefore, familiarity with the method. However, when asked whether they would embrace the FC routinely, only one woman responded affirmative. The main reasons for non-use included, partner's refusal, stable relationship, the partner discomfort and high cost compared to the male version. Research published in 2006, cites a stable union as one reason for 62.3% of couples stop using condoms¹¹.

With respect to disclosure, even observing the purchases and increase visibility of the FC, it is known that it is still necessary to consider aspects such as lower prices and consequent increased access to input¹⁷.

CONCLUSION

Although this is a group with knowledge of human anatomy and physiology, there were obvious difficulties for the use of FC. Concerning the FC, the main criticism was the excess external lubrication, which complicates the handling and lack of internal lubrication which hinders penetration.

Cultural issues linked to gender were focused, we know that gender inequalities originate largely touted the values ​​of a patriarchal society such as male superiority, which keep men in a position of power in relation to women, controlling them and repressing their experiences of sexuality. It is in this sense that it is reinforcing the importance of contraception as the female FC, which empower women by facilitating their autonomy, especially as regards the choice of safer sex and dual protection.

Nurses as professionals responsible for conducting health education, including family planning programs and prevention of STIs, need to be familiar with this method to discuss their use and expand its outreach, providing women an alternative to coping with issues associated with its sexual and reproductive health.

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