Once derided as being like plastic bag with the erotic appeal of a jellyfish, the female condom's being reinvented as the next big thing in safe sex. Emily Anthes investigates.
In 1987, an American pharmaceutical executive called Mary Ann Leeper flew to Copenhagen to get a firsthand look at what she thought might be the world's next great health innovation. She didn't expect to find it tucked away inside an old cigar box.
When she arrived at the old farmhouse owned by Danish doctor and inventor Lasse Hessel, he opened the door with a cigar in his mouth. Then he fetched the box. "Inside were all these bits and pieces – metal, plastic, all different kinds of stuff," Leeper recalls. "I took a deep breath and thought, 'Holy mother – what have I gotten myself into?'" Somehow, these bits and pieces fit together to form a contraption that women could wear during sex to prevent pregnancy and sexually transmitted infections – the world's first female condom. Female condoms: meet the ancestors
The presentation may have been unconventional, but Leeper and her colleagues at Wisconsin Pharmacal had high hopes for Hesse's invention. "The AIDS crisis in the United States was just fully being recognised, and it was clear to us that for women to have a product that they could use to help protect themselves would be a good thing," Leeper says.
Indeed, when Wisconsin Pharmacal finally introduced the female condom to the USA in 1993, public health experts hailed it as a game-changer. The condom, a polyurethane pouch inserted into the vagina before sex, would protect women from sexually transmitted infections even if their male partners refused to wear condoms.
Technically, the female condom works. When used correctly, it reduces a woman's risk of contracting HIV by around 94–97 per cent each time she had sex, according to estimates. Studies show that making female condoms available alongside the male version increases the percentage of sexual acts that are protected, and decreases the prevalence of sexually transmitted infections.
Yet, two decades after its much-celebrated introduction, the female condom still isn't living up to its potential. Less intuitive and familiar than the male condom, the device simply never caught on. Journalists mocked it, clinicians ignored it, and women shunned it, claiming that the condom was aesthetically unappealing and technically difficult to master. Today, only 1.6 per cent of all condoms distributed worldwide are female condoms.
There may finally be an opening to change the female condom's fate. For years, a handful of researchers, engineers and entrepreneurs have been quietly tinkering with the device. Their efforts are now maturing and an assortment of redesigned and reinvented female condoms are beginning to make their way onto the market. The introduction of new, more user-friendly products – coupled with renewed efforts to promote the technology around the globe – may finally be positioning the female condom for a breakthrough.
From the start, the female condom was a difficult project – far more difficult than Leeper had bargained for. After buying the rights to the technology, Leeper and her colleagues at Wisconsin Pharmacal needed to turn Hessel's prototype into a marketable product. After some tweaking, they ended up with a thin polyurethane pouch with a flexible ring at each end. A woman would insert the device by squeezing the ring that sits in the closed end of the pouch and pushing it into her vagina. Once expanded inside the vagina, this inner ring would keep the condom in place. The larger ring at the open end of the pouch would sit outside the vagina, covering the external genitalia. When a man ejaculated, the internal condom pouch would trap his semen, preventing pregnancy and sexually transmitted infections.
But before Wisconsin Pharmacal could put the condom on the market, they needed approval from the US Food and Drug Administration (FDA). Because the female condom was an utterly new kind of product, the FDA decided to regulate it as a class III medical device, a category that is generally reserved for high-risk medical equipment such as pacemakers and certain lasers that requires the highest level of regulatory scrutiny. (the FDA classifies male condoms class II devices, so they are subject to fewer controls do not require pre-market approval.)
It took six years for the female condom to wind its way through the regulatory system, and when the government finally approved it, in 1993, Leeper breathed a sigh of relief. "I thought that the hardest part was going to be getting it through FDA because it wasreally difficult and they kept changing the specifications, the requirements, the clinical studies," she says. But she was wrong. The hard part was just beginning.
As Wisconsin Pharmacal prepared to launch the Reality female condom in the USA (it would go by other brand names in other countries), they made all the standard arrangements, hiring sales reps to visit medical practices and commissioning a big advertising firm to market the product directly to consumers. "We did all the checklist things that you're supposed to do," Leeper says. "And we fell flat on our face."
The challenge, in part, was the era, and the public's squeamishness about a sex-related product. "In those days, you couldn't talk 'condom' out loud," Leeper recalls. "Male condoms were referred to as 'rubbers'. You said them in a whisper and they were held behind the counter by the pharmacist." And although the AIDS crisis was raging, for many American women, the risk of contracting HIV was abstract, something that happened to other people and not to them. While women in focus groups had said they liked the idea of the condom, according to Leeper, "when push came to shove, when they were in that bedroom, the female condom was out on the dining-room table".
There were other barriers, too. The condoms cost as much as $5 a piece, compared to male condoms, which can typically be had for $1 or less. Krissy Ferris recalls hearing about female condoms when she was a student at Oberlin College in Ohio, but the price was a deterrent. "I didn't actually try one until I got free samples," recalls Ferris, who now works at a medical practice in Cleveland, Ohio. "Am I going to buy $6 worth of condoms to try this out a couple times? It seems like maybe not. You're getting male condoms for free everywhere when you're in your 20s."
What's more, the female condom was, frankly, strange. Unlike the male condom, which is sold rolled up and compressed, the female condom came fully open. Women and men alike were turned off by the unfamiliar, big, plastic-bag-like device they found when they undid the packet. Though some women did eventually come to like the condoms, there was a definite learning curve and as many as one-third to one-half of women had difficulty inserting them. Once in place, the condom had a tendency to squeak or rustle during sex.
The media pounced on these complaints, and utterly skewered the female condom. They ridiculed its aesthetics with seemingly limitless creativity. As sociologist Amy Kaler recounts in her 2004 paper on the condom's introduction, journalists compared the product 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.'"
Though the media treatment was especially harsh, journalists "were picking up on what were genuine design issues of the first generation of the female condom," says Kaler, an assistant professor at the University of Alberta in Canada. "It wasn't the most beautiful thing in the world. It was easy to make fun of. It was kind of laughed out of existence before it really got a chance to take off."
Still, there were signs that Wisconsin Pharmacal was onto something. In 1995, two years after bringing the condom to market, Leeper got a call from an official at Zimbabwe's Ministry of Health and Child Welfare. The health worker had received a petition demanding that the government of Zimbabwe bring the female condom into the country. It had been signed by 30,000 women.
Though Leeper had initially envisioned selling the female condom in America's private sector, the call from Zimbabwe, coupled with the condom's poor reception in the USA, prompted the company to shift course.
International nonprofit groups and aid organisations have long been big buyers of male condoms. The United Nations Population Fund (UNFPA), the US Agency for International Development, Population Service International and others regularly purchase male condoms in bulk and then donate them – or sell them at a deeply subsidised price – to clinics and programmes that serve particularly high-risk populations.
In 1996, Wisconsin Pharmacal changed its name to the Female Health Company and began to focus on this global public sector, working with governments, global health organisations and aid agencies to get the condoms into the hands of at-risk women in low-income countries. The female condom became a particularly important tool in several countries in sub-Saharan Africa, where, in the early 2000s, 60 per cent of new HIV diagnoses were made in women, who often contracted the virus through their long-term partners.
Patience Kunaka, who was teaching nursing and midwifery students in Zimbabwe when she first heard about female condoms, knew these risks all too well. Two of her cousins had died of AIDS-related causes, and three additional family members were infected with HIV. Like many other women, she was not initially impressed by the female condom. "When I first saw one my immediate reaction was, 'Wow! How does it remain inside with penile movement?'" she recalls. "I thought it would be sliding in and out and what a messy act! I also thought the plastic would crumble inside me causing discomfort."
But Kunaka suspected her partner at the time of being unfaithful and was – in her own words – "obsessed about sexual hygiene", so she decided to give the female condom a shot. It didn't go well at first. "I had problems inserting it and felt discomfort from the inner ring," she says. Slowly, after some practice, she got the hang of it. Kunaka even came to like the device, especially "the fact that I don't have to beg my partner to use a condom".
She became a female-condom convert. "In my African context, where men are at liberty to have as many partners as they can have, they give me power to negotiate for safer sex," she says. She even went on to get a job as the condoms and training manager for Population Service International Zimbabwe, and now spends her days spreading the word about female condoms to men and women throughout the country.
The female condom received a better reception in Africa than it had in the USA, and as the Female Health Company sought to expand its global reach, it tweaked its original product, switching from a polyurethane condom to one made of nitrile, the same material used in many medical gloves. The nitrile condom, called the FC2, is significantly cheaper than its polyurethane predecessor, now commonly referred to as the FC1, and also less noisy during sex. In 2007, the UNFPA 'pre-qualified' the FC2, making it eligible for bulk purchasing by public-sector agencies, and between 2007 and 2010, the number of female condoms distributed globally doubled from 25 million to 50 million.
Not bad for a contraceptive device that's been likened to The Scream, but it's still a drop in the ocean compared to male condoms. For every female condom that the major donor organisations purchase, they buy 71 male condoms. And although female condoms have got cheaper, price remains a limiting factor. An aid agency purchasing the FC2 in bulk will pay anywhere from $0.55 to $0.88 per condom but can get male condoms for as little as $0.02 a piece.
In many clinics in low-income countries, the supply of female condoms can be inconsistent, and the situation's not much better in the private sector. While pharmacy shelves overflow with male condoms of every imaginable kind – ribbed, studded, ultrathin, warming, aloe-enriched, neon pink, glow-in-the-dark, bubblegum-flavoured – it can be difficult to find female condoms for sale at all.
In some places, the condoms are stigmatised, thanks to clinical trials and distribution programmes that initially focused on sex workers. Elsewhere, the devices are still saddled with the baggage of the product's first, failed introduction. In March 2013, for instance, a writer for Jezebel, a popular feminist blog and news site, published a post titled 'Stop Trying to Make Female Condoms Happen'. She expressed scepticism that "women will change their minds about wanting to line their vaginas like a waste paper basket", and concluded by noting that "female condoms are just ew".