Female (internal) condoms were hailed as a method that gave women control over their disease protection. But one factor was overlooked: Women’s reproductive health decisions are influenced by male partners. A recent study revealed that having a partner with positive attitudes toward the female condom was associated with greater odds of women using the female condom.¹

“Although the female condom is a method theoretically enabling women’s sexual agency and bypassing the need for partner involvement, women still orbit under the influence of men,” says Joanne E. Mantell, MS, MSPH, PhD, professor of clinical medical psychology at Columbia University Irving Medical Center in New York City. “Despite the hyperbole of women’s control of the female condom and other prevention technologies, in some contexts, women prefer to inform their main partner of their precautionary measures.”

Family planning providers should not underestimate how important male partner involvement and support are to sustained female condom use, says Jennifer Ann Smit, PhD, executive director of the MatCH Research Unit at the University of the Witwatersrand in Durban, South Africa.

“Communication with partners is a quintessential feature of healthy sexual relationships,” Mantell adds. “Some women may feel compelled to disclose female condom use to their main partners out of fear that their partners would find out and accuse them of infidelity if they used the method covertly.”

The study divided female university students in South Africa between those who participated in a one-session, information-only, group-delivered minimal intervention and those who participated in a two-session, group-delivered enhanced intervention.¹

Most of the study participants were in heterosexual relationships. Ninety-six percent reported having a main sexual partner, Mantell notes.

“Participants had an average of 2.4 sexual partners in their lifetime,” she says. “Partners were, on average, four years older (24 years old) than the average age (20 years) of the study participants.”

Both interventions focused on safer sex practices and reducing HIV and sexually transmitted infections (STIs). This is how the interventions worked:

Minimal intervention. This 60- to 90-minute group session included information about personal vulnerability to disease and pregnancy, and ways to address these risks and handle problems, Mantell says.

It also covered the female condom’s protection against HIV, STIs, and pregnancy. It showed women how to use, insert, remove, and dispose of female condoms. The education compared the effectiveness and use of male (external) condoms and female condoms.

Participants also received a brief review of the female reproductive system. Researchers used a pelvic model to demonstrate how the female condom was inserted, but they did not practice insertion on the model, Mantell says.

“Participants’ perceptions of the female condom and anticipated problems with use were elicited during the session,” she says. “The intervention also sensitized women to the potential for partner abuse and provided guidance on assessing signs of potential abuse and risk mitigation strategies. Women were cautioned about possible dangers of initiating male condom or female condom use in the presence of these signs and were provided with referral sources.”

Enhanced intervention. The enhanced intervention included two group sessions that lasted four to five hours. These were grounded in social learning theory.

“It included the same information as the one-session minimal intervention, but also covered partner negotiation, skills in inserting and using the female condom, and personal goal-setting regarding HIV and pregnancy prevention,” Mantell explains.

Mantell describes the main tactics covered in the enhanced intervention:

• Obtaining and maintaining a condom supply;
• Having condoms for use when needed;
• Negotiating female condom use with partners in a way likely to succeed;
• Overcoming objections, resistance, refusal, and violence that might be encountered;
• Using male condoms correctly;
• Using cognitive restructuring, behavioral rehearsal, and structured practice with feedback techniques;
• Increasing positive expectancies for female condom use by fostering positive peer norms;
• Providing encouragement and reinforcement through group social support.

“Women in both groups were given a supply of 10 female condoms and 10 male condoms,” Mantell says. “The interventions were facilitated by study staff with nursing or social science backgrounds, trained and experienced in group facilitation.”

To avoid contamination across the trial’s arms, each of the interventions was delivered by a different interventionist. “The added strength of the enhanced intervention was the opportunity for learning of skills to negotiate female condom use with partners and skills in insertion and use of female condoms,” Smit says.

This provided the young women with the confidence to try female condoms and to overcome barriers to use, she adds.

“For me, the main strength of the enhanced intervention approach was that it allowed discussion and debate amongst peers and an opportunity to hear the views of peers and ask questions of facilitators and trained study peer educators, who also were students,” Smit says.

If the same trial were held in the United States, the findings might vary because context matters, Mantell and Smit say. “I believe that findings might differ across countries dependent on gender norms, women’s empowerment status, culture, and socioeconomic status of women, including education and employment income,” Smit explains. “In countries like the United States, university students may be less influenced by partner attitudes to female condom use. However, since use of the female condom requires male partner knowledge of female condom use and cooperation in its use, positive partner attitudes may well be found to facilitate female condom use.”

REFERENCE

1. Mantell JE, Exner TM, Bai D, et al. Perceived male partner attitudes toward the female condom predict female university students’ use of the female condom. Int J STD AIDS 2020;31:753-762.