This article examines the efficacy, effectiveness, acceptability, and re-use of the female condom and reflects on the viability of the female condom as a method for family planning and STI protection. Effectiveness. Dr. Paul Feldblum of FHI discussed female condom effectiveness for preventing pregnancy and sexually transmitted infections. Rates of contraceptive effectiveness for all barrier methods, including the female condom, vary according to how well they are used.

The 12-month pregnancy rate for perfect (consistent and correct) use of the female condom is five percent, compared to the male condom at three percent, and the diaphragm at six percent. The 12-month pregnancy rate for typical use (an average experience of all users) is about the same as the diaphragm at around 21 percent but not as effective as the male condom at 14 percent. The female condom is approximately as effective a contraceptive method as the male condom, and seems more effective than vaginal spermicidal methods. For disease prevention, the polyurethane material of the female condom is impermeable to various pathogens, including HIV. But for the efficacy of the method to be translated into a beneficial health effect in populations, it must be used broadly and consistently; the level of protected sex must increase; and female condom use must augment but not replace the level of protection already achieved by male condoms. Two cluster-randomized trials that have examined the impact of female condom introduction on disease rates have produced conflicting results. One study conducted among sex workers in Thailand found that STI rates were lower among women who had been given the option of using either the female condom or the male condom, than among women who had been instructed to use male condoms consistently as usual. But another cluster-randomized trial, conducted in Kenya with 1,929 women of reproductive age employed at tea, coffee, and flower plantations, found no difference in the STI rates between women who received female and male condoms and women who received only male condoms. One other cohort study looked at the impact of alternative counselling messages and female condom introduction on levels of protection. The study, conducted with female patients in a Philadelphia STI clinic, showed slight evidence of higher rates of protected sex acts among women counselled on female condom use than among women who received counselling on male-condom use or women who received "hierarchy" counselling which promoted the use of male and female condoms, the diaphragm and cervical cap, spermicides, and withdrawal, in descending order of effectiveness against STIs. Dr. Feldblum concluded that the female condom is an efficacious contraceptive and prophylactic method, depending on consistency and correctness as with any barrier method.

Assessing the Female Condom

What is the degree of prOTection?

Is thEre an increase in the PRoportion of high-risk sex acts that are protected when the female condom is added to a male condom distribution system? Some trials have demonstrated an increase in the proportion of protected sex acts through interventions that encourage male and female condom use, teach necessary skills, and make condoms readily available. These studies have generally shown that most female condom users also use male condoms, i.e., they choose between one type of condom or the other for a given sex act.

What is the public health impact?

Does including female condoms in method mix lead to decreases in STIs and undesired pregnancies? Laboratory evidence and controlled trials have shown that correct and consistent female condom use reduces risk of pregnancy and STI transmission. Yet evidence is still insufficient to show that the incidence of STI transmission and pregnancies declines when female condoms are made available in wider-scale programs.

Does female condom availability or training in its use promote women's empowerment or sexual negotiation skills?

In conducting an investigation of empowerment in South Africa and Kenya in 1998, Dr. Amy Kaler uncovered different concepts of the term empowerment. The word can imply changes in gender relations, a concept most closely representative of sentiments expressed by feminists at the International Conference on Population and Development in Cairo in 1994. The second concept of empowerment is concerned with meeting the practical needs of women. In this framework, the female condom is assessed for its potential to help women avoid the worst aspects of heterosexual relations. The third concept is the zero-sum game this assumes that there's only so much power to go around, and if women gain power through female condom availability, men inevitably lose power. In this framework, anything that promotes women's empowerment is a threat to men. Studies assessing the effect of the female condom on empowerment require a clear definition of the term.

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