Re-use of the Female Condom: Now for the Practical Realities

Female condoms are being re-used in programmes where women do not have access to or cannot afford new ones, or there is not a consistent supply. This has led to research into the safety of re-use of female condoms.¹²

Clinical guidelines on re-use of the female condom were released by the World Health Organization (WHO) in July 2002.³ The WHO protocol states that while a new condom is best with each act of intercourse, in situations where they are not available or affordable, evidence suggests that the structural integrity of the female condom allows it to be used at least five times, if the WHO guidelines are followed.

Re-use has become a central issue for individual users of female condoms and national programme managers and policymakers. Decisions on the content of guidelines for users need to be based on individual, community and national contexts. We are walking into a new, complex arena in which success or failure in reducing HIV and STD transmission may be affected.

The Female Health Foundation and JSI–UK have constructed an interactive website 〈www.reusefemalecondom.org〉 to enable sharing of knowledge and experience, so that organisations and policymakers can learn from each other and construct tools to help them. A web-based forum to discuss the new WHO programmatic guidelines on female condoms re-use was launched in July 2003.

The website covers issues such as access to bleach for cleaning female condoms, the practicalities of re-use and how to translate the protocol into a user-friendly format. There is both information specific to elements of the protocol and their practical application and case studies of re-use, cleaning, potential adverse effects of the diaphragm for family planning, syringes, menstrual cloths and sex toys. It points out the lack of any consistent guidelines for sharing and re-use of sex toys.

A risk hierarchy approach is being adopted with female condom re-use, that is, a hierarchy of suggestions for reducing risk is offered so that those at risk have more than one option for protecting themselves and their partners. This approach follows a long tradition in HIV prevention, which also exists for safer sex practices and re-use of syringes by injecting drug users. There are important lessons to be learnt from this history, especially in translating clinical protocols into practical steps most people can follow. For example, in the past, when certain protocols have been translated into user guidelines and tested, e.g. protocols for cleaning injection syringes, issues such as the ability to measure the amount of time specified for keeping the syringe in a cleaning solution, have affected how closely such guidelines were actually followed.

The website has facilitated some dynamic interactions, including postings about the risks of re-use of the female condom for male-to-male transmission, and the opposing argument that multiple partners within a short time poses the same risk of infection for the male partner from one of those sexual partners, but stops the risk of the female-to-male transmission.

Some have advocated for a harm minimisation approach and point out that having multiple partners and unprotected sex is more risky than having multiple partners with the female condom. One said:

“I remember when the objections to re-use first arose. They usually went like this: if a prostitute re-uses a female condom all of her clients after the one with HIV/AIDS would be exposed to infection. None of these people had complained about the re-use of the woman's unprotected vagina where subsequent clients would be exposed to infection. The important thing is that the woman is protecting herself. This is an incremental improvement in an imperfect world. Oftentimes, the woman is taking up use of the female condom simply because her clients refuse to use male condoms.” ⁴

Another felt that this was an irresponsible approach:

“I urge you to not forget the principle of dual responsibility embodied in prevention efforts. We should keep in mind that, even though the female condom is primarily aimed at protecting the woman, it brings about an obligation to protect our partners as well. Incorrect usage resulting in subsequent infection of another human being, male or female, cannot be justified.” ⁵

One key element of discussion is the need to recognise the realities of people's sexual lives and their own creativity in protecting their health with limited resources. The history of syringe re-use is an interesting example of how guidelines were created, and their consequences. The first protocols for syringe re-use involved bleach and water. Bleach was chosen for practical reasons—it was a household product and could be carried without suspicion by drug users. Now, however, when carried in small bottles, bleach has come to be associated by the police with drug use, leading to arrests, in much the same way as carrying condoms may be a grounds for arrest associated with sex work. Some agencies, concerned by this problem and opposed to the use of bleach, have complained that more research could have been carried out into alternative substances such as alcohol, hydrogen peroxide and iodine. And the use of bleach has turned out to be problematic in some settings:

“…Currently, …the unavailability of bleach, soap and often water poses a major problem. Also incorrect concentrations of these chemical agents have undesirable effects on women, a common example being thrush.” ⁵

Even if short-term problems like these are resolved, the fact that female condoms and syringes are expensive and hard to come by, and that they need to be re-used at all, raises questions in itself. Why is there a need for re-use? As well as supporting safe re-use, we must push to enable access to clean needle exchanges and new female condoms.

“Male and female condoms should be available to everyone who needs them when and wherever they need them. If cigarettes can get to the remotest corners of the earth, so can condoms.” ⁶

Meanwhile, the details of safe re-use are a necessary point of discussion. Hopefully, it will become a thing of the past when every woman or man who wants to use female condoms has access to new ones.