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Picture: ISTOCK
Picture: ISTOCK

Think safe sex means boring sex? Think again — especially if you make internal condoms (formerly known as female condoms) part of your play kit.

SA has one of the largest public-funded condom distribution programmes in the world — between 2018 and 2022 the government aims to, each year, distribute 850-million male (or external) condoms and 40-million internal condoms to public health facilities.

But not enough people are catching on when it comes to inner condoms. Between the 2018/2019 and 2020/2021 financial years, the national health department dispersed only about 40% (16.3-million) of internal condoms annually, department figures show.

“We have more than enough stock to distribute 40-million internal condoms a year — our depots are full,”  the department’s director of HIV prevention, Thato Chidarikire, tells Bhekisisa. “But the community uptake at our clinics and hospitals is low and this affects the demand and distribution targets.”

For the workings of an inner condom — they’ve been available at public health facilities since 1998 —  think of the external version inside out, quite a bit wider and with a ring at both the closed and open ends. The inner condom is inserted either in a person’s vagina or anus before sex. The ring at the closed end, which is slipped inside the body, ensures that the device fits snugly (though people generally remove it for anal sex) and the ring at the open end (which is visible from outside the vagina or anus) keeps it in place during sex. 

The World Health Organisation (WHO) started to recommend internal condoms in 1996 to promote safe sex.

Internal condoms cost more, but also give women more control

Like an external condom (the male condom), the internal version is a dual barrier device, meaning it works as a contraceptive and protects against sexually transmitted infections (STIs) at the same time.

Though the WHO says internal condoms are slightly less effective than their external counterparts in protecting against pregnancy, they give women and transgender men significantly more control over their use, as they’re the ones wearing these condoms. 

Qualitative studies have shown that some women are able to use inner condoms, which can be inserted a few hours before sex, in situations where they cannot negotiate external condom use. For instance, because inner condoms don’t depend on an erect penis (male condoms do), they could be useful to women whose sex partners are under the influence of drugs or alcohol.

But inner condoms are quite a bit more expensive than their external counterparts. In the private sector in SA, for example, an inner condom costs about R17 (it can only be used once) and a standard Trust external condom about R4. In the public sector the price difference is even bigger: Chidarikire says the health department procures internal condoms at about R7.50 each and external condoms at 50c a condom.

Inner condoms are available for free at public health-care clinics.

We have more than enough stock to distribute 40-million internal condoms a year — our depots are full
Thato Chidarikire

So why the fuss? Why not just stick with male condoms?

Just like with contraception, condom research shows that the more condom choices available, the more likely people are to use condoms. One study found the chances of someone getting STIs such as gonorrhoea or chlamydia drop by more than a third when they have access to both external  and internal condoms and can pick which one they fancy.

Not having one of these STIs also reduces a person’s risk of getting infected with HIV.

Why aren’t there more people using inner condoms?

Around the world, the higher price of internal condoms (vs external condoms) plays a role in their reduced uptake — private health-care users in SA, who would have to pay for condoms, likely experience this as a barrier.

But there’s more.

For instance, though inner condoms are free at state health facilities, many people simply don’t know where to find them, a 2018 evaluation of the country’s government-funded inner condom programme found. External condoms are far more available than inner condoms at government facilities, especially in waiting areas (outside consultation rooms).

The assessment’s authors say this means the uptake of internal condoms therefore strongly relies on health worker promotion and their willingness to offer such condoms to their patients and to explain how they work.

But this was hampered by the fact that just over a third of health workers who participated in the study, and who were trained on how to use inner condoms, had never used the condoms themselves — and had questionable attitudes towards them: some (40%) described inner condoms as “weird”, “messy”  (42%) or “inconvenient” (28%). 

When patients did ask for inner condoms, and health workers had to explain how they work, equipment was often lacking: for external condom demonstrations most facilities (78%) had access to dildos, but only 22% of the sites had pelvic models they could use to show how inner condoms work.

So it’s not surprising the evaluation found that though nine out of 10 people interviewed had heard of inner condoms, only two out of 10 had tried them. Only two-thirds knew that they could ask for them at their clinic or health facility.

Enjoying sex safely forms part of what keeps us sexually healthy, because it adds to our emotional and social wellbeing

Why inner condoms can spice up your sex life

Some people don’t like that to use an inner condom well takes some practice. But once past the “getting used to it” period,  people say that they kind of like inner condoms. Like, a lot. Of nearly 600 women asked during the SA evaluation, almost 90% said their partners liked it after having used it for a month. And after six months, almost all the partners were on board. In fact, three-quarters of partners said they found the inner condom “better or much better” than the more well-known external condom.

Why? Because, users say, the condom is made of a thin, soft-feel material, with some types becoming even more pliable when it heats up to the body’s temperature. The thin material makes sex feel more natural. There’s also no tightness around the penis (as in the case of using the external condom), it comes with lube, the outer ring can give the clitoris an extra tickle for added pleasure and the inner ring can stimulate the tip of the penis.

How do we fix the low uptake?

So how, in a country with more than 200,000 new HIV infections, one in five unplanned pregnancies and a government programme that is set to distribute 40-million inner condoms this year, do we get better uptake?

In addition to better equipping health workers and increasing availability, we believe the messages we use to promote condoms need to change. Slogans that focus on using condoms to make sex less “risky” or stay away from it altogether (think “No glove, no love” or “Be wise, condomise”), instead of encouraging people to explore the pleasure of sex safely, constrain frank discussions about sexual health and wellbeing in a society that has traditionally seen talking about sex as taboo

The internal condom has a place in turning this thinking around.

Pleasure = power

Ideas of pleasure and choice are rarely at the heart of conversations about sexual health. We’re often taught not to prioritise our pleasure, sending the message that there is something wrong with enjoying sex, asking for it, or deciding for yourself what sex and pleasure look like.

Yet sexual pleasure is considered a sexual and reproductive health right, which the World Association for Sexual Health says is the “human right pertaining to sexuality”. Enjoying sex safely forms part of what keeps us sexually healthy, because it adds to our emotional and social wellbeing.

So rather than focus only on functionality and risk, we, like several other public health advocates, say we should add pleasure to the mix to teach people how to protect themselves.

To make that transition easier, the Global Advisory Board for Sexual Health & Wellbeing has developed a training toolkit to help start the conversation. Part of the toolkit is the Pleasuremeter, which is a chart that maps how much people think things such as safety, confidence, communication, physical satisfaction, expressing their desires, privacy and consent add to their enjoyment of sex. This gives health-care workers clues about what clients could be most comfortable discussing and what they might shy away from, and so makes it easier to get people to focus on the joy of sex to make it safe rather than looking only at risk. 

And there’s research to back this approach up. In February, an Oxford University study review, which looked at 33 sexual health projects that put pleasure and fun at the core of safe-sex messaging, found that programmes which eroticised condoms and made them sound like fun to use increased uptake.

Sexual pleasure should be a cherished part of our human relationships — when we incorporate it in condom messages, we make safer sex education more comprehensive and encourage people to talk openly about both their pleasures and risks and, in the process, increase their sexual agency.

Additional reporting by Linda Pretorius and Mia Malan

Tian Johnson is the head of the African Alliance. Pontsho Pilane is the head of communications at the Wits Reproductive Health & HIV Institute. Anna Matendawafa is the head of co-ordination at the African Alliance. Mamello Sejake is the advocacy and communications lead at the Noncommunicable Diseases Alliance

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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