- What are the advantages and drawbacks of female condoms for men who have sex with men?
- What future research and development should be done regarding the use of female condoms for men who have sex with men?
Key take-home messages
- Men who have sex with men who have used a female condom often complain of irritation, bunching up, unpleasant texture, noise, discomfort upon insertion, lack of pleasure, slippage, breakage and relatively high cost.(1-4)
- Men who have sex with men have also cited increased sensitivity and flexibility, spontaneity and ease of use, increased comfort, and the perception that they were stronger and safer (1;4) as reasons for using a female condom.
- Further work is needed to modify the design of the female condom to optimize it for anal sex and to identify its efficacy for HIV and sexually transmitted infection prevention among men who have sex with men.(2;4;5)
The issue and why it’s important
In Canada, gay, bisexual and other men who have sex with men continue to be the group most affected by HIV. Unprotected anal intercourse continues to be primary mode of HIV transmission among this group.(4) The use of condoms and lubricant is recommended during anal intercourse to reduce the risk of HIV transmission.(1;5;6)
While a lot is known about male condoms and HIV transmission, there is very little research on the efficacy of female condoms for men who have sex with men, even though some men may be using female condoms during anal sex.(1-5) It may be possible that redesigning the female condom specifically for men who have sex with men could increase its use among this group and lead to a reduction in the transmission of HIV and other sexually transmitted infections.(2;4;5)
What we found
Unlike the male condom, which is usually made of latex, the female condom is made up of two rings (the inner ring is sometimes removable) on both sides of a polyurethane (or nitrile) pouch. Polyurethane is perceived as stronger than latex;(1) it also produces fewer allergic reactions.
The female condom most widely cited in the literature is the Reality condom, which was approved for vaginal use in 1993.(1) There has been some research showing that, when used during vaginal intercourse, the female condom is as effective in preventing sexually transmitted infections as the male condom; however, there is no data on its efficacy during anal sex.(5) Despite the lack of research, some men who have sex with men are using female condoms for risk reduction.(1) Some health care providers in the US are recommending female condoms to their gay clients and numerous websites offer instructions on how to use them for anal sex.(5)
One of the biggest proponents of the female condom is the “FC2 Movement,” a peer-driven and community-based organization in San Francisco. Its goal is to make FC2 female condoms accessible to everybody in San Francisco free-of-charge. The FC2 Movement believes that safer sex will increase with the introduction of the female condom; their logic is that more choices will lead to more protective sex acts.(6)
While some community advocates are lobbying for their wider distribution,(1) others say that the use of female condoms during anal sex should be evaluated for its efficacy and safety before being widely promoted.(2)
Prevalence of female condom use
Prevalence of female condom use varied among the studies and populations. In an off-label study of female condom use for anal intercourse among men in New York City,(3) 17% had used the female condom for anal intercourse; of these, 89% had used the female condom with male partners, 21% with female partners, and 11% with both. According to the San Francisco study, approval rates for female condoms were higher for those at higher risk of transmitting or acquiring HIV including: HIV-positive men, men in non-monogamous relationships, and men with sero-discordant partners.(1) In a six-city study in the US, men with HIV-positive partners were twice as likely to use the female condom as men with HIV-negative partners or partners whose status was unknown.(2)
In one San Francisco Bay Area study,(6) free kits containing two Reality condoms, instructions, a self-administered anonymous questionnaire and a return envelope, were distributed to men who have sex with men. The survey was designed to gauge both positive and negative feedback on female condoms. Among those who returned the questionnaire, the feedback was positive:
- 86% of respondents said that they would use the Reality condom again.
- 54% said they preferred it to a male condom.
When asked what they liked about the female condom, the men cited:
- increased sensitivity and increased flexibility
- the spontaneity allowed for by female condoms
- the fact that inserting the condom did not require an erection and that it can occur before sex
- the fact that a female condom allows the receptive partner to be in control of his own protection.
Another study based in Seattle (4) compared male and female condoms in terms of safety (i.e., slippage, breakage, inflammation and bleeding) and the degree to which men would find them acceptable for future partnerships. The study population consisted of 56 monogamous, HIV-seroconcordant gay couples, all of whom had not been using condoms regularly over the preceding three months. For the first six weeks, couples were given 10 condoms, either male condoms or the Reality female condoms; for the second six weeks, they were given the other type of condom. After each six-week period, participants filled out a questionnaire. Those who preferred the female condom (20%) said it was easier to use and more comfortable. They also perceived it to be stronger and safer than the male condom.
In the San Francisco study, men identified the following negatives about using a female condom during anal sex:
- difficulty or discomfort when inserting or removing the condom
- its high price (~$10 for a pack of three)
- complaints such as irritation (17%), bunching up (12%), unpleasant texture (10%), noise (9%) and breakage (1%).(1)
In the Seattle study, (4) there were reports of rectal bleeding associated with female condom use. Because of the risk of HIV transmission associated with blood, this fact highlights the importance of evaluating the safety and efficacy of the use of female condoms during anal sex.(4)
In the six-city study, 2,277 participants (all men who have sex with men) completed questionnaires that asked about female condoms and their use.(2) Forty-eight percent (n=1084) of respondents had heard of the female condom and 13% had used it in the past six months. Both receptive and insertive users reported problems with their use:
- 49% of receptive users reported problems such as pain, discomfort or lack of pleasure, difficulty with insertion and difficulty keeping it in place
- 37% of insertive users reported problems, mainly related to lack of pleasure. Some found that, when the inner ring was removed, insertion became difficult and the condom did not always stay in place.(2)
According to the Seattle study,(4) the main issue with the Reality condom was slippage: 76% of receptive partners and 90% of insertive partners reported slippage, compared to 21% and 26%, respectively, of users of the male condoms. Those preferring the male condom cited ease of use, higher level of comfort and lack of slippage as positive factors.(4) In terms of willingness to use either condom in the future, far more people were willing to use the male condom than the female condom. With a partner of unknown HIV status, 21% of receptive partners and 26% of insertive partners were willing to use the Reality female condom in the future, compared to 61% for the male condom among both receptive and insertive partners.(4)
A redesign of the female condom could increase its acceptability among men who have sex with men and could address any safety concerns.(2;4;5) As the female condom is the only alternative to the male condom at the current time, it should be properly evaluated for its safety and efficacy during anal sex before it is widely promoted.(2;5)
According to one report, the lack of research and consistent messaging has relegated use of the female condom for anal intercourse to a subject of conjecture, contradiction and potential misinformation –rather than one based on sound scientific evidence.(5) Once the female condom has been redesigned for anal use and evaluated, marketing of the product should take into account the diversity of potential users, in terms of gender and sexual orientation.(5)
Future research should explore:
- the current prevalence of female condom use among men who have sex with men
- whether opinions on its use vary based on whether the partner is insertive or receptive
- whether the acceptability of the female condom varies based on ethnicity
- whether using a female condom and a male condom at the same time would provide even greater protection.(1)
The ORIGAMI Anal Condom
In addition to using female condoms for anal intercourse, research is currently underway to develop condoms specifically designed for anal use. The Fenway Institute in Boston, with the support of the Bill and Melinda Gates Foundation and the National Institutes of Health, started enrolling men who have sex with men in a new clinical trial studying condoms for anal sex.(7-9) The new ORIGAMI Anal Condom is the first condom of its kind – designed exclusively for receptive anal intercourse. It is worn internally by a receptive partner and is intended to facilitate a pleasurable and safe experience for both partners, increase its acceptability, improve sensation and comfort, and influence consistent condom compliance for those who engage in anal intercourse. It is also intended to minimize the risk of contracting HIV and sexually transmitted infections and to provide a receptive partner with the initiative to use a condom without negotiation.(9)
What we did
We searched Medline, PsychInfo and Embase using a combination of keywords (female condom*) AND [(men who have sex) OR (gay) OR (homosexual)]. We also conducted Google search using keywords (female condom). All searched were limited to studies conducted in high income countries and published since 1996 in English.
Factors that may impact local applicability
A limited number of papers were available on this topic – resulting in only a small number of studies included in this review. There is no conclusive scientific evidence of the effectiveness and safety of using female condoms, during anal intercourse, for preventing HIV or other sexually transmitted infections. Furthermore, female condoms have not been approved either in the US or in Canada for anal sex.(3;5) This limitation should be taken into consideration when interpreting the findings. In addition, all of the studies referenced in this Rapid Response were US-based and can therefore not necessarily be applied to the Canadian context.
- Gibson S, McFarland W, Wohlfeiler D, Scheer K, Katz MH. Experiences of 100 men who have sex with men using the Reality condom for anal sex. AIDS Education and Prevention 1999;11(1):65-71.
- Gross M, Buchbinder SP, Holte S, Celum CL, Koblin BA, Douglas JM, Jr. et al. Use of reality “female con-doms” for anal sex by US men who have sex with men. American Jour-nal of Public Health 1999;89(11):1739-41.
- Kelvin EA, Mantell JE, Candelario N, Hoffman S, Exner TM, Stackhouse W et al. Off-label use of the female condom for anal intercourse among men in New York City. Amer-ican Journal of Public Health 2011;101(12):2241-4.
- Renzi C, Tabet SR, Stucky JA, Eaton N, Coletti AS, Surawicz CM et al. Safety and acceptability of the Reality condom for anal sex among men who have sex with men. AIDS 2003;17(5):727-31.
- Kelvin EA, Smith RA, Mantell JE, Stein ZA. Adding the female con-dom to the public health agenda on prevention of HIV and other sexual-ly transmitted infections among men and women during anal inter-course. American Journal of Public Health 2009;99(6):985-7.
- FC2SF: A special project of San Francisco Department of Public Health STD Prevention & Control Services and HIV Prevention Sec-tion. www fc2sf com 2013; Ac-cessed on October 11, 2013.
- The Fenway Institute. Current stud-ies: ORIGAMI study. http://thefenwayinstitute.org/research/current-studies/#Negative Ac-cessed on October 24, 2013.
- Belluk P. Getting Men to Want to Use Condoms. The New York Times. Published on June 24, 2013.
- ORIGAMI Anal Condom (OAC). http://www.origamicondoms.com/#!analcondom/cow7. Accessed on October 24, 2013.
Rapid Response Service. Female condom use for men who have sex with men. Toronto, ON: Ontario HIV Treatment Network; November, 2013.
Jamie McCallum and Jason Globerman.