aMedical Research Council Programme on AIDS in Uganda, Entebbe, Uganda; bUniversity of Essex, Colchester, UK; cMinistry of Health, Entebbe, Uganda; dMRC Medical Sociology Unit, Glasgow, UK; and eLondon School of Hygiene and Tropical Medicine, London, UK.
Received: 28 April 2000; accepted: 24 May 2000.
In a recent study of the acceptability of the female condom, foaming tablets, sponge, foam, film and gel among 146 women and 35 of their male partners in south-west Uganda, we found a clear demand for, and consistent use of, these products. Although the participants understood that, with the exception of the female condom, there was no certainty about how much protection, if any, the products provided against HIV and sexually transmitted diseases (STD), they nonetheless said that the main reason for using the products was the partial additional protection they might offer .
In another, recently completed study carried out in the same area, we found that 53% (101/192) of respondents had used a male condom at least once. Condom use tended to be sporadic: only 13 out of 101 individuals claimed to use a condom regularly and the majority of those who had ever used a condom last used one more than a year previously. The commonest reason for using a condom was fear of AIDS.
The commonest reasons for almost half of respondents never having used a condom related to being in a regular relationship or to the perceived unpleasant or dangerous characteristics of condoms. Condoms were said to imply distrust in regular relationships and therefore were unacceptable in such relationships for any reason other than family planning. Respondents complained that condoms reduce sensation (mostly men), that they were physically distasteful (mostly women). There were rumours of condoms being impregnated with HIV or being porous, and stories of condoms lodging themselves in the woman. Finally, there have been recent stories of condoms causing penises to drop off.
A comparison of the reception of female controlled products with the male condom reveals a striking ambivalence. People in the study area liked the products but disliked and distrusted condoms; they used products consistently whereas condom use was sporadic; they did not mind using the products in regular relationships, whereas condom use in the same relationships was taboo; they used products for extra protection (although they knew that they did not offer much) but would not use condoms (even though they knew that they offer substantial protection) because of rumours that they might be unreliable or dangerous. Men were opposed to female control, but they claimed to like the products.
There are various possible explanations for this ambivalence. First, condoms have been around for a long time, whereas the female products were novel in the study area. Acceptability might have been influenced by participants’ curiosity and desire to experiment. Second, because the products were new there might not have been sufficient time for horror stories to develop. Third, the fact that products were used in the context of a study might have influenced their acceptability.
However, there was another, more important reason for acceptability: sexual pleasure. Most participants (90% of the women and 86% of the men) said that products did not interfere with sexual enjoyment. Indeed, 24% of the women and 67% of the men said that the products actually increased their enjoyment of sex .
This increased enjoyment was due largely to increased lubrication. In the study area ‘dry sex’ is not popular, as has been reported for many other parts of sub-Saharan Africa [2–7], and participants preferred products that were perceived to make sex ‘wet'.
If these products were widely available, negative connotations might develop: there are no intrinsic reasons why foaming tablets or sponges should not also imply distrust in regular relationships, especially if the main reason for using them is protection against HIV and STD. However, such potential negative factors might be offset by increased sexual enjoyment. After all, many of the horror stories about condoms are basically rationalizations because people do not like using them anyway because they reduce sexual pleasure. Cultural acceptability is important, but sexual enjoyment (which has been largely ignored in discussions about HIV prevention) is probably more important in the development of acceptable products.
This suggests ways forward in designing and promoting acceptable products. First, products that are to be used in sex should not be separated from sexual excitement and pleasure. Second, products should be promoted and used for positive reasons (sexual enjoyment) rather than negative ones (fear of infection). If the emphasis is on enjoyment rather than disease prevention then the negative association that the male condom has with disease and infidelity need not rub off on other products. Finally, in the context of sex inequality in patriarchal cultures (which is not likely to change radically in the short term) some emphasis on male enjoyment might lead to the use of potential vaginal microbicidal products, thus leading to increased protection of women.
James A. G. Whitwortha
Anthony K. Mbonyec
Graham J. Hartd
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