The Female Condom Knowledge, Image, and Power

Abstract

The present study examined the effectiveness of a brief intervention that provided knowledge about female condoms, promoted awareness, and allowed open discussions on an individual’s attitude and intent to use the female condom. The Theory of Planned Behavior was used to examine how knowledge, health awareness, and communication may affect an individual’s attitudes and influence her decision to use the female condom. Surveys were administered to 85 African American college students. A paired samples t-test was used to determine the effectiveness of the brief fc2 intervention at increasing knowledge, attitudes, and intentions to use the fc2 among the participants. Findings from the study suggest that providing information and open discussions about female contraception may influence intentions to use female condoms.

In the united states, the african american community continues to be devastated by the spread of the hiv virus. According to the Centers for Disease Control and Prevention (cdc) (2011), African Americans comprised 12% of the U.S. population, but accounted for 44% of all new hiv infections in 2010. Within this same year (2010), African American women accounted for 29% of estimated new hiv infections among all adults and adolescent. Eighty-seven percent of the new infections in women are from heterosexual contact (cdc, 2012). While many risk factors have been associated with hiv/aids infection rates, several studies have linked the spread of infection among the African American female population to knowledge, awareness, and the gender ratio imbalance among African American women and African American males (Broaddus, Morris, & Bryan, 2010; Laub, Somera, Gowen, & Diaz, 1999; Weeks, Coman, Hilario, Li, & Abbott, 2013). Considerable research suggests that a relationship exists between female condom usage, acceptability, and gender dynamics (Mack, Grey, Amsterdam, Williamson, & Matta, 2010; Small, Weinman, Buzi, & Smith, 2010; Wingood & DiClemente, 2000).

The 2002 National Survey of Family Growth (nsfg) stated that condoms were the primary choice of contraception and protection amongst reproductive aged women. According to the survey, 13 million women chose condoms as their primary contraceptive and protection choice (Warner & Stone, 2007). Condoms are more readily available and less intrusive on the body. There are many positive aspects of using condoms. Male condoms continue to remain the most widely available and most commonly used barrier method for the prevention of sexually transmitted infections (stis) including hiv. When used consistently and correctly, male condoms reduce risk of hiv infection and pregnancy (Warner & Stone, 2007).

While male condoms are more widely used, the female condom (known as fc2) is an alternative to using the male condom that is rarely used when compared to the male condom (Hardwick, 2002; Whipkey, East, & Coffey, 2014). There are several explanations for why the fc2 is used less than male condoms (Beksinska, Smit, Joanis, & Potter, 2012; Broaddus et al., 2010; Latka, Gollub, French, & Stein, 2000; Schwartz et al., 2008). One key factor continues to be knowledge (Beksinska, Smit, Joanis, Usher-Patel, & Potter, 2011; Wingood & DiClemente, 1998a). Many individuals have no knowledge of the fc2 and do not know how to use female condoms. Female condoms may be considered uncomfortable for users that do not know how to correctly insert the contraceptive. Most individuals have no knowledge of where they can even purchase female condoms (Broaddus et al., 2010; Latka, Kapadia, & Fortin, 2008; Wingood et al., 2011). Finally, male partners may not be as open to using the female condom as their female partner, due to their own personal preferences (Hardwick, 2002).

Despite its lack of popularity, there are many benefits to using the female condom. It is an effective contraceptive method made of nitrile material that warms to body temperature (Choi et al., 2008). The fc2 allows a female to insert the barrier in advance of sexual intercourse. When used correctly, female condoms are risk reducers (Wingood & DiClemente, 1998a; Wingood & DiClemente, 2000; Wingood et al., 2011).

An examination of health promotion behaviors including female condom usage must consider the context in which the behavior occurs. The current study utilized the Theory of Planned Behavior as the conceptual framework for understanding how providing knowledge, awareness, and open communication may influence an individual’s attitude and intention to use the female condom. Eisen and Zellman (1986) suggested that an individual’s “sex education knowledge” may influence her risk reduction practices. Thus, a female’s risk reduction practices related to the fc2 may be influenced by her general knowledge and sexual ideas that may be learned from an individual’s social environment such as parents, peers, media, or school. The Theory of Planned Behavior contends that a person’s decision to engage in a behavior is determined by attitudes, perceived behavioral control, and subjective norms (Ajzen, 2002; Ajzen & Fishbein, 1980). For female condom use behaviors, factors such as gender, social roles, and relationship dynamics may impact an individual’s ability or desire to act on intentions. Gender dynamics, while not “directly” included in the Theory of Planned Behavior, are social norms that may impact sexual attitudes and behaviors.

Rosenthal, Levy, and Earnshaw (2012) suggest that society imparts a male focused sexual ideology that may enable some women to feel discouraged about suggesting the use of the fc2. Proposing fc2 may be viewed as being forward or demanding. This idea may support the need to have educational and awareness discussions among females who address these negative images and self-doubt. Research by Corneille, Fife, Belgrave, and Sims (2012) discussed the need to understand ethnic identity, relationship status, and healthy relationship attainment when examining power dynamics, body image, and risk practices. Cash (2002) suggests the need to understand a woman’s body image perception, body satisfaction, and ideals as factors in sexual risk reduction activities.

Another social determinant that may contribute to the reduced usage of the female condom relates to the Theory of Gender and Power (Wingood & DiClemente, 2000). Latka et al. (2008) discussed the importance of understanding how female condom usage is perceived and negotiated in African American relationships. While it has been suggested by some studies that the female condom is an effective tool to reduce hiv transmission, there is some research about how the introduction of the female condom by the female may be negatively perceived by African American men (Broaddus et al., 2010; Latka et al., 2008; Lewis, Melton, Succop, & Rosenthal, 2000). While there remains a need to further investigate fc2 partner communication, DePadilla, Windle, Wingood, Cooper, and DiClemente (2011) used the Theory of Gender and Power to examine condom use in African American women. The results revealed partner communication was a significant predictor of condom use.

One thing seems clear when it comes to condoms; the power is in the hands of whoever carries and ultimately decides to consent to using the protection. When the contraception of choice is a male condom, protection is often times placed in the possession of the male partner (Rosenthal et al., 2012; DePadilla, et al. 2011). Some argue that by giving male partners the responsibility, females are intentionally handing them the power to control the fate of their health from pregnancy and acquiring sexually transmitted infections (Lewis et al., 2000). Still, others believe that many females in today’s society lack knowledge of alternative contraceptive forms that are available such as the female condom (Robinson, Bockting, Rosser, Miner, & Coleman, 2002). The female condom may be a contraceptive form that distributes the power evenly between partners (Farr, Gabelnick, Starren, & Dorflinger, 1994). As a viable alternative or in the absence of a male condom, the female condom can be used to reduce the likelihood of acquiring a sexually transmitted infection.

Previous studies have demonstrated that female condom interventions are successful in encouraging women, especially target audiences such as adult women at high risk for sti/hiv and unintended pregnancy, to use the female condom at least once (Wingood et al., 2011). Effective female condom interventions often include education and counseling sessions that address safer sex negotiation and condom use skills (Hardwick, 2002; Wingood et al., 2011).

The purpose of the present study was to examine the effects of a brief female condom use demonstration and open peer discussion about condom usage on the intentions of African American female college students. The goal of the study was to see if distributing knowledge and support to undergraduate college students about the female condom would increase their likelihood of using female condoms. There were three hypotheses in the present study. The first hypothesis is individuals with high hiv knowledge will have higher condom use intentions than individuals with low hiv knowledge. The second hypothesis is after gaining knowledge and demonstration on the use of female condoms by female peer educators/students, participants would have more positive attitudes and intentions to use the female condom. Lastly, the final hypothesis is an individual’s body image will influence her condom use intentions and fc2 usage.

Method

Participants

There were 85 participants in the current study with a mean age of 19.6 years old. The age range for the women was eighteen to twenty-five years old. All participants were recruited from a university in the southeastern region of the United States. All participants volunteered to be in the study and self-reported they never used the female condom. The University’s Institutional Review Board approved the study protocol. The majority of the participants in this study were African American females, comprising 90.7% of the sample. Approximately 1% of the sample identified themselves as Latino or Hispanic and the remaining participants (8%) were either multiracial or considered themselves as “Other”.

Participants in the study were asked to identify their sexual orientation/identity. Ninety-three percent of the participants identified themselves as heterosexual; 2.3% identified themselves as bisexual; 2.3% identified themselves as lesbian; 1.2% were unsure; and finally, 1.2% identified as something other than the choices given.

Approximately 48% of the participants had a person who they identified as their primary partner. Approximately 52% indicated that they did not have a primary partner.

Materials and Procedure

A consent form was given to the participants prior to the completion of each questionnaire. Demographic information was collected from each survey. The questionnaire used in the study consisted of the following:

Figure 1a.

Ethnicity of Participants

Figure 1b.

Sexual Orientation

Condom Attitudes and Intentions

Created by Wingood (1998a, 1998b), the Condom Attitudes Scale contains seven items that evaluates a person’s attitudes towards using condoms. An example of a question is, “Sex with condoms does not feel natural.” Participants answer each statement on a four-point Likert scale with lower scores signifying high favorability to using condoms. Reliability and validity of the scale is based on the sample in question. In the current sample, the Cronbach reliability coefficient was .75. For self-related condom attitudes, the Cronbach alpha coefficient was .79. For partner’s condom attitudes, the Cronbach alpha coefficient was .63. Participants were asked about their attitudes towards the male and female condom and their intentions to use the female condom in the pre and post surveys.

Condom Use Self-Efficacy Scale

The Condom Use Self-Efficacy Scale developed by Brafford and Beck (1991) consists of 28 items. The scale gauges a person’s perception of his or her ability to use condoms. Only nine of the 28 questions were included to address the scope of this study. Reliability of the entire scale is reported at 0.91. Test-retest reliability was reported to be 0.81. The Condom Use Self-Efficacy Scale is a valid instrument that has been translated into different languages and used in various countries such as Thailand (Thato, Hanna, & Rodcumdee, 2005) and Ethiopia (Shaweno & Tekletsadik, 2013).

Youth Risk Behavior Surveillance System

The Youth Risk Behavior Surveillance System (yrbss) was developed in 1989 by the cdc to monitor health risk behaviors that contribute to the leading causes of mortality, morbidity, and social problems among youth and adults in the United States. This survey used the sexual behaviors that contribute to unintended pregnancy and sexually transmitted disease category from the scale. The Youth Risk Behavior scale test-retest reliability was reported to be .63 (Brener et al., 2002).

Coping with Body Image Challenges Inventory

The Coping with Body Image Challenges (bicsi) was created by Thomas Cash (2002). The inventory consists of 29 items. Items are rated on a four-point Likert Scale with responses ranging from “Definitely Not Like Me” to “Definitely Like Me.” The inventory assesses how a person copes with body image threats. Reliability of the entire scale is reported at 0.93.

Procedure

For recruitment, announcements were made in common areas and women had an opportunity to anonymously indicate if they were interested in hearing more about the study on campus. The intervention was conducted by trained research staff/peer educators. The intervention discussed hiv and African American women and strategies that increased responsible sexual decisionmaking. Participants in the study completed an informed consent form and then were given a self-administered survey that was collected anonymously using a drop box. Following the collection of each pre-survey, participants listened to a presentation that explained the Female Condom 2 (fc2). The presentation consisted of information on how to use the fc2 and addressed some myths about using this form of contraception. Participants were given female condoms and asked to examine it closely and ask any questions. The participants were then shown a five minute video segment with a female approaching her male partner about using the fc2. The clip was developed by students on the campus and was reviewed and approved by the university health department to ensure correct information. The three-hour forum/intervention concluded with a question and answer period. Following the question and answer period, participants completed a post-test measure. The posttest measure consisted of questions that assessed if the participants gained knowledge on the fc2 and intention to use latex condoms (with their male partner) and the fc2. After questionnaires were collected, the researchers coded each survey. The data was entered using spss. Baseline characteristics were compared between groups using t-tests for continuous variables and Pearson chi-square tests for categorical variables. A paired samples t-test was used to determine the efficacy of the intervention.

Results

The participants surveyed were categorized as having high or low hiv risk based on their answers to the following questions: “Use of a condom during intercourse in the last 30 days” and/or “Number of sexual partners in the last 30 days.” This result was evaluated to examine the representation of risk. Scores above six were categorized as high risk; this represented approximately 39.5% of the sample. Scores that were at or below six on the scale were categorized as low risk, which represented 60.5% of the sample.

It was hypothesized that individuals with high hiv knowledge would have higher condom use intentions than individuals with low hiv knowledge. Fifty-eight participants (67.5%) achieved a score of 90% or above. The median was 90%, and the mean was 80.86%. Thus, the first hypothesis was not supported by the data. The majority of the participants scored high on hiv knowledge.

Table 1.

Pre and Post-Intervention

It was hypothesized that by gaining knowledge and demonstration on the use of the female condom by female peer educators/students, participants would have more positive attitudes about the female condom and intentions to use the female condom. A paired samples t-test was used to determine the efficacy of the intervention in facilitating communication about the female condom and attitudes/beliefs about the female condom as a viable option for safe sex practices. The mean for pre-intervention was 1.52 (sd = .97); for post-intervention, the mean was 2.38 (sd = 1.22). The paired samples two-tailed t-test revealed a significant change in attitudes regarding the female condom and an increase in knowledge about the fc2, t (64) = 5.21, p = .000. This lends support for the hypothesis that individuals presented with an open discussion would be more likely to state that they intended to use a female condom in the future. The effect size as measured by Pearson’s r was .546. After the intervention, participants were more likely to report that they learned something new, would discuss using the female condom with their partner, increased their belief in the efficacy of the female condom, and were willing to try the female condom the next time they have sex.

It was hypothesized that an individual’s body image coping style will influence her condom use intentions and fc2 usage. The majority of the participants’ primary coping style was positive rational acceptance and reflected 72.3% (n = 60) of the sample. Approximately 5% (n = 4) identified avoidant as their primary coping style and 19.3% (n = 16) were identified as having a primary appearance coping style. Three participants identified a combination of coping styles.

Figure 2.

Primary Coping Style

There was not a significant relationship between body image coping style and condom usage. When using a partial correlation and controlling for appearance fixing coping style, there was a significant relationship between being more likely to have used a condom the last time they had sex (r = .305, p = .006) and having a positive rational acceptance coping style. When avoidant body image coping style was controlled for, there was not a significant relationship with condom usage. In addition, when appearance fixing body image coping style was controlled for, there was not a significant relationship with condom usage.

Discussion

There are many factors that influence female condom attitudes, intentions, and usage among African American females. This study used a peer lead brief fc2 intervention to assist with exploring the effectiveness of using female condom demonstrations. The Theory of Planned Behavior was used to study how knowledge, awareness, and communication influenced an individual’s attitudes and contributed to one’s decision to use the female condom. The results revealed the vast majority of the participants had high hiv knowledge scores. Participants who were involved in an open discussion and a demonstration pertaining to the female condom had more positive attitudes about the female condom. Based on the Theory of Planned Behavior, the participants’ change in attitudes may positively influence their intention to use a female condom in the future. The results of this study suggest that the combination of incorporating a fc2 demonstration providing time for participants to openly discuss and ask questions about the fc2; and engaging female students in dialogue in hiv intervention programs may influence attitudes and intentions to use the female condom. Utilizing female condoms ultimately reduces the likelihood of acquiring a sexually transmitted infection including hiv. In addition, wearing a female condom may also reduce the risk of an unplanned pregnancy. Demonstrating how to use the female condom and spending time dispelling any myths about it may encourage women and their partners to consider it as a contraceptive option (Choi et al., 2008). Discussion and usage of the female condom offers some women an alternative to using the traditional male condom and empowers them to be responsible for their sexual expression.

For the university used in this study, initiatives like the Sisters Informing Sisters on the Topic of aids (sista) project may be a viable catalyst for empowering women to consider using female condoms (Wingood & DiClemente, 2000). Providing information and discussing the use of female condoms may be a part of a larger hiv/aids research agenda. The sista project is a peer-led, skill-building, gender and culturally appropriate, training intervention project to prevent hiv infection in African American women (Wingood & DiClemente, 2000). The ages of female participants for this cdc recommended intervention is 18 to 24 years old. The goal of sista is to increase the consistency of condom use in African American women. There are three objectives that support this goal: 1) increasing hiv risk reduction knowledge, 2) strengthening sexual self-control, and 3) increasing the partner’s acceptances of consistent condom use. The five session program emphasizes ethnic and gender pride, hiv risk-reduction information, sexual negotiation skills, proper condom use, and the development of partner approval of consistent condom use (DiClemente & Wingood, 1995). sista has been packaged by the cdc’s Diffusion of Effective Behavioral Intervention project. fc2 demonstrations would assist the project with increasing hiv risk reduction practices and promoting consistent condom use (DiClemente & Wingood, 1995).

There are many positive aspects of using male and female condoms (Wingood & DiClemente, 1998a, 1998b). Negotiating safe sex and partner cooperation are critical issues in health and sexuality. Crenshaw (1994) discussed the underlining idea that society has deemed it a woman’s responsibility to not become pregnant during sex. Crenshaw (1994) suggests that there continues to be strife in society (e.g., media) that may contradict a women’s ability to comfortably negotiate and maintain safe sex functioning. This strife includes division of labor (women continue to be paid less than their male counterparts) and role identification (historically, women were given more “gender” or “traditionally female roles” that were considered more submissive). Several articles discuss the need to further explore gender dynamics in relationships and the intersection of politics, sexism, and sexuality in America (Corneille et al., 2012; Logan & Leukefeld, 2002; O’Leary, Jemmott, & Jemmott, 2008). Both males and females can purchase condoms and realize the importance of using a condom during sex.

Further studies must be conducted to assist with understanding the intersection of sexuality, race, and relationships in the African American community in general (Broaddus et al., 2010; Crenshaw, 1994). This discussion should also include the influence of cultural identity and condom usage in the prevention arena (Corneille, Ashcroft, & Belgrave, 2005). The interplay between race, gender, and social dynamics certainly crosses many mediums and influences sexuality around the world (Crenshaw, 1994; Win-good & DiClemente, 2000). By giving male partners the responsibility, females are intentionally handing them the power to control the fate of their health from pregnancy or sexually transmitted infections.

Yet another factor may include self-esteem and relationship ideals (Corneille et al., 2012). This may include exploring relationship self-worth, romantic ideals, and social exchange (Choi et al., 2008; Rosenthal et al., 2012). These elements influence intimacy and support between partners. Still, others believe that many females in today’s society lack knowledge of alternative contraceptive forms that are available (Robinson et al., 2002). It has been suggested that the female condom may be a contraceptive form that distributes the capacity to influence risk reduction evenly between partners (Farr et al., 1994).

Finally, this study identifies a need to continue the discussion surrounding body image, sexuality, and condom usage. The results indicated that individuals with high body image ideals were more likely to have “used” a condom the last time they had sex. This occurred when we controlled for appearance fixing. However, this is an important distinction because it suggests that there may be a difference based on how an individual responds to her own body image (regardless of her actual body size or bmi) in relation to her sexual risk behaviors. Larger sample sizes and more research should be done to explore this possibility.

This study focused on African American college students and is only applicable to this population at this particular university. Furthermore, in relation to the Theory of Planned Behavior, this study should be replicated at other colleges and universities to ensure the findings are generalizable to the African American female population. Another limitation of this study is its inability to follow-up with the participants to see if their intentions matched their condom use behaviors. Future research could incorporate a longitudinal design so that students can be followed over time to ensure consistency of information, behaviors, and support.