Zoe Duby (Researcher, UCT; SAMRC)
Editorial Note: In this article, Zoe reflects on the naming of ‘female condoms’ and the potential negative impact of gendered packaging of condoms on sexual- and reproductive health in South Africa and beyond.
Call me nit-picky about semantics, but in the world of public health, especially in sexual and reproductive health, I believe that we need to recognise the diversities and realities of human sexuality and behaviour and make an effort to be both inclusive and reflective of reality. The perception that female condoms were made for women, and for vaginas, is problematic, limiting its potential to be used as an effective STI/HIV prevention product for the diverse range of potential users.
This piece relates to another article which came out of my PhD on challenging the “penile-vaginal” heteronormative assumptions in research and public health. Building on this blogpost, I now aim to “problematise” the gendering of condoms, by showing how the concepts of "male condoms" versus "female condoms" is an example of how HIV prevention and contraceptive technologies are gendered, and highlight the far-reaching implications of this gendered approach.
A “female condom” looks like a tube of transparent material with two flexible rings at each end. One end is open and the other end is closed.
There are 3 main issues with the labelling of these products as “female condoms” that I’d like to discuss:
1) Not just for females: Despite the name “female”, these products can be used by men, women, and non-binary individuals, regardless of biological sex or gender identity.
2) Not just for vaginal sex: These products are currently branded as “female” condoms, and the packaging provides information only about its use in vaginas.
3) Gendered naming of condoms implies responsibility for use: the name “female condoms” perpetuates the misconception that male condoms should be used and initiated by men and female condoms should be used and initiated by women.
Why are debates about these kinds of semantics so important. Language plays a crucial role in shaping behaviour and perceptions. Terminology, labels, and word choices can enable, constrain, include and exclude users. When it comes to health technology, HIV prevention and contraceptives, it is important to be accurate about both the use and effectiveness of these products, so people can make informed decisions about how to protect themselves and their health.
“There is nothing inherently gendered or female about this condom—or about vaginas, for that matter. People with vaginas commonly identify as male, nonbinary, or female” - Jae Lin
The female condom is generally described and understood to be a “female-controlled”, “female-initiated” vaginal barrier, and has been heralded for the past two decades by women’s health advocates as a means to expand the choice of pregnancy and disease prevention options and increase women’s sexual agency.1
In 1993, the female condom was evaluated and approved by the US Food and Drug Administration (FDA) for pregnancy and disease prevention when used during vaginal intercourse. When the FDA approved the product, they termed it a “vaginal pouch” rather than a gender-neutral “barrier”. In Europe, the female condom became associated with the name “Femidom”. Globally, the device was actively marketed for female bodies, more specifically for vaginas.
With the FDA’s approval of, and provision of specific instructions for the female condom to be used for vaginal sex, the safety and efficacy of the female condom for HIV/STI prevention during anal intercourse were never demonstrated. Due to FDA restrictions, the instruction booklet never made reference to the device having the potential to be used as an anal barrier.
Part of the reason there was no official approval of the product for use in anal sex until fairly recently, were the legal barriers in the United States to conducting public health research on methods of protection for anal intercourse, which were only lifted in in 2003, when the US Supreme Court invalidated all state anti-sodomy laws. Although research funding was made available for the development of other rectal prevention products, the female condom, which had already been approved for vaginal use, was never evaluated for anal use. Therefore, without official approval, and without empirical evidence on its safety and efficacy, people who use the female condom for anal sex do so “off-label”.
Historically, there was little advocacy around the heterosexist politics of official approval of "female condoms" for anal sex by the FDA, despite their wide usage. In the late 1990s, the gay rights movement advocated appropriating the female condoms, along with a name change to designate receptive or passive sexual roles rather than biological sex of the receptive sexual partner. References were made to the “bottom” (receptive partner) condom.
In 2004, Michael Scarce, a gay men’s health rights advocate, wrote about the problems relating to the gendering of HIV prevention products.2 He described the heterosexist politics inherent in the labelling of this product as a “female condom” as the “feminization” of what should be a gender-neutral barrier pouch (one could also describe this as the “vaginalisation” of an orifice-neutral pouch).2 Scarce argued that the FDA’s reasoning for excluding anal-specific language in relation to the marketing and use of this product was justified by citing several states’ sodomy laws, coupled with a resistance to ‘encourage’ illegal behaviour.2 Scarce suggested that the very ‘gendered nomenclature [naming of things]’ and marketing were ‘indicative of the systems of heterosexism and erotophobia that government regulation employs in its policing of American sexuality’.2 Scarce referred to gay men’s ‘appropriation’ of the female condom for same-sex penile-anal intercourse, and the ways in which gender lines had been constructed and maintained through systems of government regulation, consumer capitalism, and scientific invention.2
Advocates believed that the name “female condom”, and the FDA's rules and classifications, restricted the use of this useful HIV/STI prevention product. In recognition of the role that this product could play in adding to safer sex options, and thus contributing to public health, advocates have been pushing the agency for rule changes, starting with the name.
The National Female Condom Coalition, which spearheaded these efforts, argued that the gendered name of the “female condom” may prevent receptive partners who do not identify as female from using the condom. The name perpetuates the perception that this product is solely for women (and solely for vaginas) and is restrictive in terms of promoting and prescribing the use of this product for the wide range of potential users.
Gay-identified, bisexual identified, straight identified, cisgender men can use the “female condom” to prevent the transmission of HIV and other STIs. Transgender, intersex, non-binary, and gender-non-conforming individuals can also use the “female condom”. The name “female condom” alienates anyone who doesn’t identify as female from the product.
“the name ‘female condom’ reinforces the flawed notion that all women have vulvas and vaginas, and that all men have penises. When it comes to sexual health, we need to make sure that all people, regardless of their gender identity or sexual orientation, have the medical information they need to lead healthy and safe lives” - Eliana Kosova, National Women’s Health Network (NWHN)
The perception that female condoms were made for only women is problematic, limiting its potential to be used as an effective STI/HIV prevention product, especially by high risk populations. Non female-identified individuals may be discouraged from considering this product as a prevention option due to the name. One participant in a study exploring heteronormative perceptions of the female condom in a South African urban township, suggested that:
“the female condom is something for women only. Men do not like women things”.3
Additionally, the name “female condoms” perpetuates the misconception that male condoms should be used and initiated by men and female condoms should be used and initiated by women. As Mitchell Warren, the executive director of the AIDS Vaccine Advocacy Coalition, states, it is not about discounting the importance of female condoms for women’s reproductive health and empowerment, as they are still one of the only available HIV and pregnancy prevention method designed for women’s initiation, and they can help put the power of prevention in women’s hands. Rather, "female" condom is a misnomer, since it obscures the fact that men can and do initiate female condom negotiation, and often participate in their insertion and use. The same statement applies to “male condoms”, which the name implicitly associates with men. However, many women play an active role in male condom use and initiation and use, compared to female condoms, which is assumed to be initiated by women only.
“I think it’s safe to say that this "dichotomy" between men / women and female condoms / male condoms is false, and both women and men have roles and responsibilities when it comes to negotiating and using female and male condoms” - Kimberly Whipkey, Center for Health and Gender Equity (CHANGE)
It may seem that what the product is called is unimportant. However, the problem is that inconsistencies in recommendations regarding use of the female condom for anal sex may lead to confusion, uncertainty, and distrust of the product among the public. Ultimately, people may be placed at increased risk by either using the device “off-label”, in an unsafe way or by not using the product at all, thus potentially missing an additional opportunity for protection.4
"De-gendering the product name will reduce the perception that it is only intended and appropriate for use by women" - National Female Condom Coalition
At the end of 2018, the US FDA approved new rules for "female" condoms that not only changed the device's name but eased some other strict regulations. The FDA changed the female condom's name to “single-use internal condom” in order to reduce the perception that it is only intended and appropriate for use by women. The regulators now approve the device for both vaginal and anal sex.
The device is assigned the generic name single-use internal condom, and it is identified as an OTC sheath-like device that lines the vaginal or anal wall and is inserted into the vagina or anus prior to the initiation of coitus. – FDA, September 2018
Alongside efforts to de-gender the name and terminology, further safety and efficacy studies are needed in order to assess the “female condom” for anal sex and to determine the optimal method for its use if it is proven safe and effective. In the meantime, efforts should be made to design appropriate and consistent messaging about anal use of the device given the current uncertainty and lack of evidence.
Gendered terms 'female condom’ and ‘male condom’ are problematic on many grounds. One being that those names assume a binarisation of biological sex, and gendered bodies. So even if the product is used in a vagina, the person using it may not identify themselves as female. Inclusive terms are important. In language that is laden with assumptions of heteronormativity, the terminology we use perpetuates the systematic exclusion of marginalised individuals.
I don’t have the definitive answer on what we should call these products. The terms male condoms / female condoms are problematic and exclusionary. Both internal / external condoms, and insertive / receptive condoms, are also problematic and inaccurate. The name "internal condom" was suggested, because it had already been commonly used among public health professionals and sex educators. However, the term “internal condom” is also imperfect, as some users choose to use the product externally - i.e. the product is not inserted into a receptive partner, but placed over the insertive partner’s penis like a sheath (with the inner ring removed), before penetration. Others have suggested the name “pouch condom”, which has the benefit of not being specific to any “compartment”, body part of gender, but rather describes the physical appearance of the product.
In conclusion, what this article highlights is the necessity of being mindful of our language, and the power it has to include or exclude, to empower or marginalise, and importantly to enable or inhibit people to make informed decisions about how to have sex safely.
1. Kelvin EA, Mantell JE, Candelario N, Hoffman S, Exner TM, Stackhouse W, Stein ZA. (2011). Off-label use of the female condom for anal intercourse among men in New York City. Am J Public Health;101(12):2241-4. doi: 10.2105/AJPH.2011.300260. Epub 2011 Oct 20. PMID: 22021299; PMCID: PMC3222431.
2. Scarce, M. (2004). Anal Sex and the Female Condom: Are Gay Men Getting a Bum Wrap? In Appropriating Technology: Vernacular Science and Social Power by Ron Eglash, Jennifer Croissant, Giovanna Di Chiro, Rayvon Fouche
3. Mdletshe, PT & Nduna, M. (2013). Peer educators' heteronormative perception of the female condom in a South African urban township. Unisa Press. New Voices in Psychology, 9 (1&2). https://www.semanticscholar.org/paper/Peer-educators'-heteronormative-perception-of-the-a-Mdletshe/fecec4708325adaf1a5b83056af6d7e04e99a343
4. Rodriguez, K., Ventura-DiPersia, C., LeVasseur, M.T. et al. Inconsistencies on U.S. Departments of Health Websites Regarding Anal Use of the Female Condom. AIDS Behav 19, 1141–1149 (2015). https://doi.org/10.1007/s10461-014-0933-6
1. Kempner, M. (2019). 'Female Condom' Gets a Genderless Rebrand From FDA. https://www.thebodypro.com/article/female-condom-gets-a-genderless-rebrand-from-fda
2. Kelvin, EA, Smith, RA, Mantell, JE and Stein, ZA. (2009). Adding the Female Condom to the Public Health Agenda on Prevention of HIV and Other Sexually Transmitted Infections Among Men and Women During Anal Intercourse. American Journal of Public Health 99, 985_987, https://doi.org/10.2105/AJPH.2008.141200
3. Mantell, J. E., Kelvin, E. A., Exner, T. M., Hoffman, S., Needham, S., & Stein, Z. A. (2009). Anal use of the female condom: does uncertainty justify provider inaction?. AIDS care, 21(9), 1185–1194. https://doi.org/10.1080/09540120902730005
4. Rapid Response Service. Rapid Response: Female condom use for men who have sex with men. Toronto, ON: Ontario HIV Treatment Network; November 2013.
5. DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration 21 CFR Part 884 [Docket No. FDA–2017–N–6538] Obstetrical and Gynecological Devices; Reclassification of Single-Use Female Condom, To Be Renamed Single Use Internal Condom AGENCY: Food and Drug Administration, HHS. ACTION: Final order. Federal Register / Vol. 83, No. 188 / Thursday, September 27, 2018 / Rules and Regulations. https://www.govinfo.gov/content/pkg/FR-2018-09-27/pdf/2018-21044.pdf
Zoe Duby is an experienced socio-behavioural qualitative researcher in the field of HIV prevention, sexual and reproductive health. Zoe has a passion for unpacking and exploring social taboos and semantic / linguistic assumptions that impact on health. Zoe is an Honorary Research Associate at the Division of Social and Behavioural Sciences in the School of Public Health and Family Medicine, University of Cape Town, and is also a Qualitative Specialist Researcher at the Health Systems Research Unit, South African Medical Research Council.
Division of Social and Behavioural Sciences
School of Public Health and Family Medicine
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University of Cape Town