Since the beginning of the AIDS epidemic, condoms have been the one most efficient available technology to reduce the transmission of the virus as well as other sexually transmitted and transmittable diseases. In 1984, the female condom was invented by a Danish medical doctor, Lasse Hessels. The female condom is an innovative barrier contraceptive that not only offers potential protection against sexually transmitted diseases; but was supposed to be a major contraceptive without side effects. Although the idea of a female condom is not new, early designs did not become widely available [1,2]. The Reality female condom, a device made of a lighter and stronger material, polyurethane sheath inserted into the vagina prior to sexual intercourse. Since its launch, 26 years ago in Switzerland, the female condom has been approved as a single-use product and made available in commercial, social marketing, and public sector programs in 65 countries, including Nigeria [2].

A growing body of research covering technical, clinical, and human use aspects of the female condom can be seen everywhere. Some of these studies note anecdotal reports of off-license reuse of the female condom [3-5] but no details regarding reuse are provided in these reports. Some recent studies [6-8] have availed information pertaining to the safety of female condom reuse under carefully specified research study contexts. Unfortunately, not much is known about reuse outside a research study setting, and there are outstanding questions related to feasibility of reuse among whole populations, especially in low income settings [4,9-12]. This study, thus, aims at finding out the motivations for reuse; problems resulting from reuse and, whether these affect its acceptability.

A descriptive technique was used. Open-ended, minimally structured interviews were conducted among a purposive sample of self-identified women who, prior to enrolling in this study, reused the female condom of their own volition without reuse instruction. Given that, female condom use was not widespread and because reuse was discouraged [13], obtaining a representative sample of naturally occurring reusers was not feasible. Individual interviewing was selected as the research technique rather than focus groups due to the sensitive nature of the study and setting.

Study area and size

This study took place in Abuja, Nigeria, in October-December 2017. Nigeria is the country with the second-largest numbers of people living with HIV/AIDS after South Africa. The female condom introduced in 2009 following the program phases initiated by the Society for Family Health (SFH) with support from the United Nations Population Fund (UNFPA) for the Universal Access to Female Condom (UAFC) [13]. Since then, efforts are evidently yielding results towards giving the female condom use the widespread promotion it needs in order to help de-stigmatize and normalize usage. Like the male condom, female condom has an edge over non-barrier contraception methods since they also provide protection against STIs. It has the benefits over the male condom, in reducing the stress on the man and empowering the woman. Much of the reported reuse in this study involved “old” (Reality-packaged) devices, although reuse of “new” FC2 was also reported.

Inclusion criteria and process

Inclusion into the research study was voluntary. The inclusion criteria were age majority of 18 to 40 years as well as experience with or willingness to female condom reuse. We screened, obtained consent, and interviewed the participants. For screening purposes, re-use was defined as the use of a single device for more than one penetrative sex act-regardless of time between acts, removal and/or cleaning between acts, or partners with whom these acts were performed. Flyers were circulated around health facilities, clubs and women meetings as regards the study on female condoms use. Informed consents were obtained and little token given for participation; upon request.

All interviews were conducted in the pidgin English language, so as to provide a footing for all, and took place in a private setting; they were recorded on audiotape. Interviews lasted about 40 minutes each and were based on such factors regarding reuse: motivations, perceived problems, and perceptions as regards safety.

Demographics and reproductive history

We had 42 female condom users who were screened and participated in the study. Of these, 21 reused the female condom at least once, and 28 consented to a recorded interview. The age of the participants ranged from 21 to 39 years old. The minimum level of education of all participants was the primary school education; 10 had some post-primary school education, and 11 had completed postprimary education while 9 are in tertiary schools. 9 participants were married, 13 were cohabiting, and 6 were single. 8 participants identified themselves as sex workers. Majority of the participants reported that their reuse partners were aware of the reuse, although there were reports of one or more partners that were not aware, after all, enthused one of them, “they don’t have the right to know.”

Motivations to reuse

On the question of what motivated their re-use of the female condom instead of using male condom of going skin-to-skin, the study participants mostly pointed out protection from STIs as well as preventing pregnancy as prime motivator. Also, the desire for barrier protection as well as reluctance to use male condoms on the part of either the male and/or the female partner were mentioned. Lack of trust of male partners was common and contributed to reuse motivations. “To trust a man is not easy especially the married ones.” In one instance, a deliberate preference for the female condom was reported. In another reported instance, a participant (who liked the female condom) reported being coerced by her husband into using and then reusing the female condom. Various allusions to scarcity were also mentioned as motivations for reuse, including (1) paucity of supplies, (2) health facilities not open when need arose, (3) availability lacking when supply could be sought, (4) privacy concerns and (5) high cost.

Again, mentioned motivations included the need for protection in a horny moment or being temporarily out of contraceptive protection. “Time was running out, and it was at night. How would I get condom at that time?” These motivations were sometimes linked to partner insistence on sex, or fear of coerced sex without barrier protection. “You know men can be a problem, especially when they are aroused. He would practically force you to sleep with him without any condom.” The sex workers reported fear of losing a customer as a motivation. The nature of the female condom was sometimes mentioned as factors that influenced reuse. Positive aspects of such considerations of the nature of the condom reflecting a user perception that the female condom was sturdy and safe to reuse were reported. Negative risk perceptions of skin-to-skin sex (pregnancy and infections) and the male condom (e.g., device tear or tip-opening) were also relayed. “I didn’t trust men with male condoms because I hear some men tend to prick or make a hole at the tip before having sexual intercourse.” Advice from some kind of significant other such as provider, partner, or friend was mentioned in a few cases as a factor positively influencing the decision to reuse. Several participants stated that their decision to reuse the old type of device was influenced by advice they received from a provider; that is, a health practitioner suggested reuse at a time when adequate supplies of the female condom were limited.

How was the reuse done?

Two types of reuse were identified in the study, and reuse was reportedly during anal and vaginal sex. In reuse type 1, before removal and disposal, a single device was used for multiple penetrative sex acts, which reportedly involved anal sex. In reuse type 2, a single device was used for a single penetrative sex act, removed, and later reused for a subsequent single penetrative sex act. About the number of female condoms they had ever reused, participant responses ranged from one to “too many to remember,” the latter being a number in excess of 70. Also, about the number of times each device was reused, and the responses ranged from 1 to 3. However, it was not clear in all cases if participants were counting the initial use. If that were the case, this range would mildly overestimate reuse. It was also not possible that in all case they were consistently counting multiple penetrative sex acts without removal as reuse. If such is the case, reuse is underestimated. There were reported instances of borrowing or lending unused devices. One of the participants, a sex worker reported that she loaned devices, new and used, to a dear friend who would also do so for her when the need arises.

Safety concerns with reuse

A greater number of the participants mentioned no problems associated with reuse for either member of the couple. A handful had issues with poor lubrication and poor positioning. One participant, who did not re-lubricate the device before reusing, reported discomfort during intercourse for herself and her partner.

Also, following poor positioning, 9 of the study participants reported that initial reuse caused some irritation after intercourse. There was one report of a reuse partner experiencing problems with the device twisting. Giving a graphic description, she reported, “he also had problems at first, when penetrating; the condom would twist, but he would continue on with a lot of force, causing me abdominal pains.” Asking one of the participants about pain or irritation, she said “I usually have abdominal pains, so even if the female condom was to cause me some pain, I wouldn’t know.” As such, one participant opined that cleaning the used devices was too much bother.

Furthermore, without prejudice to the male condom, most of the participants maintained like its male counterpart; the female condom is prone to breakage. This is especially so, they reported, when it is constantly reused. A participant reported that she was no longer sure when cleaning the device as to tell whether the device was inside out and was afraid to use the device further. Some participants reported only reusing the device under circumstances in which no other means of protection was practicable. Some participants reported intent to continue reuse as a practice, while others did not. Some of the participants who reported their concerns as to discontinue reuse pointed to the latex quality of the FC1 condom. One of the participants, who reused the device in an anal sex reported irritation in the anus and so could increase the likelihood of STI transmission.

Acceptability

Despite the safety concerns raised as regards the reuse of FC1, most of the participant reported that they liked using the female condom and would recommend it to others. Many women indicated that they would like to use it as their method of contraception in the future. One of the participants gave a somewhat lengthy reason why she would accept the FC: “the first time I saw a female condom, I thought it was ridiculous. It looked to me like a cross between a sandwich baggy and a trash-can liner. It’s not stretchy, and flops around like an ill-fitting sweater. Surely, I thought, I would never, ever use this weird device. Then one day on a whim I slid a female condom over a sex toy and found that it made anal play with toys much cleaner and more comfortable. When I found myself bottoming for a very well-endowed man, I suggested he use the female condom like a conventional condom. That was when I went from thinking the female condom was a silly fad to thinking it is the future of safe sex”. Despite productrelated complaints included dislike of the inner ring, "didn't feel right," inconvenience, and messiness, some of the participants reported their acceptance of the FC as arising from the more assurance of protection it gives, empowering women to take decisions for their safety.

This study provides information from information provided in interviews with 28 non-randomly selected women. The interviewing method used in this study was as powerful as it was problematic. Even though, it provided rich detail and natural description of female condom acceptability, reuse and safety concerns of reuse, the lack of structure equally encouraged relatively high levels of ambiguity and inconsistency in reporting. Most of the respondents had more than one reuse experience (in some cases, dozens).

During an interview, we observed that the respondents’ responses ranged from describing a specific episode in detail, to talking about just one part of another episode; at other instances, a typical reuse behavior pattern was described. Even though they may have addressed all of the topics covered by the discussion guide, we must admit that, most respondents did not provide what a researcher would consider exhaustive details on even one reuse episode. As such, it is also likely that some reuse experiences were not specifically described at all. However, these women, despite their relatively small sample population availed descriptions of a remarkable range of actual reuse experiences. We are certain that, as awareness and distribution of the female condom increases, the absolute level of reuse is likely to increase. This is vital, especially as the WHO is recognizing the urgent need for guidance to women or couples who are re-using female condoms [12].

The report on the two types of re-use practice raise issues that essential in any discussion of female condom use. One issue is whether failure to clean between uses with one partner might pose additional risks by straining the structural integrity of the device, by increasing the potential for exchange of bodily fluids in the interim between sex acts, or via some other mechanism. This is importantly so given the fact that the female condom been used in anal sex have issues calling for urgent need to evaluate the safety and efficacy so as to help people who would use and re-use make informed choices [14]. Another issue has to do with the dynamics of failure to clean between uses in which multiple partners are involved, which can and do predispose to STIs.

Again, this study highlights some essentials of value in term of programmes to encouraging female condom use. The fact that the women had varying understanding about the concept of reuse has implications for service delivery: for information, education, and communication materials development; and for the content of female condom counseling. It invites the seriousness of ensuring reproductive health vis-a-vis safeguarding against STIs by foregoing the arguments of policymakers that demand is low because of none acceptance [15].

Some motivation to re-use was related to scarcity. Service delivery planners should consider whether poor program support resulting in scarcity might result in reuse, particularly in resource-poor settings. We suggest avenues to mould perceptions of reuse in the minds of potential re-users. For example, respondents identified differences between old and new devices despite the two products being exactly the same. Information that provider advice was effective in encouraging and also in discouraging re-use have significance for provider training and counseling content, whereas the change of client perception related to packaging has implications for marketing and advertising. This study indicates that female condom program are been sabotaged by problematizing acceptability among users and by stakeholder failing to create access that would satisfy and increase demand. It is important to know that so far as global policymaker continue to shy away behind the empty-talk of high price or the myth of low demand and hence no market; access to female condoms will remain out of reach.

Reusing is not best practice, no matter the motivation. Yet, women who have used and reused the female condom know that it offers many potential advantages over male condom it can inserted in advance of sexual activity and, as a result, should allow greater sexual spontaneity. As such, people could engage in sexual intercourse before full erection of the penis. Given its design, the female condom covers both the internal and external genitalia, thereby providing greater protection against sexually transmitted infections [16]. The female condom does not need to be removed immediately after ejaculation, providing for greater intimacy after intercourse (with the male condom, the potential for the condom's slipping off a flaccid penis is obviously great).

Surely, information from our study delineates that most women, especially in Nigeria are willing to take risks associated with an imperfect method to try to protect themselves. As such, women will look for what they perceive to be valid physical evidence, however valid it may be. However, to the extent that women are misled by mistaken perceptions of physical evidence or gaps in their applicable knowledge base, they may expose themselves to increased danger, a case of falling from frying pan to fire. These women who by this attitude are asking for advice on how to re-use the female condom can no longer remain defeated at the international level by the recommendations of microbiologists, for whom the standards of hygiene were more important than the number of women who get infected with STIs every minute. A separation of realities, it is. Indeed, for providers of the female condom, the time is now to shape responses to reuse for the better, rather than leaving women to devise their own common sense solutions. After all, the failure of recent trials to show the efficacy of new microbicide candidates and the diaphragm makes the promotion of female condom a life-saving intervention than ever.