“We see sexy commercials for Trojan. We see sexy commercials for Durex,” says Jennifer Medina Matsuki, condom availability director for the New York City Department of Health and Mental Hygiene, addressing a breakout session on FC2, the new female condom, at the National Harm Reduction Conference in October. “There was no sexy marketing. People would see it at various events and say, 'What is that?'”
FC2 was approved by the Food and Drug Administration in 2009, and bears considerable advantages over both its predecessor and male condoms—namely, they put more power in the hands of the receptive sex partner and feel better than the first female condom, also lacking its trademark rattling sound—but is still a minor player in the world of safer sex.
Matsuki's department started stocking the first female condom in 1998, seven years after its introduction, and now buys 1.5 million female condoms per year, compared to 35.5 million male condoms. Worldwide, FC2s account for just 1.6 percent of total condom distribution. So far, there's just one manufacturer, as opposed to the dozens of male condom manufacturers, though other companies—such as Origami, which is working on insertable condoms for both anal and vaginal sex—have devices in development. Where FC1 was advertised aggressively in women's magazines—only to be mocked in the same publications as a noisy, awkward novelty—FC2 has been sold via social media and gatekeepers at public health organizations. But it's yet to shrug off FC1's bad rap.
The more people one has to talk to about contraceptive options, the less daunting it is to try new options. Even those whose friends had tried the condom but didn't recommend it were more likely to try it than those who hadn't discussed it with a peer group.
While FC2 is available for purchase online and at some Walgreens stores, the Female Health Company (FHC), which manufactures and distributes it and did the same with its predecessor, has largely focused marketing efforts on public health departments at home and abroad. The consumer-oriented website, though, contains information specifically for potential female buyers, selling FC2 as a sleeker, sexier upgrade from the condom marketed as Reality and now often referred to as FC1, which not only looked like a plastic bag, but sounded like one, too. (“It made a lot of noise. It was super weird,” says my friend Megan, who tried the first female condom in the mid-2000s while working at Planned Parenthood.)
FC1 was also expensive. It came in boxes of three or six, priced at $7.50 and $15 respectively ($12.86 and $25.73 in 2013 dollars), making it something more than just a casual purchase. FC2, by comparison, is cheaper, but still retails for $6.49 for a box of three, making it more expensive than traditional condoms.
A marketing campaign targeting doctors and an ad campaign in magazines was a flop, and, for the most part, FC1 languished on clinic and drugstore shelves.
In the late 1990s, FHC founder Mary Ann Leeper looked into the reasons FC1 wasn't thriving. First, there was the fact that women in the target demographic weren't diligent about safer sex in the first place, likely because they didn't see themselves as likely to get STDs. Second, she found that clinicians rarely recommended the product in their offices, so only the patients who asked for it got it—and few did.
WHERE FC1 WAS MADE of polyurethane, FC2 is made of nitrile, just like the gloves most doctors' offices stock these days. It consists of two flexible rings of different sizes, with the larger one fitting over the labia, providing a little extra stimulation for the clitoris and the base of a penis shaft. Where traditional condoms have to be stretched out over an erect penis, receptive partners can insert FC2 and leave it in for up to eight hours safely. Public health organizations at home and abroad have focused on getting FC2 into the hands of sex workers, as well as women in countries with high rates of HIV infection, where the use of traditional condoms is minimal despite abundant availability. The long life span mitigates a lot of the awkwardness associated with traditional condoms: there's no waiting until the male partner is fully erect and no negotiation about whether a condom will be used in the first place.
And women aren't the only target demographic for the female condom. Despite the name, and the fact that FC2 comes in purple packaging emblazoned with a pink female symbol, transgender people and men who have sex with other men are the focus of many agencies' FC2 campaigns.
D.C.'s Doin' It, an FC2 education campaign in the nation's capitol, asked clients to fill out a survey about how the device is marketed. (The survey is now closed, and the campaign did not respond to an email asking about the results, or with whom results were shared.) This video, created for a program in Burkina Faso, provides animated instruction on how to use FC2 anally, and the Chicago Female Condom Campaign's website features photos of grinning men and women holding up signs that explain why they love the device.
“We have, since day one, been promoting it for men and women,” said Jacqueline McCright, the San Francisco Department of Public Health's director of community-based STD services.
That's an off-label use, albeit one acknowledged in Female Health Company's provider-facing training materials. The FDA hasn't approved FC2 for anal sex—but then, that's true of traditional condoms as well. The agency’s consumer guide to STD prevention officially recommends avoiding anal sex altogether, saying condoms may be more likely to break during anal activity because of the greater “friction and other stresses involved.” In fact, the research on condoms' efficacy at preventing HIV transmission during anal sex is minimal—comprised of just two studies, a major longitudinal evaluation performed in 1989 and a 2006 survey of gay men at a major HIV clinic in Seattle.
While those studies found reduced rates of HIV transmission (by about 76 percent) among men who used condoms most of the time, the paucity of research on traditional condoms and anal sex suggests the Female Health Company—and other companies with female condoms in development, like Origami, which has created a receptive-partner anal condom that will complete clinical trials this fall—has a long fight ahead if they want to label and sell their devices as a way to reduce STD transmission. Catherine Boland, media and communications director at FHC, says researchers would have to assess not just the safety and effectiveness of FC2 itself, but create testing procedures that would confirm the effectiveness clinically.
DAVID HOLTGRAVE, THE LEAD author of a 2012 paper evaluating the cost effectiveness of a female condom promotion campaign in the D.C. area, attributes the limited popularity of FC2 to a lack of broadly available information and ongoing misconceptions about the product.
A 2009 paper assessing the role of conversation networks on male and female condom use found that knowing at least one person who regularly uses and recommends the female condom influences our likelihood of doing the same. And having dense conversation networks—that is, having people to talk to about contraceptive choices who also regularly talk to each other—increased the likelihood of using female condoms as much as elevenfold, with people who had at least three to five people in their conversation networks being far more likely than those who discussed contraceptives with only one or two people. The authors suggested that's because of the relative novelty of the female condom: The more people one has to talk to about contraceptive options, the less daunting it is to try new options. Even respondents who said their friends had tried the female condom but didn't recommend it were slightly more likely to try it than those who hadn't discussed it with a peer group.
That paper, which assessed a handful of studies from around the world, called for further research to pin down the specific social factors that contribute to decisions about which contraceptives to use. But it suggests FC2's best chance for success is to get it into the hands of the right people—that is, those who are more likely to try new contraceptives and tell their friends. FHC has chosen not to run any traditional advertising, instead training gatekeepers; distributing FC2s for free at coffee shops, fairs, and salons; and maintaining a social media campaign. That jives with the research. But the buzz has been so quiet that my friend Megan—who's now studying to become a physician's assistant and is as clued in to new developments in sexual health as anybody I know—didn't realize the product had been upgraded until I mentioned I was working on a story about it.
There's also a learning curve associated with insertion, or as my friend Megan says: “They're definitely a little bit awkward. You pick them up and you're like, 'What do you do with this thing?.'” McCright, the San Francisco-based public health worker, says her department sets up displays at fairs with anatomical models to show how they're inserted, which invite a conversation: “You don't start off knowing how to use a female condom,” she says. But traditional condoms aren't completely intuitive, either. And taking a pill every day, inserting a NuvaRing, checking for IUD strings—we're not born knowing how to do those things, either, but we pick them up pretty quickly once we commit to the method.
“There's a learning curve with everything, but when you're an adult, you work it out,” Megan says.