The public health rationale for condom use in the refugee setting is compelling, as refugees are particularly vulnerable to HIV and sexually transmitted infections (STIs). Social dislocation, economic deprivation, increased sexual violence, lack of access to medical services, increased transactional sex and increased contact with potentially infected populations put refugees, especially women, at heightened risk.
The female condom is a loose-fitting polyurethane sheath. It has an inner ring, which is inserted into the vagina and keeps the condom in place, and an outer ring, which remains on the outside of the body. Inserting the device correctly takes some practice. The female condom is currently the only available form of woman-initiated protection against HIV. Produced in the UK, it is about ten times more expensive than the male condom. It is marketed for single-use only, but the World Health Organisation has outlined a cleaning procedure for re-use (up to five times) for cases where resources are limited and no other alternatives for sexual protection are available.
In order to promote the female condom more successfully, experiences were reviewed in thirteen country programmes, and interviews and workshops were conducted with refugees and NGO staff in Kakuma refugee camp, Kenya.
The main outlets for condom provision are through STI and family planning clinics, peer educators and community health workers, and condom dispensers. Many additional potential outlets for condom provision remain unutilised. These include: Prevention of Mother-to-Child Transmission services; support programmes for vulnerable women, the mentally impaired, orphans and vulnerable children, and commercial sex workers; home-based care and supplementary feeding programmes for HIV/AIDS patients; traditional birth attendants and healers; drug shops; links to women’s sanitary pad distribution; and dispensers sited in bars, clubs, beauty salons, schools, vocational centres, youth centres, food distribution centres and public latrines.
Uptake obstacles
Most NGO staff and refugees have never seen a female condom. In Kakuma initial reactions varied from enthusiasm, surprise and awe, to scepticism and fear. There is still much distrust and stigma associated with condoms. Stories of women dying because of male condoms lodged inside their vaginas, of men piercing the tip of condoms, of condoms breaking and of Western plots to lace condoms with HIV are common. There are wide gaps in basic knowledge on HIV/AIDS transmission (“if a man eats a lion with HIV, will he get HIV?”), adolescent development (“how will a young woman’s body develop if she doesn’t come in contact with men’s protein in semen?”) and reproductive anatomy (“won’t the female condom disappear inside the woman’s body?”). Unequal gender dynamics and traditional cultural practices prevent many women from introducing the female condom into their relationships. Many women expressed fear and discomfort at the idea of having to insert it. Previous experience with insertive devices such as tampons, diaphragms or cervical caps is limited and self-touching of genitalia is taboo in many cultures.
It is important to:
- make female condoms available through health-related, as well as non-health-related outlets
- develop posters, diagrams and pamphlets tailored to differing levels of literacy and ethnic/cultural backgrounds
- include men in all awareness-raising initiatives as they often remain the final decision-makers in the bedroom
- help women develop condom negotiation skills, for both casual and steady relationships
- encourage women to exchange tips on female condom use and break taboos associated with sex through group discussions
- promote the female condom not just for high-risk groups but for all sexually active men and women who want a method of dual protection, against HIV/STIs as well as unwanted pregnancy
- use peer educators and community health workers to access hard-to-reach groups
- train all health providers, peer educators, social workers and workshop leaders on the female condom to ensure they fully understand it and incorporate it in their activities
- consult key community members, especially when courting controversy by introducing condoms in non-health-related fora
- strengthen funding and coordination of condom provision efforts to ensure adequate supplies and avoid re-use of female condoms
- extend activities to include NGO staff and host communities
- share experiences among field staff to develop good practice which can also be used to inform the provision of future other female-controlled technologies, such as microbicides.[1]
Jacqueline Papo, a former UNHCR Research Intern, is a doctoral student at Oxford University’s Department of Public Health. Email: jacqueline.papo@stx.ox.ac.uk. To obtain a copy of UNHCR’s Female Condom Strategy, email hivaids@unhcr.ch
For online information about the female condom, visit http://www.femalehealth.com/ or www.avert.org/femcond.htm, and also download
The female condom: a guide for planning and programming, World Health Organisation, www.who.int/reproductive-health/publications/RHR_00_8/index.html.
Many thanks to UNHCR staff in Nairobi and Kakuma, and NGO and refugee key informants in Kakuma camp. Special thanks to Marian Schilperoord, HIV/AIDS Technical Officer, UNHCR Geneva.