What Is the Future of the Female Condom?
"I was scared to try it at first."
That's what Roxanne Lewis, who runs the women's sexual health education program at the JWCH community health network in Los Angeles, says about the female condom, the synthetic nitrile sheath (which can go in either the vagina or the anus) she now spends much of her work time trying to get women and some men to try.
But when she finally did, she says, "It was like fireworks went off!"
Yes, she insists: Contrary to what you may have heard about the female condom --which has been around in various incarnations for about 25 years but is so unpopular that it accounts for less than .03 percent of all types of contraception used, according to a 2012 Centers for Disease Control and Prevention study -- it was that good.
"With the male condom," she says, "I could feel the barrier." Moreover, she says, with the male condom: "Everything was predicated on this other person. I had to wait for them to put it on, make sure it wasn't coming off their body." She says of the FC2, the model of female condom that in 2010 replaced the old, thicker, squeaky polyurethane version: "This is a lot better, more natural. You can do any position you want with it. I prefer it."
Lewis's feelings are echoed by Teresa Sullivan, an openly HIV-positive activist in Philadelphia, Pennsylvania, who works with HIV-positive folks newly released from prison. She knows that because her HIV is undetectable, she won't give her HIV-negative husband HIV. And, she says, they don't exactly have an open relationship. But he's on the road a lot, and she says she prefers to "be real with him and myself" -- acknowledging that either of them might have an extramarital dalliance -- when it comes to the chance of other sexually transmitted infections (STIs).
So, when he comes back home, before they go for their ritual his-and-hers STI tests and get an all-clear, she uses the FC2, partly because her husband doesn't like male condoms.
"It enhances my feeling when it gets heated up and hits the vagina walls," she says. "It feels good."
Both Lewis and Sullivan admit that there are women out there they've met through their work who don't like the female condom. "Many have told me they think it's too much work," says Sullivan. But they both say they've made converts out of many women (and men) -- and that there would be many more if Veru, the company that makes the FC2, currently the only female condom available in the U.S., would advertise it the way insertive condoms are advertised: in magazines and on TV, billboards, and other outdoor placards.
Related: The Right Way to Use a Female Condom
Reboot or Setback?
But in June, according to female condom activists, Veru put another nail in the FC2's coffin when it switched drugstore access from over the counter (like male condoms) to prescription only. (It also now allows people to buy directly online or to get a prescription through a $1 online-prescription app Veru has partnered with called HeyDoctor.)
Brian Groch, chief commercial officer for Veru, says it took the product off shelves because sales were abysmal (as bad as a total of $12 in sales in one large retail chain in the past two years, Veru previously told TheBody.com). He also says that Veru hopes that, now that the product is available via prescription, health care providers will start promoting the FC2 with their patients. He says that Veru has 14 sales reps out there doing workshops with OB-GYNs and health agencies nationwide. However, he says that a classic TV-based ad campaign of the sort advocates are calling for would cost around $10 million, and Veru simply doesn't have the money. "It would be awesome if we did, but we don't."
Upon announcing the change last summer, Veru said that anyone who has health insurance should be able to get the product free under the Affordable Care Act's mandate of free birth control.
But Lewis and Sullivan are among advocates who worry that the product will now no longer be affordable for those without both a health provider to write a prescription and insurance. (Groch says that anyone can get a prescription via the HeyDoctor app. With the prescription but no coverage, it could cost as much as $20 per unit, up from about $3.50 per unit before the switch.)
Moreover, President Trump has since rolled back the free birth-control mandate within Obamacare, which remains under various other forms of attack from the president and possibly Congress. But Groch notes that more than half of states have their own birth-control-coverage mandates and that people in states who don't can still get FC2s free through departments of health and community-based agencies. (See more on that below.)
Despite all this, more than 200 members of the National Female Condom Coalition have sent a letter to Veru demanding that the company not only make the FC2 over the counter again but also lower its per-unit price and dramatically invest in promotion, education, and advertising around the product.
"We don't disagree with Veru that sales are poor, but we disagree with why," says Jessica Terlikowski of AIDS Foundation of Chicago, who coordinates the coalition. "They have never invested in social marketing or advertising, so this is a self-fulfilling prophecy. People don't know about it, so they're not buying it."
Groch says that Veru is doing everything it can for a small company (four main staffers plus the 14 reps in the field) to promote it. It is trying to seed over social media a very naughty video to appeal to millennials and stories like these on sites such as Huffington Post. However, he says that Veru simply can't afford TV and magazine ads.
Whether or not it's promoted well, says Terlikowski, the product should remain on shelves. "By making the product available in fewer places, we're reducing access," she says. "And by making providers gatekeepers to it, we're hurting women, and that's not really acceptable."
However, drugstores are not the only route to the FC2, especially in large and midsize cities: Both Veru and female condom advocates confirm that most people (with vaginas, rectums, or both) who access FC2s in the U.S. pick them up at various urban departments of health, community-based orgs or HIV/AIDS agencies, which have long distributed FC2s free alongside male condoms and lubricants.
In Los Angeles, Lewis says that part of her job is promoting education and free access to the FC2 within both her own community health network -- which she estimates reaches out to about 700 women a year -- and the city's health department. However, she admits that not even all of her own health network's clinics have agreed to offer the FC2. "Even internally, we get people who don't embrace things that are new," she says.
In New York City's health department, for the past eight years Jennifer Medina Matsuki, M.P.H., has overseen the free distribution of condoms, female condoms, and lubricant at health and community agencies citywide. Currently, she says, the city distributes about one million FC2s annually to about 1,000 venues. (That's about 1/36 the number of male condoms the city distributes, she adds.)
She says she does not have numbers on the pick-up rate or popularity of the FC2. But, she says that surveys indicate that users find it, in her words, "a different experience." In her experience, "They say that it took a little bit of getting used to, having to use it two or three times and practice, like with a tampon, but then they love it." She, too, thinks that the product's underuse is partly related to how little it's been promoted.
Veru recently stopped using a third-party vendor to supply FC2s to community agencies at a discount and is now providing them directly. But Groch says they will continue to be steeply discounted, at well under $1 a unit. (Lewis says that her L.A. agency currently pays $800 for 100 FC2s.)
Groch also says that Veru is committed to getting free FC2s in as many departments of health and community venues nationwide as possible and is in the process of asking such venues permission to include them in a state-by-state directory on its website -- which he says he hopes to have online in a few weeks.
"Advocates are saying we're decreasing access and that we're greedy," he says. "That's totally inaccurate. Some people just don't want to listen to what we say."
The FDA Classification
But advocates insist there's another factor here blocking access: The FC2's U.S. Food and Drug Administration (FDA) classification as a medical device (akin to breast implants), when it should be "down-classified" to the same easy access level as a male condom. Thus, advocates petitioned the FDA to follow up on its two-year-old promise to do just that. And in late November, the FDA indeed told advocates that it would propose such a change and provide a 90-day public comment period.
Such a move, says Terlikowski, would allow foreign makers of competing female condoms to do business in the U.S., where Veru holds the only patent on the product. But, were that to happen, says Groch, advocates would essentially be making contradictory demands. "You can't ask me to [compete with other makers and] sell FC2s for 30 cents a unit -- and then you want me to do a $10 million marketing campaign?"
And there's the rub. Both advocates and Veru agree that people need more awareness of and information about the long-maligned female condom (whose inner cervical ring, by the way, pops out for anal use). They just disagree on whose job it is to promote it.
"Our stance is that the company should be doing more," says Terlikowski.
Regardless of who should be doing more, it would be interesting to watch the female condom have a second chance in the U.S. Perhaps then more women (and men) would come to agree with Lewis, who insists, "They feel phenomenal!"