1. Understanding negotiation and use of female-controlled barrier methods
American Public Health Association th Annual Meeting and Expo November Washington DC
Marieke van Dijk, MD, Regional Associate Co-investigators:
Diana Lara
Sandra García
Daniel Grossman
Jhoanne Muñoz

2. Overview Background Methodology Results Conclusions Female condom
Diaphragm
Use
Negotiation
Acceptability

3. Female-controlled barrier methods
Women suffer from serious consequences of STI’s (PID, ectopic pregnancy, infertility, cervical cancer)
Vulnerable populations (e.g. sex workers) more affected and often unable to negotiate male condom use
Renewed interest in diaphragm and women-friendly microbicides

4. Methodology
Two study sites in Dominican Republic (Puerto Plata and Santiago)
In-depth interviews with
18 female sex workers
22 male sexual partners (7 regular partners, 15 new clients)
Analysis of transcriptions by two researchers
Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex)
Even distribution among PP and S
Male respondents recruited through sex establishment where most sex workers worked whoparticipated, they would bring a client
Regular partners through NGO’s
DR: female sex workers , sex work is very common, larger cities and tourist areas, DR does not explicitly criminalize sex work. Sex workers have higher prevalences of NG (2-6% general pop: 0,8%), CT (15-16%, general pop. 7.2%) and HIV (7-12%, general pop. 2,8%. (report 2003)
All with counselling
30 male and 30 female condoms, 1 diaphragm
243 sex workers completed study
Group 1: 1st month only male and female condoms, 2nd month also diaphragm
Group 2: all methods at 1st visit
4 months; monthly follow-up interviews by trained staff on experiences
Recruited with help of three local NGO’s: COIN, CEPROSH and MODEMU, work with sex workers and people living with HIV; also worked with public health services of the DR that usually perform routine STI checks on sex workers|
Criteria: working in sex industry, self-identified as sex worker
Recruited from direct and indirect sex establishments

5. Results
Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex)
Even distribution among PP and S

6. The female condom (FC)
Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex)
Even distribution among PP and S

7. FC: Use 12 women were frequent users (good experiences)
2 had difficulties inserting it
All 22 men had at least one experience with the female condom

8. FC: Negotiation Three strategies:
Give both options (male and female condom)
Negotiate the female condom when men refuse male condom
Use the female condom secretly
3 of the 7 women who use it secretly, did this only with clients, not with regular partners
Possible because often drunk

9. FC: Acceptability – men’s attitudes
According to women:
Reluctance, but they accept after explanation
They like it, as they don’t need to use a male condom
They get angry and mistreat the women
According to men:
High satisfaction with female condom!
3 of the 7 women who use it secretly, did this only with clients, not with regular partners

10. FC: Advantages According to men: According to women:
Protection against all diseases, including HIV (12)
Comfortable (male condom is tight)
Feel more ‘free’, more natural
According to women:
Women feel protected (18)
Beneficial for their business (6)
They have ‘the control’ (5)
Protection against pregnancy (4)
Comfortable (3)
No rests of lubrication gel inside of vagina (1)
protection against all diseases, including HIV (18)
Stronger, thicker material; it cannot break (6) men: Stronger material (12)
It covers ‘all’ (2)

11. FC: Disadvantages According to women: According to men:
Looks ugly (5)
Strange noise while having intercourse (2)
Excess of lubricant gel (2)
‘Penile misrouting’ (2)
Irritation of the skin (1)
According to men:
Unfamiliar method, more confidence in male condom (3)
Ugly because big size, visible outside ring
Penis went between outer ring and vaginal wall

12. The diaphragm
Regular partners: boyfriends, husbands (no paid sex), regular clients (paid sex)
Even distribution among PP and S

13. Diaphragm: Use 10 women reported frequent use
Often tried out with regular partner first (5)
3 women had problems inserting it 1st time
3 women non-compliance with 6 hrs interval after intercourse
2 women accepted sex without male condom
8 men had experience with the diaphragm (1 client, 7 regular partners)
10 frequent use (good experiences)
Without condom: 1 husband and 1 client

14. Diaphragm: Negotiation
Regular partners
Were told about use diaphragm (before or after intercourse)
Secret use
Clients
Insert it before going to work or before intercourse in the bathroom

15. Diaphragm: Acceptability - men’s attitudes
According to women:
They accept after explanation of method
They like it, as they don’t need to use a male condom
They get angry and mistreat the women
According to men:
OK, but not very safe
3 of the 7 women who use it secretly, did this only with clients, not with regular partners
Men’s reactions (when told) according to women:

16. Diaphragm: Advantages
According to men:
Protection against pregnancy (5)
Protection against diseases, including HIV (3)
No need to use male condom (2)
According to women:
Back-up method against diseases (10)
Can be used without knowledge men (10)
Can be used during menstruation (6)
Comfortable (5)
Protects against pregnancy (2)
when men refuse use male condom or when condom breaks

17. Diaphragm: Disadvantages
According to women:
Pain, irritation, discomfort (6)
Lack of confidence in protection against diseases; does not protect against HIV (4)
Has to be left in vagina for six hours (3)
Some men can feel it (3)
Problems according to men:
Lack of protection

18. Conclusions
Introduction female-controlled barrier methods improved women’s options to have protected sex
Acceptability of female condoms is high for women and men
Diaphragm use seems higher with regular partners than with clients

19. Conclusions (cont.)
More data are needed on condom migration after introducing female-controlled barrier methods
Strategies are needed to disseminate information on female-controlled barrier methods among clients and regular partners

20. THANK YOU! mvandijk@popcouncil.org.mx
Acknowledgements:
Ibis Reproductive Health
PSI
USAID – DR
Leticia Fernandez
Hector Jerez
Francisco Paz
Local partners:
CEPROSH
COIN
MODEMU
Profamilia