Think safe sex means boring sex? Think again — especially if you make internal condoms part of your play kit.
South Africa has one of the largest public-funded condom distribution programmes in the world — since 2018 the government has aimed to, each year, distribute 850 million male (external) condoms and 40 million internal (female) condoms to public health facilities.
But not enough people are catching on to internal condoms. The health department dispersed about 16.3 million (40%) internal condoms annually from the 2018-19 to 2020-21 financial years, department figures show.
“We have more than enough stock to distribute 40 million internal condoms a year — our depots are full,” said Thato Chidarikire, the department’s director of HIV prevention. “But the community uptake at our clinics and hospitals is low and this affects the demand and distribution targets.”
Regarding the workings of an inner condom, which have been available at public health facilities since 1998, think of the external version inside out, quite a bit wider and with a ring at both the closed and open ends. The inner condom is inserted either in a person’s vagina or anus before sex. The ring at the closed end, which is slipped inside the body, ensures that the device fits snugly (although people generally remove it for anal sex) and the ring at the open end (which is visible from outside the vagina or anus) keeps it in place during sex.
The World Health Organisation (WHO) started to recommend internal condoms in 1996 to promote safe sex.
Like the external condom (aka the male condom), the internal version is a dual barrier device, meaning it works as a contraceptive and protects against sexually transmitted infections (STIs).
Although the WHO says internal condoms are slightly less effective than their external counterparts in protecting against pregnancy, they give women and transgender men significantly more control over their use, because they’re the ones wearing these condoms.
Qualitative studies have shown that some women are can use inner condoms in situations where they cannot negotiate external condom use because they can be inserted a few hours before sex. And because inner condoms don’t depend on an erect penis (male condoms do), they can be useful to women whose sex partners are under the influence of drugs or alcohol.
But inner condoms are more expensive than their external counterparts. In the private sector, an inner condom costs about R17 (it can only be used once) and a standard Trust external condom about R4. In the public sector the price difference is even greater: Chidarikire says the health department procures internal condoms for about R7.50 each and external condoms for 50 cents a condom. Inner condoms are available for free at public healthcare clinics.
So why not just stick with male condoms?
Just like with contraception, condom research shows the more condom choices available, the more likely people are to use them. One study found the chances of someone getting STIs such as gonorrhoea or chlamydia drop by more than a third when they have a choice of both external and internal condoms.
Why aren’t there more people using inner condoms?
The price factor plays a part, but there’s more. Many people don’t know where to find inner condoms, a 2018 evaluation of the country’s government-funded inner condom programme found. External condoms are more available than inner condoms at government facilities, especially in waiting areas (outside of consultation rooms).
The assessment’s authors say this means the uptake of internal condoms therefore strongly relies on health workers promoting them and their willingness to offer such condoms to their patients and to explain how they work.
But this was hampered by the fact that just more than a third of health workers who participated in the study, and who were trained on how to use inner condoms, had never used the condoms themselves and had questionable attitudes towards them. Some (40%) described inner condoms as “weird”, “messy” (42%) or “inconvenient” (28%).
When patients did ask for inner condoms, and health workers had to explain how they work, equipment was often lacking: for external condom demonstrations most facilities (78%) had dildos to demonstrate how they work, but only 22% of the sites had pelvic models they could use to show how inner condoms work.
So it’s not surprising the evaluation found that although nine out of 10 people interviewed had heard of inner condoms, only two out of 10 had tried them. Only two-thirds knew that they could ask for them at their clinic or health facility.
Yet inner condoms can spice up your sex life.
It takes some practice to use an inner condom but once people got past the “getting used to it” phase, they said they like them — a lot. Of about 600 women in the South African evaluation, almost 90% said their partners were happy after having used them for a month. And after six months, most partners were on board. In fact, three-quarters of partners said they found the inner condom “better or much better” than the external condom.
Why? Because, users say, the condom is made of a thin, soft material, with some types becoming more pliable when the body’s temperature heats them up. The thin material makes sex feel more natural. There’s also no tightness around the penis (as in the case of using the external condom), it comes with lube, the outer ring can give the clitoris an extra tickle for added pleasure and the inner ring can stimulate the tip of the penis.
So how can the uptake be increased in a country with more than 200 000 new HIV infections, one in five unplanned pregnancies and a government programme that is set to distribute 40 million inner condoms this year?
In addition to better equipping health workers and increasing availability, the messages used to promote condoms need to change. Slogans that focus on using condoms to make sex less “risky” or stay away from it altogether (think “No glove, no love” or “Be wise, condomise”) constrain frank discussions about sexual health and wellbeing in a society that has traditionally seen talking about sex as taboo.
Ideas of pleasure and choice are rarely at the heart of conversations about sexual health. We’re taught not to prioritise our pleasure, sending the message that there is something wrong with enjoying sex, asking for it or deciding for yourself what sex and pleasure is.
Yet sexual pleasure is considered a sexual and reproductive health right; the World Association for Sexual Health says it is the “human right pertaining to sexuality”. Enjoying sex safely is part of what keeps us sexually healthy, because it adds to our emotional and social wellbeing.
So rather than focus only on functionality and risk, it would be better to add pleasure to the mix to teach people how to protect themselves.
To make that transiton easier, the Global Advisory Board for Sexual Health and Wellbeing has developed a training toolkit. Part of the toolkit is the Pleasuremeter — a chart that maps how much people think things such as safety, confidence, communication, physical satisfaction, expressing their desires, privacy and consent add to their enjoyment of sex. This gives healthcare workers clues about what clients could be most comfortable discussing and what they might shy away from, and so makes it easier to focus on the joy of sex to make it safe.
There’s research to back this approach up. In February, an Oxford University study review, which looked at 33 sexual health projects that put pleasure and fun at the core of safe-sex messaging, found that uptake increased. — Additional reporting by Linda Pretorius and Mia Malan
Tian Johnson is the head of the African Alliance. Pontsho Pilane is the head of communications at the Wits Reproductive Health and HIV Institute. Anna Matendawafa is the head of coordination at the African Alliance. Mamello Sejake is the advocacy and communications lead at the Noncommunicable Diseases Alliance. This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.