The future of safe sex安全性行为的未来.docx

The future of safe sex安全性行为的未来.docx

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Thefutureofsafesex安全性行为的未来

MOSAIC@FUTURE|4March2014

Thefutureofsafesex?

 EmilyAnthes

From Mosaic

Thefutureofsex:

canthefemalecondomcatchonsecondtimearound?

Oncemockedashavingtheeroticappealofajellyfish,thefemalecondomisbeingreinventedasthenextbigthinginprotectivesex.InthefirstarticlefromnewdigitalpublicationMosaic,EmilyAnthestakesanin-depthinvestigationtoseewhatchanceithasofcatchingonthistimearound.

In1987,anAmericanpharmaceuticalexecutivecalledMaryAnnLeeperflewtoCopenhagentogetafirst-handlookatwhatshethoughtmightbetheworld’snextgreathealthinnovation.Shedidn’texpecttofindittuckedawayinsideanoldcigarbox.

WhenshearrivedattheoldfarmhouseownedbyDanishdoctorandinventorLasseHessel,heopenedthedoorwithacigarinhismouth.Thenhefetchedthebox.“Insidewereallthesebitsandpieces–metal,plastic,alldifferentkindsofstuff,”Leeperrecalls.“Itookadeepbreathandthought,‘Holymother–whathaveIgottenmyselfinto?

’”Somehow,thesebitsandpiecesfittogethertoformacontraptionthatwomencouldwearduringsextopreventpregnancyandsexuallytransmittedinfections–theworld’sfirstfemalecondom.

Thepresentationmayhavebeenunconventional,butLeeperandhercolleaguesatWisconsinPharmacalhadhighhopesforHesse’sinvention.“TheAidscrisisintheUnitedStateswasjustfullybeingrecognised,anditwascleartousthatforwomentohaveaproductthattheycouldusetohelpprotectthemselveswouldbeagoodthing,”Leepersays.

Indeed,whenWisconsinPharmacalfinallyintroducedthefemalecondomtotheUSin1993,publichealthexpertshaileditasagame-changer.Thecondom,apolyurethanepouchinsertedintothevaginabeforesex,wouldprotectwomenfromsexuallytransmittedinfectionseveniftheirmalepartnersrefusedtowearcondoms.

Technically,thefemalecondomworks.Whenusedcorrectly,itreducesawoman’sriskofcontractingHIVbyaround94–97%eachtimeshehadsex,accordingtoestimates.Studiesshowthatmakingfemalecondomsavailablealongsidethemaleversionincreasesthepercentageofsexualactsthatareprotected,anddecreasestheprevalenceofsexuallytransmittedinfections.

Yet,twodecadesafteritsmuch-celebratedintroduction,thefemalecondomstillisn’tlivinguptoitspotential.Lessintuitiveandfamiliarthanthemalecondom,thedevicesimplynevercaughton.Journalistsmockedit,cliniciansignoredit,andwomenshunnedit,claimingthatthecondomwasaestheticallyunappealingandtechnicallydifficulttomaster.Today,only1.6%ofallcondomsdistributedworldwidearefemalecondoms.

Theremayfinallybeanopeningtochangethefemalecondom’sfate.Foryears,ahandfulofresearchers,engineersandentrepreneurshavebeenquietlytinkeringwiththedevice.Theireffortsarenowmaturingandanassortmentofredesignedandreinventedfemalecondomsarebeginningtomaketheirwayontothemarket.Theintroductionofnew,moreuser-friendlyproducts–coupledwithrenewedeffortstopromotethetechnologyaroundtheglobe–mayfinallybepositioningthefemalecondomforabreakthrough.

Barrierprotection

Fromthestart,thefemalecondomwasadifficultproject–farmoredifficultthanLeeperhadbargainedfor.Afterbuyingtherightstothetechnology,LeeperandhercolleaguesatWisconsinPharmacalneededtoturnHessel’sprototypeintoamarketableproduct.Aftersometweaking,theyendedupwithathinpolyurethanepouchwithaflexibleringateachend.Awomanwouldinsertthedevicebysqueezingtheringthatsitsintheclosedendofthepouchandpushingitintohervagina.Onceexpandedinsidethevagina,thisinnerringwouldkeepthecondominplace.Thelargerringattheopenendofthepouchwouldsitoutsidethevagina,coveringtheexternalgenitalia.Whenamanejaculated,theinternalcondompouchwouldtraphissemen,preventingpregnancyandsexuallytransmittedinfections.

ButbeforeWisconsinPharmacalcouldputthecondomonthemarket,theyneededapprovalfromtheUSFoodandDrugAdministration（FDA）.Becausethefemalecondomwasanutterlynewkindofproduct,theFDAdecidedtoregulateitasaClassIIImedicaldevice,acategorythatisgenerallyreservedfor“high-risk”medicalequipment–suchaspacemakersandcertainlasers–andthatrequiresthehighestlevelofregulatoryscrutiny.（TheFDAclassifiesmalecondomsasClassIImedicaldevices,sotheyaresubjecttofewercontrolsanddon'trequirepre-marketapproval.）

Thefemidomismuchbiggerthanmalecondomsbutcanbemoredifficulttoapply（SciencePhotoLibrary）

Ittooksixyearsforthefemalecondomtowinditswaythroughtheregulatorysystem,andwhenthegovernmentfinallyapprovedit,in1993,Leeperbreathedasighofrelief.“IthoughtthatthehardestpartwasgoingtobegettingitthroughFDAbecauseitwasreallydifficultandtheykeptchangingthespecifications,therequirements,theclinicalstudies,”shesays.Butshewaswrong.Thehardpartwasjustbeginning.

AsWisconsinPharmacalpreparedtolaunchtheRealityfemalecondomintheUS（itwouldgobyotherbrandnamesinothercountries）,theymadeallthestandardarrangements,hiringsalesrepstovisitmedicalpracticesandcommissioningabigadvertisingfirmtomarkettheproductdirectlytoconsumers.“Wedidallthechecklistthingsthatyou’resupposedtodo,”Leepersays.“Andwefellflatonourface.”

Thechallenge,inpart,wastheera,andthepublic’ssqueamishnessaboutasex-relatedproduct.“Inthosedays,youcouldn’ttalk‘condom’outloud,”Leeperrecalls.“Malecondomswerereferredtoas‘rubbers’.Yousaidtheminawhisperandtheywereheldbehindthecounterbythepharmacist.”AndalthoughtheAidscrisiswasraging,formanyAmericanwomen,theriskofcontractingHIVwasabstract,somethingthathappenedtootherpeopleandnottothem.Whilewomeninfocusgroupshadsaidtheylikedthe idea ofthecondom,accordingtoLeeper,“whenpushcametoshove,whentheywereinthatbedroom,thefemalecondomwasoutonthedining-roomtable”.

Therewereotherbarriers,too.Thecondomscostasmuchas$5apiece,comparedtomalecondoms,whichcantypicallybehadfor$1orless.KrissyFerrisrecallshearingaboutfemalecondomswhenshewasastudentatOberlinCollegeinOhio,butthepricewasadeterrent.“Ididn’tactuallytryoneuntilIgotfreesamples,”recallsFerris,whonowworksatamedicalpracticeinCleveland,Ohio.“AmIgoingtobuy$6worthofcondomstotrythisoutacoupletimes?

Itseemslikemaybenot.You’regettingmalecondomsforfreeeverywherewhenyou’reinyour20s.”

Screamtest

What’smore,thefemalecondomwas,frankly,strange.Unlikethemalecondom,whichissoldrolledupandcompressed,thefemalecondomcamefullyopen.Womenandmenalikewereturnedoffbytheunfamiliar,big,plastic-bag-likedevicetheyfoundwhentheyundidthepacket.Thoughsomewomendideventuallycometolikethecondoms,therewasadefinitelearningcurveandasmanyasone-thirdtoone-halfofwomenhaddifficultyinsertingthem.Onceinplace,thecondomhadatendencytosqueakorrustleduringsex.

Themediapouncedonthesecomplaints,andutterlyskeweredthefemalecondom.Theyridiculeditsaestheticswithseeminglylimitlesscreativity.AssociologistAmyKalerrecountsinher2004paperonthecondom’sintroduction,journalistscomparedtheproductto:

“ajellyfish,awindsock,afirehose,acolostomybag,aBaggie,gumboots,aconcertina,aplasticfreezerbag,somethingtolineBoston’sInnerHarborwith,acrossbetweenatesttubeandarubberglove,EdvardMunch’sTheScream,somethingdesignedforafemaleelephant,somethingoutofthescience-fictioncartoonTheJetsons,araincoatforaSlinkytoy,ora‘contraptionusedtopunishfallenvirginsintheDarkAges.’”

TheoriginalDanish-designedfemalecondomhasledtorangeofproducts（PhilCoomes/BBC）

Thoughthemediatreatmentwasespeciallyharsh,journalists“werepickinguponwhatweregenuinedesignissuesofthefirstgenerationofthefemalecondom,”saysKaler,anassistantprofessorattheUniversityofAlbertainCanada.“Itwasn’tthemostbeautifulthingintheworld.Itwaseasytomakefunof.Itwaskindoflaughedoutofexistencebeforeitreallygotachancetotakeoff.”

Still,thereweresignsthatWisconsinPharmacalwasontosomething.In1995,twoyearsafterbringingthecondomtomarket,LeepergotacallfromanofficialatZimbabwe’sMinistryofHealthandChildWelfare.ThehealthworkerhadreceivedapetitiondemandingthatthegovernmentofZimbabwebringthefemalecondomintothecountry.Ithadbeensignedby30,000women.

ThoughLeeperhadinitiallyenvisionedsellingthefemalecondominAmerica’sprivatesector,thecallfromZimbabwe,coupledwiththecondom’spoorreceptionintheUS,promptedthecompanytoshiftcourse.

Internationalnonprofitgroupsandaidorganisationshavelongbeenbigbuyersofmalecondoms.TheUnitedNationsPopulationFund（UNFPA）,theUSAgencyforInternationalDevelopment,PopulationServiceInternationalandothersregularlypurchasemalecondomsinbulkandthendonatethem–orsellthematadeeplysubsidisedprice–toclinicsandprogrammesthatserveparticularlyhigh-riskpopulations.

In1996,WisconsinPharmacalchangeditsnametotheFemaleHealthCompanyandbegantofocusonthisglobalpublicsector,workingwithgovernments,globalhealthorganisationsandaidagenciestogetthecondomsintothehandsofat-riskwomeninlow-incomecountries.Thefemalecondombecameaparticularlyimportanttoolinseveralcountriesinsub-SaharanAfrica,where,intheearly2000s,60%ofnewHIVdiagnoseswer