A look at female condoms from public school students

Abstract

OBJECTIVE

to find the social representations of female students about female condoms. Methodology: exploratory and descriptive study, with qualitative approach, based on the Theory of Social Representations.

METHOD

94 students from high school students, technical courses, and adult education participated, all from public schools from a municipality in the countryside of Bahia/Brazil, and responded to the test of free word association. The evocations were submitted to the softwares EVOC and IRAMUTEQ.

RESULTS

students recognize that the female condom is a technology that provides autonomy, protects against sexually transmitted infections, and prevents pregnancy. In contrast, they reported that their reasons for not using the method are finding it uncomfortable and strange.

FINAL CONSIDERATIONS

Social representations point to the need for strategies that promote information exchange and stimulate practical knowledge about the female condom among public school students.

Keywords:
Condoms female; Sexuality; Women´s health

Resumo

OBJETIVO

Conhecer as representações sociais de alunas sobre o preservativo feminino.

METODOLOGIA

Estudo exploratório e descritivo, com abordagem qualitativa, apoiado na Teoria das Representações Sociais. Participaram 94 alunas de Ensino Médio, cursos técnicos e Educação de Jovens e Adultos, de escolas públicas de um município do interior da Bahia-Brasil, que responderam ao teste de associação livre de palavras. As evocações foram submetidas aos softwares EVOC e IRAMUTEQ.

RESULTADOS

As alunas reconhecem que o preservativo feminino é uma tecnologia que proporciona autonomia, protege de infecções sexualmente transmissíveis e evita a gravidez. Em contraposição, relatam que o estranhamento e o desconforto são elementos importantes que justificam o não uso.

CONSIDERAÇÕES FINAIS

As representações sociais apontam necessidades de estratégias que promovam trocas de informações e estimulem o conhecimento prático sobre o preservativo feminino entre as estudantes de escolas públicas.

Palavras-chave:
Preservativo feminino; Sexualidade; Saúde da mulher

Resumen

OBJETIVO

Conocer las representaciones sociales de alumnas sobre el preservativo femenino.

MÉTODO

Estudio exploratorio y descriptivo, con abordaje cualitativo, apoyado en la Teoría de las Representaciones Sociales. Participaron 94 alumnas de Enseñanza Media, cursos técnicos y Educación de Jóvenes y Adultos, de escuelas públicas de un municipio del

interior de Bahía-Brasil, que respondieron a la prueba de asociación libre de palabras. Las evocaciones fueron sometidas al software EVOC e IRAMUTEQ.

RESULTADOS

Las alumnas reconocen que el preservativo femenino es una tecnología que proporciona autonomía, protege de infecciones sexualmente transmisibles y evita el embarazo. En contraposición, relatan que el extrañamiento y la incomodidad son elementos importantes que justifican el no uso.

CONSIDERACIONES FINALES

Las representaciones sociales apuntan necesidades de estrategias que promuevan intercambios de informaciones

y estimulen el conocimiento práctico sobre el preservativo femenino entre las estudiantes de escuelas públicas.

Palabras clave:
Condones femeninos; Sexualidad; Salud de la mujer

Introduction

The fact that women have been starting their sexual lives early has contributed for an increase in the risks that they will undergo abortions and acquire sexually transmitted infections (STIs)¹. In 2003, there were advances in the elaboration of policies and directives for the prevention of STIs/AIDS among women in Brazil, but these were limited in their implementation. It should be mentioned that STI prevention through the use of female condoms was only accessible to certain groups of women, such as the ones who go to programs for the healthcare of sexual or domestic violence victims, in addition to those in specialized healthcare services, the others, who are also vulnerable to STIs, being excluded¹.

The distribution of the female condom created stigma and prejudice among the population, both regarding the condom and its public. This embarrassment leads one to direct one's gaze to the feminist experiences in the last decade and may help to see the unknown.

[...] and listen to the silence impregnated by desires and ruptures: from conservative views regarding sexuality; from the hetero-sexism that permeates feminism in health; from the distance between organizations that fight against AIDS; from the convenient collusion within the capitalist, racist, and patriarchal system ^(2:136) .

According to an epidemiological analysis carried out through the Information System of Health Problem Notifications, from 2007-2017, regarding the Human Immunodeficiency Virus (HIV), the Northeast is third in the number of notifications, with 30,297 of the 194,217 found in Brazil. Regarding the age group, 52.5% of the cases affect the young population from 20 to 34 years of age. This is a young, productive, and especially, reproductive population, who deserves attention regarding the risks of vertical transmission. Among 13 and 19 y/o people, the number of AIDS cases is higher among females³.

Still according to the notifications, black or brown women are the most vulnerable to HIV, with 55.9% of cases. Black women are the ones affected the most by HIV, when one considers race/gender indexes. Heterosexuals, young people, women, and those with low income, are the most affected by HIV³.

The articulation of tactics that can reduce the cases of the Acquired Immune Deficiency Syndrome - AIDS, throughout the world, including the implantation and distribution of condoms to more vulnerable groups and the spreading of information, by government organs, about the efficacy, the usage, and the accessibility of these tools for the population. In the first decade of the XXI century, the Ministry of Health in Brazil (MS) became responsible for the acquisition and free distribution of the condoms, but only for women in specific risk situations.

The female condom is a technology that prevents against STIs and aims to promote female autonomy in sexual relations. Additionally, it aims to make it easier to discuss the practice of "safe sex" with a partner. However, a negative opinion from the partner is still a limit in its use, since, in society, gender relations are still asymmetric⁴.

Patriarchal relations still persist in Brazilian society, especially concerning sexual relations⁵. Decisions on the aspects of a sexual relation and of STI/pregnancy prevention, in some cases, are exclusively made by the man, indicating the difficulties for women to negotiate with their partners regarding the use of preventive methods, thus potentializing their submission to unsafe practices and vulnerabilities.

From this perspective, gender relations involve dominance from the male partner over the female one, a problem which is bigger among women with some type of dependency, such as younger women, and those with less formal education⁶. Addressing "sexual education" with young people can contribute to diminish the morbidity and the mortality in this group through education, which, therefore, would lead to preventive attitudes, among which the use of female condoms.

Young women that attend to school spaces become a specific social group, and therefore, create social representations. The Social Representation Theory (SRT) seeks to find the analytical and consensual perception of something that is popular in one’s conviviality, as built by a social group, in which representation and object are essential to one another⁷.

Therefore, the guiding question for this research was: "What do young female students think about the female condom?" As a result, this study sought to know the social representations held by female students regarding the female condom.

To describe the factors that make it harder/easier to accept the female condom by these students, this article aims to, from the knowledge acquired regarding the social representations of this group, stimulate other scientific works that address this theme and many other themes that involve women's health. It stands out that school has an essential role in the formation of young men and women, also regarding gender and sexuality. In regards to Nursing, this research aims to highlight the importance that health education has, and, especially, the need for adequate guidance on the use of the female condom.

Method

This article was based on a monograph presented at UNEB in 2017⁸. This is an exploratory and descriptive study, based on the Theory of Social Representation, with a qualitative approach. Social representations are highly relevant as a theory, since they seek to attribute meaning to known elements⁷. Among its four approaches, the structural one was selected, as it allows for information to be reached as required by the object being studied: the female condom.

In the structural approach, social representations have a nucleus and peripheral systems. The nucleus is collectively built with few changes. The peripheral systems are more subject to modifications and can become different from the content shown in the central nucleus⁷.

Students from public schools, from the city Senhor do Bonfim, Bahia, participated in this study. These schools offer high school education, technical courses, and Adult Education (EJA). The inclusion of participants from each corresponded to the following criteria: they had to be regularly registered in the last year of high school, in the evening shift, attend school regularly, and be from 18 to 30 y/o. The research excluded people who declared to be male, since they declared themselves to be transgender. The autonomy of institutions was preserved, and they authorized the study to be carried out. 94 students from 18 to 29 y/o made up the study.

To carry out data collection, a questionnaire was made, including biological, psychological and social elements, as well as a space destined to the Free Word Association Technique (FWAT). Said questionnaire was applied from October to December 2017. During its application, students were asked to present five words or expressions that came to mind as the term "female condom" was heard, and after that, to justify the term they considered to be the most important.

The printed questionnaire with the FWAT was collectively applied, considering the group. However, each student wrote down their own responses, individually and confidentially. Data from this collection was transferred to Microsoft Word and lemmatisation was carried out. Lemmatisation is the process of grouping together all the inflected forms of a word that appears in a corpus/text, and is an important tool to allow, for the researcher, to analyze and discuss this data, leading to more robust and consistent results. Therefore, different words that have the same meaning, semantically speaking, were standardized, and the most frequently mentioned word was prioritized, and added to the corpus that was the input for the EVOC, version 2005⁹.

For data organization, were used: Microsoft Word for elaborating the simple frequency of biological, psychological, and social elements; the Ensemble de programme spermettanti' analyse des evocations - EVOC, version 2005, and the Interface de R Pour les Analyses Multidimensionnelles de Textes et de Questionnaires - IRAMUTEQ for FWAT¹⁰. The EVOC software is characterized by multiple systems that act together through citation-related statistics. As a result of this process, the four-quadrant table is developed. It is organized by the frequency and order in which the words were mentioned by the participants⁹.

The four-quadrant table is configured in four quadrants that include word-groups according to the frequency in which these words were mentioned. In the upper-left quadrant, the most frequent and promptly mentioned elements are found. The focus element or the main element of social representation has a higher chance to be found here, since the most frequently cited ones are in this quadrant. In the upper-right and lower-left quadrants, terms that were mentioned with medium frequency are included. These may or may not highlight central terms. The terms in the lower-right quadrant are the ones with the fewest mentions in all the quadrants.

Among the IRAMUTEQ analysis possibilities, the word cloud was chosen, as it allows for a wider and more expressive visual interpretation, in which the most commonly mentioned terms are bigger than the others. The use of both softwares helped to analyze the data collected. In addition, studies based on SRT, involving the aforementioned information resources, guarantee that the discussion of the results is more robust, considering the application of the FWAT^7,9,11.

The results that come from the four-quadrant table and from the word cloud were confronted and analyzed under the light of the SRT's theoretical/methodological framework, and of the current literature on the subject of female condoms.

This study followed bioethics guidelines, which are: nonmaleficence, beneficence, autonomy, justice, and equity, always placing human dignity above scientific research. This research was approved by the Research Ethics Committee of the Universidade do Estado da Bahia - UNEB, under CAAE n. 65439317.3.0000.0057.

Results and Discussion

The results of the biological, psychological and social characterization of the 94 students who contributed with the research have indicated that 57 of them are between 18 and 24 y/o, and the others are from 25 to 29 y/o. The participants were going through different modalities of high school. 12 were in regular high school, 11 were in an adult education course, and 71 were in the joint technical course to the high school. Regarding religion, 55 were catholic and 24 evangelicals. 11 stated they do not have a religion. Regarding their self-declared race/color, 80 participants stated to be black.

Regarding their marital status, they self-declared as single (66) and married (24). Regarding sexual practice, 52 stated to have started their sex life after 16 years of age; 26 to have done so before being 16; and 11 stated to have no yet had their first sexual experience. Regarding their sex partners, 60 stated to have a permanent partner, although 66 stated that, in a year, they had from one to two partners.

Regarding data from the FWAT that was processed in the EVOC software, the initial corpus was made up of 450 words or terms, and after lemmatisation, these were condensed into 57 different terms. In the analysis, the mean order of the mentions (MOM) was 2.9 in a scale from one to five. Due to the criteria adopted by the researchers, the lemmas evoked less than four times were discarded. The EVOC software delimited an intermediary frequency of 13 and the corpus had an 89.6% utilization. As a result of the analysis, the software generated the four-quadrant table indicated by image 1.

Image 1:
Four-quadrant table regarding the inductive term "female condom". Senhor do Bonfim - Bahia - Brazil, 2018.

The upper-left quadrant of the four-quadrant table indicates the terms that were mentioned the most, an accessed the faster in the memory of the participants. The characteristics of this quadrant mean that its content has a higher chance of concentrating the nucleus of representation, since the terms are precursor and communicate with one another. The data in the nucleus is the main data and may give meaning to the other quadrants⁷.

As one observes the four quadrants in image 1, it becomes clear that, in the composition of the nucleus, the terms are interconnected and hegemonic. The term "prevention" was mentioned much more than the others, being evoked a total of 66 times by the students, representing 91.6% of participants. The term "protection" was evoked 24 times and, according to the understanding of the participants, it can indicate a similarity with the word "prevention", due to the semantic relations between the words. If these terms are coupled together, to increase their prominence and highlight the idea of continuity/continuation in the interface "prevention/protection", the total of times they were mentioned rises to 90, among the 94 participants of this research, to a total of 95.7%, which characterizes it as a central element in the representation.

As the words prevention/protection are activated in memory, the students who took part in the study indicate a representation that is based in knowledge which is reiterated and diffused by the Brazilian government through public. Since 2000, female condoms have been offered by the Ministry of Health as a strategy to prevent, protect, and diminish cases of AIDS in the female population, a strategy which was encouraged by public policies of HIV/AIDS preventions and by the pharmaceutic industry¹².

The high number of mentions of the terms prevention/protection, when female condoms are the subject, indicates that the students immediately accessed aspects related to its function as a technology of protection and prevention. A study has revealed that, especially when unwanted pregnancies and STIs are concerned, HIV/AIDS standing out among them, the female condom is a method (technology) that favors the autonomy of the woman, especially in situations in which the partner refuses using other methods¹³.

A previous a study pointed out that using female condoms as a contraceptive method increases the odds that its use will be interrupted after the woman starts a stable relationship or after they start using other contraceptive methods. The authors mentioned that the participants of their research stated to use the condom only in during intercourse with casual partners, and that some of these participants opted for this contraceptive method solely because they had difficulties using others. The same research also pointed out that a high percentage of women who participated in it, and were older, said it was important to recommend the use of the condom to their children, due to the risk of HIV and unwanted pregnancies¹⁴.

The term "prevention" as a cognitive element immediately accessed by the students may be related to preventing a pregnancy. Historically and culturally, women have been charged with the task to prevent future pregnancies, since the responsibility for natality control falls on females. After a pregnancy starts, several biological, psychological and social changes affect the lives of women¹⁵. When the women in this study mentioned the terms prevention/protection, regarding the female condom, they also referred to it as a device to prevent STIs.

Still in the quadrant that refers to the nucleus of representation, the term "IUD" (Intrauterine Device) signals a type of thought tied to contraception. The participants reflect about the female condom and immediately access terms that are associated to ideas of "autonomy" concerning the issue of avoiding pregnancy. The IUD term highlights the responsibility that society charges women with and they adopt by preventing pregnancy in their sexual intercourses¹⁵. The configuration of the nucleus also exposes the terms "health and care", which, despite being less frequent than the others, also show that there is a connection between female condoms and the awareness regarding their importance.

The participants in this study pointed out, in the nucleus of social representations, hegemonic and interconnected terms, recognizing the condom as a device to protect against risks (unwanted pregnancies and STIs) and to guarantee health and well-being. The terms "prevents-pregnancy and STDs" that appear in the first peripheral quadrant reiterate the idea of it being necessary to have the power to make decisions about one's own body.

The first periphery groups together terms with high frequency that did not stand out as much. In this study, the terms "prevents pregnancy" (34) and "STD" (15) give support to the idea of a female condom as a technology of protection/prevention. However, an analysis of the terms and of the frequency with which they were mentioned corroborates the studies according to which young women are more worried about unwanted pregnancies than with acquiring STIs, which leads them to, eventually, abandon the use of the condom and start using hormonal contraceptives¹⁶. The term STD, mentioned by the students, indicates the absence or low quality of conversations on the subject with this group, since the term has been changed to STI and they still use the word STD.

The terms "uncomfortable" (27) and "strange" (15), also in the first periphery, indicate some of the difficulty women face when using the condom. To use this device, intimate areas need to be manipulated, and it is necessary to know these areas. Another difficulty the participants pointed out was the change in the appearance of the female genital area during the use of the instrument. Said "strangeness" may lead to a diminution in the desire of the partner, and does not fit with the traditional and historically built female role of being the object of desire and pleasure. Another aspect may be the need for confronting resistance from the partner about the use of the method, since, oftentimes, that leads to the need for negotiation between the couple, which can lead to a loss of the trust connected to female/male fidelity⁴.

The term "safety" (26) may be related to the efficacy the female condom states to have¹⁷. The students in this study, as they mentioned the term safety, supplement the idea that using the female condom is related to preventing unwanted pregnancies and STIs, which may also be connected to a stronger sensation of tranquility during the act and to more autonomy regarding their bodies.

The contrast zone, in the lower-left quadrant, may be composed by terms that give support to ideas previously exposed in the nucleus and periphery, or be made up of a sub-group that moves in an opposite direction, reflecting different representations⁷. In image 1, the contrast zone is made up of the terms condom (10), sex (10), and necessary (7), highlighting the importance of a safe and protected sexual act.

However, the contrast zone shows terms whose appearance had a lower MOM and reveal that some women reject the method due to characteristics such as: "big" (9) and "irritating" (6), while the terms "I never used" (6) and "I don't know how to use" (4) show that these women are not familiar with the device. Not being familiar with the method or finding it strange may indicate that the sexual education offered to these women in schools and primary care was lacking, but also indicates that the theme is not properly discussed in the family nucleus. Another aspect that should be highlighted is the difficulty in accessing the method, which diminishes its use and dissemination.

Talking about aspects related to the dimension "sexuality" in the environment of one's family is still considered to be a difficult task for the parents. And when these moments take place, there is not much information transmitted, which means that school and Primary Healthcare Units (UBS) are the main responsible for generating moments in which debates and clarification on the doubts of students and users can take place¹⁸.

Sexual education in health is understood as the addressing of several themes involving sexuality, involving biological, affective, and preventive issues, as well as relations of pleasure and respect¹⁷. Primary healthcare units have been working on how to encourage the adherence to female condom use, and need to present clear and precise information, in addition to considering specific approaches, depending on the characteristics and idiosyncrasies of each woman.

Socially, women are believed to be the group with the most interest in using female condoms. Due to the immediate risks to which they are exposed, they would tend to worry more about prevention than men do. A recent study indicated that women do not feel comfortable having or carrying condoms, and when they need a condom at the time of intercourse, they admitted to leave this responsibility to the partner¹⁹.

Women understand the importance of using a female condom, but the characteristics of the method and their lack of knowledge about it lead to rejection to its use. Therefore, health professionals need to take action, by giving these women pertinent information, as to allow them to have knowledge and the opportunity to choose the method to be adopted.

Despite the fact that the female condom is offered free of charge by primary healthcare in Brazil, women are not familiar to the method, and feel strange regarding the use and manipulation of this technology. This lack of familiarity with contraceptive techniques is associated to undesirable effects caused by the lack of knowledge about the methods, by incoherent or insufficient knowledge, and to failure in using the instrument for prevention, which leads to a mistaken use of the instrument, and to a diminished efficacy in the use of the condom. These questions are related to how the lack of knowledge and the prejudice that involves the subject of female sexuality and female reproductive rights, being related to explicit gender issues, in a country where young low-income women are the most vulnerable to HIV³.

Some participants understand that the female condom offers prevention and protection, but the theory or definition that was created in the early days of the AIDS epidemic is rooted in discourses and representations of these women, who do not see themselves as a "risk group or as having risky behavior", and believe that they would unlikely acquire an STI⁴. Attitudes such as this one may lead to a lack of knowledge or to distancing from the female barrier method, as well as to being affected by pre-constructed stigma or even by prejudice⁶.

The second periphery is built by positive and negative aspects regarding the use of the female condom. As positive aspects stand out: important (F: 9); responsibility (F:7); love (F:6); trust (F:6); practical (F:6); pleasure (F:6); female independence (F:5). And as negative, are: Impractical (F:7); difficult-to-use (F:6); staying-inside (F:6); intimacy (F:5); don't-feel-like-using (F:5); diminishes-pleasure (F:5).

While many women find barriers to the use of the female condom, others report ability in using it and even a pleasurable relation with the method, which involves the discovery of a new sensation, since when using a female condom they have to touch their intimate areas in some ways which, in some cases, they had not touched them before, in addition to reports of improved sexual relations due to their acquired knowledge about their own body and female empowerment^6-7.

Data from the FWAT that were processed by the IRAMUTEQ software are shown in image 2.

Image 2:
Word-cloud resulting from the inductive term "female condom", replaced. Senhor do Bonfim-Bahia-Brasil, 2018.

The word cloud in image 2 indicates, as its central term, due to its higher frequency, the word "prevention" followed by the terms: prevents-pregnancy, protection, uncomfortable, safety, health, STD, care, and strange.

The word-cloud configuration confirms that the term "prevention", which is in the nucleus of image 1, is central, in addition to reiterating the idea of the female condom as a technology that protects against disease and prevents pregnancies. The negative terms regarding female condoms (uncomfortable, irritating, diminishes-pleasure) may be associated to the absence of familiarity and to strangeness found in the method, which is associated to the difficulty the woman might have in touching their own body and to the absence or low-quality of communication between health professionals and young women in Primary Care, which, as long as the professionals do not act as if they were the purveyors of all knowledge about the user, could be a viable solution. Health education can be built with the user in a horizontal, critical, and reflexive way, to try and eliminate doubts from all sides²⁰.

Therefore, it was found that the students use adjectives that refer to the male condom to qualify the female condom, which suggests the crystallizing of opinions related to the device "condom", whether a male or female condom is involved.

Final Considerations

The participants in the study, young female students, had social representations regarding the female condom which were gathered around two central parameters: disease and pregnancy prevention. They shared values which had been socially constructed, disseminated, and related, despite the fact that female and male condoms have quite different characteristics.

These elements highlight the gender relations which are rooted in patriarchal ideas regarding women sexuality, and are evidenced by the strangeness, discomfort, and to the failure in using this technology, the female condom, which is related to the curtailing of women's sexual freedom and reproductive autonomy.

This research, carried out from the terms evoked, shows the incipience of the knowledge on the use of female condoms among the students, and highlights that the school environment is lacking health education actions executed by the members of the Family Health Strategy, in addition to pointing out the relevance of discussions that bring up female condoms as a relevant subject, and should be had in groups and conversation circles about health and sexuality, involving both men and women.

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Publication Dates

• Publication in this collection
  29 July 2019
• Date of issue
  2019

History

• Received
  18 Aug 2018
• Accepted
  25 Feb 2019