protected ‘as clients often try to remove or even tear male condoms during sex.’ I believe this practice of removing or tearing the condom stems from the fact that some Malawian men (and women perhaps) believe that for sexual intercourse to be meaningful (an intimate social experience), there must be sharing of body fluids. Contact between mucosa to mucosa (nyama kwa nyama) is preferred and considered superior sex. Anything less than that is counterfeit. The female condom, despite being used in pilot studies and registering high acceptability rates, has not been widely accessible to the majority of the population as compared to the male condom. There were reports, as early as 1997, that UNAIDS wanted to improve the availability of the female condom in developing countries and now, almost a decade later, there seems not much progress has been made. Among the many reasons as to why the female condoms have not been readily available is the financial cost, as the female condom may cost up to 10 times as much as the male condom. The male condom continues to be sold at subsidized costs through social marketing efforts and is distributed for free to sexually transmitted infection (STI) and family planning clients in Malawi. The female condom on the other hand does not get that much attention. One of the reasons given for the lackluster promotion by social marketing organizations is that considering the gender power imbalances between men and women, it is the man who most often decides when and whether sexual intercourse is going to occur and whether a condom is going to be used or not. Promoting the male condom therefore makes much more sense than promoting the female condom, as it is deemed that the male condom target is the decisionmaker (man). Although the proportion of CSWs who perceived the female condom as unacceptable was rather small (2%), it is important that impaired sensation was mentioned as reason for unacceptability. Perception of diminished pleasure has also been mentioned as reasons for not using condoms in Indonesia. There are at least two points that can be said about this. There is some line of thought that CSWs do not mind whether sex is pleasurable or not. This thinking may not be always correct. The second idea is that if condoms (be they male or female) reduce sensation, it is possible that a significant number of people who would have used them may be prevented for using the condoms. As for CSWs, they risk losing clients and they are unlikely to accept such costs. While the perceived impairment of sensation by condoms has been mentioned in many studies, it seems there has not been a concerted effort to address this problem. For instance, while most of the condoms being promoted by social marketing organizations are the cheap ones (and although efficacious in preventing STIs), they may not be the most sexually sensitive ones. On the commercial market, there are condoms with a different thickness of latex, with ribs, with studs and other properties that could be made available widely also in order to deal with this problem of reduced ‘sweetness’ of the ‘conventional’ low-cost condoms. Yes, we may need to spend more. But we are becoming more ready to spend or ask for funding on antiretrovirals. I agree with the authors that there is preference of dry sex (as usual, for some) in Malawi and a much-lubricated condom is likely to be unacceptable to those preferring drier sex. Studies in Zimbabwe have also documented this preference for dry sex. That some of the CSWs in the study re-used the same female condom on consecutive clients would not have worried me much, had the male clients used male condoms also. It is possible these males did not use (male) condoms and that is worrying and a minus for the female condom. While I have no data to substantiate my claim, the likelihood of re-using the male condom on consecutive clients is smaller, I think. Adamson SMuula MBBSMPH

[Vesico-uterine fistula].

Citations

Vesico-uterine fistula.

References

Vesico-uterine fistula.