1. N I K O L E D . G E T T I N G S , M S N , C N M
C H O I C E S
N G E T T I N G S @ M E M P H I S C H O I C E S .
O R G
9 0 1 - 2 7 4 - 3 5 5 0
Female Condoms and Anal Sex

2. Thank YOU!
 Sara LaMonica: Intern Extraordinaire
 Katy Leopard, Community Partnerships
 Judy Palmore
 SEATEC

3. Financial Disclosure: None

4. FDA: Are condoms strong enough for anal
intercourse?
“Condoms may be more likely to break during anal
intercourse than during other types of sex because of
greater amount of friction and other stresses involved”
U.S. Food and Drug Administration. (2015, January 15). Condoms and Sexually Transmitted Diseases. Retrieved February 10, 2016,
from http://www.fda.gov/ForPatients/Illness/HIVAIDS/ucm126372.htm

5. Anti- Sodomy Laws
Kelvin, E. A. S., Raymond A. Mantell. Joanne E. Stein. Zena A. (2009).

6. National Health Survey 2002: Have you
ever…(2005)
Mosher, et al., 2005

7. NSFG: 2006- 2008 (2011)
15-44 yo Combined Report
NSFG: 2011-2013 (2016)
18-44 yo Separate Report
 Female respondents who had sex with
males (heterosexual):
 Has a male ever put his penis in your rectum or
butt (also known as anal sex)?
 Female respondents who had sex with
females (same sex):
 No questions regarding anal sex activity
 Questions referred only to giving or receiving
oral sex or “sexual activity”
 Male respondents who had sex with
females (heterosexual):
 Have you ever put your penis in a female’s
rectum or butt (also known as anal sex)?
 Male respondents who had sex with other
males (MSM behavior):
 Has another male ever put his penis in your
rectum or butt (anal sex)?
 Have you ever put your penis in his rectum or
butt (anal sex)?
 Female respondents who had sex with
males (opposite-sex):
 Has a male ever put his penis in your
rectum or butt (also known as anal sex)?
 Female respondents who had sex with
females (same sex):
 No questions regarding anal sex activity
 Questions referred only to giving or
receiving oral sex or “sexual activity”
 Male respondents who had sex with
females (opposite sex):
 Have you ever put your penis in a female’s
rectum or butt (also known as anal sex)?
 Male respondents who had sex with other
males (same sex):
 Has another male ever put his penis in your
rectum or butt (receptive anal sex)?
 Have you ever put your penis in his rectum or
butt (insertive anal sex)?
National Survey of Family Growth[NSFG]
Have you ever…
Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Copen, C. E., Chandra, A., & Febo-Vazquez, I. (2016).

8. MSM
Mosher, et al., 2005

9. MSM
0
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
Lifetime Prevalence
Recent Prevalence
(Last 3 months)
Rice, C. E., et al, (2016).

10. National Survey of Sexual Health and
Behavior[NSSHB]-2009 (2010)
0%
20%
40%
60%
80%
100%
Condom Not Used
Condom Used
Reece, M., Herbenick, D., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D. (2010).

11. Transgender?
Herbst, et al. (2008). Estimating HIV Prevalence and
Risk Behaviors of Transgender Persons in the United
States: A Systematic Review. AIDS Behavior. 12: 1-17.

12. Risks
Associated
with Anal Sex
HIV
Gonorrhea
Chlamydia
Syphilis
Herpes
Trichonomiasis?
 HIV Transmission
 Vaginal Intercourse: 0.01% per act
 Receptive Anal Intercourse: 3.4% per
act
 Other STI’s
 2.6 Increase risk for unprotected anal
intercourse vs. unprotected vaginal
Jenness, S. M., Begier, E. M., Neaigus, A., Murrill, C. S., Wendel, T., & Hagan, H. (2011).

13. Proportion of MSM* Attending STD Clinics with Primary
and Secondary Syphilis, Gonorrhea or Chlamydia by HIV
Status†, STD Surveillance Network (SSuN), 2014
*MSM=men who have sex with men; P&S = primary and secondary syphilis; GC = gonorrhea; CT = chlamydia..
† Excludes all persons for whom there was no laboratory documentation or self-report of HIV status.
‡ GC urethral and CT urethral include results from both urethral and urine specimens.
NOTE: Includes the six jurisdictions (Baltimore, Los Angeles, New York City, Philadelphia, San Francisco and Seattle) that
contributed data for all of 2014.
2014-Fig X. SR. Pg. 76.

14. Skin in the Game

15. Anatomy of Anus
 Fragile mucosa
 “Strong” Sphincter
 Specific Activities(?)
 Research???
 High Risk Populations only
 Limited data about anal sex
 Protected versus
unprotected
 Clinical correlation versus
report of STI
Jenness, S. M., Begier, E. M., Neaigus, A., Murrill, C. S., Wendel, T., & Hagan, H. (2011).

16. Female Condom:Questions
 Friction
 Slippage
 More Damage
 Safety
 Efficacy
 Inner Ring
 Knowledge
 Population(s)
 Reality (FC1) vs. FC2

17. Female Condom: Possible Protection?
 Gibson, 1999
 Gross, et al, 1999
 Woltiski, et al, 2001
 Renzi, 2003
 Kelvin, et al 2011
Kelvin et al. 2009

18. Who uses female condoms during anal sex?:
MSM
 48% have heard of using female condoms during anal
sex. 13% have used a female condom during anal
intercourse in the past 6 month (Gibson, 1999)
 35.4% have heard of using female condoms during
anal sex (Wolitski, 2001)
Gross, et al., 1999; Wolitski, et al., 2001

19. Anal Sex and Female Condom: MSM +
Anal Sex and Female Condom
Anal Sex: No Female
Condom
Anal Sex: With Female
Condom
Male Only
Partner:
78.6%
Female Only
Partner:
10.7%
Both Female
and Male
Partner:
10.7%
Kelvin, et al., 2011

20. Experiences of men who have used female
condoms during anal sex
 “pain, discomfort, or a lack
of pleasure” (n=22)
 Difficulty with insertion
(n=11)
 Issues keeping the condom
in place if the inner ring
had been removed (n=6)
for receptive users
 lack of pleasure (n=12)
and/or difficulty inserting
or keeping the condom in
place (n=12)
Gross, et al., 1999

21. Experiences With Female Condom: Anal Sex
MSM
 Irritation (17%)
 Bunching (12%)
 Unpleasant texture
(10%)
 Noise (9%)
 Breakage occurs in 3 out
of 334 uses
Gibson, et al., 1999

22. Experiences With Female Condom: Anal Sex
MSM
 Receptive partners report
significantly more pain and
discomfort with female
condoms than with male
condoms.
 The difference in condom
breakage is not significant
but female condoms slip
significantly more than
male condoms.
 The difference between
epithelial disruption after
use of male or female
condoms is not significant
Renzi, et al., 2003

23. Experiences With Female Condom: Anal Sex:
MSM+
 Removed inner ring
(64.3%)
 27% experienced slipping
 Not removing ring had +
correlation with negative
impact on pleasure
 Used Additional Lube
(82.1%)
 Problems (slipping,
leaking, breaking) (17.9%
FC2 vs 70.8% male
condom)
 FC2 Negative impact on
pleasure (25% FC2 vs
31.4% male condom)
Kelvin, et al (2011)

24. Do these experiences tell us anything?
 Small Populations
 Limited Generalizability
 MSM almost exclusively
 Only Renzi et al. (2003)
look at tissue health
 No Safety (Anal Sex)
 No Efficacy (Anal Sex)
 No Safety/Efficacy
Comparison with Male
Condom

25. Female Condoms: Accessible?
 Cost: $2/each
 Are they available?
 Walgreens: online yes, in store
on Union yes on Jackson no
 CVS: online yes, in store on
Union yes
 Rite Aid: online no, in store on
Union no
 Kroger: online no, in store on
Poplar no
 Madison Pharmacy: no
 Choices: …………..
 Coverage
 https://tenncare.magellanheal
th.com/static/docs/Preferred_
Drug_List_and_Drug_Criteri
a/TennCare_PDL.pdf

26. And Survey Says….
 48 State Health Department Websites Mention FC
 21 “mention anal sex” and FC
 8 Support
 13 Neutral
 1 Discourages
 10 Give specific instructions on use of or removal of
ring
 TN and Memphis: No mention of FC and Anal Sex
Rodriguez, K., Ventura-DiPersia, C., LeVasseur, M. T., & Kelvin, E. A. (2015).

27. And Survey Says…
“I would like to have more information about the anal
use for the female condom ...for vaginal use, I know
they have diagrams and ways of showing visually how
to insert and use and things like that. But similar
materials for anal use, and it wouldn't have to be
particularly for men, but for women who use it anally.”
“Hopefully the FDA will find out some information
regards to it [sic] and maybe it would be on the
market.”
Mantell, J. E., Kelvin, E. A., Exner, T. M., Hoffman, S., Needham, S., & Stein, Z. A.

28. CDC.GOV AIDS.ORG
 Abstinence
 Vaccination (HPV)
 Limit partners/mutual
monogamy
 Get tested for STDs,
make sure your partner
gets tested too
 Use a (male latex)
condom
 All the things you would do
for other STIs
 If you know you are HIV
positive take antiretrovirals
 If you know or suspect that
your partner(s) is HIV+ talk
to your healthcare provider
about PrEP (or PEP after a
risky encounter)
Best Advice

29.  http://www.ourbodies
ourselves.org/health-
info/how-to-choose-
lubricant/
 Mucosal Skin is delicate
 Anal mucosal skin is not
self lubricating
 Anal sphincter and
supportive musculature
should be handled gently
 Consider relative risk of
behavior
 Consider Partner
Best Advice: Skin in the Game

30. Next Steps
 Correct use: Inner Ring
 Safety
 Efficacy of Male condom:
Female Condom in regards
to STI protection, specific
to anal sex
 Change the Name?
 Wide-spread marketing
 Agreement between Health
Departments/Public
Health Agencies
Kelvin, E. A. S., Raymond A. Mantell. Joanne E. Stein. Zena A. (2009).

31. ORIGAMI™ Condoms: The future of internal
condoms for anal sex
 ORIGAMI Internal Condom™ is currently being
tested by the FDA specifically for anal use
 It is expected to reach the market later this year

32. References
 Copen, C. E., Chandra, A., & Febo-Vazquez, I. (2016). Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults Aged 18-44 in the United States: Data From the 2011-2013 National Survey
of Family Growth. National Health Statistics Reports, (88), 1–14.
 Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006-2008 National Survey of Family Growth.
National Health Statistics Reports, (36), 1–36.
 French, P., Latka, M., Gollub, E., Rogers, C., Hoover, D.R., & Stein, Z.A. (2003). Use-Effectiveness of the Female Versus Male Condom in Preventing Sexually Transmitted Disease in Women. Sexually
Transmitted Diseases, 30(5): 433-439. Retrieved January 29, 2016, from http://journals.lww.com/stdjournal/Abstract/2003/05000/Use_Effectiveness_of_the_Female_Versus_Male_Condom.10.aspx
 Gibson, S., McFarland, W., Wohlfeiler, D., Scheer, K., & Katz, M. H. (1999). Experiences of 100 men who have sex with men using the Reality condom for anal sex. AIDS Education and Prevention, 11(1),
65–71. Retrieved from http://search.proquest.com/docview/198015105/abstract
 Gross, M., Susan P. Holte. Sarah, Celum, Connie L. Koblin. Beryl A. Dougla. Jr. John M. (1999). Use of Reality “Female Condoms” for Anal Sex by US Men Who Have Sex with Men. American Journal of
Public Health, 89(11), 1739–1741. Retrieved from
http://relay.rhodes.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,url,uid,cookie&db=pbh&AN=2456262&site=ehost-live
 Jenness, S. M., Begier, E. M., Neaigus, A., Murrill, C. S., Wendel, T., & Hagan, H. (2011). Unprotected Anal Intercourse and Sexually Transmitted Diseases in High-Risk Heterosexual Women. American
Journal of Public Health, 101(4), 745–750. http://doi.org/10.2105/AJPH.2009.181883
 Kelvin, E. A. S., Raymond A. Mantell. Joanne E. Stein. Zena A. (2009). Adding the Female Condom to the Public Health Agenda on Prevention of HIV and Other Sexually Transmitted Infections Among
Men and Women During Anal Intercourse. American Journal of Public Health, 99(6), 985–987. Retrieved from
http://relay.rhodes.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,url,uid,cookie&db=pbh&AN=41039603&site=ehost-live
 Kelvin, E. A., Mantell, J. E., Candelario, N., Hoffman, S., Exner, T. M., Stackhouse, W., & Stein, Z. A. (2011). Off-label use of the female condom for anal intercourse among men in New York City. American
Journal of Public Health, 101(12), 2241–2244. http://doi.org/10.2105/AJPH.2011.300260
 Mantell, J. E., Kelvin, E. A., Exner, T. M., Hoffman, S., Needham, S., & Stein, Z. A. (2009). Anal use of the female condom: does uncertainty justify provider inaction? AIDS Care, 21(9), 1185–1194.
http://doi.org/10.1080/09540120902730005 Retrieved February 13, 2016, from http://www-ncbi-nlm-nih-gov.proxy.library.vanderbilt.edu/pubmed/20024779
 Mosher, W. D., Chandra, A., & Jones, J. (2005, September 15). Sexual Behavior and Selected Health Measures: Men and W omen 15–44 Y ears of Age, United States, 2002. Retrieved February 12, 2016,
from http://www.cdc.gov/nchs/data/ad/ad362.pdf
 ORIGAMI. (n.d.). ORIGAMI Internal Condom (OIC). Retrieved February 10, 2016, from http://www.origamicondoms.com/#!female-condom/cxt7
 Nemoto, T., BirteIwamoto, MarikoSakata, Maria. (2014). Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables.
AIDS Care, 26(4), 434–440. http://doi.org/10.1080/09540121.2013.841832
 Renzi, C., Tabet, S. R., Stucky, J. A., Eaton, N., Coletti, A. S., Surawicz, C. M., Agoff, S. N., ... Celum, C. L. (March 01, 2003). Safety and acceptability of the RealityTM condom for anal sex among men who
have sex with men. Aids, 17, 5, 727-731.
 Reece, M., Herbenick, D., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D. (2010). Condom Use Rates in a National Probability Sample of Males and Females Ages 14 to 94 in the United States. The
Journal of Sexual Medicine, 7, 266–276. http://doi.org/10.1111/j.1743-6109.2010.02017.x
 Rice, C. E., Maierhofer, C., Fields, K. S., Ervin, M., Lanza, S. T., & Turner, A. N. (2016). Beyond Anal Sex: Sexual Practices of Men Who Have Sex With Men and Associations With HIV and Other Sexually
Transmitted Infections. The Journal of Sexual Medicine. http://doi.org/10.1016/j.jsxm.2016.01.001
 Rodriguez, K., Ventura-DiPersia, C., LeVasseur, M. T., & Kelvin, E. A. (2015). Inconsistencies on U.S. Departments of Health Websites Regarding Anal Use of the Female Condom. AIDS and Behavior,
19(7), 1141–1149. http://doi.org/10.1007/s10461-014-0933-6
 Wolitski, R. J., Halkitis, P. N., Parsons, J. T., & Gomez, C. T. (2001). Awareness and use of untested barrier methods by HIV-seropositive gay and bisexual men. AIDS Education and Prevention, 13(4), 291–
301. Retrieved from http://search.proquest.com.proxy.library.vanderbilt.edu/docview/198007057/abstract
 U.S. Food and Drug Administration. (2015, January 15). Condoms and Sexually Transmitted Diseases. Retrieved February 10, 2016, from
http://www.fda.gov/ForPatients/Illness/HIVAIDS/ucm126372.htm
 U.S. Food and Drug Administration. (2015, June 19). Barrier Products. Retrieved February 10, 2016, from http://www.fda.gov/ForPatients/Illness/HIVAIDS/Prevention/ucm117899.htm

33. THANK
YOU!
Nikole Gettings, MSN, CNM
901-274-3550
ngettings@memphischoices.org