New Methods of Family Planning: Implications for Intimate Behavior.

The "long, long drought is easing" and new methods of family planning "are in the pipeline now" and "should be available in the next few years" (Burnhill, 1999, p. 1). Perhaps due to an environment in which product liability assumes priority over scientific advance, on top of antiabortion politics, industry has been very slow in developing new contraceptive technology and, hence, the United States Food and Drug Administration has not approved a new method of family planning since the female condom in 1993. Alternatives are becoming available in Europe, leading experts such as Stewart to observe that "the idea that the United States could be so many years behind other countries is pretty astonishing" (Stewart, 1999, p. 1).

The intent of this paper is to review some of the new methods in the pipeline and to ask a basic question: "How might these methods of family planning impact on my intimate behavior with my partner?" Our goal is not to provide a review of the use effectiveness of these contraceptive approaches. Rather our assignment, and intent, is to address the intimate behavioral implication of the family planning methods currently in the pipeline. Automatic acceptance of innovative technology in the field of contraception is anything but a foregone conclusion. As Snowden (1996) argued, most couples would really rather not have to use anything for family planning. Similarly, Severy and Silver (1993) suggested that couples often make choices based on the "least bad alternative" (p.225). It is not surprising that for Severy and Thapa (1994) the question became which methods couples were willing to tolerate. This negative spin on contraceptive use presents a daunting challenge for product developers and innovators. Innovations in contraceptive technology will have little, if any, impact if the new methods are not used. And, why should money be spent for development if no one will be purchasing the products? Marshall (1977) and Keller (1979) suggested that all new methods must meet a simple rule: that technology be developed to fit people, rather than requiring people to change in order to accommodate technology.

There are those who have concentrated on the positive side of the ledger. Marshall (1977) suggested that, in brief, acceptability is a quality that makes an object, person, event, or idea attractive, satisfactory, pleasing, or welcome. As will become obvious shortly, it is also our position that more positive and provocative features of contraceptive methods should be critical components of the methods and their marketing to potential consumers/users. In this regard, it is important to distinguish among several types of acceptance. In 1990, Cleland, Hardy, and Taucher differentiated among hypothetical, initial, and experiential acceptability. The first of these refers to a couple's assessment of the desirable/undesirable features of a potential new method. The second refers to their willingness to try the new method. And, the third--which some may term satisfaction--measures what actually happens when the couple uses the method. It is perhaps this third aspect--impact on behavior, especially intimate behavior--that is the primary focus of our attention here.

Recent research has finally recognized that "it takes two to tango." Although couples research has been conducted for many years (Miller, Shain, & Pasta, 1991, 1993; Rainwater, 1965; Severy, 1982; Severy & Silver, 1993), the importance of considering data from both partner's perspectives has become increasingly clear. Grady, Tanrer, Billy, and Lincoln-Hanson (1996) conclude that men play important roles in decisionmaking about sex, contraception, and child rearing. Becker (1996) argues for a focus on both partners, and demonstrates that behavioral predictions and family planning interventions are better when both partners are involved. Finally, Thomson (1997) demonstrated that partner's desires are not additive, that data from one partner can not serve as a proxy for the other, and that they carry approximately equal weight. Therefore, discussions of acceptability of new methods must pay attention to both partners in a sexually active relationship.

We have saved our most controversial introductory comment for last. Specifically, it has long been our position that family planning methods do not preclude elements or features that might enhance, stimulate and make more pleasurable the sexual experience. Developers and marketers need to think of procedures and products that might simply make sex more fun--while at the same time providing for contraceptive and/or STD preventative actions. Perhaps if conceptualizations of new methods started from the framework of "sex toys" and then also provided contraceptive action, use and sales rates might dramatically increase. Another related perspective, one that will not be developed further in this paper, relates to the other health benefits of new contraceptive technology. If temporary infertility were to be a side effect of a new health technology, and the primary effect is another important health benefit (e.g., a pill or injectable that prevents breast cancer or prostate cancer), then the paradigm for delivering and using contraception would change dramatically and positively. The following review of new methods is designed to hold open the possibility that these methods may have interesting implications for couple's intimate behaviors. Thus, is it possible that new methods can be more than nondysfunctional, can they actually enhance pleasure?

METHODS ON THE HORIZON FOR AMERICANS

Vaginal Rings

For women who want long-acting contraception and are not adverse to hormonal methods, but who want a user-controlled method, the only option is a vaginal ring. All other long acting methods are provider dependent (Norplant, IUDs, or sterilization). Women's health advocates have argued for a long-acting hormonal method that is under the control of women, does not require daily attention, and is not coitus related. Injectable contraceptives, once they are injected, can not be reversed until they wear off. One can not start them at will. Consequently, vaginal rings offer the only opportunity to have highly effective user-controlled methods with the above advantages.

Basically, there are three types of vaginal rings (Shoupe & Mishell, 1992). First, there are vaginal rings that release the natural hormone progesterone and are intended, primarily, for breastfeeding women. There has been a lot of research on this ring by Croxatto in Santiago, Chile (Massai et al., 1999; Silvin, Diaz, & Croxatto, 1997). Research and development on these rings was funded by the Population Council, the Contraceptive Research and Development (CONRAD) Program, and by an industrial partner, Silesia. This is a continuous use ring that clearly has no negative effect on breastfeeding (McCann & Potter, 1994; World Health Organization [WHO], 1988). It offers long-acting contraception for women who are no longer protected by lactational amenorrhea. The second type of vaginal ring is a synthetic progestin-only ring. By using synthetic progestins, such as Nesterone--also developed by the Population Council--or levonorgestrel, the rings can be made to last at least a year. This method is highly effective and is intended for interval use, as well as for use in breastfeeding women. The primary side effect is menstrual bleeding disturbances similar to those accompanying all progestin-only methods. The third type of vaginal ring is a combined ring that contains both a progestin and an estrogen. Also developed by the Population Council, the rings contain, for example, norethindrone acetate and ethinyl estradiol (Ballagh et al., 1994; Thau & Jackanicz, 1994). The advantage of the combined rings is that they produce fewer bleeding problems and offer more cycle-to-cycle control; they are not appropriate for breastfeeding women.

How does one use these vaginal rings? The combined ring is used very much like a package of pills. The woman inserts the ring into her vagina and keeps it in for three weeks, and then takes it out for one week. During the three weeks in, there is close to 100% contraceptive effectiveness. The week that it is taken out results in a menstrual bleed--a withdrawal bleed from removing the hormones--very similar to the experiences derived from using oral contraceptives. In fact, with the combined ring menstrual behavior is very similar to pill use, with very little breakthrough bleeding. A major factor in the use of all of the rings is that they can be left in, or taken out temporarily during intercourse. Some men report not to have noticed the ring, whereas others prefer not to have it in during intercourse. The requirement is that the ring be left in for the majority of the day during the 3-week time frame. Conversely, the progestin-only ring acts similar to Norplant, but may only last for 1 or 2 years. It is not removed for a week per cycle, but can be taken out for washing, normal hygiene, or during sex. However, it must be noted that vaginal rings do not offer protection against STDs.

Let us now focus on the implications for sexual behavior. Obviously, as just noted, the vaginal rings could interfere with intercourse because of their physical presence. The rings usually stay in vaginal fornix and fit around the cervix. The ring diameter ranges from 50 to 75mm and the cross-sectional diameter from 5 to 9.5mm. If the ring interferes, it should be removed temporarily. Alternatively, it is also possible that men and women may find that contact between the penis and the ring, and maybe the cervix and the "G spot" and the ring, is a sexual stimulus. The actual positive or negative effects on sexual behavior will not be known until these products reach the post-marketing surveillance stage in their development.

Microbicides and Spermicides.

Family Health International (FHI) and the Population Council (Heise, McGrory, & Wood, 1998) have conducted several studies on the acceptability of different formulations of spermicides. Microbicides, topical agents that destroy bacterial and/or viral causes of STDs/HIV, could be formulated in the same way that spermicides are developed. Namely, one could make a film, a gel, a cream, or a suppository. Microbicides that are also spermicidal would provide dual protection; they would effectively and safely prevent unwanted pregnancy as well as HIV and other sexually transmitted diseases. As of yet, no prospective randomized studies have been able to demonstrate that existing spermicidal products provide such dual protection. Observational studies indicate that the current nonoxynol-9 spermicides may provide up to about 25% protection against the bacterial STDs. There are several prospective studies now underway assessing spermicide protection against STDs, including HIV. The attractiveness of combination microbicide/spermicide products is that they have the potential to be highly effective, if used correctly and consistently, in preventing pregnancy and STDs/HIV. A recent international conference targeted opportunities for industrial collaboration in the development of such products (FHI Conference, "Microbes/Spermicides: Opportunities for industrial collaboration," 1998). Further, there is ample evidence that such a product may be well received. Darroch and Frost (1999) conducted a classic example of the hypothetical acceptability study described in the introduction. Further, a workshop designed to develop initial and experiential acceptability assessments of such products was held by the National Institute for Child Health and Human Development (NICHD) in October, 1999. The resultant Request for Applications (RFA) on February 1, 2000, stressed the need to focus on couples and the way in which their intimate behavior is impacted by new techniques and methods.

The impact of microbicide/spermicide products is potentially very important. If properly developed, the user could have sex without fear of either pregnancy or STDs. This may be wishful thinking as finding 100% effective products may prove impossible, which is especially true of all other user-controlled methods; they are very prone to inconsistent use. In this case, actual protection (typical use rates) would be substantially less than theoretical protection (perfect use rates). The Population Council undertook an acceptability study of various spermicides as a proxy for acceptability of microbicidal products (Elias & Coggins, 1996). Also, Family Health International conducted multi-center studies on the acceptability of different spermicidal preparations--in Mexico (Alvarado, Steiner, Spruyt, Joanis, & Glover, 1993), in Kenya (Magiri et al., 1992), and in The Dominican Republic (Cordero, Steiner, Spruyt, Joanis, & Glover, 1993). Findings from these studies have relevance for intimate behavior. The film products (VCF, Apothecus Inc., Oyster Bay, NY) were preferred when compared to gels and suppositories. The latter were thought to be "too messy." Unfortunately, films also suffered problems--they were too sticky, to the point that insertion was a problem as the film stuck to one's fingers. Given cultural and personal variation in acceptability, the logical conclusion is that new products should be made in as many different formulations as are feasible or technically possible. In this way partners would have a choice based upon personal preference which, in turn, would lead to greater use.

Cultural variation is very important in product development. For example, in some African countries, "dry sex" is preferred. Products providing vaginal lubrication would be much less acceptable to the male partner, as well as perhaps to the woman trying to please her partner. An interesting aside is that the low efficacy rates of the vaginal contraceptive film in the Cameroon film study (Roddy et al., 1998) may be related to the use of drying agents in the vagina during sex, which would have prevented the films from dissolving. Therefore, a cultural preference for certain aspects of the sexual experience may preclude the development/use of this type of product in societies most in need of alternative methods. Conversely, sales in the United States of vaginal and penile lubricants (Asterglide, Replens) indicate that some people like more lubrication during sex, including premenopausal women who are not on estrogens. Therefore, use of to-be-developed microbicides/spermicides might make sex much more pleasurable for some people. The experience might be better for both men and women as a byproduct of using these artificial lubricants. Clearly, more acceptability research is needed in this area.

Female Condoms.

Female condom research is currently being conducted by Family Health International and the Horizons Project (Population Council) in multiple countries (United States Agency for International Development [USAID], 1998). Although there are a number of female condoms in development, the only female condom that has been approved by the FDA is the Reality female condom, a polyurethane product with an inner and outer ring (Feldblum & Joanis, 1994). In Madras, India, a latex female condom is being developed by Medtech Health Products. Further, PATH, with support from the CONRAD Program, is currently working with users in an attempt to design a more user-friendly female condom.

There are a number of interesting aspects of the Reality female condom. One is that the manufacturer (the Female Health Company) makes it very clear in its advertising material that this is a product that "you need to try at least three times before you can make a decision." The implication is that with experience one will learn to like the product. Reportedly, these condoms make noise. Further, for "well-endowed" men, materials instruct women to add more lubricant to the female condom; it will make sex better for both partners. When inserted in the woman's vagina, the outer ring "hangs out;" this may not be esthetically pleasing to couples who prepare to have sex with the lights on.

Anecdotally, prostitutes have reported that they have figured out how to get their male partners to insert the penis into the pouch without the male knowing it; this involves keeping the outer ring open as the man enters (WHO, 1997). One of the issues this behavior demonstrates is that female condoms are really not, strictly speaking, a female-controlled method. Without male partner participation it is not likely to work. But, the concept for the female condom (in contradistinction to the male condom) is that it puts the locus of negotiation in the hands of the women. It is hypothesized that it is a lot easier for women to insert a female condom prior to a sex act (particularly commercial sex workers) and then negotiate from the position of already having the condom in place, and keeping it inserted, in comparison to the negotiation of trying to persuade a man to put on a male condom. The argument is to keep something in place versus making the man put something on--which should be an easier position to bargain. All such negotiation, however, is influenced by cultural norms.

Some men report that if a condom is going to be used, they would prefer to have sex with the woman wearing it. It is much more "natural" for the man. It is not constricting and makes sex more pleasurable.

The current downside of the female condom includes the expense (about $2 to $3 per device in the commercial sector and about 60 cents in the public sector) and that it is intended for a single use only. That said, behavior does not always follow product labeling--it is reported that many women in developing countries reuse the product. Research is currently under way investigating multiple reuse in terms of cleaning practices that prevent microbial retention and do not affect the structural integrity of the product.

Female condoms are clearly important options for some couples. They offer both pregnancy and STD prevention. The more options women have to protect against both, then the more likely it will be that acts of intercourse are actually protected. This is very similar to marketing research results indicating that the more brands there are of a product, the more the total sales increase--although sales in any one brand may actually decrease.

Male Condoms

The issue with male condoms is that if a condom could be developed that is believed to make sex better, it would not be very difficult to persuade men to use the product. Many men do not like the current versions of the latex condom. In fact, some men are willing to pay prostitutes more money for sex if a condom is not used. Another strategy, and maybe a more realistic one, is to make a product that at least does not detract from sex (nondysfunctional). However, this is not the same thing as enhancing sex. The prime factor to overcome is the perceived reduction in pleasure caused by many of the current brands of latex condoms. The slang expression said by some men is that it "feels like taking a shower with a raincoat on." The authors believe that many men who have abandoned condoms would be willing at least to retry a new condom product if it could be shown that sexual pleasure is not reduced during use.

Over the last several years there has been significant research aimed at developing better male latex and nonlatex condoms. Family Health International has developed a novel thermoplastic slip-on condom that is being commercialized by their private sector partner Mayer Labs (McNeill, Gilmore, Ginger, Lewis, & Schellstede, 1998). Further, the man can enter the product (called eZ.on) from either the front or the back of the product, reducing the need to find the "right" side. Some men have trouble--especially in the dark--unrolling a conventional latex condom because they try to put it on "backwards."

Incredibly, few men use condoms (McNeill et al., 1998), especially in regions with high STDs and unplanned pregnancy rates such as Africa, in part because they do not like them. Family Health International has conducted acceptability research that shows that loose fitting condoms are preferred over the current constricting latex condoms. Several commercial firms are now producing latex and synthetic loose fitting (stretchy) condoms. Unfortunately, so far research indicates that slippage and breakage rates may be a little higher with these nonlatex condoms (Frezieres, Walsh, Nelson, Clark, & Coulson, 1999). Implications for STD and pregnancy prevention are undetermined as of yet.

Male condoms are extremely effective for prevention of both STDs and pregnancy--if used correctly and consistently. This is a very big if, and much more qualitative research needs to be undertaken with men who like condoms to better understand the factors affecting perfect use. There is also an argument as to why some women like condoms. Most women do not like it that they drip semen after intercourse without a condom. Condoms make sex more enjoyable at times that they especially do not want to be dripping--such as when they are going out soon after sex. In addition to all of the activities being pursued to increase condom use (e.g., increasing availability, social marketing, reducing prices, communication strategies, better counseling, making male condoms "sexier"), an enhancement of the sexual experience rather than a detraction should certainly result in increased use of this critical method.

Emergency Contraception

Emergency contraception (EC) refers, primarily, to the use of hormonal contraception to prevent pregnancy after experiencing unprotected intercourse. The Yuzpe method (WHO, 1998) involves the provision of two high dose, or four low dose, oral contraceptive tablets (containing levonorgestrel and ethinyl estradiol) within 72 hours of intercourse, followed by another two tablets 12 hours later. WHO-funded (1998) research has shown that levonorgestrel-only pills are more effective with fewer side effects than the Yuzpe method (see also Trussell, Rodriguez, & Ellerston, 1998). Both methods are more effective the sooner they are started after an act of unprotected sex. Research has clearly demonstrated that many women do not understand EC very well, and there is an opportunity to have a very negative impact on reproductive health. Namely, if people come to believe that they can give up barrier methods and depend solely on hormonal methods, particularly if they have had the scare of an accidental pregnancy, the strategy will not serve these women very well. There is no protection against STDs provided by EC. Research from Zambia (Skibiak, Ahmed, & Ketata, 1999) indicates that people stopped using other methods as they came to believe that EC could answer all of their needs. Emergency contraception is intended to be used only in emergencies, not as the primary and/or routine method of contraception.

There is research addressing the issue of advanced provision (being prepared) for EC--having the tablets ahead of time, versus the situation in which the tablets are obtained after the "accident." The project by the Population Council in Zambia addressed issues related to access to EC. They found that the provision of pills prophylactically was dramatic. Nearly 80% of emergency contraception users who received their pills ahead of time took their first dose within 24 hours, compared with only 40% of those women who received a prescription card.

A USAID (1999) fact sheet answers the question of who needs EC. They suggest that a wide variety of women at risk of pregnancy from unprotected intercourse can benefit from emergency contraception. These include women who have been raped, women whose partners' condoms break, women who run out of other contraceptive methods, women who forget to take several consecutive oral contraceptives, and other women who were not expecting to have sex: In other words, all situations in which the result is a lack of use (or incorrect use) of routine methods of family planning. Adolescent women often fall into these categories.

There are some important issues regarding the potential impact of EC on sexual behavior. For some women, knowing that emergency contraception is available to rely on might change decision making. Specifically, infrequent sex might lead to being unprepared: "After all, there is always EC." In turn, perhaps EC availability knowledge might make it more comfortable for women and men to make the decision to go ahead and enjoy unprotected sex. Thus, knowledge of EC availability might lead to a higher rate of risky behaviors, particularly risky as related to STDs. Emergency contraception is becoming increasingly available, and more known about. It is overwhelmingly accepted (Harvey, Beckman, Sherman, & Petitti, 1999). The impact this knowledge has on sexual behavior is yet to be fully understood; yet, in separate studies in Zambia, New York City, and Edinburgh, after emergency contraception use, the use of condoms as a routine method decreased (New York City, 1998; Glasier & Baird, 1998).

PERSONA

Discussion of one last method will deviate from our established pattern. As above, it is our intention to describe a method of family planning currently available in Europe, and undergoing FDA clinical trials for potential United States approval. More importantly, PERSONA provides us with an opportunity to describe the way in which a new approach to family planning can have a meaningful impact on a couple's intimate behavior. Again, our goal for this paper was to query whether methods in the pipe line might impact sexual behavior. Preliminary data from the initial British acceptability studies, both quantitative and qualitative, are available for this discussion.

PERSONA as a Method of Contraception.

PERSONA is produced by Unipath Ltd. of Bedford, England. Unipath's products include ClearBlue and ClearPlan, the home pregnancy and LH tests, respectively. Unipath had conducted market research with over 3000 women from multiple countries regarding a concept which depends on personal hormone monitoring as a contraceptive method. They felt that there was "a growing need to find a method which is not only reliable but is non-invasive--involving no devices and being non-systemic, i.e. no drugs" (Senior, 1996, p. 57). Essentially, their approach can be thought of as an extension and enhancement of natural family planning methods. PERSONA is not a contraceptive per se. Rather, it is an educational tool that informs the couple of the woman's fertile period. Such a system would allow the woman and her partner, together, "to make a decision on how to proceed in terms of sexual activity in the knowledge of the woman's fertility status on that day" (Senior, 1996, p. 59). Unipath pioneered advances in rapid home testing for LH (Clearblue) and extended the approach to allow for the rapid and simultaneous detection of urinary hormones to delineate the fertile period. PERSONA does not offer any protection against STDs and, it is believed that couples using PERSONA are less concerned by STDs, and more concerned about avoiding pregnancy.

As described by Severy (1999), PERSONA is designed to give women information about the days during their menstrual cycle when they are, and are not, at risk of becoming pregnant. Estrone-3-glucuronide (E3G) and luteinizing hormone (LH) are the best markers to determine the fertile period: E3G as the primary marker for the start of the fertile period and LH for the end. Utilizing frequently updated information, in addition to six months of stored personal data, PERSONA identifies the days of each cycle a woman is free to have intercourse without risk of pregnancy.

PERSONA consists of two parts: urine test sticks, similar to home pregnancy tests, and a small, hand-held monitor the size of an eyeglass case. Each morning the woman checks the monitor to see which light is shining: A green light means she is not at risk of pregnancy and can have intercourse without using a contraceptive, a red light means that she is at risk of pregnancy and she should abstain from intercourse (or use a barrier method) if she wishes to avoid pregnancy, and a yellow light means that the monitor needs more information in order to determine whether it is a green or red light day for her. When the yellow light is showing, a dipstick urine test is performed and then inserted into the monitor before it can indicate a green or red light.

As one might imagine, the context of one's prior method of contraception will impact on PERSONA's acceptability. For those not at risk of STDs who always use a condom or a female barrier method, PERSONA allows the freedom to make such behavior unnecessary on all but the fertile days of the cycle. And for those who might have been using the pill or an IUD, and having sex without fear of pregnancy whenever they desired to do so, they may find the need for abstinence or barrier methods on certain days of the cycle very restrictive.

The efficacy of PERSONA has been reported by Bonnar et al. (1999), based on a United Kingdom sample which also provided acceptability data. PERSONA is sold in England, Italy, France, Germany, and Ireland. There is some evidence of use by consumers in the Scandinavian countries as well.

UK PERSONA Acceptability Study.

Sociologist Robert Snowden of the University of Exeter in Devon, England, led a team of researchers in England and Ireland focusing on the experiences of those couples first to use PERSONA. They collected data from women after their first, third, sixth and thirteenth cycles of use. In addition to a single page of Likert-style items assessing response to PERSONA features such as ease of use of the test sticks, difficulty in remembering to test morning urine, and so forth, Snowden also asked questions about the woman's perception of the accuracy of the monitor in identifying the phases of the woman's cycle and her trust in its contraceptive function. Open-ended questions allowed all respondents at all time periods to identify their experiences with PERSONA. Over 400 couples participated in the University of Exeter studies. A more complete description of the study population exists in Bonnar et al. (1999). Briefly, however, women were between 18-45 years of age, had regular menstrual cycles, wished to avoid another pregnancy for at least another one and a half years, and were sexually active.

Figure 1 presents the ratings of women after their sixth cycle of using PERSONA on the specific question "Since using the monitor my sex life is:...." Recall that by the sixth cycle these acceptability ratings reflect continuing acceptability, perhaps better labeled satisfaction, well after the "glow" or halo of any new product Hawthorne effect was worn away. These data provide a simple example that methods might enhance pleasure.

[Figure 1 ILLUSTRATION OMITTED]

As can be easily ascertained, a very small percentage felt that for some reason their sex life had deteriorated, and less than one half of the women reported no change. On the other hand, more than one half reported that their sex life was better since they began using the monitor. One could hypothesize that an improvement in sex life may be a result of paying attention to fertile and nonfertile days and then having more sex than before on nonfertile days.

These data, however, are not as interesting as the qualitative flavor shared by couples via answers to the open-ended questions about PERSONA's features. The comments presented below are not intended to reflect a random sampling of all such feedback, rather only whether any method might enhance intimate behavior. For illustrative purposes, a few statements have been sorted into three different groupings. They are statements about the impact on their over-all sex lives, ways in which PERSONA's features impact their sex lives, and the way the method has led to new activities in their intimate behavior.

Sex life in general. First consider the following comments which are rather general in nature.

   Much improved sex life and a happy partner.

   A much more relaxed sex life.

Sex life and specific features of contraceptive method. The following statements are a bit more explicit about the way in which the method features impact on their sexual behavior.

   It has given us the freedom to enjoy natural, uninterrupted sex,
   confidently, without the worry of an unwanted pregnancy.

   Improved my sex life immensely as hormonal drugs had "put me off" sex a few
   years previous to [this new method].

   No pills to be taken, no condoms to fumble with or tear, plus we both trust
   the machine--this adds to good sex.

   It was brilliant to enjoy sex on green days without the use of artificial
   contraception, secure in the knowledge it was safe to do so.

Impact of method on sexual behavior per se. Finally, Snowden was quite interested in the way in which these couples often reported that PERSONA altered the specific nature of the couple's sexual play. He thought that instead of turning to barrier methods during red days, many couples developed new (for their relationship) approaches to noncoital sex.

   With the green light you think "yeah--make the most of it" sort of thing.

   He thinks it's brilliant. He always asks me, "well, what light is it
   today?" Well, we've got a green light tonight!

   Sometimes ... if it's a red day, we'll do other things ... we've become a
   bit more experimental, you know? ... Which I think is quite good as well,
   it's like an added bonus.

   We had nonpenetrative sex more often ... we'd do other things.. it's like
   an added bonus.

Summary on PERSONA

We have argued throughout this paper that different couples, in different circumstances, are going to make different decisions regarding choice of any contraceptives. Clearly, PERSONA is not the ideal method for all couples, especially those determined to not ever have any more children. That said, it is interesting to document the way in which new alternatives can be perceived to have a positive impact on couple's intimate behavior.

DISCUSSION

Family planning methods have the unique challenge to be not only functional, but also to enhance sexual pleasure and to free women and men from the fear of unplanned pregnancy. While the methods described above are designed to assist couples to avoid unwanted pregnancy, it is hard to discuss their impact on sexual behavior without addressing their potential impact on preventing the acquisition of a fatal sexually transmitted disease such as HIV. Consequently, while some of these methods may present the prospects of enhanced sexual pleasure, some may not be the same methods that provide the best STD prevention. Again, it is our belief that there is not one ideal method for all couples. Rather, we support the development of many alternatives. Couples--depending upon their circumstances--may then choose the best fit for their needs. In this regard, methods that enhance sexual pleasure rather than detract from pleasure should be much more acceptable and, therefore, used more consistently and correctly. There are great opportunities in the field of dual protection method development. There seems to be increasing awareness of the need for user acceptability and preference data in the development of new methods. There are no limits to what technology has to offer. The plea here is to imagine what would make methods more acceptable and then to realize that dream in the contraceptive and STD prevention fields.

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Manuscript accepted July 13, 2000

Lawrence J. Severy University of Florida

Jeffrey Spieler United States Agency for International Development Washington, DC

Dr. Severy received funding (via a contract with the University of Florida) from Unipath for acceptability studies of a device designed to assist with infertility. No funding was related to the studies reviewed in this paper. No other such arrangements have been undertaken by either author with any other company. The views expressed by the authors do not necessarily reflect those of USAID.

Address correspondence to L. J. Severy, The R. David Thomas Professor of Psychology, PO Box 112250, University of Florida, Gainesville, FL, 32611.