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Rapid Responses: Rapid Responses published:
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Condoms and circumcision
- David B G Hawker (25 January 2008)
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condoms not the answer
- John Scotson (25 January 2008)
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condoms not the only answer (& infant circumcision neither an answer, nor acceptable)
- A.D. Fontain (26 January 2008)
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A policy for populations versus one for individuals
- Christopher M. Buttery (27 January 2008)
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The risk left after risk reduction can remain high
- JOKIN DE IRALA (28 January 2008)
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Condoms help STI prevention and curbing teenage pregnancies
- DAVID GWYNFOR SAMUEL (29 January 2008)
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Condoms not "the only solution" to prevent Non HIV STDs
- Manthan D. Janodia, Sreedhar D., Virendra S.Ligade, Udupa N. (1 February 2008)
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Condom promotion hand in hand with sex education is the only answer
- Teena Mathew (4 February 2008)
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The impact of condoms depends on biological and behavioural context
- Helen Ward, Peter J. White and Geoff P. Garnett (4 February 2008)
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real world please
- penelope a watson (22 February 2008)
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David B G Hawker, retired GP/Anaesthetist PL30 5LA
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Whilst agreeing that We must teach Abstinence and Faithfulness to those who will listen (and not denigrate the importance of that), the harsh realities of sexuality are there. Our young people particularly need all the protection they can get. 40% sexually active before 16 is a scary statistic. The article by Stephen Genius was an eye opener to me, demonstrating the significant limitation of condoms even used perfectly. We know that young people in heightened states of sexual arousal rarely use them properly. Human papillomavirus seems particularly hard to contain, and it is the silent killer, either via cervical cancer and probably prostate cancer. We need belt and braces. We must educate, but in the context of long term relationships, and we must again consider circumcision. I find it strange when discussion of STI transmission is aired and circumcision not aired with it. All the present trials show that removal of the foreskin significantly reduces the risk of transmission of STIs. HIV is the disease talked about much, for obvious reasons, but circumcision works for others too. If we are concerned to add circumcision to the other layers of protection for our adolescents, it had best be done in infancy, Competing interests: None declared |
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John Scotson, Retired GP Altrincham, Cheshire WA 14 2AN (Home)
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Self control not the dubious protection of latex or rubber is the answer to the spread of sexually transmitted disease. Not one study has shown unequivocally that condoms are effective in preventing the spread of STD. They give a false sense of security, encouraging promiscuity Competing interests: None declared |
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A.D. Fontain, Independent Researcher/ student Toronto, ON. Canada, M5S 1A5
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The problem is in the framing of the question. As the authors points out there is no single 'answer' to STIs. Obviously education and awareness are key priorities. Someone who is aware of the dangers of STIs and who is equipped with the knowledge of how to protect themselves are able to sufficiently mitigate their risk. I have to take exception with David Hawker's statement that we must again consider circumcision. If an adult male wishes to get himself circumcised he is free to do so. To circumcise infants and children however is a ethically unjustifiable. We cannot go cutting of healthy parts of people's bodies before they can give their consent. There is a growing number of men who have expressly objected to this surgery being performed on them in infancy. Modern medicine cannot be based solely upon utilitarianist approaches. Moreover, coming from a utilitarian standpoint, there is hardly a basis for circumcision in countries who are not experiencing an epidemic of STIs and who have running water. Modern medicine must also consider principles of patient autonomy and bodily rights. Circumcising a healthy child is not compatible with respecting an individual's basic human rights. It is impossible to predict whether or not a male may will object to having part of his sexual anatomy erased without his consent. This creates a serious problem in relation to individual bodily rights. The majority of preventative benefits cited in literature are rare and too minor to warrant surgery. Coupled by the fact that they can virtually all be achieved by less invasive means. In fact, most males do achieve the same ends simply by bathing and practicing responsible sexual conduct. Without medical need and without the surgery being the least invasive prevention method to achieve the same ends - most commonly something as minor as a skin infection that can be easily treated - there is little in the way of justification for this type of physician conduct. It is surprising to see that even still, in the year 2008, there continues to be many who exhibit such a willing blindness to the complex ethical issues raised - and which must be addressed - by allowing such an outdated practice in the context of medicine. Let it be a choice of the individual. Knowledge is key to STI prevention. It is addressing lack of awareness that must be a priority. Certainly not circumcising infants; and of course condoms alone are not the answer but they do work. I know many people, myself included, who tend not to make a habit of indulging in casual sex; not only for health reasons but for reasons of emotional well being. Yet on occasion, if situations like that arise, we know to use condoms and by doing so are using the most effective preventative technology that currently exists. With proper communication one can also reasonably assess the safety of who you are getting into bed with. I think most people know that condoms are not a license to sleep with any woman you feel like. There should be no stigma around asking a partner if they have been tested for STIs. In this day and age it is common sense. Perhaps I am from the generation where this got nailed into our heads from an early age. If their are young people these days missing the boat on this I think that needs to be a main priority. A knowledgeable person who takes care of his/her well being simply does not expose him/herself to nearly as much risk. Awareness leads to better behaviour; not only in the prevention of STIs but in all aspects of life. Competing interests: None declared |
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Christopher M. Buttery, Clinical Professor of Public Health Virginia Commonwealth Univ. Richmond, VA. USA
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I first started trying to prevent STIs when posted to Germany in 1947 as a lab tech in the RAMC, before going to medical school. I have been learning about and trying to reduce STIs ever since. The title of the discussion is misleading. It should be "focus on condom use, or on being all things for all people." This is really not pro and con. It is a discussion on setting policy for populations, versus individuals, and whether education changes behaviors. Dr. Cates confirms that condoms work. Despite religious and political activism condoms work. We should be past that discussion. Using condoms is relatively simple. I have taught thousands of adolescent and young adult males and females how to use condoms. In 60 years I never had one come back and complain that they did not work (although I am sure there were some errors in application). Genuis' main argument seems to be that despite using condoms STIs can still be trandmitted. All of us would agree. Condoms can slip off the penis. Condoms may not be used early enough in the sexual process. Abstinence is rarely selected, although when selected it is effective. If all the concerns emoted by Genuis, for the benefit of individual patients, not populations, were provided at every visit the patient who came for advice expecting 5-10 minutes of discussion might spend an hour ot more with the doctor. Then leave confused and more open to an STI than before. For the most part policy is passed by legislators who have very little acquiantance with the scientific method or the complexity of research discussion. Cates takes a look at the world of STIs. Population interventions need to be simple, cheap and easy to translate from research to practice. Condom use meets these criteria. All the issues raised by Genius while valid, one on one in the doctors office, obfuscate population intervention. This is equally true whether rthe population is a community, large or small, or institutions such as schools, colleges or even countries. The condom is or should be the first line of defense. Everything else is an add-on and can be provided as supplements to condom use for those interested.. Competing interests: None declared |
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JOKIN DE IRALA, Professor Epidemiology University of Navarre
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I was pleased to read the “head to head” articles on whether condoms are, or not, the answer for the prevention of sexually transmitted infections, defended by Markus Steiner and Willard Cates on the “yes side” and Stephen Genuis on the “no side”1. Pleased, because it was a nice scientific discussion and “ideologically free”. I have some points to add on the discussion. We need to be careful when relying on laboratory studies such as Steiner and Cates argue when affirming that condoms are effective barriers against “passage” of even the smallest sexually transmitted pathogens. This is efficacy and obviously needs to be addressed in the first place, but it is not the ultimate criteria to evaluate condoms. In practice, the problems with condoms are not due to “passage of pathogens”. They rather have to do with issues such as breakage or slippage when the aroused young and inexperienced male unexpectedly looses his erection, for example. Furthermore, condoms do not cover all surfaces that can be infectious. A study by Winer in 2003 showed that some women got infected with HPV without having had penetrative sex2. The second issue I would like to address is the misinformation that can be conveyed when affirming that condoms “reduce the risk” of an infection. It is indeed important to reduce a risk but one has to understand the magnitude of this risk reduction, and the magnitude of the remaining risk thereafter, in order to make wise decisions. The 2006 study of Winer indeed showed that condoms were effective to reduce risks because the risk of infection decreased from 89% to 38% when comparing those that used condoms consistently with those using them in less than 5% of their sexual encounters3. But what these data also show is that condoms are not as effective as we would want hem to be to “avoid” an infection because, in spite of consistent use, 37% still became infected after one year, and this is a very serious public health problem. Is it sound to inform an adolescent girl not to worry because “condoms are good in reducing the risk of HPV”, when one still has a 37% risk of infection in spite of consistent condom use? I do not think so, and similar situations can be observed with other infections that have no satisfactory treatment. Giving these facts to youth is not “denigrating condoms”, this is simply giving them the facts. Hiding these facts would conversely be discriminatory to the large youth population that is not having sex and that would benefit with clear messages that help them maintain their risk avoidance choice. And those that decide to have sex need to know this truth as well because it is their health that is at sake after all. Abstinence can be more or less difficult depending on what society chooses to promote but youth have the right and responsibility to face and respond to their own difficulties in life and make their own informed choices. Many crucial behavior changes can be difficult. Millions of young people around the world have made the difficult choice of abstaining. Thirdly, the information on condoms do not undermine abstinence programs when interventions are indeed “abstinence centered”4. However when condoms and abstinence are presented as equally valid choices for youth without sexual experience, risk compensation is an obvious possible outcome5. Yes, we should feel relieved if a program does not increase risk taking. However, a good program should go beyond and achieve a decrease in risk taking. Both the yes and the no sides seemed to agree that messages have to be tailored to specific target populations. This is what was basically endorsed in the consensus published in The Lancet that called for the promotion of sexual delay and mutual monogamy among youth and sexually active adults respectively, and condom use to those who freely chose not to accept risk avoidance6. But a recent Lancet editorial on this same issue has very much disappointed me7. I am surprised to see a scientific journal such as The Lancet taking such unscientific and partisan stances. It is not the first time this journal uses editorials to convey a certain anti pope agenda. In “The Pope and science” they state that Pope Benedict XVI was forced to cancel a speech at La Sapienza University in Rome “because of his past defense of the Church’s 1663 heresy trial of Galileo”. The editorial then goes “guestimating” the number of Catholics that are against the Church’s teachings and uses terms such as “conservative” or “progressive” Catholics to finish up giving the impression that the Pope is alone with his teaching on abortion or condom use. The Pope has never ever defended Galileo’s trial, The Lancet has simply misquoted him because it seems they have unfortunately not read his original speech where this issue was brought up. The cancellation of La Sapienza was due to the “democratic” protest of 67 out of the 4.500 professors of that university. Two hundred thousand persons gathered at Saint Peter’s place on the Sunday after this event to show their Papal support. The Church has its views on condom use and has a specific teaching on sexuality that one is free to accept or not. Scientific journals have nothing to say on this personal choice. But studies have showed that the only countries that have really been able to curb the HIV epidemic are those that have seriously implemented A and B instead of relying solely on condom promotion8. Furthermore, the church has been promoting A and B along centuries and instead of concentrating on trying to change its teachings on sexuality and condom use, we could rather learn and benefit more from church experience fostering sexual delay and mutual monogamy among youth. Jokin de Irala MD, PhD
1 Steiner MJ, Cates W. “yes” and Genuis S “no”. Are condoms the answer to rising rates of non-HIV sexually transmitted infections? BMJ 2008;336:184-185. 2 Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol 2003; 157: 218-26. 3 Winer RL, Hughes JP, Feng Q, O'Reilly S, Kiviat NB, Holmes KK, et al. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med 2006; 354: 2645-54. 4 Cabezon C, Vigil P, Rojas I, Leiva ME, Riquelme R, Aranda W, Garcia C. Adolescent pregnancy prevention: An abstinence-centered randomized controlled intervention in a Chilean public high school. J Adolesc Health. 2005;36:64 5 de Irala J, Alonso A. Changes in sexual behaviours to prevent HIV: the need for comprehensive information. Lancet 2006; 368:1749-1750 6 Haleprin D, Steiner M, Cassel M, Green E, Hearts N, Kirby D, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913-1915. 7 Editorial. The Pope and science. The Lancet 2008;371:276 8 Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Stud Fam Plann 2004; 35: 39-47. Competing interests: None declared |
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DAVID GWYNFOR SAMUEL, 5TH YEAR MEDICAL STUDENT CARDIFF UNIVERSITY CF14 4XN
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As a medical student who lives and hopes to work in Merthyr Tydfil, a town which has some of the highest rates of teenage pregnancies and Sexual transmitted infection rates in the UK and indeed, Europe I welcome any scheme that reduces these less than proud acolades that my home town currently holds. Young people are engaging in sexual intercourse at a younger age and without regard to the risks and long term consequences of their actions. I feel that condoms are a proven method of safe sex, and can be made available to all, irrespective of wealth or social status. What is needed more than ever is open access clinics in some of the poorest parts of the UK so that people can access contraception, education and advice in a non- stigmatising environment. Removing the taboo surrounding contraception and STIs will encourage safer sexual practices. The call this week by a Welsh MP to expand the availability of condoms to teenagers and improve the sex education programmes in place only strengthens Steiner and Cates' argument. They share the vision that condoms are a cheap, effective and practical method of reducing infections and unwanted pregnancies. Two issues that are currently costing the NHS large amounts of money that could be better spent improving the health of the nation. Competing interests: None declared |
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Manthan D. Janodia, Lecturer Department of Pharmacy Management, MCOPS, Manipal University, Manipal 576 104, India, Sreedhar D., Virendra S.Ligade, Udupa N.
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The article on use of condoms for prevention of non HIV STDs has been defended by the authors with relevant arguments for "Yes" as well as for "No". It would be wrong to say that condoms are 100% safer in preventing non HIV STDs. Although condoms do reduce the risk of STDs, it does not totally eliminate the risk. "Abstinence" from Sex is not possible today, rather educating youth regarding safe sex is important. It would be wrong to make government totally responsible for framing the health policy to prevent or reduce transmission of non HIV STDs; rather a pragmatic approach by individuals is required where they are made aware of the repurcussions of not having safe sex or taking enough precautions for prevention or transmission of non HIV STDs. It is moral responsibility of individual to have a "healthy sexual life" without being infected and infecting the partner. Competing interests: None declared |
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Teena Mathew, SpR in GUM Countess of Chester Hospital NHS Foundation Trust, Liverpool Road, Chester. CH2 1UL
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The promotion of condoms without appropriate education regarding their use, poor awareness of routes of transmission of sexually transmitted infections (STI ) and sex under the influence of alcohol and recreational drugs are responsible for today’s spiraling numbers of STIs and unwanted pregnancies. Many times in clinic, patients who report consistent condom use are very surprised when given a diagnosis of a STI. On further questioning it becomes evident that condom use was incorrect and knowledge is lacking regarding certain modes of transmission of STIs (e.g.. skin to skin transmission of Human Papilloma Virus (HPV), Herpes Simplex Virus and Molluscum contagiosum virus). A lot of young people (especially women) consider intravaginal ejaculation necessary for transmission of STIs. The other popular myth is that oral sex is safe. A considerable number of men who have sex with men (MSM) and commercial sex workers use condoms consistently for anal and vaginal intercourse but not for oral sex. In the recent outbreak of syphilis among MSM, almost half reported oral sex as the likely route of transmission (l). One component of a primary and recent HIV (Human Immunodeficiency Virus) infection study called the Options Project, funded by the Centers for Disease Control and Prevention at the University of California found that 7.8% of recently HIV infected MSM in San Francisco were probably infected through oral sex. Despite sustained positive efforts in sex education in secondary schools, messages about safer sex and contraception is not getting through to targeted population (16-25 years). Implementing HPV vaccination for girls around 12 years of age will give the Department of Health and National Health Service a new platform to work together to discuss sex in schools at an early age . This is a great opportunity to tackle some of the shortcomings of the current sex education strategy. In summary, condom promotion along with education regarding the A to Z of prevention strategies for STIs mentioned by Markus J Steiner et al should be the cornerstone for prevention of STIs worldwide. While there is no argument that condoms definitely decrease the transmission of HIV, reports of decreased funding for condoms in Uganda with a view to promoting abstinence, leading to a shortage of condoms, is definitely not an acceptable solution. (1)HPA. Trends in infectious syphilis; epidemiological data for the UK to 2004 and an update on the London and Manchester Outbreak. Available online at: http://www.hpa.org.uk/cdr/archives/2005/sti_syph4805.pdf Competing interests: None declared |
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Helen Ward, Reader Imperial College London, Peter J. White and Geoff P. Garnett
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To ask, “Are condoms the answer to rising rates of non-HIV sexually transmitted infections” reinforces the misunderstanding that there is a panacea. In fact, the biological and behavioural context will determine condoms’ usefulness in preventing spread. The debate (1,2) hinged on observational and trial evidence of condoms’ effectiveness in reducing an individual’s infection risk. However, interpreting such evidence, and assessing potential impact on transmission in different groups, requires consideration of the infectivity of the particular infection and the epidemiological context – i.e. the prevalence of the infection in regular, casual and commercial sex partners, the number of sex-acts with each of those partners, and the proportion of acts where condoms are used correctly with different partners. All of these factors contribute to the transmission probability per partnership – in addition to the efficacy of a condom in preventing transmission during an individual sex act. If the transmission probability per sex-act is high (e.g. gonorrhoea), then infection will occur over very few sex-acts, and condoms have to be used in nearly all acts to prevent transmission (3). Condoms can be effective in short-lived commercial or casual partnerships, as shown by studies in female sex workers (4). In longer-term partnerships, condom use may well not be sufficiently consistent or correct to have an impact. Alternatively, if the transmission probability is low (e.g. herpes simplex virus), then the risk gradually increases with the number of acts (5). Here, condoms used in some acts within a partnership will reduce – although not eliminate – risk. Clearly condom efficacy is not 100%, but it is equally clear that condoms reduce the risk of acquisition of many infections (6-8) This means condom use and reductions in numbers of sexual partners can both be promoted – and both can be achieved simultaneously (9-11) – along with introduction of vaccinations, and improving access to care (12). Communicating evidence from studies of condoms without describing the epidemiological context, and creating a false dichotomy between condoms being useful or not, fails to place their role in its proper perspective and does not allow individuals, or programme managers, to make informed choices. Individuals with multiple partners, including sex workers, should be informed that condoms used consistently and correctly for all sex acts will be highly effective in preventing some infections, but cannot guarantee protection against all. (13) References (1) Steiner MJ, Cates W. Are condoms the answer to rising rates of non-HIV sexually transmitted infection? Yes. BMJ 2008, 336: 184. (2) Genius S. Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No. BMJ 2008, 336: 185 (3) Garnett GP Chapter 4 Transmission dynamics of sexually transmitted Diseases. In Sexually Transmitted Diseases (4th Edn). Eds Holmes KK, Sparling FP, Stamm WE, Piot P, Wasserheit JN, Corey L and Cohen M McGraw-Hill 2008. (4) Ward H, Day S, Green A, Cooper K, Weber J. Declining prevalence of STI in the London sex industry, 1985 to 2002 Sex Transm Inf 2004;80(5);374-379 (5) Garnett GP Dubin G Slaoui M and Darcis T. The potential epidemiological impact of a genital herpes vaccine for women. Sexually Transmitted Infections 2004; 80:24-29. (6) Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull WHO 2004;82(6):454-461 (7) Winer RL, Hughes JP, Feng Q, O'Reilly S, Kiviat NB, Holmes KK, Koutsky LA. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med. 2006 Jun 22;354(25):2645-54. (8) Stanberry LR, Spruance SL, Cunningham AL, Bernstein DI, Mindel A, Sacks S, Tyring S, Aoki FY, Slaoui M, Denis M, Vandepapeliere P, Dubin G; GlaxoSmithKline Herpes Vaccine Efficacy Study Group. Glycoprotein-D- adjuvant vaccine to prevent genital herpes.N Engl J Med. 2002 Nov 21;347(21):1652-61. (9) Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996;335:297–303 (10) Hallett TB, Aberle-Grasse J, Alexandre EK et al. Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, Urban Kenya, Zimbabwe and Haiti Sexually Transmitted Infections 2006; 82 (Suppl 1): i1-i8. (11) Hallett TB, White PJ, Garnett GP. Appropriate evaluation of HIV prevention interventions: from experiment to full-scale implementation. Sex Transm Infect 2007;83(Suppl I):i55–i60. (12) White PJ, Ward H, Cassell JA, Mercer CH, Garnett GP. Vicious and Virtuous Circles in the Dynamics of Infectious Disease and the Provision of Health Care: Gonorrhea in Britain as an Example. J Infect Dis 2005;192:824-36 (13) Fox J, Day S, Taylor G, Ward H. The epidemiology of HSV-2 in female sex workers in London. Epidemiol Inf 2006; 134(5):1114-1119 Competing interests: Helen Ward is an editor of the BMJ journal Sexually Transmitted Infections |
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penelope a watson, gp and med practitioner in family planning westerhailes health centre, edinburgh eh14 2ss
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The quintessential sexually transmitted dis-ease must be unwanted pregnancy: also vertical transmission of blood born viruses requires consideration. I hope no-one concludes from this debate that condoms have anything other than a hugely important role in promoting reproductive health. Competing interests: None declared |
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