Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Condoms are Not the solution
- Alvin Tan (25 January 2008)
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No magic bullett
- Miguel A. Martinez-Gonzalez (25 January 2008)
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Condoms offer only limited protection against non HIV STIs
- Ravindra Gokhale, Arrowe Park Road, Upton. Wirral CH49 5PE (27 January 2008)
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Stephen Genuis is on the right track
- André E. Corriveau (29 January 2008)
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What about the knowledge?
- Jennifer L Pikard (30 January 2008)
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Sex is fun, remember?
- Elizabeth Pisani (30 January 2008)
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Condoms are the answer to rising rates of non-HIV sexually transmitted infections? Good, but not right
- Xiaofeng Ren (30 January 2008)
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Deeper Issues
- Andrew PG Mitchell (28 February 2008)
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Alvin Tan, Medical Student Ipoh, Malaysia
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To assume that condoms can stem veneral diseases is childish, and wrong. We have to change the mindset of the population to have a lasting remedy to this problem. Competing interests: None declared |
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Miguel A. Martinez-Gonzalez, Professor & Chair Department of Public Health, University of Navarra, Spain
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The data from Alberta reported by Dr. Genuis (massive promotion of condoms followed by upsurges in gonorrhoea and chlamydia) are mirrored by the situation in our country. Spain, together with Greece, stands out as the European country with the highest levels of condom use among young people, with 90% of sexually active young people reporting using a condom the last time they had sexual intercourse (Health Behaviour in School-aged Children survey: http:// www.hbsc.org / publications/reports.html). Nevertheless, our rates of sexually transmitted infections (STI) are on the rise (44 and 81 percent higher rates for gonorrhoea and syphilis, respectively during 2006, the last available data, (1-2)). Year after year we are facing increasing rates of STI precisely after more than a decade of intensive official educational campaigns transmitting to young people the only message apparently considered to be politically correct and officially acceptable in our country. This message contains a naive and simple concept: condoms and only condoms are the magical bullets to prevent all STI and unintended pregnancies. There is no room for dissent, no consideration for the accrual of persuasive scientific evidence strongly supporting that other behaviour changes, such as partner reduction, should be promoted as a priority (3-4). The ideologies, prejudices, stigma, and social agenda of some governing officials seem to precede the scientific evidence when building public health policies. The escalating figures for youth pregnancy and abortion in Spain (5) also demand a higher level of critical attitude towards the apparently sacred icon of "condoms and only condoms" dogma. The failure of this simplistic one-size-fits-all strategy in our country calls for a more comprehensive policy. Rather, different approaches or combinations of approaches may be optimal for particular individuals in diverse life circumstances. In addition, recent advances made in behavioural, social, and biomedical sciences need to be incorporated. Determinants of disease are multi- factorial and prevention strategies should not rely on a single "magical" solution (male condoms). References (1) Instituto de Salud Carlos III. Ministerio de Sanidad y consumo. Estado de las enfermedades de declaración obligatoria. Boletín Epidemiologico semanal 2006;14:256-9 (available, [in Spanish] in http://www.isciii.es/htdocs/centros/epidemiologia/boletin_semanal/bes0652.pdf). (2) Instituto de Salud Carlos III. Ministerio de Sanidad y consumo. Comentario epidemiológico a las enfermedades de declaración obligatoria y sistema de información microbiológica. Boletín Epidemiologico semanal 2006;15:109-15. (available, [in Spanish] in http://www.isciii.es/htdocs/ centros/epidemiologia/boletin_semanal/bes0719.pdf). (3) Shelton JD, Halperin DT, Nantulya V, Potts M, Gayle HD, Holmes KK. Partner reduction is crucial for balanced "ABC" approach to HIV prevention. BMJ 2004;328:891-3. (4) De Irala J, Alonso A. Changes in sexual behaviours to prevent HIV. Lancet 2006;368:1749-50. (5) Ministry of Health. IVE 2006. Officials statistics of abortion in Spain. Available [Spanish] in http://www.msc.es/profesionales/saludPublica/prevPromocion/embarazo/home.htm. Competing interests: None declared |
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Ravindra Gokhale, Lead Clinician, Dept of GU Medicine and Sexual Health Wirral University Teaching Hospital NHS Foundation trust, Arrowe Park Road, Upton. Wirral CH49 5PE
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Dear Editor There is no doubt condoms do offer some protection but as a pracicing GUM Physician I dont think it is the solution to prevent rising rates of sexually transmitted infections (STIs). Firstly inspite of wide spread availability of condoms people are still having unprotected sex and this is reflected both in terms of increase in STIs and unintended pregnancies. Secondly people simply don't use condom for oral sex. Recently we had outbreaks of syphilis in gay men in London followed by Manchester and the enhanced surveillance that followed was suggestive of transmission of syphilis through oral sex. I have also seen several cases of gonorrhoea acquired through unprotected oral sex both in men and women. Many GUM clinics now routinely take oral swabs for gonorrhoea culture in suspected cases of gonorrhoea in all patients. We have seen rises in genital herpes predominantly caused by Herpes Simplex Virus (HSV) Type 1 or the 'cold sore' virus again due to increase in oral sex. The current evidence suggests that barrier methods such as condoms offer only limited protection against acquisition of viral STIs such as Human Papilloma Virus (HPV) and HSV. In my opinion the main reason why people don't use protection or use it ineffectively is alcohol and drugs. When you take a sexual history, the common scenario is boy meets a girl or vice versa, in a club or at a party. Very often he is unable to achieve or maintain an erection under the influence of alcohol and the girl tries to help him by performing oral sex (felacio). Condoms are rarely used for oral sex as most people think it is safe. Penetrative sex may or may not happen when alcohol is consumed in excessive amount. Very often condom is used clumsilly for penetrative sex under the influence resulting into transmission of STIs such as chlamydia, gonorrhoea, HSV or syphilis. When you talk to young people, it is still considered 'uncool' to carry condoms on you. The condoms available in the vending machines in the club loos are expensive and there are many who simply hate condoms. Hence I don't feel condom is an effective answer to rising rates of non HIV sexually transmitted infections.We must look at other issues such as change in behaviour, alcohol and drug use in addition to sex education along with safe sexual practices. Dr Ravindra Gokhale GUM Physician Presently deployed as a GUM Physician with United Kingdom Medical Group at Multi National Division (South East)Field Hospital. Basra, Iraq. Competing interests: None declared |
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André E. Corriveau, Chief Medical Health Officer, Northwest Territories (Canada) Yellowknife (X1A 2T9)
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I am in full agreement with Stephen Genuis' position and arguments. Our data indicates that a significant proportion of high risk sexual behaviours occur in the context of heavy alcohol or drug use, where rational thinking is no longer an option and availability of condoms irrelevant. It is in fact not unusual for new cases of STIs to report multiple partners about whom they only remember a first name, if any, without any further contact information. We have also noted a worrisome pattern of wide age differentials between teen female cases and much older male contacts that lead us to worry about power imbalance where one of the partners has much less "voice" than the other to negotiate some of the terms of the sexual relationship and related activities. For all these reasons, we can only hope to make progress in this area with a multifaceted approach, based on social marketing principles, that fuly engages communities and specific target audiences in a dialogue on the root issues that are currently fuelling the increase in STI rates and the identification of solutions. Competing interests: None declared |
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Jennifer L Pikard, Graduate Student Queen's University at Kingston, Ontario, Canada K7L 2T1
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Genuis' article hits the nail right on the head. We sometimes forget/neglect the importance of knowledge and education about sensitive and serious issues such as STIs. Particularly, many school teachers feel uncomfortable addressing these issues and are unable to correctly inform their pubertal students. In other instances, some people believe that these infections can penetrate the holes in condoms and therefore throw out the idea of protection at all. The battle against rising rates of STIs cannot be fixed by the advocation of condom use alone - there has to be a better way. Competing interests: None declared |
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Elizabeth Pisani, Epidemiologist Independent consultant
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Steven Genuis suggests that young people have risky sex because they are trapped in miserable lives. I'm not sure how long it is since Dr Genuis was a young person, but I would suggest that most young people have sex for the same reasons most old people do: because it is lots of fun. As others have pointed out, sex often goes hand in hand with other things that are fun, like going out dancing with your mates, taking drugs and getting plastered. I don't wish to lower the tone of this debate; it is certainly useful to have all the evidence of condom efficacy and effectiveness brought together so clearly. But so long as we expect rational responses to the most irrational area of human experience, we will be disappointed. People will take risks, thank God (how dull our lives would be if we didn't). We need to do more to help people choose their risks more carefully. For some ideas, see http://www.wisdomofwhores.com/2008/01/30/ask-a-hooker-not-a-doctor/ Competing interests: None declared |
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Xiaofeng Ren, Associate Professor College of Veterinary Medicine,Northeast Agricultural University,150030,59 Mucai Street,Harbin,China
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I have read with great interest the article by Steiner M. and Cates W. as well as the accompanying "Head to Head" article by Genuis S. [1- 2]. All in all, all the authors of the two articles have expressed their viewpoints clearly and definitely and their works are positive for potential protection for the high-risk population by correct usage of condoms. By comparison, I think that the idea of the latter may be more plausible. Firstly, it is undoubted that the usage of condoms can decrease the transmission opportunity (risking rates) of non-HIV sexually transmitted infection and to give protection to the high-risk population. This is just like we usually use gloves in labs, while we do our experiments. However, the gloves we take never be a crucial factor for getting a good result. The use of condoms is mainly useful for the prevention of sexually transmitted infection to some extent and is not the answer to rising rates of such infection. I agree with Genuis that the physical/mechanical barrier provided by the condoms can be a defense line and only relatively limited areas could be protected, regardless of its concrete effect. In addition, other live style such as kiss may have a similar transmission risk for non-HIV sexually transmitted infection. If we say that condoms are the answer to rising rates of non-HIV sexually transmitted infections, it is good only from the view of behavioral science, but not right from the view of science. Therefore, the basic and clinical studies regarding such infection and/or its pathogen should still be very critical that cannot be replaced by the design and popularization of any novel condoms, at least, for very long time. However, the interesting discussion will contribute to the implements of some potential public strategies or governmental policies and the development of anti- sexually transmitted infection, in the long run, more people will benefit from that really. REFERENCES: [1] Steiner MJ, Cates W. Are condoms the answer to rising rates of non-HIV sexually transmitted infections? Yes. BMJ. 2008 Jan 26;336(7637):184. [2] Genuis SJ. Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No. BMJ. 2008 Jan 26;336(7637):185. Competing interests: None declared |
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Andrew PG Mitchell, Aid worker ,Horn of Africa Djibouti. B.P.1936
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It is well known that: Teenagers engage in sexual activity hoping to find a relationship which is stable/durable, intimacy. Many do so seeking affection which they have not found from their parents especially their father. Sexual activity too early in a relationship, before it is deep and properly formed, results in that relationship breaking down. There then follows multiple serial relationships but an inability to form longterm relationships. Casual sexual activity is dangerous! Not only the dangers and complications of(i) unforeseen pregnancies in young girls(ii) possible abortions(iii)sexually transmitted infections(STI’s)including death(even in the presence of condoms)-but also the emotional trauma of all of these as well as the sadness and rejection of broken relationships for any number of reasons along the way. Children from broken family backgrounds are not so well adjusted emotionally nor do they achieve so well at school. Why then are we as doctors promoting dangerous ,emotionally harmful, relationship weakening activities (with a condom !) which encourage family breakdown and ultimately undermine our society? Why don’t we try promoting preventative measures that encourage relationships and can lead to success in life? 1) Helping our kids to say ‘No’ to sexual pressure-Josh McDowell. 2) The Naked Ape-Desmond Morris. Competing interests: None declared |
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