The papal position on condoms and HIV
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1217 (Published 25 March 2009) Cite this as: BMJ 2009;338:b1217
All rapid responses
I have no objection to the use of condoms.
I am pleased that the BMJ agrees. However, it is unfortunate that the
BMJ, sexual health services, and, perhaps, the medical profession in
general, should be seen to champion promiscuity and infidelity.
They happen. They shouldn't be criminal. And it is not unreasonable
to minimise harm when they occur.
But they are undesirable, not just because of the risk of sexually
transmitted diseases, but also for the wellbeing of individuals and the
health of relationships.
The world would be a happier and healthier place if sexual
faithfulness in relationships were respected. And abstinence is
incontravertably effective in preventing STDs. So lets promote them!
Competing interests:
None declared
Competing interests: No competing interests
If a condom reduces the risk by 90%, or if it is 10 times safer with
a condom, then that means 10 times with equals once without. So if a
condom encourages someone to have sex 10 times because they think it is
safe, whereas if they did not have a condom they would have abstained,
then condom use encourages HIV. Believe me I see it all the time: she
comes in for PEP because the condom came off, ignoring the previous month
of regular "safe" sex. We have a word for people who use condoms for
contraception: we call them parents. A retrovirus is a lot smaller than a
spermatozoa.
Competing interests:
My last born was concieved using a condom
Competing interests: No competing interests
This is merely a general reply to the rapid response from Anne
Williams on condoms, HIV, Africa and the Pope (1).
The statistical table she provides has no p- values, and makes no
proper comparisons. There is no sense of a case/ control context. If HIV
is unstoppable without Catholic morality, then surely HIV should be much
more rampant in the veritably godless West.
She does not consider various confounders- for example, lack of
education about AIDS is the true sad reason for its cruel spread.
Pompous Pharisee- like lectures about promiscuity are not going to
work. What is the blinkered Catholic attitude to birth control? Chaos, no
planning, a Malthusian apocalypse with a planet unable to sustain too many
billions of poor neglected children. Narrow Catholicism would convert the
Third World into a desolation.
Repressing human sexuality can be cruel. Condoms are not the total
solution, but the battle against AIDS will fail without 'prophylactics' as
part of the physician's armoury. Perhaps Anne Williams has neglected a
pragmatic Protestant approach.
As for the Vatican, its grimly simple- minded homilies on condoms are
making the HIV Holocaust even worse. The Pope is not a medical genius and
his comments on condoms are blind ones.
REFERENCES:
(1) Evidence for Abstinence. BMJ Rapid Response. Anne M H Williams. 1
April 2009.
Competing interests:
None declared
Competing interests: No competing interests
As a society in the West, sexual morality in my opinion has
changed for the worse. Sexual intercourse appears to be
the norm in even brief relationships and anyone with any
notion of being chaste or abstinent is regarded as a being
moronic, sexually repressive, regressive or a Catholic.
I grew up in the 1950's and 60's and was a medical student
in the early 1970's which had already seen significant
liberalisation of sexual mores, but how things have changed
or maybe I mixed in a more conservative group of students.
Sexual intercourse is now regarded by all as the sine qua
non of being in a relationship. It's no holes barred. In
the 1970's and especially in traditional circles such as in
Greek and Italian families in Australia,social mores still
frowned upon this behaviour and this was not restricted
just to those with religious affiliations.
Now it is regarded as the norm to have sexual intercourse
after the first date or two and we see the result in HPV,
herpes, chlamydial and viral infections especially in young
girls. The fertility gynaecologists are having a field day.
Although not a Catholic I have considerable sympathies with
the Pope and the Catholic Church who espouse the idea of
chastity and a more responsible attitude to sexual
behaviour. After all being faithful to the one you love is
not such a burden, is it? But we have abandoned most of the
tenets of the Ten Commandments, Mosaic Law and live in the
swamp of self-satisfaction and self-gratification without
moral absolutes or any idea about God's judgement or sin.
To most this may sound trite and probably moronic but this
is how people thought even before Christianity arrived. As
Mick Jagger, that great example of H.sapiens once sang, "I
want my satisfaction".
But as my father oft said,
"The mills of the gods grind slow, but they grind exceeding
small."
Competing interests:
None declared
Competing interests: No competing interests
In the answer to the question about condom and AIDS some Holy
Father’s words were soundly criticized, even in medical journals (1); the
journalist Gian Guido Vecchi, as eye witness, transcribed them as follows:
“[…] And we cannot overcome this drama by distribution of condoms which on
the contrary increase the problem. […]” (2).
Theoretically the protection derived from condom use might be
counterbalanced by more risky behaviours fomented by a false security (3).
An effective example of the amplitude of the scientific debate on condom
and sexually transmitted diseases is represented by the numerous comments
to head to head articles published on a high reputed journal (4;5). Anyway
the Holy Father mentioned the paradoxical effect on AIDS epidemic of mere
“distribution” of condoms, not of comprehensive programs of prevention.
Linear regression analysis of US data provided by CDC (6;7) show a
significant correlation between state-specific use of condoms and state
prevalence of both HIV infection (R2=0,502; p<_00001 and="and" aids="aids" r2="0,438;" p00001="p00001" fig.1a="fig.1a" _1b.="_1b." significance="significance" persists="persists" also="also" after="after" correcting="correcting" for="for" percentage="percentage" of="of" people="people" living="living" in="in" poverty="poverty" p="p" hiv="hiv" infection="infection" blacks="blacks" both="both" _89.="_89." similarly="similarly" prevalence="prevalence" is="is" significantly="significantly" correlated="correlated" to="to" the="the" use="use" condom="condom" african="african" populations="populations" fig.1c="fig.1c" _1011.="_1011."/>Fig. 1 regression curves between US state-specific condom use and HIV prevalence (A), AIDS prevalence in the adult population (B) and African country-specific condom use and HIV prevalence (C).
These are facts deserving respect, beyond theories, auspices, or
desires and scientific community is well-aware that risk compensation
really may counterbalance theoretic promises (12). That does not mean
condom plays a casual role in HIV epidemic, but it may warn about possible
heterogenesis of ends in the preventive strategies and justify a critical
attitude toward reduction of the huge problem represented by the Sub-
Saharan HIV pandemic to the mere issue of condom.
The constant moral teaching of the Catholic Church considers
"consequentialism" and "proportionalism" as unacceptable because they “are
not faithful to the Church's teaching, when they believe they can justify,
as morally good, deliberate choices of kinds of behaviour contrary to the
commandments of the divine and natural law” (13).
Prevention of HIV
infection is an unanimously recognized good but cannot be achieved by an
evil action like contraception; chastity and faithfulness are the means
indicated by the catholic Magistery (14). This is for people who want to
follow catholic perspective. It is hard to believe that people violating
the catholic moral teaching about chastity and marital fidelity have
problems in violating the same moral teaching about contraception. Beyond
this Holy Father’s words may be received also as an invitation to
representatives of secular utilitarianism for a frank confrontation based
on facts and the same pragmatic, short term consequentialism they
recommend. Prevention of AIDS epidemic is a highly disputed and full of
uncertainty issue (15). In the answer to journalist during the fly to
Africa the Holy Father seemed to warn against the temptation to ascribe
difficulties in the battle against HIV in Africa to the moral teaching of
the Catholic Church (16) instead of the insufficient efforts spent on a
necessary global approach made of education, economic support,
pharmacological assistance (17;18;19). Figures demonstrate Catholicism has
not a detrimental effect on prevalence of HIV in Africa (20). As
scientific community we have a duty to clearly report facts: what is known
and what is unknown, because still controversial, undemonstrated or
unexplored and distinguish efficacy from effectiveness. According to the
original spirit of bioethics a correct analysis of the scientific corpus
of knowledge will help the formulation of the moral judgement.
References:
1. Redemption for the Pope? Lancet. 2009; 373: 1054.
2. Gian Guido Vecchi. Corriere della Sera, 2009 March 18th: page 16.
http://archiviostorico.corriere.it/2009/marzo/18/Chiesa_combatte_Aids_pr...
(accessed 21st March 2009).
3. Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels
and the lessons. Lancet 2000;355:400-3.
4. Steiner MJ, Cates W. Are condoms the answer to rising rates of non
-HIV sexually transmitted infections? Yes. BMJ 2008;336:184.
5. Genuis SJ. Are condoms the answer to rising rates of non-HIV
sexually transmitted infection? No. BMJ 2008;336:185.
6. Department of Health and Human Services, Public Health Service,
Centers For Disease Control And Prevention. Cases of HIV Infection and
AIDS in the United States and Dependent Areas, 2007. HIV/AIDS Surveillance
Report, Volume 19. (table 11).
http://www.cdc.gov/HIV/topics/surveillance/resources/reports/2007report/...
(accessed 21st March 2009).
7. Bensyl DM, Iuliano AD, Carter M, Santelli J, Colley GB.
Contraceptive Use --- United States and Territories, Behavioral Risk
Factor Surveillance System, 2002. (table 1). CDC MMWR, Surveillance
Summaries 2005; 54: 1-72.
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5406a1.htm. (accessed 21st
March 2009).
8. US Census Bureau. Poverty 2006. Percentage of People in Poverty by
State Using 2- and 3-Year Averages: 2004 to 2006.
http://www.census.gov/hhes/www/poverty/poverty06/state.html. (accessed
21st March 2009).
9. US Census Bureau. State & County QuickFacts.
http://quickfacts.census.gov/qfd/states/. (accessed 21st March 2009).
10. United Nations, Department of Economic and Social Affairs,
Population Division. World Contraceptive Use 2007.
http://www.un.org/esa/population/publications/contraceptive2007/contrace....
(accessed 21st March 2009).
11. UNAIDS/WHO. 2008 Report on the global AIDS epidemic. July 2008.
Wallchart.
http://data.unaids.org/pub/GlobalReport/2008/GR08_2007_HIVPrevWallMap_GR....
(accessed 21st March 2009).
12. Cassell MM, Halperin DT, Shelton JD, Stanton D. Risk
compensation: the Achilles' heel of innovations in HIV prevention? BMJ
2006;332:605-7.
13. Ioannes Paulus PP. II. Veritatis Splendor. N. 75; 76. 1993 August
06th.
http://www.vatican.va/holy_father/john_paul_ii/encyclicals/documents/hf_jp
-ii_enc_06081993_veritatis-splendor_en.html (accessed 21st March 2009).
14. Ioannes Paulus PP. II. Familiaris Consortio. 1981 November 22nd.
http://www.vatican.va/holy_father/john_paul_ii/apost_exhortations/docume...
-ii_exh_19811122_familiaris-consortio_en.html (accessed 21st March 2009).
15. Sangani P, Rutherford G, Wilkinson D. Population-based
interventions for reducing sexually transmitted infections, including HIV
infection. Cochrane Database Syst Rev. 2004;(2):CD001220.
16. The pope's grievous errors. Lancet2005;365:912.
17. Hearst N, Chen S. Condom promotion for AIDS prevention in the
developing world: is it working? Stud Fam Plann2004;35:39-47.
18. Magnano San Lio M, Mancinelli S, Palombi L, Buonomo E, Altan AD,
Germano P, Magid NA, Pesaresi A, Renzi E, Scarcella P, Zimba I, Marazzi
MC. The DREAM model's effectiveness in health promotion of AIDS patients
in Africa. Health Promot Int 2009;24:6-15.
19. de Irala Estevez J. AIDS: a cause and consequence of poverty.
Cuad Bioet 2008;19: 557-62.
20. Abboud A. Searching for papal scapegoats is pointless. BMJ
2005;331:294.
Competing interests:
None declared
Competing interests: No competing interests
The article by associate editor, D Kamerow (ref 1) on this topic
fails to mention recent medical scientific facts (Potts et al (ref 2) is
but one example) which show that research has produced no evidence that
condom promotion has had the desired impact on HIV infection rates at a
population level in high-prevalence generalised epidemics. Reduction has
been achieved with reduction in rates of long-term concurrent sexual
partnerships in Africa. Condoms, may in some, encourage more partners
& increase risk - 'risk compensation'. 'Condoms are the answer' was
listed as one of the ten myths about generalised HIV epidemics (ref 3).
Advocates of male circumcision which has been shown to reduce risk of HIV
transmission, also promote partner reduction.
ref 1 The papal position on condoms and HIV Douglas Kamerow BMJ
2009;338:b1217
ref 2 Reassessing HIV Prevention Malcolm Potts, Daniel T. Halperin,
Douglas Kirby, Ann Swidler, Elliot Marseille, Jeffrey D. Klausner, Norman
Hearst, Richard G. Wamai, James G. Kahn, and Julia Walsh Science 9 May
2008 320: 749-750 [DOI: 10.1126/science.1153843]
ref 3 James D Shelton Ten myths and one truth about generalised HIV
epidemics Vol. 370 No. 9602 pp 1809-1811
Competing interests:
None declared
Competing interests: No competing interests
As a complete outsider to the field of epidemiology and medicine, but
not to biology, I would be very interested to know what is the evidence
mentioned (but not cited) by Kamerow and how he replies to his critics.
The claim that "Uganda, which was successful in decreasing the number of
new cases of AIDS, probably owed most of its effectiveness to greater use
of condoms" rests on the coincidence and on the word 'probably'.
Coincidence alone is not enough, as the Ames story of storks and babies
teaches:
"The number of storks in Europe has been going down for years, the birth
rate's going down for years," Dr. Ames pointed out. "If you plot one
against the other, it's a beautiful correlation. But it doesn't mean
storks bring babies."
(cited by http://abcnews.go.com/2020/Stossel/Story?id=1898820&page=1 )
Probability alone is also not enough. When you tell somebody that the
condom protects him from AIDS and then he gets AIDS in 13 cases out of a
100, then he may get upset with scientists who told him it was safe and
that HIV/AIDS can be stopped by condoms.
Competing interests:
None declared
Competing interests: No competing interests
Kamerow 1. said the success in Uganda probably owed most of its
effectiveness to greater use of condoms. However the evidence shows that
this is not the case but abstinence was promoted. 2.
He also stated that he did not “where the evidence for this position” of
the church comes from. He does not have to look very far, for example the
references in other responses and the 2003 world fact book. 3. Where
populations where ready to listen to the Church and the message of
abstinence the infection rate of AIDS has decreased. 4.
Catholic population HIV infection Burundi 62% 6% Angola 38% 3.9% Botswana 5% 37% South Africa 7% 22% Ghana Christian63% 3.1% RC 12%
From this data, it can be seen that those who try to live in accord
with the teaching of the Catholic Church are solving the problem of AIDS
more effectively than those accepting supplies of condoms. Instead of
making Africa dependent on Western sales, the Pope is serving the needs of
the poor by giving them credit. He understands that they can aspire to
greater faithfulness rather than rely on flimsy, inadequate, false
security. The same contraceptive mentality which considers that people are
slaves to their sexual desires because they are African is increasingly
sexualising the teenagers in the UK. The Pope is encouraging people to
make mature decisions rather than putting them down.
Ref 1. Kamerow D The papal position on condoms and HIV BMJ 2009;338:b1217
Ref 2. http://allafrica.com/stories/200902170145.html,
http://www.medicalnewstoday.com/articles/21702.php
Ref 3. http://www.umsl.edu/services/govdocs/wofact2003/index.html
Ref 4. Uganda: The Real ABC’s of an Epidemic By Matthew E. Bunson
This Rock Volume 19, Number 5 May-June 2008
http://www.catholic.com/thisrock/2008/0805_final.pdf
Competing interests:
None declared
Competing interests: Catholic population HIV infectionBurundi 62% 6%Angola 38% 3.9%Botswana 5% 37%South Africa 7% 22%Ghana Christian63% 3.1%RC 12%
In England, we fine parents if their children are truant from school,
and yet we propel these young people toward risky sexual practices armed
only with a flimsy condom. Even in the studies of married men with
haemophilia, significant rates of transmission of HIV to their wives has
been found, despite condom use.(1)
As a doctor working in England I have seen some unpleasant
manifestations of HIV-AIDS. Healthcare workers and the general population
in the UK seem complacent about HIV as it is quite uncommon in many parts,
we have the drugs to treat HIV, few people see the effects of HIV AIDS and
we, like Africa, have a condom based 'safe sex' campaign. It hasn't worked
there, and it isn't working here.
I recall an expression, 'Learn from the mistakes of others as you
won't live long enough to make them all yourself.'
Ref 1 Family Planning Perspectives 1999,31(6):272-279.
Competing interests:
None declared
Competing interests: No competing interests
Re: Re: Evidence for Abstinence
This is a very late apology to Anne Williams.
I am sorry if I was rather caustic about her opinions on condoms and
Catholicism.
The Third World could not cope without the assistance of Catholic
medical workers such as herself.
The problem is that the Pope and the Vatican come across as too
repressive on sexual issues. There is no attempt at a middle way.
Catholicism pits itself against condoms, and so denies doctors a method of
defusing HIV. Religiosity without common sense is the enemy of compassion.
Malthus might have, quite cynically, defined HIV as one of nature's
cruel reactions to excess population. HIV is the number one enemy of the
modern world. HIV is an epidemiological bomb that may yet overwhelm the
planet. Without condoms, we cannot prevent it- or crippling
overpopulation.
Competing interests:
None declared
Competing interests: No competing interests