Monday, 13 July 2009

Lying for Jesus? :2 Condoms

Following on from my previous post, the second part of the Christian Medical Fellowship's submission to BCAP concerns condom advertising on TV.

They note that the Government's Independent Advisory Group on Sexual Health and HIV wrote to BCAP requesting a review of scheduling restrictions on condom advertising, noting that the UK had the highest teenage pregnancy rate in Europe and spiralling rates of sexually transmitted infections.

First off, it's western Europe. Secondly, as a PubMed article shows, such claims about pregnancy have been inflated by the media: International comparisons suggest that the rate is moderate and that the past six decades have seen a decline rather than a rise (...) We believe that the selective reporting of international and time comparisons by public policy makers results in a 'manufactured risk' and has more to do with moral panic than with public health.

This does not bode well for what follows. But back to the CMF with an open mind. Things can only get better.

Or not. They continue that: The presupposition in this proposal is that more condom advertising to an ever wider range of young people will reduce unintended pregnancy and offer some protection against sexually transmitted infections. Briefly, the evidence shows, instead, a correlation between the government's policy of increasing promotion of contraception and the very rises Baroness Gould [of the AIG] notes. (..) The negative effect of the 'message' trumps any possible positive medical benefits. (my bold)

Does the evidence show that promoting contraception correlates directly with an increase in STIs? It could well be that there are other confounding factors involved, for instance that contraception is not being promoted in the most effective way or that there are reasons for promotions being ignored. Did the rise occur before, during or after the promotion? Or it could be that the evidence doesn't show that at all. No trumps on the table just yet.

The CMF conclude that: Further promotion of condom advertising to children aged 10-16 is unnecessary and unethical.

Why is it unethical? Two papers are cited in defence of their assertion. One is Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No by Stephen Genius. This is a response to a previous piece called Are condoms the answer to rising rates of non-HIV sexually transmitted infection? Yes by Steiner and Cates.

The Steiner/Cates article is a balanced one citing strong evidence that condom use is effective in reducing STIs and unwanted pregnancy but making it very clear that condoms are not the whole story; better sex education about risk avoidance and reduction is essential, with condoms as part of the package. It warns that We need to focus on ensuring consistent and correct condom use rather than denigrating condoms as being less than perfect.

However, Genius' response does just that. His basic position is that condoms cannot be the definitive answer to sexually transmitted infection because they provide insufficient protection against transmission of many common diseases [such as] "Skin to skin" and "skin to sore" infections.

But no one is saying that they are. As all students are taught right from the start - answer the question in front of you, not some other question that you've prepared better for.

Ironically, Genius states early on that A fundamental tenet of medicine is adherence to scientific fact and experiential evidence to develop treatments and programmes that maximise and sustain health and later that Political correctness and ideological interests need to be usurped by sound science. But then he proceeds to cherry-pick data that back up his anti-condom stance. He doesn't even address the main point of the piece he is responding to, which is that condoms can work as part of an educational package. His response is that any package must be a moral one only.

Genius' other objection is that many people do not bother with condoms or do not use them properly, particularly if they are drunk or have taken drugs: protection is usually compromised by compliance issues, incorrect use, or mechanical failure. One of the supportive responses to his article adds that When you talk to young people, it is still considered uncool to carry condoms with you.

So his two arguments against promoting condoms are that they don't protect and most people don't use them properly anyway (which is irrelevant if they don't work).

Instead of recognising that the rising rate of infection is a complex problem, Genius is against anything at all that may reduce risk except for abstinence because: The more that sexual behaviour is trivialized, the greater will be the numbers of those involved in casual behaviour. The correct strategy is to promote responsible sexual choices by young people and television can have great power for good here (...) Those for whom condom knowledge is relevant will find it anyway, and the ever increasing trivialization of sexual behaviour will damage more and more children and young people.

Rather than seeing condom adverts as a way to make condom use more acceptable and more widespread, he disingenuously and consistently tries to discredit condoms to give his moral position some scientific authority. His simple solution to a complex situation is: Just say No.

His other point about condom knowledge being easy to find is the same point that the CMF make about abortions, which I dealt with in the last post.

This promotion of abstinence and warnings about 'trivializing' sex is based on as little reality as the Catholic Church's attempt to prevent teenage girls having the HPV vaccine because it would encourage them to have sex. After protests they reluctantly allowed the vaccine as long as no sex ed accompanied it, thus leaving them vulnerable to every other kind of infection, along with pregnancy.

The second article the CMF cite in support of their submission is written by Stammers, a trustee of Family Education Trust and Challenge Teams UK; both charities provide abstinence centred sex education packages to secondary schools in the UK. He is also a (volunteer) web doctor for Love for Life, the largest provider of abstinence centred sex education to schools in Northern Ireland, and did paid consultation work for them in the past.

Right away, the card are on the table this time. But again, let us not jump to conclusions before looking at the evidence. Being a Christian does not preclude being a good scientist...

Stammers position is that abstinence taught by parents is the answer, the only answer. He thinks, rather quaintly, that 'saved sex' is a more useful term than abstinence and asserts that: The false assumption that "young teens will have sex anyway" is an insult to many young people who have the capacity to rise to a far more effective challenge than just "use a condom every time".

He also says that Of course, to be involved in this way, parents have to be with their children and claims that the lower rate of single parenthood in the Netherlands is an important factor in the lower rate of teenage pregnancy.

This all fits neatly with the CMF'S own stated position that they are advocating marriage as God's intention for human sexual relationships.

So, saved sex and happy families will save society. Not condoms or sex education. Don't do it until you're married, then stay married and teach your children not to do it either. Easy.

Responses to this article in the BMJ are mixed, some in support of the moral stance, some pointing out the flaws in Stammers' argument and his biased starting point. To pick just one of the responses that challenge him:

Stammers' editorial on sex education raises a number of interesting public health issues. However, in the light of our recent investigation into abstinence-based programmes for HIV prevention in high-income countries, several of his assertions appear flawed on key methodological principles.

Recent research also contests Stammers' suggestion that declines in adolescent pregnancy rates (specifially, US adolescent pregnancy rates) are primarily attributable to delayed first sex.

It is interesting to note the contradiction between Stammers' suggestion that sex education studies assessing condom use make "false claims of success", and his acceptance of attitudinal outcomes of an abstinence-only programme trial as indications of "greatly enhanced" effectiveness.

The most methodologically rigorous systematic reviews to date have documented no behavioural or biological evidence that abstinence-only programmes can reduce sexual risk with respect to HIV infection or pregnancy, as compared to a range of control groups. (my highlighting, references to support this extract in the link above)

Flawed methodology, out of date information, cherry picking and pot calling the kettle black, then.

Whereas the part of the CMF submission dealing with abortion made overtly (and unsubstantiated) medical claims against it, this section tries to prohibit or severely limit condom adverts on moral grounds, using a spurious efficacy argument. At best, this is a muddled message; the efficacy of condoms is entirely separate from the moral question but the submission mixes the two. Not only that, the submission itself does not use the A word even though it is the principle message of the two papers. Why not, if this is their real agenda? Perhaps because it would undermine their attempt to appear scientific.

The CMF's moral recipe also appears ignorant of teenage behaviour. Teenagers do not need encouragement to have sex. Some do resist, for whatever reason, but it cannot be assumed that they will. For those who don't, there must be a safer way.

The CMF's preaching is masked as concern for teenagers and for society - the ever increasing trivialization of sexual behaviour will damage more and more children and young people - in the same way that their abortion propaganda indulged in hand-wringing about the dangers to women.

The mission is to save teenagers from themselves. The idea that the teenage sexual urge is something base to be overcome through the Grace of God is a primitive idea, harking back to Calvin and nodding to Descartes with his mind/body dualism. It also has echoes of Freud's concept of the id, the dark and lusty part of our nature to be smacked into submission if we are to be socialized (and, in religious terms, saved - that word again). And then there is the fear/hatred of sex that has permeated religion ever since St Paul. If you must have sex, wait until you're married and then do it only for procreative purposes, never ever for recreational ones. It is easy to caricature the CMF position because they lay themselves open to it with their disingenuous submission and their questionable evidence. But this should not distract from the real dangers that their position entails.

Unbiased commentators recognise that condoms are not the whole answer and that this is a complex issue; they see condoms as an essential part of a package based on evidence and real life, not just religious wishful thinking.

Addendum: Dr Petra Boyton has written in her latest blog about intitatives to reduce teenage pregnancy, something the CMF think are a waste of time.

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