Chastity is joyous - the Vatican AIDS Conference

At a two-day international conference on HIV/AIDS in Rome last weekend the Vatican reiterated its stance on condom use – never, in any circumstances.

The Catholic Church’s strategy is a combination of caring for infected people and so-called education of consciences, claiming to put human dignity at the centre of its AIDS policies. It is one of the largest providers of HIV/AIDS care in the world but its unmoving doctrine on condom use is often accused of causing millions of needless deaths and the related suffering they entail. They won't help you avoid getting infected but they will look after you when you are. Which is nice.

The conference was organised by the Pontifical Council for Health Care Workers. One of its aims was to address the confusion over the Pope’s statement last year that condom use might be justified in some circumstances to prevent disease transmission. It was made more than clear that’s not what he meant. Absolutely not. Ever. As if they hadn't already covered that one.

Just before the conference, Vatican moral theologian Father Perez-Soba provided a trailer when he published an article saying that condoms make the AIDS epidemic worse because they encourage immoral behaviour. According to him, using a condom shows a lack of respect for the other person.

His advice for married partners where one of them is infected is simple – stop having sex. Ever again. He also wrote that ‘a sexual act carried out with a condom cannot be considered a fully conjugal act.’

Monsignor Suaudeau of the Pontifical Academy for Life backed him up by saying ‘Chastity is joyous’. The Academy's remit is: 'to pay honor to pure science, wherever it is found, and to assure its freedom and to promote its research, which constitute the indispensable basis for progress in science'. Scientists of the world, look away.

The position of the joint United Nations programme on HIV/AIDS (UNAIDS) is that the correct and consistent use of condoms is an integral and essential part of HIV prevention, along with education, limiting sexual partners and marital fidelity.

Not everyone has those options. Much effort has gone into educating sex workers – both male and female - around the world into using condoms. Elizabeth Pisano's excellent book The Wisdom of Whores looks at initiatives with sex workers. It also shows just how unrealistic Vatican diktats about sex are in pretty much every way.

It’s hard to see how human dignity can be respected by preaching celibacy (something the Catholic Church itself has proven to be rather weak on) while ignoring human nature and the realities of life. The Vatican’s unchanging position is both unrealistic and inhumane. But to expect anything else from them is also unrealistic. The only real question is why they bothered having the conference.

Circumcision and sexual injuries

A study called Circumcision and Reduced Risk of Self-Reported Penile Coital Injuries published in the Journal of Urology recently looks at whether circumcision reduces the incidence of injuries to the penis during sex, which may increase the risk of HIV infection. It found that the incidence of injury was less in circumcised than uncircumcised men.


Between 2002 and 2005, 2,784 men aged between 18 and 24 in Kisumu, Kenya were randomized into two groups, immediate circumcision and delayed circumcision after two years.

Injuries were classified as 1) penis feels sore during sex 2) penis gets cuts, scratches or abrasions during sex and 3) penis bleeds after sex. At the start of the two-year period, 64.4% of the men reported injuries and 10.5% reported all three. Having two or more sex partners in the last 30 days, applying substances to the penis before sex and having ulcers increased the risk of injury. Increased age was associated with increased risk, possibly because of 'a broader range of sexual practises'.

Any conclusion that circumcision in itself reduces injury risk is not substantiated by the research, however.

Both groups had intensive STI and HIV risk reduction counseling and were provided with unlimited free condoms. The prevalance of STIs decreased, condom use increased and reporting multiple sex partners decreased. After two years, it was found that circumcision, condom use, being married or living with a partner and cleaning the penis within one hour of sex reduced injury.

At the beginning, the 64.4% reporting injuries split into 65.1% of circumcised and 60% of uncircumcised men. After two years, 31% of circumcised men and 42.8% of uncircumcised still reported injuries.

A few points:

The incidence of injury was almost the same in circumcised and uncircumcised men at the start of the trial which would suggest that it was something else that happened during the trial that caused the reduction.


The groups were not divided into men having sex with men and with women. The assumption is that all of the men's partners were female.


Injuries and sexual practices were self-reported. The types of sexual practice were not recorded. There was no enquiry into why injuries were so high to begin with or how conselling may have influenced sexual practices - or the self-reporting of them - although the conclusion admits the need to verify the injuries and questions whether familiarity with study questions may have had an influence. Why the injuries were not verified during a trial based on counting them and why familiarity was not factored in at the start are not clear if they were going to undermine the findings. It is also not possible to separate out the effects of counselling and condoms.

50% of circumcised men reporting injuries at the start were still reporting injuries at the end of the trial which suggests that other factors are involved in injury reduction.


There's a bit of an anomaly in the table showing condom use. At the start of the trial, 1010 men hadn't used condoms at their last sexual encounter; by the end of the trial, this had fallen to 259. However, 765 had used a condom the last time they had sex but two years later, this number had fallen to 275 so overall, the number of men using condoms had fallen.

Another point the research raises is that 'the high frequency of coital injuries in uncircumcised men could place sex partners of HIV positive uncircumcised men at greater risk for HIV acquisition'. However, even if circumcision does protect men, there is no good evidence yet that it helps prevent transmission from HIV positive men to women. A trial in Uganda reported in The Lancet found that rates of transmission to women increased with circumcised men. The trial had to be abandoned for ethical reasons.

The research concludes that 'circumcision, condom use and penile hygiene provided protection against reported penile coital injuries. (...) The mechanisms by which circumcision confers protection against penile coital injuries remains unknown'.

It also states that 'recent circumcision did not increase penile coital injury risk' and this is about all that it can be said to have found. Condoms, reducing the number of partners, counselling and washing are all said to reduce injury but circumcision in itself has not been demonstrated to do so independently of these other factors. Too many variables.

Evidence against circumcision for HIV prevention and the risks involved here, here and here.

UPDATE: An interesting comment on this article from Lay Science:
The big drop in injuries for both groups after six months in the study is a sign of the Hawthorne Effect - just going in a study makes a difference. The difference between the two groups after that has been excluded is relatively small.

They don't seem to mention the commonest penile injury to intact men, torn frenulum ("banjo string"). This usually happens once in a lifetime, if at all. It is hardly surprising if having a sensitive moving part on one's penis might make it (slightly) more prone to injury. Circumcision as a way to reduce penile injuries is not indicated.

This is only the latest in a steady stream of papers originating from the same few researchers (Daniel Halperin, Robert Bailey, Ronald Gray, Stefan Bailis, Stephen Moses, Malcolm Potts, Thomas Quinn, Maria Wawer, Helen Weiss, Brian Morris, Jeffrey Klausner, Edgar Schoen and Thomas Wiswell - in this case, Bailey) claiming to show that circumcision is good for everything and harms nothing. I wouldn’t call it a “conspiracy”, but many of them have authored papers jointly, and their common interest seems to be in promoting circumcision, rather than any particular benefit.

The evidence against abstinence stacks up

According to a recent report by the Centres for Disease Control in America, the rates of teenage pregnancy and STIs increased under the Bush administration (2001-2009) - despite its massive funding of abstinence programmes. There is a summary of the report here.

Janet Collins of the CDC commented that: "It is disheartening that after years of improvement with respect to teen pregnancy and sexually transmitted diseases, we now see signs that progress is stalling and many of these trends are going in the wrong direction."

The report found that 88% of pregnancies in 15-17 year olds were unplanned. Rates of chlamydia, gonorrhea and syphillis were significantly up. Nearly a quarter of women aged 15-19 had HPV in 2003-4 and a third of adolescents had not received birth control instruction by the age of 18.

The blame cannot be laid entirely at the door of Bush's pro- abstinence stance, but evidence points strongly towards it. When he was governor of Texas in the 1990s, he spent $10 million a year on abstinence education. The state still had the fifth highest teen pregnancy rate in the US.

Under his presidency, the spending continued, despite much evidence that it didn't work, including one report by the Guttemacher Institute. This states that a 9 year, $8 million evaluation of federally-funded abstinence-only-until-marriage programmes had no beneficial impact on young people's sexual behaviour. By the end of his presidency, over $1 billion had been spent.

Two other interesting findings from the CDC report are that nine out of ten states with the highest increase in teenage births voted Republican in 2000 and 2004. Also, young Hispanic women have sex less often than others but give birth more. One possible reason for this is that the vast majority of them are Catholic and are receiving even less encouragement to use birth control.

George Monbiot has an article about the CDC report in The Guardian where he writes that: A study published by the American Journal of Public Health found that 86% of the decline in adolescent pregnancies in the US between 1991 and 2003 was caused by better use of contraceptives. Reduced sexual activity caused the remainder, but this "ironically … appears to have preceded recent intensive efforts on the part of the US government to promote abstinence-only policies". Since those intensive efforts began, sexual activity has increased.

President Obama has cut funding to abstinence-only programmes but the National Abstinence Education Association is still pressing for funding, as is the Abstinence Clearing House with its links to all the 'evidence' for abstinence working. Some groups blame the failure on underfunding and say that programmes did not go far enough.

There's a good summary of pro-abstinence responses here. Some groups are now trying to rebrand themselves, talking about a 'holistic approach' and 'healthy lifestyle choices' in an attempt to claw back funding. One Christian blogger blames the increases in teen pregnancy on the media, and says rates would have been much worse were it not for Bush. She also says that rates are much higher in Europe, a sign of our moral bankruptcy - so the US is not doing so badly after all. Dogma and ideology continue their battle against science and evidence.

However, even though Obama appears to be on the right track in his own country, many US funded HIV/AIDS initiatives in the third world are still promoting abstinence, particularly PEPFAR, as I reported here. The latest partners in that initiative include pro-abstinence religious groups.

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.

Circumcision and HIV/AIDS: UPDATES

Rather than lots of short posts with updates and additional information, this post will collect them all together.

July 5 2009

The debate continues with two pieces in the Observer today, both by the same journalist, Alex Renton. They are both strongly pro-circumcision and, although detailed, don't look at the case against. Renton is a food journalist.

July 16 2009

A piece on the BBC website about how research from John Hopkins School of Public Health found that circumcision does not prevent HIV positive men transmitting  the virus to women:

"Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed."

The trial was stopped because of the rates of infection. However, they continue to recommend circumcision, in conjunction with condom use. They suggest both circumcising earlier (ie circumcising boys)  and continuing to circumcise HIV positive men in order not to stigmatize them.

"Women are disproportionately affected by HIV in sub-Saharan Africa, and - as this study shows - will still be at risk whether their partners are circumcised or not (...) The best way to guard against HIV is by always using a condom".

July 20

The link to the source article for the BBC story above, in The Lancet .

Circumcision and HIV/AIDS

An article in the Independent on May 19 2009 reports that:

'Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent'.

 It opens with the assertion that:

'New evidence suggests removal of the foreskin can protect not just against HIV, but other diseases that kill millions. Now some doctors are reconsidering their views on an ancient and controversial procedure'.

 What exactly are (or should be) doctors considering? Is circumcision the best option worldwide for HIV/AIDS prevention and why is it being promoted above condom use? Currently, around 30 per cent of males worldwide are circumcised, but this is done mostly for religious and cultural reasons rather than medical ones.

 I discussed this with Dr. Antony Lempert of the Secular Medical Forum who pointed out that interpretation of this latest research has to be tempered by the fact that the Cochrane collaboration who reported on these trials stated that the risk of bias is very high.

 Moreover, the mechanism by which circumcision may work is not even known yet. The New England Journal of Medicine (NEMJ) report, from which the Independent article is drawn, reports: ‘How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa’.

Even if the research can be shown to be good and that circumcision does reduce the transmission of HIV/AIDS, it still only brings the risk down to around 50:50 and it does not tackle the whole problem of sexually transmitted infections (STIs). According to the article, there is some emerging evidence that circumcision also reduces infection with Human Papilloma Virus (HPV) by 35% and Herpes Simplex (HSV) by 25% but again, these are not persuasive percentages when compared with condom use.

In fact, it may worsen the problem as men who have been circumcised see the operation as a licence to ride bareback, thus spreading other STIs and, of course, causing unwanted pregnancies. In fact, they may ask what is the point of being circumcised if you still have to wear a condom. Many men are not keen to use condoms as they reduce sensitivity so it is hard to see why they would opt for an operation that reduces it permanently.

 Although HIV/AIDS is the most serious of STIs, chlamidia and gonorrhoea are not without long-term risks if undiagnosed or untreated, which could be the case in remote, rural or some highly religious communities in the developing world (the jury is still out on the effectiveness of circumcision against syphilis).

 Who will benefit even from the 50:50? The NEMJ report also says: ‘Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women.’

 In addition, the new research looks only at adult men having sex with women, not at the long-term effect on boys or men having sex with men.

In fact, the Independent article quotes Professor Terence Stephenson (President of the Royal College of Paediatrics and Child Health), who says that there is ‘no evidence that circumcision is protective in men who have sex with men’.

The risks of adult circumcision are small but not negligible, especially if they are not carried out in sterile circumstances. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. (NEMJ).

So adult male circumcision doesn’t appear to protect women or men having sex with men. With such scanty evidence in favour, who is promoting adult male circumcision, particularly in Africa?

One of the largest bodies is PEPFAR, the US President's Emergency Plan for AIDS Relief who are ‘working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs’ in Africa and other countries (including Haiti and Vietnam). 

Who are these partners? They include the Catholic Relief Services, Family Health International and the Elisabeth Glaser Paediatric AIDS Foundation. The PEPFAR website lists them and their areas of concern. For many of them, ‘Abstinence and Be Faithful’ are on that list. Taking a random sample of countries, in Rwanda 11 out of the 23 partners promote abstinence and in South Africa, 28 out of 93 partners – for a few of them,  this is their only agenda.

Given the Catholic Church’s opposition to condoms to the point of lying about their effectiveness, and that of many American Evangelical organisations, could it be possible that circumcision is being promoted over condom use for less-than scientific reasons? Abstinence has been shown to be an ineffective programme in the US and under the Bush regime, many lies were spread about condom use, so are they promoting circumcision rather than condoms? Pro-abstinence campaigners, especially religious ones, are often anti-condom.

In America, circumcision has been declining in some states but the overall prevalence is still 65% (compared with 16% in the UK). As Dr Lempert points out:  ‘the majority of the American male population has been circumcised whilst they have a rather high rate of HIV infection’.

There is also the issue of consent. Adult men may be able to weigh the facts and make their own decision, but boys and new borns cannot.

To go back to the Independent article, it implies that all parents should seriously weigh up circumcising their male children. But the issue is far more complex than is being presented. There is undeniably resistance to condom use in many cultures for a variety of reasons that need to be overcome and logistical questions of distribution, but the promotion of both circumcision and condom use is tainted with many unknowns and mixed motives; should anyone – doctors, funding bodies, sexually active men or parents - be contemplating or recommending an irreversible surgical procedure just yet?

 

 

 

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