This week Archbishop George Pell joined the Vatican’s war against truth with an opinion piece in the Sydney Morning Herald claiming that condoms were not effective in preventing HIV and other sexually transmitted disease. Actually, he went two steps further than that:
…[A]ll of us who want to help prevent and reduce the spread of HIV/AIDS need to respect the evidence about what helps and what doesn’t. And the evidence is that it’s not condoms which make the crucial difference, but the choices people make about how they use the gift of sexuality.
Pell is not merely arguing against condom use based on Catholic theology, he claiming that the scientific evidence is on his side. Furthermore:
…[G]overnments and non-Catholic aid agencies can and will continue to hand out condoms in HIV/AIDS programs, although the evidence suggests they may on balance be exacerbating the problem.
So Pell is claiming that the scientific evidence says that condom promotion makes people behave more recklessly and may result in increased HIV rates.
Pell has every right to express an opinion on the morality of using condoms, but he does not have the right to misrepresent the scientific evidence. So here are some responses to Pell’s “evidence.”
What Pell says about behaviour modification: “In fact, the studies confirm that behaviour modification is possible and is occurring. In Cameroon the percentage of young people having sex before the age of 15 has gone down from 35 per cent to 14 per cent, United Nations AIDS said last year. Uganda has had a 70 per cent decline in HIV prevalence since the early 1990s, linked to a 60 per cent reduction in casual sex, says a 2004 report in Science. Similar evidence exists in Africa, from Ethiopia to Malawi.”
What the evidence says: In Uganda and in MalawiÂ and several other African countries, the HIV prevention programs were based on an ABC strategy, that is, A for Abstinence, B for Be Faithful, and C for Condoms. As AVERT, an international HIV care charity, says: “What has been particularly important in Uganda has been the combination of messages and approaches that have been used, including the widespread promotion and distribution of condoms.”Â Pell is quoting the success of programs promoting condoms as evidence that condom use doesn’t make any difference.
What Pell says about the effectiveness of condoms: “Earlier this year, theÂ British Medical JournalÂ reported: ‘In numerous large studies, concerted efforts to promote use of condoms has consistently failed to control rates of sexually transmitted infection’, even in Canada, Sweden and Switzerland.”
What the evidence says: The best evidence we have is a 2001 Cochrane Review of 4,706 research papers which concluded, “consistent use of condoms results in 80% reduction in HIV incidence” over an effective lifetime in heterosexual couples where one partner is HIV positive and the other is not. One wonders how, given this overwhelming evidence, Pell can find a report claiming the opposite. Well, it turns out that the “report” is not actually a report in the scientific sense of the word. It was an opinion piece by a Dr Stephen J Genuis. This opinion piece was very short on evidence. In fact, the sentence that Pell quoted approvingly is based on a single reference, and that reference turns out to be…another opinion piece by Dr Stephen J Genuis published back in 1994. And some of his other references are completely skewed. For instance, Genuis quotes a 2001 JAMA paperÂ in support of the claim, “Only a minority of people engaging in risky sexual behaviour use condoms consistently.” Unfortunately for Genuis’s attempt to discredit condoms, the actual key finding of this paper is that “[c]ondom use offers significant protection against HSV-2 [herpes] infection in susceptible women.” How significant? Even though usage wasn’t perfectly consistent, condoms plus education reduced the rate of infection from 8.5 to 0.9 per 100 person-years.
What’s more, Genuis’s piece appeared in the same issue of the BMJ as an opposing opinion piece by Markus Steiner and Willard CatesÂ and a quick look is all it takes to see that the references from Steiner and Cates are far more impressive (and accurately represented) than those drawn on by Genuis. Pell did not, of course, mention this contrary opinion. Pell’s idea of having the evidence behind him is to quote one unreliable essayist’s opinion as referenced by an earlier version of that essayist’s opinion and to pretend there are no countervailing arguments.
What Pell says about about condoms and risky sexual behaviour: “Condoms give users an exaggerated sense of safety, so that they sometimes engage in ‘risk compensation’. In one Ugandan study, gains in condom use seem to have been offset by increases in the number of sex partners.”
What the evidence says: One unnamed Ugandan study of unknown design and quality is not a very impressive counter to the many, many studies that show increased condom use is associated with reductions in high-risk sexual behaviour. I’m not going to list them all. (Pell can do his own literature search if he wants to claim the scientific high ground.) Here’s one recent study conducted by the CDC: “The decreased prevalence of HIV-related sexual risk behaviors has been accompanied by an increase in condom use among US high school students, according to a CDC analysis of data from 8 national Youth Risk Behavior surveys conducted from 1991 to 2005. These trends correspond with a simultaneous decrease in gonorrhea, pregnancy, and birth rates among adolescents.” And here’s another, a 2006 analysis of 174 studies of 116,735 participants that tested “whether condom-related interventions inadvertently undermine sexual health promotion efforts by increasing the frequency of sexual behavior.” And guess what? “HIV-risk reduction interventions doÂ notÂ increase the overall frequency of sexual activity. To the contrary, for some particularly at risk sub-groups, interventions reduce the frequency of sexual events and partners, especially when interventions include components recommended by behavioral science theory.”
What Pell says about abstinence-only prevention programs: “At the heart of Marr’s position is a fundamental misconception, which he states as follows: ‘And we know in our hearts – and every reputable study confirms – that the church’s call for abstinence is useless.’…In fact, the studies confirm that behaviour modification is possible…”
What the evidence says: Note that Pell misstates Marr’s argument. Marr says that abstinence programs don’t work; Pell says that behaviour modification programs do so work. But behaviour modification programs are not the same as abstinence programs and many, as we have already shown, promote condom use as one of the modifiable behaviours. As for abstinence-only programs, Marr is absolutely right. The best evidence we have is a 2007 Cochrane Review of over 20,000 reports and 326 published papers. Their conclusion? “Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective, but generalizability may be limited to US youth.”
What Pell says about his own self-awareness: “Catholic teaching is opposed to adultery, fornication and homosexual intercourse, even with condoms, not because it denies condoms offer health protection, but because traditional Christian moral teaching believes all extra-marital intercourse contradicts the proper meaning of love and sexuality.”
What the evidence says: How is it, Mr Pell, that you can say your teaching does not deny the health benefits of condoms in the middle of an opinion piece denying that condoms offer health benefits?
What Pell forgot to say about reporting evidence: Exodus 20:16