by Hugh Henry
When Cardinal Trujillo claimed on BBC Panorama’s “Sex and the Holy City” that condoms have holes which can leak HIV, a controversy erupted worldwide. The Church was accused of peddling “scientific nonsense” to underdeveloped nations, with fatal consequences. In December 2003, the Pontifical Council for the Family published a lengthy paper highlighting medical and ethical problems associated with condom use. (1) A recent Panorama programme entitled “Can Condoms Kill?” (2) revisited the issue. It investigated more thoroughly the claims made by Catholic Church officials that leakage of HIV through intact condoms was a real possibility. Focus then shifted to the wider question of overall condom failure in the context of AIDS prevention and, finally, to a simmering debate amongst Church officials as to the morality of condom use as a health measure. In contrast to its overt conclusions, the substantive evidence brought forth in the programme did little to undermine the credibility of the Church's rejection of condoms and her promotion of abstinence and chastity in the fight against AIDS.
On the subject of permeability, Cardinal Trujillo, the Prefect of the Pontifical Council for the Family, was quoted as saying that condoms might leak HIV “15%, 18% or 20% of the time”. But interviewed experts strongly disagreed with the figure cited by the Cardinal. Dr David Lytle (3) described tests he conducted which indicated that even when condoms leak tiny amounts of seminal fluid, little if any HIV would pass through any naturally occurring pores.(4) He estimated that only 1 of 470 condoms tested leaked enough seminal fluid to contain HIV.(5) Swiss expert Dr Pietro Vernazza (6) described the risk of HIV infection from such leakage rates as “such [a] miniscule risk that in general, in our regular life, is a zero risk.”
The evidence presented in the programme suggested strongly that Cardinal Trujillo’s estimate of leakage at rates of up to 20% is out by several orders of magnitude. Still, condom porosity may be of significance in certain situations. The vanishingly small probabilities of HIV transmission and infection cited by Lytle and Vernazza assume a maximum HIV cell-free virus concentration of 102 copies per ml of semen.(7).
However, what was not noted is that estimates of viral concentration vary widely. Borzy et al. (1988) (8) observed rates of 108 HIV copies/ml in cell-free seminal fluid, while rates of 106 were reported by Dyer et al.(1996) in patients undergoing antiretroviral therapy (ART). At levels observed by Borzy, 6 of 470 condoms would leak sufficient seminal fluid to transmit HIV, and infection could be a small, though not negligible, possibility: 6 acts of intercourse (the average monthly rate in the US and Africa) with a Borzy-level infected male would result in a chance of approximately 1/2000 of leakage-associated HIV infection for the female partner. (9)
But even if there were nothing to the leakage claims made by Church leaders, are they fatally misleading millions into eschewing condom use? Those eager to accuse the Church of human rights abuse on this point need to establish a causal link between the assertions of leakage-associated infection risk and the incidence of HIV/AIDS. However, the message of the Church about condoms is not just about alleged leakage, but also about their inefficacy because of breakage, slippage, lack of quality control (especially under conditions faced in poor countries) and, above all, their impermissibility on moral grounds. Establishing the net effect on infection rates from just one element of the anti-condom message of Church leaders would not be an easy task. Moreover, critics must account for the record of countries such as the Philippines and Indonesia, which have rejected condom promotion campaigns and yet have for many years recorded lower rates of HIV/AIDS infection than their neighbours. (10)
Addressing the wider question of condom failure through user error, some time was spent in the programme measuring condom effectiveness in a “perfect case” scenario. Prostitutes in Nevada who dexterously manipulate the condom during intercourse so as to insure it remains in place claimed to have avoided any incidence of HIV infection. Dr Steve Pinkerton (11) contended that between serodiscordant partners, failure rates of condoms to prevent HIV as low as 1% (12) were achievable with suitable education. But the relevance of contrived techniques of Nevada prostitutes to the everyday context of spontaneous sexual behaviour within the heterosexual population is questionable. And even supposing Pinkerton to be near the mark, his figure implies a cumulative risk (compared to abstinence) which is slightly higher than that of regular smokers contracting lung cancer.
Much of the second half of the programme was given over to advocates from both sides speculating as to the merits of the various AIDS strategies under debate. The epidemiologists consulted gave weight to the Church's position. Norman Hearst (13) and Rand Stoneburner (14) queried the effectiveness of condom campaigns in the general population, and pointed to the beneficial effects of chastity and abstinence campaigns. And although Hearst does not think there is “conclusive” evidence backing Cardinal Trujillo's claim that condom programmes promote promiscuity, he noted the coexistence of high condom usage with high HIV infection rates, and agreed the Cardinal was right to question whether condom campaigns were working.
Focus then shifted to the theological dimension. Uganda’s Cardinal Wamala insisted that condoms are never an ethical choice even if they could stem sickness and death. “Christ's teaching has never been easy”, he said. But Cardinal Danneels of Belgium recommended condom use for the serodiscordant who decide to proceed with sexual intercourse. For the Cardinal, the life-saving effect of the condom was the decisive factor. “The condom”, he argued, “cannot just be seen as a birth control measure”.
It appears that Cardinal Danneels is one of many who are – perhaps understandably - deflected from an adequate analysis of condom use in this context by the fact that the couple are intending to avoid disease and death, not to contracept.(15) But to justify condom use on this ground is to assume that the only form of moral disorder associated with sexual behaviour is the choice to prevent conception. Catholic sexual ethics has, of course, never confined itself to the ethics of contraception. In recent years especially, the “theology of the body” has added new insights to the traditional prohibition of all forms of sexual activity that, by intention or mere foresight, substitute for the complete marital act. Condomistic intercourse under any circumstances is a straightforward example. It is simply impossible for a couple to give themselves completely to each other while a condom vitiates the fertile structure of their union.
Unfortunately, no place was found in the programme for a clear exposition of this moral argument against condom use. Instead, time was given over at the end to critics attacking the Church for adhering to a morality that results in human misery. “The harshness, the aggressivity and the insensitivity, the lack of love for human beings and the unwillingness to take their situation seriously, I find that extreme. They are hurting and bringing into great danger the lives of millions out there …” said Poul Nielson, a European Commissioner. His comments have been echoed by others, including some from within the Church.(16)
But the accusation fails on three levels. As discussed above, there are serious questions being raised by public health experts over the net effects of condom promotion in the war against HIV/AIDS. It may turn out that there is no dilemma in this case and that the exclusion of condoms on moral grounds coincides with, or at least does not seriously undermine, effective public health policy.(17)
Again, even if this is not the case, the Church has always insisted that there is more to human welfare than physical health. In promoting respect for the meaning of sex as the one-flesh union of the married couple - a union deeply connected to fertility, even when not, in fact, fertile - the Church reminds us that sex is not just a neutral bodily activity to be engaged in as “healthily” as possible.
Finally, even as they accuse the Church of “placing morality over mortality”, critics of the Church will be found adhering to the same principle. After all, from the point of view of physical health alone, if Mary, wife of HIV-positive Tom, insists on having sex, the manifestly most prudent advice for her is not to have condomised intercourse with him, as the “Abstinence/Be Faithful/Use a Condom” campaign recommends. Rather, Mary should abstain from all sex with her husband henceforth and commit adultery with, say, Jack across the road whom she knows is not infected. Consistent infidelity to HIV-positive Tom is Mary’s “healthiest” alternative if she can find an uninfected willing partner. Yet those within and without the Church who question the ban on condoms either explicitly reject, or at least shy away from advocating, such safety-maximizing but ethically flawed alternatives. In so doing, they are, surely, just as “guilty” as those opposing use of condoms in upholding an ethical principle even when human life is at stake.
We can, then, set aside the censures of the critics on this point. Their bone of contention with the Church is not, as they profess, over her insistence that morality is prior to mortality – a principle which they themselves may well uphold in one or other guise. Rather, it is over a particular item in Catholic sexual ethics which does not appear in theirs: namely, a consistent respect for the “fertile meaning” of sexual intercourse which precludes, amongst other things, use of condoms. And here, the critics have simply failed to show that the Church’s view of sex as intimately - though often subtly - related to parenthood is inferior to rival views which recognise no such connection.
An earlier version of this article was published in the Catholic Medical Quarterly, February 2005; and later published by http://www.linacre.org/condoms.html
1. Alfonso Trujillo. Family Values Versus Safe Sex. December 2003. Back to Text
2. A transcript of the programme is available online at: http://news.bbc.co.uk/nol/shared/spl/hi/programmes/panorama/transcripts/cancondomskill.txt
3. Center for Devices and Radiological Health, Food and Drug Administration, Rockville.
4. In comparison to Cardinal Trujillo’s estimate of up to 20% condom leakage rates, Lytle found that 10 out of 470 (about 2%) otherwise intact condoms “leaked” fluid through inherent microscopic pores or flaws. Two more failed in other ways. One ruptured completely, while another was disqualified as a “water leaker” - i.e., the flaw was visibly detectable in a water pressure test. Perhaps because the focus was confined to the possible role of microscopic pores in latex in HIV transmission, no comment was made on the fact that in this experiment, albeit under more extreme conditions than those occurring in actual use, two out of 470 pre-tested condoms obtained from retail distributors failed on macroscopic levels. See: D Lytle et al. An In Vitro Evaluation of Condoms as Barriers to a Small Virus. Sexually Transmitted Diseases March 1997: 161 – 164.
5. Ronald F. Carey, C. David Lytle, W. Howard. Implications of Laboratory Tests of Condom Integrity. Sexually Transmitted Diseases April 1999: 220.
6. University Hospital, St Gallen, Switzerland.
7. Carey et al., op.cit., p. 220.
8. M. Borzy et al. Detection of HIV in Cell-Free Seminal Fluid JAIDS Vol 1, No 15, 1988.
9. For the derivation of these figures, see my Condom Leakage and Infectivity When Free Virus Concentration is High (unpublished).
10. UNAIDS/WHO Epidemiological Fact Sheet 2002 Update - Indonesia: 0.1%; Philippines: <0.1%. Compare Thailand: 1.8%.
11. Professor of Behavioural Medicine, Medical College of Wisconsin.
12. i.e., of 100 serodiscordant heterosexual couples consistently using condoms, 99 would remain serodiscordant after 1 year.
13. University of California, San Francisco. Hearst’s authoritative paper Male Condoms for Prevention of HIV/AIDS in the Developing World is available online: www.usp.br/nepaids/condom.pdf.
14. Health and Population Evaluation Unit, Cambridge University, UK.
15. Another is the theologian Martin Rhonheimer (The Truth About Condoms. The Tablet, July 10 2004).
16. See, e.g., When Dogma Costs Lives. The Tablet, June 26 2004, p.3.
17. See Hearst, op. cit.