In 1999, social conservatives in Congress initiated a new strategy to further their moral agenda of promoting abstinence outside of marriage as official government policy—claiming that condoms do not protect against sexually transmitted diseases (STDs). Led by then-Rep. Tom Coburn (R-OK), a physician and staunch proabstinence opponent of government-funded family planning programs, they were successful in attaching an amendment to the House version of the Breast and Cervical Cancer Treatment Act mandating that condom packages carry a cigarette-type warning that condoms offer "little or no protection" against an extremely common STD, human papillomavirus (HPV), some strains of which cause cervical cancer. Although this directive was removed before the bill was enacted, Coburn and his allies were able to secure a requirement that the Food and Drug Administration (FDA) reexamine condom labels to determine whether they are medically accurate with respect to condoms' "effectiveness or lack of effectiveness" in STD prevention. They also were instrumental in convincing the National Institutes of Health (NIH)—along with the U.S. Agency for International Development (USAID), the FDA and the Centers for Disease Control and Prevention (CDC)—to convene a workshop in June 2000 to evaluate published evidence on condom effectiveness.
At the time, Coburn's anticondom views were widely considered extreme. Certainly, they were, and continue to be, out of step with mainstream public health prevention efforts. But in the intervening few years, the political landscape has changed radically. Coburn and like-minded colleagues are now ensconced within the Bush administration, and with the imprimatur of government and the report of an NIH workshop on condom effectiveness to cite, a campaign to disparage the value of condom use is in full swing, itself the cornerstone of an effort to undermine the very notion of sexual risk-reduction, or "safer sex."
Critics in the HIV and STD prevention communities worry that the conservative crusade to promote abstinence outside of marriage comes at too high a cost. Undermining people's confidence in the effectiveness of condoms threatens people's health and even lives, they argue, since sex among unmarried people is common in the United States and around the world, and achieving correct and consistent condom use is difficult enough. Moreover, they insist, condom critics are selectively citing and intentionally misrepresenting findings from the NIH workshop report to buttress their case; the conclusion that correct condom use does not offer a high degree of protection against the vast majority of STDs, not to mention HIV and unintended pregnancy, is simply not warranted by the science, they say.
The Workshop Report
At the behest of Coburn and other condom critics, NIH in June 2000 convened a panel of experts for a two-day workshop to examine the body of evidence on the effectiveness of condoms in preventing the transmission of eight STDs: HIV, gonorrhea, chlamydia, syphilis, chancroid, trichomoniasis, genital herpes and HPV. The panel considered 138 peer-reviewed articles in all. It determined that "condition-specific" studies were sufficiently methodologically strong to warrant a definitive conclusion only for HIV and gonorrhea. Accordingly, in its carefully worded summary report issued in July 2001, the panel concluded that consistent and correct condom use prevents (in addition, of course, to pregnancy) transmission of HIV between women and men and gonorrhea transmission from women to men. Beyond that, the panel concluded, the published epidemiologic literature is insufficient to warrant definitive statements specific to the other six STDs considered by the panel.
That there are insufficient studies specific to the six other STDs reviewed by the panel to warrant a definitive statement does not mean, however, that no assumptions can be made about the protective effect of condoms with regard to those diseases. Indeed, a critical conclusion in the workshop summary report that largely has been overlooked is that condoms are "essentially impermeable" to even the smallest of STD viruses. Based on that finding—that "studies...have demonstrated that condoms provide a highly effective barrier to the transmission of particles of similar size to those of the smallest STD virus"—two important assumptions can be made and, in fact, are made in the workshop report itself. The first is that there is a "strong probability of condom effectiveness" against so-called discharge diseases that, as with HIV, are transmitted by genital secretions, such as semen or vaginal fluids. Included here would be chlamydia and trichomoniasis in addition to gonorrhea. The second is, once again, that there is "a strong probability of condom effectiveness" against infections that are transmitted through "skin-to-skin" contact—provided, however, that the source of the infection is in an area that is covered or protected by the condom. Three "genital ulcer diseases"—genital herpes, syphilis and chancroid—as well as HPV fall in this category. All can occur in genital areas that are covered or protected by condoms, but they also can occur in areas that are not. Therefore, correct condom use would be expected to protect against transmission of genital ulcer diseases and HPV in some, but not all, instances.
The report goes on to raise a number of methodological challenges that make it difficult to study the effectiveness of condoms against specific STDs. The ideal study, a randomized controlled clinical trial, has not been used because it would require control-group participants to be counseled not to use condoms. Such counseling is not considered ethically acceptable—itself an implicit acknowledgement of condom effectiveness in STD prevention within the scientific community. As a result of these standards for study design, none of the studies reviewed by the workshop panel was considered optimal, and any future studies will face similar challenges.
The Anticondom Campaign
The NIH workshop report explicitly cautions that the "inadequacies of the evidence available...should not be interpreted as proof of the adequacy or inadequacy of the condom." Yet, condom opponents were quick to ignore the caution and jump to the conclusion they desired. In July 2001, Coburn, no longer a member of Congress, issued a press release headlined, "Condoms Do Not Prevent Most STDs" and praised the NIH report for finally exposing "the 'safe' sex myth for the lie that it is." In his new job as co-chair of the Presidential Advisory Council on HIV and AIDS (PACHA) and as one of President Bush's top advisors on HIV/AIDS, Coburn continues to use his influence to insist that "the American people [should] know the truth of condom ineffectiveness" and to advocate an approach that focuses exclusively on promoting abstinence for all people outside of a heterosexual, monogamous marriage.
Coburn's views have the support of other recent appointments to PACHA, including Joe S. McIlhaney, Jr., a physician and president of the Medical Institute for Sexual Health (MISH), a Texas-based medical institute he founded that promotes abstinence-only sex education messages. In a monograph on condoms and STDs, billed as "the most comprehensive scientific review of the science on condom effectiveness to date," MISH provides an analysis of the workshop report that, while factually correct, nonetheless asserts that condoms do not make sex "safe enough" to warrant their promotion for STD prevention. According to MISH, because condoms are "not foolproof" and marriage is "generally safe" from STD infection, the government should be only promoting marriage and abstinence outside of marriage for STD prevention.
Public health experts also point to the withdrawal of a fact sheet on condoms from the CDC's Web site and the fact sheet's subsequent revision as another indication that condoms are being attacked at the highest levels. Members of Congress, as well as experts with the scientific, AIDS and reproductive health communities, reacted angrily when the fact sheet was pulled. "Removal of this information...strongly suggests an ideological, rather than a scientific, agenda at work," said Rep. Henry Waxman (D-CA) in an October 21, 2002, letter signed by a dozen members of Congress to Department of Health and Human Services Secretary Tommy G. Thompson. The fact sheet was eventually revised and reposted; as with the MISH report, the new version is factually accurate but nonetheless portrays condoms in a negative light. Where the prior fact sheet concluded from the evidence that "latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV...and...can reduce the risk of other sexually transmitted diseases," the revised version emphasizes in bold letters that abstinence is the surest way to avoid STDs and warns that condom use "cannot guarantee absolute protection against any STD."
Linked to the crusade to promote abstinence outside of marriage, the campaign to disparage condoms is also going global. In an October 24, 2002, letter to USAID Administrator Andrew S. Natsios pushing for abstinence-only programming by the agency, Rep. Chris Smith (R-NJ) asserts that "[a]bstinence until marriage...is the Administration's stated priority in HIV/STD prevention." So far, USAID has not signed on to a campaign disparaging the condom. However, in December at a meeting of 30 Asian/Pacific nations in Bangkok whose purpose was to discuss implementation of the International Conference on Population and Development Program of Action, U.S. officials demanded the deletion of a reference to "consistent condom use" to fight HIV/AIDS and other STDs ( see related story, page 3). The official U.S. statement delivered by Assistant Secretary of State Arthur E. Dewey states that, because "condoms are simply not 100% effective," the United States "promotes abstinence for the unmarried and fidelity for those who are married" as its primary STD prevention strategy.
A Dangerous Approach
HIV and STD prevention advocates acknowledge that condoms are not "perfect." They note that the current FDA labeling now under review does likewise, advising consumers that when used properly, latex condoms will help reduce the risk of HIV and other STDs, although no method can guarantee 100% protection. Still, they say, condoms must remain a key component of HIV and STD prevention efforts both in the United States and globally because, in the words of the workshop summary itself, "Beyond mutual lifelong monogamy among uninfected couples, condom use is the only method for reducing the risk of HIV infection and STDs available to sexually active individuals."
In that light, experts in the field say efforts to promote abstinence by disparaging condoms are misguided because they could increase the likelihood that people will fail to use condoms when they do have sex, thus putting themselves at unnecessary risk. "It is hard enough to convince people who choose to have sex—even those who are at high risk of HIV—to use condoms," says David Harvey, executive director of the AIDS Alliance for Children, Youth and Families. "The last thing we need is the government promoting the idea that condoms do no good. This approach will undermine the gains we have made and result in more people with HIV and other sexually transmitted infections."
STD expert Ward Cates, president of Family Health Institute, contends that intentionally undermining public confidence in the effectiveness of condoms is not justified as a matter of science. He says the fact that insufficient data exist to prove definitively that condoms protect against some STDs—while technically true—has created an opening allowing condom opponents to claim that condoms are inadequate. "While I'm impressed with the thoroughness and accuracy of the MISH report, its emphasis on condom failures can be distorted," Cates says. "By such dwelling on the failures, the successes of male condoms are obscured, and the method is unnecessarily tainted," he wrote. "From a public health perspective, the data clearly show that the glass is 90% full (that condoms are relatively effective) and only 10% empty (that data are inadequate)." In an interview Cates adds, "Thus, the question should not be whether condoms work if used (they do!), but rather what is the appropriate role of condoms in comprehensive HIV prevention programs."
All of this leads Jacqueline E. Darroch, The Alan Guttmacher Institute's vice president for science, to question the need for a great deal more biomedical research to clarify condom effectiveness against individual STDs. "We already know that latex condoms do successfully prevent transmission of most STDs, but that their effectiveness depends in large part on how consistently and correctly they are used," Darroch says. "What health educators and service providers really need from research is a better understanding of the difficulties people face using condoms effectively, so that they can better help sexually active couples wanting to avoid disease or unintended pregnancy to use condoms consistently and correctly at every act of intercourse. Our goal should be programs that reinforce this message and that get through to people who are having sex and are at risk for STDs in an unequivocal way the news that condoms are a necessary and effective way to prevent infection."
This is the first in a series of articles examining emerging issues in sex education and related efforts to prevent unintended pregnancy and sexually transmitted diseases. The series is supported in part by a grant from the Program on Reproductive Health and Rights of the Open Society Institute. The conclusions and opinions expressed in these articles, however, are those of the author and The Alan Guttmacher Institute.