Abstract
For decades, the Roman Catholic Church opposed use of condoms to prevent spread of sexually transmitted infections (STI) because of their contraceptive effect. In 2009, Pope Benedict XVI said that widespread use of condoms could worsen the situation, a position rejected as ‘unscientific’. Recently, however the Pontiff stated that because the Church considers acts of prostitution and homosexuality to be gravely immoral and disordered, in such specific cases use of a condom might become an initial step in the direction of a moralization leading to an assumption of responsibility and a new awareness of the meaning of sexuality. In doing so, he reaffirmed his belief that condoms cannot solve the problem of STI spread, stressing the Church’s position that modern societies no longer see sexuality as an ‘expression of love, but only as a sort of drug that people administer to themselves’. The new Papal position has been widely applauded, but made conservative Catholics unhappy. A dialogue with the Church now seems possible: Does concentrating on condoms hinder the effectiveness of other strategies? What are the respective roles of condoms and other approaches to prevent infection spread? Does a special situation exist in Africa requiring specific and focused interventions?
Keywords
Introduction
For decades the Roman Catholic Church has been opposed to the use of what it defines as ‘artificial contraception’, including the use of a condom, because it separates the two meanings of human intercourse: the so-called ‘unitive’ purpose from the reproductive one (
Paul VI, 1968
). The fact that condoms (both the male and female ones) could protect against sexually transmitted infections (STI) was not considered, from the ethical point of view, sufficient to modify the Church’s position. For years, not even the advent of the HIV/AIDS pandemic changed the Church’s opposition to the use of condoms. In 2003, Cardinal Alfonso López Trujillo, President of the Pontifical Council for the Family, wrote: ‘The Catholic Church has repeatedly criticized programs promoting condoms as a totally effective and sufficient means of AIDS prevention’. He went on to say that the widespread and indiscriminate promotion of condoms was immoral and a misguided weapon in the battle against HIV/AIDS. He gave several reasons: ‘The use of condoms goes against human dignity. Condoms change the beautiful act of love into a selfish search for pleasure – while rejecting responsibility. Condoms do not guarantee protection against HIV/AIDS. Condoms may even be one of the main reasons for the spread of HIV/AIDS. Apart from the possibility of condoms being faulty or wrongly used they contribute to the breaking down of self-control and mutual respect’ (López-Trujillo, 2003
). This negative position became an international drama in 2009 when an impromptu statement by Pope Benedict XVI, while travelling by air to Africa for his first pastoral visit to that continent, sparked a controversy that ranged from a request to ignore an ill-conceived statement to outright condemnation (López-Trujillo A., 2003. Family values, versus safe sex. Available from: http://www.vatican.va/roman_curia/pontifical_councils/family/documents/rc_pc_family_doc_20031201_family-values-safe-sex-trujillo_en.html. (Accessed on 1 December 2010).
Editorial, 2009
). Governments, politicians, even Church ministers, issued statements explaining that the Pope was ill informed and could not impose a religious prohibition on a secular world where the imperative is to save lives, even those of ‘sinners’, no matter what the method.The Belgian Parliament went as far as passing, on 2 April 2009, a resolution condemning the statement with the words: ‘considering that by affirming that distributing condoms worsens the situation of AIDS in the world, the Pope undermines the endless efforts of prevention and global fight against the disease propagation and, in particular the work that a number of non-governmental organisations and Catholic aid organisations have already carried out within the framework of fighting HIV/AIDS, often under very difficult conditions, … requests the Government to officially and diplomatically protest, via our Ambassador to the Holy See, the position taken by Benedict XVI during a recent visit to Africa, position that undermines the efforts by the International scientific community in preventing and fighting AIDS propagation, namely through preventive measures of scientifically established effectiveness; ….’ (
Belgian Chamber of Representatives, 2009
). Although the Belgian Foreign Minister Mr De Gucht sent a letter of protest to the Nuncio, the Belgian Senate finally blocked the passing of the Resolution.Belgian Chamber of Representatives, Third Session of the 52nd legislature, 2009. Resolution requesting the Belgian Government to condemn the dangerous and irresponsible proposals made by the Pope during his travel to Africa and to officially protest to the Holy See. Doc 52C 1907/005, dated 2 April 2009. Available from: http://wdtprs.com/blog/2009/04/belgian-parliament-attacks-pope-benedict/ (Accessed on 25 October 2009).
In another development, on 7 May 2009, during the debate preceding the approval of the ‘Annual Report on Human Rights in the World, 2008 and the European Union’s policy on the matter’, Sophia in’t Veld of the Netherlands, proposed the following amendment: ‘The European Parliament underlines the importance of promoting sexual and reproductive health rights, as a precondition for any successful fight against HIV/AIDS, which causes enormous loss in terms of human lives and economic development, affecting particularly the poorest regions in the world; firmly condemns the recent declarations made by Pope Benedict XVI, banning the use of condoms and warning that condom use could even lead to an increased risk of contagion; is concerned that those statements will severely hamper the fight against HIV/AIDS; points out that empowerment of women also helps to counter HIV/AIDS; calls on the governments of the Member States to act together to promote sexual and reproductive health rights and education, including on the use of condoms as an effective tool in the fight against this scourge’ (
in’t Veld, 2009
). The amendment was rejected by 253 votes against 199, with 61 abstentions. The mere fact that the President (Hans Gert Poettering of Germany) authorized the vote was considered a clear sign of a certain level of resentment among parliamentarians for a statement considered difficult to defend.in’t Veld, S., 2009. Proposed amendment to the text of the Annual Report on Human Rights in the World, 2008, and the European Union’s policy on the matter. Available from: http://ec.europa.eu/http://www.consilium.europa.eu/http://www.europarl.europa.eu. (Accessed on 12 January 2010).
There have been strong reactions also within the scientific community and The Lancet, at the forefront of criticism of the Pontiff’s position, pointed out in an Editorial: ‘Pope Benedict XVI made an outrageous and wildly inaccurate statement about HIV/AIDS. On his first visit to Africa, the Pope told journalists that the continent’s fight against the disease is a problem that “cannot be overcome by the distribution of condoms: on the contrary, they increase it”’. The Editorial continued: ‘The Catholic Church’s ethical opposition to birth control and support of marital fidelity and abstinence in HIV prevention is well known. But, by saying that condoms exacerbate the problem of HIV/AIDS, the Pope has publicly distorted scientific evidence to promote Catholic doctrine on this issue’ (
Editorial, 2009
).In fact, already in 2006 in another Editorial, The Lancet had called on the Pope to ‘rein in officials, like Cardinal Alfonso López Trujillo, who argue that HIV is small enough to pass through a condom’. The Editorial concluded: ‘Such scientific untruths give the Catholic Church a bad name’ (
Editorial, 2006
).While the situation seems to have precipitated on the occasion of his travel to Africa, the Pope’s position was not new: in June 2006, in a speech to the Bishops of Botswana, Lesotho, Namibia, South Africa and Swaziland, he argued that ‘the traditional teaching of the Church has proven to be the only failsafe way to prevent the spread of HIV/AIDS’ (
Benedict XVI, 2006
). The Lancet comment: ‘This is palpably untrue’.Benedict XVI, 2006. Speech to the Bishops of Botswana, Lesotho, Namibia, South Africa, and Swaziland (June 2006). Available from: http://212.77.1.245/news_services/bulletin/news/16666.php?index=16666andpo_date=10.06.2005andlang=en. (Accessed on 25 October 2009).
As already mentioned, the position of the Roman Catholic Church on contraception has clearly influenced this prohibition, implying for instance that the use of condoms by HIV-discordant couples is illicit because of its contraceptive effect. Arguing this point,
Bovens, 2009
has expressed the opinion that the doctrine of double effect to condone the use of a condom could be validly applied in such circumstance, in spite of the objection that there is an alternative action to bring about the good effect of preventing the spread of HIV, that is abstinence. Bovens believes that an HIV-discordant couple does not bring about any bad outcome through condom use because there is no disrespect for the generative function of sex. He concluded that ‘there are no in-principle objections against the use of condom by HIV-discordant couples and that policies denying them access to condoms are indefensible’, because HIV-discordant couples have a right to continue consummating their marriage with minimal risks.Then, totally unexpectedly, in a book-length interview just published, the Pope admitted that there were instances when the use of the condom should be advocated (
Benedict XVI, 2010
). This pronouncement has been considered not only a major departure on the Pope’s own repeated position, but also a departure from the doctrine formalized by Pope Paul VI in 1978 with the Encyclical letter ‘Humanæ Vitæ’ (Paul VI, 1968
). This particular point required clarification and, indeed, on 21 December 2010 the Congregation for the Doctrine of the Faith, 2010
issued a highly unusual ‘Note’ declaring that no change on this issue existed.Congregation for the Doctrine of the Faith. 2010. On the trivialisation of sexuality. Regarding certain interpretations of ‘Light of the World’. Available from: http://www.chiesa-cattolica.com/modules.php?name=Newsandfile=articleandsid=4443. (Accessed on 28 December 2010).
In the present paper, after summarizing the evolution of the Catholic Church position on the use of condoms, we will try to evaluate to what extent the Pope’s recent interview has materially changed the situation. We will also try to analyse a possible way forward in establishing a constructive dialogue with the Roman Catholic Church in the overall battle against HIV/AIDS.
Science and religion
When, in 2009, the Pontiff restated his position against the usefulness of condoms in fighting HIV/AIDS, he dramatically reopened an age-old wound: the alleged incompatibility between religion and science.
Secularists contend that religions, based on revealed truths, offer only top-down arguments (or rather, ‘diktats’) that – emanating from God – should be accepted at face value. A position that runs directly contrary to science, the bottom-up search for truth, is inscribed in natural facts.
Yet, in a 2008 Editorial, The Lancet had acknowledged that Pope Benedict XVI had shown signs of supporting science by ‘asking the Pontifical Council for Health Pastoral Care to undertake a scientific and moral study on the use of condoms in HIV/AIDS prevention’. In fact, The Lancet stressed ‘the position of many Catholics and clerical leaders who realise the importance of condoms in tackling the HIV/AIDS pandemic’ (
Editorial, 2008
). The most influential among them, Cardinal Carlo Maria Martini, a Jesuit and a former Archbishop of Milan, in an interview with the Italian weekly magazine L’Espresso, backed condoms to fight HIV/AIDS: ‘Everything possible must be done to oppose AIDS. Certainly, in some situations the use of condoms can constitute a lesser evil. Then there is the particular situation of spouses, one of whom is infected with AIDS. The infected one is obligated to protect the other partner, who should also be able to take protective measures’. Martini went on: ‘So the principle of the lesser evil – which is applicable in all the cases provided for by ethical doctrine – is one thing, while the matter of who should express such things publicly is another. I believe that prudence and the consideration of the different particular situations will permit everyone to contribute effectively to the fight against AIDS without this fostering irresponsible behaviour’ (Martini, 2006
). In the light of such pronouncements, The Lancet has encouraged the scientific community to keep the dialogue with progressive Catholic leaders open, ‘on university campuses and elsewhere, even if scientists disagree with the Church’s interpretation of the world around us’ (Editorial, 2008
). This however, may not be easy since even progressive Catholics do not necessarily view science in the same way as secular scientists. For instance, in a correspondence to The Lancet, Martínez-González, 2008
wrote: ‘I applaud a debate on science and faith because it is reason – our ability to become aware of all reality – that depends on this dialogue. There is a trend to identify reason with the methods of natural sciences, and to dismiss other forms of knowledge as subjective and irrational. However, to approach different questions, our reason needs a variety of methods …. Issues such as whether a living individual of Homo sapiens species in the 14th week of gestation deserves inalienable human rights; or the promotion of abstinence, fidelity, and condoms only for high-risk sex, instead of just encouraging condom use, involve not only science, but our global approach to reality, human dignity, and sexuality.’In general, Catholic physicians agree with The Lancet position that ‘science and religion are not incompatible’. As pointed out by Nathalie Auger, ‘This statement makes sense when we consider that both science and religion aim to explain reality. The difference, however, is that science is based on a systematic method of investigating reality, whereas religion is based on interpretation of divine revelation’ ().
In the final analysis, much will depend on whether theists are ready to accept biological and physical facts and, if necessary, re-interpret religious doctrines in the light of new scientific discoveries, as it happened for instance for the heliocentric theory.
The new position of Pope Benedict XVI
During November 2010, the press was informed that the Pontiff had granted a long interview to a German journalist, Peter Seewald, covering all major issues confronting Catholics today. Excerpts were published in Italian on 20 November by L’Osservatore Romano, the official Vatican daily (
Anonymous, 2010
). Among those excerpts, one immediately got the attention of the media. Reuters wrote: ‘The use of condoms to stop the spread of AIDS may be justified in certain cases, Pope Benedict says in a new book that could herald the start of sea change in the Vatican’s attitude to condoms’ (Pullella, 2010
). The Pullella P., 2010. Pope says ccondoms sometimes permissible to stop AIDS. Available from: http://ww.uk.reuters.com/article/idUSTRE6AJ1CC20101120. (Accessed on 30 November 2010).
Associated press, 2010
released a statement entitled: ‘Pope says some condom use “first step” of morality’ and the BBC posted on the web an article entitled ‘Pope says condoms can be used in the fight against AIDS’ (Associated press, 2010. Pope says some condom use ‘first step’ of morality. http://www.google.com/hostednews/ap/article/ALeqM5j-2et4kP8MpH9tX1ROMtBlizNkQ?docId=82e28b7ca367404b968c1aebf6d3904a. (Accessed on 30 November 2010).
Crawley, 2010
).Crawley, W., 2010. Pope says condoms can be used in the fight against Aids. Available from: http://www.bbc.co.uk/blogs/ni/2010/11/pope_says_condoms_can_be_used.html. (Accessed on 30 November 2010).
Conservatives were clearly unhappy with the Pope’s new position: Jimmy Akin of the Catholic National Register took the unusual step of criticizing L’Osservatore Romano, accusing it of having ‘unilaterally violated the embargo on the book’. He went on: ‘Among the disservices L’Osservatore Romano performed by breaking the book’s embargo in the way it did was the fact that it only published a small part of the section in which Pope Benedict discussed condoms …. Especially egregious is the fact that L’Osservatore Romano omits material in which Benedict clarified his statement on condoms in a follow-up question’ (
Akin, 2010
).Akin J., 2010. The Pope said WHAT about condoms??? National Catholic Register. Available from: http://www.ncregister.com/blog/the-pope-said-what-about-condoms/ (Accessed on 30 November 2010).
Akin concluded: ‘So L’Osservatore Romano has performed a great disservice to both the Catholic and non-Catholic communities’. What seems unbelievable is that Akin chose to ignore what he could not have ignored, namely that L’Osservatore Romano would have never published these extracts without receiving full approval at the highest level. Not content with lambasting the official Vatican newspaper, Akin went on criticizing the Pope himself, by arguing about the value of the Pope’s statement that he said had ‘the status of private papal opinions. They are just that: private opinions. Not official Church teaching’ (
Akin, 2010
). Here again, how can any Catholic person say that the Pope could make a statement at variance with Church teaching? It is a true contradiction in terms! Certainly no conservative Catholic argued that the 2009 Pope’s statement against condoms was ‘not official Church teaching’!Akin J., 2010. The Pope said WHAT about condoms??? National Catholic Register. Available from: http://www.ncregister.com/blog/the-pope-said-what-about-condoms/ (Accessed on 30 November 2010).
What did the Pope say to stir up such animosity?
During the interview, journalist Seewald asked the Pope: ‘In Africa you stated that the Church’s traditional teaching has proven to be the only sure way to stop the spread of HIV. Critics, including critics from the Church’s own ranks, object that it is madness to forbid a high-risk population to use condoms.’
And the Pope replied: ‘In my remarks I was not making a general statement about the condom issue, but merely said, and this is what caused such great offense, that we cannot solve the problem by distributing condoms. Much more needs to be done. We must stand close to the people, we must guide and help them; and we must do this both before and after they contract the disease. As a matter of fact, you know, people can get condoms when they want them anyway. But this just goes to show that condoms alone do not resolve the question itself. More needs to happen. Meanwhile, the secular realm itself has developed the so-called ABC Theory: Abstinence–Be faithful–Condom, where the condom is understood only as a last resort, when the other two points fail to work. This means that the sheer fixation on the condom implies a banalization [trivialization] of sexuality, which, after all, is precisely the dangerous source of the attitude of no longer seeing sexuality as the expression of love, but only a sort of drug that people administer to themselves. This is why the fight against the banalization of sexuality is also a part of the struggle to ensure that sexuality is treated as a positive value and to enable it to have a positive effect on the whole of man’s being’. The Pope then added: ‘There may be a basis in the case of some individuals, as perhaps when a male prostitute uses a condom, where this can be a first step in the direction of a moralization, a first assumption of responsibility, on the way toward recovering an awareness that not everything is allowed and that one cannot do whatever one wants. But it is not really the way to deal with the evil of HIV infection. That can really lie only in a humanization of sexuality’ (
Benedict XVI, 2010
).John M Haas, President of the National Catholic Centre for Bioethics in the USA, in a long comment pointed out that Pope Benedict did not address the question of the effectiveness of condom use in reducing the transmission of AIDS. According to
Haas, 2010
, the Pope ‘wants to reflect on the moral state of the person who would use it with the hope that that person would begin to assume moral responsibility for his sexual activity’. Obviously, the Catholic Church considers acts of prostitution and homosexuality as gravely immoral and disordered, but – in the mind of the Pontiff – in specific cases the use of a condom might become an initial step leading to an assumption of responsibility and a new awareness of the meaning of sexuality.Haas J.M., 2010. The Pope and Condoms. Available from: http://www.ncbcenter.org/NetCommunity/Page.aspx?pid=482. (Accessed on 03 December 2010).
Reading the text of the interview, three main issues come to mind: first of all, the Pope reaffirmed his belief that condoms per se cannot solve the problem of the spread of STI, including HIV/AIDS. The way he explained his 2009 remarks now clarifies that ‘distributing condoms’ cannot solve the problem and ‘much more needs to be done’. It is difficult not to agree with this statement.
Second, the Pope stressed the long-held position of the Church that modern societies no longer see sexuality as an ‘expression of love, but only a sort of drug that people administer to themselves’. Many would agree also with this second point. Misuse, or frank abuses, of sexuality clearly exist in today’s world and calls for a responsible use of sexuality have been made by many (
Benagiano et al., 2011
).Third, the Pontiff, acknowledged – and this is the real novelty in his position – that, there are cases in which the use of a condom ‘can be a first step in the direction of a moralization, a first assumption of responsibility’. He also added that this step should be in ‘the way toward recovering an awareness that not everything is allowed and that one cannot do whatever one wants’.
On 24 November the Vatican Press Secretary, Father Federico Lombardi, formally presented the Pope’s new book. One point that came up with the Italian version was the gender of the prostitute for whom the use of the condom would be a step in the right direction (male in English and female in Italian). As reported by Rachel Donadio, Lombardi said ‘I personally asked the Pope if there was a serious, important problem in the choice of the masculine over the feminine’, and Father Lombardi added ‘He told me: no’. For Benedict, Father Lombardi added, the heart of the matter was ‘of taking responsibility, of taking into consideration the risk to the life of the person with whom you are having a relationship: this is if you’re a woman, a man or a transsexual’ (
Donadio, 2010
). This additional explanation is of fundamental importance because it removes a critical obstacle to the use of condoms: that they cannot be utilized because they have a contraceptive effect. If female prostitutes can use it, then it doesn’t matter whether it prevents conception, as long as it protects against STI and HIV/AIDS and, therefore, saves lives.One important consequence of the Pope’s new stance is to eliminate a major criticism of the Church’s position: whereas discouraging the use of condoms on the ground that they make sexual activity ‘immoral’ may be acceptable within a monogamous married couple, when condom use is discouraged in high risk but, for the Church, already immoral situations, such as penetrative sex among men and extra-marital casual sex, then the only conclusion that could have been drawn from such a ban would be that somehow condom use makes these immoral acts ‘more immoral’.
The way forward
Given the Pope’s new position, a renewed dialogue with the Roman Catholic Church seems today possible, although methodological questions must first be resolved. In other words, scientists must realize that certain issues are also philosophical in their nature, while theologians must accept that, at least when no revealed truth is in question, biological facts, as we know them at any given time, must be at the basis of any discussion. With these pre-conditions, difficult as it may be, the search for common ground should continue and the door must be kept open to honest contributions from both sides.
We wish to point out that – in our opinion – for the fostering of dialogue it is not necessary to enter the debate on the legitimacy of contraception and therefore of the condom as a method of birth control. Rather, one should concentrate on the role of this barrier method in preventing the spread of HIV infection.
Our position seems strengthened by the already mentioned Note issued by the Congregation for the
Doctrine of the Faith, 2010
on 21 December 2010, while this paper was being reviewed by the referees. After stating that ‘Following the publication of the interview-book Light of the World by Benedict XVI, a number of erroneous interpretations have emerged which have caused confusion concerning the position of the Catholic Church regarding certain questions of sexual morality’. The Note continued: ‘the Holy Father was talking neither about conjugal morality nor about the moral norm concerning contraception … The idea that anyone could deduce from the words of Benedict XVI that it is somehow legitimate, in certain situations, to use condoms to avoid an unwanted pregnancy is completely arbitrary and is in no way justified either by his words or in his thought. In other words, whereas the Pope’s position of condom use to prevent the spread of the HIV infection remains that expressed in his book, there is no change in the Church condemnation of what the Church usually calls ‘artificial contraception’’.Congregation for the Doctrine of the Faith. 2010. On the trivialisation of sexuality. Regarding certain interpretations of ‘Light of the World’. Available from: http://www.chiesa-cattolica.com/modules.php?name=Newsandfile=articleandsid=4443. (Accessed on 28 December 2010).
Given this reality, here we will consider issues that seem important in combating the spread of HIV infection, without any reference to the condom as a contraceptive. Three points will be debated: (i) whether concentrating on condoms may hinder the success of other, more effective strategies; (ii) the comparative role of condoms and other strategies to prevent the spread of HIV infection; and (iii) the existence of a special situation in Africa requiring unique policies for that continent.
Concentrating on condoms may hinder the success of other, more effective strategies
In replying to the already mentioned position taken by The Lancet (
Editorial, 2008
) on the possibility of a dialogue between Catholics and scientists on how to best fight the HIV/AIDS pandemic. Ciantia et al., 2009
have written ‘We know how important condoms can be in focal epidemics in high-risk groups; there is limited or no direct evidence, however, that the common and popular prevention measures, including social marketing of condoms, voluntary counselling and testing, and syndromic or mass treatment of sexually transmitted infections, have contributed to the reduction or slowing down of HIV in generalised epidemics’. While this statement is open to criticism, as it will be pointed out below, the issue raised by the Pope’s impromptu remarks in 2009, went further to express the opinion that the risk of contracting HIV/AIDS may be increased if widespread distribution is advocated.We have already mentioned the strong negative reactions from scientists, politicians and social workers to this statement, but, at the same time, it is important to note that not everyone working on HIV/AIDS agreed that the 2009 Pope’s remarks on potential damage from widespread use of condoms in Africa were ill conceived. In an article published in the Washington Post on 29 March 2009, Edward C Green of the AIDS Prevention Research Project at Harvard University ventured: ‘current empirical evidence supports him’. Although acknowledging that a liberal like him, working in the fields of global HIV/AIDS and family planning takes ‘terrible professional risks’ siding with the Pope on a divisive topic such as this, Green stated that a number of studies have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa. He specifically referred his remarks to Africa and went on saying: ‘intuitively, some condom use ought to be better than no use. But that’s not what the research in Africa show’.
He gave several reasons for this conclusion: first, a phenomenon called ‘risk compensation’ (when people think they’re made safe by using condoms at least some of the time, they actually engage in riskier sex); second, the fact that people seldom use condoms in steady relationships because doing so would imply a lack of trust; third, the specific African reality, namely that it is ongoing multiple relationships that drive Africa’s worst epidemics. He concluded that in Africa successful strategies are those that ‘break up these multiple and concurrent sexual networks’ (). A year later, Green repeated his views in the foreword to a book published by the National Catholic Bioethics Centre: he seemed to agree with Benedict XVI when he wrote: ‘In fact, [condom use] might actually contribute to higher levels of infection because of the phenomenon of risk compensation, whereby people take greater sexual risks because they feel safer than they really ought to because they are using condoms at least some of the time’ (
Hanley et al., 2010
).These views, however, remain isolated and widespread support was placed on the strategy now being promoted by UNAIDS, known with the acronym ABC or ‘Abstain; Be faithful; and consistent, correct use of Condoms’ (see
UNAIDS, 2010a
, UNAIDS, 2010b
). Indeed, the early successes in Uganda have been attributed to the implementation of this strategy (UNAIDS, (Joint United Nation Programme on HIV/AIDS), 2010b. UNAIDS welcomes Pope Benedict’s support to HIV prevention. 20 November. Available from: http://unaidstoday.org/wp-content/uploads/2010/11/20101120_PR_Pope.pdf. (Accessed on 1 December 2010).
Kilian et al., 1999
). It is not clear where the idea came from; according to Daniel Halperin (verbal communication) it may have been in the Philippines in the early 1990s, but it seems that the strategy got international attention after the publication of a comment in The Lancet (Halperin et al., 2004
), endorsed by some 150 organizations. In that comment, it was stressed that ‘All three elements of this approach are essential to reducing HIV incidence, although the emphasis placed on individual elements needs to vary according to the target population’. It was also pointed out that ‘it is not essential that every organisation promote all three elements’. This innovative approach has been credited with many success stories in quenching the HIV epidemics, although critical voices have also been heard. Five years ago Sinding, 2005
, while acknowledging that abstinence for younger adolescents, faithfulness in marriage and condom promotion have a place in international HIV/AIDS programmes, has complained that ‘by twisting the ABC concept important international voices – the US government and the Vatican, in particular – have made ABC controversial. The actions of these major political actors are not only regrettable; given their influence over millions of people around the world, they represent a serious setback to efforts to bring HIV/AIDS under control’. Sinding suggested that an alternative strategy called CNN (Condoms, Needles, Negotiations) may work better than ABC, but acknowledged that ‘instead of debating CNN versus ABC, we must recognize the complexity of sexual relations, which embrace every facet of our lives, including issues of culture, tradition, power and status’.Other critical voices have been heard: a rigorous examination of the success of ABC carried out by
Dworkin and Ehrhardt, 2007
raised important questions. When HIV/AIDS prevention successes are attributed to some combination of ABC strategies, who actually enjoyed the benefits of success? For how long can a region maintain success? If successes begin to recede, what are the reasons for these changes? Do these changes tell us about which strategies we should consider successful in the fight against HIV/AIDS? They concluded that, to be considered successful, ‘intervention strategies should critically engage with the reasons for the differences in rates of infection that are found between heterosexually active females and males’.To improve the situation,
Dworkin and Ehrhardt, 2007
proposed three additional strategies called GEM: Gender-specific and gender-empowering HIV prevention interventions; Economic and educational contexts and structural interventions, including those that are culturally specific; more attention to Migrations and population movements.It seems therefore that the question of the relative roles of various measures undertaken by the international community to quench the HIV epidemic remains only partially answered. On the one hand, there are examples of situations where, in the 1990s, countries such as Thailand and Uganda, where the prevalence of HIV/AIDS was among the highest recorded anywhere, by promoting and distributing condoms, together with a number of other equally useful interventions, have been able to reduce the overall prevalence of HIV and other STI (
Celentano et al., 1998
, Hanenberg et al., 1994
, Limpaphayom, 1996
, UNAIDS, 1998
). On the other hand, more recently, in spite of the massive promotion of condoms, in Thailand there has been an upsurge in youth STI infection rates (Ross et al., 2004
), whereas HIV has been again on the rise in Uganda, with some advocacy groups attributing this upsurge to condom shortage created by the Ugandan government under pressure from the Bush administration. The Health Ministry of Uganda refuted this allegation, stating that delays in the distribution of condoms have been the result of enhanced inspection of shipments after a batch of Chinese condoms was purportedly discovered to be faulty (Ross J., Godeau E., Dias S. 2004. Sexual health. In: Currie C, Morgan A, (Eds.), Young people’s health in context: international report from the HBSC 2001/02 Survey. Copenhagen, WHO Regional Office for Europe, 2004. Available from: http://www.euro.who.int/__data/assets/pdf_file/0008/110231/e82923.pdf. (Accessed on 25 November 2010).
Alsan, 2006
), but the situation remains unclear.Alsan M., 2006. The Church and AIDS in Africa. Condoms and the Culture of Life Commonweal: A Review of Religion, Politics, and Culture. vol. 133 (8), 24 April. Available from: http://www.commonwealmagazine.org. (Accessed on 1 December 2010).
Finally, very recently,
Gregson et al., 2010
have shown that, in Zimbabwe, changes in sexual behaviour have contributed to a decrease in HIV prevalence between 1997 and 2007 from 29.3% to 15.6%.Now that the Pope has clarified the meaning of his own words and explained that he was not making ‘a general statement about the condom issue, but merely said … that we cannot solve the problem by distributing condoms. Much more needs to be done’ (
Benedict XVI, 2010
), things may change and the position of the Catholic Church will be that, whereas there are cases when condom use can be a positive step, only additional measures will, in the final analysis, solve the problem. Our interpretation seems strengthened by a sentence in the already mentioned Note by the Congregation for the Doctrine of the Faith, 2010
pointing out: ‘Those who know themselves to be infected with HIV and who therefore run the risk of infecting others, apart from committing a sin against the sixth commandment are also committing a sin against the fifth commandment – because they are consciously putting the lives of others at risk through behaviour which has repercussions on public health’. The Note continues: ‘In this context, however, it cannot be denied that anyone who uses a condom in order to diminish the risk posed to another person is intending to reduce the evil connected with his or her immoral activity’.Congregation for the Doctrine of the Faith. 2010. On the trivialisation of sexuality. Regarding certain interpretations of ‘Light of the World’. Available from: http://www.chiesa-cattolica.com/modules.php?name=Newsandfile=articleandsid=4443. (Accessed on 28 December 2010).
Under the circumstances, we hope that the past position assuming that widespread condom distribution may hinder final success in the war against HIV/AIDS will no longer be an issue.
Use of condoms in fighting the HIV/AIDS pandemic
Some 15 years ago, Ronald Bayer pointed out that ‘from the onset of the AIDS epidemic in 1981, it became increasingly clear that questions of sexual ethics could not be avoided’ (
Bayer, 1996
). The controversy over condom promotion as a strategy for preventing HIV infection is therefore primarily a debate over ethics, not technology and – in this sense – there is widespread agreement with Pope Benedict’s argument that an effective strategy to control and reverse the spread of STI, including the HIV pandemic, cannot simply focus on condom distribution, because delaying sexual debut, mutual monogamy and, above all, reducing the number of partners represent crucial factors in any comprehensive strategy.Following this line of thinking, after the publication of the Pope’s book-length interview, UNAIDS issued a press release welcoming the statement by Pope Benedict XVI calling for ‘a humane way of living sexuality’ and that the use of condoms are justified ‘in the intention of reducing the risk of HIV infection’. ‘This is a significant and positive step forward taken by the Vatican today,’ said UNAIDS Executive Director Michel Sidibé. ‘This move recognizes that responsible sexual behaviour and the use of condoms have important roles in HIV prevention’ (
UNAIDS, 2010b
).UNAIDS, (Joint United Nation Programme on HIV/AIDS), 2010b. UNAIDS welcomes Pope Benedict’s support to HIV prevention. 20 November. Available from: http://unaidstoday.org/wp-content/uploads/2010/11/20101120_PR_Pope.pdf. (Accessed on 1 December 2010).
In 2004, Hearst and Chen carried out a literature review on condom use; they concluded that condoms are approximately 90% effective for preventing HIV transmission and they produce substantial benefit in countries where both condom promotion and distribution are concentrated in the area of commercial sex. They also acknowledged that the public health benefits in settings with widespread heterosexual transmission remain unproven, with countries continuing to have high rates of HIV transmission despite high reported rates of condom use among the sexually active (
Hearst and Chen, 2004
). Among the reasons for the limited impact of condoms are inconsistent use, low use among those at highest risk and negative interactions with other strategies. A notable exception to this limited effect is represented by intensive interventions in structured institutions. In a trial involving Thai military men, the incidence of STI was seven times lower among soldiers assigned to the intervention than the combined controls (relative risk, 0.15; 95% confidence interval, 0.04–0.55), after adjusting for baseline risk factors. The intervention decreased the incidence of HIV by 50% in the intervention group and, interestingly, there was no diffusion of the intervention to adjacent barracks (Celentano et al., 2000
).In conclusion, it seems fair to accept the view of
Genuis, 2008
that also in the case of non-HIV STI, condoms alone cannot represent the answer to rising rates. At the same time, at the individual level, the idea of considering condom use as an act of responsibility, care and love merits further exploration from a social marketing perspective. Within this context, condom promotion should seek to create a culture of responsible sex in which condom use is seen as a mechanism to promote responsible behaviour (Benagiano et al., 2000
). Indeed, 10 years ago, people who insisted on condom use in extra-marital sex tended to be viewed more positively by their partners (Hocking et al., 1999
). Thus, a more effective strategy should include increased condom promotion for groups at high risk, more rigorous measurement of the impact of condom promotion and more research on how best to integrate condom promotion with other prevention strategies (Hearst and Chen, 2004
).It is hoped that, at least in part, these conclusions may also begin to be shared by the Catholic Church and, by changing the Church’s position, the Pope has now opened the way to full collaboration with the international community on this vital topic.
The African situation requires unique strategies for that continent
The uniqueness of the sub-Saharan situation vis-à-vis HIV/AIDS has been effectively summarized by Stephen Lewis, the UN Special Envoy for HIV/AIDS in Africa: ‘To this catalogue of horrors, there must be added, in the case of Africa, that the pandemic is now, conclusively and irreversibly, a ferocious assault on women and girls’ (
Lewis, 2002
). It is precisely because HIV/AIDS affects primarily innocent women and girls, through their husbands, partners or boyfriends, that everyone believes that, although the HIV pandemic has spread to all corners of the world, sub-Saharan Africa – with, in 2009, 25.5 million people affected or more than two-thirds (67%) of the total of 33.3 million people with HIV and three-quarters of all AIDS deaths – is where the war against this deadly infection will be won or lost. Indeed, women and children in sub-Saharan Africa make up 64% of all infected persons (UNAIDS, 2010b
). Protecting them is a moral imperative; this is why the Church position on condoms is vital to the future of the struggle to free the continent from HIV.UNAIDS, (Joint United Nation Programme on HIV/AIDS), 2010b. UNAIDS welcomes Pope Benedict’s support to HIV prevention. 20 November. Available from: http://unaidstoday.org/wp-content/uploads/2010/11/20101120_PR_Pope.pdf. (Accessed on 1 December 2010).
As forcefully put by Marcella Alsan, an American physician who worked in Southern Africa: ‘The typical patient is a young woman between 18 and 30 years of age …. More shocking still, she is married; her husband infected her with the deadly virus’. She added: ‘a married woman living in Southern Africa is at higher risk of becoming infected with HIV than an unmarried woman. Extolling abstinence and fidelity, as the Catholic Church does, will not protect her, since – in all likelihood – she is already monogamous. It is her husband who is likely to have HIV. Yet, refusing a husband’s sexual overtures she risks ostracism, violence, and destitution for herself and her children’. Faced with this reality, many Catholics at the African front lines of the global HIV battle felt that ‘the condom acts as a contra mortem and its use is justified by the Catholic consistent ethic of life’ (
Alsan, 2006
).Alsan M., 2006. The Church and AIDS in Africa. Condoms and the Culture of Life Commonweal: A Review of Religion, Politics, and Culture. vol. 133 (8), 24 April. Available from: http://www.commonwealmagazine.org. (Accessed on 1 December 2010).
While the situation remains extremely dangerous, the Uganda success story documented by
Stoneburner and Low-Beer, 2004
encourages a cautious optimism, because they have shown that, even in a country of limited resources, marred by a long civil war, HIV is preventable if populations are mobilized to avoid risk. Uganda has shown a 70% decline in HIV prevalence between the early 1990s and the early 2000s, linked to a 60% reduction in casual sex. It has been calculated that this is equivalent to a vaccine of 80% effectiveness. As pointed out by Stoneburner and Low-Beer, success seems attributable in good part to the ability to communicate facts about AIDS through social networks since, despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioural responses, nor HIV prevalence declines of the same scale. Green et al., 2006
believe that in Uganda a decline in multi-partner sexual behaviour was the change most likely associated with HIV decline, particularly when extensive promotion of ‘zero grazing’ (faithfulness and partner reduction) was involved. Referring to the continuing debate on the Ugandan programme, they conclude: ‘Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality’. Confirmation of the reality of Ugandan changes, Kirby, 2008
examined seven different types of evidence and concluded that all seven produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners. Kirby believes that first reducing the number of sexual partners and breaking-up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalized epidemics.Without denying the Ugandan success, the already-mentioned Commentary by
Dworkin and Ehrhardt, 2007
stresses the reality of the ‘feminization’ of HIV/AIDS and points to the fact that in that country, the significant reductions in overall HIV seroprevalence that took place from 1997 to 2001, was accompanied by persistent differences between young women and men. In 2002, the virus affected 2.4% of young men and 5.6% of young women aged 15–24 years, with a male-to-female ratio for new HIV infections of 1:5.The existence of such a dire situation is why, commenting on the remarks made by the Pope in 2009 on his way to Africa, Riazat Butt of the British daily The Guardian stated that ‘the timing of his remarks outraged health agencies trying to halt the spread of HIV and AIDS in sub-Saharan Africa, where an estimated 22 million people are infected’ (
Butt, 2009
). According to Butt R., 2009. Pope claims condoms could make African Aids crisis worse. The Guardian, 17 March 2009. Available from: http://www.guardian.co.uk. (Accessed on 2 December 2010).
Butt, 2009
, commenting on the Pope’s remarks Rebecca Hodes, director of policy for the Treatment Action Campaign in South Africa, said: ‘his opposition to condoms conveys that religious dogma is more important to him than the lives of Africans’.Butt R., 2009. Pope claims condoms could make African Aids crisis worse. The Guardian, 17 March 2009. Available from: http://www.guardian.co.uk. (Accessed on 2 December 2010).
Irrespective of past polemics, the new position taken by Pope Benedict removes a stumbling block in the efforts to combat the spread of HIV in Sub-Saharan Africa, because now the ABC strategy can be implemented everywhere in Africa. Indeed, in his book-length interview, the Pontiff specifically mentions this strategy. ‘Meanwhile, the secular realm itself has developed the so-called ABC Theory: Abstinence–Be faithful–Condom, where the condom is understood only as a last resort, when the other two points fail to work’ (
Benedict XVI, 2010
). We believe this implies that the Church now accepts that using condoms, even as a last recourse, may be useful.At any rate, it is important that the Catholic Church acknowledges the African reality and in particular the fact that, whereas it is self-evident that never having sex will significantly reduce the risk of contracting an STI, including HIV, abstaining from sex is not a choice that many women living in Africa (or, to that matter, in the developing world) have. With this in mind, the Church can now join the international community in helping the African poor to improve their access to education and health services. This is vital to the success of the battle against HIV in Africa, because, according to UNAIDS, the vast majority of young people have no idea how HIV/AIDS is transmitted or how to protect themselves from the disease. This is of particular importance in sub-Saharan countries with generalized HIV epidemics such as Cameroon, Central African Republic, Equatorial Guinea, Lesotho and Sierra Leone, where – in 2002 – more than 80% of young women aged 15–24 did not have sufficient knowledge about HIV and students believed that they could screen out risky partners by simply looking at them (
UNICEF, UNAIDS, WHO, 2002
). Research by the Nelson Mandela Foundation (Shisana and Simbayi, 2002
) has shown that 35% of 12–14-year-olds thought (or were not sure) that sex with a virgin cured AIDS. This means that efforts at providing simple, but comprehensive information should take front stage.Shisana O. (Principal Investigator), Simbayi L. (Project Director), 2002. Nelson Mandela HSRC. Study of HIV/AIDS. South African national HIV prevalence, behavioural risks and mass media household survey. Available from: http://www.nelsonmandela.org/index.php/publications/category/hiv_aids_consultative_forum/. (Accessed on 28 November 2010).
Conclusions
The new position of the Roman Catholic Church on condom use, as expressed by Pope Benedict XVI in his recent interview, opens the possibility of a fruitful collaboration with the Church in the overall fight to contain the spread of the HIV pandemic. This is even more so after the publication of the Note by the Congregation for the Doctrine of the Faith that, while reaffirming Catholic opposition to contraception, clearly endorses the use of condoms whenever a sexual act threatens to endanger the life of one of the partners. There is however one issue that still remains unanswered, namely how partners should behave in a discordant married couple. We hope that even this issue will be positively resolved, since it is difficult to accept that ‘sinners’ can protect themselves against HIV in immoral sexual acts, whereas sanctioned couples cannot when engaging in legitimate sexual activity.
Appendix A. Supplementary data
- Supplementary data 1
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Article info
Publication history
Published online: February 14, 2011
Accepted:
February 8,
2011
Received in revised form:
January 26,
2011
Received:
December 10,
2010
Declaration: The authors report no financial or commercial conflicts of interest.Footnotes
Giuseppe Benagiano is Professor Emeritus at the ‘Sapienza’ University in Rome. Until his retirement in 2009, he was the Dean of the Post-graduate School of Gynaecology and Obstetrics. He became professor at the ‘Sapienza University’ in 1980 and was director of the First Institute of Obstetrics and Gynaecology during 1982–1993. He was nominated Director of the Special Programme of Research in Human Reproduction of WHO in 1993 and became Director General of the Istituto Superiore di Sanità in 1997. He has studied at Karolinska Institute, Stockholm and Population Council, Rockefeller University, New York. His long-standing interest is hormonal contraception; in addition, he pioneered the use of GnRH analogues for gynaecological disorders of endocrine origin, such as endometriosis, adenomyosis and leiomyomata. His present interests include proliferative disorder of the female reproductive tract and bioethics of reproduction.
Identification
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© 2011 Reproductive Healthcare Ltd. Published by Elsevier Inc. All rights reserved.
