In praise of the condom

Sensible people that they were, the ancient Greeks believed that the good things in life – olive oil, wine, music, to name a few – were sent by the gods for the benefit and happiness of mortals. Had the condom been invented in that society it would also have been hailed as a heaven-sent gift, obviously intended to protect people from sexually transmitted disease and unwanted pregnancy. What could be more rational, and indeed pious, than to use it for these purposes? The society in which the condom did eventually make its debut was not, however, a rational one, but a world of religious fanaticism and increasing sectarian strife, as the forces of Reformation and Counter-Reformation contended for the hearts, minds and bodies of Europe. The Renaissance had recovered much ancient learning and literature, as well as its spirit of inquiry, but the revival of pagan sensuality was a fitful process, limited to bohemian pockets that somehow escaped the scrutiny of the inquisitors. In this context the predominant – and certainly the official – response to the condom was not to hail it as a gift of God, but to revile it as a snare sent by the Devil to tempt men and women from those paths of rigid chastity or fatalistic child-bearing that the Church had laid down as the only permissible courses for fallen humanity to follow.

Gabriele Falloppio and de Morbo Gallico

It was not, however, as a contraceptive that the condom made its first appearance. Fanciful stories about prehistoric cave drawings, gladiators and Roman ladies aside, the condom – or something resembling what we understand by the term – was invented by the sixteenth century anatomist Gabriele Falloppio as a prophylactic against the new and fearsome disease that was then ravaging Europe – syphilis. He gave men little linen sheaths to be tied over their penis before intercourse, and he claimed that of a thousand or so clients who tried the device, not one became infected. From this point on the condom became a common accessory of the man about town (it was too expensive for labourers or servants), though it was not until the more sexually relaxed eighteenth century that we hear much about its use – James Boswell complaining about the necessity for his armour, and Casanova delighting in the way it permitted his lovers to admire the abundance of his sperm, have become familiar vignettes from that libertine world. It was, indeed, the association of condoms with a licentious and promiscuous lifestyle (mistresses, prostitutes etc) that made them almost unthinkable as a birth control device for the respectably married. Preoccupied as they were with family limitation as a means of raising working class living standards and improving the status of women, none of the prominent sexual radicals of the nineteenth century (Francis Place, Richard Carlile, Robert Dale Owen, Annie Besant) recommended them for this purpose. Instead, they advocated early withdrawal or a post-coital sponge to discourage babies, while trusting to fidelity as the means of avoiding disease. The latter was not, of course, much use if either partner had been sowing or receiving wild oats before marriage, and the steadily rising incidence of syphilis and gonorrhoea throughout the Victorian period only goes to show that such admonitions were as ineffective then as they are today.

George Drysdale

There was one remarkable exception to the general rejection of condoms in the person of George Drysdale, whose radical views on sexual freedom made him a pariah from respectable society and suspect even among the avant garde. Although largely forgotten today, his daring manifesto Elements of Social Science (1855) had a massive underground circulation in the second half of the nineteenth century, and helped to lay the foundations for the transformation of sexual attitudes and practices that followed the two world wars. At a time when the medical profession was insisting that sexual indulgence was dangerously debilitating, and extreme moderation the only safe course (especially for men), Drysdale's counter-arguments that sex was as health-giving as it was pleasurable, and that young people should form casual attachments as soon as they became sexually mature, made him a frequent (though unnamed) target of abuse in the mainstream medical press. Doctors were equally angered by his advocacy of condoms as a simple and straightforward means of avoiding the risks implicit in his vision: venereal disease and pregnancy.

Although many aspects of the sexual revolution that Drysdale foreshadowed have come to pass, at least in parts of the world not blighted by politico-religious obscurantism, his strictures against those who sought to prevent the use of condoms on so-called moral grounds remain relevant today. "By far the most certain preventive of ... venereal diseases is the condom, an artificial sheath for the penis made of very delicate membrane ... so thin as not very greatly to interfere with the venereal enjoyment." It was unfortunate, however, that the sheath was little used in Britain, mainly because it had been "proscribed by moralists as an unnatural, and therefore immoral, interference with the normal act", and it was often difficult to obtain. Drysdale looked forward to the enlightened day when society had recognized the value of the sheath as the surest means of passing "scatheless through the very midst of infection", and when disease was no longer seen as a salutary warning to sinners. "When society has become fully alive to the desire to prevent venereal diseases ... then and not till then will the great value of the sheath be perceived as a most powerful means of such protection". Meanwhile, he hoped that it would come into more general use; it was only misguided adherence to outdated notions of sin and guilt that stood in the way of "the sacred cause of the prevention of disease".  [1]

Condoms annoy agenda pushers

As Aine Collier's history makes abundantly clear, condoms have always infuriated those wishing to enforce puritanical standards in sexual behaviour or to drive the agendas that condoms made unnecessary – chastity and male genital mutilation, to name a couple. It was, in fact, the very effectiveness of  condoms as a shield against infection and pregnancy that made them so objectionable, for they abolished the old argument, influentially reformulated by Thomas Malthus, that the only legitimate purpose of sex was reproduction and that venereal disease was divine retribution for sexual transgression. Throughout the nineteenth century the medical profession opposed any form of contraception and campaigned specifically against the use of condoms as a protection against syphilis. Malthus's moral views had been shaped by the teachings of William Paley (1743-1805), especially his Principles of Moral and Political Philosophy (1785), in which he argued that God had designed a world in which pleasure or pain was the reward or penalty attached to actions that were either conducive or detrimental to our virtue and happiness. In line with this outlook, Malthus wrote:

This system of moral consequentialism implied that sin would produce unhappiness, meaning that happiness was best achieved by a moral course: because sexual excess would lead to disease and too many children, the sensible thing from both a moral and practical point of view was restraint. But the system of penalty and reward relied on people reaping the wages of sin. If they could somehow avoid the consequences of excess by contraception to block pregnancy or prophylactics to protect themselves against venereal disease, the punishment for immoral behaviour would vanish, and the system would break down. Thus we find a medico such as Henry Bickersteth objecting to sex education on the ground that if ordinary people had such information they might be able to evade the punishments ordained by God for sexual transgression: "it is not intended to extend these directions ... to the diseases which the Almighty has been pleased to inflict as a bitter scourge on the unlawful indulgence between the sexes". [3] In the 1860s a few diehard surgeons, such as Samuel Solly, still opposed efforts to combat syphilis on the ground that it was a scourge specifically created by God to punish illicit sex, and as late as 1900 Jonathan Hutchinson objected to regulation of and health checks on prostitutes because he felt they would reduce the penalties for fornication. Both Solly and Hutchinson were extremists, but the medical profession as a whole remained violently opposed to both contraception and prophylactics throughout the nineteenth century and until well into the twentieth, a position usually justified on the basis of this sort of Paleyite-Malthusian reasoning.

Jonathan Hutchinson

Despite his extremism, Hutchinson's celebrity status as Britain's leading authority on the most feared disease of the time – syphilis – made him a powerful force. As a devout Quaker with deeply puritanical objections to non-procreative sex, he regarded any methods of contraception with "disgust": such practices were "prejudicial to both moral and physical health". [4] His solution to the syphilis epidemic was neither condoms nor regular sex with trusted partners, but abstinence and circumcision of boys, a case he had first advanced in the 1850s and pushed strongly throughout the 1890s. In a typical lecture, "The advantages of circumcision", delivered at the turn of the century and widely reported in British and American medical journals, he contended that the strongest argument in favour of "the general practice of circumcision" was that it "would reduce the prevalence of syphilis"; in support of this view he pulled out some old statistics, "which proved" that, while gonorrhoea was as common among Jews as among Christians, syphilis was "much less frequent". This fact showed that it was not superior morality which gave Jews their "comparative immunity", but some "adventitious advantage" which could only be "the absence of the prepuce". Hutchinson assured readers that no measure for the prevention of syphilis was as efficient as circumcision, but he made no mention of safe sex alternatives such as condoms, a silence consistent with his opposition to contraception as morally unacceptable and physically harmful: any measure which made "irregular sexual intercourse less dangerous" were "injurious to decency ... and detrimental to the moral conscience of a community". Circumcision did not present this drawback: "Effected in early infancy, and with other avowed objects, it would silently become the means of preventing ... a loathsome and misery-producing disease." The value of the operation would be enhanced by its effect in diminishing the sexual appetite:

In other words, in controlling syphilis circumcision was preferable to condoms or health checks because it would discourage pre- and extra-marital sex.

Circumcision versus condoms: An old argument

Although Drysdale was keen to keep up to date with modern medical advances, he had no time at all for this particular innovation. In the 1850s genital surgeries, for both males and females, were being urged as the latest and most scientifically proven approach to the cure or prevention of many intractable complaints, particularly masturbation and nervous diseases such as epilepsy. In 1855 Hutchinson had published clinical evidence that male circumcision reduced the risk of syphilis and claimed that he had thereby established a compelling case for routine circumcision of male infants and boys. [6] Drysdale was not impressed: he condemned "the unnatural 
practice of circumcision, wantonly inflicted on helpless infants" as a symbol of the "spiritual" disgust at the human body that the English had inherited from the religious code of the ancient Hebrews; their numerous laws against sexual impurity were also a factor contributing to the oppression of women in his own society. "These awful cruelties, the very thought of which fills us with horror, 
are ... the most remarkable proofs of sexual barbarism 
recorded in history," he wrote. [7] Although Drysdale was sufficiently of his period to accept that masturbation was harmful, he never entertained the possibility (urged by so many doctors at that time) of circumcision as an appropriate preventive or cure, and continued to advocate sexual intercourse with a loving partner as the best alternative.

Similarly with syphilis. Although Drysdale accepted Hutchinson's demonstration that circumcised men were at less risk of infection, he did not agree that widespread circumcision was the best response, much less that the operation should be inflicted on everybody. Instead, he suggested that "those who have much promiscuous intercourse might imitate this, by drawing back the prepuce, and so keeping the glans habitually exposed", thus hardening it and making it more resistant to penetration by the infectious particle. [8] Even more effective, however, was the sheath, regular use of which would be a powerful safeguard. [9] Drysdale was perfectly aware that those who did not have much promiscuous intercourse and did not patronize prostitutes were at negligible risk of syphilis, and he regarded the notion of circumcising everybody "as a precaution" as no more scientific than the Inquisition's guiding principle that it was better for a thousand innocents to be burnt than for a single heretic to escape punishment.

Why don't we learn from history?

It is frequently said that those who fail to learn from history are condemned to repeat it, and in no sphere does this cliché seem more applicable than in contemporary American responses to STD control and sex education. The spirit of Jonathan Hutchinson seems very much to have been the animating force behind the Bush administration's policy of promoting circumcision in Africa as the strategy against AIDS and abstinence education at home as a tactic against STDs and teen pregnancy. Despite the results of three, much vaunted, clinical trials in Kenya, Uganda and South Africa, it is still too early to evaluate the usefulness, much less the acceptability, of  circumcision as a prophylactic measure against HIV infection, though the approach has been attacked by the South African Medical Journal as costly, ineffective, a violation of accepted principles of bioethics and human rights, culturally insensitive and smacking of medical colonialism. [10] In the United States, however, the abstinence programs launched, with much fanfare, in 1998 have been the subject of a rigorous evaluation by Mathematica Policy Research, which found no difference at all in sexual behaviour, STD acquisition or condom use between those who had done the course and a control group who had missed out, and only a small difference in sexual knowledge. (The control group knew a bit more.) There was one small difference between the two groups: very slightly more of those who had received the education had enjoyed four or more sexual partners in the period following the course. (They had evidently learned something.) Collier quotes presidential candidate Bush stating, in his homely way in 1998, that "the folks that are saying condom distribution is the best way to reduce teenage pregnancies obviously haven't looked at the statistics"; but the facts show that it is he and his friends who have ignored the data.

These results are consistent with other research which shows, contrary to the received and much trumpeted wisdom of those who assert that religious belief is the surest guarantee of restrained sexual behaviour, and thus of disease avoidance, that higher rates of STDs are found in countries that are more religious. A  recent study of the world's eighteen major democracies by Gregory Paul found that the more atheistically-inclined societies tended to have lower rates of murder, suicide, STDs, abortion and teen pregnancy than the more religious, and that among the developed nations the United States was remarkable in boasting the highest incidence both of these problems and of religious fervour. Although the late twentieth century STD epidemic has been curtailed in all prosperous democracies, he writes, rates of adolescent gonorrhoea infection remain six to three hundred times higher in the United States than in the more secular democracies. The U.S.A. also experiences uniquely high adolescent and adult syphilis infection rates, while in strongly secular Scandinavia the two main curable STDs have been almost eliminated. "Increasing adolescent abortion rates show a positive correlation with increasing belief and worship of a creator, and a negative correlation with increasing non-theism and acceptance of evolution; again rates are uniquely high in the U.S." [11] It should also be pointed out that the European countries with low rates of STD infection are precisely those which do not practise circumcision, a fact which throws serious doubt on the proposition that it provides meaningful protection in the sexual minefield, and which leads the writer in the SAMJ to comment that "the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the  developed world." [12]

AIDS in Africa: Human anatomy not the problem

It is generally understood that the AIDS epidemic in Africa is driven by a combination of poverty, population mobility, a high incidence of transient sexual unions and prostitution (of various kinds), leading to numerous concurrent sexual partnerships and extensive sexual networks; that the problem was allowed to get out of control by the delayed response of governments; and that it is massively aggravated by a general reluctance to use condoms or practice safe sex. It is further agreed that widespread and regular condom use would go a long way to addressing the problem, as it has done in places such as Britain, Australia and western Europe.

A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. [13] It is interesting to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: almost exactly the same as the risk reduction achieved by condom use 30 per cent of the time. Yet African men remain reluctant to use condoms, a rejection abetted by the churches, which preach vigorously against them, not merely on the ground that their use is contrary to Christian teaching, but with gross falsehoods, such as the claim that condoms are impregnated with the AIDS virus and are otherwise risky or dangerous. We may laugh grimly at Vatican Cardinal Trujillo's statement in 2003 that the latex of condoms does not give full security against the AIDS virus and that governments should therefore require them to be accompanied by a health warning, like cigarettes; but similar disparagement of condoms as not totally reliable has also been heard from medico-scientific figures who wish to promote circumcision instead. [14]

 The sad lesson of all this is that it is the very effectiveness of condoms as a shield against both disease and pregnancy that has, at least since the time of Malthus, been the biggest obstacle to their deployment. Their use by libertines made them suspect as a birth control device, while their effectiveness as a contraceptive earned them the ire of the nineteenth century medical profession, the United States government (which made it illegal to distribute contraceptive devices or information by post) and of course the Vatican – though it took a while to make an authoritative pronouncement. Falloppio does not seem to have got into any hot water for promoting his proto-condoms back in the sixteenth century, but the Catholic Church's traditional opposition to any form of contraception, originally codified by Thomas Aquinas, was reaffirmed in the strictest terms by the encyclical Casti Connubii in 1930, [15] and the Vatican continues to reject the argument that the situation is different when a condom is used for the purpose of protecting oneself or another person from disease. The most authoritative research has found that condoms are 90 to 95 per cent effective against STDs, including HIV, when used consistently, meaning that consistent condom users are ten to twenty times less likely to become infected when exposed to the virus than are inconsistent or non-users. The authors further estimate that condoms decrease the per-contact probability of male-to-female transmission of HIV by about 95 per cent. [16] Given these data, there can be no earthly reason for failing to promote their use as widely as possible, nor for preferring inferior alternatives.

Books referred to

Aine Collier. The Humble Little Condom: A History. New York: Prometheus Books, 2007. pp 371, index. Paper, $18.98. ISBN 978-1-59102-556-6.

George Drysdale, Elements of Social Science: Physical, Sexual and Natural Religion. London: George Standring, 1855; available on-line through Google Books

Christopher Trenholm et al, Impacts of four Title V, Section 510 Abstinence Education Programs, Final Report. Mathematica Policy Research, April 200

References

[1].  Elements of Social Science, 136-7

[2].  An Essay on the Principle of Population [1803], ed. Donald Winch (Cambridge Texts in the History of Political Thought, 1992), Bk. 4, Ch. 1

[3].  Angus McLaren, Birth Control in Nineteenth Century England (London: Croom Helm, 1978), 80

[4].  Herbert Hutchinson, Jonathan Hutchison: His Life and Letters (London: Heinemann, 1946), 200

[5].  Jonathan Hutchinson "The advantages of circumcision", Medical Review, Vol. 3, 1900, 641-2.

[6].  Jonathan Hutchinson, "On the influence of circumcision in preventing syphilis", Medical Times and Gazette, NS Vol. II, December 1855, 542-3. For a detailed analysis, see Robert Darby, "Where doctors differ: The debate on circumcision as a protection against syphilis, 1855-1914", Social History of Medicine, Vol. 16, 2003, 57-78, and A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain  (University of Chicago Press, 2005), Ch. 12. See also The Crotchets of Jonathan Hutchinson on this site.

[7].  Elements, 159-60

[8].  Elements, 137

[9].  Elements, 155-6

[10].  D. Sidler, J. Smith, H. Rode, "Neonatal circumcision does not reduce HIV/AIDS infection rates"; A. and J. Myers, "Editorial:  Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable", both in South African Medical Journal, Vol. 98, No. 10, October 2008.

[11].  Gregory S. Paul, "Cross-national correlations of quantifiable societal health with popular religiosity and secularism in the prosperous democracies", Journal of Religion and Society, Vol. 7, 2005

[12] Sidler et al

[13].  E.N. Ngugi et al, "Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes", Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890. In case it is suspected that the foreskin might have been a factor here, it should be remembered that the vast majority of Nigerian men are circumcised, and that female genital cutting is also common. Abstract of Lancet article available here.

[14].  For example, Brian Morris, In Favour of Circumcision (Sydney: New South Wales University Press, 1999), 51, and, along with Daniel Halperin, in numerous opinion pieces in medical journals and comments in the media. Both are insistent that circumcision should be mandatory not merely for Africa, but for the entire planet.

[15].  It is interesting to note that while the encyclical did not mention condoms, it did include (Paras 70 and 71) an explicit prohibition on mutilation of bodily members.

[16].  Steven D. Pinkerton and Paul R. Abramson, "Effectiveness of condoms in preventing HIV transmission", Social Science and Medicine, Vol. 44, No. 9, 1997, 1303-1312

Further reading

Lawrence Green et al, Male circumcision is not the HIV vaccine we have been waiting for, Future HIV Therapy, Vol. 2, 2008

Robert Van Howe and J. Steven Svoboda, Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al, Medical Science Monitor, Vol. 14, 2008