Flesh and Blood

Following the recent decision in the UK to allow homosexual men to donate blood, Ethan Troy-Barnes investigates why Ireland is yet to follow suitThe Irish Blood Transfusion Service (IBTS) is no stranger to controversy. The body, responsible for the regulation and provision of all donor blood products in Ireland, has been the focal point of a number of public health scandals in the past. Perhaps the most notable of these was the provision of Hepatitis C-contaminated blood to numerous patients in the eighties.It is understandable, therefore, that the IBTS is determined to exclude any high-risk donors whose contributions may endanger the safety of patients in receipt of donor blood, particularly by transmitting infections such as HIV or Hepatitis C. To this end, many groups are prohibited from donation. One such group is men who have sex with men (MSM), which includes any man who has ever had intercourse with another man.However, in recent years, there has been widespread relaxation of exceptions regarding MSM. “Germany, Italy, Poland and Spain allow MSM to donate,” explains Dr. Conor Malone of Gay Doctors Ireland, a group representing LGBT medics nationwide. “A number of other countries have deferral periods of six to twelve months. Even our neighbours in the UK have revised deferrals down to twelve months.”It is this recent loosening of restrictions in the UK earlier this year that has sparked renewed criticism regarding the IBTS’s stance on the issue. Many expected Irish policy to change following the new British legislation, but no such changes were made. The IBTS has since stated that there are no plans to revise their policy on blood donations in the near future. They defended their current policy, arguing that they have “a responsibility to ensure that there is a sufficient supply of safe blood to meet the needs of patients.”“Men who have sex with men are disproportionately affected by HIV according to recent Irish data,” say the IBTS, insisting that the exclusion of MSM donors is based solely on sexual conduct uniquely practiced by homosexuals which may lead to the spread of blood-borne viruses, rather than the sexual orientation itself. “The reason for this exclusion rests on specific sexual behaviour (such as anal and oral sex). There is no exclusion of gay men who have never had sex with a man, nor of women who have sex with women. The decision is not based on sexuality or orientation, only specific actions.”Dr. Ernesto Vasquez Del Aguila, a medical anthropologist from the UCD School of Social Justice, challenged these assertions. He commented that the screening questionnaire currently used to assess the risk posed by potential donors before donation “doesn’t look at if the person was using protection or not, but the emphasis is if the person was having sex with someone of the same sex. That’s a direct discrimination.”According to Dr. Del Aguila, the survey is obsolete and assumes that only MSM may donate infected blood. “The origin of this [survey], of these concerns, was in the eighties, where HIV/AIDS was considered a ‘gay disease’. That is a myth now, all the evidence says that AIDS is spread [throughout] the general population.”This raises concerns that by focusing on, for example, HIV/AIDS as a ‘gay disease’, the IBTS is understating the risk posed by HIV-infected heterosexual donors. “HIV/AIDS is becoming more and more a heterosexual disease,” explains Dr. Del Aguila. “There are certain countries – particularly in Africa – where the pattern of transmission is heterosexual [and] there are more heterosexual people who are HIV positive than homosexual people.”However, despite HIV and other blood-borne viruses’ higher prevalence in heterosexual communities in some countries, recent Irish data suggests that new cases of HIV/AIDS are on the rise in Ireland’s homosexual population.This fact is used by the IBTS to defend its discrimination between prospective heterosexual and homosexual donors, as they believe it shows a clear difference in the risk posed by these two groups. “The fundamental difference between heterosexual and homosexual risk is the different rates of new infections with sexually transmitted infectious diseases in the two populations. [A 2010] report clearly shows that there is a continued rise in the number of new HIV cases among MSM, who are now the majority of new cases of HIV infection in Ireland. New cases of HIV infection among MSM has doubled since 2005.  MSM have a much higher rate of both existing and new HIV infections than the heterosexual population.”On the other hand, Dr. Del Aguila disagrees. He insists that the IBTS is generalising, and by doing so, missing the key issue at hand. “It’s not the practice that they are looking at – if the practice is safe or unsafe – but who is [having sex] with whom,” says Dr. Del Aguila, who continues that a more appropriate assessment would instead look at sexual practices known to increase a potential donor’s risk of carrying an infection. “It should be, ‘Are you using condoms?’, ‘Have you used condoms in the last six months?’, or these kinds of questions where you can see if the person represents a risk or not, independent of his or her sexual identity.”This view is echoed by Gay Doctors Ireland. “IBTS policies stigmatise gay men, [and] are a form of government-sponsored homophobia” according to Dr. Malone, who claims that Irish policy is outdated. “The IBTS enforces an arbitrary ban based on the fears of the 1980s HIV epidemic. Some MSM are high risk, while many others are low risk.  The same is true of heterosexual donors. We are asking the IBTS to distinguish between these groups, instead of lumping all gay men into a single category.”Dr. Malone’s comments highlight a common criticism of the IBTS policy. It is often claimed that current legislation unnecessarily prohibits low-risk homosexuals, such as those who practice monogamous, safe sexual behaviour. However, the IBTS counter that “individuals can only attest to their own behaviour when donating and [cannot] speak for their partner,” implying that even if a homosexual person considers themselves to be low risk, their partner may practice unsafe sex with other individuals without their knowledge, making them high-risk by association.Yet, the IBTS also claims that “Evidence from heterosexual partnerships suggests that ‘innocent’ partners are very often entirely unaware that their partner/spouse is unfaithful.” Despite this fact, in their assessment of donors, the IBTS will not prohibit heterosexual donors who practice monogamous, safe sex from giving blood on the grounds that their partner/spouse may be unfaithful.“IBTS policies are internally inconsistent. For instance, a woman who has sex with an MSM would be banned from donating for 12 months, but a man who has sex with an MSM is banned for life.  What is the scientific basis for this difference? There is none,” argues Dr. Malone. “As doctors, we know that these donors have similar risk profiles, and yet the IBTS discriminate against the gay man. This is blatant homophobia.”The subject of laboratory screening of donated blood is also an issue covered by IBTS policy. All blood is currently screened following donation. This is to ensure that donated blood is free of blood-borne viruses. Therefore, many question the need for prohibition of MSM donations if all blood will also be subjected to laboratory testing to ensure its safety anyway.The IBTS believes that this train of thought is incorrect and maintains that exclusion of MSM donations is necessary as the current screening techniques are not perfect. “Every blood donation is tested for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and human T-lymphotropic virus (HTLV). However, despite improvements in blood screening tests, a small number of infected donations may be missed because of the ‘window period’ between getting the infection and the test showing a positive result.”Dr. Del Aguila again calls the IBTS’s protocol into question in this regard, claiming that the IBTS is still discriminating against homosexual individuals. “[This ‘window period’ is] a risk with everybody. My point is: why are they treating homosexual people in a different way to heterosexual people? The window period works for both. But here, it only works for gay people.”Despite his criticism, however, Dr. Del Aguila understands that the IBTS’s main priority is to safeguard the wellbeing of patients in receipt of donor blood. “It’s a public health initiative. The intentions were very good. The intentions were to protect the general population. That was the original goal.”He continues that the issue of MSM blood donation is a complex one. “I’m a medical anthropologist. I work with public health, and I’m absolutely aware of these topics. They don’t want another crisis like in the UK,” he says, before suggesting that the IBTS has a dual responsibility. “I think they need a balance, and I would emphasise this, between protecting the general population, [and the] need to protect the rights of these people who need [this] blood” but warns “they don’t have access because of this very restrictive policy.”In light of these criticisms, why is Ireland so reluctant to introduce change, unlike other countries such as the UK? Dr. Del Aguila believes that it is difficult to pinpoint the exact reason for Ireland’s hesitance to amend its policy. “I don’t think that this is a cultural issue, I don’t think that Ireland is behind the UK. In terms of gay marriage for instance, the majority of the Irish population are supporting gay marriage.”In the end, he muses that “people make policies,” and it is therefore up to policy makers to remedy the situation. “Health practitioners need to revise this [policy], and learn from other countries, because [currently] they are limiting the access for people who need these blood transfusions.”