A letter to a senior colleague on the conflict between advocating both healthcare and 'equality'.



Dear [colleague],      

I have come to respect your vigorous and thoughtful stewardship of the Trust and your evident passion for the interests of its patients and staff. With considerable opportunities and difficulties to face in the months ahead, I realise prioritising and focussing on key matters is important.  I do not desire to distract from these vital labours, however there is an area in which I continue to feel deep disquiet and I address it here candidly.

I welcome the Trust's aspiration to be 'a great place to work and a great place to be treated', but I am writing to express concern about its policy of advocating and celebrating lifestyles which involve practices themselves extensively documented to be detrimental to health.

Due to the characteristics of the rectal mucosa, the risk of microbial blood to blood transmission from anal intercourse is considerably higher than vaginal intercourse (1-3). The risk of HIV transmission in particular is 'much higher' (4).

Receptive anal sexual intercourse, both homosexual and heterosexual, is also associated with up to 93% of anal cancers (5) and an increased (up to 33 fold) risk of developing anal cancer (6,7). Although still uncommon, changes in sexual activity have been attributed as the principal explanation for the fivefold rise in incidence of squamous cell carcinoma in Danish women and a 2.5 fold rise in men (8) and a near doubling in both groups in the US over 27 years (9). The risk of cancer is greater in HIV infected patients, but not confined to them (10).

Passive anal sex causes anal warts (11) and has been reported to be associated with alterations in anal sphincter function (12) and in one larger study faecal incontinence (13).

Durex' website in 2001 acknowledged, 'Anal intercourse is a high-risk activity because of the potential for infection from STDs including HIV transmission. Currently, there are no specific standards for the manufacture of condoms for anal sex. Current medical advice is therefore to avoid anal sex. However, whenever this advice is not followed, the medical profession recommends that stronger condoms should be used although studies have shown that there is still a risk of breakage and slippage' (14).

Whilst it is essential to ensure strictly the non-discriminatory provision of health care and to safeguard vulnerable staff and patients from aggression, is it appropriate for a health service to actively promote lifestyles that actually cause ill health? What drives a policy that undermines the central function of the hospital, could it be a species of evil?

With my best wishes,

Yours sincerely, 

Charles Soper


1 Gastroenterology. 2009 May;136(5):1609-17

2 J Med Virol. 2005 Jul;76(3):311-7.

3 JAMA. 1992 May 13;267(18):2477-81.

4 Lancet Infect Dis. 2009 Feb;9(2):118-29

5 Cancer. 2008 Nov 15;113(10 Suppl):2892-900

6 N Engl J Med. 1997 Nov 6;337(19):1350-8

7 N Engl J Med. 1987 Oct 15;317(16):973-7.

8 Dan Med Bull. 2002 Aug;49(3):194-209.

Cancer. 2004 Jul 15;101(2):281-8.

10 Journal of the National Cancer Institute 2001 93(11):843-849

11 Acta Derm Venereol Suppl (Stockh). 1996;198:1-55.

12 Chun AB, Rose S, Miltrani C, Silvestre AJ, Wald A. Anal sphincter structure and function in homosexual males engaged in anoreceptive intercourse. Am J Gastroenterology. 1997: 92: 465–468.

13 J R Soc Med. 1993 March; 86(3): 144–147.

14 accessed 26/4/01, (curiously the link no longer functions).



Other ethical and medical aspects of anal intercourse

Seven serious spiritual wounds from sex outside of marriage