Dáil Éireann díospóireacht -
Thursday, 3 Jun 1993

Vol. 431 No. 8

Health (Family Planning) (Amendment) Bill, 1993: Second Stage.

Question proposed: "That the Bill be now read a Second Time."

Minister for Health (Mr. Howlin):

When I spoke on the Health (Family Planning) Amendment, Bill, 1992 during the Dáil debates in July of last year I set out what I considered to be the two main elements for an effective programme to prevent the spread of the AIDS virus. These were proper and non-moralistic programmes of education directed at the various sections of the community and legislation which would remove the restrictions on the purchasing of condoms.

In regard to the former, last week, I launched a new AIDS media campaign which deals in a clear, unambiguous fashion with the role of the condom in preventing HIV. This campaign is directed at all sexually active people and will be complimented by further measures aimed at various groups within the community such as drug abusers.

On the legislation, I stated during the debates last year that we should have a Bill that is in keeping with the times and does not seek to be a throwback to a time long forgotten. The Bill which is now before the House is clear in its content and its intent. It provides for greater access to condoms at a time when there is clear evidence that they are an effective barrier against the spread of HIV.

I am very pleased, therefore, to bring legislation before the House which demonstrates both my commitment and that of the Government to rationalise family planning legislation initially in so far as this is required for public health reasons but ultimately in regard to all family planning issues.

I propose to look at the broader issue of family planning as part of an overall strategy for health which is currently being developed in the Department and which will guide and direct the Department's work over the next three to four years.

In the context of public health protection, I would like to remind the House of the necessity for the Bill in tackling the problems of HIV/AIDS, and, indeed, other diseases which are sexually transmitted.

In Ireland, we have an increasing number of persons who are testing positive for HIV. To date, a total of 1,368 persons have tested positive and it is accepted that this figure understates the true situation. I hope, by several of the initiatives I have taken, to broaden the scope of testing still, of course, on an anonymous basis to have a more accurate picture in the immediate future. We extended the HIV surveillance programme in October 1992 to include the analysis of blood, on an anonymous, unlinked basis, which is taken at ante-natal clinics for routine clinical purposes and which is surplus to requirements. We propose to extend the programme, on a phased basis, to include blood taken at STD clinics and hospital in-patients and out-patients, in an effort to develop as comprehensive a picture as possible for the prevalence and spread of the infection in Ireland.

Our current data base indicates that the infection is largely present in certain groups of the population — IV drug users, homosexuals, haemophiliacs and to a lesser extent, in heterosexuals. In the latter, there is a steady presence of new HIV positive cases.

Our efforts, therefore, have to concentrate, to a great extent, on preventing those who are not infected from becoming so, and to ensure that those who have contracted the virus do not transmit it to others.

People generally are now aware that the main routes of transmission are (i) through sexual intercourse and (ii) through sharing needles while abusing intravenous drugs. Even though they are aware of these facts many, nonetheless, continue to put themselves at risk of exposure to the virus. We must encourage these people to behave in ways which will reduce or eliminate this risk. We know that the surest way of avoiding sexually transmitted HIV infection is by being faithful to one person who is also faithful to you, assuming that neither person has shared needles while injecting drugs.

However, there are sexually active people who do not adhere to these guidelines for behaviour and they must be encouraged to behave responsibly. Our national AIDS strategy, therefore has a strong emphasis on primary and secondary prevention. Our primary prevention programmes are designed to prevent persons from becoming infected in the fist place and education and information are key components in a HIV/AIDS primary prevention programme. So too is easy access to condoms.

Our secondary prevention programmes are aimed at preventing the transmission from an infected person to persons who are not infected and this is implemented through risk-reduction service, such as Outreach, methadone availability, needle-exchange, condoms and counselling.

In programmes to prevent HIV, and other sexually transmissible diseases, it is recognised and accepted that a good quality condom, properly used, is the most effective prophylactic against these diseases.

It is essential, therefore, that people are aware of the role of condoms as an effective prophylactic and, recognising that people are sexually active from an early age, they should have reasonable access to condoms.

The primary purpose of the Bill, therefore, is to provide for improved access to condoms, as a necessary and practical response to the evolving HIV/AIDS problem here. The Bill implements the recommendations of the National AIDS Strategy Committee, which called for the supply of condoms, through vending machines. It also brings us into line with public mores and thinking in Ireland and with the situation in other EC member states where condoms are supplied through vending machines.

The Bill provides for the amendment of the Health (Family Planning) Act, 1979, which is the Principal Act, and for the amendment of the Health (Family Planning) Amendment Act 1992, as follows: (i) the removal of controls for the supply of condoms, (ii) the exclusion of condoms from the definition of "contraceptive", and (iii) the provision of enabling powers to the Minister for Health to regulate the location of vending machines for condoms and to prescribe standards for condoms. I am also taking the opportunity in the Bill to remove the licencing requirements to import and manufacture other contraceptives.

Section 1 defines "contraceptive sheath" to include condoms for men and women. Deputies will recall that the position under the legislation of the female condom was raised during the Dáil debates last year. I have included the female condom in the definition of contraceptive sheath under section 2 to ensure that it is also excluded from the legal controls.

Section 2, therefore, amends the definition of "contraceptive" to exclude condoms, thereby removing the controls over the sale and supply of condoms altogether. The consequences for the 1992 Act of amendment to section 2 are as follows. As a result of the exclusion of condoms from the definition of "contraceptive" under section 2, I am proposing, in section 8, to repeal sections 5 and 6 of the Health (Family Planning) (Amendment) Act, 1992. These are necessary and consequential on the proposed new definition. The effect of this will be to remove the controls in section 5 of the 1992 Act which prohibited the sale or supply of condoms to persons aged under 17 years or from certain outlets, such as vending machines, mobile outlets or street vendors. It will also remove the controls contained in section 6 of the Act relating to the age limit of 17 years of persons to whom condoms could be supplied for resale.

I consider the amendment of the definition of "contraceptive" and the consequent removal of the controls over condoms arising from this and the repeal of section 5 of the 1992 Act as being extremely important developments, not alone in the fight against HIV/AIDS but also towards ensuring that the State is now retreating from unnecessary intrusion into the private lives of its citizens.

In the context of HIV/AIDS, these proposed amendments and repeals are fundamental and essential. The attempts in the 1992 Act to liberalise the availability of condoms have simply transferred their supply from one type of supervised sale to another type of supervised sale. This did not result in a realistic, practical or effective approach to HIV prevention. It is reasonable to assume, however, that the supply of condoms through vending machines will provide that degree of privacy to encourage sexually active persons who require the protection of condoms to avail of them and thus protect themselves and their partners from exposure to disease and infection.

The Government was mindful, however, of the possible adverse consequences of removing the controls contained in the 1992 Act and has decided to include in the Bill, a provision in section 3 which would enable the Minister for Health, if it was deemed necessary, to prohibit by regulations the sale of condoms in places which could be considered to be inappropriate and a provision in section 4 which would enable the Minister to prescribe, by regulations, standards for condoms.

Section 3 might be required in the event of a proliferation of vending machines in, for example, places where very young persons congregate or in certain locations in main streets. The expectation is, however that the removal of the controls in section 5 of the 1992 Act will lead to the location of such machines in appropriate internal locations to the extent that inappropriate internal or external locations may not arise. I expect, therefore, that it may not be necessary to bring in any regulations.

Section 3 (3) provides that a person who contravenes this section will be guilty of an offence.

Section 4 provides an enabling power to the Minister for Health to prescribe standards for condoms. This provision is necessary to safeguard against the supply of condoms which are inferior and do not meet recognised international standards.

The European Committee for Standardisation has drafted standards for latex rubber male condoms. It is expected that the draft standards will be finalised and adopted later this year as a European standard. The European standard will then become our national standard.

In the meantime, I propose to recognise, in regulations, a recognised standard of an EC member state or condoms of an equivalent standard.

Subsection (2) of the section provides that a person may not sell or supply contraceptive sheaths which do not comply with the standards set.

Subsection (3) provides that a person who contravenes subsection (2) will be guilty of an offence.

Section 5 of the Bill provides for technical amendments to the 1992 Act.

It provides for the deletion of the phrase "in accordance with section 3 (3) of the Principal Act" in section 4 (1) paragraph (b) (i) (iv) of the Act of 1992. This is necessary as section 3 of the 1979 Act was repealed by the Act of 1992. I am sorry to be so convuluted but it is difficult to follow a series of amendments to Bills that relate to previous legislation and, indeed, to a Principal Act. I hope that the clarity of the legislation will be followed by all in the House.

This section also provides for the amendment of paragraph (c) of section 4 (1) of the Act of 1992. This is consequential on the repeal of sections 5 and 6 of the Principal Act under section 8 of the Bill. I will refer to section 8 later.

Section 4 of the Act of 1992 sets out the list of persons who may sell contraceptives. That section provides in general terms, that contraceptives may be sold by the following categories of people, pharmacists, registered medical practitioners, employees of health boards, family planning services and employees of hospitals.

Section 4 of the 1992 Act also provides for the sale of contraceptives by a licenced importer or manufacturer to the persons which I have mentioned.

Section 8 is designed also to remove the licencing requirements to import and manufacture contraceptives, other than condoms, by repealing sections 5 and 6 of the 1979 Act. As a result, paragraph (c) of section 4 (1) of the 1992 Act requires to be amended to delete the references to sections 5 and 6 of the 1979 Act, but at the same time ensure that importers, distributors or manufacturers of contraceptives can sell contraceptives to the persons listed in section 4 (1) of the 1992 Act, whom I mentioned earlier.

Section 6 provides for the making of regulations in relation to any matter referred to as being specified or prescribed by regulations. This is a standard provision in legislation.

The sections of this Bill which refer to regulations are: section 3 regarding controls on the location of vending machines and section 4 regarding standards for condoms.

Section 7 specifies the penalties for offences committed under the Bill when enacted. The sections to which it applies are section 3 for contravening regulations on the location of vending machines, and section 4 for contravening regulations on the standards for contraceptive sheaths.

As I mentioned earlier, section 8 will repeal the current requirements that imports and manufacturers of contraceptives, other than condoms, should be licenced, through the repeal of sections 5 and 6 of the 1979 Act. The EC Commission has expressed its unhappiness at the existence of these controls in the context of the completion of the EC Internal Market. I am pleased this Bill will remove those restrictions.

I also mentioned earlier that section 8 of the Bill proposes the repeal of sections 5 and 6 of the 1992 Act.

Section 9 (1) gives the short title of the Act and is a standard provision.

Section 9 (2) provides that the Health (Family Planning) Acts, 1979 and 1992 and this Act may be cited together and will be construed together.

I am happy that the enactment of this Bill will bring to a conclusion the longrunning saga of legislation relating to the control of condoms in Ireland.

Irish society has moved a long way from the era of "Irish solutions to Irish problems" and the all party support which I have received following the publication of this Bill is a sign of the maturity of the Members of this House. We have moved in a period of 14 years from the restrictive 1979 Act with its emphasis on "bona fide family planning", through the 1985 Act which restricted the sale of condoms to registered outlets, through the 1992 Act which failed to recognise the requirements of an effective AIDS prevention programme to the present enlightened Bill. I look forward to the contributions of Members to this debate.

I hope I have explained the Bill in sufficient detail and I commend it to the House.

Mr. Flanagan:

On behalf of the Fine Gael Party I wish to state our support for this measure and wish the Bill a speedy passage through the House and on to the Statute Book. However speedy a passage I might wish for this legislation, I would like to record my total dissatisfaction at the manner in which the Bill is being treated in this House. It was explained in the House earlier by my party's chief whip that because of the extension of time given to the Finance Bill the consideration of this Bill would have to be somewhat limited. It is bordering on the outrageous that Opposition spokespersons should be required to submit amendments to legislation in 24 hours before the legislation is introduced by the Minister. It makes a joke of many of the Opposition's contributions. It is an indication of the manner in which successive Governments — and I do not blame the Minister in this regard — have treated the contributions of Opposition Deputies within the Chamber. There should be a time lapse of at least 48 hours between the conclusion of the Minister's Second Stage speech and a consideration of the Bill on Committee Stage. However, there is little we can do about it and I welcome the Minister's initiative in introducing this Bill.

The subject matter of this Bill has had a turbulent history spanning over 20 years which generated heated debate of a type rarely seen in this House and aroused passions throughout society resulting in unfortunate and consequent bitterness and divisiveness. It is most regrettable that the matters contained in this Bill were not addressed last year by the Fianna Fáil-Progressive Democrats Administration. Indeed, if amendments in the name of Fine Gael and Deputy Howlin had been adopted by the then Government we would not as a Legislature be discussing condoms in the House in June 1993.

I compliment the Minister on this initiative which brings our family planning legislation somewhat closer to current thinking in society as well as addressing the far more important public health issues involved. By dealing directly with matters expressly opposed last year by the then Minister, we are enacting legislation reflecting the majority view of Members in this House. The ban on vending machines and the imposition of an age limit by former Health Minister, Dr. O'Connell, was an absolute nonsense. The thinking in certain circles was so removed from reality that one could be forgiven for believing that sexual activity was confined to a 40-hour five-day week among people of a certain age. Under the Health (Family Planning) (Amendment) Act, 1992 birthdays were given the added status of a licence for sexual activity. It is surprising that the present legislation has not been challenged as to its constitutionality on the basis that it unduly interferes with the right of married couples under the age of 17 to have access to the purchase of condoms. In this regard it is worth recalling the words of Judge Brian Walsh in the McGee case 23 years ago when he stated:

It is outside the authority of the State to endeavour to intrude into the privacy of the husband and wife relationship for the sake of imposing a code of private morality upon a married couple which they do not desire.

He further stated:

The right to the use of contraceptives by married couples cannot be frustrated by the State taking measures to ensure that the exercise of that right is rendered impossible.

The present restrictions being placed on married couples under the age of 17 would be found to be beyond the powers of the State. It is surprising that no action was taken within the last 12 months on the matter. Of course, such action is rendered unnecessary by the Minister's Bill this morning.

In the existing legislation consideration was not given to the fact that many shops close at weekends and at night thus denying access for those who may be interested in the purchase of a condom. Outside our major cities access to condoms was severely restricted, in that many licensed outlets refused to retail condoms while others hid them away in a corner, almost embarrassed to display them. The vending machine will remedy the access deficit.

I am reminded of a recently reported incident in a provincial town where a licensed vintner, in anticipation of the Minister's legislation, installed a condom vending machine after Christmas. Being the law abiding citizen that he was, he did not furnish the machine with condoms. While preparing the machine in advance of the Minister's legislation he found, to his amazement, the sum of £70 lodged in the machine. The point worth bearing in mind is the embarrassment and furtiveness on the part of people wishing to purchase a condom. That licensed vintner did not receive one complaint from any member of the public or any consumers on his premises and no one asked for a return of their money. In the light of this example, we must examine the manner in which we as a society regard the condom. The anonymity in using the vending machine is welcome.

In an ideal world sexual activity should be carefully planned but unfortunately we do not nor will we ever live in an ideal world. Up to now the restricted availability of condoms added to a view that they were in some way unsafe or dangerous. By curbing the sale of condoms we contributed to unsafe sexual behaviour. Machines are important not only in broadening access but in preserving anonymity and minimising any embarrassment for those purchasing condoms. The age restriction was even more ludicrous. Young people can under existing legislation marry, work, obtain full driving licenses and drive cars, serve prison sentences, purchase cigarettes, even, in some circumstances, obtain a licence for a shotgun and yet they cannot buy a condom.

The Minister has dwelt at some length on the matter of HIV and AIDS. This Bill, as he said, is basically an anti-AIDS measure and this is welcome. Sadly however, it speaks volumes for our society that it has taken the killer disease AIDS to highlight the need for an increased use of condoms throughout society.

AIDS is a problem that we underestimate at our peril. Those testing positive for HIV are increasing in numbers as are deaths from AIDs. There are far more people HIV positive than the officially recorded statistics reflect. It is now known that the period of incubation — prior to the manifestation of any symptoms — may be ten or 12 years. It is likely that much infection took place in the late seventies and early to mid eighties. Since prior to 1985 no reliable HIV testing procedure existed, many new AIDS cases are being discovered. The fight against AIDS must be close to the top of the Minister's agenda. The Department of Health AIDS publication clearly states that, besides celibacy or a life long monogomous commitment, for sexually active people who are not in one faithful partner relationships a good quality new condom, correctly used, is the single most effective defence against HIV infection. This does not mean that condoms will rid us of the AIDS crisis. Neither does it mean that every condom all of the time guarantees 100 per cent that the virus will not be transmitted. It does mean, however, that for many people who are sexually active condoms offer a method of protection of life saving proportions.

The number of AIDS cases is rising each year and will, unfortunately, continue to do so for the foreseeable future. There are no medical means available to prevent the spread of the virus. Neither is there any cure for the disease. The provision, therefore, of sound information and good education is of critical importance in curtailing the spread of the condition. Major risk categories in respect of the AIDS virus are not the same throughout Europe. In the UK and Germany, for example, the homosexual community form the largest at risk group while in Ireland, Italy and Spain intravenous drug abusers are top. In common however with all our European neighbours the incidence of the disease is rising among the heterosexual community. In the six years to 1992 heterosexual cases have risen from 6.5 per cent to 10 per cent of the overall while over the same period in Ireland the increase has been from zero to 10 per cent.

AIDS is no longer the concern of any one group within society; it is a concern of us all. There is no danger if persons or their sexual partners do not engage in high risk sexual behaviour or use shared needles or syringes to inject illegal drugs into the body. Those who engage in high risk sexual behaviour or who shoot drugs are risking infection with the virus and are risking not only their own lives but those of others including unborn children. The most certain way to avoid infection and to control the spread of AIDS is for individuals to avoid promiscuous sexual practices, to maintain mutually faithful monogamous sexual relationships and to avoid injecting illicit drugs. The real world and the frailty of human nature, however, means that avoidance is aspirational and as legislators we must accept reality as it is. Our responsibility is to act in the public good and in a society where people engage in high risk sexual behaviour we must offer a measure of protection by way of education and information. We cannot, as has often been stated in the Oireachtas, legislate for morality. We cannot set ourselves up as a chamber of morals but we must legislate for reality.

Much has been said on the matter of condoms and AIDS. There can be no doubt that the overwhelming evidence suggests that use of a condom is of extreme importance in curtailing the spread of HIV. It is however interesting to note that many opponents of the condom in the drive against AIDS are those groups who oppose the use of condoms in any event. I recently heard a member of Family Solidarity argue that condom failure actually contributes to the spread of AIDS. It is extraordinary however that this line should be spun by a group opposed to all forms of contraception from a perspective that has nothing to do with AIDS. I would venture to say that groups such as the one mentioned are using the AIDS issue to peddle their propaganda. This type of scaremongering is of little help in the fight against HIV.

In the course of his speech the Minister referred to regulations concerning the quality and standards of the condoms that will be more widely available under the legislation. This is a matter that should be reverted to in the course of Committee Stage. I note that the Minister has power to require standards and it is the monitoring and policing of this power that is of importance. The Minister said he hopes to imprint on Irish regulations the European standard. That reminds me of a story told about the purchaser of a condom, not in this jurisdiction because it was purchased from a machine. On his purchase the person questioned the occupier of the premises as to the British standard stamped on the condom, asking "What does this standard mean?". The owner of the premises responded that it was British Standard 1234, to which the purchaser replied, "We must remember that the Titanic also conformed with the British standards of the day”. We must ensure a proper system of monitoring and policing in this area so that all retail outlets conform with whatever standards apply, be they Irish or European. There should be provision for appropriate penalties in the event of non-compliance with the standards.

The location of vending machines, as dealt with under section 3, requires reflection. The Minister has stated — not in the House — that he does not envisage the location of vending machines in schools. It is important that machines are not placed in locations where easy access would be available to young people or where the availability of condoms might act as an allurement to young people towards sexual activity.

Location should be restricted to places where only adults frequent, such as public houses, discos, night clubs and so on. Again, this matter can be reverted to on Committee Stage. What standards will the Minister employ to ensure substandard products are not peddled? It has been said that condoms stored in machines for a long time lose quality and are more likely to fail by virtue of storage. These claims are without foundation as no supporting evidence has been produced to show that distribution by way of vending machine diminishes the quality or strength of the condom. I am sure the Minister will take expert advice on this matter and will allay my fears before the conclusion of the debate.

Evidence however does suggest that condom failure is more likely to occur from ignorance or misuse than from poor quality and this is a matter that must be addressed. The World Health Organisation, the Paris Centre for AIDS Research and governments all over the world agree that condoms when used properly can and do prevent the spread of disease. I quote from Dr. James Walsh, former Irish AIDS co-ordinator:

There is no argument on this one; all the data and research in Western Europe indicates that the condom is more than 90 per cent effective in preventing the spread of disease. Everyone agrees that HIV is lethal if contracted but it is not in itself a particularly infectious agent. The condom therefore is a most effective barrier. Condoms represent an important health protection for those who remain sexually active. Those who do not use a condom may be exposed to 100 per cent risk. Condoms in effect are a vital weapon in the battle against AIDS. It can in effect be a matter of life and death.

As well as the issue of AIDS, the greater availibility of condoms will hopefully lead to a decline in the number of unwanted pregnancies in this State. The tragedy of thousands of women seeking abortion abroad every year and figures showing one birth in five to single mothers should be sufficient to prompt positive action in this regard. A recent survey of 2,000 leaving certificate students in Munster revealed that one in four had engaged in sexual intercourse. Teenage pregnancies continue to rise here and studies of teenage pregnancies show that 855 were unplanned and most had not even considered contraceptives.

By liberalising our condom laws we are as a Legislature recognising the changing pattern of sexual behaviour in recent times. It is a fact that young people are more sexually active than ever before and our response must be more than to make condoms more widely available. I regret that successive Governments have failed in their duty to inaugurate a programme of education seeking to promote a clear appreciation of responsible sexual behaviour. It is an indisputable fact that there is a direct link between teenage pregnancies and a lack of education in the area of sex and relationships. Teenage pregnancy rates vary directly in inverse ratio to the provision of sex education in our schools. It is regrettable that we do not have in our schools an adequate programme of lifeskills and sex education.

Perhaps the Minister will consult with his colleague, the Minister for Education, on this matter. It is of fundamental importance that we set in place a comprehensive health education programme in schools, with the aim of promoting an understanding of responsible sexual behaviour. This process should commence in primary school by way of lifeskills and should be properly part of the school curriculum thereafter until the completion of secondary school course. I ask the Minister, before the conclusion of this debate, to give specific commitments in this regard. I will be proposing an amendment on Committee Stage to deal with the matter. Our negative attitude towards sex is fostered by a refusal to include proper sex education in our schools.

I am surprised and disappointed the Minister did not avail of the opportunity in this Bill to address the lack of a comprehensive family planning service in the State. Last year the then Minister, Dr. John O'Connell, burdened himself with the task of "securing the orderly organisation of comprehensive family planning services", a rather convoluted task. The insertion in legislation of phraseology such as that is most unhelpful. Success in the last 12 months in regard to the former Minister's initiative has been very limited. The report of the Second Commission on the Status of Women dealt at some length with this matter. Perhaps the Minister will address these concerns in the course of the debate.

Family planning throughout much of the country is limited, haphazard and unsatisfactory rather than comprehensive. Sterilisation services vary greatly throughout the country. A uniform service in this regard is required. In many areas sterilisation is assessed on the basis of moral, theological or philosophical grounds rather than on a medical basis.

The report examined the practice in our maternity hospitals and found that the scheme of family planning services is less than uniform. Some hospitals have family planning clinics. Others provide information only in respect of natural family planning. Others have little or no information process of any description. We need a full family planning service as part of post-maternity care. The recommendations contained in the report will be referred to by my able colleague, Deputy Frances Fitzgerald, in her contribution.

Many people of differing political persuasions and differing religious persuasions passionately oppose all forms of contraception. The sincerity of these views in most cases cannot be called into question and must at all times be respected. Many people in our society campaign against the use of condoms and speak against the use of contraception at every opportunity. It is their right to do so. These people may use every opportunity to dissuade people, particularly our young people, from using condoms, but the line must be drawn at seeking to impose one's moral view on our fellow citizens. In the matter of private morality, the State has no role and must remain on the fence. Justice must be based on the concept of equality and respect for the belief of all people, not only those of a majority persuasion. Tolerance and respect are the cornerstones of a genuine pluralist, just and equitable society. The repeal of the offensive sections of the 1992 Act are very welcome in this regard, and the new proposals outlined this morning by the Minister are fully supported by Fine Gael.

Ms O'Donnell:

I welcome this Bill. I am happy to welcome it on my own behalf and on behalf of my party. It represents another sequel to the long and tortuous road in the availability of contraceptives by legislation and jurisprudence which touches on the vast area of public policy which has evolved with regard to female reproduction and contraception. It is strange that the impetus which drives this legislation is not a loosening up of the law restricting access to reproductive freedom for women, but part of a comprehensive and very welcome anti-AIDS initiative. I am tempted to indulge in irony, and the only reason condoms are being liberated from the law with regard to family planning restrictions is not to allow reproductive freedom to women but to prevent the spread of HIV and AIDS. I will not labour the point as I am genuinely delighted in any context to welcome this legislation. I wonder if this legislation would be going through unopposed if it were not for the threat of HIV and AIDS.

Mr. Howlin:

It would be put forward by this Minister.

Ms O'Donnell:

I congratulate the Minister. It has taken 25 years of lobbying and legislation, long periods of inaction, Supreme Court decisions and Private Members' Bills by former Senator Mary Robinson, now our esteemed President, to liberalise contraceptives. This issue has dodged politicians since the seventies. The issue has divided parties. Former Deputy Liam Cosgrave, as Taoiseach, voted against his Minister's legislation in 1974 and our Ceann Comhairle had a political difficulty with the Labour Party at one time.

For years, the pill had been prescribed as a cycle regulator. Only this year this lie has been undone by the welcome availability of oral contraceptives to GMS patients as contraceptives. All contraceptives should be available free to GMS patients. The slow gestation of public policy around reproductive freedom goes on and much has still to be achieved. Tubal litigation is still only available in a very restricted way in public hospitals for medical reasons rather than on the free choice of a woman who does not wish to have any more children. Indeed, the right of women not to have children has never been conceded yet in this State. One of the first frontiers of the women's movement was the right to have true reproductive freedom for women. The battle goes on.

This measure is motivated solely to stop the spread of HIV and AIDS. I applaud the Minister for dealing with this public health issue in a forthright way. The growing problems of HIV and AIDS needed strong, effective, courageous action from the Minister and he has risen to that challenge. Nothing happens by chance in politics, especially when moving towards the liberalisation of contraceptives.

I congratulate the National AIDS Strategy Team who have done excellent work over the last few years. I note also that the Minister has been strong in his response in dealing with the campaign to halt the spread of HIV and AIDS in confronting head on the opposition to the advertising campaign by the conservative mandarins in RTE. The Catholic Church, through the Bishops, have restated their traditional opposition to the campaign. That is to be expected and they have a right to put it on record in terms of their brief in this world. Our brief is to deal with public health and not spirituality.

The freer availability of condoms is only one part of the comprehensive approach which is appropriate and desirable in the fight against the spread of HIV and AIDS. The other major aspect, which the Minister has taken on board, is the educational response. The television advertising campaign is a major part of that. The educational response in terms of targeted messages being sent to high risk sectors is important. We need to get this right and ongoing evaluation and consultation with specialists such as AIDSWISE and Dr. Kevin McKeon of the Merchant's Quay Project, and the GPs who run the STD clinics throughout the country is needed. It is essential to develop a truly informed educational response based on feedback from the front line.

We have a very high level of infection associated with HIV drug users in Dublin in particular. A recent report stated that over half of the Dublin hard drug population is HIV positive. That estimate was much higher than the Department of Health estimate but it was endorsed by the Irish College of Practitioners. The high incidence of the virus among IV users accounts for the abnormally high incidence in hetrosexual men and women who become infected with the virus. The departmental emphasis has been influenced by this fact and there may be a fear that the national policy is being determined by a Dublin perspective which may not be necessarily true for the rest of the country. Ongoing evaluation of the campaign is in order.

The STD clinic in Cork, which covers Cork and Kerry, report a much greater incidence of infection of homosexual men rather than drug users. Likewise, smaller urban centres in Limerick, Galway and Waterford where there is not a very large hard drug abuse culture as there is in Dublin, reports similar figures. The tendency so far in this excellent campaign has been to try to influence the whole community and not to target specific categories of particularly high risk people. This may have to change as we learn more and evaluate current campaigns.

The task force set up by the Department of Health has mainly been influenced by the Dublin experience. Walkin clinics and needle exchange, while appropriate for Dublin needs, may not be so appropriate outside Dublin. Targeting of schools and sexually active adolescents is the way forward to kill the myth particularly among the very young people that this disease affects "30 somethings" and has no relevance for them. That message must be got across, especially to sexually active adolescents. There needs to be an audit of the quality of the educational response nationwide. It should not be allowed to be an ad hoc response dependent on individual teachers and schools. For example, a health board may write to a school inquiring whether they have a type of HIV/AIDS module included in their curriculum.

It is necessary that there be some standardisation, that the real issues be focussed on and confronted in the case of young people, such as how to use a condom; when to put it on. It must deal also with negotiation skills on the part of couples. This is particularly important for young girls who may very well need to adopt an assertive role in sexual relations. It must be pointed out that girls are in a double jeopardy in all of this, being subjected to the original risk of becoming pregnant and also to the secondary risk of being susceptible to HIV and AIDS infection.

The positive increase in the number of births mentioned earlier, among girls outside marriage between the ages of 15 and 24 is quite astonishing. Indeed, we, as a society and in this House, have been remiss in addressing that pheonomenon, by allowing it merely to happen and throwing welfare at it. That is not appropriate in the case of a phenomenon which is reshaping our society in such a major way, placing a huge burden on our welfare services, housing and so on. There is not yet in place a specific targeted response to that issue which I shall return to it at another time.

Child pregnancy must be brought to the top of the political agenda. I predict that, if we do not address it, we shall be banking up a huge sociological problem in the future which will only fester and worsen. The statistics in this respect are frightening in that one in every five births is to single women, mostly those aged between 15 and 24. We should remember that many of these girls are condemning themselves unwittingly to a life of poverty their children to inevitable disadvantage, particularly if they come from urban areas already heavily disadvantaged. There is a limited benefit to be had from treating the problem by throwing welfare at it. The wisdom of girls giving birth on their own — in some cases exchanging their dolls for babies, enjoying the whole notion of having buggies provided by the State — must be challenged by public policy sooner rather than later. I was glad to note that the Minister is interested in this issue and I hope we shall return to it at a later date.

It is worth mentioning the startling phenomenon which has emanated from the Merchant's Quay project report, that many of the partners of HIV drug users are willing to have children. There is a desire there to procreate, another tragedy emanating from an existing one which also needs to be tackled.

On the quality of condoms, as with all consumer products, a condom must be suitable for the purpose for which it was bought. It must be of BSI standard, which is internationally recognised as appropriate, and the highest and, indeed, the only standard we, as public policy makers, should promote. I was interested to hear the Minister refer to the European standard which should be adhered to also. We should be aspiring to the highest possible standard.

Since the purpose and impetus of this Bill is the prevention of the spread of HIV and AIDS — of which we must keep reminding ourselves — the preventive product must be particularly robust and stand up to wearers' demands. In other words, the condoms promoted in this campaign must be of good quality. They serve a dual purpose, first to prevent pregnancy and, second, to prevent the virus from entering the body fluids of the sexual participants.

The main brands of condoms are lubricated. The lubrication is a spermicide which, in the event of failure of the condom, can kill the virus and also deactivate the sperm. This vital ingredient is called Nonoxynol 9. I believe that the Durex company has introduced a hypoallergic lubricated condom called Sensitol to respond to those who are allergic to Nonoxynol 9. However, the lubricant in Sensitol is an effective spermicide for contraceptive purposes but does not appear to kill the HIV virus. That issue must be discussed since the distinction to be drawn in the efficiencies of the spermicides used in lubricants are very important, not to mention the added risk of wearing a non-lubricated condom in the case of homosexual men if it is the case that Nonoxynol 9 is a vital ingredient.

The Minister has said, and I agree with him, that previously the response of the State to HIV and AIDS has been coy. I have no wish to go into the intimacies of homosexual acts here for fear, God forbid, we might tempt opposition to this Bill, but I do not think we can be coy. Nonetheless, I hope I will not offend anybody by the hardy spirit of my approach. Indeed, a hardy spirit is a vital ingredient in politics, especially in regard to the issue of contraceptives.

As the Minister has acknowledged, many of the condoms at present available are not up to standard. This deficiency must be tackled if we are to be comprehensive in our approach to this campaign. For example, I have heard that some of the condoms available from some illegal vending machines at present are substandard. That is not good enough. Vending machines must be available in places frequented by women; their traditional placement being in gents' toilets. They should be available in women's toilets also since women have a double incentive in gaining access to the best possible product, and must be vigilant in their choice of protection. I agree that there should be a regulatory process to inspect the quality of condoms available on the market and their availability through clinics. Will the Minister advise us as to the quality monitoring envisaged under the Bill; everybody is extremely interested in that matter.

I note that there have been some noises from traditionalists that condoms are not effective in the fight againt the spread of HIV and AIDS. If I can keep the language simple and non-medical, their claim is that the micron of the virus is smaller than the micron of the condom. That is true but the virus exists only in a molecule of water, not on its own, so that the molecule of water embracing the virus is actually bigger than the micron in the condom. That would appear to put an end to that piece of scare-mongering. Nonetheless, I should like the Minister's assurance on that micron issue. Indeed, the advancement of that argument — to knock the wisdom of the use of condoms as an efficient method against the spread of HIV and AIDS — is very feeble, but must be answered. Dr. Jim Walsh said that hypocrisy would lead to a greater spread of HIV and AIDS than any faulty condom. Therefore, we must confront these issues head-on, answering the scientific and technological argument advanced against their good usage. We must remember that condoms were the original and best prophylactic and, as far as I can ascertain, are the best we can promote in this campaign.

A further argument advanced by the traditionalist is that greater availability of condoms contributes to and actually promotes promiscuity. That is a hoary old chestnut, like the notion that umbrellas bring rain. We are all fairly new to this research material on AIDS but the international community has undertaken a wide body of research into people's behavioural responses, particularly for campaigns such as this. For example, a recent report to an international AIDS conference, based on a very scientifically researched three-year programme in Switzerland, had some interesting findings on this matter of relating availability of condoms to sexual behavioural changes and safe sex practices. The findings of that report showed that the liberal availability of condoms, which is part of this campaign, does not encourage young people to be more sexually active than they would be normally, it does not induce more sexual partners. Rather the findings showed that it encouraged those already sexually active to use condoms and safer sex practices. After the campaign, among adolescents, there was an increase of 17 per cent in the number of girls who adopted safer sex practices and 13 per cent among boys. It will clearly be seen that international experience disproves that argument, even if it needed disproving, which I do not think is the case.

Most young people here are sexually active from as early as age 13. While that may be unwise, undesirable and horrific to us as parents to accept, nonetheless it happens. Our public health responsibility places a duty on us to respond to real life, rather than to the sort of Brigadoon or aspirational 30s' dream of de Valera's Ireland. We must respond to circumstances prevailing in today's Ireland. The Bill removes the age limit which is a welcome step.

Sex and condoms should go together like a horse and carriage — I was going to say like love and marriage but I will avoid the moral debate about marriage. The issue of morality is only relevant in the period prior to sexual activity and does not apply in respect of the act itself. Whether one should use a condom or another contraceptive is a public health issue and I have no problem with the issue of morality which centres around the relationship and a person's individual freedom to enter into relationships.

It is honest and worthy to note the vast contribution which has been made in combating the spread of HIV and AIDS by non-governmental agencies in the field. Groups such as AIDSWISE, AIDS Alliance, the Merchant's Quay Project, Condomsense, individual GPs and many other voluntary agencies throughout the country have set the agenda which has been taken up admirably by the Minister and by his predecessor to a limited degree.

In particular, I commend AIDSWISE as I have a special interest in the educational response which is its territory. It is a small educational effort which I hope will be resourced as part of the promised educational response aspect of this campaign. With very meagre resources, both financial and human, and often driven by purity of commitment to health they have undertaken important work in the cause of public health and the related rights of gay men. Almost all of their work has been funded from DG V in Luxembourg. In all they have received £94,000 from Europe. Last year they received a total of £5,000 from the Department of Health but they have received nothing this year although they submitted an application last September for funding.

They are compiling a European AIDS directory and in the autumn they intend to provide grief bereavement training for health professionals working the field of HIV and AIDS and a peer educational training programme for young adolescents in Ballymun. Along with many other non-governmental agencies, they have to be congratulated for playing their part. I know that the Minister has risen to the challenge but those people have set the agenda.

In conclusion, I warmly welcome the Bill which has my full support. It is a pity that it is being rushed through in one day since I am sure in a healthy Committee Stage debate we could tease out some of the matters I have raised in my contribution on which others would like to dwell. This matter will not go away but there are people waiting in the long grass for us, as legislators. This is significant legislation and I congratulate the Minister on bringing it before the House.

Ms McManus:

In welcoming the Bill I would like to commence by saying what it will not do. It will not put an end to the spread of AIDS or the number of teenage pregnancies. It is not a licence for promiscuity, either heterosexual or homosexual. Neither is it an undue restriction on human sexuality, either heterosexual or homosexual. It is a Bill which provides for greater access to condoms which have been available for some time. Although legal, under certain restrictions, many outlets do not stock them because of the personal beliefs held by shop owners. Three years ago a survey carried out in my home town of Bray showed that about 50 per cent of chemists did not stock condoms.

We need to be specific in acknowledging the limits of this Bill. When it comes to AIDS and HIV false information or over reliance on obvious solutions are dangerous; they can endanger people's lives. We must be clear and unequivocal about the effect the Bill will have.

The availability of condoms is only one part of the prevention strategy which needs to be put in place to combat the spread of AIDS. As Dr. Joe Barry said recently at the IMO conference: "Once the condom machines are in place the debate should move swiftly to education because that, not condoms, is the real issue"

Condoms however, are the matter of today's business and education forms part of this in relation to advising people about condoms. People do not automatically know how to use a condom; this is not knowledge they can absorb in their mother's milk. When people are ignorant, condoms fail; condom failure is mainly due to incorrect use rather than to a flaw in the material it is made from. This matter is not referred to in the Bill. There is no reference to the need to educate people in the use of condoms. I suggest to the Minister that he accept the amendment which will be put forward by Democratic Left in this regard.

Providing unrestricted access to condoms is the least that can be done. We need to be more aware of the myriad conditions which define their use. This is particularly important in the context of education in the use of condoms as a possible barrier to HIV and AIDS. It should be openly acknowledged that the condom will change sexual practice not just because of its presence as a barrier but because it introduces the idea of negotiation to sexual relationships. Things cannot go on as they are — it needs to be stated openly and honestly that condom use will change the context of sexual relationships. It is not a question of adding condom use to the store of existing practices.

If this is to be effective, access to the market cannot be limited. The expectation that by leaving it to individual shop keepers, pub owners and disco owners somehow everybody will be catered for is false; that is not the way of the world and access does not guarantee that those whose behaviour puts them at risk will start to use condoms because one will be able to buy them over the counter more easily.

If there is to be a serious attempt to encourage the use of condoms it will be necessary to make them available free to medical card holders. In Britain pilot projects are already in place where doctors provide condoms free to anyone who wants them. So far no assessment has been made of the efficacy of the projects but it would be a good model to examine closely. At this stage it would be foolish to ignore the usefulness of such an approach. Again, I will be tabling an amendment which I hope the Minister will consider seriously. Targeting risky behaviour should be much easier if this facility is provided in the medical and social services and through them to the risk groups.

There is an interesting shift in the Bill which is worth noting. The condom, or the contraceptive sheath as it is described, is being taken off the list of contraceptives. Its use as something other than a contraceptive is being recognised. This gets rid of the knotty moral question which has dogged the debate about contraception for so long. However, this shift should be reflected in the way manufacturing companies market their products. Condoms are generally marketed as contraceptives whereas they should also be marketed as health promoters.

The Minister will have the power to set standards in relation to condoms. This is an important element of the Bill. I was glad to hear that European standards will apply in the case of male condoms but I would ask the Minister to specify the standards which will apply in respect of the female condom. The evidence shows that condoms with the certified British standard mark can be declared safe for contraceptive purposes; the co-called "fun" condoms do not provide the same protection but standards may well have to be reassessed once HIV protection is taken into account. For example, if condoms are viewed solely as contraceptives gay men will see them as having no application to their behaviour.

Once condoms are viewed as health promoters the need to use different criteria will arise. Condoms for use in anal intercourse need to be stronger and of a higher quality. At the moment there is no way of knowing if condoms are of sufficiently high quality to match the use to which gay men put them. Setting standards in manufacturing should also include the setting of goals in relation to advertising the product and promoting its health aspects.

With regard to advertising I must express certain reservations about the current television advertising campaign. I have no argument against the idea of a television campaign but it may not be possible to justify the amount of money spent on it. In Britain the frightening advertisments used did not have any effect and it is obvious that that is not the way to proceed. I felt that the designer approach adopted in those advertisements, which were rather bland and middle aged, did not have an impact.

There may be better ways of using this costly process to get the message across to people. If television does not get the message across there may be other ways of doing this.

One criticism which has been made of the advertisement is that it does not sufficiently target the relevant groups. In this context there is a much wider problem which needs to be mentioned and which was not given the importance it should have been given. It is clear that targeting is a crucial factor in the fight against AIDS. We need to target young people, drug abusers, gay men and men who have sex with gay men but who, for understandable reasons, for example, discrimination or legal reasons, may not regard themselves as gay. It is important that HIV/AIDS is not inherently associated with the margnalised — the gay plague or a junkie's disease. The targeting of the advertisement should not marginalise people; rather it should reach people whose behaviour may be putting them at risk. This is a distinction which needs to be made. The professionals working in the field are very sensitive to this difference.

I note that the Department of Health does not provide a gender breakdown of people with HIV-AIDS. It should be useful to have figures on the number of women affected by this disease as opposed to the number of men, as specific services may need to be geared towards women. Targeting applies equally to prostitutes of both sexes. It is something of a myth that the greatest threat of AIDS to heterosexual men is posed by prostitutes. It seems that the opposite may actually be true. Women who regard sex as a commodity are more likely to insist that their partners take precautions. However, it should be pointed out that there may be pressure by clients not to use condoms even though it may put them at tremendous risk.

Consideration should be given to the provision of condoms in our prisons. While no research has been carried out on the level of sexual activity in our prisons, research in other countries shows a significant level of such activity in prisons. The availability of condoms in prisons might offend some people but given the high rate of HIV among some prisoners, the provision of condoms might save lives and protect those at risk. I was very impressed when I visited the Outreach satellite unit in Amiens Street. The principle behind those units is very sound. This kind of approach meets the needs of people who may have difficulty in coming forward to the traditional medical or social services. I was very impressed by the level of care and attention being given by this unit to these people.

This raises two questions about the future of satellite units. First, the areas of high deprivation and poverty in Dublin city where these units are primarily located are also the areas in which considerable illegal drug dealing is carried out. If a similar level of illegal drug dealing — in some areas this drug dealing is quite open — was carried out in places such as Foxrock and Castleknock, I have no doubt that there would be a far swifter response by the Garda and the State. It seems that there is an acceptable level of drug peddling when it comes to our poorer, more marginalised communities. This ambivalence needs to be challenged. We need to be ruthless when it comes to the perpetrators of drug use while at the same time being compassionate to its victims. Second, the satellite units need to be expanded. The AIDS-HIV infection is not solely a Dublin problem. The problem in Cork city requires urgent attention. The profile of AIDS-HIV infection is different in Cork city but it is still of worrying proportions. The disease is largely sexually transmitted in Cork city. The Outreach programme is capable of taking on that factor and dealing with it.

The overall profile in Ireland shows a significantly high number of drug users who are either HIV positive or have AIDS. In December 1992, 243 out of the 308 cases of AIDS were from the categories of drug users and gay men. We should not over-dramatise the extent of the problem. Of the 12 EC counties we have the second lowest rate of AIDS, next only to Greece, and the rate of the increase is less than previously estimated. The failure of the actual rate to match the projected rate is a phenomenon that has appeared in many countries. We need to be absolutely accurate in terms of any information given out about AIDS. If the problem is over-dramatised people will not believe the information being given out and if it is under-estimated it will not be treated as seriously as it should be. The reality is that HIV and AIDS are on the increase.

The Government strategy, as described in the most recent Eastern Health Board report, is based on prevention, care and management, AIDS-HIV surveillance and anti-discrimination. Another heading which should be included in that list is education. At present within the formal education system schools can opt in or opt out of any AIDS and sex education programmes. This is not good enough any longer; such an approach does not meet modern needs. The Green Paper on Education refers to the preparation of a plan by each school. Sex education and AIDS education could be easily slotted in as a matter of course in that plan. The Department of Education has never faced up to this aspect of education. It has run away from this aspect and left it to schools, boards of management and principal teachers. The Department has never given leadership in this area. It is time this matter was challenged and the Department finally faced up to its responsibilities in this area.

The Outreach programme is vital in getting to groups whose behaviour may put them at risk — gay groups, drug users, prostitutes, etc. During the period 1991-92 HIV growth showed an increase of 67 in the number of intravenous drug users; an increase of seven in the number of children at risk; an increase of 44 in the number of homosexuals and an increase of 37 in the number of heterosexuals, risk unspecified. There was a noticeable growth of HIV in the heterosexual community during the year. It would be useful to know more about that community, the characteristics of these heterosexuals, if we are to target them within the general population. It is probably harder to target that group than any other group. We need to have more basic information about their characteristics.

When it comes to targeting, it is clearly the matter of judgment and knowledge upon which to base that judgment. Too wide a focus and the purpose is lost; too narrow a focus and vital omissions are made. In order to get the focus right we require research, resources and resourcefulness. It has taken ten years for a Bill which will make condoms widely accessible to be brought before the Dáil, ten years during which we have know about AIDS and its implications. We have been slow to fully realise the dangers of AIDS. It is important that we do not over-estimate the problem or underestimate the strategy required to combat it. I agree with the approach being adopted not to make this a notifiable disease. Driving the issue of HIV - AIDS underground has its own dangers and obviously we need to prevent this happening. Research carried out in England shows that less than 50 per cent of HIV infected patients inform their GPs that they have the disease. The figure in Ireland is higher. In the context of the relationship between the doctor and patient, it is important that we are able to extract information in a way which is acceptable to the patient and feasible for the doctor. At present many notifiable diseases are not notified. Thrush is a notifiable disease but I do not imagine many doctors go to the trouble of advising the health boards about the number of cases of thrush they deal with.

Truth is paramount if people are to take the killer disease seriously. We do not need any inflated claims as to the efficiency of this Bill or the role of condoms in the fight against this disease. Neither do we need any diminution in the long haul that lies ahead with regard to AIDS, nor scaremongering about the extent of AIDS, which is still a relatively rare disease, particularly among homosexuals.

I welcome the Bill. My party, Democratic Left, supports it and we are glad to have the opportunity to discuss it. We have reservations about access to condoms and the crude approach that presumes that because condoms are for sale everybody has access to them. One needs to take into account that many people simply have not the resources or the knowledge to acquire condoms for themselves. A much more subtle approach would be to avail of the health boards and the services general practitioners provide for medical card holders to draw people into thinking about prevention and to ensuring that the entire population, who are at risk, are covered. That will cost money and I am not arguing that point. It should not be a question of having money in your pocket that determines whether you are at lesser risk of getting AIDS.

I will be suggesting amendments to improve the Bill. At the end of the day I am conscious that, while the Bill removes limitations, it will have only a limited role to play in the much larger battle against AIDS and HIV infection.

Debate adjourned.