Lisa Magnusson Falsely Claims Blood Donation Rules Are “Pure Moralism”

Bad science journalism is a considerable threat to the integrity and process of the public understanding of science. Far too often, good science reporting is replaced by sensationalist and agenda-driven misunderstandings.

Lisa Magnusson is a Swedish journalist and columnist and have written many pieces for newspapers such as Metro and DT, the latter of which she is most active today with new material several times a week. Recently, she wrote an ignorant screed on the eligibility criteria and qualified donor system in use in Sweden blood donation system. Apparently, she wrongly thinks that these evidence-based systems are “pure moralism” and that the Sweden National Board of Health and Welfare and The Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights are not only wrong, but dangerously so.

She fails to understand that, according to experts from both government agencies and non-governmental activist organizations, the qualified donor system is the major reason why Sweden has substantially fewer donations of infected blood than many other countries. Furthermore, she fails to grasp that no medical test is 100% accurate and even though newer tests have a much smaller window period, combining tests with the qualified donor system is both evidence-based and pragmatic. Magnusson does not even know enough about transmission of infectious diseases to understand why sex is riskier than tattooing for hepatitis and thus justifies different waiting periods. She even conflate sexual orientation and sexual behavior, thereby ignoring that not all gay people have sex and a substantial minority of self-identified heterosexuals engage in same-sex sexual behavior. On top of this, both the headline and her personal Twitter messages are misleading.

Men who have sex with men =/= gay or bisexual men

Magnusson makes a common bait-and-switch by trying to falsely equate men who have sex with men (MSMs) with gays and bisexuals (my translation):

There are, however, people who would like to donate, but are simply not allowed to. In many cases this depends on the health risks for the donor or the receiver.

Other times though, the rules are completely incomprehensible. In particular, the group that is considered to be sexually at risk of disease, and that group includes all sorts of people: gay, bisexual, sex workers, people who sleep with someone who is tattooed.

No, men who have sex with men is not the same group as gay and bisexual men. If a person is a MSM, it means that he has had sex with another guy. It says nothing whatsoever about his sexual orientation. It has no bearing on who he is romantically or sexually attracted to. It is just a statement about sexual activity.

UNAIDS explains this in detail:

Sex between men occurs in diverse circumstances and among men whose experiences, lifestyles, behaviours and associated risks for HIV vary greatly. It encompasses a range of sexual and gender identities among people in various sociocultural contexts. It may involve men who identify as homosexual, gay, bisexual, transgendered or heterosexual.

There are also plenty of self-identified heterosexual men who have sex with other men in different ways. For instance, a study by Pathela et al. (2006) of over 4000 self-identified straight men in New York City reported that approximately 10% of them had same-sex sexual behavior (oral or anal sex) with another man in the past year. A recent book that delves deeper into this subject is “Not Gay: Sex between Straight White Men” (2015) by Jane Ward.

By falsely equating MSMs with gay and bisexual men, Magnusson confuses sexual orientation with sexual behavior. This may reinforces the belief that self-identified straight MSMs are not at the same risk of HIV as gays and bisexual men (the Pathela study above reported less condom use among the first group) and the excessive association between being gay or bisexual and being overly obsessed by sex.

HIV tests are not infallible and eligibility criteria are important

Magnusson reveals her ignorance of HIV tests (my translation):

It does not matter if they protected themselves with a condom. It also does not matter that the mandatory HIV tests can track the virus already one week after the infection. It is the sex act itself that determines, and the waiting time afterwards is a full year

It is true that there are HIV tests called combined antibody/antigen tests that can detect the virus after 6.5 days. However, this fails to take into account that no medical test is 100% accurate and that even a small percent fail rate can mean many cases of missed HIV infections since there are about half a million blood bags taken every year.

An expert report from the National Board of Health and Welfare makes this same point, and highlights the crucial need for eligibility criteria as a much bigger factor than HIV testing:

In this review, the risk that a potentially infectious donor is not discovered at testing is discussed. It is then important to point out that there is no and will never be any test that can to 100% guarantee that all infection is avoided. Therefore, the measures above [e. g. eligibility criteria, not paying donors, not taking blood at first visit etc. – Emil’s remark] are very important to reduce the risk. The risk of infection with HIV, HCV or HBV during blood transfusions and similar is much low in Sweden — in many cases even considerably lower — than in most other countries. It is not primarily due to the fact that we have access to better tests, but the blood donors that are tested have an extremely low risk for infectivity thanks to the conditions, recommendations and routines that have been described.

In other words, Magnusson does not appear to know that experts point to e. g. eligibility criteria as a major factor behind safe blood donations in Sweden. Had she just consulted The National Board of Health and Welfare or talked to experts on the subjects, she might have learned this, but she did not.

Skin versus sex: different risk profiles

Magnusson complains that the waiting period for someone who has just gotten a tattoo is different from the person who has had sex with a person who just got a tattoo (my translation):

In particular, the shaky logic is manifested when it comes to tattoos. People who have gotten tattooed is considered to be at risk for hepatitis and cannot give blood for six months. Their partner, on the other hand, has to wait a full year, since they have been at risk sexually. [italics in original – Emil’s remark]

No, they are not “considered” to be at risk. It is a scientific fact that they are at higher risk of hepatitis infection. Carney et al. (2013) found that hepatitis C infected patients were much more likely of having a history of tattoos with an odds ratio of 5.17, even after excluding individuals who have used intravenous drugs and have had blood transfusions before 1992. A systematic review of 31 studies by Jafari et al. (2012) found that odds ratio for hepatitis B infection and tattoos was 1.48. A comparable meta-analysis for hepatitis C by Jafari et al. (2010) found the odds ratio to be 2.74.

Apparently, Magnusson does not understand that there are different levels of risk. A tattoo is deposited in the dermis of the skin and not in the blood stream and a lot of tattoo parlors use sterile equipment. This means that the risk is lower compared to injection and sex and thus different waiting period is appropriate.

This is also independently supported by scientific research. For instance, Haley and Fischer (2001) found that intravenous drug use had an odds ratio of 23.0 and commercial tattoos had an odds ratio of 6.5 and the CDC reports that hepatitis B is most commonly spread through sex (2/3 of all cases).

Now, Magnusson could easily have found out the rationale behind those different waiting time periods. She could just have done a PubMed search, visited the CDC website or asked a public health expert in Sweden. Yet she did none of that.

Eligibility rules are pragmatic and empirical, not attempts at absolutist justification

Predictably, Magnusson attempts to bring up potential exceptions:

In other words, for instance, a man that is living in a long-term monogamous relationship with another man can never be a blood donor in Sweden, even though he cannot, in any way, be said to belong to a group exposed to sexual risk.

What Magnusson fails to understand is that eligibility criteria are pragmatic rules based on empirical evidence and no absolutist justification attempted. The idea is not that all MSMs are at increased risk of sexually transmitted infections individually regardless of e. g. condom use. That would be as absurd as dismissing the existence of the gender pay gap simply because a few women make more than a few men. Instead, it is an observed trend on the group level and the eligibility criteria is a pragmatic system that has been shown to work empirically to reduce risk of infectious through blood transfusion (see the above expert report). The alternative is to ask detailed questions about sexual behavior that would entail substantial invasion of privacy and there is no scientific evidence that such a system outperforms the current one in Sweden. Of course, even in her world, there would be similar exceptions, so it is not at all clear that her alternative is any less problematic.

Individual human ignorance is not an argument

Magnusson points out that some people who work in the health care system are ignorant and cannot themselves understand the rules properly as if that was an argument against the system itself (my translation):

In several of the health care system’s information pamphlets, “men who have had sex with men” have been imperceptibly rephrased to “homosexuals”, which means that some blood centrals even deny lesbian women from donating. This is very ironic considering the fact that the majority of the people infected with HIV are heterosexual.

Yes, these kinds of errors are extremely bad. Those individuals should be reprimanded and those information pamphlets should be changed right away. However, this is not an argument against the system, since (1) that system is supported by evidence and (2) there are always going to be ignorant people. There is no guarantee that even on he system that health care personnel will not misunderstand the rules or make these kinds of mistakes.

Magnusson also makes an elementary statistical mistake when she confuses raw data with data normalized for size of the subpopulation. As an example, imagine someone saying “well, it is ironic that doctors focus on people who high blood pressure when it comes to the risk of stroke, since most strokes happen to people who are right-handed. Here it is crucial to understand that it is not the raw data that is important, but the raw data normalized to subpopulation size i.e. the fact is that people with high blood pressure, relative to their subpopulation size, is at much higher risk of stroke than people who are right-handed relative to the size of right-handed subpopulation.

Even worse, the ignorant arguments made by Magnusson may distract from giving vulnerable populations the extra support and care they need (since they are, according to her false belief, at no larger risk). For instance, one of the biggest risk factors for HIV transmission is not knowing your HIV status and so we must not falter in offering HIV testing and counseling to those who need it the most.

There is substantial scientific evidence for qualified donor systems

In her final paragraph, she arrogantly declares that there is no medical basis for qualified donor systems and that the National Board of Health and Welfare are completely wrong:

Now, it is not a right to be able to give blood, and it is important that all blood donations occur safely. But as important is that the protective measures have a factual, medical basis.

This is not the case with the regulations made by the National Board of Health and Welfare. Actually, it most of all resembles moralism. And moralism is a bad bedfellow for the severely sick and stricken who will need blood during Christmas and new year.

So without any evidence whatsoever, either published scientific research papers or expert reports from any governmental medical agency, Magnusson declares that they are not based on scientific evidence (despite what the expert report from National Board of Health and Welfare says). Instead, it is a massive moralistic conspiracy by public health care experts and the public health system to impose wicked morality on people. Clearly, Magnusson has abdicated from reason, which is a shame because she has done very valuable journalistic work previously, such as criticizing failed terrorist hunt in Sweden, the absurdity of anti-immigration extremism and so on. She use to be a bright star on the journalist sky, but is now flickering and perhaps even slowly fading into darkness. This is very unfortunate.

What does The Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights think?

Let us look at another source besides the National Board of Health and Welfare and primary scientific papers, namely the 2015 position statement made by The Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL). They differ from the National Board of Health and Welfare in that they want a 4 month waiting time instead one 1 year (and there is an important arguments to be had there), but they too think that there should be specific rules for MSMs (my translation):

Why does RFSL think there should different rules for MSMs than others?

• Men who have sex with men are at a considerably higher risk than the general population to acquire or have HIV, syphilis and hepatitis B, which is very clearly revealed in the disease statistics that is put together by the Public Health Agency of Sweden every year.
• Research within the MSM-group shows that about half who have an established partner has also had other partners the past year. Condom is not always used during these sexual encounters and the respective partner does not always know that parallel sexual activity is ongoing.

For the first statement, they reference statistics from the Public Health Agency of Sweden, such as this and this and their claim checks out.

For the second statement, they reference “MSM-survey” by Tikkanen from 2010. A quick Google search reveals that the survey can be found here. The relevant pages here are pp. 72-73 and the RFSL statement also checks out here (report said “slightly less than half”).

They also comment on why safe sex is not enough:

Why does RFSL think that MSMs should not have had any sex at all for four months — why not safer sex?

Safer sex i.e. using condom during intercourse gives 80-85% protection against HIV. For syphilis, the same number is about 55-60%. Syphilis can also be transmitted through oral sex with or without a condom.

For this, they cite the aidsmap website and this source supports their statement above.

In other words, Magnusson does not appear to have talked to experts at RFSL either.

The issue of misleading headline

The headline of the story is this:

Pure moralism that homosexuals and other “risk groups” are not allowed to donate blood

This headline has two problems: (1) it conflate sexual orientation with sexual behavior because the rules apply to men who have sex with men regardless of what sexual orientation they have and (2) it puts the term risk group into scare quotes, wrongly suggesting that this kind of analysis is not based on evidence.

Now, journalists do not always set the title of their articles. I therefore fully accept that the blame for the incorrect headline is not Magnusson’s alone to bear. However, I am convinced she understands the problem with misleading headline, and so she could have stepped in and demanded that it would not be misleading, but she did not.

Even worse, she makes even more misleading descriptions on Twitter, such as “rule that homosexuals cannot donate blood is without any medical basis”, completely misunderstanding that they can but that they waiting period is currently 1 year.

The intellectual responsibility of journalists

In the end, Magnusson is contradicted by both public health experts and LGBT experts on key claims in her article. It cannot stand. Furthermore, she fails to uphold the intellectual responsibility that should be inherent in any journalistic endeavor, particularily when it comes to fact-checking.