Blood, safety, and arbitrary guidelines.

Today, I tried to give blood. It’s a thing that I- like many people- had always thought that I should do. Recently, I had to get tested for haemochromatosis. I made my mind up that since if I had it I’d have to get blood taken regularly, if I tested negative I’d get my bum down to the blood transfusion clinic, stat, and just bloody well donate.

Turns out that, after feeding myself a rather impressively large lunch and downing almost three pints of water* before my appointment, I’m ineligible to donate. I’ve lived in a malaria zone, you see. While being in a malaria zone for less than six months only means a 12-month ban on donation, doing so for more than that time leads to a lifetime ban. This was a bit disappointing, but hey. But then I got thinking. And what I am thinking about is this, as well as another factor which renders people ineligible to donate, and how this impacts on safety.

The reason, as far as I can tell, why I cannot donate is because malaria can, very rarely, have an incredibly long incubation time. Given that it’s a bloodborne disease, it’s good to be careful.

This is not a thing I have a problem with. Taking care to make sure that people don’t get malaria is a Good Thing! Malaria is a godawful illness, I know several people who’ve died of it. I am very, very much in favour of making sure that the blood that people donate is safe. However, I’m not sure that this ban does that.

Here’s the thing. If there is a chance that everyone who goes to or lives in a malarial zone could, entirely asymptomatically, be carrying around malaria in their systems, then why do we allow people who have been in malarial zones to donate at all? Why is this tied to time spent in a malarial zone and not, say, whether or not the person in question was rigorously taking antimalarials? Anecdata time: I know of people who’ve come down with malaria within a week of landing in a malarial zone. In my (anecdotal!) experience, people tend to get bitten more when they first arrive, and within very short order get very, very sick of mosquito bites and start getting sensible about not getting bitten. Wearing shorts at sunset and not tucking in your mosquito nets properly gets very old, very fast, when the alternative is those whiny feckers making you itch. While I’m happy to see any stats people could provide on this one, I find it hard to accept that there is a vastly increased risk of exposure to malaria when you’ve been in a malaria zone more than a very short time indeed. And yet we allow people who went to a malaria zone for 5 1/2 months and spent their entire time lounging about in shorts at sunset next to stagnant water forgetting to take their antimalarials to donate after a year! But those who were there for a few weeks longer, who took their antimalarials, wore their long sleeves at sunset, stayed away from stagnant water, used their mosquito repellant and tucked in their mosquito nets at bedtime? Lifetime ban.

And yes, there’s a huge parallel here. I’ve advocated for years against the gay blood ban, where any man who’s had sexual contact with another man, ever, even protected, is banned forever from donating blood. Whereas as a cis woman, I could cheerfully have unprotected sex with as many men as I pleased, wait a year, and donate.

My question is this: How do these rules protect people? If I am a significant malaria risk despite having gone 15 years since leaving a malarial zone and never having had malaria, how is a person who was in the same place as me for five months, a year ago, not a risk? If John sleeps with Bob on Tuesday, and me on Wednesday, then how is it safe to allow me to give blood after a year, when Bob is barred for life? These things simply don’t make sense.

*I had hoped that one of those would be exiting through my arm. No such luck.

Blood, safety, and arbitrary guidelines.
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13 thoughts on “Blood, safety, and arbitrary guidelines.

  1. Mel

    The gay blood ban is a Red Cross thing, their guidelines are what dictate most of the local health guidelines considering blood donations.

    My local aids task force don’t want to rock the boat on this, they represent gays, people of African heritage (who are also banned, because of… well, being African) and I heard a panel explaining the guidelines and why they’re in place.

    They were very convincing, but the arbitrariness is something to be contested.

    1. 1.1

      Hi, this is Gloria from the Red Cross. The gay blood ban has been a very controversial topic and there are many sources at play, but I wanted to clarify that the decision on the ban parameters and guidelines is the FDA’s decision – not the Red Cross. The Red Cross and its partners have recommended to the FDA that the ban be revisited:


  2. 2

    Some of these stats can be collected. Just look at all the cases of malaria, and see how long people were in the malarial zone. You’ll also have to look at the number of people in the malarial zone. Then you can see if you’re “lots of bites at the start” has any truth.

    I also think you can’t give blood ever if your partner is a man who’s had sex with a man.

    > Whereas as a cis woman, I could cheerfully have unprotected sex with as many men as I pleased, wait a year, and donate.

    Is this the case? Does the IBTS service have any 12 month ban on having lots of sexual partners? Could it be that you can sleep with 20 men, then give blood *the next day*?

    1. 2.1

      I really would love to see any stats available. If the stats hold up the guidelines, then that’s fantastic!

      Regarding women whose partners are men who’ve had sex with men, though, there’s a 1-year ban. So any (cis, I assume? Happy to be corrected) woman who has, in the past year, had sex with a man who’s ever had sex with a man cannot give blood. After a year, though, you can again.

      So, you know, if I had been in a monogamous relationship for the past decade with Inigo Montoya, who had previously had sex with men, then I couldn’t give blood. If I broke up with Inigo and spent a year sleeping around, then as long as I was having protected sex with women and straight men? I could donate, no problem.

      …yes, I am being a bit flippant here.

  3. 3

    I’m definitely with you on this one. Although the requirements for giving blood to the American Red Cross are different (you only get a 3-year ban for residing in a “malaria risk” country), there are plenty of rules that are just as moot:

    I looked forward to turning 17 because–as a healthy, compassionate person–blood was one very important thing that I could give and give, without actually losing anything. It seemed like the *least* I could do, and I was determined to donate blood on a regular basis, every 56-or-so days.

    In college, I met many people who were either ineligible to donate blood according to the American Red Cross’ guidelines (had sex with another man since 1977; had a tattoo or piercing in the last six months, although that rule has changed; traveled abroad recently), or who boycotted my college’s donation drives (based mainly on the anti-gay-male blood ban, but also on the anti-prostitution blood ban), and I started to wonder if my donations were such a good idea. I concluded that they were: in spite of the Red Cross’ sometimes arbitrary and stupid rules, there are still people who NEED blood, and giving it to them was still the least I could do.

    And then I got a piercing or three. *Wait six months.* And then I got a tattoo. *Wait twelve months.* And then I started traveling to places like *gasp* Europe! ( And now, I *might* have a lifetime ban if ALL the time I’ve spent in Europe adds up to more than 5 years, but, you know, I don’t want to have to figure it out. Or to go to a donation center, fill out paperwork, wait, and then find out that I’m ineligible for that–or some other–reason. Some people I know–who are confident their blood is healthy–lie, and some tell me to do the same. But I don’t know if I want to get into that.

    I think what actually drove me away from donating, though, was how both the Georgia AND California Red Crosses started dogging me over the phone for donations after I lived in each state, in spite of my constantly asking them to take me off their call lists and my constantly insisting that I’d donate blood when I could. They were worse than telemarketers. I feel awful for anyone who might suffer due to any blood shortage, but, after everything, I just haven’t gotten back into the whole blood-giving thing. (On the other hand, I’m sure I’ve given more blood at this point than most people I know. Do kudos work like that?)

  4. 5

    They are desperate for blood at the moment, so bravo for trying even if it didn’t work out. My mum got two phone calls on Monday asking her to come in.

    The ban on gay blood donations isn’t because they think “the gays have AIDS”, it’s because anal sex is an extremely high-risk activity when it comes to blood-borne pathogens. The concern is that people engaging in anal sex will be more likely to pass on a new pathogen that hasn’t become common yet, as happened when AIDS was first encountered. That’s also why women who have had sex with men who have had sex with men are screened. It’s always a question of trying to prevent any risky blood from getting into the people being donated to. The people getting this blood are in extremely vulnerable conditions and their nervous systems probably can’t cope with any extra stress. Statistically, if a new syndrome or disease or whatever was encountered, especially one with a long incubation period like HIV, the gay community would be at extremely high risk. It’s what happened in the 80’s, and it sucks, but the suggestion that this is discrimination based on who you are attracted to doesn’t justify the risk to the eventual recipients of the blood.

    Rory, I’m pretty sure unprotected sex with partners who have engaged in high-risk behaviour is covered on the questionnaire, so if the woman had had unprotected sex with ten prudish virgins, she would be fine, but if one of the ten had ever engaged in anal sex with a man or used needles to inject drugs or had Hepatitis or any one of several questions asked on the questionnaire given to people wishing to donate, then she would not be allowed.

    Contact with people engaging in high-risk activity is the concern, and anal sex is a high-risk activity. Paying for or being paid for sex is also covered. Even if a gay man wanting to donate has only ever had one partner, you can’t be certain of the partner’s history – and yes, that is true for all couples, monogamy can’t be assumed, but this is about controlling risk for the sake of patients. So frankly, I’d have been pretty pissed off about your comment, too.

    They don’t hate anyone, they don’t want to turn anyone away, they want all the blood they can get and they are trying to get it by hook or by crook because it’s a bank holiday weekend and people are going to die because they can’t get enough blood. So if you can – if anyone reading this can – please go and give blood, because you really will be saving lives.

  5. 6

    So my understanding of this is based on epidemiology-for-statisticians, rather than epidemiology-for-actual-doctors, so if anyone can correct me please do so, but here goes.

    In assessing risk, you can look at either risk factors or risk markers. Risk factors are things which genuinely increase your risk of some outcome (Like malaria. Or HIV. Or anything else you fancy). Risk markers are associated with a risk factor, and thus indicate increased risk without *causing* increased risk.

    So, suppose you wanted to know what put people at risk of having a stroke, so you did a great big study and found that people with grey or white hair are far more likely to have a stroke than people with any other colour hair. If you were a bit daft you could conclude that hair colour genuinely influences the chances that you’ll have a stroke. Maybe advocate Hair Dye For Better Health. Or, more likely, you would note that having grey hair is quite strongly associated with increased age and age is associated with increased risk and that probably all the hair dye in the world won’t change that.

    Age is a risk factor. Hair colour is a risk marker.

    So, why would you ever want to look at risk markers? Don’t they just confuse the issue? Well, sometimes a risk factor is hard to assess directly. Having had lotsa mosquito bites is a risk factor for malaria, we can presumably agree. But “have you had lotsa mosquito bites?” is kind of subjective. One man’s “Meh, bit itchy” is another man’s “Oh the itchy burny bitey ENDLESS TORMENT OF AGONY”. So you can instead use “Having lived in a malarial area” as a risk marker for having had lots of mosquito bites, and that’s less subject to opinion and sloppy recall and all the rest, and everyone’s happy. (Except for itchy bitey torment man, but he is hypothetical anyway so he doesn’t get to complain.)

    They have to put the cutoff somewhere. Not having been privy to any of the decision-making by the IBTS I could not tell you how they did it, but I can tell you that sound and reasonable and non-arbitrary methods for choosing a cutoff do, at any rate, exist.

    The other snag with risk markers, though, is that they are more subject to change than risk factors. Which brings us neatly onto the ever-thorny gay blood issue. Having had a lot of sexual partners is a risk factor for STD’s. At one point in recent history, being a gay man was a risk marker for having had a lot of sexual partners, and thus a risk marker (MARKER!) for HIV, among others.

    Now. It’s my belief that that marker is no longer very current, in part because of the huge safety awareness campaigns that stemmed from the eighties, and at this point I know more women than men* who admit to having had unprotected sex with a man. As such, it would probably be wise for the IBTS to update their screening procedure to reflect that.

    (Eimear – the questionaire does not distinguish between oral and anal sex between men, which suggests strongly to me that they’re thinking more about promiscuity than mucosal tears and so on.)

    To be fair, I do not know how the IBTS makes these policy decisions, so I can’t flat-out defend OR flat-out condemn any of them. But I would urge anyone who doesnt donate on principle to reconsider – donate, and have a full and frank exchange of views with the nurse, instead – sure they’re stuck listening to you for as long as the donation takes; how often do you get a captive audience like that?

    *As a data analysis person I deplore anecdata, but as a person commenting on a blog I just can’t resist!

    1. 6.1

      I have wondered about that myself in the past. I know that passing HIV via unprotected oral sex is less likely, but it’s still possible. No more likely for males than females, of course, but I have wondered if it’s because they view a partner having oral sex with another man as more likely to have had anal sex with a third man in the past.

  6. 7

    Also, the lifetime bans if you have had sex for money or injected drugs. A window of time for injecting drugs makes sense, with no ban for paid sex that doesn’t apply to unpaid.

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