Does "safe sex" really exist?

Condoms don't protect against all STDs. Social conservatives, goaded by George W. Bush, are taking advantage of that little-known fact. First of two parts.

Published July 21, 2000 7:00PM (EDT)

Nothing is ever as simple as it seems. Like the idea that a lubricated latex barrier is all it takes to keep a lover's germs private.

No, Virginia, condoms and safe sex are not exactly synonymous. Not necessarily. Not entirely. Not scientifically.

It turns out there may be some things we don't know about condoms, although public health officials are convinced that the devices are the strongest defense we have against the spread of sexually transmitted diseases. The problem is, before the AIDS epidemic, no one ever bothered to do the difficult research needed to confirm that.

And into this gap of knowledge, the opponents of extramarital sex have leapt, with a vengeance.

With GOP hopeful George W. Bush goading them on, social conservatives have found a new way to discourage sex: by promoting the half-true claim that condoms do not really protect against sexually transmitted diseases.

Led by Rep. Tom Coburn of Oklahoma and an Austin, Texas-based medical institute, conservatives convinced the NIH to hold a conference last month revisiting the issue of condom safety, and passed a bill in the House in May that would require condoms to carry a message saying they don't protect against all sexually transmitted diseases.

Meanwhile, as faith-based groups distribute videos and pamphlets to teens depicting the horrors of diseases spread by STDs, the federal government is spending $50 million a year to promote abstinence-only sex education messages. A chunk of that money is going to Texas, which has one of the highest teen pregnancy and STD rates in the country.

Many public health experts and scientists believe the effort to convince people, especially teenagers, that condoms will not protect them against disease is risky and ultimately wrongheaded. They say abstinence education should be mixed with information on how people can use condoms to protect themselves against germs.

But the conservatives' condom campaign is not entirely groundless. The proponents of abstention are absolutely correct in saying the only sex that is certain not to spread venereal disease is no sex at all.

Coburn, a family practitioner before he entered Congress in 1994, laid out his campaign for a fornication-free future in a September 1998 speech on the House floor.

"What we have today in our country is an epidemic of sexually transmitted diseases that is covered up, that is not talked about, that nobody wants to know about," he said. "This knowledge is valuable. It is powerful for us as parents, as a nation, to see the consequences of the sexual revolution of the 1970s."

Coburn went on to argue that most people who say they use condoms end up pregnant or sexually diseased at high rates -- another undisputed fact -- and thus the answer is "a new sexual revolution," abstinence.

The fact is that teenage pregnancy, AIDS and some other STDs have declined nationwide over the past four years, although they are still at extremely high levels. (For example, 21 percent of all Americans 12 and older have herpes.)

While it is widely believed by scientists everywhere that condoms are a strong, though imperfect, barrier to most STDs, measurements of effectiveness against microbes other than HIV just haven't been widely done. Although Coburn and conservative groups like the Family Research Council acknowledge that properly used condoms protect against HIV, they have harped on the fact that research on other STDs is spotty.

"It's very hard to track a microbe from person to person," says Maurizio Macaluso, an STD epidemiologist at the University of Alabama School of Public Health, in Birmingham. "To do really good research you need to start with a cohort of virgins and carefully trace each contact they have."

It is also clear, however, that most people who use condoms some of the time -- that's about half the sexually active U.S. population -- aren't entirely successful at avoiding sexually transmitted germs. There are many reasons for this, including the fact that condoms break or slip off in sex about 3 percent of the time. In a much larger percentage of cases, however, condoms fail because people who describe themselves as "condom users" either put them on after an initial period of penetration, or fail to put them on every time.

Anthony Smith, an Australian researcher who examines the minutiae of condom usage, publishing papers with names such as "Does penis size influence condom slippage and breakage?" (yes on breakage, no on slippage) found in a 1998 study that 38 percent of couples were "condom cheats." The men didn't put on their rubbers until after they had already enjoyed a period of naked vaginal or anal penetration.

Empirical evidence at family planning centers supports this.

"I never hear stories like, 'I put it on but still got the clap,'" says Stacey Little-Pyfrom, director of education at Planned Parenthood of Metropolitan Washington, which has among the highest rates of STDs in the country. "It's more like, 'We were grinding, then I stuck the condom on.' They don't realize there are sperm and germs in the pre-cum."

Most of the women she counsels, Little-Pyfrom says, stop using condoms altogether after they've slept with a man a few times and feel he's trustworthy and "clean."

The men, for their part, do things like "dip and sniff" to evaluate whether to deploy a condom. "What exact aroma they're looking for I'm not sure," she says, "since the most properly groomed and well-manicured woman can still be HIV-positive."

For abstinence-only proponents, however, the mechanism of condom failure -- whether it is human or latex error -- is beside the point.

They also emphasize that even perfect condom use won't prevent the spread of human papilloma virus, which can cause cervical cancer, and herpes-2, an incurable viral infection that causes episodes of irritation and pain. In the case of these two diseases, the virus can spread from contact with areas of skin that aren't physically covered by the condom. For example, papilloma virus can be shed from a man's testicles; and herpes sores can be found almost anywhere.

Dr. Joe S. McIlhaney, head of the Austin-based Medical Institute for Sexual Health, says he quit his OB-GYN practice and founded the nonprofit abstinence-promotion group after seeing scores of girls become infertile or sick as a result of venereal diseases that condoms didn't stop.

Although the institute works closely with faith-based groups like Focus on the Family and the Family Research Council, its doctors scrupulously avoid mention of religious or moral messages. They emphasize science and medicine to hammer home their message that only abstinence can prevent STDs.

"You're struck by the lack of data in support of condoms," says Dr. Curtis Stine, executive vice president of the institute. "There's a lot we don't know, and the public is misinformed on this point. We want to make sure that alternative messages get out there."

"Teenagers would come to me saying, 'I used a condom but I still have this thing" says Stine, who was formerly a family practitioner in Colorado. "Society bombards these kids with sexual messages and they don't get any reinforcement for abstinence."

But thanks to Coburn, a federal government headed by President Bill "I-did-not-have-sex-with-that-woman" Clinton is now paying, indirectly, to organize abstinence education in Texas.

The money comes out of a $250 million, five-year grant that Coburn tacked onto the 1996 Welfare Reform Bill. Texas spends about $10 million a year -- half from the federal program -- on an abstinence-only education program set up by Bush. The Medical Institute for Sexual Health is one of 30 contractors that help get the message out.

In fact, abstinence only is becoming the dominant sex message in Texas. Public schools have no mandated sex education and the state education department's attitude toward condom distribution is "no way, no way in hell, ever," says Jean Gibson, spokeswoman for the state Health Department's HIV/STD prevention bureau. Shortly after Bush took office in 1995 the Legislature rewrote state laws to require state sex education classes to "present abstinence as the preferred behavior" and to teach that condom use wasn't necessarily effective.

Bush appeared at least twice at abstinence rallies with McIlhaney in the past two years, and publicly frowns on condom use. In March, when a new Texas law exempting over-the-counter medication from taxes turned out to make condoms tax-free too, he said through a spokesman at the time that he "never wanted condoms to be exempt."

"The governor supports abstinence education and believes it is an important part of encouraging young people to be responsible," Bush spokesman Ray Sullivan said Thursday when asked to characterize Bush's position on sex education. "He calls for increasing abstinence funding at the national level to at least the level of contraception funding." When asked what abstinence education has done for Texas teens, Sullivan said teen births in Texas were lower than the national average. But that doesn't seem to be true, in fact quite the opposite.

So far, at least, it looks as though abstinence education hasn't kept Texas teenagers from doing what comes naturally stupidly. On the contrary, Texas has the fourth highest AIDS rates and ranks second, behind Mississippi, in births among teens ages 15 to 17, according to a new study by the Annie E. Casey Foundation that draws on federal statistics. Chlamydia and gonorrhea rates are among the highest in the nation, according to Texas Department of Health statistics, and have increased since Bush became governor in 1995.

In fact, says Peggy Romberg, director of the Texas Family Planning Association, "I don't think there's any data that shows the abstinence education programs are working at all. There are concerns that no one's evaluating them to see if they do work, which is the normal thing for any federal or state program."

Despite this, abstinence advocates are hoping to have a wider impact -- an impact that almost certainly would grow with Bush's election.

Responding to the conservative critique of condoms, the NIH hosted a conference last month to examine scientific research on condom effectiveness, and it invited McIlhaney's institute to participate. While the findings haven't been released yet, several people who attended the meeting said the final report will conclude that condoms are very effective against AIDS, probably very effective against gonorrhea and chlamydia, and less protective against herpes and human papilloma virus.

To most of the established scientists and doctors working on STDs who were at the meeting, the abstinence-only message has a latent potential for danger.

"They have an uninformed position," says Dr. Robert D. Burk, a cervical cancer expert and professor of medicine at Albert Einstein College in New York. Burk says there is "unequivocal scientific evidence" that condoms reduce the risk of cervical cancer, in addition to their protection against other organisms.

"I think there are some major conceptual problems about what people use condoms for," he says. "Some use them for birth control, some to prevent STDs, some for both. People in long-term relationships think they are no longer at risk and stop using them, and that's probably when the majority of STDs are transmitted."

As for the conservatives' call for more condom research, Burk says it would be a waste of time and money. "It's a political agenda. They should be using those resources to develop vaccines or other preventive methods."

Macaluso, however, says that while public health officials should continue to stress condom use, "scientists have to face the fact that there is weaker evidence that condoms prevent the spread of things like chlamydia and gonorrhea." But he adds: "The consensus of the meeting was that it's not evidence of a lack of efficacy -- it's just a lack of evidence."

But to Dr. Allan Brandt, a medical historian at Harvard Medical School who has written about the staggering rates of syphilis and gonorrhea that unprotected American soldiers got in France after World War I, there's something deeper to the condom discussion than questions of scientific evidence.

"The debate you're watching now is deeply historical," says Brandt. "There's always been this anxiety that if you put technology into the hands of people to promote sexual health you will also encourage what's perceived to be illicit sexuality. There's always been a perceived tradeoff between public health goals and the deep anxiety about sex in American culture. It comes out especially strong during times of war or epidemics."

"Implicit in the debate," he adds, "is the idea that it might be better for people to get STDs because that acts as a brake on sex."

In other words, says Brandt, the condom debate may be just a big, magnum-sized Trojan horse.

Monday: What's wrong with requiring condom wrappers to carry a warning about a cancer-causing virus?

By Arthur Allen

Arthur Allen writes on health, science and other issues for Salon and Kaiser Health News. He lives in Washington.

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