Dr. Patricia Sulak, wearing a wireless microphone and a plain dark suit, strides across an auditorium stage in Copperas Cove, Texas, and describes in graphic detail the contagious, oozing and occasionally deadly viruses that are the consequences of adolescent sex. The hourlong lecture -- given that day to a rapt audience of 800 local school district employees -- covers everything from pregnancy to AIDS, but one topic in particular seems to grab the doctor's attention: human papillomavirus, or HPV.
In the first 10 minutes of her lecture, she mentions the sexually transmitted disease three times, and HIV only once. She shows graphic pictures of people with HPV infections but no photographs of anyone with AIDS. And when she speaks at length about HPV, in a slight Ross Perot drawl that cements the impression that she's a straight shooter, Sulak seems to revel in the virus' frequency and effects.
"How many people know that human papillomavirus is the most common sexually transmitted disease and that it causes cervical cancer?" she asks. Then she offers a handful of factoids: "Fifty percent of sexually active women have been infected ... In one study, 90 percent of sexually active adolescents were infected with HPV ... Even if a small percentage develops problems, so many people are infected that we have a huge health problem in this country."
Even more frightening, Sulak says, is the fact that HPV can't be prevented through safe sex. Because it thrives on the skin in the genital area, HPV can be passed on even if condoms are worn. The only way to keep the public safe from this dangerous virus, Sulak argues, is through long-term monogamy.
And there, in the name of public safety, is Sulak's agenda. Along with being a doctor and a professor of medicine at Texas A&M University, Sulak is also the founder of Worth the Wait, a popular abstinence-education program that seeks "to educate adolescents and adults on the consequences of teen sexual activity."
Thus, for Sulak, HPV is worth emphasizing not just because it's dangerous but also because it seems to puncture the myth that condoms can keep you safe. That is the key idea that Sulak hammers home, and the one that hundreds of abstinence-education programs now preach with zeal. Indeed, while HPV was largely unheard of only a decade ago, it's now the social conservatives' STD du jour, a part of nearly every abstinence curriculum, lecture and Web site -- "the No. 1 weapon we have," says Leslee Unruh, founder of the Abstinence Clearinghouse, a network of abstinence educators.
In fact, the jury's still out on the actual health threat posed by HPV and the efficacy of condoms to prevent it. Medical research is inconclusive. But in the absolute-minded, black-and-white world of the sex-fearing conservative right, uncertainties are an easily avoided hurdle. Abstinence-only advocates are using nothing less than the threat of death to prevent young people from engaging in sex, with or without a condom. For people like Unruh, who calls HPV "the silent killer," and President Bush -- who plans to increase abstinence-only education funding by $50 million -- agenda trumps scientific complexity. The scare tactic -- with its potential for reducing condom use and a concomitant increased risk of HIV and unwanted pregnancies -- is their chosen strategy, regardless of public-health implications.
Sulak, who insists that she has only a medical, apolitical agenda, is actually one of the abstinence movement's more moderate activists. Other anti-sex programs employ far more frightening scare tactics to make HPV seem as horrific as AIDS. Some falsely claim that HPV is also known as genital warts, ignoring the fact that most HPV cases never lead to warts. Other groups, like the Heritage Foundation, simply call the virus nothing less than "the deadly HPV" -- even though more than 99 percent of the people who contract HPV never die from it. Some legislators, including Rep. Billy Tauzin, R-La., have even begun questioning whether condom packages ought to carry a warning label saying that they don't prevent HPV, "the cause of nearly all cervical cancers."
I first discovered HPV about a year ago -- not from politicians but through personal experience, when my ex-girlfriend told me she had contracted the virus. She had no idea whether I was the source, or whether it was the boyfriend she dated between our first and second attempts to stay together. But regardless, she told me that I'd better make sure that my new girlfriend had a pap smear. "If you were infected, you may not have known it," she said. "But you can pass it on even if you don't have symptoms." (In fact, according to most studies, 80 to 95 percent of HPV cases disappear without symptoms.)
I immediately panicked. HPV -- What the hell is that? I asked. What are the effects and how scared should I be?
My questions were hardly unique. There are more than a hundred strains of the virus, and an estimated 75 percent of sexually active people contract one of them at some point; about 20 million people in the United States have genital HPV infections at any given moment; and every year, about 5.5 million people become infected, according a 2000 Centers for Disease Control report. And yet, few of those who have to deal with HPV understand its significance. The CDC has found that healthcare providers rarely know how it relates to cervical cancer, and one national survey even found that more than 7 out of 10 American women had never heard of HPV.
How could we all be so ignorant?
Much of the problem stems from HPV's understudied status. The virus isn't new; doctors have known for decades that HPV exists. But until recently, researchers couldn't scrutinize the virus closely because they couldn't find a way to grow it outside the body. "The explosion of knowledge occurred after the mid-'80s, when technology let us simply clone the virus instead of growing it," said Dr. Keerti Shah, professor of public health at Johns Hopkins University.
The most important findings related to cancer. Several studies done in the mid-'90s showed that HPV was frequently present in patients with precancerous and cancerous cells in the cervix. In 1996, a 13-member panel of scientists at the National Institutes of Health reviewed the studies and officially confirmed that "carcinoma of the cervix is causally related to infection with the human papillomavirus (HPV)." The report also questioned the utility of condoms, noting that "the data on the use of barrier methods of contraception to prevent the spread of HPV are controversial but do not support this as an effective method of intervention."
The combination -- cancer plus suspected condom failure -- changed HPV forever. Suddenly, HPV was medically and politically significant. Politicians began to notice its existence, college students feared its spread, and sex educators rushed to include it in their curriculums.
Abstinence advocates -- funded for the first time to the tune of $50 million in the 1996 welfare reform bill -- led the way. "We've been talking about it for four or five years," says Unruh, whose organization is affiliated with several hundred abstinence-education programs throughout the country. "Most every abstinence-education provider is going to talk about STDs, and they will always talk about HPV."
Comprehensive sex educators -- those who speak about abstinence and birth control -- also began including HPV in their curriculums about five years ago. But the virus has never become a dominant part of the programs. Most of the organizations in charge of comprehensive sex ed have rejected the way that abstinence educators use HPV "as a wedge to try and discourage condom use -- to say having sex is deadly," says Elizabeth Cavendish, legal director at NARAL, the National Abortion and Reproductive Rights Action League. Instead, they focus on other clear and more immediate dangers. "The big-ticket item is AIDS, and there is no question that condoms protect against HIV," Cavendish says. "The other big-ticket item is pregnancy, and there's no question that condoms prevent against pregnancy."
Doctors and public health advocates say that HPV is also too complex and unknown to justify the kind of attention given to it by most abstinence educators. It's true, as studies have shown, that HPV is related to cancer and genital warts, that it can be passed through skin-to-skin contact, and that it's common. But these facts tend to raise more questions than they answer. When does a positive HPV test lead to cancer or genital warts? What are the risk factors for HPV infections that persist? Do condoms offer any protection against the spread of the virus, and if so, how much? Is there an effective form of therapy?
Those are the unanswered questions cited by the CDC as key challenges to understanding and eradicating the virus. There are no clear answers to any of them, despite the increased interest in HPV from medical researchers. Nor are they the only queries that doctors want to figure out.
Jim Rothenberger, the Morse alumni distinguished teaching instructor of public health at the University of Minnesota, says that at least three more questions need to be answered before HPV can be taught within a nonpolitical framework. "What percentage of infections actually do go on from basic infection to a disease stage where you can see something? Does it really leave the body, or does it simply hide somewhere like chicken pox? And can we get a vaccine out there?"
Liberal sex educators tend to admit that the uncertainty exists. "The hard thing for us and a lot of people is that it's still being studied," says Tamara Kreinin, president of the Sexuality Information and Education Council, a sex-education nonprofit. "Speaking clearly about it is a hard thing." But the abstinence-only crowd, with its focus on absolutes and its disdain for relativism, continues to emphasize only the facts that line up with its mantra of abstinence.
Today's abstinence programs wrap themselves in a cloak of medical accuracy. Sulak stresses that she's only giving kids the often overlooked facts about condom failure. Unruh points out that kids aren't hearing "the truth about HPV." And when I clicked through an interactive CD-ROM sent by the National Physicians Center, an abstinence nonprofit run by doctors, I was greeted by the conservative radio host Dr. Laura Schlessinger, who informed me that "my friends at the National Physicians Center have provided medically accurate information."
Most of the medically focused abstinence programs (as opposed to the more religious curriculums that courts are beginning to bar from federal funding) use citations from established medical journals. But every one of them, in varying degrees, brings a conservative ideology to the analysis and to the choice of data emphasized. Comprehensiveness is nowhere to be found. Organizations like Sulak's "Worth the Wait" avoid the uncomfortable fact that for every study showing HPV's dangers or condoms' lack of usefulness, there seems to be another suggesting more nuanced conclusions.
For example, one of the documents most often mentioned by the abstinence education movement is a 2001 NIH report on condoms, which supposedly shows that, according to Sulak, "there's no scientific data showing that condoms prevent HPV." Other organizations make similar claims about the report. Unruh simply calls it "devastating" to those who favor safe-sex education.
But actually, the report argues that condoms do in fact "afford some protection in reducing the risk of HPV-associated diseases." Independent studies confirm these findings. The CDC, while acknowledging that abstinence is the best way to prevent HPV, also stresses that condoms reduce the virus' spread.
"Condoms don't necessarily protect against external spread of genital warts, but if you're trying to prevent cervical cancer, condoms clearly help," says Rothenberger at the University of Minnesota.
Neither Sulak's lecture (which I watched on video), nor the Abstinence Clearinghouse, nor the "Prescriptions for Parents" CD-ROM from the National Physicians Center mention these findings, which are widely accepted in the medical community. They also fail to point out that the NIH condom report begins by pointing out that latex condoms can effectively reduce the transmission of HIV/AIDS, an STD that has killed nearly 500,000 Americans in the past 20 years, far more than those who have died from cervical cancer.
The right-wing spin doesn't stop there, either. Students, teachers and parents who attend abstinence lectures or read their curriculums probably won't be told that warts are typically a minor problem that can be easily treated with topical ointments. While cervical cancer is serious, resulting in death in 30 percent of cases, the 15,700 America women who contract it each year could avoid the disease through proper screening, according to the National Cancer Institute. "Cervical cancer is preventable," says Shah at Johns Hopkins. "You could eliminate it from the world with regular pap smears."
Sulak says that she's trying to focus on the primary point of prevention. If kids stay away from sex, they're going to be safe. But not even abstinence may be able to stop the spread of HPV. The virus thrives in the skin, not just the genitals. "We're getting more and more evidence that HPV can be spread through fingers," says Rothenberger. "It's beginning to look like it's possible to get HPV even if you don't have sex."
Sulak, Unruh and most other abstinence educators argue that they're not trying to ignore these studies and others that cast doubt on their assertions. Sulak in particular stresses that she's making every possible effort to be scientifically accurate. "It's not that I'm against contraception," she says, noting that she often prescribes birth control for her patients. "It's just that I'm against what kids are being told about safe sex."
And yet, under the guise of accuracy, Sulak's lecture leaves the distinct, incorrect impression that sex is as dangerous with condoms as without, and that HPV is a problem that's nearly as urgent as AIDS. Other curriculums and videos, such as "No Second Chance" -- a video that equates premarital sex with death -- may go further, but at what point do such distinctions matter?
Each abstinence-education curriculum, even the most moderate, "is a political program with an agenda," says Kreinin at the Sexuality Information and Education Council. It's politics masquerading as science, experts say.
"I spent years arguing with individuals who focus on the supposed science of [condoms'] limited efficacy, and I stopped doing it because it's just biased," says Dr. Robert Johnson, director of adolescent and young adult medicine at the New Jersey Medical School and a board member of Physicians for Reproductive Choice and Health. "Once you have biases in science, you don't have science at all."
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