05/05/11

Of penises and pasta-measurers: sex ed in the dark ages (circa 2011)

Thirty years ago next month, the first reports of the illness that came to be known as AIDS were published. Five cases, all among young gay guys in Los Angeles. Since then, we’ve racked up over 60 million HIV prevention failures worldwide. But new draft guidelines on safe sex advice proposed for the UK suggest we’ve learned almost nothing from three decades of failure.

The guidelines, proposed by the British Association for Sexual Health and HIV are depressing, at very best. They seem to assume that it is the duty of health professionals to protect people from their own bad behaviour, in part by informing them of every possible risk, however marginal. They seem also to assume that the sort of people who take significant risks on a regular basis care about their long term health prospects. We don’t. And that comes from someone who today happens to be wearing a T-shirt embazoned with a slogan picked by algorithm on the basis of answers to 10 behavioural questions. Mine reads: “Runs with scissors”, but it might equally have read “Cycles without a helmet”, “Shags without a condom” or “Rolls her own cigarettes”.

The guidelines available here in pdf form, are open for public comment for another week or so. I would strongly urge people (especially people who’ve ever used a sexual health clinic) to look through them and put in their tuppence worth. The full text of my own comments is available in a doc file here.

In summary, I’m upset that we are still telling people to use condoms every time they have anal, vaginal or oral sex, even though we know perfectly well that that’s no more feasible than never having sex at all, for the same reason: for most of us, consistent condom use in every act of sex involving every orifice with every partner type at every age and level of sobriety is not feasible because it is not desirable.

I’m upset that we don’t give more practical and nuanced advice that people are more likely to act on. Example from my response:

“If you don’t have a condom handy, or don’t want to use one, then oral is your safest bet”. More useful still to a random gay man would be: “Do you have HIV? Yes? Then try always to use a condom if you’re top in anal sex. It would be great if you could use one if you’re bottoming too, but it’s less important, especially if you’re good about taking your meds. Don’t worry too much about oral, though it’s best if you don’t come in some other guy’s mouth. Definitely don’t come in his mouth if he’s just been to the dentist, or looks like he needs to go!”

I’m upset that we’re using evidence selectively. The guidelines imply there’s evidence that condoms work, and no evidence that abstinence works. In fact, condoms work and abstinence works even better, when they are used consistently and correctly. The more important evidence is around whether the promotion of condoms or abstinence lead to their consistent and correct use. Frankly, there’s very little recent evidence from the UK that condom promotion works very well; what worked in an age when HIV meant AIDS and an ugly death does not necessarily work in this post-AIDS age.

And I’m upset that, not content with giving clients information they won’t act on, we’re suggesting things that service providers won’t act on either. Sizing your clients up for condoms using a pasta measurer? Really?

I hate to wish HIV a happy 30th birthday, but I think at this rate it can expect to stay alive and well for several decades to come.

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This post was published on 05/05/11 in Condomania, Good sex and bad.

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  1. Comment by Eren Bilgin, 11/05/11, 05:29:

    Your comments in the attached file are great. This information needs be repeated and repeated. I wonder if the people writing the guidelines are unaware of the realities, don’t want to rock the boat or think they can’t.

    It’s refreshing to hear everything you’ve got to say knowing your education and experience in epidemiology. I would like to hear more scientists being vocal about public health guidelines all over the world which give advice that is not ‘likely to be actionable.’

  2. Comment by Juliana, 15/05/11, 06:41:

    Wow, what a depressing article, though very informative. I think that there needs to be a middle ground between both, stressing that constant condom use is the most effective way, and providing advice for those moments when people choose not to use them. Right?

  3. Comment by Merrian Brooks, 19/06/11, 07:56:

    As a physician, I see this as a problem with patient education in general. Its equally frowned upon to advise with nuances in other areas ie hey kid smoking cigs is bad for you and heres why, but if you’re going to do it stop by age 25 and studies show your lungs should heal. I think it is partially related to the way that physicians want patients to just ‘do what I say’ instead of ‘if you won’t take all of your pills take these 3 most important ones’ and the simplified message that public health workers shoot out in order to appeal to the masses like ‘always wear a helmet’ vs ‘if you don’t always wear a helmet at least wear one on the road where more serious injury can occur’ Guess the second one doesn’t fit onto a poster very well… Thanks for your blog in general I enjoy reading your honest perspectives.

  4. Comment by Bryan, 23/06/11, 04:00:

    I don’t disagree with the idea that public health messages need to be realistic, obviously people will incur risks for any number of reasons…least of which, they just want to. But I know many gay men who feel that “topping” sans rubber is safe (ie. they can’t contract HIV doing this). Obviously, it’s not “safe.” Truthfully though, we don’t quite know enough yet to determine how risky it is. There are still many unanswered questions regarding how infectious anal mucous is, what kind of tearing goes on in the anus and the presence of blood in anal sex (gross, but it’s very common!), the role of circumcision, and problems with response bias among gay men (they don’t like to say that their “bottoms” or ever “bareback.”) …

  5. Comment by Daniel Reeders, 21/07/11, 10:51:

    I honestly believe the problem is there are so many BORING PEOPLE writing these strategies and recommendations, people who’ve never taken a risk in their entire lives. This produces what Paul Ward has called “epistemological dissonance”, so even if we give feedback, they won’t understand why we’re saying what we do.

  6. Comment by Andy, 24/01/12, 11:16:

    Bullsh*t. Part of the problem with HIV prevention – at least in the developed world with gay men – is that we’ve shifted the burden of prevention to people that already have the virus. These are the very people who have the least to gain from prevention. Altruism sounds great, but its nit a rational public health expectation. Telling poz guys to “wear a comdom” to protect someone else is so idiotic, so against human nature, and so plainly condescending that it makes me want to vomit. Telling gay men with HIV that they should “always use a condom” when they top makes a nice sentiment when undertaken as a voluntary measure, but doesn’t do anything for the masses who aren’t so nice, the majority of poz gay men who rightfully feel maligned by the focus on prevention or the 50% of poz guys who don’t know their status. How about this: negative? Want to stay that way? Wrap it up.

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