No Place to Sit

After watching a video from 1993 about the HIV/AIDS epidemic today, I brought up the differences in risks between anal and vaginal sex in the US, and how it was different than in Africa. Upon my citing the low incidence of penile vaginal transmission my teacher said- “Shhhh… if you say that people wont use condoms.” This is in my pharmacology class, which is part of the nursing program I have recently begun.

Apparently, she thinks it’s better to use scare tactics to reduce disease transmission than to provide people with all of the information and let them make well informed decisions. Of course she isn’t remotely alone in this opinion; I remember clearly most of my childhood being filled with the red ribbons of Nancy Reagan’s “Just Say No” campaign. I also remember people wearing those t-shirts in high school while smoking pot.

It is probably (certainly?) true that there is a population of people on whom the assertion that any and all drug use will lead to a life of absolute despair and chaos, will be a convincing deterrent to experimentation, but that leaves out everyone who knows someone that gets high every now and again. I fall into the latter category and remember when I was told about how people are more dangerous when they get high, thinking about adults in my life sitting around laughing and upbeat while passing a joint. As a child I was very sensitive to incongruities, and had a strong radar for bull shit. This led to my throwing the baby out with the bathwater; if they had lied about the risks of marijuana, they were probably lying about everything else too.

As an adult I know that there are risks associated with marijuana use, but they are different to what I was told in 3rd grade. The effects on memory seem more important as I get older and try to cram more and more information in my head; the effects on motivation become apparent as I look at some of my more dedicated stoner friends. However, I am still at a loss at how these are more deleterious to society than say, chronic TV watching, or much more obviously, alcohol.

They say the pot is a gateway drug, and I think this may be true in more than one way. When you are told that something that isn’t very dangerous is very dangerous, you begin to question all assertions of danger. In other words, if they lied about pot, they probably lied about everything else. This is unfortunate because all risks are not created equal, but lumping all illicit drugs together can give the impression that they are.

After experimenting with drugs as a teenager I had found that most risks had been immensely overblown, but was disconcerted to find that there were real risks, and these had been overshadowed by threats of death, derangement, and homicidal tendencies. I began to wish that I had been given more accurate information about the effects and risks of drug use.  Like the subtle effects they can have on your emotional and mental health. Or the very real effects they can have on developing brains. I’m not saying that these facts weren’t shared, they were just lost in the cascade of horrors surrounding drug use that were imparted to me throughout my childhood and adolescence. Luckily, with or without accurate information I survived the recreational drug use of my teenage years to become an upstanding adult. However, I am left with the impression that the Just Say No campaign probably did more to encourage my drug use than to deter it.

But what does this have to do with condoms? Good question. For years, people in the health education community have presented an all or none dichotomy for sexual safety. Recently, as harm reduction has bled over from drug safety into sex safety, we have seen some softening of these lines, but apparently my teacher isn’t up on the cutting edge. The truth is, not all sexual behavior carries the same risk, and by telling people they have to use condoms for vaginal, oral, and anal sex in order to protect themselves from HIV, there will be some people who feel that since they can’t or wont reach perfect condom use, that they may as well not try.

With HIV education condom use has increased, and that is fantastic. I absolutely support condom use, and encourage anyone who wants to obtain the greatest amount of protection to use barriers for all sexual behavior. However, condom use still isn’t even close to a hundred percent, even among very sex-educated people who are incredibly aware of the risks. The thing is, until they invent a barrier that doesn’t interfere with sensation or comfort of sex in any way, that is going to be the case. But all is not lost! There are, in fact, ways to mitigate the risks of disease transmission without using barriers a hundred percent of the time.

It’s hard for me to keep in mind that spreading researched information is a radical act. But I know that any deviation from abstinence, or consistent condom use admonitions, is indeed thought of as reckless, and endangering lives. Understanding that, I am going to slog on, because I believe providing all the information, and asking people to make well thought out decisions, is our best chance at curbing disease progression and unwanted pregnancies.

People are terrified of HIV. It is an easy disease to use as a scare tactic, it’s the boogie man of our generation, but to put some perspective on its lack of virulence consider this: the risk of becoming infected from a needle stick from a used needle that was known to be contaminated from an HIV positive patient is 0.3 percent according to the CDC. Contrast this to the same needle being infected with hepatitis B and your risk rises to 30 percent. When I shared this statistic with a classmate he responded, “Yah, but I’m not going to go around sticking myself with HIV infected needles.” And for anyone reading this, I ask that you take his advice, please do not go around looking for dirty needles to play with. People HAVE been infected from accidental needle sticks, and as someone going into the health care industry Universal Precautions are very important to me. However, I think that it is useful to realize that there are more dangerous risks that we take everyday that people don’t think twice about. In 2007, 52,306 people died of pneumonia, 123,706 people died in accidents, and about 393,600 people die a year because they smoke cigarettes. The CDC estimates about 37,991 people were infected with HIV in 2008. Deaths from AIDS is harder to assess, since people infected with HIV die from a variety of opportunistic infections, but the CDC estimates in 2007, 18,089 people died who had been diagnosed with HIV. Perhaps the most important statistic is this, of the people infected with HIV in 2008, only 13,180 were infected through heterosexual contact, that’s a little more than half of the number of men who got it from having sex with other men. This is an even bigger difference if you consider that the vast majority of sex that is being had in the United States is heterosexual. So what’s going on?

Simply put: your risk of catching HIV during receptive vaginal intercourse is about 0.1%, while the risk during receptive anal intercourse is about 3%, which is about 30 times higher (insertive anal and vaginal sex are about 0.1% as well). Of course these are just averages, there are different factors involved in each sexual event, confection with another STD can increase risk, as can any irritation or tiny tears that may develop. Going back to the very beginning of this rant I mentioned that different geographic areas had strains of HIV that “preferred” different routes of transmission, this is one of the factors of why HIV has spread so much more quickly in some areas of the world. A good explanation of this can be found here. This means that if I was practicing health care in another area, such as Africa, these statistics would be different and risk assessment around condom use would involve much more emphasis on vaginal intercourse.

So, of course I am saying that people should stop using condoms for vaginal intercourse in the US. Somehow I’m guessing that is what many people reading this are going to accuse me of, so let me address right now why I would never say that. First of all, there is still some risk of transmitting HIV, and it’s an avoidable risk, so why not protect yourself? Secondly, there are plenty of other STDs that transmit quite well through vaginal sex, and thirdly condoms are a great way to prevent pregnancy.

What am I saying? That women should know that not all sexual acts carry the same risk for contracting HIV. The risks for oral sex are negligible, the risk for vaginal sex are real, but fairly low, and the risks for anal sex are relatively high.  So for a girl who finds that she is very often not using condoms, even though she has the best of intentions, in addition to helping her find ways to increase condom use I would tell her that it is extra super important to always use a condom during anal sex. And that some condom use is better than no condom use, because every additional exposure increases the risk of transmission.