Volume CXXXII, Number 6 October 25, 2002 f

Safer sex and abstinence
JEFF BENSON, M.D.

Dear Dr. Jeff: "I keep coming across information that "safer sex" isn't nearly safe enough. The argument seems to be that condoms do not adequately protect against STD's, especially HPV, and that the only "Safe sex" is "NO SEX". What do you think?" P.S.

Dear P.S.: I've seen some of that information, sometimes put out by medical authorities, and always promoting abstinence as the only safe option. For many, abstinence may in fact be a good choice. For many others, however, the issues may not seem so black-and-white.

Health educators suggest we think through the risks of sex and safer sex like we do other risks in life, such as driving a car. Some of us choose not to drive for fear of getting hurt in an accident. Most people seem willing to accept some level of risk, and try to find ways to reduce it. They wear seat belts, maintain their cars, drive defensively, and avoid driving after drinking or in bad weather.

People have safer sex to protect themselves and their partners from STD's and from unplanned pregnancies. They understand that sex is more enjoyable if they are not afraid. Safer sex is about what they do, or don't do, and not about who they are. It is about figuring out their own "risk limits," and then avoiding sexual activities that fall outside of them.

Safer sex practices require self-reflection, a great deal of communication between partners, and some familiarity with the "tools of the trade," especially condoms.

A 1996 consensus panel at the National Institutes of Health reviewed studies on Human Papilloma Virus, cervical cancer, and condoms. This panel reported controversy over the scientifically-proven protective efficacy of condoms against HPV.

"Abstinence Only" campaigns have focused in on this one small part of the NIH report, and use it to instill fear and to further their own political agenda.
The Heritage Foundation, for instance, always refers to HPV as "the deadly HPV," even though more than 99 percent of people who contract the virus never die from it. Representative Billy Tauzin-Republican representative for Lousiana and Chair of the House Commerce and Energy Committee-has been pushing for legislative action that would require condom packages to carry a warning label about not being protective against HPV, "the cause of nearly all cervical cancer."

Human Papilloma Virus is by far the most prevalent of the sexually transmitted infections. The numbers involved are truly staggering. It is estimated that 75 percent of sexually active people contract HPV at one time or another, and that at any given point in time, 20 million Americans have genital HPV infections that can be transmitted to others.

Every year, over 5.5 million people become infected. Very fortunately, however, the majority of HPV infections are overcome by our immune systems and resolve without further complications.

Two of the over 30 sexually transmissible strains of the virus, though, cause cellular changes which can lead to cancer. In particular, cervical cancer is virtually always associated with untreated HPV Type 16 or Type 18.

Cancer of the cervix is one of the most common malignancies in women, accounting for nearly 16,000 new cases and almost 5,000 deaths in the U.S. each year. It is also one of the most treatable and preventable cancers. Microinvasive carcinoma of the cervix is nearly alway curable surgically. More importantly, it has a long pre-clinical phase which permits early detection.

In fact, regular screening Pap smears very effectively pick up early, pre-cancerous changes, and treatment at these early stages is curative. More than half of women newly diagnosed with invasive cervical cancer have never had a Pap smear, and another 10 percent have not had one in the previous 5 years. Cervical cancer may indeed be an HPV-related "STD", but it is more importantly a disease of medical neglect.

Now, back to condoms! Because HPV can infect genital areas not covered by condoms, condoms provide incomplete protection against the spread of HPV. This is the crux of the "No such thing as safer sex" argument: "HPV is rampant, cannot be fully prevented by condom use, and by causing cervical cancer, kills thousands of women each year."

The suggested solution? Abstinence, followed by lifelong, mutually monogamous marriage.

Obviously this argument oversimplifies and distorts many of the critical elements of the problem mentioned above. It is also important to note that, according to this same NIH report, condoms do in fact offer not just some, but some VERY worthwhile protection against HPV, particularly against cervical infection. Even more importantly, condoms offer VERY effective protection against the spread of HIV, an STD that has claimed almost 500,000 American lives over the past 20 years, and which threatens to kill untold tens of millions more around the world.

Condoms also offer VERY effective protection against chlamydia, an STD that infects over 3 million people in this country each year.

Condoms, finally, also offer reasonably effective protection (about 85 percent) against unwanted pregnancies. From a public health standpoint, it seems to me simply criminal to discourage condom use.

Total abstinence would presumably offer nearly 100 percent protection against STD's and unplanned pregnancies. And for some people, abstinence remains the best choice. For others, however, it is not. And those individuals need useful, scientific information to make their own best choices.

Take a look at the Health Center webpage. Talk to someone at the Health Center, the Counseling Center, or the Women's Resource Center. Talk to members of the Bowdoin Gay/Straight Alliance or HIV/AIDS Peer Educators. Check out cdc.gov, consensus.nih.gov, goaskalice.columbia.edu, fenwayhealth.org, or ourbodiesourselves.org. And to be fair, take a look at heritage.org, medinstitute.org and worththewait.com.

Think hard for yourselves, and take good care of yourselves-and each other!

Jeff Benson, M.D.
Dudley Coe Health Center