Safe Words

On Good Morning America in February, pop sensation Lady Gaga tested the limits of A.M. chatter by bringing up cavalier attitudes toward sex. Gaga (given name: Stefani Joanne Angelina Germanotta), was there with 1980s pop icon Cyndi Lauper to promote their lipsticks for MAC Cosmetics' Viva Glam line, whose proceeds go toward services for those living with HIV/AIDS. The two were dressed in sedate photo-negative outfits -- Lauper in a stiff, geometric black jacket and Gaga in a ruffled white dress. The chyron billed them as "Champions for Women's Health," but the two were focused on women's attitudes toward sex.

"I don't know if this is too much for morning TV," Gaga started. "Everyone has that ... phone call of 'Oh my gosh, you won't believe what I did last night. I was so stupid I didn't use a condom,' and there's all this laughter on the phone. ... I've gotten those phone calls, and it's our job as friends to one another to say, 'I don't know why you're laughing because it's very serious.' I really don't feel there's enough women who are educated about AIDS, how quickly it's spreading, how dangerous it really is, how many people really have it."

The 24-year-old pop star's rapid rise to fame and outrageous fashion choices (a bodysuit encased in a cloud of clear plastic bubbles for the cover of Rolling Stone, a bondage-inspired red latex gown to meet the Queen of England) have earned her comparisons to Madonna. "I want to make it fashionable to have safe sex," Gaga told the London Sun on a visit to an HIV support center in Manchester, England, last year. Of course, Madonna was spreading a similar message in the 1990s, but today it's rare to hear megastars lauding the virtues of condom use. Has safe sex really fallen so far off the radar?

In the nearly 30 years the United States has grappled with HIV/AIDS, public and private groups have struggled with how to best spread the message of prevention. Despite more than 100 years of public-health campaigns about sexually transmitted infections (STIs), the message of how to prevent them -- talking openly with your partner, using a condom properly, getting tested regularly -- still hasn't stuck. Condom use, particularly among teens, has increased over the past decade, but between 2004 and 2007, the time period of the most recent data available, diagnoses of HIV increased 15 percent, and STIs are on the rise. "Our HIV rates are appalling, given that we know how to prevent infection," says Ellen Friedrichs, a sex educator in Brooklyn.

What happened? Federal efforts to ensure public-school students receive accurate education about HIV/AIDS and other STIs have been chronically underfunded, when they have existed at all. Funding for HIV/AIDS prevention campaigns has shrunk to less than half of what it was in the mid-1990s, as the federal government adopted the counterproductive policy of funding abstinence-only curricula. The discovery of effective antiretrovirals, along with widespread understanding of how HIV/AIDS was transmitted, minimized the threat in many people's minds. Even celebrities largely stopped pushing the message that safety is sexy. (While many stars are involved in efforts like Product RED -- the consumer campaign launched by U2's Bono whose proceeds go to fight AIDS in Africa -- very few make a point of telling Americans to "wrap it up.")

The result is that both the general population and specific demographics where HIV infection rates are the highest have had limited exposure to safe-sex messaging over the last decade. The number of Americans who reported hearing about the HIV epidemic in the past year dropped (from 70 percent in 2004 to 45 percent in 2009) as did the percentage of those concerned with getting infected. "A lot of people, they don't see AIDS as a contemporary problem; it isn't seen as the serious threat that it once was," Friedrichs says.

Gaga's comments on Good Morning America sounded straight out of the early 1990s because that was the last time having a frank, national conversation about safe sex seemed not just possible but popular.

***

When HIV/AIDS began to emerge, groups like the Gay Men's Health Crisis, established in New York City in 1982, were the first responders, creating campaigns to educate and spread awareness. The federal government lagged behind in offering public leadership on prevention.

Improbably, the man who changed that was Surgeon General C. Everett Koop. An evangelical Christian physician from Philadelphia, Koop was picked by President Ronald Reagan to appease the right -- he was an outspoken conservative who had co-authored a 1979 book that linked the legalization of abortion to increases in child abuse. Upon taking office in 1982, Koop made clear the role religion played in his work. "I knew I was to practice my Christianity through my surgery."

Initially, Koop was forbidden by the Reagan administration to speak about AIDS and was not invited to join the task force working to address the crisis. The first time Koop -- who had become a trusted public figure on health matters -- spoke publicly about AIDS was in a 1985 interview with Christianity Today. "As a public-health officer," he said, "I'm not entitled to a moral opinion in a situation like this. But the public-health opinion that I give happens to coincide with a moral position of a very large segment of the country." Despite his previous conservative stance toward sexuality, Koop rallied behind age-appropriate comprehensive sex education, beginning in kindergarten. He also issued a detailed report on AIDS. "AIDS is preventable. It can be controlled by changes in personal behavior. ... This report will tell you how," he declared in the introduction. In a break from previous surgeon general's reports, it was unusually succinct and jargon-free.

Koop also oversaw the production of a brochure on HIV/AIDS, which was printed in multiple languages and mailed to every U.S. household. The federal government sponsored a series of televised public-service ads about condom usage. And Congress called for a major survey of Americans' sexual behavior. Conservatives were not amused.

Alexandra Lord, a former historian with the U.S. Public Health Service and author of the recent book Condom Nation: The U.S. Government's Sex Education Campaign from World War I to the Internet, says much of the success of the federal government's early AIDS education effort was due to Koop standing up to the members of Reagan's administration who would have preferred to skip the frank talk about sex. "So much of what happened in the early period was actually related to Koop's personality," Lord says. "He really liked to take on a fight."

Because AIDS first appeared in marginalized communities, public-health officials had to push the message that this was a disease with which all Americans needed to concern themselves. This was, as cultural historian Sander Gilman writes, "a radical restructuring of the image of the disease." The message became, in the words of a Centers for Disease Control official, "It's not who you are; it's what you do." In 1989, a series of posters produced by the CDC were aimed at heterosexual women: "If he doesn't have a condom, you just have to take a deep breath and tell him to go get one," the text reads. A 1987 poster from the Baltimore, Maryland, Health Education Resource Organization shows an attractive black couple in profile, with the text, "We Didn't Think We Could Get AIDS!" As Gilman writes, "If everyone is at risk, at least, if all the beautiful people are, where does the danger lie?" Generalizing the risk encouraged everyone to practice safe sex.

Federal education efforts breached some of the long--standing barriers against media depiction of sex and condoms. At the time, most major media outlets did not accept advertising for condoms -- or any birth control. In late 1986, The New York Times and Time Incorporated both announced they would begin accepting condom advertisements in response to the AIDS crisis. Given that the two companies raked in just over 25 percent of the media ad dollars in the United States at that time, their policy change marked a shift in what was acceptable. In October of 1988, CBS, ABC, and NBC announced they would air an entire series of government-sponsored public-service announcements on AIDS. ABC and NBC had previously shown safe-sex PSAs, but this was the first time either had committed to running a full campaign. For CBS, it was the first time condom ads appeared. Koop lauded the campaign: "Those in the communications field have a responsibility to repeat this message again and again until the use of a condom becomes a habitually conditioned reflex."

Public opinion about the suitability of condom advertising and the portrayal of sex was shifting as well. A 1987 poll commissioned by Planned Parenthood found that 72 percent of Americans "would not be offended" by condom advertising on television. And 63 percent agreed with the statement that "television programs give the impression that sex is all fun and no risk."

The early 1990s saw a generation of celebrities who showcased sex explicitly in their art and also made a point of talking about safety. Madonna included a separate insert about AIDS and safe sex in her 1989 album Like a Prayer. In 1991, Salt-N-Pepa released "Let's Talk About Sex," which was nominated for a Grammy the following year. The trio appeared on The Arsenio Hall Show to talk about the hit. "Sex is so hush-hush. And that's why it contributes to our problem with AIDS," said Salt-N-Pepa member Spinderella. A year later, the group rerecorded the song as "Lets Talk About AIDS": "You see a nice kind face, you think you're safe/I'm sorry, that's just not the case. There's no debate, conversate with your mate/And don't wait until it's too late." Magic Johnson, who announced he was HIV–positive in 1991, appeared on Arsenio in 1992 and implored sexually active teenagers to be safe. "If you're going to do it, you should have safe sex. Not only for yourself, for your partner, too."

AIDS awareness had moved into the mainstream, and condoms had become pop-song fodder. "When you have public figures going on TV, when you have condoms normalized, you make it seem like something everybody does," Friedrichs says. "I definitely think it has an effect on whether people are going to use condoms." Pop culture is undoubtedly powerful, but it is also fleeting -- no substitute for robust, comprehensive education and federal public-health campaigns.

***

Just as the public was becoming more comfortable with messages about safe sex, the federal government began to falter. The increasing dominance of abstinence-only language in sex education complicated public-health educators' attempts to codify the accepted facts about HIV prevention.

President George H.W. Bush's surgeon general, Antonia Novello, was far more reticent than Koop about speaking out on HIV/AIDS. During her tenure, the survey of sexual behavior was called off, and Novello's follow-up to Koop's ground-breaking report was delayed (many suspected for political reasons) until after the 1992 election.

The election of a Democratic president and Congress was not an improvement for public-health policy on STI prevention. Bill Clinton appointed a more sex-positive surgeon general (Joycelyn Elders, who was later forced out for discussing the role masturbation plays in human sexuality) and, at the urging of the Congressional Black Caucus, funneled $156 million to AIDS prevention efforts in the minority communities where the epidemic was increasingly focused. But it was during his presidency that federal support for the most basic part of AIDS prevention -- sex education -- began to shift. In 1996 as part of welfare-reform efforts, $50 million annually was committed to abstinence-only curricula. Known as Title V, this was the first major funding for abstinence-only education.

"The abstinence-only trend has had a huge impact; I'd say it's probably had a bigger impact than anything else, because it has sent sex back underground," says Gloria Feldt, former president of Planned Parenthood. In 1996, Feldt was serving as the head of Planned Parenthood of Arizona, where she worked on an AIDS–education curriculum with the state Education Department. "When it started being developed, it was a perfectly straightforward, honest program; when we saw the materials after they were prepared to be distributed to the school districts, they had taken out the anatomical drawings," Feldt says. "They were supposedly going to be teaching children how to prevent HIV and AIDS without divulging what went into what."

The George W. Bush administration continued the steady erosion of federal prevention efforts. Bush's championing of HIV/AIDS prevention overseas, via the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), helped inculcate the notion that the disease was not a domestic problem. Even in Bush's international efforts, prevention was de-emphasized -- a 2003 law mandated that 55 percent or more of PEPFAR funds be spent on treatment, rather than prevention. This was a major shift from previous strategy. Domestically, according to a report by the Sexuality Information and Education Council of the United States (SIECUS), prevention programs languished. Prevention funding fell from 10 percent of HIV/AIDS spending in 1995 to 4 percent in 2006. Meanwhile, abstinence-only funding grew to over $200 million annually.

Abstinence-only programs weren't merely taking up funding that could have been used for educating students about proven prevention methods; they were also sowing misinformation. In 2004, Rep. Henry Waxman released an investigation of federally funded abstinence-only programs. His office found that over 80 percent of federal grantees provided "false, misleading, or distorted information about reproductive health." This included teaching children that HIV can be spread via sweat and tears and that condoms fail to prevent HIV transmission as often as 31 percent of the time in heterosexual intercourse. A 2006 Government Accountability Office report confirmed Waxman's findings.

There is another reason for the decline in the public conversation about safe sex: A diagnosis of HIV was no longer an immediate death sentence. The same year that abstinence-only education began receiving federal funding, highly active antiretroviral therapy became available. It was heralded as a possible end to the crisis. "It was a game changer across the board," says Ernest Hopkins, the D.C. policy director for the San Francisco AIDS Foundation. "I think the media assisted researchers in making initial claims around the research that first of all weren't proven and ultimately resulted in a whole spate of messages that they had solved the epidemic. That AIDS was over."

In February of this year, The New England Journal of Medicine published an editorial titled, "AIDS in America: Forgotten But Not Gone." The authors noted that infection rates in certain U.S. communities rival those of countries in sub-Saharan Africa. While HIV/AIDS gained notoriety as a gay disease (the first proposed name was GRID -- Gay-Related Immune Deficiency), the epidemic is now prevalent in other disenfranchised and socially marginalized communities. HIV disproportionately affects the black community -- women of color are 22 times more likely to be diagnosed than white women. The number of new HIV infections, which dropped from 130,000 in 1984 to 60,000 in 1991, has since stalled. In 2009, 56,000 new cases were reported. And certain STI rates are increasing. Syphilis, which was once nearly eliminated in the U.S., has re-emerged as a prevalent threat, with women's infection rates increasing 36 percent from 2007 to 2008. In 2009, young women aged 15 to 19 had the highest reported rates of Chlamydia and gonorrhea.

If STIs are concentrated in specific demographics, do we need a national push on prevention? Hopkins says yes. States and localities continue to rely on federal resources for STI and HIV/AIDS prevention. "We still need more resources targeted to the populations that are most at risk for AIDS and HIV, but it's not OK to send the signal by putting resources in, say, the gay and bisexual community that straight people are off the hook," Hopkins says. "You can send a false message by targeting alone."

Any sex educator will tell you that prevention has to be part of an ongoing conversation. "People will immediately be very careful, and then the more time that passes from the time that they were first exposed to [a safe sex] message, they become more and more complacent," Lord says. When she began researching 20th-century sex-education programs, she was surprised to find government officials at the turn of the last century calling for comprehensive sex ed beginning at the age of 4 or 5. "This is the advice that public-health officials have been giving for almost 100 years," Lord says.

The Obama administration has a mixed record so far. In 2009, the Centers for Disease Control and Prevention launched a five-year campaign, Act Against AIDS, to increase public awareness of HIV and decrease the number of new infections. The Office of National AIDS Policy is creating the first national HIV/AIDS strategy, due out in June, which is designed to coordinate the efforts of the various agencies and departments involved with prevention. "If," Hopkins says with a laugh, "we can get the resources to pay for it, it will go a long way toward addressing the needs we have."

But even implementing a national AIDS strategy doesn't mean we're closer to a major federal push for safe sex. Consider the two sex-education measures funded by the health-care reform bill. The first was a resurrection of Title V, which Democrats had let lapse for the first time last year. In September, Sen. Orrin Hatch quietly slipped a renewal of Title V into the Senate Finance Committee bill. Despite the fact that health reform passed the Senate without any Republican votes, Democrats didn't remove the funding. Title V is now funded at $50 million annually for the next five years.

The second was the first dedicated federal funding for comprehensive sex ed. The Personal Responsibility Education Program, introduced by Sen. Max Baucus, is a five-year, $75 million annual state-grant program. Advocates herald the latter as a step in the right direction but are disappointed that abstinence-only funding lingers. "It's not just getting funding out there for more comprehensive approaches to education," says Jen Heitel Yakush, director of public policy for SIECUS. "It's also important that we are not providing support for programs that misinform."

Ultimately, the battle is not over preventing any one disease or educating any one community about sexual health. It's about sending a broad public message about the importance of responsible sexual behavior -- be that monogamy, condom use, or regular testing -- and ensuring that funding is available to target the most at-risk populations. Changing the mind-set on sex involves everything from ensuring condom access to de-stigmatizing women who take control of their sexual choices. "Girls who get this abstinence message feel that buying a condom or carrying a condom means they are preparing for sex, and they can only justify sex if 'oops, it just happened,'" Friedrichs says. "We still judge people for trying to protect themselves. It's a message we're constantly passing in America. You're supposed to look sexually available at all times, but you're not actually supposed to act on it."

America is still struggling to have an informed, responsible conversation about how to prevent HIV/AIDS. "It's not that the messages were wrong," Hopkins says, "but without the resources, there hasn't been much of an effort to innovate them and make them more relevant to the people who need to hear them today."

Now more than ever, it is politically possible for the federal government to fully support comprehensive sex education and effective public-health messaging. But that won't happen without external public pressure and some internal leadership from the Obama administration. (Where's Koop when you need him?)

Maybe Obama should take a cue from Gaga, who described her commitment to the safe-sex message this way: "I look out ... and there are 18,000 screaming young people, and I have a responsibility to them -- and you're an idiot if you don't know that."

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