You're Teaching My Child What? (14 page)

She presented the petition, signed by 70 MDs, to the Board. The response was minimal.

A few months later, she returned with over 270 signatures. I have the list in front of me. It includes family practitioners, neurologists, surgeons, OB/GYNs, gastroenterologists, ER docs, cardiologists, pediatricians, pathologists, urologists, oncologists, endocrinologists—just about every medical specialty. Impressive, right? Not to the Board of Education of Montgomery County. Instead of recognizing her determination and effort—to say nothing of her time and expense—Dr. Jacobs's efforts fell on deaf ears. No changes were made.

Having the FDA, a surgeon general, and over 270 MDs in agreement about the hazards of anal intercourse was not enough, it seems, for the Montgomery County Public School system. Even with all that authority, the words “anal intercourse is simply too dangerous to practice” couldn't get through the schoolhouse doors. Can you believe it? An alien landing in Maryland would conclude that it's not lifelong herpes or deadly HIV that pose the greatest dangers to our kids; instead, we should fear a physician, board certified in internal medicine, infectious disease, and immunology, by the name of Ruth Jacobs.

In December 2007, a headline on the SIECUS website declared: “Prevalence of Unprotected Anal Sex among Teens Requires New Education Strategies.”
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A study in a recent
Journal of Pediatric and Adolescent Gynecology
was “very disturbing,” the site reported, as it indicated teens were not using condoms consistently for vaginal sex, and that they were using them even less consistently for anal sex. SIECUS was worried about the idea teens have that anal sex is somehow “safer” than vaginal sex. This, they said, is “a dangerous misconception”; anal sex is, they reported, “as risky” as vaginal sex, in terms of infections.

Kudos to SIECUS for acknowledging that new strategies are necessary. A good place to start would be in their own backyard.

SIECUS encourages books like
Daddy's Roommate
and
My Dad Has HIV
for kids in early elementary school, in order to begin conversations about sexual orientation. It's vital, they say, to explain to young children that some people are attracted to members of the same sex.

But it's never the right time, it seems, to warn teenagers that the varieties of sexual expression carry vastly different risks, especially for transmission of HIV, and to explain in accurate and up-to-date detail why. They never find it appropriate to instruct kids to avoid behaviors that are high-risk, and to flat-out tell them, “Don't do it.”

Instead, SIECUS provides lessons like those in the old MCPS video, the one the lawsuit helped to eliminate. Here's what SIECUS says about anal sex, HIV, and staying safe in their pamphlet for youth, “All About Sex”:
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When sex educators teach that HIV can be transmitted by “any exchange of body fluids—blood, semen, vaginal secretions, and breast milk,” when they say infection can occur via vaginal, oral, or anal intercourse, and when they claim, “Anyone can get HIV,” their message is technically accurate. The problem is, however, that the various “anyones” have vastly different risks—some would say million-fold differences, depending on their behavior.
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It's like saying, “Lung cancer can be caused by radon, asbestos, tobacco, and air pollution.” The
statement is correct, but 80 percent of lung cancers are due to tobacco,
³⁷
and a person smoking four packs a day of unfiltered Camels is at much greater risk than someone living in Los Angeles's polluted air, and everyone would agree he needs to know that.

It's as if the smoker is being discriminated against, and, that being unacceptable, all causes of the disease must be portrayed as carrying the same risk. You might call it the equal opportunity approach to epidemiology. It goes like this: All individuals face the same risk of illness, regardless of their genetics, diet, use of nicotine, or drinking habits. It's only fair.

Like the original MCPS curriculum, SIECUS said nothing in “All About Sex” about the highest risk of transmission during anal sex or the increased likelihood of condoms failing. And surely absent is the recommendation to avoid this high-risk act; to the contrary, unsuspecting kids are told, “Many couples (both opposite and same sex) choose to have anal sex.” gURL.COM, a site recommended to teens when they log on to SIECUS, is better. Their “Anal Sex: Fast Facts”
³⁸
warns of the dangers:

But the warning refers only to the condom-less act. With a condom,

At Planned Parenthood's site for teens,
³⁹
a reader calling himself “Crazylivedevil” has a question for the experts. He and his girlfriend are going to try anal sex, and she is concerned about safety. What, he asks, are the consequences of anal sex? In their answer, they do not
even mention of the 20-fold increased risk
to his girlfriend, not him
, of HIV transmission, or increased risk of condom failure, compared to vaginal sex:

Elizabeth Schroeder, chair of SIECUS Board of Directors, is on the medical advisory board
⁴¹
that reviews the content of Rutger University's “Sex, Etc.”
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The award-winning site warns teens about the risk of damage to rectal tissue, explaining that tears can make it easier to transmit STDs, including HIV. It also points out that a condom can rip or tear. So far, so good.

Then they turn to the sanitation issue, with the heading, “But, it's nasty!” What follows is this astonishing reassurance, based on the insights of one Jennifer Johnston, identified as an educator at Planned Parenthood of Western Washington.

While there is a possibility of coming into contact with feces, Johnston reassures that “the rectum isn't the main storage area for feces. The colon is. So if a person has had a recent bowel movement and eats healthy food and keeps regular, the rectum can be feces-free, especially if it is washed thoroughly before engaging in anal sex.”

Heather Corinna, of Scarleteen, goes further. She not only provides instructions on how to engage in anal sex in her book for teens,
⁴³
she
introduces readers to “oral stimulation of the anus or rectum.” This, kids learn, is “something people of all genders and orientations may enjoy.”
⁴⁴

Jennifer and Heather would benefit from Dr. Jacobs's “swirly talk,” don't you think? In case you forgot, here are a few of the nasty organisms found in the rectum: salmonella, shigella, amoeba, hepatitis A, B, and C, giardia, and campylobacter, among others.

For Heather, ever the social activist, every subject, even this one, is related to oppression. When “Teenie” wonders why anal sex is “a bad thing,” Heather answers:
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Over at the Columbia's GoAskAlice, a male reader (“well adjusted . . . with a steady girlfriend”) finds himself drawn toward trying anal intercourse, on the receiving end.
⁴⁶
Is he bisexual, he wonders?

Labels, Alice answers, “act like a ball and chain around our desires.” Don't feel you need to pigeonhole your sexuality into a comfortable box, she advises. “Alice applauds you for getting in touch with what flies your flag.”

That's it. No warnings or suggestions for this reader who is poised to try out something a former surgeon general instructed the country “is simply too dangerous to practice.”

So began a report called “Social Injuries of the Rectum” in the
American Journal of Surgery,
November 1977.
⁴⁷
The article described two cases—one a rectal tear with profuse bleeding, the other a laceration of the colon requiring emergency surgery. Both were due to what the authors called “fist fornication”—“the practice of introducing the closed or clenched fist into the rectal ampulla, upper rectum, and sigmoid colon to achieve sexual gratification.”

Thirty years later, courtesy of Alice
⁴⁸
and Heather,
⁴⁹
teens can easily find guidance—indeed, books are suggested—on how to engage in this behavior and reduce the risk of “social injuries.” I suppose some people would consider that progress. Colorectal surgeons are probably not among them.

As mentioned earlier, all self-respecting microbes have one goal: to find a home and reproduce. The same is true for HIV. And there is no doubt, the deadly virus has an easier time doing this in the rectum than anywhere else.
⁵⁰

Having receptive anal intercourse with someone who is HIV positive is dangerous; the studies confirming this are voluminous.
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The reason is biology—actually, to be more precise, histology. Histology is the study of cells, what they do, and how they are organized. To fully understand how HIV is transmitted, and why a “generic” notion of intercourse is dangerously false, a comparison of the histology of the vagina with the histology of the rectum is mandatory.

For infection to occur, keep in mind that HIV must either enter the bloodstream or gain access to deeper tissues. This makes it a relatively difficult bug to pass along. Consider for example the highly contagious
viruses that cause conjunctivitis (commonly known as pink eye).
⁵²
They are easily transmitted on your finger, when you touch one eye and then the other. They can also live on inanimate surfaces, like towels or pillows, and infect you from there.

In contrast, HIV must reach a group of cells in the immune system called “target cells.” Only here can the virus make a home and reproduce. To reach target cells, the HIV must either bypass or pass through a barrier. For example, the heroin addict sharing a dirty needle infects himself by injecting the virus directly into his bloodstream, bypassing the natural barrier, skin. The same is true for persons infected through blood transfusions. The infant nursed by an HIV positive mother is infected when the virus passes through the lining of the digestive system. So the barrier is important to look at: it is the wall the virus must breach to succeed.

Assuming a girl is healthy—without any STIs or conditions that would weaken her immunity—her vagina has some built-in conditions
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that are protective from the get-go. In fact, one of the functions of the vaginal lining is protection from infection.
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The pH is low, which inactivates HIV.
⁵⁵
Its mucus has anti-HIV proteins.
⁵⁶
Langerhans cells in the cervix can destroy the virus.
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The vaginal wall is 20 to 45 cells thick,
⁵⁸
increasing the distance to be traversed by the virus. Under the wall is a layer in which target cells are found; this area is rich in elastic fibers. Next is a layer of muscle, then more elastic fibers. This architecture allows for significant stretching of the vagina without tears or abrasions. Some researchers believe that HIV is unable to reach target cells in the human vagina under normal circumstances;
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others disagree.
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The rectum has a different structure. As part of the gastrointestinal system, it has a lining whose primary function is absorption, bringing in molecules of food and water. The pH is higher. Most important, the rectal lining—the barrier to be breached—is only one cell thick. Below that delicate lining are blood vessels and target cells. Elastic fibers are absent.

Early in the epidemic, it was assumed that fragility of the rectal barrier accounted for the more common male-to-male transmission. But later in the eighties came a discovery: infection could occur
without
disruption of the barrier. Specialized cells on the surface “swallow” the virus and deliver it unchanged to target cells.
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