As Michael Specter pointed out in TheNew Yorker last month, the Bush administration spends hundreds of millions of dollars touting the benefits of abstinence. Most abstinence-promoting programs waste the government's money funneling misinformation directly to adolescents. But one such group, the Medical Institute for Sexual Health, has another audience in mind—medical students. With the help of Congress, the institute has finagled $200,000 out of the Centers for Disease Control and Prevention to develop a sexual-health curriculum for doctors in training. It's a small bit of pork, but it represents the hijacking of a government agency that normally funds research based on merit. And the CDC's imprimatur could persuade medical schools to use the institute's work.
Based in Texas and Washington, D.C., the Medical Institute provides technical material on sexual health to youth organizations and educators. Its founder, Dr. Joe McIlhaney, served as adviser to President George W. Bush while he was governor of Texas and now sits on the Presidential Advisory Council on HIV/AIDS, as well as on the Advisory Committee to the Director of the CDC. Unlike some conservative groups, the Medical Institute strives for medical respectability, focusing on public-health arguments in favor of virginity rather than moral virtues. The institute objects to being called "abstinence-only," perhaps because it wants to distance itself from more blatantly ideological groups, or perhaps because according to a recent poll, most Americans believe that abstinence-only education doesn't work. Yet the institute mainly discusses condoms to disparage them and sexually transmitted diseases to assert that only abstinence offers reliable protection. Its core message is that "the behavior choices necessary for optimal health are sexual abstinence for unmarried individuals and faithfulness within marriage."
The Medical Institute secured CDC backing for its med school curriculum by way of a Congressional earmark. (It won't say which members of Congress intervened on its behalf, and they're not jumping to take credit, either.) To lead the project, the institute tapped obstetrician-gynecologist David Hager, author of As Jesus Cared for Women: Restoring Women Then and Now and a major player in the effort to thwart Food and Drug Administration approval of over-the-counter emergency contraception. Hager chose a panel to write the sexual-health curriculum. With one or two exceptions, it lacks academic experts on sexually transmitted diseases.
When word got out about the curriculum, sexual-health experts affiliated with the CDC were taken by surprise. The agency had posted no request for proposals. It had put on no competitive bidding process. Instead, the earmark was all the Medical Institute needed. Earmarks may be business as usual when it comes to building bridges or museums. But in academic public health, they are almost unheard of. "I worked for CDC between 1985 and 1989 and have worked closely with them since leaving, and have never seen this type of funding mechanism for STD-related work," says Jonathan Zenilman, chief of the Infectious Diseases Division at Johns Hopkins Bayview Medical Center.
In 2000, the Medical Institute was instrumental in getting the National Institutes of Health to conduct a large-scale assessment of the effectiveness of condoms. The NIH report, issued in 2001, confirmed that correct and consistent use of condoms can prevent heterosexual transmission of HIV and gonorrhea. But it said there wasn't enough data to support the same conclusion about herpes, chlamydia—and the human papillomavirus. HPV quickly became a favorite talking point for conservatives because the virus can cause cervical cancer, although the risks are low for women who receive regular pap smears.
The Medical Institute had a field day with HPV. In January 2004, it put out a paper called "Human Papilloma Virus: A Major Unrecognized Epidemic," which Hager co-authored with Dr. Freda Bush, a member of the Institute's National Advisory Board. Two months later, at Congressional hearings on HPV, Bush testified, "We must stop promoting methods that are known to have high failure rates in preventing HPV transmission, notably the condom. … We must continue to emphasize highly effective methods of prevention, namely abstinence, whenever possible." Most public-health experts support encouraging teenagers to remain abstinent for as long as possible. But persuading them not to have sex by arguing that condoms don't offer meaningful protection just doesn't work. There is no credible evidence showing that any abstinence-only program has been effective in lowering the rate of STDs. By contrast, there is substantial evidence to show that teaching people to protect themselves by using condoms can successfully reduce the spread of disease.
And since the NIH report on condoms came out five years ago, a substantial body of new research has demonstrated that condoms do, in fact, prevent herpes, gonorrhea, chlamydia—and HPV. A recent study by epidemiologist Rachel Winer found that over a period of eight months, women who used condoms 100 percent of the time were about 70 percent less likely to acquire a new genital HPV infection than women who used condoms less than 5 percent of the time.
Now the first vaccine to protect against the types of HPV most likely to cause cancer is close to FDA approval (a second one is also moving through the pipeline). This puts conservative groups in an awkward position. Some have fretted aloud that a successful vaccine could undermine their message that premarital sex is never safe. But opposing a cancer vaccine makes for lousy PR.
The Medical Institute says it supports the vaccine, with some caveats. Still, the institute is likely to join a conservative push to use approval of the HPV vaccine, however improbably, to kick off a fresh campaign on the limits of condoms and the dubiousness of safe sex. And soon enough, the institute will be able to reach budding doctors directly, with its very own government-funded curriculum.
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