The campaign for abstinence hits a dead end on HPV.
In late June, a study published in the New England Journal of Medicine showed that consistent condom use protects against human papillomavirus, or HPV. This is good news for women. It is also a problem for some social conservatives, who have relied on uncertainty about HPV and condoms to disparage the notion of "safer sex" and to promote abstinence until marriage as the only responsible way to prevent sexually transmitted diseases.
There are other recent signs that fear-mongering about HPV increasingly looks like a losing approach: Last Thursday, a federal vaccine advisory panel recommended that all 11- and 12-year-old girls routinely receive an HPV vaccine that protects against the two types of the virus that cause 70 percent of cervical-cancer cases. The panel's recommendation followed the vaccine's approval earlier in June by the Food and Drug Administration.
In the late 1990s, after a few preliminary studies suggested that condoms might not protect against HPV, conservatives seized on the findings for their abstinence campaigns. The National Institutes of Health convened an expert panel in 2000 to assess the evidence on condoms' effectiveness in preventing a range of STDs. The panel found that condoms offer substantial protection (for men and women) against HIV, the virus that causes AIDS, and (for men) against gonorrhea. But there was not enough data to draw conclusions about other sexually transmitted diseases, including HPV.
The panel's report cautioned that for these diseases, "the absence of definitive conclusions reflected inadequacies of the evidence available and should not be interpreted as proof of the adequacy or inadequacy of the condom." Nonetheless, as I wrote about for Slate here, HPV quickly became a rallying point for social conservatives. In 1999, Sen. Tom Coburn, R-Okla., then a U.S. Representative, finagled the passage of legislation that required the FDA to reexamine the "medical accuracy" of condom labels, particularly with regard to HPV. The idea was to make condom manufacturers write on packages a warning to convey that their product might not prevent the virus. Calls for such cigarette-style labels issued regularly from the hothouses of abstinence promotion. At the urging of Coburn, Mark Souder, R-Ind., and others, the Food and Drug Administration last fall released a draft guidance document for condom manufacturers that included cautionary language about HPV. The FDA has yet to release final guidelines; one might hope the NEJM study will prompt some rethinking.
Then again, fear-mongering about HPV has always lacked a certain logic. Women who get the virus but receive regular pap smears and follow-up are unlikely to develop cervical cancer. And since 2000, new evidence has also emerged to show that condom use is associated with faster clearance of HPV from the body and faster regression of cervical lesions. (Other new research shows that condoms protect against herpes, chlamydia, and syphilis, as well.)
The NEJM paper strikes the most serious blow yet to the use of HPV in the abstinence campaign against condoms. Conducted by Rachel Winer, an epidemiologist at the University of Washington, the study found that over a period of eight months, college-age women who used condoms 100 percent of the time were 70 percent less likely to acquire HPV compared with women who used condoms less than 5 percent of the time. These results were presented last summer at an STD conference in Amsterdam. Now their appearance in a top-tier journal makes them much harder to ignore.
The methodology of Winer's study is as important as its results. Unlike some of the older research, this work was designed specifically to determine whether condom use offers protection against HPV. The 82 women Winer followed had never been sexually active or had become active for the first time just before the study began. This meant virtually none of them were infected with HPV at the outset. The women recorded information about their sexual activity and condom use every two weeks—an interval short enough to ensure good recall. And they did so in anonymous computer diaries, a format shown to be more reliable than face-to-face interviews. No previous work on HPV and condoms tracked subjects so closely and took advantage of computer diaries, Winer says. Finally, the women received pelvic exams and DNA-based HPV tests every four months.
Even some critics were impressed. "This is about as ideal a study as you can get," Tom Fitch of the Medical Institute for Sexual Health, a group known for bashing condoms and promoting abstinence, told the Associated Press. Still, Fitch was unwilling to concede that the study ended the STD-based fight against condoms, arguing that some women who used condoms consistently still became infected with HPV.
Other conservatives similarly hedged. Souder announced, illogically, that the work demonstrated the "high failure rate" of condoms in preventing HPV transmission. The Focus on the Family Web site noted that Winer's study was small and said it needed to be replicated.
Of course, scientific research must always be confirmed and expanded on. But that doesn't mean we shouldn't take a strong study seriously in the meantime. Now that a federal advisory panel has recommended vaccination for all 11- and 12-year-old girls—and has said the vaccine should be included in the free Vaccines for Children Program—conservatives must decide whether to launch campaigns that aim to prevent states from making it mandatory. Some conservative leaders may insist on doing so. But as the smart ones should now realize, the HPV playbook is pretty much played out.
Amanda Schaffer is a science and medical columnist for Slate.
Photograph of condom package by H. Allen.