Monday, December 18, 2006

NICHOLAS D. KRISTOF: When Prudishness Costs Lives

POIPET, Cambodia

This is an impoverished, authoritarian, war-ravaged country, but it offers an important lesson for President Bush and American school boards: Don’t fear those lifesaving bits of latex known as condoms.

Cambodia has become one of the world’s few success stories in the struggle against AIDS, and it has achieved that success partly by vigorously promoting condoms. This strategy has saved thousands of lives.

Cambodia has cut the prevalence of H.I.V. in adults from 3 percent in 1997 to about 1.8 percent today. In rural Cambodian towns like this one, billboards and posters promote condoms, and clinics and brothels have buckets of them. Health centers don’t have X-ray machines or oxygen tanks, but they have phalluses to show visitors how to put on condoms.

Here in Poipet, I met a 27-year-old woman with AIDS, Tem Phok. She had been a prostitute in a brothel, so I assumed that that was how she contracted AIDS. “Oh, no,” she said. “I got AIDS later, from my husband,” who has already died.

“In the brothel, I always used condoms,” she said. “But when I was married, I didn’t use a condom. … A woman with a husband is in much more danger than a girl in a brothel.”

That’s an exaggeration, but she has a point: It doesn’t do much good for American officials to preach abstinence and fidelity in places where the big risk of contracting H.I.V. comes with marriage. In countries with a high prevalence of AIDS, just about the most dangerous thing a woman can do is to marry.

Mr. Bush’s AIDS program, which has greatly increased spending over the levels in the Clinton years, is the single best thing he has done, and is projected to save some nine million lives around the world. That’s a genuine and historic achievement.

But the Bush program has also been undermined by a resistance to condoms. The administration has taken information about condoms off government Web sites, and its AIDS prevention efforts abroad, when aimed at young people, have emphasized abstinence to the exclusion of condoms.

Likewise, in much of the U.S., social conservatives with administration backing have instituted “abstinence only” sex education, so that teens are encouraged to take “virginity pledges” but aren’t given a backup plan.

Careful studies of “abstinence only” programs in the U.S. suggest that they do delay sexual intercourse, but that young people are then less likely to use condoms afterward. The evidence indicates that a balanced approach — encouraging abstinence but also promoting condoms — is far more effective at protecting young people in America or abroad from sexually transmitted infections, including H.I.V.

In the past, social conservatives routinely cited Uganda as proof that it’s best to focus just on abstinence. It’s true that Uganda cut H.I.V. rates significantly, partly by promoting abstinence and fidelity — but also by promoting condoms. More recently, Uganda has been backing away from condoms, with U.S. support, and its H.I.V. prevalence is rising again.

Despite the hostility to condoms in Washington (and at the Vatican), in the field, even conservative missionaries tend to endorse them.

“Why should we be afraid of latex, when we see that it can save lives,” a Catholic nun in Cameroon told me, adding that her clinic hands out large numbers of condoms. She explained: “I just don’t mention that in my reports to the bishop.”

For all the fears that condoms lead to promiscuity, the opposite has been true in Cambodia. Growing condom use has been accompanied by a drop in casual sex (probably because of increased nervousness about AIDS).

Abroad, Washington’s prudishness about condoms is routinely undermined by pragmatic officials, so that at the grass roots in Africa condoms are encouraged much more than Washington probably would like. But that same pragmatism hasn’t reached American schools, particularly in the South.

According to the Guttmacher Institute, which conducts research on reproductive health, the proportion of American adolescents receiving formal instruction in birth control methods has tumbled since the mid-1990s.

One study found that among sexually experienced American adolescents, only 62 percent of girls and 54 percent of boys had been instructed in birth control methods at the time of their first sexual intercourse.

The upshot is that we do a better job using our tax dollars to protect the health and lives of Cambodian prostitutes than we do protecting school kids in Texas.

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