Analysis Contraception

Hormonal Contraception and HIV: Weighing the Evidence and Balancing the Risks

Jodi Jacobson

An article in yesterday's New York Times suggesting that injectable contraceptive use might double the risk of HIV transmission among women in Africa sent waves of anxiety through the global public health community, leading some to ask whether we should halt delivery of injectables. But experts say: "Not so fast."

Editor’s note: This article was updated at 7:02 pm on Thursday, October 6th to correct the second paragraph, which originally implied that Heffron was the first author on the study on pregnancy and HIV risk.  The first author actually is N.R. Mugo.

An article in yesterday’s New York Times by Pam Belluck suggesting that injectable contraceptive use might double the risk of HIV transmission among women and their partners sent a wave of anxiety through the global public health community. The story is based on a study conducted in Africa by Renee Heffron and her colleagues and published online this week in The Lancet. Heffron’s study suggests that HIV-negative women using injectable contraception might face a two-fold risk of acquiring HIV from their infected partners, and that HIV-positive women using injectable contraceptives may be twice as likely to pass the virus on to their uninfected partners.

Another analysis of these same data found that pregnancy itself doubles the risk of transmitting HIV and that pregnancy also doubles the risk of acquiring HIV (largely because of differences between pregnant and non-pregnant women in age, contraceptive use, and sex without condoms).

If the findings on injectable contraceptives are confirmed through further research, the implications are profound. Women make up 60 percent of those infected with HIV in sub-Saharan and are highly vulnerable to HIV infection for a range of economic, social, and biological reasons.  Women are simultaneously at high risk of death and disability from complications of pregnancy and unsafe of abortion.  Ending the spread of HIV, filling the unmet need for contraception, and preventing the large number of unintended pregnancies in Africa are critical and highly-intertwined global health goals which, if reached, would save millions of lives and dramatically improve prospects for women and children.

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Remove injectable contraceptives from this mix and the picture becomes rather bleak.  “The injectable birth control shot has revolutionized women’s access to modern contraception in developing countries,” said Latanya Mapp Frett, Vice President-Global, of Planned Parenthood Federation of America. “This method allows women with infrequent access to health centers to prevent unintended pregnancy, thereby reducing rates of complicated pregnancies, unsafe abortion and maternal death. We need to seriously weigh the evidence before restricting women’s access to this life-saving resource.”

As the Times noted, the World Health Organization (WHO) plans to convene a meeting in January 2012 to review the Heffron study in light of existing evidence and examine the meaning of these findings for delivery of health services.

The possibility that one proven and highly effective health intervention–injectable hormonal contraception–is exacerbating another public health crisis is of course cause for deep concern, and raised reasonable questions among advocates as to why WHO would wait until January to convene a meeting on these issues, and whether distribution of injectable contraceptives should be halted immediately.

Experts say: “Not so fast.”

Public health and women’s rights experts are taking the study very seriously but also caution against drawing conclusions from the NYT story in part because it overstated or misrepresented some of the study’s findings while neglecting to mention several potential weaknesses. And because the stakes for women are so high, they also say it is important to take a step back and look at the broader range of evidence on this issue carefully, especially in an era when promotion of evidence-based public health interventions such as family planning and safer sex have become so politicized and misinformation spreads rapidly.

There appears to be consensus among public health experts on three basic steps:

1) Consider the effects of methodological weaknesses in the analysis and whether these may have influenced the conclusions.

2) Weigh this study against the existing evidence and conduct research specifically designed to examine these questions.

3) Balance the risks women face from both HIV and unintended pregnancy.

A discussion of each of these points follows:

1) Examine possible methodological weaknesses.

The Heffron study was originally designed to examine the effectiveness of the antiviral medication acyclovir in preventing HIV infection associated with Herpes simplex virus in both sero-discordant couples (in which one partner is HIV-positive and the other HIV-negative) and concordant couples (in which both partners have the same HIV status). It was not designed to examine the connections between hormonal contraceptives and HIV transmission. Findings on their initial research question were inconclusive so Heffron and her colleagues went back through their data to look for other outcomes including the association between hormonal contraception and HIV transmission.

While evaluating the kinds of data they collected for these outcomes is a highly complicated exercise, reviewers of the paper say the study that resulted is in several ways methodologically stronger than earlier studies examining these questions. The analysis also, however, contains weaknesses that could make the results less conclusive than initially appears to be the case and certainly less than the Times story suggested.

In a research note published in the same volume of the Lancet, Charlies Morrison and Kavita Nanda of the international health organization FHI 360, write:

The main strength of the study is that exposure to HIV was known. The study population consisted of HIV-serodiscordant couples, and analysis was limited to HIV infections genetically linked to the index partner. As such, the study was able to provide direct data on the risk of HIV-infected women using hormonal contraception transmitting the virus to their male partner. By contrast with many other studies, self-reported condom use was similar between hormonal and non-hormonal groups. Finally, the investigators used sophisticated analytical techniques and were able to adjust analyses for the plasma viral load of the infected partner.

However, they also note that:

[S]imilar to all observational studies, this study was open to aetiological pitfalls. Potential selection bias and confounding could have distorted interpretation. Furthermore, like all but two studies on this topic, this study was a secondary analysis of an HIV-prevention trial—not specifically designed to examine hormonal contraception and HIV risk. Few women used hormonal contraceptives (only 196.6 [11%] of the total person-years of follow-up were among hormonal-contraceptive users) and few HIV infections (ten for DMPA and three for oral contraceptives) occured for these users.

In selecting quotes, the Times article glazed over these and other possible limitations of the study, including the fact that contraceptive use was self-reported and not confirmed by the researchers through examination of clinical records.  Contraception was not provided in all 14 sites used in the study and therefore not consistent across them. Participants in the study often switched contraceptive methods: Almost half of the women who reported using hormonal contraceptives also used non-hormonal methods at some point, but switching was not taken into account in analyzing the data. All of these are methodological weaknesses that could skew the results. 

The Times also over-stated the conclusiveness of findings on condom use.  Belluck, for example, wrote:

The researchers recorded condom use, essentially excluding the possibility that increased infection occurred because couples using contraceptives were less likely to use condoms.

This is not accurate. Condom use in the study was self-reported. It is very difficult to accurately measure condom use from self-reporting because people tend to overstate to researchers the consistency with which they use condoms (a well-known phenomenon), and there was no way to measure whether couples in the study reporting condom use actually used condoms during all sex acts, some sex acts and not others, or even consistently and correctly over the three-month period. The researchers did control for condom use but based on data that were not systematically collected to answer these questions.  Because of this, Morrison and Nanda note that the researchers’ “analytical adjustment for condom use might be insufficient.” One expert, speaking off the record, suggested that while the findings of this study absolutely require further examination, the analysis of condom use alone was cause for “healthy skepticism” of whether the findings were conclusive.

Also not taken into consideration in the Heffron study and not reflected in the Times article were considerations such as whether women using injectable contraceptives had more frequent sex, which may have been their motivation in seeking out long-acting contraception in the first place. More frequent sex would mean more frequent exposure to unintended pregnancy and its potential complications, but also to HIV from an infected partner, especially in the absence of consistent and correct use of condoms or “dual protection” (contraception for pregnancy prevention and condom use for prevention of infection). Sexual coercion or lack of control over the timing and nature of sex may also leave women more vulnerable to unsafe sex, HIV infection, and unintended pregnancy, and might further confound the analysis.

2) Weigh the evidence.

Experts underscore that while this study should be taken seriously, it does not, according to Heather Boonstra, Senior Public Policy Associate at the Guttmacher Institute, “change the weight of the body of evidence to date, which currently suggests no relationships between hormonal contraception and HIV transmission or acquisition.” 

In a guidance memo sent to field offices after the initial presentation of the Heffron study at an AIDS conference ealrier this year, USAID states:

Previous studies have examined these issues. Some found similar associations (including one of the largest studies on this topic); most have not found HC [hormonal contraception] to be associated with HIV acquisition or transmission in a general population. The new [Heffron] findings raise concerns, particularly since the analysis involved a large sample size of serodiscordant couples, used sophisticated statistical techniques, and may provide biological support by measuring viral shedding.

Still, continues the memo, “a cautious interpretation of the findings is justified as the scientific community gathers additional information. Like previous analyses, these findings were derived from observational data, which may be biased by self-selection.”

The memo concludes that because there is as yet insufficient information and analysis on the study and its implications, “USAID does not believe that a change in contraceptive policy or programming is appropriate or necessary at this time” and stated it will:

continue to offer a wide variety of contraceptive methods, and ensure that women and couples have access to a wide variety of contraceptive methods, are counseled about the known risks and benefits of those methods (including that all methods other than male and female condoms provide no protection from sexually transmitted infections (STIs), including HIV), and are able to select the method that best fits their individual needs.

The WHO meeting in January is intended to bring together a range of experts to look at this and previous data in as many as 12 other studies, and examine the body of evidence as a whole.

Virtually everyone agrees that carrying out systematic research examining as a primary question the possible connections between hormonal contraception and HIV infection should be a high priority.

3) Balance the Risks.

In the lives of women in sub-Saharan Africa, nothing involving sex and reproduction is “risk free.” In low-resources settings characterized by extremes of gender bias, the combined lack of consistent access to basic family planning methods, prenatal care, trained birth attendants and emergency obstetric care all make pregnancy a dangerous undertaking.  Lack of access to family planning to prevent unintended pregnancy and lack of access to safe abortion services mean millions of women each year suffer dire consequences trying to exert some control over their lives. Lack of control over sex and reproduction contribute to both high rates of unintended and unwanted pregnancies, and to high rates of HIV infections. 

Injectable contraceptives are widely used in sub-Saharan Africa in large part because these methods give women control over whether and when to become pregnant. Approximately 12 million women between the ages of 15 and 49–six percent of all women in this age group–depend on this method.  If it is found that use of hormonal contraception does indeed increase the risk of acquriing or transmitting HIV infection, we are faced with the potential loss of a major public health intervention. Removing the method from the mix of options leaves women vulnerable to different but also dangerous risks from unintended pregnancy, which may also increase their risk of HIV infection, or unsafe abortion or both.

Irrespective of whether conclusions from the Heffron study stand up to further research and examination, there is are no easy answers.

Still, to some degree, some answers are already clear.

First, at the most basic level, it is critical to the health and lives of women and their families to expand, not reduce, access to essential family planning services, continue to improve the quality of services, and continue to underscore the critical nature of dual prevention strategies, via the use of effective methods of contraception combined with correct and consistent condom use, including both male and female condoms.  Expanding integrated family planning and HIV prevention services is also critical and can not be over-emphasized.  Unprotected sex can lead to both unintended pregnancy and to HIV infection. We know how to prevent both, but we must both invest in these services while ending the stigma associated with safer sex practices.

Second, we need to invest more in expanding the range of reproductive technologies.  “What the debate over this study underscores more than anything is the need for more methods that protect couples from both unintended pregnancy and HIV,” said Vanessa Cullins, MD, Vice President of Medical Affairs at PPFA. “Until these products are developed, women and their partners need better access to condoms; and they should not have their birth control taken away.”

Third, we must greatly expand efforts to promote and secure the rights of women, economically, socially, and culturally.  High rates of maternal mortality and illness, and high rates of HIV infection among women are but symptoms of the broader social illness rooted in gender discrimination, gender-based violence, and the lack of investment in health, education, and economic power of women and girls.  Only when women’s health needs are made a priority by every government everywhere, and when women can exercise their rights will we eradicate HIV and make maternal morality a very rare event.

Analysis Law and Policy

Do Counselors-in-Training Have the Right to Discriminate Against LGBTQ People?

Greg Lipper

Doctors can't treat their patients with leeches; counselors can't impose their beliefs on patients or harm them using discredited methods. Whatever their views, medical professionals have to treat their clients competently.

Whether they’re bakers, florists, or government clerks, those claiming the right to discriminate against LGBTQ people have repeatedly sought to transform professional services into constitutionally protected religious speech. They have grabbed headlines for refusing, for example, to grant marriage licenses to same-sex couples or to make cakes for same-sex couples’ weddings-all in the name of “religious freedom.”

A bit more quietly, however, a handful of counseling students at public universities have challenged their schools’ nondiscrimination and treatment requirements governing clinical placements. In some cases, they have sought a constitutional right to withhold treatment from LGBTQ clients; in others, they have argued for the right to directly impose their religious and anti-gay views on their clients.

There has been some state legislative maneuvering on this front: Tennessee, for instance, recently enacted a thinly veiled anti-LGBTQ measure that would allow counselors to deny service on account of their “sincerely held principles.” But when it comes to the federal Constitution, providing medical treatment—whether bypass surgery, root canal, or mental-health counseling—isn’t advocacy (religious or otherwise) protected by the First Amendment. Counselors are medical professionals; they are hired to help their clients, no matter their race, religion, or sexual orientation, and no matter the counselors’ beliefs. The government, moreover, may lawfully prevent counselors from harming their clients, and universities in particular have an interest, recognized by the U.S. Supreme Court, in preventing discrimination in school activities and in training their students to work with diverse populations.

The plaintiffs in these cases have nonetheless argued that their schools are unfairly and unconstitutionally targeting them for their religious beliefs. But these students are not being targeted, any more than are business owners who must comply with civil rights laws. Instead, their universities, informed by the rules of the American Counseling Association (ACA)—the leading organization of American professional counselors—merely ask that all students learn to treat diverse populations and to do so in accordance with the standard of care. These plaintiffs, as a result, have yet to win a constitutional right to discriminate against or impose anti-LGBTQ views on actual or prospective clients. But cases persist, and the possibility of conflicting court decisions looms.

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Keeton v. Anderson-Wiley

The first major challenge to university counseling requirements came from Jennifer Keeton, who hoped to receive a master’s degree in school counseling from Augusta State University. As detailed in the 2011 11th Circuit Court of Appeals decision considering her case, Keeton entered her professional training believing that (1) “sexual behavior is the result of personal choice for which individuals are accountable, not inevitable deterministic forces”; (2) “gender is fixed and binary (i.e., male or female), not a social construct or personal choice subject to individual change”; and “homosexuality is a ‘lifestyle,’ not a ‘state of being.'”

It wasn’t those views alone, however, that sunk her educational plans. The problem, rather, was that Keeton wanted to impose her views on her patients. Keeton had told both her classmates and professors about her clinical approach at a university-run clinic, and it wasn’t pretty:

  • She would try to change the sexual orientation of gay clients;
  • If she were counseling a sophomore student in crisis questioning his sexual orientation, she would respond by telling the student that it was not OK to be gay.
  • If a client disclosed that he was gay, she would tell him that his behavior was wrong and try to change it; if she were unsuccessful, she would refer the client to someone who practices “conversion therapy.”

Unsurprisingly, Keeton also told school officials that it would be difficult for her to work with LGBTQ clients.

Keeton’s approach to counseling not only would have flouted the university’s curricular guidelines, but also would have violated the ACA’s Code of Ethics.

Her conduct would have harmed her patients as well. As a school counselor, Keeton would inevitably have to counsel LGBTQ clients: 57 percent of LGBTQ students have sought help from a school professional and 42 percent have sought help from a school counselor. Suicide is the leading cause of death for LGBTQ adolescents; that’s twice or three times the suicide rate afflicting their heterosexual counterparts. And Keeton’s preferred approach to counseling LGBTQ students would harm them: LGBTQ students rejected by trusted authority figures are even more likely to attempt suicide, and anti-gay “conversion therapy” at best doesn’t work and at worst harms patients too.

Seeking to protect the university’s clinical patients and train her to be a licensed mental health professional, university officials asked Keeton to complete a remediation plan before she counseled students in her required clinical practicum. She refused; the university expelled her. In response, the Christian legal group Alliance Defending Freedom sued on her behalf, claiming that the university violated her First Amendment rights to freedom of speech and the free exercise of religion.

The courts disagreed. The trial court ruled against Keeton, and a panel of the U.S. Court of Appeals for the 11th Circuit unanimously upheld the trial court’s ruling. The 11th Circuit explained that Keeton was expelled not because of her religious beliefs, but rather because of her “own statements that she intended to impose her personal religious beliefs on clients and refer clients to conversion therapy, and her own admissions that it would be difficult for her to work with the GLBTQ population and separate her own views from those of the client.” It was Keeton, not the university, who could not separate her personal beliefs from the professional counseling that she provided: “[F]ar from compelling Keeton to profess a belief or change her own beliefs about the morality of homosexuality, [the university] instructs her not to express her personal beliefs regarding the client’s moral values.”

Keeton, in other words, crossed the line between beliefs and conduct. She may believe whatever she likes, but she may not ignore academic and professional requirements designed to protect her clients—especially when serving clients at a university-run clinic.

As the court explained, the First Amendment would not prohibit a medical school from requiring students to perform blood transfusions in their clinical placements, nor would it prohibit a law school from requiring extra ethics training for a student who “expressed an intent to indiscriminately disclose her client’s secrets or violate another of the state bar’s rules.” Doctors can’t treat their patients with leeches; counselors can’t impose their beliefs on patients or harm them using discredited methods. Whatever their views, medical professionals have to treat their clients competently.

Ward v. Polite

The Alliance Defending Freedom’s follow-up case, Ward v. Polite, sought to give counseling students the right to withhold service from LGBTQ patients and also to practice anti-gay “conversion therapy” on those patients. The case’s facts were a bit murkier, and this led the appeals court to send it to trial; as a result, the student ultimately extracted only a modest settlement from the university. But as in Keeton’s case, the court rejected in a 2012 decision the attempt to give counseling students the right to impose their religious views on their clients.

Julea Ward studied counseling at Eastern Michigan University; like Keeton, she was training to be a school counselor. When she reviewed the file for her third client in the required clinical practicum, she realized that he was seeking counseling about a romantic relationship with someone of the same sex. As the Court of Appeals recounted, Ward did not want to counsel the client about this topic, and asked her faculty supervisor “(1) whether she should meet with the client and refer him [to a different counselor] only if it became necessary—only if the counseling session required Ward to affirm the client’s same-sex relationship—or (2) whether the school should reassign the client from the outset.” Although her supervisor reassigned the client, it was the first time in 20 years that one of her students had made such a request. So Ward’s supervisor scheduled a meeting with her.

Then things went off the rails. Ward, explained the court, “reiterated her religious objection to affirming same-sex relationships.” She told university officials that while she had “no problem counseling gay and lesbian clients,” she would counsel them only if “the university did not require her to affirm their sexual orientation.” She also refused to counsel “heterosexual clients about extra-marital sex and adultery in a values-affirming way.” As for the professional rules governing counselors, Ward said, “who’s the [American Counseling Association] to tell me what to do. I answer to a higher power and I’m not selling out God.”

All this led the university to expel Ward, and she sued. She claimed that the university violated her free speech and free exercise rights, and that she had a constitutional right to withhold affirming therapy relating to any same-sex relationships or different-sex relationships outside of marriage. Like Keeton, Ward also argued that the First Amendment prohibited the university from requiring “gay-affirmative therapy” while prohibiting “reparative therapy.” After factual discovery, the trial court dismissed her case.

On appeal before the U.S. Court of Appeals for the Sixth Circuit, Ward eked out a narrow and temporary win: The court held that the case should go to a jury. Because the university did not have a written policy prohibiting referrals, and based on a few troubling faculty statements during Ward’s review, the court ruled that a reasonable jury could potentially find that the university invoked a no-referrals policy “as a pretext for punishing Ward’s religious views and speech.” At the same time, the court recognized that a jury could view the facts less favorably to Ward and rule for the university.

And although the decision appeared to sympathize with Ward’s desire to withhold service from certain types of clients, the court flatly rejected Ward’s sweeping arguments that she had the right to stray from the school curriculum, refuse to counsel LGBTQ clients, or practice anti-gay “conversion therapy.” For one, it said, “Curriculum choices are a form of school speech, giving schools considerable flexibility in designing courses and policies and in enforcing them so long as they amount to reasonable means of furthering legitimate educational ends.” Thus, the problem was “not the adoption of this anti-discrimination policy, the existence of the practicum class or even the values-affirming message the school wants students to understand and practice.” On the contrary, the court emphasized “the [legal] latitude educational institutions—at any level—must have to further legitimate curricular objectives.”

Indeed, the university had good reason to require counseling students—especially those studying to be school counselors—to treat diverse populations. A school counselor who refuses to counsel anyone with regard to nonmarital, nonheterosexual relationships will struggle to find clients: Nearly four in five Americans have had sex by age 21; more than half have done so by the time they turn 18, while only 6 percent of women and 2 percent of men are married by that age.

In any event, withholding service from entire classes of people violates professional ethical rules even for nonschool counselors. Although the ACA permits client referrals in certain circumstances, the agency’s brief in Ward’s case emphasized that counselors may not refuse to treat entire groups. Ward, in sum, “violated the ACA Code of Ethics by refusing to counsel clients who may wish to discuss homosexual relationships, as well as others who fail to comport with her religious teachings, e.g., persons who engage in ‘fornication.'”

But Ward’s approach would have been unethical even if, in theory, she were permitted to withhold service from each and every client seeking counseling related to nonmarital sex (or even marital sex by same-sex couples). Because in many cases, the need for referral would arise well into the counseling relationship. And as the trial court explained, “a client may seek counseling for depression, or issues with their parents, and end up discussing a homosexual relationship.” No matter what the reason, mid-counseling referrals harm clients, and such referrals are even more harmful if they happen because the counselor disapproves of the client.

Fortunately, Ward did not win the sweeping right to harm her clients or otherwise upend professional counseling standards. Rather, the court explained that “the even-handed enforcement of a neutral policy”—such as the ACA’s ethical rules—”is likely to steer clear of the First Amendment’s free-speech and free-exercise protections.” (Full disclosure: I worked on an amicus brief in support of the university when at Americans United.)

Ward’s lawyers pretended that she won the case, but she ended up settling it for relatively little. She received only $75,000; and although the expulsion was removed from her record, she was not reinstated. Without a graduate counseling degree, she cannot become a licensed counselor.

Cash v. Hofherr

The latest anti-gay counseling salvo comes from Andrew Cash, whose April 2016 lawsuit against Missouri State University attempts to rely on yet murkier facts and could wind up, on appeal, in front of the more conservative U.S. Court of Appeals for the Eighth Circuit. In addition to his range of constitutional claims (freedom of speech, free exercise of religion, equal protection of law), he has added a claim under the Missouri Religious Freedom Restoration Act.

The complaint describes Cash as “a Christian with sincerely-held beliefs”—as opposed to insincere ones, apparently—”on issues of morality.” Cash started his graduate counseling program at Missouri State University in September 2007. The program requires a clinical internship, which includes 240 hours of in-person client contact. Cash decided to do his clinical internship at Springfield Marriage and Family Institute, which appeared on the counseling department’s list of approved sites. Far from holding anti-Christian bias, Cash’s instructor agreed that his proposed class presentation on “Christian counseling and its unique approach and value to the Counseling profession” was an “excellent” idea.

But the presentation itself revealed that Cash intended to discriminate against LGBTQ patients. In response to a question during the presentation, the head of the Marriage and Family Institute stated that “he would counsel gay persons as individuals, but not as couples, because of his religious beliefs,” and that he would “refer the couple for counseling to other counselors he knew who did not share his religious views.” Because discrimination on the basis of sexual orientation violates ACA guidelines, the university determined that Cash should not continue counseling at the Marriage and Family Institute and that it would be removed from the approved list of placements. Cash suggested, however, that he should be able to withhold treatment from same-sex couples.

All this took place in 2011. The complaint (both the original and amended versions) evades precisely what happened between 2012 and 2014, when Cash was finally expelled. You get the sense that Cash’s lawyers at the Thomas More Society are trying to yadda-yadda-yadda the most important facts of the case.

In any event, the complaint does acknowledge that when Cash applied for a new internship, he both ignored the university’s instructions that the previous hours were not supposed to count toward his requirement, and appeared to be “still very much defend[ing] his previous internship stating that there was nothing wrong with it”—thus suggesting that he would continue to refuse to counsel same-sex couples. He continued to defend his position in later meetings with school officials; by November 2014, the university removed him from the program.

Yet in challenging this expulsion, Cash’s complaint says that he was merely “expressing his Christian worldview regarding a hypothetical situation concerning whether he would provide counseling services to a gay/homosexual couple.”

That’s more than just a worldview, though. It also reflects his intent to discriminate against a class of people—in a manner that violates his program’s requirements and the ACA guidelines. Whether hypothetically or otherwise, Cash stated and reiterated that he would withhold treatment from same-sex couples. A law student who stated, as part of his clinic, that he would refuse to represent Christian clients would be announcing his intent to violate the rules of professional responsibility, and the law school could and would remove him from the school’s legal clinic. And they could and would do so even if a Christian client had yet to walk in the door.

But maybe this was just a big misunderstanding, and Cash would, in practice, be willing and able to counsel same-sex couples? Not so, said Cash’s lawyer from the Thomas More Society, speaking about the case to Christian news outlet WORLD: “I think Christians have to go on the offensive, or it’s going to be a situation like Sodom and Gomorrah in the Bible, where you aren’t safe to have a guest in your home, with the demands of the gay mob.” Yikes.

Although Cash seems to want a maximalist decision allowing counselors and counseling students to withhold service from LGBTQ couples, it remains to be seen how the case will turn out. The complaint appears to elide two years’ worth of key facts in order to present Cash’s claims as sympathetically as possible; even if the trial court were to rule in favor of the university after more factual development, Cash would have the opportunity to appeal to the U.S. Court of Appeals for the Eighth Circuit, one of the country’s most conservative federal appeals courts.

More generally, we’re still early in the legal battles over attempts to use religious freedom rights as grounds to discriminate; only a few courts across the country have weighed in. So no matter how extreme Cash or his lawyers may seem, it’s too early to count them out.

* * *

The cases brought by Keeton, Ward, and Cash not only attempt to undermine anti-discrimination policies. They also seek to change the nature of the counselor-client relationship. Current norms provide that a counselor is a professional who provides a service to a client. But the plaintiffs in these cases seem to think that counseling a patient is no different than lecturing a passerby in the town square, in that counseling a patient necessarily involves expressing the counselor’s personal and religious beliefs. Courts have thus far rejected these attempts to redefine the counselor-patient relationship, just as they have turned away attempts to challenge bans on “reparative therapy.”

The principles underlying the courts’ decisions protect more than just LGBTQ clients. As the 11th Circuit explained in Keeton, the university trains students to “be competent to work with all populations, and that all students not impose their personal religious values on their clients, whether, for instance, they believe that persons ought to be Christians rather than Muslims, Jews or atheists, or that homosexuality is moral or immoral.” Licensed professionals are supposed to help their clients, not treat them as prospective converts.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.