Analysis Sexual Health

PEPFAR, Youth, and the AIDS Epidemic: A Call for Real Leadership on Prevention

Debra Hauser

We must seize this opportunity to promote a truly science-based, holistic, HIV prevention strategy for young people in the U.S. and abroad. In the end, it is young people who hold the key to ending this epidemic. That's why they should be at the center, not the periphery, of our programs and policies.

The global HIV and AIDS strategy is at a turning point. We have witnessed dramatic scientific advances in the fight against the pandemic, spurring renewed hope that the end of AIDS is in sight. President Obama and Secretary Clinton recently delivered major speeches announcing new targets and goals for achieving an “AIDS-free generation.” Yet globally, young people continue to account for four in ten new infections and those directing the U.S. effort to combat the epidemic are not taking the bold steps necessary to match the inspiring vision outlined by the President and the Secretary of State.

But rather than building a firewall of prevention around the largest youth generation in the world’s history, the Office of the Global AIDS Coordinator (OGAC) is pursuing a limited, politically-safe approach–based largely on a biomedical approach to prevention–that downplays the sexual health needs and rights of youth throughout the world.

In a newly-released report, Advocates for Youth analyzes youth policies within the President’s Emergency Plan for AIDS Relief (PEPFAR), including its legislative authority, most recent five-year strategy, relevant guidance documents, and all twenty-one currently available PEPFAR country Partnership Frameworks. Our analysis outlines a series of policy recommendations that could help the agency address the real challenges at hand. This first-of-its kind, in-depth analysis assesses PEPFAR policy and programming according to nine youth indicators, including:

  • Requirements that comprehensive sex education, which includes information about abstinence and condoms, be provided for all youth;
  • Emphasis on the meaningful inclusion of youth in the development, implementation and/or evaluation of youth HIV prevention and care strategies;
  • Clear support for the integration of youth-friendly HIV/AIDS and family planning/reproductive health services;
  • Emphasis on specific prevention strategies for young people living with HIV or AIDS;
  • Recommendations for the compilation and reporting of age disaggregated data and statistics;
  • Explicit inclusion of programs and strategies targeting young men who have sex with men, young commercial sex workers and young intravenous drug users;
  • Language that identifies youth as a Most-At-Risk Population;
  • Policies and programs designed to reach at-risk and out-of-school youth; and
  • Policy reforms that improve youth access to sexual health services, including condom availability.

The report finds that the while there are promising advances for youth sexual and reproductive health in PEPFAR’s second phase, progress is being significantly hampered by a siloed, segmented approach to prevention that fails to address the holistic needs of youth or to engage young people themselves as partners in prevention. In addition, the report notes a tepid commitment within OGAC to the rights of young people to the information and education they need to protect their health and lives in the era of AIDS. The report concludes with a set of recommendations for the U.S. Congress, OGAC, and Partner Country governments, to design and implement the bold policy needed to support youth sexual and reproductive health and rights, including promotion of comprehensive sexuality education and youth-friendly, integrated, HIV and family planning services.

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While “combination prevention” approaches may be all the rage in Washington these days, a key piece of the prevention puzzle is missing—the health and rights of young people. We all understand that prevention of mother-to-child transmission (PMTCT), male circumcision, and treatment as prevention are critical interventions in the global HIV prevention arsenal. However, they represent only a partial picture of prevention—one that focuses entirely on biomedical approaches at the expense of behavioral and structural interventions. We simply cannot afford to take the path of least resistance and promote politically easy biomedical approaches while minimizing attention to more comprehensive strategies that recognize the realities of young people’s sexual lives. The 2,500 young people who are newly-infected with HIV every single day serve witness to the inadequacy of our current approach.

We have to recognize that young people have the right to accurate and complete sexual health information and services; that young people deserve our respect; and that as a leader in the global HIV fight, the U.S. has a responsibility to require that those receiving U.S. funds provide young people with all of the tools they need to safeguard their sexual and reproductive health. Yet, all too often, young people are ignored or caught in the crosshairs of controversy and politics. One of the many costs of this fallout: only 34 percent of young people in low- and middle-income countries (24 percent of young women and 36 percent of young men) can correctly answer the five basic questions about HIV and how to prevent it.

We’ve got to do better than this.

As the host of the International AIDS Conference this July, the United States and Washington, DC, in particular, will be in the spotlight. And thousands of young people will be at the forefront, thanks to efforts of Youth Force, expecting their leaders to not just listen, but to take action to address the health and rights of young people. We must seize this opportunity to promote a truly science-based, holistic, HIV-prevention strategy for young people in the U.S. and abroad. In the end, it is young people who hold the key to ending this epidemic. That’s why they should be at the center, not the periphery, of our programs and policies. The ultimate challenge we face is not money or technology—it’s leadership. And the time to exercise it is now.

Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Analysis LGBTQ

Reimagining Safety for Queer and Trans Communities in Wake of Orlando

Tina Vasquez

“We need to have a national conversation about racism, homophobia, and transphobia,” said Alan Pelaez Lopez, a member of the organization Familia: Trans Queer Liberation Movement. “If these things do not happen, the nation, by definition, will have done nothing to support our communities.”

The same day of the Orlando Pulse nightclub shooting that would take the lives of 49 mostly Latino and LGBTQ-identified people, thousands of miles away in Santa Monica, California, a man was found with weapons, ammunition, and explosive-making materials in his car with plans to attend the annual Pride festival taking place in West Hollywood later that day.

Conversations around security and safety were raised by law enforcement almost immediately. In the days since, reports have emerged that from San Francisco to New York, there will be more police and “ramped-up security measures” at Pride events nationwide.

But queer and trans people of color (QTPOC) say these responses are missing the mark, because what their communities really need are deeper conversations and more resources that address their specific experiences, including fewer police at Pride events.

House Democrats held a sit-in on gun control this week as a direct response to the Orlando shooting. Though Alan Pelaez Lopez—an Afro-Latinx, gender-nonconforming immigrant, poet, and member of the organization Familia: Trans Queer Liberation Movement—agrees that gun control is important and should be considered by Congress, they said it can also feel like the community affected by the shooting almost always gets erased from those discussions.

“We need to have a national conversation about racism, homophobia, and transphobia,” the poet said. “If these things do not happen, the nation, by definition, will have done nothing to support our communities.”

Rethinking ‘Pride’ for People of Color

In mid-May, Rewire reported on the National Queer Asian Pacific Islander Alliance (NQAPIA)’s week of action to #RedefineSecurity, which encouraged participants to reimagine what safety looked like in Asian and Pacific Islander communities, and called for them to push back against police presences at Pride events.

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Pride events and festivals take place each June to commemorate the Stonewall riots in New York City, a clash between police officers and members of the LGBTQ community—led by trans women of color—that would kickstart the modern LGBTQ movement.

Even after the Orlando shooting at a gay nightclub, NQAPIA organizing director Sasha W. told Rewire their stance on police at Pride events hasn’t changed, but only grown more resolute.

As an organizer working with queer and trans Muslim, South Asian, and Middle Eastern communities, Sasha W. said the populations they work with say that framing the Orlando shooting as a “terrorist attack” makes them feel “increasingly unsafe.”

“I think part of what we need to remember is to examine what ‘terror’ looked like in queer and trans communities over the course of our history in this country,” Sasha W. said. They cited the Stonewall riots and the inaction by the government during the HIV and AIDS epidemic as examples of some of the many ways the state has inflicted violence on queer and trans communities.

Sasha W. added that pointing blame at Daesh is too easy, and that the oppression queer and trans people face in the United States has always been state-sanctioned. “We have not historically faced ‘terror’ at the hands of Muslim people or brown people. That is not where our fear has come from,” they said.

What’s missing, they said, is a conversation about why police officers make certain people feel safe, and “interrogating where that privilege comes from.” In other words, there are communities who do not have to fear the police, who are not criminalized by them, and who are confident that cops will help them in need. These are not privileges experienced by many in queer and trans communities of color.

Asking the mainstream LGBTQ community to rethink their stance on police and institutions that have historically targeted and criminalized communities of color has been challenging for queer and trans people of color.

What’s become clear, according to Familia: Trans Queer Liberation Movement founder Jorge Gutierrez, is that after a tragedy like Orlando, white LGBTQ members want to feel united, but many don’t want to discuss how things like race and citizenship status affect feelings of safety. Instead, some will push for a greater police presence at events. 

There have already been instances of white members of the LGBTQ community publicly shutting down conversations around racial justice. Advocates say the public needs to understand the broader context of this moment.

“The white LGBTQ community doesn’t face the criminalization and policing that our community faces every day. Not just at Pride, but every day, everywhere we go. That’s our life,” Gutierrez said. “If you don’t listen to us when it comes to these issues of safety, you’re not just erasing us from a tragedy that impacted us, but you’re really hurting us.”

As Gutierrez explained, in the hours after the shooting, some media coverage failed to mention Pulse was a gay club, failed to mention it was people of color who were killed on Latino night, and failed to mention that trans women were performing just before the shooting broke out. Gutierrez told Rewire he felt like his community and their pain was being erased, so his organization put together a video featuring queer and trans immigrants of color, including Lopez, to discuss their immediate feelings after the Pulse shootingand many shared sentiments similar to Sasha W.’s and Lopez’s. One trans Latina said the shooting was “years in the making.”

“The video was important for us to release because the shooting was being framed as an isolated event that randomly happened, but we know that’s not true. We know that the United States has a history of hurting queer and trans people of color and we needed to produce our own media, with our own messaging, from our own people to tell people what really happened, the history that lead to it happening, and who it really impacted. We didn’t want our voices and our realities as immigrants, as undocumented people, as queer and trans people of color, erased,” Gutierrez said.

Without even factoring in an increase in law enforcement, Lopez told Rewire Pride already felt unsafe for people like them.

“I have experienced a lot of racism [at Pride events], the pulling of my hair from people walking behind me, and I have also been sexually harassed by white people who claim to want to experiment with being with a Black person,” Lopez said.

Though Lopez didn’t attend any Pride events in Los Angeles this year, they told Rewire that in previous years, there was already a large police presence at Pride events and as a “traumatized person” who has had many negative interactions with police officers, including being racially profiled and stopped and frisked, encountering law enforcement was scary.

“Seeing [cops] at Pride makes me remember that I am always a target because at no time has the police made me feel protected,” the poet said. “Signs of heavy police presence are really triggering to people who have developed post-traumatic stress disorder from violent interactions with the police, for undocumented communities, for transgender communities, for young people of color, and for formerly incarcerated individuals. When I think of security, I do not think of police.”

Lopez isn’t alone. Whether it’s law enforcement violence against women and trans people of color, law enforcement working with Immigration and Customs Enforcement (ICE) for the detainment and deportation of undocumented people, or the way law enforcement has reportedly discriminated against and harassed gender-nonconforming people, QTPOC have very real reasons for feeling vulnerable around police officers, advocates say.

Another reason Lopez chose not to attend Pride this year: It was being sponsored by Wells Fargo. The banking corporation sponsors over 50 yearly Pride events and has been called a “longtime advocate of LGBT equality” by organizations like the Human Rights Campaign, which also lists Wells Fargo as a top-rated company on its Corporate Equality Index. But Wells Fargo has a history of investing in private prisons, including detention centers. Calls to drop Wells Fargo from Pride events have been unsuccessful. For queer immigrants like Lopez, attending Pride would mean “financially contributing” to the same corporation and system that they said killed their friends, the same corporation that they said has incarcerated their family, and that they said has tried—but failed—to incarcerate them.

Sasha W. told Rewire that for QTPOC, it’s easy to forget that the event is supposed to be about celebration.

“For many of us, we can’t really bring our whole selves into these places that are meant to make us feel free or we have to turn off parts of who we are in order to enjoy ourselves” the organizer said. “And as far as the policing of these events go, I think it’s worth noting that policing has always been about protecting property. It’s always been about property over people since the days of the slave trade. When we see police at Pride events the assumption [by our communities] is that those police will protect money and business over our queer brown and Black bodies.”

“Really Troubling Policies”

As organizations and corporations work to meet the short-term needs of victims of the Orlando shooting, advocates are thinking ahead to the policies that will adversely affect their communities, and strategizing to redefine safety and security for QTPOC.

Gutierrez told Rewire that what has made him feel safe in the days since the Orlando shooting is being around his QTPOC community, listening to them, mourning with them, sharing space with them, and honoring the lives of the brothers and sisters that were lost. His community, the organizer said, is now more committed than ever to exist boldly and to make the world a safer place for people like themand that means pushing back against what he believes to be a troubling narrative about what safety should look like.

However, Gutierrez said that politicians are using his community’s pain in the wake of the Orlando shooting to push an anti-Muslim agenda and pit the LGBTQ community against Muslims, conveniently forgetting that there are people who live at the intersection of being queer and Muslim. Perhaps more troubling are the policies that may arise as a result of the shooting, policies that will add to the surveilling and profiling Muslims already experience and that will further stigmatize and criminalize vulnerable communities.

“The government, the police, politicians, they’re trying to equate safety with having more police on the street, at gay clubs—that are like home to many of us, and at Pride. We know that doesn’t make us safe; we know police are part of the problem,” he said.

“Of course we need to make it more difficult for people to get guns, but we also need more resources for our communities so our communities can truly be safe on the streets, in the workplace, at school, at the clubs, and at Pride,” he said. “That means having healthy communities that have resources so people can thrive and live authentically. The answer to our problems is not more police.”

Sasha W. echoed Gutierrez, saying that their community is already fearful of what’s to come because moments of national crisis often create the space for “really troubling policies.”

“That’s how we got the Patriot Act,” the organizer said. “There is a fear that we are in another one of those moments where there are calls for protection and it’s being tied to the false idea of a foreign threat that requires an increase of surveillance of Muslims. Think of how calls for protection have also hurt queer communities, communities of color, trans communities, like the idea that bathrooms aren’t safe because of trans people. Who is really unsafe in this country, and why do policies hurt us instead of protect us?”

Lopez added: “The Orlando shooting was powered by the fact that the United States has a history of violence against LGBTQIA communities, a history of violence against immigrants, a history of violence against women, and a history of colonization of the island of Puerto Rico … The U.S. needs to address institutional problems of race, ethnicity, class, gender, sex, and sexuality if it wants to put an end to future massacres.”

The question remains: How can vulnerable communities be made to feel safer not just at Pride events, but in a political moment when transphobia is state-sanctioned, Islamophobia is applauded, and communities of color still have to fight for their humanity?

Sasha W. urges QTPOC to “expand their political imagination” and re-envision what security looks like. In the long term, the organizer said, they hope more people recognize who their communities’ “actual enemies” are, instead of turning on each other.

“Let’s recognize that the state has always been something we’ve had to fight to survive and that institutions that hurt us are growing increasingly strong in this moment of crisis, as they often do, so we have to work to disarm and dismantle the institutions that terrorize our communities” they said.

“On another note, we have always been our own best defense, especially in communities of color,” they said. “Supporting each other to protect ourselves better doesn’t happen overnight, I know, but so much of this starts with building community with each other so that we know each other, love each other, and throw down for one another.”