Roundups Sexual Health

Sexual Health Roundup: Study Finds Gardasil is Safe, New Jersey Lawmaker Seeks Ban on Reparative Therapy

Martha Kempner

A new study has found that the HPV vaccine, Gardasil, is safe. A New Jersey lawmaker wants to ban reparative therapy for minors. And Memphis schools respond to Tennessee's new sex-ed law.

New Study Finds Gardasil is Safe

A new study published in the Archives of Pediatrics & Adolescent Medicine found that Gardasil, one of the vaccines designed to prevent HPV and cervical cancer, is safe. Researchers at Kaiser’s vaccine study center examined 190,000 female members of Kaiser Permanente’s health system. The women received at least one dose of the HPV vaccine between August 2006 and March 2008; about 44,000 women received all three doses.

Researchers followed the health of these women for two months following each dose of the vaccine, including visits to the emergency room and hospitalizations. They looked at more than 200 categories of illnesses. “Asthma, diabetes, nervous-system disorders, and medical conditions such as attention deficit disorder, back pain and other injuries were reviewed. In most cases the condition existed before the vaccine was given.”

They found the vaccine caused skin irritation, including redness and swelling at the injection site that occurs within two weeks of the shot, and possible fainting episodes on the day of inoculation. But they found no connection to any serious health problems.

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Gardasil protects against four strains of HPV, two of which account for about 70 percent of all cervical cancer. Since it was first approved in 2006, the vaccine has been the subject of controversy, in part because it is recommended for girls as young as nine years of age. Opponents of the vaccine have argued without evidence that this forces parents to have uncomfortable conversations and gives young women permission to be promiscuous. Opponents have often used—and inflamed—parents’ fears about the safety of vaccines in general and this vaccine in particular to discourage its use. This study should help public-health experts and medical providers allay fears about safety.

As I like to say every time I write about this topic, we now have a vaccine to prevent a type of cancer. Run, don’t walk to the pediatrician’s office as soon as you can.

New Jersey Lawmaker Looking to Follow California’s Lead and Prohibit Reparative Therapy for Teens

Last week, California became the first state to ban reparative therapy, the practice of trying to change a person’s sexual orientation or “cure” homosexuality. Now, a lawmaker in New Jersey would like his state (which is also my state) to follow suit. Recently-elected Assemblyman Tim Eustace, from Bergen County,  plans to introduce a bill this week to outlaw so-called gay conversion therapy. Like California’s law, this law would apply only to licensed practitioners. This could mean that some New Jersey young people would be exposed to it anyway.

Still, Eustace, an openly gay man who has two sons with his partner of 32 years, argues that the ban is important and likens it to the government protecting young people from other potentially harmful activities, such as underage drinking, indoor tanning, or smoking cigarettes. In a statement Eustace said:

Studies and personal testimony have shown this practice creates irreparable harm on young people struggling to come to terms with their sexuality. Forcing someone to deny their innate feelings and their very existence has led to depression, suicidal tendencies, and other untold harm. Leading psychological professionals agree that this practice has no place in legitimate mental health therapies. I hope New Jersey will join California in leading the way on standing up to this harmful practice.

But not everyone in the state agrees with the congressman’s position. Jeffery Danco, a clinical psychologist based in Bridgewater, practices “reparative therapy.” As a licensed health-care provider, he would be directly affected if the law were to pass. Danco believes that reparative therapy can help and tells his teen patients that they can change their homosexuality like “any other sense of inadequacy or inferiority.” He calls the law “a politically-motivated government intrusion” and argues that parents have the right to choose what kind of therapy their kids receive.

The legislation has a long way to go before it could pass in New Jersey, and it will be interesting to see whether, if passed during his term, New Jersey Gov. Chris Christie will join California Gov. Jerry Brown in signing such a law. Groups in California are already working on lawsuits opposing the law, and any law passed in New Jersey might face the same.

Memphis Responds to New Tennessee Sex-Ed Law by Requiring Parental Consent

You may remember that Tennessee passed a new sex-education law last year.  Though most such laws change without too many people noticing, this law got national attention because of the phrase “gateway behaviors.” Specifically, the law says that courses cannot “promote any gateway sexual activity or health message that encourages students to experiment with non-coital sexual activity.”

The law became the target of jokes. Steven Colbert teased that “kissing and hugging are just the last stop before the train pulls into Groin Central Station.” The law does not indicate exactly what constitutes a gateway behavior. (I vote for a bouquet of flowers and a back rub.) But the author of the bill swears that we will know it when we see it. Rep. John DeBerry (D-Memphis) argued in his testimony to the Tennessee House of Representatives that:

Everybody knows there are certain buttons when you push them, certain switches when you turn them on, there’s no stopping, especially for undisciplined, untrained, untaught and unraised children who just want to feel affection from somebody or anybody.

Despite its status as a national joke, the law was signed by the governor in May and went into effect in July.

In response to the law, Memphis public schools changed to an “opt-in” policy. This change was based, not on the gateway language but on the law’s emphasis on parental control over sex education. John Barker, the district’s chief of staff, argued that:

“The new law really pushes more for parents to have a say in whether their children are taught a more specific curriculum with regard to sex ed.”

An opt-in policy means that students must bring back a signed permission slip from their parents before they can participate in any sex-education courses.

Sex-education advocates are opposed to opt-in laws because they cause administrative headaches. More important, they may prevent some young people from receiving education because of lack of organization, not strong opinions: The form got left in the bottom of a kid’s backpack, lost in a pile of bills, or a parent just forgot to send it back. One parent in the area said that the change will “absolutely” mean fewer kids will get sex education. She went on to say:

“Everybody needs this. The ones already falling between the cracks are the ones that are going to be hurt. The cycle of poverty will continue with more unwanted children and pregnancies.”

Parental-consent policies are frequently debated by school boards and state legislators, but this change was not required by the new Tennessee law. In fact, under the law, parents simply have the right to take their children out of class by signing a “non-consent” form. This type of a policy is referred to as “opt-out” and is common in states and communities across the country.

Though a spokesperson for the Tennessee School Boards Association said he had not heard of changes in other districts, the decision in Memphis should remind us that laws can have a far-reaching and even unexpected impact on whether young people learn about sexuality in schools.

Analysis Abortion

Attacks on Abortion Rights Continued in 2015, Ensnaring Family Planning Funding and Fetal Tissue Research

Rachel Benson Gold & Elizabeth Nash

The year will be remembered not only because 17 states enacted a total of 57 new abortion restrictions, but also because the politics of abortion ensnared family planning programs, providers, and life-saving fetal tissue research.

During 2015’s state legislative sessions, lawmakers considered 514 provisions related to abortion; the vast majority of these measures—396 in 46 states—sought to restrict access to abortion services. The year will be remembered not only because 17 states enacted a total of 57 new abortion restrictions, but also because the politics of abortion ensnared family planning programs and providers, as well as critical, life-saving fetal tissue research.

2015 may also be memorable for setting the stage for what is widely anticipated to be one of the most significant Supreme Court rulings on abortion since 1992. In November, the Court agreed to hear a challenge to a Texas law requiring abortion providers to adhere to the standards set for ambulatory surgical centers and to have admitting privileges at a local hospital. At stake is the question of how far states may go in regulating abortion before their actions amount to an unconstitutional “undue burden” on women’s ability to access care. The Court will hear the case in March, with a decision expected in June; it is still considering whether to review a Mississippi admitting-privileges law. (Also in 2016, the Court will revisit the contraceptive coverage guarantee under the Affordable Care Act, weighing its importance and approach against the contention of religiously affiliated employers that they deserve to be entirely exempt from the law.)

At the same time, several states made important advances in 2015 on other sexual and reproductive health and rights issues. Some of the new provisions include measures that allow women to obtain a full year’s worth of prescription contraceptives at one time from a pharmacy, that allow a provider to treat a patient’s partner for an STI without first seeing the patient, that prohibit the use of “conversion therapy” with minors, and that expand access to dating or sexual violence education. See our full analysis for details.

Access to Abortion Services

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Including the 57 abortion restrictions enacted in 2015, states have adopted 288 abortion restrictions just since the 2010 midterm elections swept abortion opponents into power in state capitals across the country. To put that number in context, states adopted nearly as many abortion restrictions during the last five years as they did during the entire previous 15 years. Moreover, the sheer number of new restrictions enacted in 2015 makes it clear that this sustained assault on abortion access shows no signs of abating.

StateTrends2015-restrictions

The 288 new restrictions enacted since 2010 include a broad range of approaches, from banning certain types of abortions to putting restrictions on the providers allowed to perform the procedures to limiting insurance coverage.

StateTrends2015-access

Thirty-one states—spanning all regions of the country—enacted at least one abortion restriction during the last five years. The ten states that enacted at least ten new restrictions together accounted for 60 percent of the 288 new abortion restrictions adopted over the last five years. These states are overwhelmingly located in the South and the Midwest, and it is likely that access to services for women in these regions has been impacted significantly. Four states—Arkansas, Indiana, Kansas, and Oklahoma—each enacted at least 20 new abortion restrictions, making this handful of states, which together adopted 94 new restrictions, responsible for a third of all abortion restrictions enacted nationwide over the last five years. Kansas has the dubious distinction of leading the pack with 30 new abortion restrictions since 2010.

heat map

Although the 57 new abortion restrictions enacted during 2015 include a wide range of provisions, four topics stood out as the subject of particular attention among lawmakers:

1. Counseling and Waiting Periods

Five states adopted new (Florida and Tennessee) or lengthened existing (Arkansas, North Carolina, and Oklahoma) waiting period legislation in 2015. (The new Florida law has been temporarily blocked by the courts; the Oklahoma law is also being challenged, but a state court allowed it to go into effect while the case is pending.) Including these new laws, 27 states have waiting periods in effect. The new laws in Florida and Tennessee require the pregnant person to receive state-mandated abortion counseling in person, meaning that she must make two separate trips to obtain an abortion. With enforcement of the Florida law blocked, 13 states have two-trip requirements in effect.

2. Medication Abortion

Three states sought to use longstanding strategies to restrict access to medication abortion. Arkansas, Idaho, and Kansas enacted new measures banning the use of telemedicine for the provision of medication abortion. Arkansas also mandated use of the regimen specified in the FDA-approved labeling, which bans the use of the newer evidence-based regimen that is less costly, has fewer side effects, and can be used several days later in pregnancy; the law is not in effect due to a court case. Currently, 18 states ban the use of telemedicine and four require providers to follow an outdated medication abortion regimen.

Arizona and Arkansas debuted a new approach to discourage a woman from obtaining a medication abortion. Both states adopted laws requiring doctors to counsel women that the abortion could be stopped if the woman takes a high dose of progesterone after receiving the first of the two drugs included in the medication abortion regimen. According to the American Congress of Obstetricians and Gynecologists, this new approach is based on scant scientific evidence; it relies on a single flawed study of only six cases that did not have oversight by an institutional review board. The Arizona law is blocked pending a legal challenge; the Arkansas law is in effect.

3. Abortions After the First Trimester

Anti-choice lawmakers unveiled a new strategy in 2015 by moving to ban the use of the procedure used most often for second-trimester abortions. Kansas and Oklahoma both enacted measures to ban this safe and medically proven method that has long been used for abortions after 14 weeks; both laws are enjoined pending court action.

West Virginia and Wisconsin enacted laws banning abortion at or after 20 weeks post-fertilization (which is equivalent to 22 weeks after the woman’s last menstrual period). The West Virginia measure is in effect; the one in Wisconsin is slated to go into effect in February. Currently, 12 states have similar bans in effect.

4. Targeted Regulation of Abortion Providers (TRAP)

Even as the stage was being set for the U.S. Supreme Court to review TRAP laws, as we reviewed above, legislative action continued apace in several states. Five states adopted TRAP laws in 2015. Following a 2014 ballot initiative that granted lawmakers the ability to enact virtually limitless abortion restrictions, Tennessee enacted a new TRAP law that requires abortion providers to meet the standards that apply to ambulatory surgical centers even though these centers typically provide more invasive and risky procedures than abortion and use higher levels of sedation than commonly provided in abortion clinics.

Arkansas, Indiana, Ohio, and Oklahoma made existing requirements more stringent.

Family Planning Providers

In the aftermath of the release of a series of deceptively edited sting videos aimed at Planned Parenthood, attempts to defund the organization have flared at both the federal and state levels. By the end of 2015, some 11 states had moved to slash funding either for Planned Parenthood health centers specifically or for any family planning provider that also offers abortion services. A Guttmacher analysis shows that defunding Planned Parenthood could seriously impair women’s access to needed services: In two-thirds of the 491 counties in which they are located, Planned Parenthood health centers serve at least half of all women obtaining contraceptive care from safety-net health centers. In one-fifth of the counties in which they are located, Planned Parenthood sites are the sole safety-net family planning center.

PlannedParenthoodIsCritical

States have targeted a variety of funding streams on which family planning providers rely to fund the breadth of their services and activities, and are likely to continue in this vein in the upcoming 2016 legislative sessions:

Medicaid

Mirroring events in Congress, five states—Alabama, Arkansas, Louisiana, Oklahoma, and Texas—took steps to exclude Planned Parenthood from the Medicaid program in 2015. These efforts were blocked by federal courts in Alabama, Arkansas, and Louisiana; a challenge was just filed in November in Texas. Similar efforts made by Arizona and Indiana in recent years were also rebuffed by federal courts.

Other Family Planning Funding

Following the release of the videos, North Carolina expanded its existing provision blocking state funding of “non-public” family planning providers to explicitly apply to family planning providers that also offer abortion services. (Similar measures to bar funding for family planning providers that offer abortion care were introduced in Illinois, Pennsylvania, and Wisconsin.) In addition, New Hampshire’s Executive Council, an administrative board charged with overseeing large funding streams in the state, excluded Planned Parenthood health centers from receiving federal Title X dollars that flow through the state. (Title X funding that Planned Parenthood receives directly from the federal government is not affected.)

Currently, ten states limit eligibility for family planning funding. Eight of these states—Arizona, Arkansas, Colorado, Indiana, North Carolina, Ohio, Texas, and Wisconsin—prohibit abortion providers from receiving state family planning dollars. Kansas and Oklahoma exclude family planning providers not operated by public entities from eligibility.

Funding for Related Services and Activities

North Carolina and Utah moved to exclude family planning providers from eligibility for funding for related services. Legislation enacted in North Carolina bars family planning providers that offer abortion services from receiving funding for adolescent parenting and teen pregnancy prevention programs. Utah Gov. Gary Herbert (R) directed the state department of health to discontinue any funding for Planned Parenthood health centers, including funding for STI surveillance efforts, STI testing and treatment, and abstinence education; a federal appellate court recently prohibited the state from excluding Planned Parenthood from the funds.

Fetal Tissue Donation and Research

As yet another consequence of the release of the Planned Parenthood sting videos, ten states moved to regulate either the process for fetal tissue donation or biomedical research conducted in the state using fetal tissue resulting from induced abortions. Fetal tissue research has been integral to many of the major medical advances of our age. For example, fetal cell lines were used in the development of the polio vaccine and vaccines for diseases such as measles, mumps, rubella, chickenpox, hepatitis A, and rabies. In short, fetal tissue research has saved and improved the lives of millions of people worldwide.

During the final months of 2015, North Carolina and Arizona moved to regulate fetal tissue donation and research. A law enacted in North Carolina prohibits the sale of fetal tissue for a profit, paralleling federal requirements. Arizona adopted an emergency regulation requiring facilities to report any donation of fetal tissue to the state. Measures related to fetal tissue donation and research were introduced last year in Alabama, California, Michigan, New Jersey, Ohio, New York, and Wisconsin.

Editor’s note: Gwendolyn Rathbun and Zohra Ansari-Thomas also contributed to this analysis.

Roundups Sexual Health

This Year in Sex: It’s Time to Take Action

Martha Kempner

We have the tools to work against sexually transmitted infections, harmful "conversion therapy" for LGBTQ teens, and sexual assault on college campuses. Now, we just have to use them.

This Year in Sex takes a look back at the news and research related to sexual behavior, sexuality education, contraception, sexually transmitted infections, and other topics that captured our attention in 2015.

STIs Are on the Rise in Every Group

This year, it seemed like every week there was a new headline about a rise in sexually transmitted infections or diseases among a specific group, in a certain geographic area, or even among the general population. When states released their 2014 STI data, we learned that Minnesota’s rates hit a record high and that the rate of gonorrhea nearly doubled in Montana between 2013 and 2014. Counties across the country reported rising rates of chlamydia, gonorrhea, and syphilis. California’s Humboldt County, for example, noted a tenfold increase in gonorrhea since 2010, and Clark County, Nevada—home of Las Vegas—reported a 50 percent increase from 2014 in the number of cases of primary and secondary syphilis.

In fact, many of the headlines this year involved syphilis—a curable disease that the United States was once close to eliminating because rates were so low has continued its resurgence. A Department of Defense report, for example, points to a 41 percent increase in the rate of this disease among men in the military. Another disturbing report showed a dramatic rise in the number of babies born with syphilis; congenital syphilis can cause miscarriage, stillbirth, severe illness in the infant, and even early infant death. This reflects both an increase in cases of the disease among women and a lack of prenatal testing that could catch and treat syphilis during pregnancy. This year, there was also an outbreak of ocular syphilis on the West Coast that led to blindness in at least one patient.

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While syphilis is on the rise in both men and women, 90 percent of cases are in men, 83 percent of which are those who have sex with men in cases where the gender of the partner is known.

Young people are also disproportionately impacted by STIs, specifically chlamydia and gonorrhea—54 percent of the cases of gonorrhea and 66 percent of cases of chlamydia reported to the CDC occurred in those younger than 25. Though if detected early and treated, those STIs can be cured, they can also cause future health problems, including infertility.

Perhaps the ultimate headline about STIs this year, however, was the one in which we learned that almost everyone has herpes. A report by the World Health Organization estimated that 3.7 billion people worldwide—or about two out of every three adults across the globe—are infected with herpes simplex virus 1.

All of this news should remind us that sexually transmitted diseases and infections are a public health crisis and we have to up a fight. We need to prevent the spread by educating young people and adults and making condoms readily available. We need to invest in testing that can help people detect STIs before they face many potential health consequences and prevent them from spreading further. And, we need, of course, to provide access to treatment and combat stigma-based fear.

We Know How to Prevent HIV (Now We Just Have to Keep Doing It)

There was a lot of good news this year when it comes to preventing HIV, much of which focused on how well pre-exposure prophylaxis (PrEP) can work. PrEP is a combination of two antiretroviral drugs—tenofovir and emtricitabine—used to treat people who have HIV. When taken daily by people who are HIV-negative, these drugs have been shown to prevent transmission of the virus. In fact, a study by Kaiser Permanente found that since the approval of PrEP in 2012, none of the patients who were using it became infected with HIV. This was actually better than the researchers expected given the findings in clinical trials.

Incorporating PrEP into a multifaceted HIV-prevention program can work, and San Francisco—once a hotbed of the national HIV and AIDS epidemic—proved that, with just 302 new HIV diagnoses in 2014. Getting those HIV-negative residents who are at high risk of contracting the virus onto PrEP is one of the strategies the city uses. In addition, the city provides rapid treatment for the newly diagnosed and continued follow-up appointments to make sure that patients stay on their treatment plan. This can not only help them stay healthy but can prevent the further spread of the virus, as people who adhere to an antiretroviral drug protocol can suppress the virus to the point that they cannot transmit it to others. In San Francisco, 82 percent of residents with HIV are in care and 72 percent are suppressed. This is significantly higher than national statistics, which show that 39 percent of those with HIV are in treatment and only 30 are taking their drug regimen regularly enough to be considered suppressed.

While it will be difficult for many places to adopt a system as expensive as the one in San Francisco, its success shows us that we have the tools we need to prevent HIV. And, in fact, diagnoses of HIV are down in the United States by 19 percent, though the success was not evenly spread: some groups, such as Latino and Black men who have sex with men, are actually seeing increases. It’s time to renew our investment in ending this epidemic for everyone.

Vaccines (Including the HPV Vaccine) Are Not Dangerous, But Skipping Them Is

The year started with a massive outbreak of the measles on the West Coast, so it’s not surprising that there was a lot of conversation about the value of inoculations and what happens when too many people in a certain area are not vaccinated. In the midst of the epidemic and the debate, some schools asked unvaccinated children to stay home, and some states tried to close loopholes that make it easy for parents to opt of required vaccines because of “personal beliefs.”

Unfortunately, many of these personal beliefs are based on false reports and misinformation suggesting that certain vaccines cause autism. A study of anti-vaccine websites found that this misinformation is abundant on the Internet. Of 480 sites dedicated to the anti-vaccine movement, about 65 percent claimed that vaccines are dangerous, about 62 percent claimed vaccines cause autism, and roughly 40 percent claimed vaccines caused “brain injury.” Many of these facts lacked citations, but some were based on misinterpretation of legitimate research.

The scientific truth is that vaccines are safe and have no connection to autism. If there was any doubt, yet another study was released this year confirming it. In fact, the only study that has ever found a connection was proven to be falsified by an unethical researcher who stood to make a profit.

Of course, that didn’t stop the field of Republican presidential hopefuls—which includes two medical doctors—from trying to score political points by suggesting the government may “push” “unnecessary” vaccines.

Though not mentioned by name, they may have been referring to the HPV vaccine, which has always been controversial because of its connection to sex. There seems to be a sense that because HPV is sexually transmitted, vaccinating against it is less important or will give teens permission to have sex. Numerous studies have shown this to be false. One study published this year even found that girls who have gotten the HPV vaccine take fewer sexual risks.

But the fear and misinformation continues, and it turns out doctors might not be helping matters. One study showed doctors may be discouraging the HPV vaccine by not strongly recommending it, not doing so in a timely manner (the CDC advises that vaccinations should start at age 11), and only suggesting it to young people they perceive to be at risk. This could be part of why HPV vaccination rates still lag behind those of other recommended vaccines.

We need to remember that this vaccine prevents cancer. The newest protects against nine strains of the virus and has the potential to prevent 90 percent of cervical, vulvar, vaginal, and anal cancer. And there is reason to believe it will also prevent oral cancer. That’s five cancers prevented by one series of shots.

Of course, like the others, it can only work if our children obtain it. Hopefully, it will not take another outbreak of a preventable disease like measles for us to realize how lucky we are to live in an age in which we know how to stop so many of the diseases that disabled and killed generations before us.

Government Weighs in on ‘Conversion Therapy’

This year saw many positive developments in the struggle for LGBTQ rights, one of which was a willingness of both the White House and many senators to come out against “conversion therapy” for young people. Sometimes called reparative therapy, this is the practice of trying to change a person’s sexual orientation or “cure” their homosexuality. While no legitimate medical organizations sanction such a practice, some young people are subjected to it because their parents or their religion disapprove of same-sex relationships.

Conversion therapy can include anything from Bible study to forced heterosexual dating to aversion therapy, in which patients are shown homosexual erotica and shocked every time they display arousal. Research has found not only that it does not work to change an individual’s sexual orientation, but that it can be harmful and lead to depression, shame, and suicidal thoughts.

In April, the White House released a report condemning the practice for teenagers and asking states to ban it for minors. In an accompanying letter President Obama wrote: “Tonight, somewhere in America, a young person, let’s say a young man, will struggle to fall to sleep, wrestling alone with a secret he’s held as long as he can remember. Soon, perhaps, he will decide it’s time to let that secret out. What happens next depends on him, his family, as well as his friends and his teachers and his community. But it also depends on us—on the kind of society we engender, the kind of future we build.” Two Democratic legislators echoed this sentiment when they offered a resolution asking the Senate to condemn the practice as well, and a report from the Substance Abuse and Mental Health Services Administration attempted to offer parents alternatives that can support LGBTQ young people.

This year Oregon joined those states—including New Jersey, California, and the District of Columbia—that do ban the practice. Furthermore, a challenge to New Jersey’s ban failed when the U.S. Supreme Court turned the case away.

Doing away with harmful practices is a step in the right direction for LGBTQ adolescents, but there is still much more to do in order to protect and educate all of our young people.

We All Continued Talking About Consent

The problem of sexual assault on college campuses was pervasive in the news in 2015. At the end of last year, California became the first state to pass a law mandating affirmative consent on college campuses, also known as “yes means yes.” This year, New York joined it, and other states are considering doing the same.

Affirmative consent has its critics, who say that the standard is unclear and unrealistic in real-life settings. A poll by the Kaiser Family Foundation found that most college students (83 percent) had heard of affirmative consent and many (69 percent) felt it was very or at least somewhat realistic. But when asked whether different scenarios met the standard, students showed a variety of opinions, proving that putting the standard into practice might be tricky.

Still, I believe the conversations about affirmative consent have been useful. They have given us a platform to talk more about the role of alcohol in sexual behavior and sexual assault, and what happens when one is not passed out but clearly very drunk—and therefore incapable of giving consent. We’ve made college students more clearly establish their own boundaries. And educators have been able to both reiterate and go beyond the “no means no” message to talk about what good, consensual sex might look like.

Affirmative consent is not the end-all solution to sexual assault—it won’t, for example, prevent some perpetrators intent on raping. But if we talk about it enough and start before college—California, for example, mandated affirmative consent message in high school—we might have a generation who can think critically about their own behavior and the behavior of others, a generation that is prepared for healthy sexual relationships and knows that, at the bare minimum, a sexual encounter must include consent.