Analysis Sexual Health

Why the CDC Stopped Calling Sex Without a Condom ‘Unprotected Sex’

Martha Kempner

For many years, the term “unprotected sex” has been synonymous with “sex without a condom." But some HIV advocates argue that this language is outdated and imprecise, and the CDC has agreed to change it.

For many years, the term “unprotected sex” has been synonymous with “sex without a condom,” and we’ve been told that the only real way for sexually active individuals to protect themselves from sexually transmitted diseases (STDs), including HIV, is to use a condom every time during sex.

Though we know everyone hasn’t followed this advice, the idea became so ingrained in our conversations about safer sex that it was clear protected sex equaled sex with a condom, while unprotected sex equaled sex without one. Some HIV advocates argue, however, that in this day and age of HIV treatment, pre-exposure prophylaxis (PrEP), and behavior changes that can decrease risk, this language is no longer accurate or precise. To that end, in December, a group of advocates, spearheaded by the HIV Prevention Justice Alliance, sent a letter to the Centers for Disease Control and Prevention (CDC) requesting a terminology change.

In January, the CDC announced on a call with more than 80 advocates that it would indeed change the decades-old language. Now, instead of referring to “unprotected sex” to mean sex without a condom, the CDC will refer simply refer to it as “condomless sex.”

The advocates’ argument hinges on the fact that there are now multiple ways to have safer sex when the goal is preventing HIV transmission. Condoms obviously still play an important role, but there are other ways individuals can protect themselves as well. Many HIV experts, for example, talk about treatment as prevention. Individuals who are on antiretroviral therapy (ART), which suppresses the replication of HIV, often have an undetectable viral load (a measure of the number of copies of HIV in a given blood sample). Though it is possible to transmit HIV even when one’s viral load is very low, it is much less likely.

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Another, newly available prevention method for HIV is referred to as PrEP. In 2011, the Food and Drug Administration (FDA) approved the use of an existing HIV medication called Truvada, a once-daily pill designed to prevent infection. Studies have shown that it is effective. For example, one study among men who have sex with men (MSM) found that those who were given PrEP were 44 percent less likely to contract HIV than those who weren’t. Moreover, those who remembered to take their medication every day or almost every day saw a reduction in risk of 73 percent or even more (some up to 92 percent). Similar studies of HIV discordant, heterosexual couples found that PrEP reduced the risk of the uninfected partner becoming infected by 75 percent, or as much of 90 percent among those who took the pill every day or almost every day.

Advocates also note that some couples, men who have sex with men in particular, use practices knows as serosorting and seropositioning to reduce their risk. Serosorting essentially means limiting condomless anal intercourse to those partners with the same HIV status as themselves. The CDC, however, does not consider this to be a safer sex practice:

Serosorting is not recommended because: (1) too many MSM who have HIV do not know they are infected because they have not been tested for HIV recently, (2) men’s assumptions about the HIV status of their partners may be wrong, and (3) some HIV-positive men may not tell or may misrepresent their HIV status. All of these factors increase the risk that serosorting could lead to HIV infection.

Seropositioning is the practice by which men who have sex with men choose their position (as the insertive or receptive partner) based on sero-status; the HIV-positive partner would be receptive, as there is less risk that he transmits HIV in that position. Again, this assumes partners have accurate knowledge of their own and each other’s status.

Though there is some disagreement over the safety benefits of these behavioral practices, there is agreement that the landscape of HIV prevention has changed. Suraj Madoori, coordinator of the HIV Prevention Justice Alliance at the AIDS Foundation of Chicago, told Rewire via email that the language change “opens doors for us to discuss the myriad of challenges and progress on effective methods of HIV prevention. By continuing to use ‘unprotected sex’ to mean ‘condom-less sex’ you fail to acknowledge and lose the breadth of the entire prevention narrative in how individuals and groups choose to protect themselves and mitigate risk.”

Jim Pickett, director of prevention advocacy and gay men’s health at the same organization, said in an email, “Of course, there are gradations of risk and safety. The only truly ‘safe’ act is to not have sex, right? Anything else has some level of risk—even oral sex (though you are more likely to get hit by lightning twice than get HIV from oral sex).”

A spokesperson for the CDC told the Bay Area Reporter that the changes have been under assessment for some time because, as “HIV prevention strategies evolve, the terminology needs to evolve as well.”

Other HIV experts welcomed the change as well. Dr. Kenneth Mayer, medical research director and co-chair of the Fenway Institute at Boston’s Fenway Health, told the Reporter, “Unprotected sex conveys a sense of irresponsibility that may not accurately reflect a person’s decision about how to avoid HIV and other STD’s.” 

“For example,” he added, “someone in a committed monogamous relationship may decide not to use condoms after having been screened for HIV and STDs, and coming to an agreement with a partner about not engaging in intimate relations with others. It would be rare to refer to a heterosexual couple trying to conceive as engaging in ‘unprotected sex.’”

Todd Heywood echoes this in his piece for HIV Plus Magazine in which he writes:

Ultimately, this change holds the opportunity to shift the conversation in the gay community about clean and dirty gays, and good and bad gays — and instead put the focus on actual risk and prevention.

How this language change will play out in the long term is not yet known. For example, it’s not clear whether the CDC will continue to use the phrase “unprotected sex” to refer to sex in which no HIV prevention methods are used or when discussing STDs other than HIV, or whether it will simply retire the term altogether. The HIV Prevention Justice Alliance says it plans to meet with the agency later this month to discuss the change further.

It is also not clear how the rest of the public health community, specifically those who focus on other STDs, will react to the change or how likely they will be to adopt it, as the new prevention methods it is designed to include apply only to HIV. Condoms still remain the only way for sexually active couples to reduce their risk of chlamydia, gonorrhea, syphilis, and other diseases, which means that sex without a condom leaves individuals unprotected against these diseases. Moreover, many public health experts have feared that as alternative HIV-prevention methods become more popular among men who have sex with men, condoms will become less popular, leaving men open to other STDs. A recent study, however, shows that this fear may be unfounded, as people on PrEP were not more likely to engage in risky sexual behavior. That said, rates of other STDs are on the rise, and men who have sex with men are disproportionately affected.

It will be interesting to see how the new language becomes incorporated in messages about HIV and other STDs and if other organizations will follow the CDC’s lead.

Correction: A version of this article included an incorrect spelling of Suraj Madoori’s name. We regret the error.

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.

Commentary Politics

No, Republicans, Porn Is Still Not a Public Health Crisis

Martha Kempner

The news of the last few weeks has been full of public health crises—gun violence, Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography.

The news of the last few weeks has been full of public health crises—gun violence, the Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography. Without much debate, a subcommittee of Republican delegates agreed to add to a draft of the party’s 2016 platform an amendment declaring pornography is endangering our children and destroying lives. As Rewire argued when Utah passed a resolution with similar language, pornography is neither dangerous nor a public health crisis.

According to CNN, the amendment to the platform reads:

The internet must not become a safe haven for predators. Pornography, with its harmful effects, especially on children, has become a public health crisis that is destroying the life [sic] of millions. We encourage states to continue to fight this public menace and pledge our commitment to children’s safety and well-being. We applaud the social networking sites that bar sex offenders from participation. We urge energetic prosecution of child pornography which [is] closely linked to human trafficking.

Mary Frances Forrester, a delegate from North Carolina, told Yahoo News in an interview that she had worked with conservative Christian group Concerned Women for America (CWA) on the amendment’s language. On its website, CWA explains that its mission is “to protect and promote Biblical values among all citizens—first through prayer, then education, and finally by influencing our society—thereby reversing the decline in moral values in our nation.”

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The amendment does not elaborate on the ways in which this internet monster is supposedly harmful to children. Forrester, however, told Yahoo News that she worries that pornography is addictive: “It’s such an insidious epidemic and there are no rules for our children. It seems … [young people] do not have the discernment and so they become addicted before they have the maturity to understand the consequences.”

“Biological” porn addiction was one of the 18 “points of fact” that were included in a Utah Senate resolution that was ultimately signed by Gov. Gary Herbert (R) in April. As Rewire explained when the resolution first passed out of committee in February, none of these “facts” are supported by scientific research.

The myth of porn addiction typically suggests that young people who view pornography and enjoy it will be hard-wired to need more and more pornography, in much the same way that a drug addict needs their next fix. The myth goes on to allege that porn addicts will not just need more porn but will need more explicit or violent porn in order to get off. This will prevent them from having healthy sexual relationships in real life, and might even lead them to become sexually violent as well.

This is a scary story, for sure, but it is not supported by research. Yes, porn does activate the same pleasure centers in the brain that are activated by, for example, cocaine or heroin. But as Nicole Prause, a researcher at the University of California, Los Angeles, told Rewire back in February, so does looking at pictures of “chocolate, cheese, or puppies playing.” Prause went on to explain: “Sex film viewing does not lead to loss of control, erectile dysfunction, enhanced cue (sex image) reactivity, or withdrawal.” Without these symptoms, she said, we can assume “sex films are not addicting.”

Though the GOP’s draft platform amendment is far less explicit about why porn is harmful than Utah’s resolution, the Republicans on the subcommittee clearly want to evoke fears of child pornography, sexual predators, and trafficking. It is as though they want us to believe that pornography on the internet is the exclusive domain of those wishing to molest or exploit our children.

Child pornography is certainly an issue, as are sexual predators and human trafficking. But conflating all those problems and treating all porn as if it worsens them across the board does nothing to solve them, and diverts attention from actual potential solutions.

David Ley, a clinical psychologist, told Rewire in a recent email that the majority of porn on the internet depicts adults. Equating all internet porn with child pornography and molestation is dangerous, Ley wrote, not just because it vilifies a perfectly healthy sexual behavior but because it takes focus away from the real dangers to children: “The modern dialogue about child porn is just a version of the stranger danger stories of men in trenchcoats in alleys—it tells kids to fear the unknown, the stranger, when in fact, 90 percent of sexual abuse of children occurs at hands of people known to the victim—relatives, wrestling coaches, teachers, pastors, and priests.” He added: “By blaming porn, they put the problem external, when in fact, it is something internal which we need to address.”

The Republican platform amendment, by using words like “public health crisis,” “public menace” “predators” and “destroying the life,” seems designed to make us afraid, but it does nothing to actually make us safer.

If Republicans were truly interested in making us safer and healthier, they could focus on real public health crises like the rise of STIs; the imminent threat of antibiotic-resistant gonorrhea; the looming risk of the Zika virus; and, of course, the ever-present hazards of gun violence. But the GOP does not seem interested in solving real problems—it spearheaded the prohibition against research into gun violence that continues today, it has cut funding for the public health infrastructure to prevent and treat STIs, and it is working to cut Title X contraception funding despite the emergence of Zika, which can be sexually transmitted and causes birth defects that can only be prevented by preventing pregnancy.

This amendment is not about public health; it is about imposing conservative values on our sexual behavior, relationships, and gender expression. This is evident in other elements of the draft platform, which uphold that marriage is between a man and a women; ask the U.S. Supreme Court to overturn its ruling affirming the right to same-sex marriage; declare dangerous the Obama administration’s rule that schools allow transgender students to use the bathroom and locker room of their gender identity; and support conversion therapy, a highly criticized practice that attempts to change a person’s sexual orientation and has been deemed ineffective and harmful by the American Psychological Association.

Americans like porn. Happy, well-adjusted adults like porn. Republicans like porn. In 2015, there were 21.2 billion visits to the popular website PornHub. The site’s analytics suggest that visitors around the world spent a total of 4,392,486,580 hours watching the site’s adult entertainment. Remember, this is only one way that web users access internet porn—so it doesn’t capture all of the visits or hours spent on what may have trumped baseball as America’s favorite pastime.

As Rewire covered in February, porn is not a perfect art form for many reasons; it is not, however, an epidemic. And Concerned Women for America, Mary Frances Forrester, and the Republican subcommittee may not like how often Americans turn on their laptops and stick their hands down their pants, but that doesn’t make it a public health crisis.

Party platforms are often eclipsed by the rest of what happens at the convention, which will take place next week. Given the spectacle that a convention headlined by presumptive nominee (and seasoned reality television star) Donald Trump is bound to be, this amendment may not be discussed after next week. But that doesn’t mean that it is unimportant or will not have an effect on Republican lawmakers. Attempts to codify strict sexual mores are a dangerous part of our history—Anthony Comstock’s crusade against pornography ultimately extended to laws that made contraception illegal—that we cannot afford to repeat.