“BARRIERS” TO THE CONDOM’S PUBLIC HEALTH BENEFITS

About Thomas Auen: As a graduating senior from Grinnell College, I’m making my way to Boston where I will continue my education and science applications as a research assistant. With a major in biological chemistry, my new position in the Department of Endocrinology at Boston Children’s Hospital and Harvard Medical School will allow me to gain new experience as I pursue a Ph.D. or M.D. in the future years. Based on previous coursework in public health and a personal interest in social influences on the medicine and healthcare, I found this investigation of the condom eye-opening. With a historical narrative that assesses the public’s shifting opinions of condom-based prophylaxis, I believe one could easily model evidence-based solutions to promoting better public health measures against current venereal disease issues and STIs.

NOT-SO-HUMBLE BEGINNINGS

Smart phones and…condoms? Yes, public health programs are taking the initiative to combine phone apps with health-based projects. Case and point, the Find Condoms NYC app.[1] With the ability to scan the New York Health Department’s list of over a thousand sites that distribute free condoms, the initiative hopes to help teens find free, confidential aids to prevent pregnancy and STDs. These modern examples of the condom’s contraceptive and prophylactic purposes contradict previous views on the protective sheath. As a matter of fact, the condom’s past has seen opposition from social-based moral issues and politically-aligned campaigns, specifically in World War I and the 1980’s HIV/AIDS epidemic. Historically though, the condom’s stigma stems back to the sixteenth century.

First described by Gabriello Fallopio within his De morbo gallico in 1564, “the animal gut moistened and tied at the end before use” was a useful prophylactic against syphilis.[2] With syphilitics symbolizing sexual corruption and socially degraded individuals, the unfortunate condom quickly received a stigmatized label: the lascivious tool of a bodily punished sinner. Even at a time with high venereal disease prevalence and an expected demand, the condom remained a limited and expensive commodity until the 1860’s. However, once Goodyear and Hancock developed and improved upon their vulcanization process, the mass-produced rubber condom hit the market with surprising consumption.[3]

The condom’s innovative period fell short with the introduction of the Comstock Act in 1873, which outlawed the condom’s sale to the general public. As the Comstock Act clearly stated, “”Every obscene, lewd, or lascivious…article or thing intended or adapted for any indecent or immoral use…shall not be conveyed in the mail, nor delivered from any post-office, nor by any letter-carrier.”[4] Aligning with societal opinions, the condom developed as a threat to late-nineteenth century morals. Rather than distribute an item granting individual protection from venereal disease, public health officials emphasized continence and self-control as the best way to remain healthy. This late nineteenth century mindset would carry past the turn of the century and continue to shift the projection of disease-based interventions, particularly in World War I.

WORLD WAR I

As the world entered the Great War and fit young men were contracted into the fight, older officers felt it unlikely “to expect the youngsters to keep the trenches…intact, and their chastity inviolable at one and the same time.”[5] This made the challenges of war all the more difficult as soldiers were given demotions or docked in pay if they contracted a venereal disease. By the time Woodrow Wilson announced America’s entrance into WWI in the spring of 1917, military programs worked to counter the soldiers’ temptations in training or deployment overseas. With thirteen percent of the originally drafted men having positive diagnosis of syphilis or gonorrhea before deployment, emphasis was thrown into the Commission of Training Camp Activities (CTCA) and the Young Men’s Christian Association (YMCA) to curb the men’s sexual appetite.[6]

Within these programs, the use of published pamphlets and lecture series were essential to spreading the anti-sex message among troops. The most widely distributed Keeping Fit to Fight pamphlet explicitly emphasized the importance of social hygiene. The document’s authors wrote that, “A venereal disease contracted after deliberate exposure through intercourse with a prostitute is as much of a disgrace as showing the white feather…You lessen the man-power of your company and throw extra burdens on you comrades.”[7] Thus, the attitude of prophylactics turned sour as men were encouraged to abstain from sexual activity rather than don a condom to allow protective sex. Morals entrenched in troop programming, it seemed, were trumping the importance of public health measures.

American troop programming followed the surgeon general’s six-step approach to solve venereal disease issues.[8] First, amusement tried to keep the soldier’s minds off of sex. In more extreme cases, the second step involved temperance-based social programming to remove alcohol-based sexual actions. Inspections of all soldiers were held as the third step to ensure no one was hiding a venereal disease capable of spreading to others. Similarly, the fourth step enforced all men found harboring venereal disease to receive treatment until non-infectious. Lectures about venereal effects were a fifth step meant to circumvent the sixth and last resort,chemical prophylactics.

Absent from this methodology, condoms remained removed as a measure of silencing the spread of syphilis. During WWI, American society focused on the protection of a nuclear family unit while remaining moral straight. According to the opinion of the generals planning social hygiene campaigns, “not only will men bring back into the social structure a vast volume of venereal disease to wreck the lives of innocent women and children, but they will bring back into it other attitudes and practices which will destroy homes, cause misery, and degenerate society.”[9] Thus, the condom was seen as a device to instill continued promiscuity rather than an effective prophylactic.

Unlike American forces, British and New Zealand army regiments did not hold back from condom use.[10] Though their implementation was not enthusiastically promoted, studies conducted at the time showed that providing condoms as a means to lower venereal disease could be effective. Specifically, one study shows that condoms lowered gonorrhea rates from 625 to 35 infections out of 1000 exposures.[11] However, the American forces would learn a valuable and hard lesson about preventing sexual infections. Even with the campaign’s emphasis on chastity and fear mongering, only thirty percent of the troops who fought in France managed to abstain from sex.

In the time between WWI and WWII, the condom’s prophylactic efficacy would promote a loosening of the Comstock regulation. In fact, the 1920’s saw a rise in the production and sale of condoms to prevent syphilis and gonorrhea. By the 1930’s, court cases like United States vs. One Package had initiated the beginning of the end of Comstock’s morality crusade.[12] Instead, the public accepted the necessity of sexual tools used for prevention of illness, the promotion of health, and the protection of citizens from contagion. However, the condom would be brought back into debates of public health, specifically in the 1980’s.

THE HIV/AIDS OUTBREAK

A silent threat, unknown to scientists and lay people, emerged in the early 1980’s. As the Center for Disease Control (CDC) continued active surveillance of the situation, reports become more prevalent as the strange pneumonia-like illness quickly became associated with gay communities across America. By the decade’s end, 27,408 individuals had succumbed to this new disease called AIDS.[13] In the epidemic’s early stages, the response among the gay male community was pivotal to curbing the disease’s full, lethal potential.

That’s not to say there was an ease in changing the gay public’s perceptions on protective sex. Epidemiological surveillance data collected during the early 1980’s highlight this challenge. In a study done in San Francisco during 1983, gay men were surveyed to understand sexual behavior and attitudes toward safe sex.[14] Non-monogamous relationships showed a decrease in unprotected anal intercourse following informative sessions on prescribed behavior for AIDS risk reduction. Likewise, men not in relationships reported substantial reductions in high-risk sexual activities.

Acting as “a driving force in responding to the epidemic and seeing how change is made”, two individuals living with AIDS in New York were able to impact the suffering community.[15] Michael Callen and Richard Berkowitz helped spread an essential idea in preventing the spread of the HIV virus: use of a condom when having sex with other men. However, larger campaigns across America butted heads in how they promoted the condom. While gay groups in Los Angeles, San Francisco, and New York worked to sexualize safety, they quickly met opposition from the federal government.

In 1987, Congress banned federal funding for homosexual-oriented AIDS prevention and education campaigns. Federal programs, instead, tried to homogenize AIDS awareness.  As noted by a New York Times reporter, “Much of the government’s $600 million budget was used to combat disease among college students, heterosexual women and others who faced a relatively low risk of contracting the disease.”[16] Nevertheless, gay grassroots groups challenged federal actions. With the condom acting as a symbol in poster and visual promotions, smaller health education resources took the initiative typically handled by public health initiatives.

Creative tactics proved difficult to model, especially since “until recently gay men had as much interest in condoms as Eskimos [did] in air conditioning.”[17] With this opening line, the San Francisco AIDS prevention campaign designer Les Pappas addressed the CDC and geared his remarks to an audience of public health officials and condom manufacturers. His example demonstrates how AIDS activists were able to use the condom to circumvent the CDC and federal government. The answer: capitalistic ventures. With 25 million gay consumers waiting for the government and private industry to fill a demand for protective sex, the lucrative spin caught the government and manufacturer’s attentions.[18] With an all-inclusive market, the following decade witnessed the condom’s rebirth as an instrument of disease prevention.

PROTECTIVE REFLECTIONS

When one juxtaposes current condom opinions with stances taken during WWI or the 1980s HIV/AIDS epidemic, it is clear that things have drastically changed. Restrictions by the Comstock Act worked against the condom’s ability to save troops from venereal disease in WWI. At a time when the condom could have aided Allied forces, American forces sought an image of the honorable family man capable of circumventing his sex drive in order to serve his country. With the end of the War, ideas of abstinence and morality were shown to be ineffective in protecting soldiers from syphilis or gonorrhea contraction.

By the 1980s, AIDS brought the condom back into the public health sphere. Families now accepted the condom as a prophylactic and contraceptive, but the previous era’s stigma shifted toward the gay community. Individuals suffering from AIDS and working to promote condom distribution among their fellow communities felt back-lash though a lack of federal funding. But once research indicated heterosexual couples or cross-contamination by needles could spread HIV/AIDS, the issue soon required intervention. By the 1990s, a combination of capitalistic mentality and governmental public health interventions would raise the condom to a position similar with our understanding today. Thus, these historical “barriers” to the condom’s effective use in public health suggest the ability of public opinions to eclipse prevention, protection, and promotion of greater social well-being.

[1] Nancy Shute, “Looking For Free Condoms? There’s A Health Department App For That”, accessed 7 May 2016 http://www.npr.org/sections/health-shots/

[2] R. Davenport-Hines, Sex, Death, And Punishment, (London: Collins, 1990): 52.

[3] Ron O. Valdeserri, “Cum Hastis Sic Clypeatis: The Turbulent History of the Condom,” Bulletin of the New York Academy of Medicine 64, no. 3 (1988): 239-240.

[4] “Anthony Comstock’s Influence”, accessed 13 May 2016, http://www.case.edu/affil/skuyhistcontraception/online-2012/Comstock.html

[5] R. Davenport-Hines, Sex, Death, And Punishment, 180.

[6]Allen Brandt, No Magic Bullet, (New York: Oxford University Press, 1985): 59-61.

[7] Ibid: 62-63.

[8] Ibid: 98.

[9] Ibid: 57.

[10] I. Palmer,”Sexuality and Soldiery Combat & Condoms, Continence & Cornflakes,” JOURNAL-ROYAL ARMY MEDICAL CORPS 149, no. 1 (2003): 39.

[11] Valdeserri, “Cum Hastis Sic Clypeatis”, 241.

[12] Joshua Gamson, “Rubber Wars: Struggles Over the Condom in the United States,” Journal of the History of Sexuality 1, no. 2 (1990): 269.

[13] Natasha Geiling, “The Confusing And At Times Counterproductive Response To The AIDS Epidemic”, accessed 7 May 2016, http://www.smithsonianmag.com/history/

[14] Leon McKusick, “AIDS and Sexual Behavior Reported by Gay Men in San Francisco,” American Journal of Public Health 75, no. 5 (1985): 496.

[15] Geiling, “The Confusing And At Times Counterproductive Response To The AIDS Epidemic.”

[16]  Ibid

[17] Jennifer Brier, Infectious Ideas: US Political Responses to the AIDS Crisis, (Univ of North Carolina Press, 2009): 45

[18] Ibid: 46.

For Further Reading, See The Following Sources:

Collier, Aine. The Humble Little Condom: A History. Massachusetts: Prometheus Books, 2007.

Frieden, Thomas R., Moupali Das-Douglas, Scott E. Kellerman, and Kelly J. Henning. “Applying Public Health Principles to the HIV Epidemic.” New England Journal of Medicine 353, no. 22 (2005): 2397-2402.

Schneider, M.J. Introduction to Public Health. New York: Jones and Bartlett Publishers, 2013.

Youssef, Henry. “The History of the Condom.” Journal of the Royal Society of Medicine 86, no. 4 (1993): 226-228.