Abstinence, Evidence, and Analogies
In August, I wrote about a comment published in The Lancet arguing that UN resolutions should stop promoting abstinence and fidelity as central components of HIV prevention. The authors of that comment positioned themselves as proponents of evidence over ideology:
“With scientific evidence rather than dogma, countries should adopt and implement a progressive agenda to end AIDS and ensure sexual health and wellbeing for all.”
This trope of science over religious teaching is a frequent feature of arguments that are profoundly ideological in their own right. The sentence above casually refers to the “is” of empirical observation and immediately pivots to the “should” of worldview-infused policy prescriptions.
But policymaking is inherently prescriptive, so we may as well lay our cards on the table: we’re all ideological to some extent, whether that is informed by religion or some other philosophical tradition. (As an aside, there are few people more dogmatic in their pronouncements these days than those who claim to eschew dogma.)
Returning to the debate over abstinence as a feature of UN resolutions, and of public health more broadly, the Lancet recently published some further correspondence related to the original comment. Chika Edward Uzoigwe and Luis Carlos Sanchez Franco responded that while not all abstinence-based programs are equally effective, the effectiveness of abstinence, delay of sexual debut, and reducing the number of sexual partners in HIV prevention is unquestionable.
Uzoigwe and Sanchez Franco draw an analogy to two other important public health concerns: smoking and nutrition:
“[T]he primary message from the CDC is single-minded, uncompromising, and unequivocal that smoking kills and smoking cessation results in substantial health benefits. Evidence that this message does not dissuade the annual 1-2 million new smokers could never justify abdicating our professional responsibility to highlight behaviour and practices that engender low risk and those that attract high risk. The same would apply to diet, exercise, and sexuality.”
The authors of the original piece, Kent Buse, Sarah Hawkes, and Mikaela Hildebrand, responded, taking issue with some of the analogies used by Uziogwe and Sanchez Franco:
“They cite tobacco and advocate for abstinence—omitting to mention the absence of any known health benefits from smoking. A better analogy would be nutrition. Several undesirable effects can happen if people eat the wrong foods or too much of the right foods. It is our duty as health professionals not to stop them from eating but to guide them to healthy eating choices.”
Admittedly, both analogies fall short, as all analogies inevitably do at a certain point. In addition to imparting no health benefits, smoking is entirely optional. Food, on the other hand, is not only something that can improve health if eaten in accordance with basic nutritional guidelines, but is also essential not only for quality of life but for life itself. Protracted abstinence from sex may be undesirable, but prolonged abstinence from food is lethal. Buse and colleagues go on:
“We posit that there are many health benefits from pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. But in the real world there are risks from unsafe sex, including unintended pregnancies, STIs, and HIV. Hence, we support programmes based on evidence to reduce those risks—rather than specious notions of abstinence (for how long?) or reducing the number of sexual partnerships (what would a safe number be exactly?).”
This knee-jerk fatalism is surprising in juxtaposition to the immediately previous reference to the “undesirable effects” of eating “the wrong foods or too much of the right foods.” How exactly do Buse and colleagues think we came up with our notions of what constitutes good nutritional behavior? Could a similar approach not be taken to sexual behavior? What exactly is “specious” about promoting abstinence until marriage and fidelity within marriage as an ideal, both from the perspective of epidemiology and human flourishing more broadly?
The claim of “health benefits from pleasurable and safe sexual experiences” likewise needs to be examined more closely: at a minimum, it would seem to be highly context-specific with regard to the age of the individuals, the nature and stability of their relationship, the presence of any concurrent partners, and other factors such as drug or alcohol use. For instance, there is little evidence to suggest that sexual activity among adolescents is at all beneficial to their well-being or correlated with better life outcomes.
Returning once more to the food analogy, public health policy deals not only with the nutritional value of various types of food, but also with its provenance and history within supply chains. For a produce-rich diet to be truly healthy, it follows that the produce must be free from illness-producing pathogens. Similarly, the promise of a healthy and pleasurable sex life can be rapidly undercut by needless exposure to risk from many partners. In a context where sexually transmitted infections are rapidly spreading and, worryingly, increasingly resistant to treatment, it is highly irresponsible to suggest that the number of sexual partners, or the concurrence of multiple partners, does not matter and should not be the focus of health policy.
In closing, Buse and colleagues allude to the larger debate:
“There exists a wider morality-driven, political project that seeks to limit sexual rights—including prohibiting comprehensive sexuality education, abortion, and same-sex sexual relations. Once again, we see that ensuring sexual and reproductive health and rights for all requires more than evidence, it requires managing the inherent politics therein.”
At last, they admit that this isn’t really all about evidence after all, but a competing political project set up in opposition to the “morality-driven” one, or a secular “dogma” under another name.