The Politics of Sex

Abortion, HIV/AIDS, abstinence, sex workers ... There is no shortage of controversy when politics collides with the sexual and reproductive health agenda. In a spirited early April discussion, four Bloomberg School researchers share their experiences at the rocky nexus of politics and science.

How influential is the U.S. in global sexual and reproductive health programs and research?

Duff Gillespie: Dollars mean a lot. Very few NGOs concerned with health, very few national governments, very few UN organizations do not receive a significant amount of money from the U.S. government. In Ethiopia, the amount of funds for HIV/AIDS coming from PEPFAR [the President's Emergency Plan for AIDS Relief] is just about the equivalent of the Ethiopians' entire health budget. When a donor of that dominance coughs, people actually pay attention.

Chris Beyrer: I would say ... one of this administration's largest programs is PEPFAR, which I think is important historically because it very explicitly took the control over global HIV/AIDS from the CDC, NIH and other federal agencies that have done a lot of good work around HIV prevention, for example, and put it in the State Department, and set an unprecedented level of political and state control over what is essentially an emergency plan for AIDS relief . ...

Where are we historically in terms of political influence on the sexual and reproductive health agenda? Say, since the 1960s?

Amy Tsui: The dollars may have been fairly steady and steadily increasing, but the administrations' positions on things like family planning wavered a lot. Every 10 years, when we had population conferences, the U.S. delegation position was always different from what it was before.

Were these shifts following the political winds or the latest research?

Tsui: It was hardly evidence-driven. It was likely whatever the administration's philosophy was at the time.

But aren't presidents elected to drive a specific agenda? Don't they have the right to set the policies that they were elected to carry out?

Gillespie: They do. I think the distinction, though, is that [the current administration's] worldview ... is not only not evidence-based, it's counter to evidence. So I think when you have a policy that is ideologically driven and harms people, then I think you do have to speak out.

Beyrer: The question was put to [former Secretary of Health and Human Services] Tommy Thompson that "abstinence only" in sexual health education doesn't have any evidence for efficacy. And he essentially said, That's an old way of thinking. We're not interested in looking at the past, the evidence. We are going to change the paradigm. We're going to fund what we think is the right thing to do, and then generate the [evidence]. Which never happened.

Is it really a conservative mind-set versus science? President Bush after all did create PEPFAR, and President Clinton would not support federal funding for needle exchange.

Gillespie: I've worked in the federal government for over 30 years and never been in an administration that's been so ideologically driven. They have political appointees in the lower reaches of the bureaucracy ... going to meetings and seeing if the proper nomenclature is used. If you're at a meeting and you use, for example, "commercial sex worker," you're likely to get called on it.

David Celentano: That actually happened. People from the conservative think tanks in Washington all of a sudden started coming to [NIH grant review meetings]. It was a very, very odd time because generally you have 15 scientists sitting around dealing with science, and all of a sudden you have these people from faith-based organizations asking questions. It didn't last very long.

When was that?

Celentano: 2003 ... [In a separate incident] we got calls, multiple calls from our NIH handlers, our project officers, to the point where we were asked to change [words] that were in grants.

Such as?

Celentano: Commercial sex worker. To remove it. To get it out of the public domain.

Did you still do the research?

Celentano: We did. We refused to go along with it. I think there was just, you know, momentary panic from the administration officials. It was quickly dropped.

Beyrer: It was an attempt to sort of make hay while the sun shines. Look how your taxpayer dollars are being wasted on this, you know, immoral research. That kind of attempt.

Was your funding withdrawn?

Celentano: Everything was fully funded. Everything has been renewed. It really hasn't had any long-term effects, although today I don't use the word "prostitution" or "sex worker" in an abstract. We talk about women, vulnerable women, women at high risk, just to avoid getting picked off. Can I back up a little bit? ... I think we need to address Bill Clinton and the needle exchange. In recent interviews that he's given, he's basically said one of the greatest regrets he's had in his presidency was not standing up to the opponents of the needle exchange program. And literally tens of thousands of people dying as a result of not having access to clean needles.

Gillespie: Well, that was one of many disappointments of the Clinton administration. That administration was very strong on rhetoric. Not very strong on action. You must give the Bush administration their due. What they've done in malaria and TB and health infrastructure, I mean there are a lot of good things that they have done. ...

Tsui: What's so disappointing ... is you look to the United States' political leadership to be the most informed. There is absolutely no excuse for them not to be informed. There is so much science that is generated here, and yet in the face of all of that, they adhere to these unusual, distorted trains of thought that then have repercussions.

As scientists, how hard do you push back? Or engage in advocacy?

Gillespie: As many people have said, public health is politics. It's unavoidable. Some [people] in the public health community must get engaged in that process in a constructive, evidence-based way. Otherwise you don't have public health. The past eight years—it's going to take a long time to get this damage out. Even us, who I think are strong, [we] are influenced in subtle ways through self-censorship, through second-guessing things that we would not have second-guessed in terms of doing something or writing something.

Tsui: I think what's so important about public health is that it's essentially a democratic construct. I remember when I was trying to find schools of public health in South Africa and Russia, where democracy was not yet embedded. They didn't understand what public health was. They didn't understand that everybody had a right to health. Public health is, in fact, something that is everybody's. It's a right for every country. It's a right for every individual. And it requires almost a democratic kind of thinking to promote itself.