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A Public Health Rant

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I’m in the middle of writing an academic paper on the effect of drug and alcohol use on contraceptive decision-making [edit: I actually originally wrote this post a couple of years ago, and the paper was eventually published here]. For many years, I’ve been a researcher in the public health world. But I’m a long way from being one of the people who actually has much influence over what doctors and public health professionals actually do.

When I started this research years ago, I’d never slept with anyone except my husband. I wasn’t exactly one of the people that public health professionals spend much time worrying about. And while I’ve still never had a drink or smoked a cigarette, I’m continually frustrated by the abysmal failure of the public health world to cope with the real lives of people like me, who live relatively “high-risk” sexual lives.

For starters, there’s the fact that my insurance doesn’t want to cover multiple STI (Sexually Transmitted Infection) tests a year. What the fuck??? When I went to the doctor in March and asked for more STI tests (I had been tested in January), they told me that it had been too recently since my last test. I blinked at them and sputtered, “But I’ve slept with a lot of people since then!”

It’s clearly in the best interest of the public as a whole (not to mention me and my partners) for me to get tested regularly. For Goddess’ sake, I can’t even calculate the extent of my overall potential disease network (I can calculate the very short fluid-bound intercourse network, but not the condoms-and-unprotected-oral-sex network). I would wager large sums of money that within three degrees of separation (my partners’ partners’ partners) that there are well over 100 concurrent people in it. It might very well be a helluva lot more than that. That’s an entire small community worth of people. Can’t my doctor just declare me to be a “high-risk case” and recommend me for more testing? Instead, I had to learn the code words that “a condom broke” or a “partner experienced symptoms” to get my insurance to cover more tests. Good grief. I’m 31-years-old and I don’t enjoy going to the doctor’s. I don’t get tested for kicks.

Then there’s the fact that the public health people really really really don’t get it. My doctor asked me if I had had “any new partners” since the last time I was in for an appointment. I realize that I haven’t explained my life in very great detail to her, but I’ve explained that I’m non-monogamously married, so she should know that me having a new partner only encompasses a relatively small portion of my overall STI risk. Back to that whole disease-network issue: what matters is what me and my partners and my partners’ partners are doing. The public health community really isn’t prepared to grasp the particular STI risks of people who maintain concurrent multiple partners.

And then there’s the way that the places that do offer cheap or nearly free testing tend to treat people when they go in. So far, I’ve been fortunate and never once been condescended to by a doctor when I went in for STI testing, but I’m guessing have a Ph.D. helps a lot with that. My husband complains that every time he goes in for testing, the doctors just look at him skeptically and seem to be assuming that he’s cheating on me (we got around this tidily one time by simply going in together, but that isn’t always practical). Other partners of mine have complained that doctors were extremely patronizing to them when they went in for testing. Medical condescension is not helpful. If you’re smart enough to be at the testing clinic, you’re smart enough to know that what you’re doing is risky. Doctors don’t need to lecture the people who are there getting responsibly tested. The people they need to lecture are the people who aren’t there. Lecturing people who’ve had the good sense to calculate their level of risk and realize that it’s not low just makes those people not want to come back and do the right thing. It’s like when teachers yell at the beginning of class about how “many students are late to this class”: it’s an understandable frustration directed at the wrong people. When people show up for preemptive testing (that is, symptom-free testing), say, “I’m so glad you’re here. Do you have any questions? Have some condoms! Please come back soon!”

It doesn’t apply to me personally, but I’m also frustrated by the total failure of the public health community to deal with the fact that the vast majority of “high-risk” sexual encounters (that is, casual sex with someone a person doesn’t know well) typically occur under the influence of drugs and alcohol. I haven’t figured out yet how to deal with that fact better, but I know that just assuming that telling people over and over again to use condoms will solve the problem is probably insufficient. In general, one of the great paradoxes of the public health world (that the medical community is totally blind to) is that the kinds of people who are most likely to have casual sex are the kinds of people who are most likely to be lousy contraceptors (hence my paper linked to above). Currently, The Condom Message has mostly penetrated the ears and brains of the people who are actually at very low risk (obviously, me and many of my friends would be an exception here…). I don’t know what to do about this problem other than to try to teach people to put condoms on bananas while intoxicated (or encourage them to put in female condoms while they’re still sober, but Goddess help a drunk person trying to use one of those things). What I do know is that a lot more smart people need to be putting their brains into solving this problem.

In conclusion, doctors and public health professionals need to start figuring out how to politely and successfully help people manage their changing sexual health risks in a world where traditional monogamy is becoming less popular overall, and where the average age of marriage just keeps going up and up (while the average age of virginity loss stays about the same). Current estimates say that 25% of young American adults will never marry, and our best-guess data suggest that various forms of consensual non-monogamy are becoming more popular. However, I can report that a growing body of research suggests that ethically non-monogamous people are, somewhat ironically, probably a lower STI risk to one other than “monogamous” people. Here’s the most recent study to say so. Go figure.

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