Thursday, July 31, 2008

Abstinence thongs

Finally. More abstinence-themed thongs

Australian abstinence-only controversy: separation of church and state

The abstinence-only sex education (AOSE) movement was started under the early Reagan administration after prompting by the newly-energized Christian right, and expanded as different churches created curricula, most notably the Southern Baptist Conference's True Love Waits program in the early 1990s. AOSE has never, as far as I'm aware, been promoted in a purely secular context, but secular curricula have been written by organizations which are either religious or run by evangelical Christians. The curriculum I'm most aware of is the Catholic church's Pure Love program, which has both secular and religious versions of their virginity pledge.

Apparently, the same is true in Australia --- a pro-abstinence (though not abstinence-only, it sounds like) curriculum originally written by Presbyterian and Baptist churches is taught in some schools, and a member of Parliament is protesting that because the curriculum is more conservative than the beliefs of most Australians (80% of whom approve of abortion choice) and violates requirements that school instruction be secular.

I'm sympathetic to that position, but to play devil's advocate for a moment: is there any such thing as a secular sex ed curriculum? For every sex ed curriculum, there's some religion which would agree with it as their own view. Even a curriculum which says, "Some people believe abstinence before marriage and others believe in saving sex for a relationship with someone you love, but you should make your own decision." is the position of some religion, I would guess UCC and UU have a statement like that in their curricula, for instance.

Something that I would like to see is a source reader with excerpts of essays from a range of religious perspectives: mainline, evangelical, Catholicism, Islam, Judaism. It's a bit meta, but that's what public education is: you learn the positions of religions X, Y and Z on sex, without much discussion about how it applies to life. To prevent it from being too meta, there could be an assignment where adolescents discuss the material with their parents and find out what their parents believe. That's the closest thing you can get to a truly secular curriculum, in my opinion.

It's also much more sophisticated than the standard sex ed books which are written at a middle school grade level even for what's taught in high school. I'm sure that a college level reader like this must exist, though cursory look I haven't found one.

If there were one, what should be in it?

- The theology of the body essays
- Rabbi Eliezer Berkovits's 1976 essay on sexual ethics (in _Essential Essays on Judaism_)
- If it will go into abortion: selections from the Talmud and Maimonides on when abortion is justified. If I recall correctly there are similar in the (Muslim) hadiths, and they reach similar conclusions.

What is the most prominent evangelical writings on sexual decision making? I'm only aware of the popular ones (Lauren Winner, Josh Harris, John Townsend, Doug Rosenau and Michael Wilson).

Other recommendations? Anything good in First Things published lately? What are the leading Muslim essays on the subject? Anything by Eastern Orthodox figures?

What are the more left-wing intellectual essays on sexual ethics? Most of the ones I'm aware of, even by e.g., R Eugene Borowitz the preeminent philosopher in Reform Judaism, are relatively conservative, which makes sense because what leads someone to write on a topic is disagreeing with the prevalent practice in the culture.

To be continued . . .

Abstinence and LBGT students

Critics of abstinence-only sex education note that it doesn't teach any material to help LGBT students understand and feel comfortable with their sexual orientations. One school which teaches AOSE has used this to justify a ban against allowing a student Gay-Straight Alliance to meet in the school, saying "The defendant's club policy is not discriminatory because it legitimately removes an entire subject matter category from its limited public forum, a category the defendant determined poses a risk to student well-being because school students are adolescents who lack the maturity to properly handle the sensitive subject of sexuality."

The school's justification is a funny statement in itself, but particularly so because the issues of a student LGBT club are primarily for psychosocial and even mental health support given the high rates of mental health issues among LBGT adolescents. If they wanted to be smart-asses about pointing out that the club has very little to do with sex, they could properly call the club, "The Gay Suicide- and Runaway- Prevention Club."

At any rate, such a renaming is unnecessary because a federal judge rejected the school's justification, so the one student who wants to revive the club may now do so.

Monday, July 28, 2008

A Catholic Church contraception counterfactual

An op ed from a former Catholic priest on Pope Paul VI's anti-birth control encyclical 40 years ago, and how it might have been different:

In traditional Catholic morality, the nature of a human act, the intention and the circumstances must be all considered in weighing its rightness or wrongness.

But as Pope Paul presented his case, intention and circumstances are irrelevant. The nature of contraception is so heinous, so intrinsically evil that alleviating circumstance and good intention don't count.

We can all acknowledge that contraception is on a different level from, say, killing a human being. Yet killing is an act that may not be determined good or bad until we know intention and circumstances. The placing of absolute judgment on contraception itself—by pill, condom or whatever—raises the bar to a level that seems to many responsible and thoughtful people to be irresponsible.

Killing is not always wrong. But contraception always is?
The problem with Humanae Vitae is rigidity. The pontiff was correct in seeing what strange fruits the revolution would produce, but his cure was as bad or worse than the disease.

He could have acted differently. He could have said that the world is facing an unprecedented challenge in human history that requires careful study and expert inquiry. He could have said that selfish, non-generative lifestyles are not acceptable, that thoughtless contraception cheapens sex, that circumstances count very much and that people have an obligation to weigh carefully what they do.

He could even have praised the values of natural family planning. He could have become a respected conversant among national and world bodies seeking credible answers. But because of the absolute ban, popes, bishops and theologians have had little to offer except a repeated no, no, never!

Church leadership left the table 40 years ago, painting itself into this corner.

Within the church itself the saddest byproduct is what has been happening to its membership. Many parents of the 1960s retained an overall confidence in the church while dissenting on the contraception issue. Their children widened the sense of separation, and the grandchildren may not even realize there ever was a religious institution that had wisdom and a sense of real community to share.

I've never known very much about Catholicism, so I've never thought that the pope's decision on contraception could have been any different from how it was. Many religions have confronted issues of modernity, especially sexual, with barriers rather than moderation. The possibility that the Catholic response could have been more moderate raises the question of whether the American political landscape and even other religions' stances might have also been more nuanced.

On the other hand, an issue that the author does not consider is that as a religious policy issue, people are generally not very good at moderation. Moderation can be interpreted as outright acceptance.

So on one hand, the religious authorities can decide to maintain credibility by proclaiming a moderate position, but risking that the public would be too liberal with the position. Or the religious authorities can risk losing credibility with the public by proclaiming a clear-cut ban. If the religion's major objective is to ensure that people follow the law, is it possible that there might be more compliance in the first scenario? As much as I would like to say that there would be more compliance under a liberal stance, I don't have any information that would lead me to conclude one way or the other. Obviously the solution is that in cases where the religious authorities just want a specific outcome, they should conduct randomized policy experiments before they decide on religious law. It's a pipedream, I know, but I'm mostly serious. Many religious decisions turn on predicting outcomes that are unknowable without formal study.

Wednesday, July 16, 2008

Shutting down dialog happens in both directions

The cases where people suggesting condoms as STD prevention are shouted down and find themselves in a hostile environment are well known. It also happens the other way, apparently: a story from Uganda about a 16 year old mocked for being pro-abstinence.

DURING a high school classroom discussion on HIV/AIDS prevention, the teacher asked the students: “What can be done to stop the spread of this fatal disease?” Some students talked about condoms and received the knowing affirmation of the teacher.

However when James, 16, raised his hand and answered: “We must promote and support young people to abstain until marriage,” he was attacked and stigmatised!

The teacher laughed derisively and mockingly told him, “Abstinence does not work for young people. It is just a dream.” James, who had chosen to abstain from sex after an abstinence presentation in Grade Eight, felt ashamed but he knew better. Other students began to mock and sneer at him. Again, James raised his hand and tried to explain how he had made the choice to abstain till marriage. “For some of us,” he said, “abstinence is not a dream, it is a present reality.”

The comments of the teacher had already created a hostile environment for James, and now he became the butt of the class jokes. Subsequently, James was mockingly labelled stereotype names ranging from “little mamas boy,” “ignorant kid”, “holy pope”, “virgin Mary” to “you are so ugly, that’s why you can't get any.” As if bent on breaking his will, two girls approached him and sarcastically told him they wanted to cure him of this dreaded disease called virginity. They recited stories of people who abstained and their genitals withered and fell off and that he was a good for nothing boy. They then walked away laughing.

Their use of gay pride terminology is perhaps unintentionally ironic:

Children who abstain are forced to survive shame and psychological violence by hiding in the “closet.” They are treated as lepers, social outcasts whose virginity is not a badge of pride, but rather a mark of disgrace. This is what I call “abstinence stigma.” While many parents teach their children the value of abstinence and saving sex for marriage, they are un-aware that the social contexts where young people make informed decisions about sex are contaminated with hostile and judgmental attitudes towards abstinence. It is a form of phobia.

Those who promote the fear of abstinence and virginity should be referred to as “abstino-phobes.” The word abstinophobia can aptly convey the irrational fear and discrimination meted out on the children who choose to abstain.

Paradoxically, while popular culture seeks to celebrate diversity, the only children who must go into the closet of shame are the “virgin and the abstainers.” Who will break the doors of this closet and tell these children to “break the shame” and walk in the abstinence pride?

We need to break the chains of “abstino-phobia” with campaigns of breaking the silence. We need school-based safe spaces of small groups where young people can meet for support without fear and stigma.

We need large school rallies where those who are in the abstinence closet of shame can come out loud and proud.

I've heard other anecdotes from young adults and even adults who received negative reactions or simple bafflement after their lack of sexual experience was revealed. Bias and stigma does go in both directions.

Tuesday, July 15, 2008

How to communicate weight loss messages to patients

A college friend of mine wrote in her live journal about her reaction to a doctor's initiation of the topic of weight at an appointment she had to address a recent injury. The doctor's approach seemed to be attempting to be non-intrusive: she gave a neutral factual statement that my friend looked from a picture like she used to be lighter. What happened next was interpreted as my friend as "asking if I knew I was going to DIE OF THE FAT."

Clearly something went wrong here in the immediate clinical encounter. Probably the doctor should have sensed from the conversation that my friend wasn't terribly open to discussing the subject and found it intrusive, especially since weight was completely irrelevant to the purpose of the appointment. If the doctor didn't want to just let the subject drop, she could have at most asked neutrally how she felt about that difference, and let it drop when my friend said that she felt fine.

But there's a larger question: how do physicians manage to acknowledge fat acceptance, but also send a message of obesity prevention?

Contrary to the blog comments, research is clear that on average mortality increases monotonically with BMI. Walt Willett's book has some nice plots of this. Fertility decreases monotonically with BMI. Even if recent research showing mortality improvements for some diseases in the BMI range 25 to 29 is completely free of confounding, so it's the weight which is associated with the decreased mortality rather than another factor that wasn't adequately adjusted for, it's only for a few of the evaluated diseases and mortality is much higher for BMI over 30.

Not to belabor the obvious, but these studies can only be refuted by studies of similar validity. They're not a massive conspiracy against anyone. They're just what the data revealed. Anyone who wants to reexamine the data to find a better explanation or find deemphasized null findings within the reports is free to do so, but so far no one has. And it's not impossible. See this reexamination of Framingham Heart Data on diet and cholesterol.

Anecdotes about outliers are just that. The studies hold on average, and while no one likes to think of themselves as average, all of us are average in most domains of life.

How can the overriding medical evidence be communicated in this sensitive way? I don't know, but here are some stabs at some of the issues:

- Many people feel powerless to change their weight, or feel that only heroic efforts can be successful. There does seem to be such a thing as a weight setpoint which is clearly resistant to change, see e.g. Gina Kolata's book.

- If it's not possible to change weight and live one's life in what one feels as a reasonable way, it makes a great deal of sense to accept weight as a given, and to see messages about overweight as taunting from people who just don't understand. Especially since sometimes they are.

- A never-overweight person sees their entire relationship with food, hunger, meals, clothes, and society completely differently and may therefore say stupid things like "Just lose weight," when it's anything but "just." Even the statements like "even 10 pounds makes a difference" while well-intentioned don't entirely help. One of the nicest but perennially thin people I know once said, "you're not that fat."

- It's not that easy, but it's usually not impossible either. In the spirit of self-discovery and self-experimentation while attaching no emotional weight to the results, people can design tests of the many approaches to food and diet, a few weeks long for each, to see whether anything changes their relationship to food or their weight.

And there are so many: beyond the obvious popular ones, the support-group types, there's the most kooky-seeming and yet potentially most profound by Berkeley psychology professor Seth Roberts.

-Logically, of course, it's not possible to prove a negative; it's not possible for people to prove what they perceive as reality that "weight loss is impossible for me" or "weight loss is only possible for me at an unacceptably high physical or emotional cost." But honestly these questions of obesity prevention and fat acceptance have such high emotional content on both sides that it's hard to say that there's much logic left.

No answers here, but maybe useful questions come out of it.

Tuesday, July 8, 2008

The ultimate in the because-I-think-you-need-it present

The CDC has created unintentionally funny health-themed greeting cards, such as:

- What have you been up to since your last HIV test? --- Let's go get tested again!

- Feel better from your surgery --- and walk around soon afterwards, so you don't get Deep Vein Thrombosis

- Don't just "Wait and See"! --- Just because a sore is painless and disappears doesn't mean that the disease is gone. Get tested for Syphilis today.

Is there any way to make a health-themed greeting card which does not seem preachy?

At least they had the good sense not to make "obesity awareness" greeting cards.

Monday, July 7, 2008

Wrong number

Last night I went on a second date with someone.

The next morning at 6:45, I was sitting down to breakfast and had just finished a reprint of the NYT article about need for Orthodox Jews to be more open about sex, and the phone rings. I run to get it.

Guy, sounding a bit muffled for the entire conversation and at times inaudible: "Hi. How are you doing?"

Me, assuming it was my date: "Pretty good. You're up early."

We exchange the usual generic preliminaries. I had been in the kitchen preparing to put breakfast together, but went into my room and sat on my bed to avoid waking up my roommate.

Guy: "It sounds like you're still in bed."

Me: "I've been up for awhile. I was just preparing breakfast, but went back to my room to talk to you."

Guy: "I really wish I could be there with you and hold you. Are you dressed? What are you wearing?"

Me, thinking that this seemed pretty premature: "I'm not dressed yet. I'm thinking about going jogging, so dressed for that."

Guy, wistfully: "Do you want to run together? I'll come over."

Me, thinking doesn't he have to get to work?: "Well, I don't run very fast. I think you'd be disappointed."

Guy: "But we could run together holding hands... Say something sweet."

Me: "Chocolate. Popsicles."

Guy: "Something sweeter."

Me: "Um, .... I can't perform on cue. Aren't the sweetest things the things that come up spontaneously? Anyhow, I didn't peg you for being such an early riser."

Guy: "I just missed you."

Me, thinking it's been less than 8 hours and wondering whether I would hear from this guy every 8 hours from now on: "Um, I missed you too. So, shall we get together later this week?"

Guy: "Wait, is this Shira [not the name he used]?"

Me: "Shira?" My first thought was that my second date was seeing other people, which is totally reasonable, but how tacky after the conversation.

He gets embarrassed as we figure out it's a wrong number. He tells me his name, say Yonatan. I give my full name, first and last. I explain that I thought he was last night date, and somehow he asks me if I'm religious, and how religious. We establish that we're both observant Jews. In spite of the confusion somehow it was a comfortable conversation and this being a huge coincidence, it is the kind of thing which is always billed as fate (I've heard at least one wrong number story where they ended up getting married), so he feels the need to add, "But I have a girlfriend." Obviously. We exchange sociological affiliations, high school, synagogue, grew up where, which yeshiva in Israel, etc., and establish how this mistake happened. I'd never heard of his synagogue, high school, or Israel yeshiva, so I assume that they are black hat (yeshivish).

I'm ready to hang up, but somehow it feels momentous that we had this phone call, and maybe we should keep in touch, though that would be ridiculous, so I settled for saying that I'm sure we would see each other around given how small the world evidently is.

But he asks my advice what to get as a gift for his girlfriend for her birthday. She's just-out-of-college age from a very religious background, and he's a few years older, and they've been together 2 years. He remarks on the irony that she's from a much more religious background, but rebelled a lot more than he did, and I ask if it's really an irony.

I ask why they don't get married already: 2 years is a long time, and honestly I'm a bit afraid for her that the relationship will drag on and break up and she'll lose the time. Her family wants her to marry someone more religious, and continues to set her up with more religious guys. It's unclear whether her family knows about him, but she apparently isn't willing to go against them at this point, or maybe she doesn't feel that it's necessary to think about marriage yet. Around her family, she adheres to the standard dress code, but in other circumstances she wears pants (normally not worn except among the most liberal Orthodox), and her roommates think she is with relatives when she is staying over at his place. He says dreamily, "It's so nice just to spend the night together, just kissing and holding each other, nothing else."

We have a generic conversation about gift ideas, almost anything he gets her she'll love etc etc, somewhere in the middle of which he says she wants to be shocked and he wants to get her something "shocking, sexy and fun."

"Sexy" seemed like a funny word to use --- obviously he and his girlfriend were somewhat intimate, but I had no idea how much. I was thinking of recommending one of the women-owned sex shops in NY, but didn't want to make any assumptions, so I asked what he meant by "sexy."

He tells me that they're going upstate for her birthday, and I exclaimed what a wonderful birthday present that was, but apparently he has to get her something in addition. He says he's also worried about spending shabbat in the hotel because of electricity is prohibited on shabbat, and that brings questions about the TV (don't turn it on?) and electric beds (?!). I suggested he bring a timer for the lights (he joked maybe they should just have the lights off the whole time), and added that if he's really concerned about the electric locks, in a pinch he has what to rely on to use electric locks on shabbat, but obviously other key options are better. After we talk a bit about the keys, he adds, "Will this rabbi say it's okay to make as much love as we want?"

I said that I didn't think that was likely, but some rabbis are accommodating about premarital sex using the mikvah, following usual procedure of married couples.

He says, "The thing is, we've done everything and anything. Everything! But not the act itself. And now we're planning to do the act while we're away."

I ask about protection, and he responds immediately, "Birth control or condom. We haven't decided yet. She doesn't want to use a condom because she wants to feel [incomprehensible]." I get worried, but apparently she started the pill awhile ago in anticipation, so they're safe.

I repeat the textbook line about condoms always being a good idea just in case and to get into the habit, although in this case, it seems unlikely that they're likely to have sex with other people --- it's already a big deal with each other after 2 years of dating. I think about mentioning UTI risk, but don't.

We talk about mikvah and premarital sex, and what different people do. He's been resigned that premarital sex was wrong, ans they decided they were going to break the law, and there was nothing to do about it. He knew that it was better for his girlfriend to go to the mikvah, but the force of the social stigma against premarital sex was so strong that he was willing to do a huge sin rather than violate the social norms. This is unusual, so I'm going to repeat it: he clearly cares about the religion, but he was willing to pick the worse option religiously rather than violate a social norm.

When we think about other religions that ban premarital sex, they can't mitigate it. In Judaism, everyone agrees sex without following the ritual laws involving mikvah is a huge sin, at least as bad as eating on Yom Kippur; premarital sex following the mikvah laws is more murky, but almost everyone will agree that using the mikvah for premarital sex is better than not using the mikvah for premarital sex, and there's a substantial opinion that it's negligibly wrong compared with the alternative.

He was amazed that people talk about religiously reasonable ways to have premarital sex, and I gave him some tips on ways to get around the social issues (i.e., not going to a formal mikvah, but instead using a body of natural water, even with a bathing suit (, but ultimately it's a matter of conscience how much to keep the laws.

He seemed happy to bring his actions a bit closer to Jewish law since that's the usual framework he's working in, but then he realizes that if they're going to have sex for the first time, and follow the Jewish law, they can't have sex again for 7 days, which uses up the time that they have upstate. He really wants the first time to be special. I break the news that of course the first time is special for being the first time, but it tends to last 30 or maybe 90 seconds, and it's only on the second time that couples start to figure everything out. That seems to sober him: if he's going to think about keeping the laws, having sex for the first time will last a very short time and then they won't be able to have sex again for the rest of the vacation, so the vacation can't be so momentous.

He tells me how much he loves her, and from his tone at the beginning of the conversation, it was clear, so again I asked about marriage. We talk some more about the possibilities, and the fact that sometimes people keep the laws and sometimes not. He says he'd like to be more religious; as excited at the prospect of having sex he sounded, he even sounds a little relieved about the idea of marriage, but he's not sure she would be for it. (He didn't say why: liberals would say it's because he doesn't want to sneak around anymore and this is the only way he saw not to sneak around; religious would say that he want to do the right thing; my guess is a bit of both.)

In the end, it sounds like he decided not to have sex and maybe to think more about marriage. It's not clear.

"I have one final question. But I'm too embarrassed."

"It's okay." We go back and forth a bit, with lots of silence on my end to give him space to ask the question before I add, "If you have any further questions, please feel free to call, or I can give you my email address. You can send a question by email if you prefer." It was probably a bit much for him to anchor the conversation more in the real world, so he asked me to hold on and the line went dead.

The conversation lasted half an hour. Presumably he has my number, but I'm sure that's the last I'll ever hear from him. So many times he said, "I can't believe we're having this conversation." Neither could I.

My reactions:

1. What a coincidence that out of all the phone numbers in my city, he reaches someone who speaks a religious language he recognizes, who had personal circumstances such that the first few minutes of the conversation were able to turn into a longer conversation, who at that very moment had just been reading the next page of the newspaper which was about premarital sex among Orthodox Jews, and who was open to having a balanced discussion about the big problem weighing on his mind.

2. Her family likely has no idea how little control they have anymore. They think that they can constrain her marriage choices, but in fact they're just delegitmizing marriage and making it more likely that their daughter is going to have substantial not-leading-to-marriage relationships.

Religious groups lament decline of marriage, and wonder why. In this case, it seems pretty clear. Here the family probably feels more religious pressure than they would have felt in the past to adhere strongly to ever-stricter social norms, so they pressure their daughter, probably about trivial issues. The daughter lives in a different city than her family and has enough autonomy to pursue this relationship, but it takes a real act of courage to stand up to them for a more public issue like marriage, especially given that she doesn't feel any real pressure to get married right then.

3. This guy so clearly wants to do the religiously acceptable thing, but he is also feeling constrained by social norms . He of course wants to have sex, and he was quite proud emphasizing the Everything! they had done prior to this, but he is not too impatient to wait for marriage. I was saying pretty radical things about how it's not unreasonable to have premarital sex with mikvah, so I probably did not prompt his self-presentation instinct to kick in. I think he really did seem to be reconsidering having sex with his girlfriend, and proposing instead.

4. I'm really not primed for early morning counseling. I was groggy and spoke way too much and told him things he already knows. Now that it's afterwards I have so many questions. Perhaps better under the circumstances that I didn't get to ask them.