America is not a “condom nation.” American teenagers, for instance, have about the same rate of sexual activity as their European contemporaries. But they have a higher rate of sexually transmitted diseases, and of unplanned pregnancies, and of abortions. They aren’t using condoms the way they ought. But Condom Nation: The U.S. Government’s Sex Education Campaign from World War I to the Internet (Johns Hopkins University Press) is the title Alexandra M. Lord has given her book (can it be that she was not only being ironic, but was punning on “condemnation”?). Condoms work, and so do IUDs or the pill or other measures if all you want to do is prevent pregnancies. That’s a good thing, but the bad thing is that they keep people who enjoy sex from bearing what other people think they ought to have as consequences from enjoying sex. Americans have a split on the issue: using a condom is a responsible action, but having the sex that makes using a condom a responsible action, well, that’s irresponsible and immoral. Lord, a former historian for the Public Health Service, has documented this ambivalent stance throughout her fascinating book, which surprises throughout in showing just how little sex education changed through the twentieth century, even though we profited from an increase in scientific knowledge and from improved contraceptive and prophylactic technologies.

The split opinion has often been seen as medicine on one side and morality on the other. Though there was a generally positive opinion about sex education up to the 1960s, that was to change as young people got more openly sexually active and, of course, when AIDS became an issue. President Ronald Reagan spoke about the split openly and simplistically in 1987 when he said, “After all, when it comes to preventing AIDS, don’t medicine and morality teach the same lessons?” They do not teach the same lessons, nor do they teach opposite ones; they are quite obviously different ways of looking at a problem. Conflating the two, or insisting on their opposition, has played a big role in defeating the efforts of the Public Health Service. The service didn’t have these problems when came into being. It had its roots in the eighteenth century within the Marine Hospital Service, which was dedicated to treating American seamen; in doing so, it offered some protection to the rest of society from epidemics. (The military connection is why we have a “surgeon general” as our chief public health officer.) When science began to understand the role germs played in illness, the Marine Health Service performed such non-nautical efforts as investigating dairies for typhoid. The organization became the Public Health Service in 1912. There wasn’t anything controversial about the PHS fighting typhoid, tuberculosis, or malaria: they weren’t connected to sex.

By the late nineteenth century, some Americans were shocked by what they saw as changes in sexual behavior. Women were going to work, for instance, and courtships were started in the workplace without the family being around to provide chaperones. Reformers felt that it was essential to protect young women; the Ku Klux Klan wanted to protect white women, for instance, and more liberal reformers wanted to protect immigrant and working class women. Antony Comstock was shocked by the “vice” he saw in New York City, and championed the involvement of the federal government (as well as private organizations like the YMCA) to protect mothers and future mothers. Certainly the government wanted to promote health and productivity, and the PHS early produced sex education materials to be used not at the federal level, but stamped by state boards of health or private organizations as their own. That federal sex education had to be done piecemeal like this, with modifications state-by-state, is a constant theme of Lord’s book, and contrasts with the efficacy of national sex education efforts in other countries.

After World War One, with growing confidence that there was effective treatment for syphilis and gonorrhea, the PHS constructed its health education against disease, not against pregnancy; babies were held to be the welcome effect of sex, which ought to happen in marriage anyway. It sponsored Keeping Fit, a campaign for young men, emphasizing athletics, self-control, and willpower. It hardly mentioned reproduction or sexual diseases. While the PHS could not, in 1918, repeat scientifically unsound folklore about masturbation causing blindness or insanity, it could say that the practice was the result of a lack of self control, the same lack that would lead to venereal disease someday. Abstinence was stressed and condoms were not mentioned. By 1937, the PHS broke the taboo on mentioning condoms, referring to them in a short sentence in a pamphlet on syphilis and gonorrhea that explained that condoms protect both the man and the woman. The government was not interested in preventing pregnancies, and no contraceptive use of condoms was mentioned. In the years around World War Two, when soldiers were being briefed on the necessity of condoms, kids in school were not; there was a study (now realized as flawed) that kids who learned about condoms would be encouraged into sexual experimentation, so schools taught morals instead of public health. Federally funded efforts to increase sexual knowledge would remain weakened because of fear of offense to conservative segments of American society.

Conservative teaching was just what was expected when C. Everett Koop was appointed by President Reagan in 1981 to be surgeon general. Progressives were worried that the born-again Koop was only there to appease evangelicals and to reverse the legality of abortions. Koop knew little about Washington, and assumed he would be able to advocate sex education any way he thought best. For the first five years of his tenure, however, he was forbidden to talk publicly about the newly-understood AIDS epidemic. When unleashed, he spoke like a doctor but not the way the fundamentalists wanted him to. His 36-page report on AIDS was widely disseminated in 1986, and not only did it explain that the disease was a public menace (not just to “any one segment of society”), and that those who merely shook hands, kissed, used public restrooms, or masturbated were safe from it, it also depicted condoms and stressed their usefulness. Koop thought he was building a bridge between religion and science, but he alienated many Christian fundamentalists, who named him the “Condom King.”

Such fundamentalists were much more comfortable with abstinence-only programs which were pushed especially during the second Bush presidency. (The biggest news during the Clinton years, besides the education many people got about what oral sex was, was when his appointed surgeon general Joycelyn Elders publicly announced that masturbation was part of human sexuality and might be a subject of classroom discussion, a harmless and correct stance that got her fired.) The medical and moral forces on the abstinence question continually talk past each other: yes, if you abstain you can never get pregnant or catch a disease from sex; but yes, people are not by nature abstinent and need other tools. Not only was abstinence stressed, there was condom-bashing that was unscientific and untrue. It isn’t surprising that teens who took abstinence-before-marriage pledges broke them almost 90% of the time, but they were far less likely (perhaps because they had been told how wicked or unreliable condoms were) to use condoms when they strayed. It isn’t surprising that many states were refusing to accept federal dollars for abstinence nonsense.

Lord’s book provides an entertaining and useful historic overview that shows, mostly, that we have not gotten far from where the PHS started. In 1918, parents and teachers were in favor of government-sponsored sex education; today, they still are. The question has always been what to teach, and it has always been colored by our worry about sex, and that young people indulge in it, and even that some of them might masturbate. If the best we can come up with after all this time is abstinence, it is hard to be optimistic that the PHS will be able to get useful scientific advice out to the public as long as conservative religious forces are holding it back.

Condom Nation
(Johns Hopkins University, November 2009; ISBN-10: 0801893801)
Available at: Amazon | Amazon UK

© 2010 Rob Hardy. All rights reserved. Content may not be copied or used in whole or part without written permission from the author.