Safer sex in the time of Covid; the urgent need to keep vital services funded
Published in Maverick Citizen, 14 April 2020
Michael Callen was my earliest activist crush. I loved his skilful combination of rage, scientific smarts and creativity. The lyrics to his Aids anthems have been bouncing around in my head ever since I flicked on a blog called “What you need to know about sex and Covid-19” from the International Planned Parenthood Federation (IPPF). Many phrases from Callen’s songs seemed apt, especially those in tracks like How to Have Sex, words that churned with the struggle to know how this new virus is transmitted:
… I’m not crazy,
I don’t take no chance
I don’t kiss, I just reminisce
And I keep it in my pants…
They say I can’t do this
and I can’t do that
Oh, I’m soooo confused
Can you tell me? Who can say?
When what is safe
and what is not
Changes day by day
Returning from my first International Aids Conference in 1989 (in Montreal, Canada) I insisted that the contact tracers, health advisers, volunteers and doctors at the Genito Urinary Medicine (GUM) clinic where I worked sat in silence to listen to several songs from Callen’s album, Purple Heart. It had just been released and he’d performed extracts in Montreal.
Songs like Living in Wartime, Love don’t need a Reason and How to Have Sex seemed to be the perfect way to explain the dynamism of this extraordinary global gathering, summing up many of the challenges faced at the epicentre of the exploding Aids crisis in the United States.
In 1983, Callen had co–founded the New York People with Aids (PWA) Health Group and, with his friend Richard Berkowitz, a person living with Aids, and visionary Aids specialist Dr Joseph Sonnabend, he co-wrote the controversial book “How to Have Sex in an Epidemic: One Approach”. This earliest description of Safer Sex caused a furore in gay New York City, with other gay men condemning them for alleged “internalised homophobia” for suggesting that gay men should reduce their number of sexual partners and avoid the backrooms and bath houses where many men met in the 1980s.
As the epidemic raced through New York, scientific understanding of transmission increased and Safer Sex advice was constantly updated, loosening restrictions as it became clearer what sex acts really posed a risk. The fear of contagion didn’t decrease as fast.
When the IPPF Blog popped up on my Twitter feed late last month, I was relieved to see some reliable, useful information amid the flood of hysteria, anxiety and “funny” memes.
It was impressive stuff. I rejoiced that a mainstream international NGO – historically known for rather stodgy “family planning” advice – was now promoting the pleasures of masturbation and encouraging people to try out sex toys, especially if they didn’t already have a stash at home.
Anticipating having more time on their hands, sales in sex toys reportedly tripled in New Zealand in the 48 hours before their (very well handled) lockdown; UK on-line sales are also seeing a jump, with sex education gurus at the womens’ Erotic Emporium Sh! reporting on-line sales doubling just three days after the UK lockdown started.
I confess to raising an eyebrow at a couple of bits of advice, and imagined myself back in the 1980s when I read:
”If you are wanting to have sex with people outside of your household, you may want to consider having sex with as few partners as possible.”
My worries were joined by giggles when I got to the advice:
“If you do have sex, it is recommended that you wash before sex and after sex.”
Physical distancing is a blunt public health instrument, and I’m nervous to say anything that could undermine it since (as my son reminds me whenever I shout at people on the radio) “They have to treat people like idiots because half of them are.”
I’m not quite as gloomy as my son about human nature/intelligence, but I do respect that public health messages are tasked with capturing the bulk of the population with generic messages that fit most of the people most of the time. Over-complicating things might confuse the cynical and those who want to avoid the uncomfortable restrictions that are needed to limit an already catastrophic situation. Still, I don’t believe that overly simple messages help people to make good personal risk assessments.
‘Physical distancing’ is a smart, broad approach to limit the number of people we get close to. We are trying to avoid sneezing, or spitting, or in some other way letting our droplets get close to their membranes – either directly or by leaving them lying around on a surface.
We don’t have to distance within our current households because the Covid-19 models expect all people within a household to infect each other. Early reports from Wuhan showed plenty of households where everyone got sick – but eventually transmission of the virus slowed because it stayed within those walls and never spread outside. It worked because households didn’t mix.
So hats off to IPPF for getting clear that if – during lockdown – you choose to look outside your current household for sex, then you should “only have sex with someone you wouldn’t mind being quarantined with for 14 days”. Is that bar too high? Moving someone new in for the duration is the only coherent option beyond having sex with people already in your household, solo sex or “no touch” sex.
This virus moves faster than many dating apps, hence the instruction to self isolate for seven days if you are sick, and 14 days if your household member is sick. It’s smart because the incubation time is short, and (in most cases) disease progression swift. If you get sick with Covid-19 you will likely be on the other side of it within a week – and the 14 days gives your other household members time to track whether or not they have picked it up from you.
I’m told that IPPF is updating its message on ‘partner reduction’ and I’m glad because it’s a tactic that never worked for HIV. In part because it’s too imprecise: My, “Not SO many partners” is your “Wow! I’m still in single digits.”
When it comes to disease prevention in intimate settings, the issue is always about the acts you engage in, not the number of partners – especially in a context where the vast majority of us have no idea whether we or the other person is infected. What matters is avoiding getting the fluids that contain the virus in or out of your body. Since you probably don’t know if you have it, you need to act as if you do. And because it is too early in the epidemic to know all the details, we simply have to rely on the fact that the virus is super-infectious, and be extra cautious for now.
What does this mean?
Well, no one thinks the coronavirus is in sexual fluids, and there is no proof that it is in our blood. Small studies suggest it is in faecal matter, and may even be infectious there for longer than in droplets – where it is definitely present.
Since it is in mucus and saliva, you can certainly assume that if you have the coronavirus, it is in your mouth, making kissing and licking risky. And of course – as every manufacturer of disinfectant wipes knows – it hangs around for a while on some surfaces (stainless steel and most metals, plastic and cardboard).
Public health messages are pushing the hand washing message (remember: at least 20 seconds) because hand-to-mouth/nose/eye is a brilliantly effective route of transmission (you only need to know a thing or two about the frequency of hand washing among men to find the research on faecal matter especially worrying).
But clean hands don’t make other forms of close contact safe. Saliva has some antibacterial impact, but no one is suggesting that it kills the virus or that hugging and kissing people outside your household is okay. The message is “Keep at least two metres apart”, not “Wash your hands before you lurch in for a quick snog.”
Many of us have lots of extra time on our hands, but the bottom line is that now is not the best time to start dating, unless you’re happy with virtual chat or fancy checking out Zoom sex (perhaps kinky – as a friend suggested – but only if you aren’t nervous about getting hacked).
The challenge of sex and Covid-19 doesn’t start and stop with dating. The day after the UK lockdown started, as sex toy sales were rising, tabloid newspapers reported that experts were debating whether or not there would be a baby boom once the whole thing was over.
Childbirth rates had shot up after other major crises, notably the World Wars – although reports of similar phenomena after 9/11 and other disasters have been discredited. The other day, expert statisticians and economists debated the evidence on BBC’s Radio 4 and concluded that a baby boom was unlikely.
Certainly many people have lots of extra time and less money, so they’re looking for more free forms of entertainment (as my neighbours’ creaky bed springs attest). But will that lead to more babies in early 2021?
The expert advice is that baby booms tend to be driven by unplanned pregnancies, and with lockdowns creating less opportunity for random meetings among young people compared to the post-war years, that blast of fertility is curtailed.
In the words of Dr Marina Adshade at the University of British Columbia: “You can’t get pregnant over a snapchat”.
On top of that, IVF (in vitro fertilisation) treatment has been paused in most places, and anyone contemplating the best time to start a family may be put off by apocalyptic visions of a post-pandemic world.
So that’s the case against a baby boom. But, as Covid-19 rides roughshod across societies, its heavy impact in many spheres becomes clearer.
For a start, there is a surge in gender-based violence, including sexual violence, in all countries. We saw similar impacts during the Ebola crisis, and the UN Secretary General has been among the many voices raised to demand an end to this. The Global Fund to fight AIDS, TB and malaria is reallocating funds to help countries get ready to tackle Covid-19 and has put out advice warning:
“Stay-at-home orders can increase HIV and other risks such as gender-based violence for women and girls living in violent or abusive households. Spikes in HIV incidence among newly out of school girls, sex workers, people who use drugs and others are therefore increasingly predicted.”
Sexual violence is the most extreme, ugly end of the spectrum, but there are many other unintended harms created by Covid-19 – often with equal or greater levels of life-changing damage. These have not yet been factored into the statistical analysis about potential surges in child bearing.
At the same time as providing reliable personal information about sex, IPPF has been checking how Covid-19 is affecting member associations in the 143 countries where they work around the world.
Within two short months, 5,600 IPPF clinics and distribution sites have been closed, stopped services, furloughed staff and been put at risk by the pandemic. Nearly all IPPF member associations (88%) have closed at least one service and there were 20% fewer clinics open by the end of March 2020 than by end 2019. Of course there is gratitude for the many staff redeployed to help national Covid-19 efforts, but it is a disaster for many of the people needing their specialist skills and services.
Covid-19 impact is not just counted in the number of people dying from the virus, but also those whose lives are churned up, displaced or ruined by the consequences. That includes women who cannot end their pregnancies because abortion is not deemed to be an essential service in their countries; those whose contraceptive choices are terminated or paused by the pandemic; those who cannot get the reliable products they need. As a midwife from Lesotho, Mamello Makhele, put it on her Facebook page:
“I wish it was possible to lockdown my uterus during this period.”
It’s not. Yet throughout the world IPPF’s network of clinics report problems with the supply of contraceptives, HIV medication, pregnancy tests, safe abortion and emergency obstetric kits.
At the start of the year there were reports of contraceptive supplies running out, as the (mainly) Chinese manufacturers shut down. Now a looming condom shortage is forecast, with Malaysian company Karex Bhd closing its three factories – collectively responsible for 20% of the global supply.
You already see this on London supermarket shelves – in the past week it’s become easier to get toilet paper, hand sanitisers and bags of pasta than a condom. IPPF has released nearly $9-million from its reserves to ease the impact on its member associations, and for the emergency procurement of commodities and PPE (personal protective equipment) for its staff. But they know this is not enough.
As products that help women and men to manage their sexualities fall into short supply, and clinics around the world have to limit and close their services, the long-term shadow of the Covid-19 crisis looms into view.
It’s rather jolly to think about a baby boom; it sounds like a fun little side effect of a global catastrophe – but the reality is that without the information, supplies and services that are needed, unplanned pregnancies will increase with all the attendant challenges and tragedies for individuals and families. Sexually transmitted infections, including HIV, will likely increase, and the necessary support and interventions for all sexual and reproductive care services will not be at hand.
And so I find myself back with Michael Callen, whose lyrics in the song Living in Wartime from over three decades ago sound shockingly prescient:
“They try to break our spirits
try to keep us in our place
They do it to the women
and the poor of every race
One way or another
no one will be spared…
It’s like living in wartime…
It will not go away
More die every day…
But if we fight together
we can find the strength we need”