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Posts Tagged ‘trust’

Catching up to Reality on Blood Donations by Gay Men

March 7th, 2010 No comments

When Obama was seeking the Presidency, the GLBT community had a well-defined punch list of action items, and he promised big things on all of them: repeal of DADT; repeal of DOMA (although he doesn’t support marriage equality); passing ENDA; passing inclusive hate crimes law (the only hole punched so far). A few others, notably the administrative implementation of the-then recent repeal of the insane prohibition against HIV-positive immigrants, were perhaps further down on the list, but also up for discussion. Conspicuously absent from the mainstream agenda has been an item of interest to the public health community: lifting of the ban on gay blood donors.

So I was buoyed to see that just a few days ago, a group of sixteen U.S. Senators sent a letter to FDA Commissioner Margaret Hamburg, urging the agency to reconsider its twenty-seven-year-old lifetime ban (“deferral” is the quaint term used, but it’s politely Orwellian in this case) on blood donations for men who have had even one sexual encounter with another man.

The policy is long overdue for an overhaul. As the letter notes, the policy is inconsistent with various other exclusions, and is an artifact of a time when all that was really known of HIV infection — and we weren’t even calling it that, in 1983 — is that it disproportionately struck gay men. Even today, MSM (“men who have sex with men,” which is the term used by the CDC because it focuses on sexual behavior, rather than on orientation) are prohibited, forever, from donating blood if they have had sex, even once, with another man, at any time since 1977. The Senators’ letter points out the many inconsistencies in the policy, including the fact that there’s no exclusion of those who have had high-risk, unprotected heterosexual sex, no matter how recently. Even more absurdly, those who have had heterosexual sex with those known to have HIV are only deferred for one year; not for 33! And “sex” isn’t defined when it comes to MSM: the safest kind of protected sexual acts are, in theory, treated the same as the riskiest.

It should go without saying that none of this can be justified from a public health perspective.

These inconsistencies should be enough to sink the policy which, as the letter notes, has lately been repudiated by the major blood banking organizations, most significantly including the Red Cross. But the problems are much deeper and more serious than even the letter recognizes. A few years ago, I discussed the issue in detail in this law review article. Here, I’ll summarize the arguments I made there that weren’t explicitly raised in the letter.

First, while the CDC is careful to distinguish behavior — men having sex with men — from identity, the FDA policy undermines this sound epidemiological distinction by effectively collapsing the two. By excluding any man who’s had any kind of “sex” (not defined!) with even one other man during the past thirty-plus years, the FDA has created a policy that isn’t about relevant behavior, but about some weirdly expansive view of (gay) sexual orientation. Because if it were about behavior, the line would have been drawn in an entirely different place; say, for a year after specifically identified, high-risk behavior.

Second, the policy undermines trust in public health in a few related ways. Obviously, as a practical matter the policy isn’t enforceable, and the sheer breadth of it has doubtless caused many to ignore it. People aren’t stupid: Gay men who know they have an HIV-negative serostatus might give blood, understanding that they pose no threat. (According to this very unscientific poll over at 365gay.com, almost 200 of 800 respondents admitted to having lied about their sexual practices on the questionnaire.) But by attempting to fence them out, the FDA has sent gay men an unwelcome message that could undermine the community’s trust in other ways. One important public health principle is that it recognizes the long-term value of respecting the dignity of all populations.

Why has the policy persisted for so  long? One argument seems sensible, at first blush: If the exclusion were changed to, say, one year, there would be some infinitesimal increase in the number of HIV-positive blood transfusions (well less than one in a million, it’s estimated), so why do anything to increase the risk? But the “let’s not do anything if there’s a tiny risk of harm” canard — which, by the way, is also prevalent in arguments against marriage equality — wouldn’t be, and hasn’t been, applied to any other category of people, or of conduct. Of course there will be some tiny uptick, not  because of the three-week window period between infection and ability to identify it, which any contemplated new rule would  easily accommodate, but because of the irreducible human error associated with the process: If you add more people, some will get through who should not. But this could be said of any proposal to add donors; it’s just that “MSM” have had such a draconian policy applied to them for so long that the donor baseline is essentially zero for this group.

It seems that uprooting this policy is fairly far down on the priority list for the LGBT community. Indeed, this story seems to have attracted but little attention. But messages matter. The radical, embarrassingly outdated FDA policy sends a terrible signal that ought to concern us. It’s good to see that someone is finally suggesting action. Will Obama back them up?

The Public Health Peril in Oklahoma’s Anti-Abortion Obsession

October 18th, 2009 1 comment

Nan Hunter has just run a good summary of recent legislation in Oklahoma that, taken as a whole, is designed to prevent women from having abortions altogether. The state’s determination shows that, Roe v. Wade not to the contrary, there’s plenty that states can do to restrict what the Court has declared to be part of a fundamental right to self-governance, privacy, and autonomy.

The state’s zeal, though, shows that ideologues on a mission can wreak havoc with settled public health principles, thereby jeopardizing the public’s trust in health care — just in case there’s any such trust left. There are at least two recent examples of this misguided approach.

First, a recent piece of legislation — later declared unconstitutional — required women to undergo an ultrasound (vaginally in the case of early pregnancies) before an abortion could be performed. Such coerced invasion of the body has typically been required only in cases of epidemic; even there, often the resisting party can usually forego vaccination and pay a fine, or suffer the less objectionable deprivation of liberty. This would have been the first case I’m aware of where an unwanted, invasive procedure would have been made a prerequisite for a procedure that someone has a legal right to have, and where that first procedure isn’t needed for some other medical reason. In other words, this is quite different from requiring a biopsy before surgery to remove a tumor.

Laws educating women about fetal development (although also typically a smoke-screen for restricting access to abortions) are OK with me, at least in principle. This weird law, on the other hand, is creepy and offensive, and it’s lucky that the legislators blew it through a technicality (shoving too many subjects into a single piece of legislation).

The second, and more recent example, is a law currently under challenge. This one  would set up publicly available, web-based reports on anyone who obtains an abortion. The information would have to be reported to doctors, who would then be required to pass it on to public health officials. This is a very, very bad idea. I don’t even need to talk about abortion (thankfully!) to explain why.

This law will drive a wedge between physicians and their patients. Many people have distrust of the medical and public health professions, and won’t be warmly encouraged to make that next visit to their provider — or to any other — when they’re met with a battery of identifying questions that can then be used to pick them out of a probably hostile community. As a flimsy subterfuge for the laws’ true intent, names aren’t required — but, as a lawyer from the Center for Reproductive Rights has pointed out, names won’t be needed to identify someone from sufficiently small communities, especially when so much other identifying information is exposed. According to this article, quoted extensively by Hunter, there will be “answers to 34 questions including…age, marital status and education levels, as well as the number of previous pregnancies and abortions. Women are required to reveal their relationship with the father, the reason for the abortion and the area where the abortion was performed.”

It’s clear that the legislators are trying to slap a different kind of scarlet “A” on these women, hoping that the shame and ostracism of expected discovery will keep them from carrying out their intended abortions. It might have this effect, but the more sweeping result will be a lack of trust that will penetrate relationships between patients, doctors, and public health practitioners. Patients will learn how to lie their way around the obviously unenforceable law (some of the facts sought depend on patients’ willingness to disclose, such as “reason for seeking the abortion” and, often, the number of previous pregnancies), and doctors may be less than forthcoming with public health officials if they see them as interfering with the MD/patient relationship. And any public health official with good training will despise and, one thinks, try to circumvent the law.

Even in states that require doctors to report HIV infection to public health, the goal is partner notification and contact tracing to eliminate an established risk. These laws are controversial, but they at least have arguments to recommend them — and the results aren’t published on public websites.

With this level of identifying information, the Oklahoma statute looks more like the sex-offender laws (which have their own problems, btw) than anything else. What more do you need to know?