Teens: The Rising Risk Of AIDS

By NANCY GIBBS

When health department officials in rural Maryland learned from a Johns Hopkins survey that by the eighth grade, 61% of the boys and 47% of the girls ! at the local schools had had sexual intercourse, they approached the school board about providing condoms on demand. Given the speed at which the AIDS virus is spreading among teenagers -- the number of cases is still quite small, but it doubles every 14 months -- it was not surprising that the board seemed open to the proposal. But when it came time to decide, the condom measure lost by one vote. In a way, that was not surprising either. "Personally," declares Allen Whiteley, who was board vice president at the time, "I think it would have been encouraging sex rather than discouraging it."

That episode, and his comment, captures the fundamental dispute among parents, educators, health-care workers and activists over how to stop the spread of AIDS before it becomes a teenage epidemic. One side says the only safe sex is no sex; the other counters that chastity has no hold on America's youth, and that if children as young as 12 are becoming sexually active they should know how to protect themselves.

The two sides disagree not only about morality but also about what approach would be most effective. "We don't say, 'Smoke carefully.' We say, 'Don't smoke,' " argues Monsignor John Woolsey, director of Family Life for the Roman Catholic Archdiocese of New York City. "A huge campaign could work to stop kids from having sex. We don't water down principles." The goal, echoes John Walsh, spokesman of the Archdiocese of Boston, is to teach children to be good, not just safe. "AIDS was caused in this country by promiscuity and casual sex. It is not traditional values that have brought us to where we are."

But AIDS activists and health-care workers have seen firsthand the devastation that ignorance can yield. Of the 1 million to 1.5 million HIV- infected Americans, an estimated one-fifth are teenagers. So far, the cases are clustered in certain populations: mostly blacks and Hispanics who are gay or drug users, living in major cities. "We have a teenage client dying with AIDS right now," says Frances Kunreuther, executive director of New York City's Hetrick-Martin Institute, a service center for gay and lesbian young people. "No one told him about AIDS, condoms or homosexuality. If you deny young people information based on your morality, you are sentencing them to death. Nothing is more immoral than that."

The battleground where the forces meet tends to be the classroom. As of last year, 31 states and the District of Columbia had mandated that schools provide some form of AIDS education, and virtually every state encourages such programs. But the curriculum varies greatly among schools, even among teachers. The most ardent proponents argue that health education should begin in kindergarten and eventually include detailed instruction about the nature and risks of homosexual and heterosexual intercourse. Conservatives are appalled. "We've seen the ACT-UP and Planned Parenthood curriculum proposals," says Monsignor Woolsey. "I wouldn't put them in Times Square bookstores, let alone schools. The average parent would throw up reading them."

In many communities the debate has focused on whether the schools should provide more than information. In a handful of American cities, school-based clinics have begun to distribute condoms to students, but not without resistance from community activists. "These people believe that clinics shouldn't be in the schools because they are usurping the authority of the family," explains Jackie Sadler, director of the HIV/AIDS Education Program in the Washington public schools. "They don't want us to be doing anything they perceive as condoning sexual behavior."

But there is plenty of evidence that teens need no encouragement. Though there are few sources of reliable information about teenage sexuality, it is clear that the level of activity is rising. One sign is that each year the number of teens infected with a sexually transmitted disease grows, with 3 million cases reported last year. The syphilis rate among 15-to-19-year-olds jumped 50% in the 1980s. "We know that STDs tend to travel together," says Dr. Edward Hook III, chief of Sexually Transmitted Disease Control for the Baltimore Health Department. "People who acquire an STD are at risk to get HIV; certainly they're not practicing safe sex."

While reported adult AIDS cases occur predominantly among males -- there are seven infected men for every infected woman -- the profile of the disease among urban teens is more mixed, much like AIDS in Africa. There are three teenage males to every female with the virus, according to Dr. Karen Hein of Montefiore Medical Center in the Bronx, who founded the nation's first adolescent AIDS clinic. "We are seeing more younger girls, sometimes 14-year- olds," says Hein. "Among teens, a far greater number of cases are spread by heterosexual sex."

Those who favor a values-based approach to AIDS prevention urge some variant of Just Say No. Their argument is bolstered by several studies showing that even well-informed, well-equipped teenagers engage in high-risk sexual activity. "The strategic mistake we're making is to assume that more knowledge and greater access to condoms are going to change high-risk behavior," says Stan Weed, 48, director of the Institute for Research and Evaluation, a nonprofit laboratory in Salt Lake City. "Teens approach sex in neither a logical nor a rational way."

This gap between knowledge and behavior is a major challenge facing AIDS educators, says Richard P. Keeling, chair of the American College Health Association's Task Force on AIDS in Charlottesville, Va. "I suspect any parent or teacher would point to peer pressure, or teens' sense of invulnerability," he says. But there are other important factors. A teenage girl may be too embarrassed to ask her partner to wear a condom. Or a youth might not want to buy condoms because it makes him feel guilty for having sex. Many prefer not to question their partners' sex practices, as a sign of trust. And finally, Keeling says, the mixed messages that teenagers receive can be deeply confusing. "Kids do what they see, not what they know. We tell kids not to have sex and then we use sex to sell everything."

All too often, logic and good judgment are clouded by alcohol and drugs, so that disease prevention becomes far more difficult. "Most of the time I had sex with guys I was drunk," says a 23-year-old San Francisco woman who contracted HIV as a teenager. "I never thought a guy would care for me unless I slept with him. I was so uncomfortable with myself I had to be drunk."

Some researchers suggest that teenagers cannot imagine themselves at risk because they never meet infected teens. This view, in a sense, is an extension of the idea that gay men only started taking precautions after seeing their friends die. But teenagers are unlikely to meet many ailing peers since the incubation for HIV averages 10 years. Jennifer Andre, 21, who was infected by a dirty needle three years ago, regularly speaks to youths in Massachusetts in order to bring home the point that everybody is at risk. "A few months ago, I was at a Boston inner-city school, and there was a kid who wouldn't believe I was infected," she recalls. "He kept saying that I was a paid actress and that I was just saying I had AIDS."

While the debate unfolds, both the traditional and progressive approaches are likely to roll along side by side -- and rightly so, since teaching about sexual behavior in a moral vacuum would not serve young people well, any more than ignoring the practical pressures to experiment with sex and drugs that they confront each day. Any AIDS education should be coupled with programs about drug and alcohol abuse, in order to address all the risk factors that intertwine. School is by no means the only, or even always the best, place for this to happen. In Columbia, S.C., a beauty-shop owner named, memorably, DiAna DiAna began her own crusade six years ago. Impatient with skimpy newspaper accounts of the spread of AIDS, she wrote away for pamphlets and photocopied them for her clients. "I read that you had to have condoms," she says, "so I ordered 5,000." And she talks to the local teenagers as bluntly as possible. "You cannot shock or embarrass me," she tells them. The most effective part of her programs, she says, is that they "get people to talk and communicate -- to make sex not such a big mystery."

Judging which approaches to AIDS prevention are most effective will be impossible without more complete knowledge of the attitudes and behavior of young people. But that information may be hard to come by. Last month the Bush Administration blocked a comprehensive survey of adolescent sexual practices after critics charged that its questions about oral and anal sex were too explicit for children. Others greeted the cancellation with outrage. "We have a terrible deficit of knowledge about sexual behavior as a whole in this country," says Dr. Hook. "We don't know if youngsters in low-risk areas are just not having sex or if the virus hasn't got there yet." Without better information, researchers might find out only when more people start dying. That is not a scientific method that any country can afford.

With reporting by David M. Gross/Boston and Anne E. West/Washington