Magic
March, 1992
has magic johnson changed what we know about the transmission of h.i.v.? actually, no
The media would have us believe that Magic Johnson's affliction with human immunodeficiency virus will forever change the way we have sex, that he will be an effective spokesman for abstinence. But there is a basic absurdity to the proposition "If it can happen to Magic, it can happen to anybody."
Magic is an exceptional man. He is graceful, charismatic and brilliantly successful, and as a result, he has had more sexual opportunities and liaisons than most men can even imagine. He loved women and they loved him. He could accomplish more with a smile than you or I could in a year of sophisticated courtship. We can't hit the open man on the court, or the open woman off, with anything approaching his success. And yet we have been asked to take him as a representative of heterosexual risk--of our risk. He says he lived "the bachelor's life," but that is like saying he could play a little ball. Just as he redefined the guard's position on the basketball court, he redefined the number of sexual conquests that it is possible for a bachelor to achieve off the court. All of his passes were caught. In his press conference and in his appearance on The Arsenio Hall Show, Magic alluded to a personal history that is less heterosexual than hypersexual. It is a tale of thousands of sexual partners, of innumerable instances of risk.
The press conference cleansed the story of detail and doubt, left us with the heroic image of Magic bravely facing the challenge of living with HIV. We don't question the heroism; we applaud it. Still, Magic provided no useful information for sexually active heterosexuals. Assuming that he did not contract the virus from his dentist (no one checked), another male (he denies the rumors) or intravenous-drug use (steroids?), Magic is simply the newest member of a very small group of men who have contracted the AIDS virus through heterosexual contact. How small? You be the judge.
The Centers for Disease Control claims that 4300 men in the U.S. have contracted AIDS after having sex with a woman, as opposed to 152,000 who have contracted it in other ways. And the difference between those numbers is even greater than it seems. The CDC number for heterosexual transmission has become set in stone, repeated endlessly in the press. But that doesn't mean it is accurate. The number is grossly inflated by victims who misrepresent their behavior, by sloppy investigation and by including foreign nationals who may have contracted the disease in their home country. The latter group alone may constitute half of CDC's heterosexual cohort.
Dr. Elizabeth Whelan, president of the American Council on Science and Health, challenges the CDC number on those grounds and others. She writes, "New York City accounts for approximately 20 percent of all U.S. AIDS cases. It is logical then to expect that the number of heterosexually transmitted AIDS cases in men reported in New York City would account for approximately 20 percent of all [such cases] reported in the U.S. That is, 520 cases. However, New York City has reported only 12 such cases in 11 years."
Why the discrepancy? The overwhelming majority of men who claim they got AIDS through heterosexual contact eventually admit to a history of intravenous-drug use or sexual contact with men. Whelan writes, "It is quite possible that if every local and state health department investigated AIDS cases as aggressively as New York City, there would be fewer than 100 men over 11 years who acquired AIDS the way Magic Johnson said he did."
We checked figures from the San Francisco Department of Public Health: Since 1981, it has found 25 men who contracted AIDS the way Magic did.
Los Angeles had 87. Now it's 88.
•
Magic is indeed an exceptional case. When you investigate other cases of heterosexual transmission, you find equally exceptional behavior.
We don't deny that heterosexual transmission exists. It accounts for 75 percent of all AIDS cases in the world. But when you scrutinize the studies and statistics, you get a different picture; when you look behind the headlines, a more detailed, human story emerges.
Almost all the stories on Magic cited a California study on heterosexual transmission. Dr. Nancy Padian found 72 women who were infected with the AIDS virus. At regular intervals, she tested their male partners. In the six years of the study, only one man out of 72 contracted the virus. That individual had sex with his wife 15 times a month for seven years without condoms, persisting even during episodes of vaginal and penile bleeding. They also engaged in a threesome, raising the possibility that he contracted it from the other man's sperm.
How did the woman contract HIV in the first place? In the five years before she enrolled in the study, she had more than 600 partners. (In the same period, her husband had only three.) She had more than 2000 contacts with a bisexual, an unknown number of contacts with an intravenous-drug user and more than 1000 contacts with a man she knew to be HIV-infected.
Exceptional man, exceptional woman, exceptional behavior, exceptional result.
Michael Fumento, author of The Myth of Heterosexual AIDS, examined another AIDS study done in New York City by Dr. Joyce Wallace, who recruited 340 men who were regular clients of prostitutes and who denied both homosexual activity and drug abuse. "Of these," Fumento writes, "the average number of sexual exposures to prostitutes over the last ten years was 94, and the most common act was fellatio. They averaged one sexually transmitted disease a year; and while a third of them occasionally used condoms, one half never did. Of these 340 men, six tested positive [for HIV]. Three of these, upon requestioning, admitted to either drug use or homosexuality. Of the three remaining, they averaged 575 sexual exposures to prostitutes (six times the average number in the study group) and none had used condoms. In other words, assuming these men had no other risk factors and were infected by prostitutes, they were exceptions because of exceptional behavior. They played the odds and lost."
It is possible to find some comfort in these numbers, especially if you fall outside the groups being counted. But numbers are not the point. We're not dealing with a roll of the dice, we're dealing with lifestyles. Sex is actual, not actuarial. It is sweat and semen, the sound of zippers, the collision of flesh. There are statisticians who calculate that your odds of becoming infected with the AIDS virus are one in five billion if your partner has no history of high-risk behavior and you use condoms--and still only one in 500 if you have unprotected sex with someone who does have the virus. But what do those numbers mean to each of us? To Magic Johnson? Not much. We have lives to lead, and that includes sex lives.
If you reduce AIDS awareness to playing the odds, you depersonalize sex. Instead of taking responsibility for your actions, you are as passive as gamblers around a roulette wheel. Some might say Magic gambled and lost; we say he had a delirious sex life but that somewhere in his personal history a deadly detail brought him down.
Playboy has maintained that heterosexual transmission is a rarity, that if you are a healthy, heterosexual male and you don't use intravenous drugs or have sex with someone who did, you could spend the rest of your life trying to catch the AIDS virus and fail. The odds are overwhelmingly against infection. We meant this not as a challenge or as permission but as a means of establishing perspective, of reducing panic. In the face of the recurrent hysteria, we should all remember that Magic Johnson took enormous risks, and that he was also extremely unlucky.
This magazine has also been quick to repudiate those who prey on the disease and its victims. This affliction is not an excuse for a sermon; it is a tragedy that happens to be associated with sex. A useful comparison to AIDS statistics can be drawn from the number of traffic fatalities. Even though 44,000 people die on our highways each year, the government doesn't advise, "Just say no to driving." We do not believe that urging abstinence is anything other than the abdication of responsibility to educate. We need to address reality: Sex happens, so how can we make it safer?
The Great Dilemma
There are two things to consider when evaluating your risk of contracting AIDS: your peer group and your behavior. When scientists identified the disease that was devastating San Francisco and New York in the early Eighties, they considered calling it by the acronym CAIDS--community acquired immune deficiency syndrome. What was obvious to observers was that the disease struck subcultures: gays, people who injected drugs, immigrants from Africa and the Caribbean, hemophiliacs. The prevalence of the virus in your community is the single greatest indicator of risk.
But the doctors naming the new disease faced a moral and political dilemma: A community can quickly become a leper colony and compassion can give way to quarantine. To focus national resources on the problem, researchers had to eliminate community and risk group as a consideration, to tell us that this is not just the gay plague or an addict's disease but a problem for everybody. Activists expanded the boundaries of our concern to make AIDS a problem of the world community. They accomplished that mission, heroically. They loosened government purse strings, put pressure on drug companies to speed AIDS research and began a formidable public information program.
Education focused on behavior. You can change behavior more easily than you can change community. The risky behavior also seemed clear-cut: You can contract the virus through contact with infected blood, through needle sharing and through unprotected vaginal or anal intercourse. Promiscuous sex and other behaviors within certain communities turned it into a localized epidemic: In New York shooting galleries, a single needle might be shared by 50 addicts in one night. In the bathhouses of San Francisco, gay men could engage in anonymous anal sex with thousands of partners a year. In both groups, the infection rate has reached as high as 50 percent. Stop the behavior and you stop the epidemic.
The gay community got the message; the intravenous-drug users did not. The CDC reports that 43,964 I.V.-drug users contracted the disease from shared needles. They have passed it on to 4255 women and 1772 men through heterosexual contact (this assumes that their partners would admit to drug use). It is not surprising that a community that did not toe the party line on the dangers of drugs would also ignore the party line on safe sex.
Having unprotected sex in the gay community or the I.V.-drug community is akin to playing Russian roulette with a double-barreled shotgun. But how safe is sex outside of those communities? Here we must assess the interaction between behavior and prevalence. As one public health official told us, "What will kill you in the South Bronx will make you a living legend in your home town of East Podunk."
Magic is a living legend. He belonged to the subculture of superstar athlete/celebrity. After his announcement, the press regaled us with stories of jock groupies and party girls. The Los Angeles Times reported on one woman who bedded more than 100 NBA stars and had the autographed sneakers to prove it. The NBA is a subculture that shares partners. By the time we go to press, most of the worried jocks will have been tested. You can judge for yourself how dangerous heterosexual transmission of AIDS is by how many players have called press conferences.
Here's how we might judge the likelihood of that happening. In large-scale testing of blood donors and military recruits, researchers have found antibodies to the AIDS virus in about four out of 10,000 people. (The good news is that the rate has dropped over the past few years.) This means that in a crowded stadium of 20,000 people, eight might have the virus. Six would be gay, one or two would be I.V.-drug users and maybe one would be a heterosexual. From the sound of it, that one was lined up, every night in every NBA-franchise city, waiting for Magic.
The truth remains simple: If you don't have the virus and your partner doesn't have the virus, then you can do everything your heart desires for the rest of your long and lusty life.
If you live outside the safe group, you must take precautions.
Heterosexual Transmission
All of the focus on gay men, bisexuals and drug users seems to offer a free ride to heterosexuals. But heterosexual transmission does, of course, exist. The means of transmission remain mysterious, however. Why does one person get the virus after one encounter, while others can have unprotected sex a hundred times a year for five years with a partner who has HIV and never contract it themselves? And why are African men and women so vulnerable to the virus, while their American counterparts seem relatively impervious?
The S.T.D. Factor
During the most contagious outbreaks of AIDS hysteria, the media often seem to suggest that anyone who has had an erection in the past decade is at risk and should be tested. Women's writers suggest that anyone who ever thought her boyfriend was a jerk should rush out for an ELISA or Western Blot (the standard tests that detect antibodies to HIV). But by far the clearest sign of vulnerability to HIV is a personal history of sexually transmitted diseases (S.T.D.s). If you've had an S.T.D., you should probably be tested for HIV. There are all sorts of reasons.
S.T.D.s break the skin. They tear the body's first, and most powerful, line of defense. When epidemiologists contemplate HIV-transmission routes, they look for blood-to-blood or semen-to-blood contact, the kind that is achieved through tears in skin or through the particularly absorbent and fragile cells that line the rectum. Vaginas and penises are built to sustain the rigors of sex, and as long as they remain uninfected by S.T.D.s, they are relatively tough and HIV-resistant. But when the skin is harmed by infection, the genitals can become a primary pathway for HIV transmission.
S.T.D.s are implicated in other ways. They weaken the immune system. If another virus invades, the body can't fight it off as effectively as it could have done before infection. And since the virus lives in white cells, and white cells congregate at the site of infections, if your partner has an S.T.D., you may receive a higher concentration of virus. Moreover, if both partners have S.T.D.s, HIV-infected cells from one partner have the opportunity to invade HIV-free cells of the other, vastly increasing the chance of infection. The uninfected white blood cells represent a kind of open-door invitation to HIV.
The evidence backing up these assertions is convincing. In the first wave of homosexual infections, 95 percent of the victims had some other S.T.D. The gay communities in San Francisco and New York had already endured epidemics of hepatitis B, syphilis, gonorrhea, Epstein-Barr virus, herpes and cytomegalovirus.
Those who had S.T.D.s before or after contracting HIV developed AIDS much more quickly than those who did not.
In Africa, where heterosexual transmission is considered the norm, the disease is associated with other S.T.D.s. In a study of U.S. and African cases, it was determined that most AIDS victims have had herpes (90 to 100 percent), cytomegalovirus (90 to 100 percent), hepatitis B (78 to 82 percent), as well as nonvenereal bouts of malaria and other parasitic infection.
The difference between America and Africa is that we have a sophisticated health-care system and a wide array of pharmaceuticals to treat S.T.D.s. The Africans do not. Time magazine notes that "most Americans do not have the venereal diseases that make it so much easier for the virus to be transmitted through heterosexual intercourse." True enough, but enough do for us to express concern.
Among teenagers alone, there are 3,000,000 S.T.D.s a year. For many Americans, their first round of sex education comes from the clinic that diagnoses their S.T.D. This is a classic case of too little too late. Since HIV can remain undetected for years, many people find out they have it when they visit an S.T.D. clinic for other treatments. The only sites with a higher percentage of HIV-positive patients are drug-abuse clinics. Clearly, if we want to stop AIDS, we should stop S.T.D.s. It would be a lot cheaper, both in insurance dollars and, obviously, in lives.
The head of the American Social Health Association says that regular tests for sexually transmitted disease should be part of the standard health-maintenance plan for Americans. Every two years, or two partners, go in for lab work.
Another expert suggested a national "wide-spectrum antibiotic day." If everyone attended to their health at the same time, the chain of infection might be broken. During World War Two, we almost succeeded in wiping out V.D. Why not finish the job now, when the stakes are much greater?
Promiscuity
The media moralists have used AIDS to attack nonmonogamous lifestyles, but so far as heterosexual transmission goes, promiscuity per se is not the most significant risk factor. As the CDC pointed out in a recent newsletter, study after study shows that the "number of partners did not vary between cases [those who caught AIDS] and controls [those who did not]."
The overwhelming evidence is that heterosexual AIDS does not come from promiscuity but from repeated sexual intercourse with the wrong person. Who stands a greater chance of getting AIDS: a teenager going out with his second or third girlfriend or Cookie Johnson, Magic's wife? The answer is clear.
Getting back to the issue of promiscuity, the evidence is compelling. Studies of prostitutes--who certainly fit everyone's definition of promiscuous--show that it is shared needles, not shared customers, that spread the disease. Prostitutes who work in the 32 legal brothels in Nevada, where sex is not typically associated with I.V.-drug use, do not have a single case of AIDS. Condom use among these prostitutes also helps keep the rate of infection down, but the lesson still holds.
In communities where the virus is present, sleeping around typically increases your chance of running into someone with HIV; for the rest of us, sleeping around increases our chances of running into someone with an S.T.D., creating a climate in which we are more vulnerable. But it does not seem to be the single important factor. If anything, the statistics demonstrate that it is monogamy with the wrong person that kills.
The study by Dr. Padian cited earlier showed only one male out of 72 living with infected women coming down with HIV; the same study showed only 61 women out of 307 living with infected men coming down with the virus. Why? Padian says that failure to use condoms accounted for most of the cases of male-to-female heterosexual transmission. An Italian study by Dr. Massimo Musicco followed 171 women with HIV-infected partners. If the partner used condoms, the women did not contract the virus. Male-to-female transmission is much easier than female-to-male; any woman uncertain of her partner's sexual history should insist on his using a condom. Still, you cannot use a condom to shield bad judgment, or to eliminate the consequences of high-risk behavior.
Safe Sex, Scared Sex
The notion behind safe sex is that unless you know otherwise, you should act as if you or your partner were infected. This is fine in theory, but most of us find love and suspicion to be incompatible. The studies bear this out. Most of what we know about heterosexual transmission comes from couples who have continued to make love in the most intimate, risky ways even when they knew that their partner was infected. Love conquers all, even fear of death.
Scientists have isolated some factors that seem to increase the risk of maleto-female transmission. Their findings are useful only if you refuse to find out your own HIV status, yet want to behave in a responsible fashion toward your partners. They are crucial to Magic and Cookie now but are a footnote to partners who take the trouble to learn that they are HIV-free.
Still, the guidelines are there for those who need them:
Anal sex: Dumb. A health column in The Advocate counsels gay men: "Being the passive partner carries an almost certain risk of becoming infected. Statistically, the rate of seroconversion [when the immune system responds to contact with HIV by producing antibodies] is between one in ten and one in 100. Being the active partner carries a lower risk of becoming infected." In studies of heterosexual activity, anal intercourse has been found to triple the risk of infection for women.
Vaginal intercourse: Less dumb. More threatening to the woman than the man, by a factor of ten in one study, 17 in another. Avoid sex during menstruation, unless your partner is virus-free.
Oral sex: It depends. Your mouth and digestive tract are equipped with defensive mechanisms not shared by other orifices. Saliva and stomach acid kill the virus. In this case, the active partner runs the greater risk, especially if there are cuts or sores in the mouth or if the gums are inflamed.
Harold Jaffe at the CDC says, "If you get blood in your mouth, I'd be worried. If you get semen in your mouth, there's some risk. Saliva in your mouth has to be a very low risk."
The most convincing and most troubling evidence on oral sex comes from studies of gay men. Researchers estimate chances are one in 10,000 that a gay man will contract HIV from a single episode of active oral sex. Another study increases the likelihood to one in 1000. In any case, these odds are based on communities with a 50 percent prevalence rate. For male heterosexuals, the equivalent would be practicing insertive oral sex with a steady supply of HIV-positive prostitutes. Indeed, Fumento calculated that the three infected men cited in Dr. Wallace's study fell prey to one-in-1000 odds. For the rest of us, just add zeros until your calculator breaks. The Padian study of heterosexuals found that oral sex posed no real risk.
Mutual masturbation: This used to be on everyone's safe-sex list. Now comes word of a nurse afflicted with eczema (a condition that caused her skin to crack) who contracted the virus by handling the bleeding wound of an AIDS patient. This resembles no sex act that we know of.
Miscellaneous risks: The Italian study found that if the woman used an I.U.D., it tripled the chance of contracting HIV. Another study found that birth-control pills seem to make women more vulnerable, doubling their chance of infection. Contrary to the Padian study, having sex during menstruation, or other bleeding during sex, increased the risk by 13 percent. An African study found that uncircumcised men who had genital lesions stood a 50-50 chance of infection from a single act of intercourse.
This Magic Moment
Has Magic changed the way we think of AIDS? No. AIDS remains a disaster. It has taken the most intimate form of human contact and turned it into a lethal means of transmitting disease.
We are moved by Magic's courage, by his refusal to blame his plight on his partners, by his unwillingness to accept shame as the penalty for leading the life he chose to live. We will watch with interest to see how he chooses to describe that life. We would speculate on three things:
1. The amount of sex he participated in created the opportunity for novel routes of transmission. Were there ménages à trois with a woman and another man? The Padian study suggests that proximity to other men's sperm can be deadly.
2. Did Magic play hurt? That is, did he have sex while he was fighting off another sexually transmitted disease?
3. Among all those partners, he may have accommodated an intravenous-drug user or two. Or four. Or 50. Even if Magic never used drugs himself, they were almost certainly present in his circle of sexual partners.
It is easy to understand how any of these conditions might have slipped past even a vigilant man. The celebrity sex that Magic enjoyed was the enemy of candor in his partners. Who can imagine a woman pausing during a moment of passion and saying, "Hey, Magic. My boyfriend just went into a drug-rehab program, I'm having my period and, by the way, isn't that a sore on your genitals? Let's do this some other time. When's the next time you'll be in town?"
It wouldn't happen.
But that scenario doesn't have anything to do with the way most of us live our lives. Magic is, indeed, an anomaly. If the rest of us act sensibly, we can avoid becoming anomalies, too. Our knowledge can help all of us beat back the fear, the overreaction, and preserve the joy of sex. It is our most loving form of communication, the deepest, most intimate expression of our humanity, and we must defend it from all attackers, be they viral or just plain hysterical.
Magic has indicated that he won't answer questions about his bachelor past. He told Connie Chung that he has always kept his home life private. "Yes," he said, "it was my fault. Yes, unprotected sex. Yes, morally I was wrong in sleeping with a lot of women. But after that?" He simply faces the challenge of living with an uninvited guest.
Chung asked if he tried to find out when or from whom he caught the virus. He said that wasn't the purpose of the phone calls he was making. "I'm a man," he said. "I have a responsibility to everyone that I had sex with. And to the people they had sex with."
He said that he would devote his time to education. Anger and blame have no place in his life. Neither does abstinence. He told Chung that the stories in the tabloids were false: Cookie is not sleeping in the basement. "We can have protected sex," he said.
His words carry an enormous emotional weight. Slogans have no place in this discussion. If Magic can articulate the role of intimacy in his own life--the commitment that supersedes fear of infection--then we all stand to learn something. This is the real meaning of the marriage vow "till death do us part." This is the real face of love.
If he can articulate that for two people within a marriage, then he can articulate it for those who are reaching for intimacy outside of marriage or for anyone at risk of contracting HIV. He can protect sex for us all.
Fact: "We should remember that Magic Johnson took enormous risks, and he was also extremely unlucky."
Question: "Did Magic play hurt? That is, did he have sex while he was fighting off another sexually transmitted disease?"
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