Sex, crime, disease and the parathyroid hormones

Hail,
The following contains strong sexual references. And the article that got me thinking about this is here.

I was reading up on some ICU stuff and HIV came up, and I started thinking about some of the HIV positive patients I have seen, and about HIV in general. The young guy in prison, the gay sex worker with the (at that time) unbelieveable sexual history, the bipolar bisexual Spanish sailor from Sabin Psych ward when I was an intern.

So, here are the thoughts.

The way I was taught, and what I still reflexively believe, is that people who are HIV positive have a moral duty to inform all past and then subsequently potential partners. But there is a difference between a moral and a legal duty, and the law is very much involved in this area in some states. There is a crime over here - it varies from state to state, but just after Christmas someone across the border got twenty five years for "maliciously causing a grievous bodily disease".

(I don't know the exact legal situation here with regards to "knowingly exposing" (I'll look it up) but when we detect HIV in one of our clients the pathology lab informs the communicable diseases people, who then contact the client themselves. HIV is what is called a "notifiable disease" over here, along with measles, leprosy and some form of rabies you get from being bitten by a bat.

This informing another person or body violates patient confidentiality, but legally "duty to the public" beats "patient confidentiality". Having said that, it's difficult to tell people this stuff, often embarrasing and distressing and frightening to the patient, and it would be an unusual doctor who didn't feel some sympathy with the patient under these circumstances).

Anyway. I've been thinking about the law, and some of the stuff near the edges, where things get complicated, blur the absolutist dichotomies of good and bad, legal and illegal.

Look at these ideas:

Some practices are low risk, so low risk that there are no records of transmission ever happening. Readers of a sensitive disposition look away now, but giving oral sex to someone* when you are infected - as far as I know unless both participants are seriously unwell, or intentional or unintentional bloodletting occurs, the risk is fairly low. Not zero, but the CDC in the US has no documented cases of people getting HIV from receiving oral sex.

(I do have a patient, by the way, who has schizophrenia, who had sex with someone who was HIV positive, who knew she was HIV positive, and didn't wear a condom. He had what is called concrete thinking - another example of how mental illnesses kill you. Not him, by some stroke of good fortune. I will also point out that from a careful survey of the two people of my aquaintance who have herpes - become a doctor, people tell you stuff - it's not always the Lotharios who get it).

Making something a crime stigmatises it, and stigmatising something means people won't want to be tested and won't want to tell "all past and then subsequently potential partners" of any sinister results, and that means more and more HIV, more and more AIDS. This is a big effect, a well documented effect: Denial is death. It is a simple thing that I feel is impossible for some otherwise intelligent people to understand.

Sex crimes are notorious for having low conviction rates, in part because of the difficulty of distinguishing between (say) what he said and what she said. Juries are not particularly good at determining the truth, the whole truth and nothing but the truth in these murky and emotive waters. Juries sit through months of the defence lawyer listing hundreds of other people that this "so called victim" could have got the disease from, they become increasingly enmeshed in a soap opera made up of shallow caricatures fueled by revenge and hatred, capable only of deceit. The jury ends up increasingly unsure as to who did what when, and you end up seeing rich white lawyers and poor black convicts, if you get a conviction at all.

Disease, especially sexual disease, especially sexual diseases that are still associated with junkies, ethnics and queers, tend to evoke visceral, "yuck" responses. Everybody hates these diseases. Nausea, disgust and revulsion are not strong predictors of what makes a good law. Unfortunately they are strong predictors as to how people vote, and thus what laws we get.

And lastly, and most heartlessly - and these are just ideas, not my policy or my practice - is there a responsibility on behalf of the uninfected partner? These questions will come up in court: Had s/he not heard of HIV/AIDS? Had s/he not heard of condoms? In civil cases in the US there are findings of partial responsibility - the train ran you over, but you leapt on the train track, that kind of thing. To what extent are you responsible?

Anyway. I am not in any way saying that knowingly exposing someone to HIV is not a bad thing, I am not even saying that it should not be a crime. I am just saying that it is an area where laws should be carefully framed, in awareness of the milieu in which they will operate, with the larger public good in mind.

Okay. Back to the role of parathyroid hormone in calcium metabolism. I am giddy, expectation whirls me round. Troilus and Cressida, Act III, Scene II.

Thanks for listening,
John

*so much better a phrase than "performing upon", which always brings to mind people holding up scorecards, or those people in the mall who paint themselves gold and stand there.