Actually, Prohibition Was a Success

Actually, Prohibition Was a Success


Monday, July 01, 2013

The following article is an opinion piece by Mark H. Moore, a criminal justice professor at Harvard, that was published in the New York Times on October 16, 1989. It can be viewed at http://www.nytimes.com/1989/10/16/ opinion/actually-prohibition-was-a-success.html.

Although Moore only specifically addresses drug use, his article is a part of our series on homosexuality because it touches on an issue relevant to both topics. People frequently cite America’s prohibition years as proof that we cannot legislate morality, and that any attempts to do so will only create worse problems. They apply this logic to homosexuality, arguing that the law cannot be used to discourage homosexual behavior, even if it comes with severe health risks and offers no benefit to society (which, as you can see from many of the other articles we’ve posted, is the case). But did prohibition truly fail? Is using the law to discourage behavior really as futile as we’ve been led to believe?

History has valuable lessons to teach policy makers but it reveals its lessons only grudgingly.

Close analyses of the facts and their relevance is required lest policy makers fall victim to the persuasive power of false analogies and are misled into imprudent judgments. Just such a danger is posed by those who casually invoke the ”lessons of Prohibition” to argue for the legalization of drugs.

What everyone ”knows” about Prohibition is that it was a failure. It did not eliminate drinking; it did create a black market. That in turn spawned criminal syndicates and random violence. Corruption and widespread disrespect for law were incubated and, most tellingly, Prohibition was repealed only 14 years after it was enshrined in the Constitution.

The lesson drawn by commentators is that it is fruitless to allow moralists to use criminal law to control intoxicating substances. Many now say it is equally unwise to rely on the law to solve the nation’s drug problem.

But the conventional view of Prohibition is not supported by the facts.

First, the regime created in 1919 by the 18th Amendment and the Volstead Act, which charged the Treasury Department with enforcement of the new restrictions, was far from all-embracing. The amendment prohibited the commercial manufacture and distribution of alcoholic beverages; it did not prohibit use, nor production for one’s own consumption. Moreover, the provisions did not take effect until a year after passage -plenty of time for people to stockpile supplies.

Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928.

Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent.

Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition’s 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after.

Fourth, following the repeal of Prohibition, alcohol consumption increased. Today, alcohol is estimated to be the cause of more than 23,000 motor vehicle deaths and is implicated in more than half of the nation’s 20,000 homicides. In contrast, drugs have not yet been persuasively linked to highway fatalities and are believed to account for 10 percent to 20 percent of homicides.

Prohibition did not end alcohol use. What is remarkable, however, is that a relatively narrow political movement, relying on a relatively weak set of statutes, succeeded in reducing, by one-third, the consumption of a drug that had wide historical and popular sanction.

This is not to say that society was wrong to repeal Prohibition. A democratic society may decide that recreational drinking is worth the price in traffic fatalities and other consequences. But the common claim that laws backed by morally motivated political movements cannot reduce drug use is wrong.

Not only are the facts of Prohibition misunderstood, but the lessons are misapplied to the current situation.

The U.S. is in the early to middle stages of a potentially widespread cocaine epidemic. If the line is held now, we can prevent new users and increasing casualties. So this is exactly not the time to be considering a liberalization of our laws on cocaine. We need a firm stand by society against cocaine use to extend and reinforce the messages that are being learned through painful personal experience and testimony.

The real lesson of Prohibition is that the society can, indeed, make a dent in the consumption of drugs through laws. There is a price to be paid for such restrictions, of course. But for drugs such as heroin and cocaine, which are dangerous but currently largely unpopular, that price is small relative to the benefits.

Dr. Frank Spinelli: Cruise Control

Dr. Frank Spinelli: Cruise Control


Tuesday, March 26, 2013

Screen Shot 2013-04-05 at 1.20.29 PM

This article was originally posted on Advocate.com on 2/18/2011. It can be viewed at http://www.advocate.com/health/living-well/2011/02/18/cruise-control?page=0,0

COMMENTARY: Imagine for a moment that you’re a doctor — a gay doctor with a practice that predominantly treats gay men. Now guess how many text and phone calls you might receive during any given weekend involving questions that have to do with recreational drugs, penile discharge, or the risk of contracting HIV from unprotected sexual encounters. Now take that number and multiply it by 10 if that weekend should occur around Gay Pride, Folsom Street Fair, Gay Days at Disney, or any one of the Atlantis cruises. Welcome to my world.
At this point, you might be thinking, What did you expect when you decided to treat gay men? I knew what I was signing up for. The life of a gay party boy is not foreign to me. I’ve been to Folsom, Gay Days at Disney, and several Atlantis cruises. But even I struggle to understand the brain of a gay man, especially of those who make the regular 3 a.m. Sunday calls to me seeking advice, reassurance, or quick pharmaceutical relief.

Over the years I have monitored and treated gay men with curiosity. I’ve concluded that some of the most telling insights into the gay mind come from watching my own (presumably) heterosexual nephews. At age 15 and 16, they don’t always listen to their parents, they’re eager to push the limits set by their teachers, and when confronted about their risk-taking behavior, they invariably roll their eyes to show their disinterest in having a rational conversation. That’s because teenagers, like gay men, are a conundrum, baffling to scientists and doctors.

I’m not alone. My colleagues in Manhattan and Los Angeles give similar reports about their patients. We scratch our heads and wonder why the rates for syphilis are at an all-time high among men who have sex with men. And with all the media attention paid to HIV prevention and risk modification, the majority of new HIV cases in the United States are among gay men.

As doctors, we do our best. I counsel my patients about drugs and sexually transmitted diseases, including HIV. Although I feel confident in my abilities, I still picture my nephews’ eyes rolling into the back of their heads when I try to instill some sense of caution in my patients before a circuit event. I don’t judge, or at least that is what I tell myself. But I suppose I do. I stopped going out years ago when it became a never-ending merry-go-round of witnessing overdoses and re-treating STDs. I tell myself I’m getting older. When I was younger, I didn’t listen either, but the age of the modern-day party boy is well beyond the age when any of us should be referring to each other as “boy.” I’ve read that the average age of an Atlantis cruise ship passenger is 41.

The trouble with gay men is that, like teenagers, they fall prey to the rush of hormones that drive the reward-system network. Essentially, this is the spot in the brain that reacts to desire or a bump of crystal. The body responds to this reward-system network by releasing the neurotransmitters dopamine and norepinephrine. Cocaine raises dopamine levels 400% above normal, and methamphetamine triggers a 1,500% increase in dopamine. Although dopamine affects many parts of the brain and body, the effect is most important on two brain sites: the nucleus accumbens and the ventral tegmentum. These two brain sites are connected by a bundle of cells called the mesolimbic pathway, or the brain-reward center. This is the area of the brain that is most powerfully associated with pleasure and addiction. Stimulating this pathway makes a person want to repeat this behavior in order to feel the reward it brings. Unfortunately, that reward is never truly like the first time — no matter how much sex you have or how many bumps you take.

Of course, the obvious culprit is that we are fueled by our desires, whether these are sexual or drug-fueled escapes, especially when these desires have been liberated after years of confusion and confinement. Who wouldn’t want to go on a sex, drug, and alcohol binge while drifting through the Caribbean on a gay cruise where there are no judgmental eyes watching your every move?

On February 6 the Royal Caribbean ship Allure of the Seas set sail from Port Everglades, Fla. In what was billed as the largest gay cruise ever, Atlantis hosted more than 5,400 passengers. “Where does it go?” I asked one patient as he reviewed a list of prescriptions he would need for his upcoming trip: Cialis, Xanax, and Ambien …

“Who cares,” he said. “I’m never getting off the boat.” Several days later the text messages started to arrive, “This trip is a disaster. Guys are overdosing left and right. The authorities boarded the ship and arrested a drug dealer. They have dogs and they’re making surprise room searches.”

Agents who searched a suspected dealer’s cabin reported finding more than 140 ecstasy pills, nearly three grams of methamphetamine, a small quantity of ketamine, and about $51,000 in cash. While waiting for the suspect in his cabin, two more passengers stopped by seeking drugs, according to agents.

When I read the article online and spoke to passengers upon their return, I felt angry. In a time when gay men and women want to be taken seriously so that we can serve openly in the military and have the legal right to marry, isn’t it counterproductive to read about the drug busts and overdoses on a floating circuit party? Or maybe we just want it all — the rights we deserve and the option to choose which, if any, fit into our particular circumstances and plans.

The normal reward system in the brain serves a vital evolutionary purpose. As this center matures it helps us deal with the terrifying realities that face us in the modern world. This world also includes access to illegal drugs and risky sex. If these signals continue to trigger the reward system, they may lead to anxiety, depression and addiction. On the other hand, the cognitive control network is the part of the brain that acts like our moral conscience. In teenagers, the reward-system network matures rapidly due to the rush of hormones. These hormones do not speed up the cognitive control network. In fact, cognitive control matures slowly. So then why doesn’t an adult gay man have the cognitive control to chaperon their risk-taking behavior? One explanation is that most gay men do not feel the same pressures of responsibility as most heterosexual men. Gay men who enjoy circuit events are more likely to be single. If they are in a relationship, the couple often negotiates rules that include three-ways or sexual encounters outside their relationship. More often these men do not have children. This freedom supports exploratory behavior to indulge in sex and drugs. For most teenagers, gaining control of the reward-system center comes with maturity, especially as their cognitive center develops. Unfortunately for some gay men, the strong impulses of the reward-system center often outweigh the associated risks that face the average partygoing male.

If 5,400 people, mostly gay men, go on an Atlantis cruise, what percentage will succumb to the impulses of the reward system by using recreational drugs, drinking alcohol, and engaging in unsafe sex? Now take that number and multiply it by 10. Despite the arrest, Atlantis announced that it will repeat the trip in 2012. I hope it’s over a weekend when I’m not on call.

Ten Things Gay Men Should Discuss with their Health Care Providers: Commentary

Ten Things Gay Men Should Discuss with their Health Care Providers: Commentary


Monday, March 25, 2013

by Vincent M. B. Silenzio, MD, MPH
Board of Directors, GLMA
Co-Editor, Journal of the Gay and Lesbian Medical Association
Private Practice & Assistant Professor, Columbia University, New York

The following list was originally released by the Gay and Lesbian Medical Association in 2002. It can be viewed at http://www.publichealth.pitt.edu/docs/10things_gay.pdf

1. HIV/AIDS, Safe Sex

That men who have sex with men are at an increased risk of HIV infection is well known, but the effectiveness of safe sex in reducing the rate of HIV infection is one of the gay community’s great success stories. However, the last few years have seen the return of many unsafe sex practices. While effective HIV treatments may be on the horizon, there is no substitute for preventing infection. Safe sex is proven to reduce the risk of receiving or transmitting HIV. All health care professionals should be aware of how to counsel and support maintenance of safe sex practices.

2. Substance Use

Gay men use substances at a higher rate than the general population, and not just in larger communities such as New York, San Francisco, and Los Angeles. These include a number of substances ranging from amyl nitrate (“poppers”), to marijuana, Ecstasy, and amphetamines. The long-term effects of many of these substances are unknown; however current wisdom suggests potentially serious consequences as we age.

3. Depression/Anxiety

Depression and anxiety appear to affect gay men at a higher rate than in the general population. The likelihood of depression or anxiety may be greater, and the problem may be more severe for those men who remain in the closet or who do not have adequate social supports. Adolescents and young adults may be at particularly high risk of suicide because of these concerns. Culturally sensitive mental health services targeted specifically at gay men may be more effective in the prevention, early detection, and treatment of these conditions.

4. Hepatitis Immunization

Men who have sex with men are at an increased risk of sexually transmitted infection with the viruses that cause the serious condition of the liver known as hepatitis. These infections can be potentially fatal, and can lead to very serious long-term issues such as cirrhosis and liver cancer. Fortunately, immunizations are available to prevent two of the three most serious viruses. Universal immunization for Hepatitis A Virus and Hepatitis B Virus is recommended for all men who have sex with men. Safe sex is effective at reducing the risk of viral hepatitis, and is currently the only means of prevention for the very serious Hepatitis C Virus.

5. STDs

Sexually transmitted diseases (STDs) occur in sexually active gay men at a high rate. This includes STD infections for which effective treatment is available (syphilis, gonorrhea, chlamydia, pubic lice, and others), and for which no cure is available (HIV, Hepatitis A, B, or C virus, Human Papilloma Virus, etc.). There is absolutely no doubt that safe sex reduces the risk of sexually transmitted diseases, and prevention of these infections through safe sex is key.

6. Prostate, Testicular, and Colon Cancer

Gay men may be at risk for death by prostate, testicular, or colon cancer. Screening for these cancers occurs at different times across the life cycle, and access to screening services may be negatively impacted because of issues and challenges in receiving culturally sensitive care for gay men. All gay men should undergo these screenings routinely as recommended for the general population.

7. Alcohol

Although more recent studies have improved our understanding of alcohol use in the gay community, it is still thought that gay men have higher rates of alcohol dependence and abuse than straight men. One drink daily may not adversely affect health, however alcohol-related illnesses can occur with low levels of consumption. Culturally sensitive services targeted to gay men are important in successful prevention and treatment programs.

8. Tobacco

Recent studies seem to support the notion that gay men use tobacco at much higher rates than straight men, reaching nearly 50 percent in several studies. Tobacco-related health problems include lung disease and lung cancer, heart disease, high blood pressure, and a whole host of other serious problems. All gay men should be screened for and offered culturally sensitive prevention and cessation programs for tobacco use.

9. Fitness (Diet and Exercise)

Problems with body image are more common among gay men than their straight counterparts, and gay men are much more likely to experience an eating disorder such as bulimia or anorexia nervosa. While regular exercise is very good for cardiovascular health and in other areas, too much of a good thing can be harmful. The use of substances such as anabolic steroids and certain supplements can adversely affect health. At the opposite end of the spectrum, overweight and obesity are problems that also affect a large subset of the gay community. This can cause a number of health problems, including diabetes, high blood pressure, and heart disease.

10. Anal Papilloma

Of all the sexually transmitted infections gay men are at risk for, human papilloma virus —which cause anal and genital warts — is often thought to be little more than an unsightly inconvenience. However, these infections may play a role in the increased rates of anal cancers in gay men. Some health professionals now recommend routine screening with anal Pap Smears, similar to the test done for women to detect early cancers. Safe sex should be emphasized. Treatments for HPV do exist, but recurrences of the warts are very common, and the rate at which the infection can be spread between partners is very high.