Throughout the 1980s, culture wars debates over sex education and condoms pitted religious morality against secular permissiveness, dividing conservatives and liberals largely on these rhetorical grounds. In this battlefield of rhetoric, the Reagan-appointed evangelical Surgeon General C. Everett Koop seemed to be crossing the lines. In 1986, he published a report detailing how HIV was transmitted that candidly discussed drug use and sexuality, including oral and anal sex. The report drew the most attention for its call for sex education in public schools to start at the earliest age possible. While public health experts and AIDS activists applauded Koop’s bold approach, religious conservatives quickly spun his position into a call to teach elementary schoolers about sodomy.
By 1988, Koop hadn’t just crossed the line; he’d redrawn it. That year his pamphlet Understanding AIDS brought straight talk about sex into nearly every home in the U.S. AIDS provided a learning experience, as media coverage introduced the lives of gay men and lesbians to mainstream America. Descriptions of gay sex, often sensationalized, had never before reached so large an audience. And now the surgeon general pressed Americans to learn even more about sex through his education campaign, which maintained the importance of using condoms. Koop’s office printed 107 million copies, enough to be mailed to nearly every household in the United States, making this the largest mailing sponsored by the federal government at the time. If the sexual revolution of the 1960s and 1970s had not yet reached every small town and rural outpost in the heartland, Koop’s pamphlet did.
Koop maintained that faith informed his approach to public health during his time as surgeon general. Yet he consistently distanced his positions on AIDS from his religious views, arguing that his position was not “moralistic.” There is little reason to believe Koop was not sincere about this point, even if he was mistaken in his self-assessment. Though conservative religious beliefs did not dominate Koop’s AIDS policy, as was the case for some of his colleagues in the White House, Koop remained preoccupied with the question of sexual morality and with the role of churches and synagogues in the formulation of AIDS education. In fact, Koop’s first printed interview on AIDS appeared not in a government publication or mainstream newspaper, or even in a publication addressing the gay community, which was most at risk of infection and in need of information at the time. Rather, it appeared in the leading evangelical magazine Christianity Today in November 1985.
Koop responded to questions about whether AIDS was a homosexual disease (he said it was not), whether he would address the moral aspects of HIV transmission, and what challenges Christians faced in AIDS ministry, given that they viewed homosexuality as sinful. Koop affirmed that his statement on AIDS was a public health position, but that “it is interpreted by people who don’t like prohibition of a permissive sexual lifestyle as a moral statement.” As a public health officer, he maintained, “I’m not entitled to a moral opinion in a situation like his. But the public health opinion that I give happens to coincide with a moral position of a very large segment of the country.” Koop walked a thin line in this interview between moralist and public health officer. But the attempt to keep these two positions separate ultimately proved impracticable.
Koop would embark on a lecture circuit among religious groups to share his message, one that increasingly blurred the lines between the gospel of condoms and the gospel of Jesus.
Early on, Koop witnessed the pernicious role that anti-gay crusaders played by calling for extreme measures in the face of the AIDS crisis, including quarantine and mandatory testing for homosexuals. “I could see where these people were coming from,” Koop recalled in his 1991 memoir, “but I could not agree with them.” He continued:
I strongly disapproved of the forms of behavior responsible for most AIDS transmission: promiscuity, homosexual behavior, sex outside of marriage, and drug use. My Christian faith forms the basis for my moral standards, and I knew that the practice of homosexuality was anathema to most Christians, who believe that it, along with much that we humans do, is sinful.
Koop professed two obligations, as a Christian and as physician: to save lives and to alleviate suffering. “Knowing what Christians believe,” Koop continued, “I felt I was in a unique position to understand their point of view.” He hoped to reason with members of the pro-life movement with whom he had worked in the past. Ultimately, Koop aspired to draw his religious supporters into his AIDS campaign: “I hoped that we could work together after the release of the report to unite morality and science.
Perhaps more than any surgeon general before him, Koop made a concerted effort to draw religious communities into the fold of public health programming. Koop sought a broad array of opinions while conducting research. He met with the expected slew of medical and health organizations, but also gay rights groups such as the National Coalition of Black Lesbians and Gays and religious organizations like the United States Catholic Conference, the National Council of Churches, the Synagogue Council of America, and representatives from the Southern Baptist Convention (SBC). Koop found the SBC representatives to be “delightful, but very naïve about AIDS. I think they were shocked by what we had to tell them, about how the virus was sexually transmitted.” Koop challenged them to write their own sex education program for the members of their denomination. But these meetings suggested an opening for the surgeon general to make headway among evangelical Christians who were receptive to hearing him out, even if they did not agree with all of his positions. It was also an opportunity to shore up his political and religious quarrels with former conservative supporters.
Following the release of the 1986 Surgeon General’s Report on AIDS, Koop would embark on a lecture circuit among religious groups to share his message, one that increasingly blurred the lines between the gospel of condoms and the gospel of Jesus, as the surgeon general’s sphere of influence came to encompass that of the itinerant public health preacher.
Koop’s first stop was Liberty University, where he was invited to speak by his friend Jerry Falwell, founder of the Moral Majority, on January 18, 1987. Despite Falwell’s fulminations against homosexuals, and his infamous declaration that AIDS was a punishment from God, Koop recalled his friend as “one of the most understanding and far sighted members of the religious community in reference to AIDS.” Koop presented his lecture to an audience of students at Liberty, and it was also broadcast live on southern television networks.
In the lecture, Koop described details of homosexual sex that he thought necessary to understand the history and transmission of AIDS, a point he made explicit for an audience he assumed knew little about such details. He then stressed two messages. First, monogamy. “My advocacy of monogamy may sound like a morality lesson,” the surgeon general explained, “but it also happens to be good science. In containing the epidemic of AIDS, science and morality advance hand-in-hand toward the same goal.” Koop’s second message was for people who did not yet have a partner, and his advice to them was caution. He called “fool-hardy” all those people “who will not be abstinent or will not achieve a faithful monogamous relationship and, therefore, will expose themselves and others to the AIDS virus.” His reluctant advice to such foolhardy people was the following: “Don’t have sex with someone who could carry the virus of AIDS […] a person who, for example, practices high-risk behavior. That includes homosexuals, intravenous drug users, prostitutes and other persons who have many different sex partners.” Finally, Koop continued, if you do have sex with such a person, “a decision that could have serious health consequences—then, if you’re a man, at least use a condom from start to finish. If you’re a woman, make sure your partner uses a condom.”
Here Koop favored abstinence and monogamy, not simply as scientific measures to prevent the spread of AIDS, but as moral lessons—anything else was “fool-hardy.” Koop advanced this opinion among secular organizations as well. Speaking to the Annual Meeting of the National School Boards, he stated, “I believe children should be taught to be abstinent until they grow up, assume the role of a responsible adult, and find a mutually monogamous relationship. That doesn’t seem to be too far-fetched. In fact, it was considered the norm for this country and a return to such a norm would insure the end of sexually transmitted AIDS.” In this instance, Koop referenced America’s ostensibly moral past, before the sexual revolution of the 1960s and 1970s eroded what used to be the norm—good kids who remained abstinent until happily married. Koop’s vision of this moral past was shortsighted. If Alfred Kinsey’s infamous reports on human sexuality were not convincing enough, historians have amply demonstrated that this notion of an idyllic, moral America is more fantasy than reality. By nearly all demographic measures, “including divorce rates, age at marriage, and number of children per family,” writes Robert Self, “the 1950s and 1960s stand out as historical exceptions to longer trends.” Koop’s vision of this moral past may have proven more aspirational than factual, but its rhetorical power persisted.
Much has been written on the construction of innocent versus guilty victims of AIDS: gay men, drug users, and female sex workers have not fared well in this economy of blame and innocence.
The surgeon general also addressed the National Religious Broadcasters, an association representing over 650 evangelical Christian radio and television broadcasters. He stressed the importance of “good values,” which included developing children’s sense of personal responsibility and strengthening the concept of the family. Koop countered accusations that he advocated a form of sex education lacking moral prescription: “I’ve been attacking sex education curricula that just teach technique and don’t mention responsibility and morality.” “And I took that position,” he continued, “before some of my critics knew there was such a thing as sex.” The surgeon general did not retreat from his position on safe sex, including condom use, but he qualified his support: “You will hear a lot about ‘safe sex’ and how this or that technique is a way of containing the AIDS epidemic. But the safest approach to sexuality for adults is to choose either abstinence or faithful monogamy.”
Drawing his speech to a close, Koop pleaded for more compassion for people with AIDS, but he made a telling distinction in the process. “A large number of truly innocent people are being infected by the AIDS virus and they are going to die,” he explained. “Who are they? They are…the wives of bisexual men…they are the spouses of I.V. drug users…they’re the wives and husbands of promiscuous spouses,” he declaimed. But perhaps worst of all, “I’m afraid we must also count the babies born to I.V. drug users or otherwise infected mothers,” Koop concluded: “They are the most innocent victims of all.” Much has been written on the construction of innocent versus guilty victims of AIDS: gay men, drug users, and female sex workers have not fared well in this economy of blame and innocence, which Koop reproduced here. But he did not stop short of showing compassion for gay men as well, as he refused to sidestep the question of homosexuality. “[Y]ou can’t avoid it, if you’re going to discuss AIDS,” he warned his religious audience. His advice for them was to “please remember that one of your fundamental teachings has been to ‘separate the sin from the sinner.’ You may hate the sin…but you are to love the sinner.”
Koop reaffirmed his commitment to sexual values when speaking before the Christian Life Commission of the Southern Baptist Convention in Charlotte, North Carolina, in March 1987. “The reason people have become so interested in my views on education,” he remarked, “is that the issue goes to the heart of each person’s own system of moral and ethical values…or lack thereof.” For evangelicals such as Koop, moral and ethical values were fixed in advance and detailed in the Bible—and one either had them or didn’t. This assumption allowed him to construct both an argument for moral truth regarding sexuality as well as a distinction between those communities (or persons) that possessed these moral and ethical values and those that did not.
He began his lecture, for instance, by reminding his audience of their previous efforts in teaming up for moral causes, including the Baby Doe case and the fight against pornography. “I would have to say that nothing is a more powerful weapon against this disgusting material,” Koop argued, “than the honest truth about human sexuality.” For the surgeon general, true sex was moral—loving, benign, and non-commercial. This understanding of sex could only lead to contempt for pornography. He linked this point to his education campaign: “I believe that a child who is given the facts about his or her own sexuality—in a matter-of-fact yet caring manner—is a child who will feel more secure as an evolving adult and will have only contempt for pornography.”
The same logic held for AIDS, a problem more pressing as the geography of contagion shifted. “It is no longer primarily a disease attacking the homosexual communities of San Francisco, Los Angeles, and New York City,” Koop explained: “It is now appearing in all 50 states and among heterosexuals. And that means the rest of us.” By invoking “the rest of us,” Koop marked his Southern Baptist audience apart from northern and western urban dwelling homosexuals, an assumption that marked as well the implausibility that his Christian audience could be among them.
I underscore these speeches for three reasons. First, they illustrate the extent to which Koop reached out to religious organizations, including politically and theologically conservative groups known for their opposition to homosexuality. Koop himself noted how unusual it was for a surgeon general to take seriously the involvement of such religious groups, but he did not shy away from challenging religious conservatives to discuss homosexuality, sex education, and AIDS. Perhaps more revealing, however, was that Koop focused his educational efforts on religious (and mostly white evangelical) groups rather than gay and lesbian communities, racial minorities, or drug users. Apart from his initial meetings with representatives from the National Coalition of Black Lesbians and Gays, Koop’s archive suggests little contact with gay and lesbian community representatives, despite the well-established network of AIDS service organizations that had developed by the mid-1980s. The surgeon general’s efforts to save America from AIDS led him not to those populations most at risk, but to those most likely to renew the moral fabric of the nation.
Koop’s language also requires a more complicated reading of his position on sex education, including his own contention, often repeated in journalistic and historical accounts since, that his approach was that of a public health officer, not a moralist. The line between the two, already permeable in his AIDS report, blurred in his speeches—as promiscuous students and adults became “fool-hardy,” as personal responsibility and family values became the cornerstone of sex education, and as morality and medicine bent toward one another to justify this approach. If Koop differed from other conservative Christians, it was less on the question of when to have sex or how to do it, than that of who would continue, pragmatically speaking, to have sex with whom.
Koop joined other evangelical conservatives in preaching the gospel of abstinence and monogamy, which became not only the markers of safe sexuality, but also definitive of sex deemed moral and healthy
Since some men were not likely to stop having sex with other men, Koop maintained, he had to address them. Unlike conservative White House aides William Bennett and Gary Bauer, the surgeon general stopped short of denouncing “homosexuality” through the language of public health, restricting his moralizing against homosexuality to his lectures to more conservative, often-religious audiences. As a Christian, he maintained the sinfulness of homosexuality, but as the nation’s public health leader, he saw the need to resist stigmatizing gays and lesbians. Koop departed from his conservative contemporaries in at least three other ways as well: in his call for a state-sponsored public education program, in his support for comprehensive sex education in public schools, and in his insistence on the need to mention condoms as a last-ditch preventative measure. But these positions far from established Koop as an unbiased public health leader, not to mention the liberal activist—or gay agenda supporter—some of his critics accused him of being.
Rather, through his pamphlet and lectures, Koop joined other evangelical conservatives in preaching the gospel of abstinence and monogamy, which became not only the markers of safe sexuality, but also definitive of sex deemed moral and healthy—a claim backed by the imprint of the state and presented through the logic of public health. Through Koop’s mass mailing, the state called upon the American people to be compassionate toward the sick. Understanding AIDS also imagined and reproduced the American mainstream as straight, caring, concerned, and moral: in a word, normal. Most Americans could see themselves reflected in the pamphlet’s photos, leading happy lives free from disease. So long as they had monogamous sex, or no sex at all, the pamphlet told them, they would be safe. If they ignored such warnings and still had sex, they were instructed to use a condom during every sexual encounter “from start to finish.” While the language of the pamphlet struggles to be inclusive, it betrays the normative understanding of sex that Koop and other members of the PHO held.
This point would have been abundantly clear to gay men looking for representations of themselves in the pamphlet: they were notably absent, despite composing the largest number of AIDS cases to date. Paula Treichler quips that “gay men looked for themselves in vain among the target groups pictured in the mailer’s photos and had to settle for the construction worker whose hard hat might—in a stretch—be seen as an effort at gay iconography.” The mailing was never for them, as gays (and lesbians) were scripted outside of moral citizenship.
In the end, Koop was not merely offering a “middle road” between the Christian Right and the AIDS activist Left. He was also engaged in a project of moral reform: his target was the “sexual revolution” and his prescription a return to a golden age of sexual innocence. This was a project he shared with many evangelicals—indeed, with many Americans—despite his resistance to adopting the Christian Right’s moral fulminations against homosexuality. My point here is not to criticize Koop’s moral approach to sex education or the idea that any moral approach is undesirable, but rather to color in the overlooked moral presuppositions of the government’s major public health spokesperson on AIDS—to consider how public health itself encodes various normative or moral positions. Far from neutral, Koop’s approach placed AIDS education within a specific moral framework, one that would come to dominate public discussions not only of AIDS, but of sexuality more generally. It is a framework that has fueled the rise of abstinence-only morality campaigns that have gained influence in the last three decades.
Reflecting on Koop’s tenure as surgeon general, an author for Time Magazine described the physical appearance of the pediatric surgeon-turned-national AIDS educator as making him look like “Moses come down from Mount Sinai to deliver commandments eleven through twenty.” Koop’s likeness to the biblical prophet went beyond mere visual appearance, as the article continued: “Smoking? It’s an addiction that will kill you. Sex? Only in marriage. AIDS? The best preventative device is a monogamous relationship; the second best, a condom.” One of Koop’s greatest accomplishments was not to spare medicine and public health of moral politics, but instead to translate public health into no less than a religious and moral commandment itself.
Anthony Petro is Assistant Professor of Religion and Women’s, Gender, and Sexuality Studies at Boston University, where his research focuses on religion in the United States, gender and sexuality studies, and religion and medicine. His current project examines how feminist and queer artists since the 1960s have used religious symbols and ritual in their work.
Excerpt from After the Wrath of God. Oxford University Press, 2015. Copyright © 2015. Reprinted with permission.
 Mary Harris Veeder, “Authorial Voice, Implied Audiences and the Drafting of the 1988 AIDS National Mailing,” Risk: Issues in Health & Safety 4 (1993) and Barbara Gerbert and Bryan Maguire, “Public Acceptance of the Surgeon General’s Brochure on AIDS,” U.S. Department of Health and Human Services; Public Health Reports, 104 (April 1989), 130–133.
 C. Everett Koop, “Interview: Addressing the AIDS Threat,” Christianity Today, 29:17, November 22, 1985, 52.
 Koop, “Interview,” 52.
 Koop, The Memoirs of America’s Family Doctor (New York: HarperCollins, 1993 ), 264–265.
 Koop, Memoirs, 264–265.
 Koop, “Introduction to the AIDS Archive,” Reminiscence, 2003, Koop Papers, National Library of Medicine.
 Koop, “Address at Liberty University,” Reminiscence, 2003, Box 105, Folder 65, Koop Papers, National Library of Medicine.
 Koop, “Address at Liberty University,” January 19, 1987, Box 105, Folder 65, Koop Papers, National Library of Medicine.
 Koop, “Address Presented to the Annual Meeting of the National School Boards Association,” San Francisco, CA, April 4, 1987, Box 105, Folder 89, 26, Koop Papers, National Library of Medicine.
 J. Brooks Flippen, Jimmy Carter, The Politics of the Family, and the Rise of the Religious Right (Athens: University of Georgia Press, 2011), 117; National Religious Broadcasters, “History,” available at http://nrb.org/about/history/.
 Koop, “Address Presented to the National Religious Broadcasters, Washington, D.C.,” February 2, 1987, Box 105, Folder 70, Koop Papers, National Library of Medicine.
 Koop, “Address Presented to the National Religious Broadcasters, Washington, D.C.,” 20 (underlining in original transcript).
 Koop, “Address Presented to the National Religious Broadcasters, Washington, D.C.,” 29.
 Koop, “Address Presented to the National Religious Broadcasters, Washington, D.C.,” 29–30.
 Koop, “Address to Christian Life Commission,” Charlotte, NC, March 23, 1987, Box 105, Folder 84, Koop Papers, National Library of Medicine.
 Koop, “Address to Christian Life Commission.”
 Koop, “Address to Christian Life Commission.”
 Koop cites information from Gay Men’s Health Crisis, a nonprofit AIDS organization founded in New York City in January 1982, but I have not yet found any record of a meeting with representatives from this group or similar organizations. As Jennifer Brier, Infectious Ideas: U.S. Political Responses to the AIDS Crisis (Chapel Hill: University of North Carolina Press, 2009), 11–44, has argued, the contributions of these earlier organizations are often eclipsed by the more radical group ACT UP in histories of AIDS relief work and activism.
 Health and Human Services, Understanding AIDS, 4.
 Paula A. Treichler, How to Have Theory in an Epidemic (Durham, NC: Duke University Press, 1999), 57, but also see 42–98.
 Margaret Carlson, “A Doctor Prescribes Hard Truth,” Time, April 24, 1989, p82, Box 148, Folder 43, Koop Papers, National Library of Medicine
Gary Brookins’ political cartoon, titled “I take it the Surgeon General’s ‘AIDS’ pamphlet came today!” ran in the Richmond Times-Dispatch in 1988, shortly after the release of the pamphlet Understanding AIDS. (Gary Brookins: ©1988. Distributed by King Features Syndicate. Courtesy of the National Library of Medicine.)