December 2, 2015

The stigma of sexually transmitted infections

It's been a big month for sexually transmitted infections (STIs).  Actor Charlie Sheen announced he has HIV, the virus that causes AIDS.  The Center for Disease Control and Prevention (CDC) came out with report describing the sharp increase in many STIs last year, including chlamydia, gonorrhea, and syphilis.  And the World Health Organization announced that two-thirds of the world's population has herpes.  Did reading this surprise you, or did you have a different reaction?

Last week, I participated in a conference about reducing the stigma around sexually transmitted infections.  A whole day, dedicated just to stigma.  Sometimes the stigma is related to fear. This is something I deal with in clinic a lot — the fear in the eyes of the patient when we discuss that his/her symptoms may be related to an STI, or the look of horror when I suggest that we do a routine screening for STIs even though the patient is not experiencing any symptoms.  Sometimes the stigma is related being the butt of jokes. Many movies have bits about STIs (The Hangover is the first to pop in my mind: "Whatever happens in Vegas, stays in Vegas...except herpes.."). Sometimes the stigma is related to shame. The stigma around HIV is so bad that Charlie Sheen reportedly paid millions of dollars to keep the few people who were aware of his diagnosis quiet. Why is the stigma of these particular bacteria/viruses different from all the other bacteria/viruses? Is it solely the mode of transmission that we're reacting to?

There appears to be a few common myths regarding STIs that help perpetuate the stigma.

Myth #1: STIs are a result of inappropriate behavior (someone deserves an STI, or STIs only happen to promiscuous people).

As evident by their name, sexually transmitted infections are acquired through sexual activity.  Any sexual activity, not just vaginal intercourse. In fact, all intimate activity can lead to STIs.  Oral sex can lead to oropharyngeal STIs (infections of mouth and throat), including human papillomavirus (Michael Douglas blames his throat cancer on oral sex), herpes, gonorrhea, among others.  STIs can be spread through anal sex — in fact, anal sex is the riskiest behavior is regards to HIV transmission. Sharing sex toys can lead to STIs, if the item is not properly cleaned. Even kissing can transmit herpes.

In other words, everyone is at risk for getting an STI. In fact, at least 50% of people will have an STI at some point in their lifetime.

Myth #2: People with STIs know they have them (and they're dirty).

STIs, especially when not treated in a timely manner, can cause long lasting outcomes including infertility (untreated STIs are one of the leading causes of infertility in the US), increased rate of HIV transmission, and adverse pregnancy outcomes.  That may be one of the reasons that they are so feared.

However, STIs may cause no symptoms and these long term consequences may occur years later. Other STIs may cause brief period of symptoms, which go away without treatment (to be clear, the symptoms go away without treatment, the STI is still present).  If one person has an STI but no symptoms, they can still spread the STI to sexual partners. Take herpes for example.  You can acquire it even if the other person doesn't have (or never had) symptoms, since the virus sheds about 10 percent of the time for asymptomatic infections.

The asymptomatic (or briefly symptomatic) nature of some of these STIs contributes to a significant underreporting of the true incidence of STIs.  It is also the reason that routine screening for certain infections (gonorrhea, chlamydia, HIV, and syphilis) is recommended, even if the person has no symptoms.  Many people are not aware that they have an STI.

Myth #3: Sex and STIs are not appropriate topics for conversation for adolescents.

STIs need to be part of the overall sexual health conversation, and is oftentimes left out of sexual health education (especially abstinence-only sexual health curricula).  Depending on where the teenager lives, up to 1 in 4 teens are never taught about HIV/AIDS in school, not to mention the other STIs that are never discussed.   In our society, sex is a "naught" thing most people love to do and hate to talk about.

In conclusion...

Stigmas around STIs do not decrease the sexual behavior, but may discourage someone from getting protective measures (like the HPV vaccine), prevent someone from getting tested, inhibit someone from insisting their partner wear a condom prior to sexual activity, or notifying their partner that they have been exposed to an infection. Until we can combat the stigma and talk about STIs in a mindful manner, instead of focusing on the diseases, let's start addressing overall sexual health. And there is no stigma to wanting good health.