Issues Magazine

Sexually Transmissible Infections and Socially Tragic Insurgents

By Cheryl Power

The stigma and sometimes silent nature of sexually transmissible infections are challenges to reducing the impact of this group of diseases.

Sexually transmissible infections (STIs) have been around for centuries. Hippocrates described the curse of genital herpes around 400 BC, and gonorrhoea, almost certainly known in mediaeval times, was colourfully described as the “perilous infirmity of burning” in a decree passed by the English Parliament in the 17th century.

STIs have had a profound effect on not only individual people but also the history of the world. Both Napoleon Bonaparte and Henry VII were alleged to have suffered from syphilis. Al Capone was ill with late stage syphilis when incarcerated in Alcatraz.

Untreated syphilis can cause serious irreversible damage to the brain and other organs, profoundly affecting rational behaviour and sensible decision-making – hardly a desirable condition for a person in power. Other STIs can also alter both the attitude and actions of those afflicted, seriously affecting their lives and others around them.

In times gone by, neither the causes of, nor specific treatments for, STIs were known. An early treatment for syphilis included a drug called Salvarsan, an organoarsenic compound with highly unpleasant side-effects. This drug was taken willingly because people were desperate to be cured of what was a devastating disease. Penicillin was later used and was not only more effective but also completely safe and without side-effects except in those few people with a penicillin allergy.

Today, when the causes of the common STIs are known and effective methods of prevention and treatment are available, why are STIs still not only found but increasingly common?

In William Shakespeare’s Romeo and Juliet, Juliet says that the names of things do not matter, only what things “are”.

What’s in a name? that which we call a rose
By any other name would smell as sweet.

It is debatable how many people today, in this time of intense “branding”, would agree with Juliet. Names do matter. They dramatically affect the way we perceive things and people. If you Google venereal disease today you will be directed to a few sites that still use that term but overwhelmingly you will be directed to sites using sexually transmissible infections or, even better, sexual health.

The original name, venereal disease, often abbreviated to VD, was supposedly derived from the name of Venus, the goddess of love. Clinics providing VD diagnoses and treatment were all too often places where those seeking help were treated as “dirty people” whose main problem was their immorality rather than a microorganism transferred by sex. Today, with a new name, comes a new attitude – or does it?

The hope of many sexual heath professionals is that the prevention and management of STIs will eventually be seen in the same way as regular exercise and a balanced diet – as strategies that promote a healthy lifestyle.

Why does this matter? What is the difference between STIs and other infectious diseases? STIs are simply infections that can be passed on from one person to another during unprotected sex. Respiratory infections are passed on by inhaling the air that an infected person has contaminated by coughing, sneezing or speaking. Gastrointestinal infections are usually acquired from food that has been contaminated at its source, or by subsequent careless or unprofessional handling practices.

All of these types of infection result in some degree of pain or discomfort, and the production of excesses of body waste fluids invoking some degree of distaste, even disgust – none more so than sexually transmissible infections. For many years, and still today, STIs have been the infectious diseases that very few people talk about, let alone admit that they are themselves infected.

Whereas a recent respiratory tract infection or even a case of gastrointestinal infection can be spoken about at length, and the question of where it was acquired discussed in detail, this is most definitely not the case for STIs. Can you imagine the response if, over a coffee with a group of friends, someone described the symptoms associated with an acute case of gonorrhoea and speculated as to its source? STIs are diseases not to be discussed in public, the stigma of having one is still, even in these days of seriously personal disclosures on Facebook and other social media, definitely and profoundly uncool.

This unease extends to talk of management strategies. It can be sufficiently embarrassing to talk in a classroom situation about using a condom let alone in a personal, one-on-one scenario. It can also be confronting to seek treatment. This is one time when a friendly, caring family GP is not the doctor of choice because of shame or a concern about being thought of in a less favourable way.

Probably the biggest deterrent to seeking treatment, however, is the silent nature of many STIs, which can be asymptomatic – the person has no symptoms so is not aware that they are infected and sees no need to seek help. Yet these people are still able to pass the infection to a sexual partner.

A further complicating factor is the reluctance of many men to seek medical help, even if they do have symptoms. Sometimes an STI can resolve without intervention but this is neither a sensible nor a reliable strategy, especially when specific treatment is available.

So what is the outcome? The incidence of STIs around the world continues to rise, and in all age groups, not just youth, who have traditionally been the group in which up to half of STIs occur. Although many people have more than one STI at a given time or more than one episode of a single infection in a calendar year, the increases cannot be fully explained by these facts.

As explained in a 2012 report by the Australian Bureau of Statistics, the rise in notification rates (state health departments must be notified of any STI diagnosis) may be the result of rising infection rates, an increased level of testing due to higher awareness, or both. So public health campaigns promoting STI screening for safer sex may be having the desired effect of persuading people to be tested, or maybe not. Without knowing the reasons behind the increased rates it is hard to evaluate the success of education and prevention programs. Would sales of condoms provide more useful data? This information is crucial to the selection and funding of campaigns to prevent and reduce the burden of STIs worldwide .

Two analyses published by the Centers for Disease Control and Prevention (CDC) provide an up-to-date and in-depth look at the impact, both human and economic, of the cost imposed by STIs in the USA. The CDC estimates that there are about 20 million new infections per year. The total population of the USA is approximately 300 million, which means that roughly one in 15 people overall have an STI. However, not all the population is sexually active, so the odds are considerably higher for younger people learning about and experimenting with sex. If new infections are added to already existing infections, the CDC data suggests there are more than 110 million total STIs among men and women across the US. We worry about a new strain of influenza affecting thousands while living in the midst of an STI epidemic. It is arguable which is the more dangerous and damaging infection.

STIs are mainly caused by bacteria, viruses and protozoa. The eight most common STIs are three different types of bacterial disease, chlamydia, gonorrhoea, and syphilis; four different types of disease caused by four different viruses, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV 2), human immunodeficiency virus (HIV) and human papillomavirus (HPV); and a protozoan disease, trichomoniasis. There are other types of STIs of concern, depending where in the world people are living.

Because the microorganisms that cause STIs are such a diverse group, their diagnosis and treatment costs are very different. Some STIs, especially HIV, require lifelong treatment and care, and thus cost the most. However, the annual cost of curable STIs, of which chlamydia is most common and therefore costs most, is $742 million. Overall, the CDC conservatively estimates that the lifetime cost of treating the eight most common STIs contracted in just 1 year in the USA is $15.6 billion. STIs are large, but potentially preventable, contributors to healthcare costs and human suffering.

So what are the best strategies to protect people from STIs and prevent their upward trajectory?

Very few health professionals would seriously advocate abstinence from sex. Sex is a huge issue for teenagers, who are thinking about having fun and not about their future fertility. The message about the potential damage to their reproductive tract by STIs or other untoward effects is not really a big news item with this age group. For most, the potential risk of contracting an STI barely rates on the danger scale.

The Internet plays a powerful role here. Easy availability of pornography, creating unrealistic expectations of what and how sex should be, has undoubtedly shaped attitudes to sexual behaviour, especially among the younger generation. There is also the exploitation offered by unfriendly use of social media such as Facebook. It’s not just a matter of saying no to unwanted sex or that no really does mean no, but it’s also no to providing iPhone images with unspecified destinations.

Of course this mighty power can be also harnessed towards education about safer sex and information about where and how to get help. Many sexual health clinics provide accurate, reassuring and friendly advice online while still sending a strong message about the possible undesirable outcomes of unprotected sex.

Another strategy is to advise reducing the number of sexual partners. This measure makes sense for some people but not others. In the long term most people are serial monogamists but for the most vulnerable groups this is not the usual pattern. Experimentation rates highly for younger age groups. Highly sexually active core groups are known to be not only most at risk of contracting STIs but also crucial in the maintenance of these diseases. Travellers may come home with more than the souvenirs they purchased. What this all means is that specially targeted programs are essential to achieve the best outcomes – one message or strategy does not reach or fit all.

Consistent and correct use of condoms, and their ready availability, is probably the most effective strategy to ensure safer sex, but this isn’t always easy. Many young girls contract STIs when they are drunk or under the influence of drugs. In this situation, inhibitions and common sense about using a condom are forgotten or ignored.

Safer sex is about being prepared, conscious and alert, and this may not always coincide with being “cool”. What does it say about you if you carry condoms “just in case”? Does it mean a girl is a slut or that a guy is “on the make”? Again a moral judgement confuses the real issue and sidetracks the best strategy to prevent the potential transmission of disease.

Often myths are confused for facts and distract from the safer sex message. For example, how many teenagers are aware that while the contraceptive pill may protect against unwanted pregnancies it does not protect against unwanted STIs?

Uptake of vaccines for HBV and HPV is also a very helpful strategy and wisely included in our public vaccination programs. But this is only a small part of a big overall picture of cost and suffering.

Regular STI screening and treatment from free, confidential clinics is the most effective way to uncover and destroy these socially tragic insurgents and reduce their devastating impact on our daily lives. All STIs can be treated, if not cured, so the damage to both the sufferer and their sexual partner can be avoided or minimised.

A final quote from Shakespeare: in Much Ado About Nothing, Hero explains that love has inherent risks when he says:

Some Cupid kills with arrows, some with traps.

In many ways STIs are the ultimate traps, but open disclosure of their location and how they can be avoided is the secret to disarming their potential for personal and social damage.