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15
Sexually
Transmitted
Infections
MAIN
TOPICS
The STI Epidemic 483
Principal Bacterial STIs 493
Principal Viral STIs 500
Vaginal Infections 506
Other STIs 508
Ectoparasitic Infestations 509
STIs and Women 510
Preventing STIs 511
481
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“Up to this date, I have
slept with about
thirteen men. My most
recent ‘wake-up call’
was from a threat
from a prospective
partner and from a
Student
human sexuality
Voices
course. I took a test
for HIV; the result was
negative. However, I did get infected and passed on genital warts
to my ex-boyfriend. I simply pretended that I had never slept with
anyone else and that if anyone had cheated it was him. It never
fazed me that I was at such a risk for contracting HIV. My new
resolutions are to educate my family, friends, and peers about sex,
take a proactive approach toward sex with prospective partners,
and discuss sex openly and honestly with my mother.”
—23-year-old female
“My partner and I want to use a condom to protect ourselves
from STIs. But I feel inadequate when we are intimate and he
cannot keep an erection to put a condom on. I feel too embarrassed for him to discuss the situation. So, we both walk away a
T
O rose, thou art sick!
The invisible worm
“ That
flies in the night,
In the howling storm,
Has found thy bed
Of crimson joy,
And his dark secret love
Does thy life destroy.
—William Blake
(1757–1827)
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bit disappointed—him because he could not stay erect and me
because I did not take the time or have the courage to help him.
I think if he masturbated with a condom on it would help him
with his performance anxiety problem.”
—22-year-old female
“STIs and HIV are precisely the reason I exercise caution when
engaging in sexual activity. I don’t want to ever get an STI,
and I’d rather never have sex again than have HIV.”
—24-year-old male
“Why do males often convince women to have sex without proper
protection? I don’t understand this because there is always a risk of
getting an STI. I know that women think about this just as often as
men do, but why is it that men do not seem to care?”
—21-year-old female
“I am usually very careful when it comes to my sexual relations and
protecting myself from STIs, but there have been a couple of times
when I’ve drunk a lot and have not practiced safe sex. It scares me
that I have done things like that and have tried to make sure it
doesn’t happen again. STIs are just a very uncomfortable subject.”
—27-year-old male
he term “sexually transmitted infections” (STIs) refers to more than
25 infectious organisms passed from person to person primarily through
sexual contact. STIs were once called venereal diseases (VDs), a term derived
from Venus, the Roman goddess of love. More recently, the term “sexually
transmitted diseases” (STDs) replaced “venereal diseases.” Actually, many
health professionals continue to use “STD.” However, some believe that “STI”
is a more accurate and less judgmental term. That is, a person can be infected
with an STI organism but not have developed the illness or disease associated
with the organism. So, in this book, we use “STI,” although “STD” may
appear when other sources are cited.
There are two general types of STIs: (1) those that are bacterial and curable,
such as chlamydia and gonorrhea, and (2) those that are viral and incurable—
but treatable—such as HIV infection and genital herpes. STIs are a serious
health problem in our country, resulting in considerable human suffering.
In this chapter and the next, we discuss the incidence (number of new
cases) and prevalence (total number of cases) of STIs in our country particularly among youth, the disparate impact of STIs on certain population groups,
the factors that contribute to the STI epidemic, and the consequences of STIs.
We also discuss the incidence, transmission, symptoms, and treatment of the
principal STIs that affect Americans, with the exception of HIV/AIDS, which
is the subject of Chapter 16. The prevention of STIs, including protective
health behaviors, safer sex practices, and communication skills, is also addressed
in this chapter.
Sexually Transmitted Infections
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The STI Epidemic
The federal Institute of Medicine (IOM) characterizes STIs as “hidden epidemics
of tremendous health and economic consequences in the United States,” adding
that “STDs represent a growing threat to the nation’s health and national action
is urgently needed.” The IOM notes that STIs are a challenging public health
problem because of their “hidden” nature. The IOM adds that “the sociocultural
taboos related to sexuality are a barrier to STD prevention” (Eng & Butler, 1997).
The “silent” infections of STIs make them a serious public threat requiring greater
personal attention and increased health-care resources.
STIs: The Most Common Reportable Infectious Diseases
STIs are common in the United States, but identifying exactly how many cases
there are is impossible, and even estimating the total number is difficult. Often,
an STI is “silent”—that is, it goes undiagnosed because it has no early symptoms
or the symptoms are ignored and untreated, especially among people with limited
access to health care. Asymptomatic infections can be diagnosed through testing,
but routine screening programs are not widespread, and social stigmas and the
lack of public awareness about STIs may result in no testing during visits to
health-care professionals. And even when STIs are diagnosed, reporting regulations vary. Only a few STIs—gonorrhea, syphilis, chlamydia, hepatitis A and B,
HIV/AIDS, and chancroid—must be reported by health-care providers to local
or state health departments and to the federal Centers for Disease Control and
Prevention (CDC). But no such reporting requirement exists for other common
STIs, such as genital herpes, human papillomavirus (HPV), and trichomoniasis.
In addition, the reporting of STI diagnoses is inconsistent. For example, some
private physicians do not report STI cases to their state health departments
(American Social Health Association [ASHA], 2006a; CDC, 2011f). In spite of
the underreporting and undiagnosed cases, several significant indicators illustrate
the STI problem in the United States:
■ STIs are the most common reported infectious diseases in the United
■
■
■
■
■
States. In 2008, STIs represented four of the five most frequently
reported infectious diseases (CDC, 2010d) (see Figure 15.1).
An estimated 19 million new STI cases occur each year (CDC, 2011g).
STIs negatively impact the lives of more than 65 million Americans
(CDC, 2008g).
By age 25, 1 in 2 young persons will acquire an STI (Cates, Herndon,
Schulz, & Darroch, 2004).
More than one half of sexually active men and women will become
infected with an STI at some point in their lives (CDC, 2011f ).
One in four teenage girls (3.2 million) in the United States is infected
with at least one of the most common STIs: HPV, chlamydia, genital
herpes, or trichomoniasis (CDC, 2008h).
Who Is Affected: Disparities Among Groups
Anyone, regardless of gender, race/ethnicity, social status, or sexual orientation, can
get an STI. What people do—not who they are—exposes them to the organisms
that cause STIs. Nevertheless, some population groups are disproportionately
The STI Epidemic
•
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• FIGURE 15.1
Selected Notifiable Diseases,
United States, 2008. (Source:
Centers for Disease Control and
Prevention, 2010d.)
1,210,523
Chlamydia
Gonorrhea
336,742
Salmonellosis*
51,040
Syphilis
46,277
AIDS
39,202
0
300,000
600,000
900,000 1,000,000 1,300,000
Number of cases, 2008
*Infection with the Salmonella bacterium that causes diarrheal illness.
affected by STIs; this disparity reflects gender, age, and racial and ethnic differences
(CDC, 2011g).
Gender Disparities Overall, the consequences of STIs for women often are
more serious than those for men. Generally, women contract STIs more easily
than men and suffer greater damage to their health and reproductive functioning.
STIs often are transmitted more easily from a man to a woman than vice versa.
Women’s increased likelihood of having an asymptomatic infection results in a
delay in diagnosis and treatment (ASHA, 1998a; CDC, 2011f).
A kind of “biological sexism” means that women are biologically more susceptible to infection than men when exposed to an STI organism (Hatcher
et al., 2007). A woman’s anatomy may increase her susceptibility to STIs. The
warm, moist interior of the vagina and uterus is an ideal environment for many
organisms. The thin, sensitive skin inside the labia and the mucous membranes
lining the vagina may also be more receptive to infectious organisms than the
skin covering a man’s genitals. The symptoms of STIs in women are often very
mild or absent, and STIs are more difficult to diagnose in women due to the
physiology of the female reproductive system. The long-term effects of STIs for
women may include pelvic inflammatory disease (PID), ectopic pregnancy,
infertility, cervical cancer, and chronic pelvic pain, as well as possible severe
damage to a fetus or newborn, including spontaneous abortion, stillbirth, low
birth weight, neurological damage, and death (CDC, 2011f ).
Lesbian and bisexual women may also be at risk for STIs. A nationally representative study found the rates of self-reported genital herpes and genital warts
to be 15–17% among self-identified bisexual women and 2–7% among selfidentified lesbian women (Tao, 2008), both groups aged 15–44. Another study
of lesbian and bisexual women found that many underestimated their risk for
STIs, had limited knowledge of potential STI transmission, and reported little
use of preventive behaviors with female partners, such as washing hands, using
rubber gloves, and cleaning sex toys (Marrazzo, Coffey, & Bingham, 2005).
According to a study conducted in Sydney, Australia, women who had sex
with other women had a higher rate of bacterial vaginosis (BV) than heterosexual
women. Among the women who had sex with other women, 93% reported
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previous sexual contact with men; they had a median (the numerical value in the
middle of the upper half and lower half of a group of numbers) of 12 lifetime
male sexual partners, compared with 6 lifetime partners for the heterosexual
women. Thus, lesbian women may not be free of STI risk because many women
who have sex with other women and self-identify as lesbian also have sex with
men during their lifetime (Fetters, Marks, Mindel, & Estcourt, 2000). A study
of 35 lesbian and bisexual women aged 16–35 found that BV was associated with
reporting a partner with BV, vaginal lubricant use, and the sharing of sex toys
(Marrazzo, Thomas, Agnew, & Ringwood, 2010). Studies have found that women
who had sex with both men and women had greater odds of having acquired a
bacterial STI and had more HIV/STI behavioral risk factors than women who
had sex only with men (Bauer, Jairam, & Baidoobonso, 2010; Kaestle & Waller,
2011; Mercer et al., 2007; Scheer et al., 2002). A case study found that femaleto-female transmission of syphilis occurred through oral sex (Campos-Outcalt &
Hurwitz, 2002).
Surveillance data on several STIs suggest that an increasing number of men
who have sex with men (MSM) are acquiring STIs. For example, in recent
years, MSM have accounted for an increasing number of estimated syphilis
cases in the United States. In 2010, 67% of syphilis cases in the U.S. were
among MSM (CDC, 2011f ). (HIV/AIDS data for men who have sex with
men will be presented in Chapter 16.)
Age Disparities Compared to older adults, sexually active young adolescents,
12 to 19 years old, and young adults, 20 to 24 years of age, are at higher risk
for acquiring an STI. About one half of new STI cases are among individuals
aged 15–24 although they comprise only about one quarter of the sexually active
population (CDC, 2011f; Weinstock, Berman, & Cates, 2004). Young people
are at greater risk because they are, for example, more likely to have multiple
sexual partners, to engage in risky behavior, to select higher-risk partners, and
face barriers to accessing quality STI prevention products and services (CDC,
2007e, 2011f ).
Racial and Ethnic Disparities Race and ethnicity in the United States are
Rate (per 100,000 population)
STI risk markers that correlate with other basic determinants of health status,
such as poverty, access to quality health care, health-care-seeking behavior, illegal
drug use, and communities with high prevalence of STIs. STI rates are higher
among racial and ethnic minorities. (See Figures 15.2 and 15.3 for rates of two
STIs—chlamydia and gonorrhea—by race/ethnicity, 2000–2009.) Social factors,
2,000
1,500
• FIGURE 15.2
American Indians/Alaska Natives
Asians/Pacific Islanders
Blacks
Hispanics
Whites
Rates of Chlamydia by Race/
Ethnicity, United States,
2000–2009. (Source: CDC, 2010e.)
1,000
500
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
2009
The STI Epidemic
•
485
• FIGURE 15.3
Rates of Gonorrhea by Race/
Ethnicity, United States,
2000–2009. (Source: CDC, 2010e.)
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800
700
600
500
400
300
200
American Indians/Alaska Natives
Asians/Pacific Islanders
Blacks
Hispanics
Whites
100
0
2000
2001
2002
2003
2004 2005
Year
2006
2007
2008
2009
such as poverty and lack of access to health care, in contrast to inherent factors,
account for this discrepancy.
Factors Contributing to the Spread of STIs
According to the Institute of Medicine, “STDs are behavioral-linked diseases
that result from unprotected sex,” and behavioral, social, and biological factors
contribute to their spread (Eng & Butler, 1997). These factors are obstacles to
the control of STIs in the United States.
Behavioral Factors
Early Initiation of Intimate Sexual Activity People who are sexually active
at an early age are at greater risk for STIs because this early initiation increases
the total time they are sexually active and because they are more likely to have
nonvoluntary intercourse, to have a greater number of sexual partners, and to
use condoms less consistently (Manlove, Ryan, & Franzetta, 2003). For example, a nationally representative sample of 9,844 respondents found that the
odds of contracting an STI for an 18-year-old who first had intercourse at age
13 were more than twice those of an 18-year-old who first had intercourse at
age 17 (Kaestle, Halpern, Miller, & Ford, 2005).
The more exclusive sexual partners an
individual has over a period of time (called serial monogamy), the greater the
chance of acquiring an STI. (For a discussion of serial monogamy, see Chapter 7.)
For example, according to one national study, 1% of respondents with
1 sexual partner within the past year, 4.5% of those with 2–4 partners, and
5.9% of those with 5 or more partners reported that they had become infected
with an STI (Laumann, Gagnon, Michael, & Michaels, 1994). In addition,
the more sexual partners respondents had, the more likely it was that each of
those partners was unfamiliar and nonexclusive. Being unfamiliar with partners, especially knowing the person for less than 1 month before first having
sex, and having nonexclusive partners were both strongly associated with
higher STI incidence. Data from the National Survey of Men and the National
Survey of Women discovered that the likelihood of contracting an STI
increased with an increase in the number of lifetime sexual partners: Compared
to persons with 1 partner, those reporting 2 or 3 partners have 5 times the
likelihood of having an STI, and the odds were as high as 31 to 1 for those
Sequential Sexual Relationships
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reporting 16 or more lifetime partners (Tanfer, Cubbins, & Billy, 1995). A study
found that 34% of sexually active women aged 15–44 were at risk for STIs
because either they had more than 1 sexual partner (21%) or their partners had
2 or more partners (23%). Interestingly, 20% of the women whose partners had
multiple sexual partners thought that they were in mutually exclusive sexual
relationships. Among men aged 18–24, 24% were at risk for STIs because of
having 2 or more sexual partners (Finer, Darroch, & Singh, 1999).
Concurrent Sexual Relationships Having concurrent sexual relationships—
overlapping sexual partnerships—facilitates the spread of STIs. Research has shown
that sexual concurrency is associated with individual STI risk (Manhart, Aral,
Holmes, & Foxman, 2002). This risk is especially true during acute HIV infection,
when transmission is greatest. A nationally representative study of men found that
11% reported concurrent sexual relationships in the past year, mostly involving
women. These men were less likely to use a condom during their last sexual
encounter; were less likely (than those not reporting concurrent sexual partners)
to be married; and were more likely to report several risk factors including drug
or alcohol intoxication during sexual intercourse, nonmonogamous female and
male partners, and sexual intercourse with men (Adimora & Schoenbach, 2007;
Doherty, Schoenbach, & Adimora, 2009). Among women in a nationally representative study, the prevalence of reported concurrent sexual relationships was
12%, with lowest concurrency being among those currently married (Adimora
et al., 2002). A study of STI clinic patients—one half reporting concurrent sexual
partners in the past 3 months—found that both men and women believed that
having concurrent partners was normal. They thought that no one was exclusive
and that, based on previous relationships with nonexclusive partners, they found
it difficult to trust their partners and be emotionally invested in the relationship.
Most of the study participants, particularly the women, were looking for exclusive
sexual relationships (Senn, Scott-Sheldon, Seward, Wright, & Carey, 2011).
Having sex with a person who has had many
partners increases the risk of acquiring an STI. One example of this is a female
who has a bisexual male partner. Often, the female does not know that her
male partner also has sex with men. Another example is when an older, sexually
experienced person has sex with a younger and less experienced partner (Boyer
et al., 2000; Thurman, Holden, Shain, & Perdue, 2009). Also, a survey of
1,515 men aged 18–35 attending health centers found that those who had
purchased sex were twice as likely to be infected with an STI than those who
had not purchased sex (Decker, Raj, Gupta, & Silverman, 2008). People often
select new sexual partners from their social network. If a person acquires an
STI, then the social network could be considered a high-prevalence group, thus
increasing a person’s chance of future STI infections. Research has shown that
selecting new partners from outside one’s social network is associated with
reduced risk for repeat STIs (Ellen et al., 2006).
High-Risk Sexual Partners
Certain sexual behaviors with a partner put
individuals at higher risk for acquiring an STI than other behaviors. For example, a study of 1,084 heterosexual men and women patients at an STI clinic
found that individuals who had ever engaged in anal intercourse were more
likely to report a history of having had an STI (Gorbach et al., 2009). A study
High-Risk Sexual Behavior
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of women in the rural southern U.S. found that those who reported engaging
in more high-risk behaviors in the past 12 months were more likely to report
having an STI during that same time (Yarber, Crosby, & Sanders, 2000).
Inconsistent and Incorrect Condom Use Correctly using a latex male condom during each sexual encounter and at any time the penis comes into contact with the partner significantly reduces the risk of STIs. Several studies have
shown that both correct and consistent condom use is associated with lower
STI rates in both men and women and lower rates of PID outcomes in women
(Grimley, Annang, Houser, & Chen, 2005; Hutchinson, Kip, & Ness, 2007;
Nielson et al., 2010; Paz-Bailey et al., 2005; Shlay, McClung, Patnaik, &
Douglas, 2004; Wald et al., 2005). (See the box “‘Do You Know What You
Are Doing?’ Common Condom-Use Mistakes Among College Students” in
Chapter 16 for a review of recent studies of college students and condom-use
errors and problems.)
The abuse of alcohol and drugs is associated with high-risk
sexual behavior, although researchers are not certain if there is a cause-and-effect
relationship between alcohol/drug use and risky sexual behavior. Substances
may affect cognitive and negotiating skills before and during sex, lowering the
likelihood that partners will protect themselves from STIs and pregnancy (U.S.
Department of Health and Human Services, 2011a). A review of 11 studies of
problem drinking and STIs showed an overall association between problematic
alcohol use and STI infection (Cook & Clark, 2005).
Substance Abuse
Sexual Coercion Not all people enter sexual relationships as willing partners,
particularly women. The 2009 Youth Risk Behavior Survey (CDC, 2010a)
revealed that 8% of the adolescents surveyed had experienced forced sexual
intercourse, with a greater percentage of females (11%) being coerced than
males (6%). Individuals experiencing violence are less able to protect themselves
from STIs.
Lack of Knowledge of and Concern About STIs It is important for persons
who are sexually active with partners to have knowledge about the wide range
of STIs and the ways they are transmitted and prevented. With increased STI
information on the Internet and in school health classes, most persons have
some fundamental knowledge of STIs and the potential for acquiring an STI
through risk behavior. Yet, there are gaps in knowledge among some persons.
For example, a study of 393 adolescents found that their specific knowledge
about non-HIV STIs was only cursory, despite their reports of having received
education about STIs (Clark, Jackson, & Allen-Taylor, 2002). A study of 300
sexually active adolescent females, some of whom had received an STI diagnosis
and were recruited from health-care sites, concluded that they knew more about
their previous STI than about other STIs, including ones they had unknowingly
contracted. That is, they appeared to learn about STIs mainly after an STI diagnosis, too late for effective prevention behavior, early medical detection, or
prompt disease treatment (Downs, de Bruin, Murray, & Fischhoff, 2006). Lastly,
focus groups of lesbian and bisexual women revealed that the knowledge of the
potential for STI transmission between women and of bacterial vaginosis was
limited (Marrazzo, Coffey, & Bingham, 2005). A study of 1,101 women aged
18–25 found that 75% believed they were at low risk of acquiring an STI in
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practically
speaking
Preventing STIs: The Role of Male
Condoms and Female Condoms
For decades, the male condom has been promoted by public
health officials as an important STI prevention device for
sexually active individuals. However, there has been much
discussion about how effective condoms really are in preventing
HIV and other STIs. Some skeptics argue that condoms fail too
often and that claims of condom effectiveness are misleading and
exaggerated. Interestingly, despite these claims and denunciations
by skeptics, a random telephone survey of 517 Indiana residents
found that nearly 92% considered condoms at least somewhat
effective in preventing HIV and STIs (Yarber, Milhausen, Crosby, &
Torabi, 2005).
The Centers for Disease Control and Prevention (CDC) has
issued statements and recommendations on male condoms,
female condoms, and STI prevention for public health personnel.
Male Condoms
The CDC’s (2007f, 2009b) recommendations about the male
latex condom and the prevention of STIs, including HIV, are based
on information about the ways the various STIs are transmitted,
the physical nature of condoms, the coverage or protection that
condoms provide, and epidemiological studies of condom use
and STIs. About STI prevention and condoms, the CDC has this
to say:
For persons whose sexual behaviors place them at risk for
STDs, correct and consistent use of the male latex condom
can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot
guarantee absolute protection against any STD. Furthermore,
condoms lubricated with spermicides are no more effective
than other lubricated condoms in protecting against the
transmission of HIV and other STDs. In order to achieve the
protective effect of condoms, they must be used correctly
and consistently. Incorrect use can lead to condom slippage or breakage, thus diminishing their protective effect.
Inconsistent use (e.g., failure to use condoms with every
act of intercourse) can lead to STD transmission because
transmission can occur with a single act of intercourse.
In addressing specific STIs, the CDC has stated that latex condoms, when used consistently and correctly, are highly effective
in preventing the sexual transmission of HIV and reduce the risk
of transmission of gonorrhea, chlamydia, and trichomoniasis.
Correct and consistent use of latex condoms reduces the risk of
genital herpes, syphilis, and chancroid only when the infected
area or site of potential exposure is protected. Genital ulcer
diseases and human papillomavirus (HPV) infections can occur
in both male and female genital areas that are covered or protected by a latex condom, as well as areas that are not covered.
Condom use may reduce the risk for HPV infection and HPVassociated diseases such as genital warts and cervical cancer.
Two other nonlatex condoms are available. The first type is made
of polyurethane or other synthetic materials and provides protection against STIs. It can be substituted for a latex condom for
persons with latex allergies. The other type is natural membrane
condoms, which are not recommended for protection against
STIs (CDC, 2011f, 2011i).
Female Condoms
Research has shown that female condoms, when used properly,
are as effective as barriers to semen during intercourse as male
condoms (Macaluso et al., 2007). When used consistently and
correctly, the female condom might substantially reduce the risk
for STIs including HIV. The CDC recommends that when a male
condom cannot be used properly, sexual partners should consider using a female condom. The female condom has also been
used for STI/HIV protection during receptive anal intercourse
(Gross et al., 1999).
SOURCES: Centers for Disease Control and Prevention. (2007). Male latex
condoms and sexually transmitted diseases. Available: http://www.cdc.gov/
condomeffectivness/latex.htm (Last visited 10/12/08); Centers for Disease
Control and Prevention. (2010). Sexually transmitted diseases treatment
guidelines, 2010. Morbidity and Mortality Weekly Report, 59 (No. RR-12); Yarber,
W. L., Milhausen, R. R., Crosby, R. A., & Torabi, M. R. (2005). Public opinion about
condoms for HIV and STD prevention: A midwestern state telephone survey.
Perspectives on Sexual and Reproductive Health, 37, 148–154; Centers for
Disease Control and Prevention. (2011). Condoms and STDs: Fact sheet for
public health personnel. Available: http://www.cdc.gov/condomeffectiveness/
latex.htm (Last visited 11/16/11). Gross, M., et al. (1999). Use of Reality “female
condoms” for anal sex by US men who have sex with men. American Journal of
Public Health, 89, 1739–1741; Zimmerman, R. (2002, September 25). Some
makers, vendors drop N-9 spermicide on HIV risk. The Wall Street Journal Online.
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the next year even though most were having unprotected sex. Some of the
women did not perceive STIs as a “big deal” and were desensitized to the risk
of contracting STIs (Yarnall et al., 2003).
Erroneous Perception of Partner’s STI Status People also often do not have
an adequate perception of whether or not their sexual partner has been diagnosed with an STI. In one study of STI clinic patients in Southern California,
participants indicated that they did not use condoms when they perceived new
sexual partners to be STI-free. Instead of directly discussing their partners’ sexual history, they relied on both visual and verbal cues to judge whether their
partners were disease-free. This assessment reflected serious error in judgment
because most of the study participants had, in fact, contracted an STI (Hoffman
& Cohen, 1999). A recent study of heterosexual couples attending outpatient
clinics found that 10% of women and 12% of men were unaware that their
partner had recently received an STI diagnosis. Two percent of women and
4% of men were unaware that their partner is HIV-positive (Witte, El-Bassel,
Gilbert, Wu, & Chang, 2010). This kind of information underscores the need
for communication and honesty as part of STI prevention.
Social Factors
Poverty and Marginalization Individuals in lower socioeconomic groups and
those in social networks in which high-risk behavior is common and access to
health care is limited are disproportionately affected by STIs. These groups include
sex workers (people who exchange sex for money, drugs, or other goods), adolescents, persons living in poverty, migrant workers, and incarcerated individuals.
STIs, substance abuse, and sex work are closely connected (Eng & Butler,
1997; U.S. Department of Health and Human Services, 2000b). Analysis of
nationally representative data of adults aged 18–27 found that contextual
conditions were associated with prevalence and recent contraction of STIs. As
the number of contextual conditions increased, STI prevalence similarly
increased. Conditions associated with STI included housing insecurity, exposure to crime, having been arrested, gang participation, childhood sexual
abuse, frequent alcohol use, and depression (Buffardi, Thomas, Holmes, &
Manhart, 2008).
Access to high-quality and culturally sensitive
health care is imperative for early detection, treatment, and prevention
counseling for STIs. Unfortunately, health services for STIs are limited in
many low-income areas where STIs are common, and funds for public
health programs are scarce. Without such programs, many people in highrisk social networks have no access to STI care.
Access to Health Care
One factor that separates
the United States from other countries with lower rates of STIs is the cultural stigma associated with STIs and our general discomfort with sexuality
issues. (For further discussion about stigma, see the box “The Stigmatization
of HIV and Other STIs” in Chapter 16.) Historically, a moralistic, judgmental
stance on STIs has hindered public health efforts to control STIs. For example,
significant funding for AIDS research did not begin until it was clear that heterosexual individuals as well as gay men were threatened (Altman, 1985; Shilts, 1987).
Secrecy and Moral Conflict About Sexuality
It is important for persons who
are sexually active to have
knowledge about the wide
range of STIs and the ways they
are transmitted and prevented.
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Biological Factors
Asymptomatic Nature of STIs Most STIs either do not produce any symptoms or cause symptoms so mild that they go unnoticed or disregarded. A long
time lag—sometimes years—often exists between the contracting of an STI and
the onset of significant health problems. During the time in which the STI is
asymptomatic, a person can unknowingly infect others. The individual may not
seek treatment, allowing the STI to damage the reproductive system.
Resistance to Treatment or Lack of a Cure Because resistant strains of
viruses, bacteria, and other pathogens are continually developing, antibiotics that
have worked in the past may no longer be effective in treating STIs. Infected
people may continue to transmit the STI, either because they believe they have
been cured or because they currently show no symptoms. And some STIs, such
as genital herpes, genital warts, and HIV, cannot be cured. The individual who
has any of these viruses is always theoretically able to transmit them to others.
Susceptibility in Women Adolescent women are highly susceptible to acquiring chlamydia and gonorrhea because of an immature cervix (ASHA, 1998c).
Women who practice vaginal douching are also at greater risk for PID and
STIs (National Women’s Health Information Center, 2002b).
For many STIs, most scientific literature appears
to support the preventive value of circumcision; however, other studies refute
these findings. A circumcised penis has been linked to reduced risk of STIs
such as HPV, gonorrhea, HIV, genital herpes, and syphilis (Bailey et al., 2007;
Gray, 2009; National Institutes of Health, 2011; Weiss, Thomas, Munabi, &
Hayes, 2006), and one study found reduced risk of HPV for female partners
of circumcised males (Wawer et al., 2011). Other studies found that circumcision was not related to reduced syphilis and genital herpes prevalence (National
Institutes of Health, 2011; Xu, Markowitz, Sternberg, & Aral, 2007), and one
study found that early childhood circumcision does not markedly reduce the
risk of genital herpes in the general population (Dickson, van Roode, Herbison,
& Paul, 2008). Further, research on male circumcision and STI infection in
women found that women with circumcised partners had similar risk of chlamydia, gonorrhea, and trichomoniasis (Turner et al., 2008).
Male circumcision has been associated with lower risk of HIV infection in
international observational studies and clinical trials in Africa. From these studies, the World Health Organization (WHO) states that “there is compelling
evidence that male circumcision reduces the risk of heterosexually acquired
HIV infection in men by approximately 60%” (WHO, 2011c). The WHO
continues to state that it and the Joint United Nations Programme on HIV/
AIDS recommend that male circumcision should be considered as an effective
intervention for HIV prevention in countries and world regions with
heterosexually-acquired HIV epidemics, high HIV prevalence, and low male
circumcision prevalence. The groups also note that male circumcision provides
only partial protection as one element in a comprehensive HIV prevention
program that includes HIV testing and counseling, STI treatment, promotion
of safer sex behavior, and provision of male and female condoms and promotion of their correct and consistent use. The U.S. Centers for Disease Control
and Prevention (CDC) states that it has not yet determined if male circumcision
Other Biological Factors
The STI Epidemic
•
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practically
speaking
STI Attitude Scale
T
his scale was developed by William L. Yarber, Mohammad
Torabi, and C. Harold Veenker to measure the attitudes of
young adults to determine whether they may be predisposed
to high or low risk for contracting a sexually transmitted
infection. The scale presented here is an updated version of the
originally published scale. Follow the directions, and mark your
responses to the statements below. Then calculate your risk
as indicated.
15. I would feel that I should take my sexual partner with me to
a clinic if I thought I had an STI.
16. It would be embarrassing to discuss STIs with my sexual
partner if I were sexually active.
17. If I were to have sex, the chance of getting an STI makes me
uneasy about having sex with more than one partner.
18. I like the idea of sexual abstinence (not having sex) as the
best way of avoiding STIs.
Directions
19. If I had an STI, I would cooperate with public health people
to find the source of my infection.
Read each statement carefully. Indicate your first reaction by
writing the letter that corresponds to your answer.
20. If I had an STI, I would avoid exposing others while I was
being treated.
Key
21. I would have regular STI checkups if I were having sex with
more than one partner.
22. I intend to look for STI signs before deciding to have sex
with anyone.
SA ⫽ Strongly agree
A ⫽ Agree
U ⫽ Undecided
D ⫽ Disagree
SD ⫽ Strongly disagree
23. I will limit my sexual activity to just one partner because of
the chances of getting an STI.
1. How I express my sexuality has nothing to do with STIs.
24. I will avoid sexual contact any time I think there is even a
slight chance of getting an STI.
2. It is easy to use the prevention methods that reduce my
chances of getting an STI.
25. The chance of getting an STI will not stop me from
having sex.
3. Responsible sex is one of the best ways of reducing the risk
of STIs.
26. If I had a chance, I would support community efforts to
control STIs.
4. Getting early medical care is the main key to preventing the
harmful effects of STIs.
27. I would be willing to work with others to make people
aware of STI problems in my town.
5. Choosing the right sexual partner is important in reducing
my risk of getting an STI.
Scoring
6. A high prevalence of STIs should be a concern for all people.
Calculate points as follows:
7. If I have an STI, I have a duty to get my sexual partners to
seek medical treatment.
8. The best way to get my sexual partner to STI treatment is
to take him or her to the doctor with me.
9. Changing my sexual behaviors is necessary once the presence
of an STI is known.
Items 1, 10–14, 16, and 25: Strongly agree ⫽ 5,
Agree ⫽ 4, Undecided ⫽ 3, Disagree ⫽ 2, Strongly
disagree ⫽ 1
Items 2–9, 15, 17–24, 26, and 27: Strongly Agree ⫽ 1, Agree ⫽ 2,
Undecided ⫽ 3, Disagree ⫽ 4, Strongly disagree ⫽ 5
11. If I were sexually active, I would feel uneasy doing things
before and after sex to prevent getting an STI.
The higher the score, the stronger the attitude that may predispose a person toward risky sexual behaviors. You may also calculate your points within three subscales: items 1–9 represent the
“belief subscale,” items 10–18 the “feeling subscale,” and items
19–27 the “intention to act” subscale.
12. If I were sexually active, it would be insulting if a sexual
partner suggested we use a condom to avoid getting an STI.
SOURCE: Adapted from Yarber, W. L., Torabi, M. R., & Veenker, C. H. (1989).
10. I would dislike having to follow the medical steps for treating
an STI.
13. I dislike talking about STIs with my peers.
14. I would be uncertain about going to the doctor unless I was
sure I really had an STI.
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Development of a three-component sexually transmitted diseases attitude
scale. Journal of Sex Education and Therapy, 15, 36–49. With permission from
the authors.
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should be recommended for any population in the United States. The CDC
(2009c) declares that the implementation of any male circumcision recommendation would be voluntary and that the ultimate decision rests with individuals and parents.
For men who have sex with men, little evidence supports circumcision for
HIV/STI prevention. A review of 15 studies involving 53,567 gay and bisexual
men in eight countries failed to show any benefit for HIV protection for those
who were circumcised (Millett, Flores, Marks, Reed, & Herbert, 2008).
Whether male circumcision should be routinely done as an HIV/STI prevention strategy is still debated and remains controversial at the time of the printing of this book. On a side note, some males worry that being circumcised will
decrease their sexual pleasure; most studies have found little difference in sexual
sensation and sexual function between those circumcised and those not (CDC,
2008c; Kigozi et al., 2008).
Consequences of STIs
The list of problems caused by STIs seems almost endless. Women and infants
suffer more serious health damage than men from all STIs. Without medical
attention, some STIs can lead to blindness, cancer, heart disease, infertility, ectopic
pregnancy, miscarriage, and even death (CDC, 2007g, 2010d; Yarber, 2003).
A serious outcome of STI infection is that the presence of other STIs increases
the likelihood of both transmitting and acquiring HIV. When someone who is
infected with another STI is exposed to HIV through sexual contact, the likelihood of acquiring HIV infection is at least 2–5 times higher than when he or she
is not infected with an STI. Research has also shown that if an HIV-infected
individual is also infected with another STI, that person is more likely to transmit
HIV through sexual contact than HIV-infected persons not infected with another
STI (CDC, 2010g; U.S. Department of Health and Human Services, 2000b).
Besides having human costs, the estimated cost of STI treatment within
the U.S. health-care system was $16.9 billion in 2010. This cost does not
include indirect, nonmedical costs such as lost wages and productivity due to
illness, out-of-pocket expenses, and costs related to STI transmission to infants
(Chesson et al., 2011).
•
Principal Bacterial STIs
In this section we discuss chlamydia, gonorrhea, urinary tract infections, and
syphilis, the major bacterial STIs. As indicated earlier, bacterial STIs are curable.
Table 15.1 summarizes information about all of the principal STIs, including
bacterial STIs, viral STIs, vaginal infections, other STIs, and ectoparasitic
infestations (parasites that live on the outer skin surfaces).
Chlamydia
The most common bacterial STI and most commonly reported infectious disease (see Figure 15.1) in the United States is caused by an organism called
Chlamydia trachomatis, commonly known as chlamydia. In 2010, 1,307,893
cases of chlamydia were reported to the CDC, representing a rate increase
of about 5% over the 2009 rate. The 2010 national rate of chlamydia was
Principal Bacterial STIs
•
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TABLE 15.1
•
STI and
Infecting
Organism
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Principal Sexually Transmitted Infections
Symptoms
Time from
Exposure to
Occurrence
Medical
Treatment
Comments
Bacterial STIs
Chlamydia
(Chlamydia
trachomatis)
Women: 75% asymptomatic;
others may have abnormal
vaginal discharge or pain
with urination. Men: About
one half asymptomatic; others
may have discharge from
penis, burning or itching
around urethral opening, or
persistent low fever.
7–21 days.
Antibiotics
If untreated, may lead
to pelvic inflammatory
disease (PID) and
subsequent infertility
in women. Sexually active
females aged 25 and
younger need testing
every year.
Gonorrhea
(Neisseria
gonorrhoeae)
Women: Up to 80%
asymptomatic; others may
have symptoms similar
to those of chlamydia.
Men: Some asymptomatic;
others may have itching,
burning or pain with,
urination discharge from
penis (“drip”).
Women: Often no
noticeable symptoms.
Men: Usually 2–5 days,
but possibly 30 days
or more.
Antibiotics
If untreated, may lead
to pelvic inflammatory
disease (PID) and
subsequent infertility
in women. People with
gonorrhea can more
easily contract HIV.
Urethritis
(various
organisms)
Painful and/or frequent
urination; discharge from
penis; women may be
asymptomatic. Can have
discharge from vagina and
painful urination.
1–3 weeks.
Antibiotics
Laboratory testing is
important to determine
appropriate treatment.
Syphilis
(Treponema
pallidum)
Stage 1: Red, painless sore
(chancre) at bacterium’s
point of entry.
Stage 2: Skin rash over body,
including palms of hands and
soles of feet.
Stage 1: 10–90 days
(average 21 days).
Antibiotics
Easily cured, but untreated
syphilis can lead to
damage of internal organs.
There is a two- to
fivefold increase of
acquiring HIV when
already infected with
syphilis.
Possible flulike symptoms but
often no symptoms during
early phase. Variety of later
symptoms, including weight
loss, persistent fever, night
sweats, diarrhea, swollen
lymph nodes, bruiselike rash, persistent
cough.
Several months to
several years.
No cure available,
although new
treatment drugs have
improved the health
and lengthened the
lives of many HIVinfected individuals.
HIV infection is usually
diagnosed by tests for
antibodies against HIV.
One in five people living
with it are unaware of
their infections.
Stage 2: 6 weeks
after chancre
appears.
Viral STIs
HIV infection
and AIDS
(human
immunodeficiency virus)*
*HIV infection and AIDS are discussed in detail in Chapter 16.
426 cases per 100,000. An estimated 2.8 million individuals are infected annually with chlamydia. Rates of reported chlamydia infections have been increasing annually since 1990, and adolescent and young women remain the
population most affected by chlamydia (see Figure 15.4) (CDC, 2011f, 2011i;
Satterwhite, Tian, Braxton, & Weinstock, 2010).
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STI and
Infecting
Organism
Time from
Exposure to
Occurrence
Symptoms
Genital
herpes
(herpes
simplex
virus)
Small sore or itchy bumps on
genitals or rectum, becoming
blisters that may rupture,
forming painful sores; flulike
symptoms with first outbreak.
Within 2 weeks
No cure, although
antiviral medications
can relieve pain,
shorten and prevent
outbreaks, and reduce
transmission to
partners when
medication is taken.
Virus remains in body, and
outbreaks of contagious
sores may recur. Most
people diagnosed with first
episode have four to five
symptomatic recurrences a
year, although recurrences
are most noticeable in first
year and decrease in
frequency over time.
Genital
human
papillomavirus
infection
(group of
viruses)
Over 40 HPV types,
including genital warts,
infect the genitals;
rectum, mouth,
and throat.
Most people with
genital HPV infection
do not know they
are infected; some
get visible genital
warts. In 90% of
cases, the body
clears HPV naturally
within 2 years.
Visible genital warts
can be removed
by patient or healthcare provider with
prescribed
medication.
Some HPV types can
cause cervical cancer.
HPV usually disappears on
its own without causing
health problems Most people
who have sex acquire HPV at
some time in their lifetime.
Vaccines protect girls and
women against genital warts
and cervical, anal, vaginal and
vulvar cancers and boys and
men against genital warts
and anal cancers.
Viral
hepatitis
(hepatitis A
or B virus)
Fatigue, diarrhea, nausea,
abdominal pain, jaundice,
darkened urine due to
impaired liver function.
1–4 months
No medical treatment
available; rest and
fluids are prescribed
until disease runs
its course.
Hepatitis B is more
commonly spread through
sexual contact. Both A
and B can be prevented
by vaccinations.
Within a few days
up to 4 weeks.
Depends on
organism; oral,
topical, and vaginal
medications are
available.
Not always acquired
sexually. Other causes
include stress, birth control
pills, pregnancy, tight
pants or underwear,
antibiotics, douching, vaginal
products, and poor diet.
Hatching of eggs
in 6–10 days.
Creams, lotions, or
shampoos—both
over-the-counter
and prescription.
Avoid sexual contact with
people having unusual
spots or insects or nits in
the genital area. Also avoid
contaminated clothing,
sheets, and towels.
Medical
Treatment
Comments
Vaginal Infections
Vaginitis
(Gardnerella
vaginalis,
Trichomonas
vaginalis, or
Candida
albicans)
Intense itching of vagina
and/or vulva, unusual
discharge with foul or fishy
odor, painful intercourse. Men
who carry organisms may be
asymptomatic.
Ectoparasitic Infestations
Pubic lice,
crabs
(Pediculosis
pubis)
Itching, blue and gray spots,
and insects or nits (eggs) in
pubic area; some people may
have no symptoms.
Chlamydia is so common in young women that, by age 30, 50% of sexually
experienced women show evidence that they had chlamydia sometime during
their lives (CDC, 2001). Women who develop the infection 3 or more times
have as great as a 75% chance of becoming infertile. Pelvic inflammatory disease
(PID) occurs in 10–15% of women with untreated chlamydia. Also, research
Principal Bacterial STIs
•
495
• FIGURE 15.4
Rates of Chlamydia by Sex,
United States, 1990–2010.
(Source: CDC, 2011f.)
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750
625
500
Men
Women
Total
375
250
125
0
1990
1992
1994
1996
1998
2000
Year
2002
2004
2006
2008
2010
shows that women infected with chlamydia have a 5 times greater chance of
acquiring HIV if exposed (CDC, 2011i). Untreated chlamydia can be quite
painful and can lead to conditions requiring hospitalization, including acute
arthritis. Infants of mothers infected with chlamydia may develop dangerous eye,
ear, and lung infections.
Any sexually active person can become infected with chlamydia. This is
particularly true for adolescent girls and young women since their cervix is
not fully matured and is probably more susceptible to infection. Chlamydia
can be transmitted during vaginal, anal, or oral sex and from an infected
mother to her baby during vaginal childbirth. Men who have sex with men
are at risk for chlamydial infections since chlamydia can be transmitted during oral or anal sex. Chlamydia is known as a “silent” disease; about three
fourths of infected women and about one half of infected men have no
symptoms. If symptoms do occur, they usually appear within 1–3 weeks after
exposure.
When early symptoms occur in women, they are likely to include unusual
vaginal discharge, a burning sensation when urinating and frequent urination,
and unexplained vaginal bleeding between menstrual periods. Later symptoms,
when the infection spreads from the cervix to the fallopian tubes, are low
abdominal pain, lower back pain, bleeding between menstrual periods, a lowgrade fever, and pain during intercourse. One third to one half of men are
asymptomatic when first infected. Men’s symptoms may include unusual discharge from the penis, a burning sensation when urinating, itching and burning around the urethral opening (urethritis), pain and swelling of the testicles,
and a low-grade fever. The last two symptoms may indicate the presence of
chlamydia-related epididymitis, inflammation of the epididymis. Untreated
epididymitis can lead to infertility. Chlamydia responds well to antibiotic therapy. Rectal pain, discharge, or bleeding may occur in men or women who
acquired chlamydia during receptive anal intercourse. A study of 3,076 men
who have sex with men that was conducted in London HIV clinics found that
the prevalence of chlamydia in the rectum was 8% and in the urethra 5%.
HIV and rectal chlamydia coinfection was 38%. Most of the rectal infections
(69%) were asymptomatic and would not have been found if screening had
not been conducted (Annan et al., 2009). Chlamydia can also be found in the
throats of men and women engaging in oral sex with an infected person (CDC,
2011f, 2011j).
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The CDC recommends yearly chlamydia testing for all sexually active
women aged 25 and younger, older women with risk factors (new sex partner
or multiple sex partners), and all pregnant women. Two types of laboratory
tests can be used to detect chlamydia. One kind tests a urine sample; another
tests fluid from a man’s penis or a woman’s cervix. A Pap smear does not test
for chlamydia (CDC, 2011j).
Gonorrhea
Gonorrhea is the second most commonly reported notifiable disease in the
United States, where the highest reported rates of infection are among sexually
active teenagers, young adults, and African Americans. The CDC estimates that
more than 700,000 persons in the United States become infected with gonorrhea each year. Less than half of these infections are reported to the CDC. In
2010, 309,341 cases of gonorrhea in the U.S. were reported to the CDC, a
rate of 101 per 100,000 (CDC, 2011f, 2011k). Popularly referred to as “the
clap” or “the drip,” gonorrhea is caused by the Neisseria gonorrhoeae bacterium.
The organism thrives in the warm, moist environment provided by the mucous
membranes lining the mouth, throat, vagina, cervix, urethra, and rectum. Gonorrhea is transmitted during vaginal, anal, or oral sex with an infected person.
Ejaculation does not have to occur for gonorrhea to be transmitted or acquired.
Men tend to experience the symptoms of gonorrhea more readily than
women, notably as a watery discharge (“drip”) from the penis, the first sign of
urethritis. (“Gonorrhea” is from the Greek, meaning “flow of seed.”) Some men
infected with gonorrhea may have no symptoms at all. Other men have signs
and symptoms that appear 2–5 days after infection. But symptoms can take as
long as 30 days to appear (CDC, 2011k). Besides a watery discharge, symptoms
in men may include itching or burning at the urethral opening and pain when
urinating. If untreated, the disease soon produces other symptoms, such as thick
yellow or greenish discharge, increasing discomfort or pain with urination, and
painful or swollen testicles.
Up to 80% of women with gonorrhea show no symptoms or very mild
symptoms, which they tend to ignore. Because untreated gonorrhea, like
untreated chlamydia, can lead to PID, it is important for women to be on
guard for symptoms and to be treated if they think they may have been exposed
to gonorrhea (e.g., if they have had numerous sexual partners). Symptoms a
woman may experience include thick yellow or white vaginal discharge that
might be bloody, a burning sensation when urinating, unusual pain during
menstruation, and severe lower abdominal pain. Both females and males may
have mucous discharge from the anus, blood and pus in feces, irritation of the
anus, and mild sore throat.
Gonorrhea is curable with several antibiotics. However, drug-resistant strains
of gonorrhea are increasing in many parts of the United States and the world,
making successful treatment more difficult. Persons with gonorrhea should be
tested for other STIs. Untreated gonorrhea can cause sterility in both sexes,
ectopic pregnancy, prostate damage, epididymitis, scarring of the urethra in men,
and testicular pain. Gonorrhea may be passed to an infant during childbirth,
causing conjunctivitis (an eye infection) and even blindness if not treated. People with gonorrhea can more easily contract HIV. People with HIV infection
and gonorrhea are more likely than people with HIV infection alone to transmit
HIV to others (CDC, 2008j, 2011k).
Gonorrhea infection in men
is often characterized by a
discharge from the penis.
Principal Bacterial STIs
•
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I had the honor
“ To receive, worse luck!
From a certain empress
A boiling hot piss.
—Frederick the Great
(1712–1786)
And he died in the year fourteen-twenty.
“ Of the syphilis, which he had a-plenty.
—François Rabelais
(1490–1553)
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Urinary Tract Infections
Urethritis, the inflammation of the urethra, can result from sexual exposure and
noninfectious conditions. Among the several organisms that cause these infections,
the most common and most serious is chlamydia. Urinary tract infections are
sometimes referred to as nongonococcal urethritis (NGU). The diagnosis of
NGU occurs more frequently in men, largely due to their anatomy. In men, urethritis may produce a burning sensation when urinating, burning or itching around
the opening of the penis, white or yellowish discharge from the penis, and underwear
stain. Women are likely to be asymptomatic. They may not realize they are infected
until a male partner is diagnosed. If a woman does have symptoms, they are likely
to include itching or burning while urinating and unusual vaginal discharge.
It is important to have a laboratory test for an unusual discharge from the
penis or vagina so that the appropriate antibiotic can be prescribed. Antibiotics
are usually effective against NGU. Untreated NGU may result in permanent
damage to the reproductive organs of both men and women and problems in
pregnancy. The organisms that cause NGU in men may cause other infections
in women, such as cervicitis, which is discussed later in this chapter (ASHA,
2008, 2011a; CDC, 2011f ). The most common urinary tract infection among
women, cystitis, is briefly discussed later in this chapter.
Syphilis
Syphilis, a genital ulcerative disease, is caused by the bacterium Treponema
pallidum. In the United States, health officials reported 45,834 cases of
syphilis in 2010, including 13,774 cases of primary and secondary syphilis
(see below for explanation of primary and secondary syphilis). Most syphilis
cases in 2011 occurred in individuals aged 20–36. Although syphilis rates
decreased steadily in the United States during 1900–2000, the rate increased
annually during 2001–2009 before decreasing in 2010 to 4.5 cases per
100,000 in the population. Syphilis continues to be a serious problem in
the south and in urban areas in other parts of the U.S. and among MSM
(CDC, 2011f; Su, Beltrami, Zaidi, & Weinstock, 2011). In 2010, 67% of
the reported primary and secondary (P&S) syphilis cases were among MSM,
largely because of high rates of HIV coinfection and high-risk sexual behavior.
Treponema pallidum is a spiral-shaped bacterium (a spirochete) that requires
a warm, moist environment such as the genitals or the mucous membranes
inside the mouth to survive. It is spread by direct contact with a syphilis sore
during vaginal, anal, and oral sexual behavior. Syphilis cannot be spread through
contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs,
shared clothing, or eating utensils. The syphilis bacterium of an infected mother
can infect the baby during the pregnancy. Depending on how long the woman
has been infected, she may have a high risk of having a stillborn baby or giving birth to a baby who dies soon after birth. An infected baby may be born
and not have any signs or symptoms, but if not treated immediately, the baby
may develop serious health problems within a few weeks. Untreated infants
may become developmentally delayed, have seizures, or die. Untreated syphilis
in adults may lead to brain damage, heart disease, blindness, and death.
Syphilis has often been called “the great imitator” since many of its signs
and symptoms are indistinguishable from those of other diseases. Yet, many
people infected with syphilis do not have any symptoms for years but remain
at risk for complications if they are not treated. Although transmission occurs
Sexually Transmitted Infections
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The first symptom of syphilis is a
red, pea-sized bump called a
chancre at the site where the
bacterium originally entered the
body.
from individuals with sores who are in the primary and secondary stages, many
of these sores are unrecognized or hidden. Thus, transmission may occur from
people who are unaware of their infection. Syphilis progresses through three
discrete stages, although it is most often treated during the first two:
■ Stage 1: Primary syphilis. The first symptom of syphilis appears from 10
to 90 days (average 21 days) after contact with an infected partner. It is a
small, red, pea-sized bump that soon develops into a round, painless sore
called a chancre (SHANK-er). The person’s lymph nodes may also be
swollen. The chancre may appear on the labia, the shaft of the penis, the
testicles, or the rectum; within the vagina; within the mouth; or on the
lips. Unless it is in a visible area, it may not be noticed. Without treatment, it will disappear in 3–6 weeks, but the bacterium remains in the
body, and the person is still highly contagious.
■ Stage 2: Secondary syphilis. Untreated primary syphilis develops into secondary syphilis about 6 weeks after the chancre has disappeared. The principal
symptom at this stage is a skin rash that neither itches nor hurts. The rash
is likely to occur on the palms of the hands and the soles of the feet, as
well as on other areas of the body. The individual may also experience
fever, swollen lymph nodes, patchy hair loss, headaches, weight loss, muscle
aches, and fatigue. The rash or other symptoms may be very mild or may
pass unnoticed. The person is still contagious.
■ Stage 3: Latency. If secondary syphilis is not treated, the symptoms
disappear within 2–6 weeks, and the latent stage begins. The infected
person may experience no further symptoms for years or perhaps never.
After about a year, the bacterium can no longer be spread to sex partners,
although a pregnant woman can still transmit the disease to her fetus.
The late stages of syphilis can develop in about 15% of people who have
not been treated for syphilis and can appear 10–20 years after infection was
acquired. In the late stages, damage may occur many years later in internal
organs, such as the brain, nerves, eyes, heart, blood vessels, liver, bones, and
joints. Damage could also include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, dementia, and even death.
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think
about it
The Tuskegee Syphilis Study:
A Tragedy of Race and Medicine
In 1932 in Macon County, Alabama, the U.S. Public Health
Service, with the assistance of the Tuskegee Institute, a
prestigious Black college, recruited 600 African American
men to participate in an experiment involving the effects of
untreated syphilis on Blacks. Of this group, 399 men had been
diagnosed with syphilis and 201 were controls. The study was
originally meant to last 6–9 months, but “the drive to satisfy
scientific curiosity resulted in a 40-year experiment that followed
the men to ‘end point’ (autopsy)” (Thomas & Quinn, 1991). The
history of this experiment—the racial biases that created it, the
cynicism that fueled it, and the callousness that allowed it to
continue—is chillingly chronicled by James Jones (1993) in Bad
Blood: The Tuskegee Syphilis Experiment and Susan Reverby (2009)
in Examining Tuskegee: The Infamous Syphilis Study and
Its Legacy.
The purpose of the study was to determine if there were racial
differences in the developmental course of syphilis. The racial
prejudice behind this motivation may seem hard to fathom
today, yet, as we shall see, the repercussions still reverberate
strongly through African American communities (Ross, Essien,
& Torres, 2006).
Much of the original funding for the study came from the
Julius Rosenwald Foundation (a philanthropic organization
dedicated to improving conditions within African American
communities), with the understanding that treatment was to
be a part of the study. Although Alabama law required prompt
treatment of diagnosed venereal diseases, the state Public
Health Service managed to ensure that treatment was withheld
from the participants. Even after 1951, when penicillin became
the standard treatment for syphilis, the Public Health Service
refused to treat the Tuskegee “subjects” on the grounds that the
experiment was a “never-again-to-be-repeated opportunity”
(Jones, 1993).
The Tuskegee participants were never informed that they
had syphilis. The Public Health Service, assuming they would not
understand medical terminology, referred to it as “bad blood,”
a term used to describe a variety of ailments in the rural South.
The participants were not told their disease was sexually
transmitted, nor were they told it could be passed from mother
to fetus.
It was not until 1966 that anyone within the public health
system expressed any moral concern over the study. A congressional subcommittee headed by Senator Edward Kennedy began
hearings in 1973. The results included the rewriting of the
Department of Health, Education, and Welfare’s regulations on
the use of human subjects in scientific experiments. A $1.8-billion
class-action suit was filed on behalf of the Tuskegee participants
and their heirs. A settlement of $10 million was reached out of
court. Each survivor received $37,500 in damages, and the heirs
of the deceased each received $15,000. Also, a congressionally
mandated program, the Tuskegee Health Benefit Program,
provides comprehensive lifetime medical benefits to the affected
widows and offspring of participants in the Tuskegee syphilis
study (Reverby, 2009).
Current public health efforts to control the spread of HIV
infection, AIDS, and other STIs raise the specter of genocide
and beliefs of conspiracy among many members of the
African American community. Research on African American
people living in the United States has found that a significant
proportion of respondents endorsed HIV/AIDS conspiracy
beliefs; that is, HIV/AIDS was created by the federal government
to kill and wipe out African Americans. Among African American
men, stronger conspiracy beliefs were significantly associated with
negative attitudes about condoms and lower likelihood of condom
use (Bogart, Galvan, Wagner, & Klein, 2011; Bogart & Thornton,
2005; Hutchinson et al., 2007; Ross, Essien, & Torres, 2006).
In the primary, secondary, and early latent stages, syphilis can be successfully
treated with antibiotics. There is an estimated two- to fivefold increase in the
chances of acquiring HIV if exposed to that infection when syphilis is present
(CDC, 2008k, 2011l).
•
Principal Viral STIs
Four principal viral STIs—HIV and AIDS, genital human papillomavirus
infection, genital herpes, and hepatitis—are discussed here. Recall that diseases
caused by viruses are treatable, but not curable.
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Many of the current beliefs of African American people
about HIV/AIDS as a form of genocide are attributed to the
Tuskegee syphilis study. On both physiological and psychological
levels, there is much healing to be done. Even though it is
unthinkable that such a study would be done today, efforts
must still be made to ensure that all people are protected
against such tragedies.
For reflections on the legacy of the Tuskegee study, see
Caplan, 1992; Jones, 1993; King, 1992; and Reverby, 2009).
Several Internet sites provide further information about this
terrible experiment, including the transcript of President
Clinton’s 1997 formal apology to study participants.
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Think Critically
1. Is it possible for another medical experiment like the
Tuskegee syphilis study to happen in America today?
Explain your view.
2. What can be done to prevent another Tuskegee
syphilis study?
3. What can the medical and scientific community do to
gain the trust of all Americans?
AUTH © 1972 The Philadelphia Inquirer. Reprinted with permission of UNIVERSAL PRESS SYNDICATE. All rights reserved.
HIV and AIDS
On June 5, 1981, the U.S. government published a report warning about
a rare disease, eventually named as acquired immunodeficiency syndrome,
or AIDS (CDC, 1981). Since that time, this disease has become an enormous public health challenge nationally and globally. Human immunodeficiency virus (HIV)—the virus that causes AIDS—and AIDS have claimed
millions of lives worldwide, becoming one of the deadliest epidemics in
human history. Despite advances in medical testing and treatment and prevention efforts, HIV/AIDS remains a significant public health problem.
Because of its major global impact and continued medical and prevention
Principal Viral STIs
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challenge, we have decided to devote an entire chapter to HIV and AIDS,
which follows this chapter.
Genital Human Papillomavirus Infection
Genital human papillomavirus infection, or genital HPV, is a group of viruses
that includes more than 100 different strains; over 40 are sexually transmitted
and can infect the genitals, rectum, mouth, and throat. Currently, at least
20 million people in the U.S. are infected with HPV, with 6 million new infections reported each year, accounting for one third of all new STIs. HPV is the
most common STI among young, sexually active people, particularly women.
At least one half of sexually experienced men and women acquire genital HPV
infection at some point in their lives. By age 50, at least 80% of women will
have acquired genital HPV infection (ASHA, 2011b; CDC, 2008l, 2011h).
The type of HPV that infects the genital area is spread primarily through
sexual contact with an infected person. In rare instances, a pregnant woman
can pass HPV to her baby during vaginal delivery. The incubation period (the
period between the time a person is first exposed to a disease and the time the
symptoms appear) is usually 6 weeks to 8 months. You cannot see HPV. Most
people who have a genital HPV infection do not know they are infected, and
most infections are temporary.
Sometimes, certain types of HPV can cause genital warts in men and
women. Other HPV types can cause cervical cancer and less common cancers
of the vulva, vagina, anus, and penis. The types of HPV that can cause genital
warts are not the same as the types that can cause cancer. HPV types are
referred to as “low risk” (wart causing) or “high risk” (cancer causing). In 90%
of the cases, the body’s immune system clears the HPV—both high-risk and
low-risk types—naturally within 2 years. If a high-risk HPV infection is not
cleared by the immune system, it can linger for many years and turn abnormal
cells into cancer over time. About 10% of women with high-risk HPV on their
cervix will develop long-lasting HPV infections that will put them at risk for
cervical cancer (CDC, 2008l, 2011h).
The Pap test can identify abnormal or precancerous tissue in the cervix so
that it can be removed before cancer develops. An HPV DNA test, which can
find high-risk HPV on a women’s cervix, may also be used with a Pap test in
certain cases. There is no general test for men and women to check one’s overall “HPV status,” nor is there an approved HPV test to find HPV on the
genitals or in the mouth or throat. HPV usually goes away on its own, without
causing health problems. So an HPV infection that is found today will most
likely not be there a year or two from now. Hence, there is no reason to be
tested just to find out if you have HPV now. But you should get tested for signs
of diseases that HPV can cause, such as cervical cancer (CDC, 2008l, 2011h).
(See Chapter 13 for recommendations about frequency of pap smears.)
The genital-wart history of a national sample of 8,849 men and women
found that 7% of women and 4% of men reported ever being diagnosed with
genital warts (Dinh, Sternberg, Dunne, & Markowitz, 2008). About 1% of
sexually active adults in the U.S. have genital warts at some point in their
lives. Genital warts usually appear as soft, moist, pink, or flesh-colored swellings, usually in the genital area. They can also be flat, single or multiple, small
or large, and sometimes cauliflower shaped. They can appear on the penis or
scrotum, in or around the vagina or anus, on the cervix, or on the groin or
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thigh. Visible genital warts can be removed by the patient him- or herself with
prescribed medications or treated by a health-care provider. Some people
choose not to treat warts but see if they disappear on their own. No one
treatment is better than another. If the warts cause discomfort or problems
(such as interfering with urination), they can be removed by cryosurgery
(freezing) or laser surgery. Removal of the warts does not eliminate HPV from
the person’s system. Because the virus can lie dormant in the cells, in some
cases warts can return months or even years after treatment. The extent to
which a person can still transmit HPV after the visible warts have been
removed is unknown.
In recent years, a major medical breakthrough has occurred in protecting
thousands of females and males against the health-impairing outcomes of HPV
infection. Two HPV vaccines have been developed, and the U.S. Department
of Health and Human Services highly recommends their use. In June 2006,
the U.S. Food and Drug Administration approved the HPV vaccine Gardasil
(Merck) for use by females aged 9–26; in October 2009, this vaccine was also
licensed for use in males aged 9–26. Gardasil protects against HPV types 6 and
11 (the cause of 90% of genital warts) and types 16 and 18 (the cause of 70%
of cervical cancer). Gardasil also prevents HPV associated with anal, vulvar and
vaginal cancers. In 2009, another HPV vaccine, Cervarix (GlaxoSmithKline),
was approved for types 16 and 18. Both of these vaccines are given in three
shots over 6 months (ASHA, 2011a; CDC, 2011f, 2011m). One study found
that since the Gardasil HPV vaccination began in 2007 in Australia, the number of women seeking treatment for genital warts decreased 59% (Donovan
et al., 2011). Despite its significant health value, the effort to vaccinate all
young people has faced difficulties. For example, nationally representative data
have shown that only one third of girls aged 13–17 have been vaccinated (Pruitt
& Schootman, 2010). Studies have shown that some girls taking the HPV
vaccine did not complete the vaccine series in the 6-month time period or did
not complete the series (Widdice, Bernstein, Leonard, Marsolo, & Kahn, 2011)
or would not take the vaccine even if it was free (Crosby, Casey,
Vanderpool, Collins, & Moore, 2011). In addition, parental acceptance of the
HPV vaccine has been mixed (Dempsey, Butchart, Singer, Clark, & Davis, 2011;
Milhausen, Crosby & Yaber, 2008). Although many parents accept HPV vaccination, some parents believe that vaccinating girls against HPV condones
premarital/teen sex. Further educational efforts to promote the value of HPV
vaccines, particularly to parents, need to occur.
The American Social Health Association (ASHA) has developed a support
service for people with HPV called the HPV and Cervical Cancer Prevention
Resource Center (http://www.ashastd.org). It provides information about HPV
and its link to cervical cancer, support groups for emotional issues surrounding
HPV, and an e-mail address (mystory@ashastd.org) where people share their
experiences with HPV, which are posted on the ASHA website.
If you have HPV, don’t blame your current sexual partner or assume that
your partner is not sexually exclusive with you. Remember, most people who
have sex will have HPV at some time in their lives, and they may have HPV
for a very long time before it is detected. Most people do not realize they are
infected or that they are passing on the virus to a sexual partner. Sexual partners
usually share HPV, particularly those who are together for a long time. There
should be no shame or blame involved with having genital HPV; the virus is
very common.
Genital warts appear in a variety
of forms.
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Genital Herpes
Genital herpes is an STI caused by the herpes simplex virus (HSV) type 1
(HSV-1) and type 2 (HSV-2). Most genital herpes is caused by HSV-2. Nationally representative data show that genital herpes infection occurs commonly in
the United States, with 16.2% of people aged 14–49, or about 1 in 6 persons
in that age group, having a genital HSV-2 infection. Over the past decade, the
percentage of Americans with genital herpes in the United States has remained
stable. Genital HSV-2 infection is more common in women (about 1 in 5 women
aged 14–49) than men (about 1 in 9 men aged 14–49). This may be due to
male-to-female transmission being more likely than female-to-male transmission. Herpes can make people more susceptible to HIV infection, and it can
make HIV-infected individuals more infectious (CDC, 2010h). Actually, many
HIV-infected persons are coinfected with HSV-2 (Romanowski et al., 2009).
HSV-1 and HSV-2 can be found and released from the sores that the viruses
cause, but also can be released between outbreaks from skin that does not
appear to be broken or have a sore (Tronstein, 2011). Generally, a person can
get HSV-2 infection only during sexual contact with someone who has a genital HSV-2 infection. It is important to know that transmission can occur from
an infected partner who does not have a visible sore and may not know that
he or she is infected. HSV-1 can cause genital herpes, but it more often causes
infections of the mouth and lips, so-called fever blisters. HSV-1 infection of
the genitals can be caused by oral-genital or genital-genital contact with a
person infected with HSV-1. Genital HSV-1 outbreaks recur less regularly than
genital HSV-2 outbreaks.
Most infected people have no or minimal signs or symptoms from HSV-1
and HSV-2 infection. When signs appear, they typically occur within 2 weeks
after the virus is transmitted and appear as one or more blisters on or around
the genitals or rectum. The blister breaks, leaving tender ulcers (sores) that may
take 2–4 weeks to heal the first time they occur. Most people diagnosed with
a first episode of genital herpes can expect to have several (typically four or
five) outbreaks within a year, but they are almost always less severe and shorter
than the first outbreak. Even though the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years (CDC,
2008m, 2010a).
There is no cure for herpes, but there are medications that
can help to keep the virus in check (Handsfield, Warren, Werner, & Phillips,
2007). Antiviral medications can relieve pain, shorten the duration of sores,
prevent bacterial infections at the open sores, and prevent outbreaks while the
person is taking the medications. Other actions that may be useful in preventing, shortening the duration of, or lessening the severity of recurrent outbreaks
include getting plenty of rest, maintaining a balanced diet, avoiding tight
clothes, keeping the area cool and dry, taking aspirin or other painkillers, and
reducing stress.
Individuals with herpes should inform their partners and together decide
what precautions are right for them. Because having sex during a recognized
outbreak or when other symptoms are present (e.g., flulike symptoms, swollen
glands, fever) puts an uninfected partner at risk, people should abstain from
sex when signs and symptoms of either oral or genital herpes are present. The
male latex condom can help prevent infections, but only when the condom
covers the ulcer. Condoms should be used between outbreaks of the ulcers.
Managing HSV
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Herpes lesions may develop on
the penis, perineum, anus, vulva,
or within the vagina.
Also, daily suppressive therapy for symptomatic herpes can reduce transmission
to partners. Pregnant women or their partners who have HSV should be sure
to discuss precautionary procedures with their medical practitioners.
Genital herpes often causes psychological distress in people who know they
are infected. ASHA has developed a support service for people with herpes
infections called the Herpes Resource Center (http://www.ashastd.org). It provides accurate and current information about herpes, such as the STI Resource
Center Hotline (919-361-8488), and referrals to local support groups.
Viral Hepatitis
Hepatitis is a viral disease meaning inflammation of the liver. The most common types of the virus that can be sexually transmitted are hepatitis A and
hepatitis B. A third type, hepatitis C, is a common virus passed on primarily
through contact with infected blood; risk of transmittal from sexual partners
or from mothers to newborns during birth is low.
Hepatitis A is transmitted primarily through oral contact with contaminated
food or water or through sexual contact, especially oral-anal sex. In the United
States, there were an estimated 21,000 new hepatitis A infections in 2009, a
decrease from 56,000 estimated new infections in 2004. A highly effective vaccine, which is routinely given to all children, travelers to certain countries, and
persons at risk for the disease, can prevent hepatitis A. Although the symptoms
of hepatitis A are similar to those of hepatitis B, the disease is not considered
as dangerous. Individuals infected with hepatitis A usually experience shortterm illness, recover completely, and develop immunity against reinfection
(CDC, 2009d, 2011n).
Hepatitis B is 50–100 times more infectious than HIV. It is commonly
spread through sexual contact, in blood, semen, saliva, vaginal secretions, and
urine. In the United States, two thirds of acute hepatitis cases resulted from
sexual contact with the virus. It can also be contracted by using contaminated
needles and syringes, including those used in ear piercing, acupuncture, and
tattooing, and by sharing the toothbrush or razor of an infected person. Unlike
hepatitis A, hepatitis B is not spread routinely through food or water. It is not
spread by sharing eating utensils, breastfeeding, hugging, kissing, holding
hands, coughing, or sneezing. An estimated 700,000 to 1.4 million Americans
are chronically infected with hepatitis B. The number of new infections per
year has declined dramatically from an average of 260,000 per year in the 1980s
to about 38,000 in 2009 (CDC, 2009e, 2011n). Anyone can get hepatitis B,
Principal Viral STIs
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but individuals in their teens and twenties are at greater risk. Because hepatitis
B spreads “silently”—that is, without easily noticeable symptoms—many people are not aware it is in their communities. Chronic hepatitis B is a serious
disease that can result in long-term health problems and even death. About
2,000 to 4,000 people die every year from hepatitis B–related liver disease
(CDC, 2009e).
Hepatitis B can be prevented by a simple, widely available vaccine. The
CDC (2009e) recommends routine vaccination for those most at risk, including sexually active people not in a long-term, exclusive relationship, men who
have sex with men, people who share drug-injection equipment, people whose
sexual partner has hepatitis B, and people with HIV. Screening for hepatitis B
is also recommended for pregnant women so that their newborns can be immediately vaccinated if necessary. Usually given as three or four shots over a
6-month period, the vaccine is safe and effective and provides lasting protection. Tattoos and body piercings should be done at parlors that thoroughly
sterilize the instruments used to penetrate the skin.
In 2009, there were an estimated 16,000 new hepatitis C virus infections in
the United States. An estimated 3.2 million individuals in the U.S. have chronic
hepatitis C, and about 75–85% of people who become infected with hepatitis
C will develop a chronic infection. About 8,000 to 10,000 people die every
year from hepatitis C–related liver disease (CDC, 2009f, 2011n). Risk of infection from sexual activity is low unless it involves blood contact; numerous
sexual partners, failure to use condoms, a history of STIs, and sexual activities
involving trauma (e.g., “rough” sex) increase the risk. About 50–90% of HIVinfected persons who use injection drugs are also infected with hepatitis C.
Most cases of hepatitis C can be traced to blood transfusions before 1992, the
sharing of needles during injection drug use, and accidental needle-sticks.
Known as the “silent epidemic,” hepatitis C damages the liver over the course
of many years, and even decades, before symptoms appear.
The symptoms of all forms of hepatitis include fatigue, diarrhea, nausea,
abdominal pain, jaundice, darkened urine, and an enlarged liver. About 15–25%
of people who get hepatitis C will clear the virus from their bodies without
treatment and will not get a chronic infection. There is no medical treatment
nor vaccine for hepatitis C. Occasionally, serious liver damage or death results.
•
Vaginal Infections
Vaginal infections, or vaginitis, affect 3 out of 4 women at least once in their
lives. These infections are often, though not always, sexually transmitted. They
may also be induced by an upset in the normal balance of vaginal organisms
by such things as stress, birth control pills, antibiotics, nylon panty hose, and
douching. The three principal types of vaginitis are bacterial vaginosis, candidiasis, and trichomoniasis.
Bacterial Vaginosis
Bacterial vaginal infections, referred to as bacterial vaginosis (BV), may be
caused by a number of different organisms, most commonly Gardnerella vaginalis, often a normal inhabitant of the healthy vagina. An overabundance of
Gardnerella, however, can result in vaginal discharge, odor, pain, itching, or
burning. Bacterial vaginosis is the most common vaginal infection in women
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of childbearing age and, in the United States, is common among pregnant
women. An estimated 29% of American women (21 million) aged 14–49 have
BV now, but the vast majority do not report symptoms to their health-care
provider (CDC, 2008q, 2010i; Koumans et al., 2007). Not much is known
about how women get bacterial vaginosis, and there are many unanswered
questions about the role that harmful bacteria play in causing it and what role
sexual activity plays in its development. Any woman can get BV, although some
activities can upset the normal balance of bacteria in the vagina and put women
at risk, including having a new sexual partner or numerous partners and douching. Research has shown that douching at least once a month is associated with
BV but that most female hygienic behaviors, such as type of underwear, menstrual protection, or hygienic spray or towelettes, were found not to be related
to BV (Hutchinson, Kip, & Ness, 2007; Klebanoff et al., 2010). Bacterial
vaginosis may also be spread between female sex partners (Bailey, Farquhar, &
Owen, 2004). Women who never had sexual intercourse may get BV (Tabrizi,
Fairley, Bradshaw, & Garland, 2006). Most often this infection causes no complications, although having it can increase a woman’s susceptibility to HIV
infection and other STIs such as chlamydia and gonorrhea and can increase
the chances that an HIV-infected woman can pass HIV to her sexual partner.
BV may also put a woman at increased risk for some complications during
pregnancy.
Even though bacterial vaginosis sometimes clears up without treatment, all
women with symptoms of BV should be treated with antibiotics so that the
bacteria that cause BV do not infect the uterus and fallopian tubes, an infection
called pelvic inflammatory disease, or PID. Male partners generally do not need
to be treated (CDC, 2010d). A study of women at high risk for STI found
that consistent condom users had a 45% decreased risk for BV than women
not using condoms consistently (Hutchinson et al., 2007).
Genital Candidiasis
Genital candidiasis, also known as a “yeast infection,” is a common fungal
infection that occurs when there is an overgrowth of the fungus called Candida
albicans. Candida is always present in the body (e.g., vagina, mouth, gastrointestinal tract) in a small amount; however, when an imbalance occurs, such as
when the normal acidity of the vagina changes or when hormonal balance
changes, Candida can multiply. Women with a vaginal yeast infection usually
experience itching or burning, with or without a “cottage cheese–like” vaginal
discharge. Males with genital candidiasis, which occurs on rare occasions, may
have an itchy rash on the penis. Nearly 75% of all adult women have had at
least one vaginal yeast infection in their lifetime. Vaginal yeast infections are
rarely transmitted during sexual activity. While most cases are caused by the
person’s own Candida organisms, the use of birth control pills or antibiotics,
frequent douching, pregnancy, and diabetes can promote yeast infections. Genital candidiasis occurs more often and with more severe symptoms in people
with weakened immune systems.
Antifungal drugs, taken orally, applied directly to the affected area, or used
vaginally, are the drug of choice for vaginal yeast infections and are effective
80–90% of the time. Because over-the-counter (OTC) treatments are becoming
more available, more women are diagnosing themselves with vaginal yeast infections and using one of a family of drugs called “azoles” for therapy. However,
“Sex is a pleasurable exercise in
“ plumbing, but be careful or you’ll get
yeast in your drainpipe.
—Rita Mae Brown
(1944–)
Vaginal Infections
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personal misdiagnosis is common and studies show that as many as two thirds
of OTC drugs sold to treat vaginal yeast infections are used by women without
the disease, which may lead to resistant infections. Resistant infections are very
difficult to treat with currently available medications. Therefore, it is important
to be sure of the diagnosis before treating with OTC or other antifungal medications (CDC, 2010j).
Trichomoniasis
Trichomoniasis is caused by a single-celled protozoan parasite, Trichomonas
vaginalis. Trichomoniasis is the most common curable STI in young, sexually
active women. An estimated 7.4 million new cases occur each year in women
and men (CDC, 2007i). One study of 1,209 women attending three STI clinics found that trichomoniasis, unlike other STIs, was found more often in older
compared to younger women (Helms et al., 2008). In women, the vagina is
the most common site of infection; in men, it is the urethra. The parasite is
sexually transmitted during penile-vagina intercourse or vulva-to-vulva contact
with an infected person. Women can acquire the disease from infected men or
women, but men usually contract it only from infected women. Symptoms are
more common in women than men, although up to one half of infected
women are asymptomatic. Some women have signs and symptoms usually
within 5–28 days after exposure, which include frothy, yellow-green vaginal
discharge with a strong odor. The infection may also cause discomfort during
intercourse and urination, as well as itching and irritation of the female genital
area, and, rarely, lower abdominal pain. Some men may temporarily have an
irritation inside the penis, mild discharge, or slight burning after urination or
ejaculation. For both women and men, a physical examination and a laboratory
test are used to diagnose trichomoniasis, although it is harder to detect in men
(CDC, 2007i).
Prescription drugs are effective in treating trichomoniasis. To prevent reinfection, both partners must be treated, even if the partner is asymptomatic.
•
Other STIs
A number of other STIs appear in the United States, but with less frequency
than they do in some developing countries. Among these other STIs are the
following:
■ Chancroid is a painful sore or group of sores on the penis, caused by
the bacterium Hemophilus ducreyi. Women may carry the bacterium but
are generally asymptomatic for chancroid.
■ Cytomegalovirus (CMV) is a virus of the herpes group that affects people with depressed immune systems. A fetus may be infected with CMV
in the uterus.
■ Enteric infections are intestinal infections caused by bacteria, viruses,
protozoans, or other organisms that are normally carried in the intestinal
tract. Amebiasis, giardiasis, and shigellosis are typical enteric infections.
They often result from anal sex or oral-anal contact.
■ Granuloma inguinale appears as single or multiple nodules, usually on
the genitals, that become lumpy but painless ulcers that bleed on contact.
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Chapter 15
Sexually Transmitted Infections
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■ Lymphogranuloma venereum (LGV) begins as a small, painless lesion at
the site of infection and then develops into a painful abscess, accompanied by pain and swelling in the groin.
■ Molluscum contagiosum, caused by a virus, is characterized by smooth,
round, shiny lesions that appear on the trunk, on the genitals, or around
the anus.
•
Ectoparasitic Infestations
Although they are not infections per se, parasites such as scabies and pubic lice
can be spread by sexual contact. Scabies and pubic lice are considered ectoparasitic parasites or infestations since they live on the outer surfaces of the skin.
Scabies
The red, intensely itchy rash caused by the barely visible mite Sarcoptes scabiei
is called scabies. It usually appears on the genitals, buttocks, feet, wrists,
knuckles, abdomen, armpits, or scalp as a result of the mites’ tunneling
beneath the skin to lay their eggs and the baby mites’ making their way back
to the surface. Typically, fewer than 10 to 15 mites can be present on the
entire body of an infested person. On a person, scabie mites can live as long
as 1–2 months, but off a person they usually do not survive more than 48–72
hours. It is highly contagious and spreads quickly among people who have
close contact, both sexual and nonsexual. The mites can also be transferred
during prolonged contact with infested linens, furniture, or clothing. Scabies
is usually treated with a prescribed lotion, applied at bedtime and washed off
in the morning. Clothing, towels, and bedding of people who have scabies
should be disinfected by washing in hot water and drying in high heat or by
dry cleaning (CDC, 2010k).
Pubic Lice
The tiny Phthirus pubis, commonly known as a “crab,” moves easily from the hair
of one person to that of another (probably along with several of its relatives). Pubic
lice usually are found in the genital area on pubic hair, although they can be found
on other coarse body hair such as hair on the legs, armpits, mustache, and beard.
To live, lice must feed on blood. When pubic lice mate, the male and female grasp
adjacent hairs; the female soon begins producing eggs (nits), which she attaches to
the hairs at the rate of about three eggs a day for 7–10 days. The nits hatch within
6–10 days and begin reproducing in about 2–3 weeks, creating a very ticklish (or
itchy) situation. Although pubic lice and nits can be large enough to be seen with
the naked eye, a magnifying lens may be necessary to find lice or eggs.
Pubic lice can be transmitted during sexual contact with a person who has
crabs, moving from the pubic hair of one person to the pubic hair of another.
They may fall into underwear, sheets, or towels, where they can survive up to
a day and lay eggs that hatch in about a week. Thus, it is possible to get crabs
simply by sleeping in an infected person’s bed, wearing his or her clothes, or
sharing a towel.
People can usually tell when they have pubic lice. There is intense itching,
and upon inspection, they discover a tiny, pale, crablike louse or its minuscule,
pearly nits attached near the base of a pubic hair. There are both prescription
Pubic lice, or “crabs,” are easily
spread during intimate contact;
they may also be transmitted via
bedding, towels, or underwear.
Ectoparasitic Infestations
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and over-the-counter treatments for pubic lice. An infested person does not
have to shave off his or her pubic hair to get rid of crabs. In addition to killing all the lice and nits on the body, infested individuals must wash all linen
and clothing in hot water and dry it in high heat, or the crabs may survive
(ASHA, 2011d; CDC, 2010l).
•
STIs and Women
In addition to the direct effects that STIs have on the body, women are vulnerable to complications from STIs that threaten their fertility. These are related
to the biological factors, discussed earlier, that make women more susceptible
to STIs and make STIs more difficult to detect in women than in men.
Pelvic Inflammatory Disease (PID)
As discussed in Chapter 12, pelvic inflammatory disease (PID), also known as
salpingitis, is one of the leading causes of female infertility. Up to 750,000
women experience an episode of acute PID annually, resulting in 10–15% of
these women becoming infertile each year due to the consequences of PID.
PID occurs when bacteria move upward from a woman’s vagina or cervix
into her uterus, fallopian tubes, and other reproductive organs. Several organisms can cause PID, but many cases are associated with gonorrhea and chlamydia. A prior episode of PID increases the risk of another episode because
the reproductive organs may have been damaged during the initial episode.
Sexually active women in their childbearing years are at most risk, and those
under age 25 are more likely to develop PID than those older than 25. Because
the cervix of teenage girls and yo...
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