Preventing sexually transmitted diseases

Preventing sexually transmitted diseases – includes related articles on the spread of sexually transmitted diseases and pelvic inflammatory disease

Originally termed “venereal” diseases in reference to Venus, the goddess of love, sexually transmitted diseases or STDs encompass various infections caused by different microorganisms. Some STDs such as syphilis and gonorrhea have been recorded since antiquity. However, many of the 50-plus viruses, bacteria, protozoa and other microorganisms now known to be sexually transmitted have only been identified in this century. Despite the advent of antibiotics, STDs still pose a serious health threat, especially to adolescents and young adults.

Teens, especially girls, at particular risk of STDs

While gonorrhea is decreasing among the population at large, the proportion among Canadian adolescents is increasing. The spread of chlamydia (its after-effects include sterility and risks of ectopic pregnancy – outside the womb) continues unabated, mainly among young women. As one University of Toronto expert puts it, “teens are moving into the forefront of the STD epidemic. Girls aged 15-19 are gaining on men in their 20s for the highest incidence of gonorrhea, herpes, chlamydia and genital wart infections.” The increase is explained partly by the early onset of unprotected sexual activity, the high “pool of STD infection” among young people, plus the fact that STDs so often produce no symptoms. The recent Canada Youth and AIDS Study (CYAS). found that 48 per cent of boys and 46 per cent of girls in Grade 11 were already sexually active around age 16. Moreover, teenagers tend to change sex partners frequently (every four to six months in many cases), may not be prepared for sexual intercourse, don’t discriminate in their choice of partners and are likely to be “caught off guard.”

Yet teens disdain condoms as “unesthetic” or “premeditated,” failing to realize how easy it is to contract an infection or get pregnant even at the first sexual encounter. To add to the risks of intercourse in teenage girls, the adolescent genital tract – not yet fully matured – is extra vulnerable to invading microorganisms. The CYAS survey found strong adolescent reluctance or negative attitudes towards condom use, whether or not they’d had sexual intercourse. In fact, youngsters with the most sexual experience were the least likely to use condoms. The survey also indicated that 22 per cent of sexually active female first-year college students and 18 per cent of sexually active male students had had anal intercourse at least once. Yet anal sex is high risk behaviour for transmitting AIDS and other STDs.

Sexual health education should start long before Grade 9. Teens need explicit information on how STDs are contracted, what the risks are and practical advice on how to prevent them. They need to know that prompt (early) treatment can prevent serious health impairment later on. They also need to realize that saying “no” to sex is one sure way to prevent STDs, including AIDS. No one is obliged to have sex until ready, even if pressured. But for those who do choose to have sex, protection by consistent, correct condom use is the best way to avoid infection. Girls should try to insist that their panner(s) wear a condom.

Untreated STDs can have devastating consequences-especially for women

STDs are sometimes called “sexist” as women face far more drastic health consequences from them than men. For anatomical reasons, women are likelier than men to have “hidden” STDs in their internal reproductive organs that are less obvious and harder to detect – for example internal sores or a cervical discharge. Health complications from STDs are also more destructive in women than men. They include: pelvic inflammatory disease (PID), sterility, ectopic pregnancy and cervical cancer which is now linked to human papillomavirus (genital wart) infections. Women should take as much care to protect themselves from STDs as to avoid unwanted pregnancy.

Anyone can get them but some types of sex are riskier than others

Sexually transmitted infections don’t respect class or race. They strike men and women of every type, tall or short, thin or fat, rich or poor, gay, heterosexual or bisexual. In short, any sexually active person who doesn’t take proper precautions is vulnerable to STD infection. On the STD danger scale, some sexual practices are riskier than others. Anal sex is the riskiest, vaginal sex less so and oral sex the least likely to transmit an STD. (But that doesn’t mean oral sex is “safe”- it can still transmit infections, including AIDS.) While one encounter is enough to catch a sexually transmitted disease, the risks increase the more lovers one has – particularly if they are chosen from groups at high risk of STDs. Epidemiologists have identified certain groups with behaviours that increase STD risks – such as adolescents (who don’t take precautions); those with many sex partners; injection drug users; male homosexuals; bisexuals; anyone who practices unprotected anal sex (especially with multiple panners); those who have unprotected sex with “sex-trade workers” (prostitutes); and those who use non-barrier contraceptives, unless they also use a condom. Young children can get STDs as a result of sexual abuse.

Carriers often unknowingly spread STDs One reason for the rampant spread of STDs is their ability to “hide” in symptomless carriers. Many men and women don’t know they have a bacterial, viral or parasitic STD because they are asymptomatic, with no sign of infection. Having no symptoms, they don’t go to be checked and aren’t treated. Hence infected carriers who continue to have sex without condoms spread disease. For example, up to 50 per cent of men and women with gonorrhea and/or chlamydia may be asymptomatic, although the disease is injuring their reproductive systems. Weeks, months or years may elapse before the serious (and possibly irreversible) complications of an untreated STD become apparent. Some STD carriers such as those harbouring human papillomavirus (genital wans), AIDS, hepatitis B or herpes infections stay permanently contagious as these diseases aren’t curable. Whether or not they have symptoms, carriers can infect their partners or unborn children. Depending on the particular infection, children born to mothers with STDs may be endangered by pneumonia, conjunctivitis (eye inflammation -perhaps producing blindness), hepatitis B, serious forms of syphilis, herpes or HIV (AIDS) infection.

Ways 10 practice “safer” sex

The only sensible approach to sexually transmitted diseases is prevention. STDs can be avoided by abstaining from sex and for some, saying “no” may be fight for a time. Those who do decide for sex should choose safer options, such as selecting a faithful, monogamous non-infected partner (hard to determine) or consistently using condoms. Men and women should carry a packet of good (latex) condoms to use “just in case.” Condoms provide a reasonable barrier against gonorrhea, syphilis, chlamydia, hepatitis B and HIV (AIDS), but not against herpes or genital wan (HPV) infections because condoms may not cover the open sores.

Unfortunately, many women feel embarrassed or don’t insist that their sex panners wear condoms, and men may use them inconsistently or incorrectly. Nevertheless, although many dislike condores, the risk of STD infection far outweighs minor aversion. Women are urged to take a more “empowering” approach to protect their sexual health and insist that male sex panners wear condoms. Or they could try the new female condom or vaginal pouch. Women and men need to know that anal sex is particularly dangerous because the delicate anal canal is more easily damaged than the tougher vaginal wail, allowing easier access to microorganisms and exposure to blood. (A woman’s risk of STD infection is twice as high bv anal as by vaginal intercourse.)

A rundown of some common STDs

Gonorrhea (GC): Popularly known as the “clap,” gonorrhea is caused by the bacteria Neisseria gonorrhoeae. Although decreasing among the population at large, its proportion is increasing among Canadian youth. Up to 50 per cent of men and women with gonorrhea show no symptoms of infection, although they can pass the disease to their sex partners. If any symptoms do occur (usually about one week after exposure) they may include:

In men:

* thick yellowish-green penile discharge

* sore throat (from oral sex)

* pain on voiding and frequency of urination

* lower abdominal pain.

In women:

* thick vaginal discharge

* sore throat (from oral sex)

* lower abdominal pain

* urinary frequency and pain when urinating

* increased or painful menstrual periods.

Gonorrhea often coexists with chlamydia (in up to 50 per cent of cases). Untreated, it can result in pelvic inflammatory disease, tubal scarfing, infertility and ectopic pregnancy. The gonococcal organism can be passed to newborns, causing a severe eye infection that can possibly lead to blindness. To prevent infant eye disorders from gonorrhea (or chlamydia) newborns are usually given eyedrops containing silver nitrate or erythromycin.

Gonorrhea is curable with antibiotics but some strains have become resistant to penicillin and tetracycline. Therefore health authorities now recommend other antibiotics such as cefixime, ceftriaxone, ciprofloxacin or ofloxacin as first line treatment. (Since gonorrhea may coexist with chlamydia, doxycycline or tetracvcline is given at the same time.) Those with gonorrhea should inform current and past sex partners as they may have been infected without knowing it.

Chlamydia: Three to five times more common than gonorrhea and more frequently detected in women than men, this STD is a serious bacterial infection due to Chlamydia trachomatis. It’s now the most prevalent sexually transmitted disease in Canada. Surveillance data (probably an under-estimate) put its overall incidence at 315 cases per 100,000, but far higher (1,550 per 100,000) among adolecent girls aged 15-19. Chlamydia has been dubbed “the silent epidemic” because it so rarely produces any symptoms, half of the men and women infected showing no symptoms. If symptoms do occur in either sex, they resemble those of gonorrhea but are usually milder – a discharge, pain on urination, perhaps lower abdominal pain.

The consequences of chlamydia can be devastating for women in whom the infection may penetrate the whole reproductive tract, causing pelvic inflammatory disease (PID) with probable infertility and a danger of ectopic pregnancies (fatal to the fetus and a serious threat to the mother). At birth, chlamydia can cause newborn conjunctivitis (eye inflammation) and pneumonia in infants of infected mothers. In men, chlamydia can lead to urethritis (urinary tract inflammation). Early treatment with antibiotics such as tetracycline and doxycycline can avert these consequences.

Syphilis: Caused by the spirochete Treponema pallidum, syphilis has been the scourge of many famous people, including King Henry VIII, Oscar Wilde, Van Gogh, Napoleon and Franz Schubert. Although less common than gonorrhea or chlamydia, syphilis is still surprisingly prevalent, with rates rising in some parts of Canada. It is passed on via sexual contact and may facilitate AIDS transmission. Untreated syphilis remains contagious for at least one, possibly four years.

Syphilis develops in three stages, over many years. Stage one, primary syphilis is a painless, red sore or chancre usually on the man’s penis or rectal area, on the woman’s cervix, or in the mouth of either sex, which heals in about two weeks, even without treatment. Stage two or secondary syphilis occurs one to three months later, with a non-itchy rash often on palms of the hand or soles of feet, sometimes also fever, muscle aches and swollen lymph nodes. Symptoms disappear without treatment. During stages one or two, syphilis can be cured with antibiotics preventing progress to stage three, tertiary syphilis, rare today. However, tertiary syphilis can occur up to 30 years later, damaging heart, bones and brain. Since syphilis can cause fetal defects or be passed on at birth, expectant mothers are screened by blood tests and treated with antibiotics if necessary.

Genital herpes: Very common, affecting one in six or more Canadians, the symptoms may be hardly noticed or can cause an intense burning or tingling sensation, pain on urination, swollen lymph glands and small blisters anywhere in the groin area (including penis, foreskin, buttocks, vulva, cervix or anus). Herpes is most contagious when the sores are visible, but transmission is still possible (although less likely) after the sores have healed. The herpes virus may lie dormant within nerve tracts causing flare-ups which usually last about 10 days.

Treatment of herpes symptoms is with warm sitz baths, good hygiene, wearing loose cotton underwear and possibly acyclovir pills, to reduce vital shedding and shorten the length of the illness. Although a distressing nuisance to sufferers and contagious to others, herpes does not cause serious health problems unless it affects newborns. Over half the newborns infected at birth develop neurological problems. Condoms help to reduce its spread. (For more on herpes, see Health News, June 1983.)

Trichomonas vaginalis or “trich”: This very common, sexually transmitted protozoan infection may produce few symptoms and both sexes can carry the organism for years without knowing it, transmitting it to sex partners. In some women trich causes vaginitis – an irritated or itchy vulva, a malodorous, frothy discharge and perhaps pain on urination. While mainly passed on through sexual contact, trichomonas is hardier than gonorrhea, HIV or syphilis and can survive on wet towels, washcloths or douching equipment. The infection is treated with oral metronidazole (Flagyl). Partners of infected individuals are also treated as “ping pong” reinfection is common. (For more on trichomonas see Health News, April 1988.)

Chancroid: Relatively rare in Canada, this STD remains common in the southern U.S. and developing countries, where it has been identified as a co-factor for AIDS. Chancroid produces painful, red sores although they may produce no symptoms if on the women’s cervix. It is treated with erythromycin, ciprofloxacin or a single shot of ceftriaxone.

Human papillomavirus (HPV): These viruses cause genital warts – small, flat, pink or greyish growths, usually painless but sometimes irritated if on vagina, cervix or penis. The warts, which may not be visible to the naked eye, usually appear two to three months after contact so anyone who has a sex panner infected with HPV or genital wans should be checked for infection. HPV viruses are easily passed on between sex partners and are strongly linked to cervical cancer in women. Therefore regular Pap smears are a must for women, especially those with male panners who have wans; for them colposcopy (cervical examination) may also be advisable. Men are at small risk of developing (penile) cancer from HPV wart viruses. Condoms may help to curb transmission. The wans are removed with chemical application of podophyllin or trichloroacetic acid, cryotherapy (freezing with liquid nitrogen), cautery (burning) or lasers. (For more on genital warts, see Health News, October 1989 & December 1989 issues,)

Hepatitis B: Passed on mainly by sexual contact, this serious liver infection is also acquired via shared household items such as razors, toothbrushes or from infected blood products and dirty injection needles. About 10 per cent of those infected become lifetime carriers with greatly increased risks of developing liver cirrhosis and cancer. Cartier mothers can pass the disease to their babies at birth. Since there is a very effective vaccine for hepatitis B – all at risk should get immunized. Pregnant mothers should get a blood test for hepatitis B and their babies are immunized at birth if necessary. Infected people should not have sex until their partners are safely vaccinated against hepatitis B. (For more on Hepatitis B, see Health News, February 1991 issue.)

How to curb the spread of STDs

While many relegate STD education to health professionals and educators, studies suggest that is hardly enough. Surveys show that Grade 11 students would like to receive sex-related information from parents but perceive parental knowledge of AIDS and other STDs as “inadequate.” Yet many don’t know where else to turn for advice. Parents and educators need to discuss sexuality and STDs candidly and explicitly with youngsters well before they reach adolescence. Teens need advice both on pregnancy avoidance and STD prevention. Physicians can play a major role in helping to prevent STDs by giving teenagers the facts at medical check-ups, taking care to respect their natural urge to explore sexuality. A non-judgemental approach works best, making it clear that adolescents are responsible for their own sexual health but that adults can and will help if asked. Adults can point out hazards and arm youngsters with suggestions for less risky alternatives, but ultimately teens decide for themselves when, how, with whom and whether to have sex. It might help to suggest that teens talk to each other and try to discuss with sex panners use of condoms or other safer ways to have sex.

Adolescents need to know they are not alone in having to adopt new sexual practices in the age of AIDS. Today’s challenge facing many is how to decline sex while respecting the other person’s feelings. Although not an indefinite option for most young people, abstinence from intercourse is increasingly considered an acceptable choice for some. (And it’s still alright to say “no” even if not a virgin!) “Calls for abstinence are probably less effective” says one University of Toronto expert “than suggesting postponement of sexual intercourse until ready- either to engage in safer sex or to enter a known, risk-free sexual relationship.” Giving valid scientific reasons can strengthen the argument.

“Abstinence can be defined as refraining from intercourse rather than restraint from all sexual activity” states another expert. “Sex need not involve penetration of penis into vagina (or rectum). Kissing and mutual massage are safer, non-insertive ways to enjoy sexual contact provided there is no exchange of body fluids.” Teens can be encouraged to choose non-penetrative yet pleasurable intimacy (or “outercourse”) rather than intercourse – in short … “everything but.” The sexual health of teenage girls is enhanced by postponing intercourse because the immature cervix is easily invaded by HPV and other organisms. Teens who do opt for intercourse require precise advice on how to avoid STDs as well as unwanted pregnancy.

For more information: contact your local health department; an STD clinic; your family physician; Toronto’s STD hotline (416) 392-7400; the Ontario STD treatment guidelines and fact sheets – available from the Ontario government, (416) 327-4327; the revised Canadian guidelines for the prevention, diagnosis, management and treatment of sexually transmitted diseases in neonates, children, adolescents and adults -available from: Health and Welfare Canada’s Division of STD control, at the Laboratory Centre for Disease Control, Ottawa.

When to get checked for a possible STD

* if you know or suspect your sex partner is infected

* if changing sex partners often. (Wait about four weeks, then get tested)

* if there are signs of:

* a vaginal or penile discharge (“the drip”)

* rash, warty growths, pimple, itchiness or sore on genitals

* persistent lower abdominal pain

* pain when urinating

* changes in menstrual flow, unusual bleeding (in women).

NB: Women should get regular Pap smear tests to detect early signs of cervical cancer.

Why STDs spread

* more permissive sexual attitudes following wide availability of the birth control Pill;

* earlier onset of sexual activity among adolescents;

* multiple sex partners (two or more in six months);

* complacency about STDs because of the past success of penicillin and other antibiotics in curing some of them;

* misconception that STDs affect only “high-risk” groups-giving others a false sense of security, imagining that they are immune to infection;

* lack of knowledge about STD symptoms (and reluctance to be tested by a physician or STD clinic even if infection is suspected);

* the insidious nature of STDs, many of which have few or no symptoms;

* asymptomatic STD carriers who have no symptoms but continue to have sex and spread the infection(s);

* denial of sexual desire by many adolescents and an unwillingness to “prepare ahead” for possible intercourse;

* teenage belief that “it’ll never happen to me,” and similar parental beliefs that “STDs can’t strike my son or daughter”;

* a macho attitude among men, many of whom refuse condoms (despite knowledge that they reduce STD risks);

* inadequate medical school training in the recognition and treatment of STDs;

* old habits that “die hard”- failure of healthcare professionals who regularly give women Pap smears to “think STDs,” do relevant tests, recognize STDs or give appropriate treatment -perhaps because some don’t keep up with medical advances (e.g., still using penicillin for drug-resistant gonorrhea);

* too little effort put into preventive STD education – especially for teenagers;

* school boards and teachers who don’t discuss sexuality, STDs or contraception adequately, for fear of “promoting promiscuity” or “triggering parental protests”;

* a hypocritical society willing to condone explicit sex in movies, on TV and in magazines, usually without mentioning pregnancy or STD risks;

* a moralistic view that says: “You play, you pay!” which regards STDs as proper punishment for sexuality.

Tips for preventing STDs (including AIDS)

* Always use a condom for sexual intercourse to prevent infection until sure (hard to know) your partner is free of STDs. Use only recommended latex (not lambskin) condoms. And use them correctly!

* Be selective about sexual partner(s), avoid one night stands, casual pickups and sexual intimacy with people you hardly know.

* Get to know your partner as well as possible.

* Never let sex become a power struggle where one “wins” and the other “loses” (and risks getting an STD).

* Do not assume that STDs cannot infect married people, those from “nice” families or seemingly committed sex partners.

* Remember that avowed commitment to a sex partner does not mean freedom from infection and should not engender false security or failure to use condoms.

* Teens might consider postponing intercourse until ready; to avoid both unwanted pregnancy and STDs.

* If on the Pill or using an IUD, also use a condom to combat STDs.

* Watch for symptoms of STDs: genital sores, rash, discharge, pain on urinating, low abdominal pain.

* Don’t be afraid, ashamed or embarrassed to seek medical attention if you suspect you may have an STD.

* Avoid sex with anyone who has obvious genital or anal sores.

* Avoid kissing, oral or genital sex when herpes sores are present.

* Remember that past (cured) STDs are no guarantee against reinfection.

* Never engage in anal intercourse without “double bagging,” using two condoms and ample lubrication.

* If using lubricant with condoms for anal sex, choose only waterbased types (e.g., K-Y jelly) not petroleum-based products (e.g., Vaseline), which weaken the condom.

* Male homosexuals should remember that even use of double condoms with ample lubrication is not foolproof as condoms tear easily with the friction of anal sex. Since spermicide irritates the rectum, its use for anal sex is controversial and many now advise against it.

* Women should consider refusing anal intercourse: it is very risky for them.

* Avoid oral-anal contact which is very high risk behaviour for STDs and other infections.

* Since STDs can be transmitted by fellatio (penile-oral sex) and cunnilingus (oral stimulation of female genitals) avoid these practices with an infected partner. Use a condom if not sure.

* If you suspect an STD infection, get tested as soon as possible. If the test is positive, get prompt treatment, tell any sex partner(s) and refrain from sex until cured.

* lf sexually active with more than one partner request regular STD check-ups.

Pelvic inflammatory disease a frequent consequence of untreated STDs in women

Pelvic inflammatory disease or PID is a very serious health threat for women, 17,000 being hospitalized each year with the condition in Canada. But PID is probably far more common than statistics indicate, affecting mainly women under age 25. PID usually results from gonorrheal or chlamydial infections that pave the way for other invading microorganisms which damage the female genital tract. Pelvic inflammation ensues if infection ascends from the vagina or cervix, past the endometrium (uterine lining) to the fallopian tubes. PID can cause severe lower abdominal pain, fever, vaginal discharge. bleeding, nausea, pelvic abscess and peritonitis (general abdominal infection). But many PID sufferers have no symptoms other than consequent infertility. About 10-20 per cent of those with PID become sterile through tubal scarring. Ectopic pregnancy, another consequence of PID. causes death of the fetus and can seriously endanger the mother. In Canada, there are about 6,000 ectopic pregnancies a year, the majority due to PID. Recent studies suggest that douching is an independent risk factor for PID as it spreads the infection. Sexually active women are advised to avoid douching. Early treatment of PID is essential to prevent complications. Antibiotics can eradicate the infecting organisms, but may not reverse the infertility. Women with severe PID need hospital treatment.

COPYRIGHT 1992 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group