Sexual Psychology – Critical Reflection #4 – Due Fri 12/3

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CHAPTER OUTLINE

Introduction, 313 Sexually Transmitted Infections, 313 Bacterial Infections, 314

Viral Infections, 317 Other Infections, 322

Factors That Increase the Spread of STIs, 323 Biological, 323 Psychological, 324 Social and Environmental, 326

The Psychological Impact of STIs, 327 Implications for Romantic and Sexual Relationships, 328

Preventing Infection, 329

Sexually Transmitted Infections and Safer-Sex Practices

©Dr. Lance Liotta Laboratory, via National Cancer Institute Visuals Online.

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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Introduction

Although sex has many positive features associated with it (e.g., pleasure, intimacy), there is also a potential dark side to sexual activity. In this chapter, we will begin to explore this dark side by considering the various infections that can be spread through sexual contact. The rea- son for discussing this topic is not to discourage you from being sexually active or to make you feel scared or anxious about having sex in the future; rather, the goal is simply to ensure that you have a complete picture when it comes to sex so that you can make informed decisions and take appropriate precautions. In addition, there are a lot of myths and misconceptions about sexual infections and how they are spread that are worth correcting (e.g., some people think that oral sex poses no disease risk, while others think that HIV can be spread through sweat).

We will begin by describing the most common sexually transmitted infections (STIs). We will talk about how these infections are transmitted, their prevalence, and their potential effects. This biological background is necessary for understanding the psychological and relational implications of having an STI, a topic we will address later in the chapter. We will also con- sider biological, psychological, and social factors that contribute to the prevalence of STIs, and explore the steps that you can take to prevent infection in your own sex life.

Before we move on, please note that we will use the term STI throughout this chapter instead of sexually transmitted disease (STD), a term some of you may be more familiar with. The rea- son for this is because STI is broader and more inclusive in that it refers to any case in which an infection is present in an individual, regardless of whether symptoms exist. In contrast, STDs only refer to cases in which there is an infection causing symptoms. Thus, not all STIs are STDs, but all STDs had to be STIs first. In addition, not all STIs will go on to become STDs (e.g., only some cases of the human papilloma virus or HPV will go on to produce symptoms).

Sexually Transmitted Infections

In the United States alone, there are approximately 20 million new cases of STIs each year and about $16 billion in associated health care costs, which makes this a major public health issue (CDC, 2015a). Young people are disproportionately affected by the STI epidemic, with persons aged 15–24 comprising approximately half of all new diagnoses. Although STIs are certainly a concern for people across all stages of the lifespan (e.g., consider that STI outbreaks are being documented among nursing home patients with increasing frequency; Jameson, 2011), it is clear that STIs are something the college crowd should be especially worried about.

Of course, STIs are a global concern and the United States represents only a small portion of the total number of infections worldwide. As some evidence of this, see Table 12.1, which presents incidence and prevalence data on three of the most common curable STIs through- out world regions. This table also reveals that the highest prevalence rates of these particular STIs are in Africa, North and South America, and the Western Pacific Region (e.g., China, Japan, Australia); prevalence rates are substantially lower in South-East Asia (e.g., India) and the Mediterranean (e.g., Iran, Pakistan). Incidence and prevalence rates for incurable STIs, such as HIV, also vary considerably across cultures. For instance, 7.1% of the population has HIV in eastern and southern Africa, compared to a prevalence of 0.3% in both North America and western and central Europe (Kaiser Family Foundation, 2017).

Below, we will review the most common STIs and provide some basic information about each. Given the nature of this book, we will not go into great depth about how each disease affects the body and its clinical presentation. However, if you would like more detailed information, you

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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are encouraged to check out the Centers for Disease Control and Prevention website (cdc.gov), which contains a massive database of sexual health information and statistics. If you would like to get tested for STIs, the CDC also has a helpful online tool (hivtest.cdc.gov) for finding local resources in the US. For current CDC screening recommendations, see Table 12.2.

Bacterial Infections

The three most well-known sexual infections caused by bacterial agents are chlamydia, gonor- rhea, and syphilis. Each of these infections is spread primarily through sexual contact, which includes oral, anal, and vaginal sex. Chlamydia is the most prevalent of the bacterial STIs. In the United States there are approximately 1.4 million new cases each year, and 66% of these infections occur among persons under the age of 24 (CDC, 2015a). Although chlamydia infec- tions are relatively easily cured through an antibiotic regimen, the unfortunate reality is that chlamydia infections are not always caught because symptoms are often minimal and, in some cases, completely nonexistent. The danger in this is that, if left untreated, chlamydia can cause a range of problems, including premature birth among pregnant women, blindness (in cases where the bacteria come into contact with the eye), and both male and female infertility. It is

Table 12.1 Incidence and prevalence of selected curable STIs across world regions.

Region Number of new cases in

2008 (incidence) Number of adults ages

15–49 Prevalence

Africa 32.8 million 384.4 million 8.5% North and South America 40.2 million 476.9 million 8.4% South-east Asia 35.6 million 945.2 million 3.8% European region 24.2 million 450.8 million 5.4% Mediterranean region 6.9 million 309.6 million 2.2% Western Pacific region 82.5 million 986.7 million 8.4%

Note: This table only presents data on three curable STIs: syphilis, gonorrhea, and chlamydia. Data obtained from World Health Organization (2008).

Table 12.2 CDC screening recommendations for STIs.

All adults and adolescents from ages 13-64 should be tested for HIV at least once. Sexually active women age 25 and younger should be tested yearly for chlamydia and gonorrhea. Older women who have new or multiple sexual partners or partners with an STI should be tested annually as well. All pregnant women should be screened for HIV, syphilis, chlamydia, and hepatitis B. At-risk pregnant women should also be screened for gonorrhea. Repeat testing should occur as needed. All sexually active men who have sex with men (MSM) should be screened annually for gonorrhea, syphilis, chlamydia, and HIV. MSM with multiple partners or anonymous partners should be screened every 3 to 6 months. Sexually active heterosexual men should be screened according to risk, meaning annual STI screenings should occur for men at high risk (e.g., men with multiple partners or who have inconsistent condom use). Anyone who has unsafe sex or shares injection drug equipment should be tested for HIV annually.

Source: CDC (2016).

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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estimated that as many as 20,000 US women become infertile each year as a result of undiag- nosed and untreated STIs like chlamydia (CDC, 2015a). In addition to these risks, untreated chlamydia can impair sexual pleasure and ability to reach orgasm. For more on this, see the Digging Deeper 12.1 box.

Gonorrhea (“the clap”) is one of the oldest known STIs and, historically, has been a major problem during times of war due to large numbers of servicemen patronizing sex workers. As some evidence of this, during World War II, the US government created a series of posters warning mil- itary members against visiting “good time girls” and prostitutes because “you can’t beat the Axis” if you have gonorrhea (see Figure 12.1). In fact, it was this fear of losing eligible servicemen to STIs that prompted the US government to outlaw prostitution near military bases. While gonorrhea used to be one of the more prevalent STIs, the infection rate has dropped dramatically since the 1970s. There are approximately 350,000 new cases of it each year in the US, with 54% occurring among individuals under age 24 (CDC, 2015a). Like chlamydia, symptoms of gonorrhea are often minimal, which means many infected individuals do not realize they have it and fail to get tested.

Digging Deeper 12.1 Do Sexually Transmitted Infections Affect Women’s Ability to Orgasm?

The short answer to this question is lySn. The long answer is that there are both physical and psy- chological reasons STIs affect female orgasm.

Let us cover physical causes first. One of the most well-known factors that affects women’s ability to reach orgasm during sex is edlynpuTSxamu (Butcher, 1999). This is a clinical term that refers to any type of genital pain experienced during sexual activity (see chapter 13 for more on this). When sex is painful, it is likely to be attempted less frequently and for shorter durations. In severe cases, sex may be avoided entirely. Many factors can cause female dyspareunia, including STIs such as chlamydia and gonorrhea. If a woman has one of these infections and is not treated for it, she may develop pelvic inflammatory disease (PID). This occurs when the initial infection spreads from the vagina or cervix to other reproductive organs, such as the uterus and fallopian tubes. Because chlamydia and gonorrhea infections often produce few or no early symptoms in women, many women do not realize they have an STI until the infection has advanced to PID. If you are a woman who is experiencing pain during intercourse, it is advisable to see a physician to determine the exact cause. This is important not only for improving your sex life and poten- tially restoring ability to orgasm, but also because if PID is the cause, it can potentially result in infertility if left untreated for too long.

With regard to psychological factors, having an STI can evoke a number of emotional responses that interfere with both sexual arousal and orgasm. Sexual scientists have known for a long time that negative emotions and feelings are strongly related to sexual problems (Nobre & Pinto-Gouveia, 2006), and STIs are just one of many factors that can negatively affect one’s mood state. For instance, a woman with herpes or HPV may experience a loss of sexual pleasure because she is afraid of or distracted by the thought of passing the infection to her partner. Likewise, emotions that frequently accompany being diagnosed with an STI are shame and guilt, which may not only lead one to shy away from sexual activity, but also to enjoy it less. Some people may also be so fearful of contracting STIs that they have a hard time relaxing and getting into the moment during sexual activity.

Thus, STIs can reduce a woman’s ability to reach orgasm both biologically and psychologically. Although we focused primarily on how STIs affect women here, similar effects sometimes occur in men and can create the same types of sexual difficulties for them.

Note: Reprinted with permission from Se uaed Pnlyehiaigly (www.lehmiller.com).

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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If left untreated, the infection can cause infertility in both men and women. Although gonorrhea used to be easy to treat with a massive dose of penicillin, antibiotic-resistant strains of this bac- terium have popped up in recent years, making gonorrhea more difficult to manage (Unemo & Nicolas, 2012). Public health officials are concerned that gonorrhea may eventually become an untreatable “superbug” because it has developed resistance to almost all known antibiotics and, at the same time, drug manufacturers have very few new antibiotics in the pipeline, in large part because they are relatively unprofitable to produce at this time.

Despite being very well-known as an STI, syphilis is a far less common bacterial infection than both gonorrhea and chlamydia, with about 20,000 new cases diagnosed each year in the United States (CDC, 2015a). Rates have declined dramatically over the past half-century; how- ever, there has been a recent, dramatic uptick in cases among men who have sex with men (MSM). In fact, whereas 7% of cases of syphilis could be attributed to MSM in 2000, the pro- portion jumped to 67% in 2010 (CDC, 2011) and 83% in 2014 (CDC, 2015a)! Syphilis tends to have more noticeable symptoms of infection than the other bacterial STIs. Symptoms vary depending upon the stage of the disease, with the most prominent being a chancre or painless sore at the site of infection during primary syphilis (the earliest stage) and a rash on the hands or feet during secondary syphilis. As you learned in chapter 2 in our discussion of the Tuskegee

Figure 12.1 Historically, the US government sought to alert servicemen about the dangers of STIs during times of war. ©US National Library of Medicine.

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Syphilis Study, untreated syphilis can be devastating and deadly the longer it goes on, with the potential for insanity, paralysis, and heart failure to occur. Syphilis is generally treatable with penicillin, although the dose required depends upon how far the disease has progressed.

Viral Infections

Some STIs are caused by viruses instead of bacteria, and these tend to be the most worrisome because, unlike bacterial STIs, we cannot cure viral STIs. As a result, viral infections are much more prevalent and far more difficult to eradicate. The most common viral STI (and also the most common sexual infection in general) is the human papilloma virus (HPV), which infects at least 14 million people in the United States each year (CDC, 2014). HPV is spread through sexual activity and skin-to-skin contact. It is possible to spread HPV even when practicing safe sex because the virus can sit on portions of the skin that are not protected by condoms. Most people who have HPV do not realize it because there are dozens of different strains of the virus and only a few of them cause health problems. Likewise, only a few strains have obvious symp- toms, with the most notable being genital warts.

HPV has increasingly troubled the medical community due to research indicating that advanced infections are linked to an increased risk of cancer in the cervix, anus, and throat (Gillison, Chaturvedi, & Lowy, 2008). Although there is no cure for HPV, there is a vaccine (Gardasil) that has been approved for use in both men and women and can protect against the highest-risk strains of the virus (i.e., those linked to genital warts and cancers). Research has found that this vaccine is highly effective and, since its introduction, it has cut HPV rates by nearly two-thirds among sexually active teen women (Markowitz, 2016). The recommended age to receive this vaccine is 11–12, with the goal being to catch people before they become sexually active. However, this vaccine is also recommended (and typically covered by insurance) for anyone up to age 26 in the United States. Age guidelines vary across countries, though. For instance, in Australia, the vaccine is recommended for women through age 45. If you are over the recommended age in your country, consult with your doctor to determine whether the vac- cine is right for you.

Despite strong efficacy and safety data, efforts to mandate this vaccine for adolescents in the United States have been met with fierce resistance from certain political and religious groups, with some arguing that such vaccines will effectively license children to be promiscuous as adults. However, research on girls who have received this vaccine has found that they do not have more sexual partners than girls who do not get the vaccine (Bednarczyk, Davis, Ault, Orenstein, & Omer, 2012). What do you think about adolescents receiving vaccines for sexual infections? Weigh in with your perspective in the Your Sexuality 12.1 box.

Herpes is another common viral STI that is characterized by painful blisters on or around the genitals, anus, and/or mouth. There are two strains of the virus that are of particular inter- est to sexual health researchers: Herpes simplex virus type 1 (HSV-1) and Herpes simplex virus type 2 (HSV-2). HSV-1 is typically linked to oral lesions (often referred to as “cold sores” or “fever blisters”), whereas HSV-2 is typically linked to genital area lesions; however, these viral strains can “cross over” and potentially cause sores in either area. It is estimated that 15.5% of individuals in the United States aged 14–49 have a genital HSV-2 infection, and a far higher number are thought to have the oral HSV-1 infection (CDC, 2015b). CDC data also reveal that HSV-2 infection is about twice as common among women compared to men (it is easier to spread the virus from man to woman rather than the other way around), and three to four times as common among Blacks compared to Whites, even when accounting for differences in number of sexual partners (CDC, 2015b). Thus, this racial disparity is not necessarily due

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to differences in sexual risk behavior—it has more to do with socioeconomic (e.g., access to healthcare and condoms) and other factors.

Herpes is highly contagious and easily transmitted from one person to the next through sexual activity, skin-to-skin contact, and kissing. Part of the reason herpes is so prevalent is because the infection can be spread even when no obvious symptoms are present. Like HPV, herpes can potentially be transmitted even when wearing a condom, because the virus may reside on areas of the skin that condoms do not protect. Herpes is experienced differently across individuals, with some persons experiencing regular flare-ups of symptoms, and others experiencing them rarely or never. In fact, most people with herpes have no symptoms or only mild symptoms, which may be mistaken for other skin issues (CDC, 2015b). We do not fully understand why, but some psychological factors have been implicated in frequent symptom outbreaks, including depression, anxiety, and stress (Massad et al., 2011). For those who expe- rience frequent outbreaks, antiviral drugs such as Valtrex can either be taken daily to suppress future outbreaks or episodically to lessen the severity of current symptoms.

Despite the annoyance and pain of occasional blisters, the only major complications of her- pes infection are the potential to transfer the virus to the eye (resulting in ocular herpes), an elevated risk of encephalitis and meningitis, and the possibility of exposing a newborn to it through vaginal delivery. Herpes and many other STIs (including chlamydia and gonorrhea) pose a very serious health risk to infants during childbirth owing to their underdeveloped immune systems, which makes it all the more important for women who are pregnant or hop- ing to become pregnant to be up front with their doctors about their sexual histories and to receive appropriate STI screenings.

The final viral infection we will cover is the human immunodeficiency virus (HIV), a ret- rovirus that targets and destroys a certain type of lymphocyte (T4 helper cells). By doing so, the immune system becomes compromised and susceptible to opportunistic infections (i.e., infections that are not normally harmful, but that can be deadly to someone with poor immune

Your Sexuality 12.1 Should STI Vaccinations Be Mandated For Adolescents?

As soon as the HPV vaccine Gardasil hit the market, several US states took the initiative to man- date the vaccine for adolescents or at least make a concerted effort to inform the public about the benefits of it. Although such legislation has been introduced in 42 states and territories since 2006, only 25 have enacted anything (National Conference of State Legislatures, 2016). Legisla- tion has stalled in so many states partly because of cost and safety concerns, but also as a result of moral objections. Many political and religious groups feel it is wrong to require an adolescent to be vaccinated for a disease that is transmitted through sexual contact because they feel it presumes a certain level of promiscuity and fear that it may instill a false sense of security that ultimately licenses adolescents to engage in riskier sexual behavior. Some also argue that a man- datory vaccine infringes upon religious freedoms and individual choice. The counterarguments are that most people become sexually active as teenagers, you only need to have one partner in order to contract an STI, and this vaccine has the potential to prevent against some of the most devastating cancers.

Are there any other arguments you can think of for or against mandatory STI vaccinations? Which set of arguments do you find most persuasive and why? What type of legislation (if any) would you want your government to support?

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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functioning). When an individual already has HIV and that person’s T4 cell count drops to a dangerously low level, the acquired immune deficiency syndrome (AIDS) is diagnosed. It is at this time that opportunistic infections are most likely to take hold.

In the US, the incidence of HIV is estimated at 50,000 new cases each year, with about 1.1 million citizens in total currently living with an HIV infection (CDC, 2015c). Historically and even today, most cases of HIV in the United States have been attributable to MSM, with this group currently representing 63% of all new cases (CDC, 2015c). This is largely because anal sex—a common sexual activity among MSM—carries a risk of HIV transmission that is many times higher than vaginal intercourse. In the US, racial minorities are also disproportionately affected, with Blacks and Hispanics comprising 44% and 21% of new HIV infections, despite making up 12% and 16% of the overall US population, respectively (CDC, 2015b). There are numerous reasons for this racial disparity, but one of the biggest is that Black and Hispanic Americans are more likely to live in poverty, which has significant implications for access to HIV testing and treatment.

The nature of HIV/AIDS is dramatically different worldwide in terms of incidence, preva- lence, and the groups most likely to be affected. For instance, in Sub-Saharan Africa, there are 1.5 million new cases per year and about 24.7 million individuals are currently infected (Avert, 2015). That effectively means that in parts of Africa, one in 20 adults is living with HIV/ AIDS. The other major departure from US statistics is that, as opposed to disproportionate infection by gay men, most cases of HIV globally are attributable to heterosexuals, with men and women being equally impacted.

HIV is spread through sexual activity, including unprotected vaginal and anal intercourse, as well as other activities in which there is an exchange of cell-containing bodily fluids (e.g., childbirth, shared needles among injection drug users or people getting tattoos or body pierc- ings). The greatest potential risk lies in exposure to the semen or blood of a person with a new or advanced infection because they tend to have the largest amounts of the virus in their

Figure 12.2 Many people fail to realize that “cold sores” and “fever blisters” are caused by the herpes virus and that they are highly contagious through kissing and oral sex. ©CDC/Dr. Herrmann, via CDC Public Health Image Library.

Lehmiller, J. J. (2017). The psychology of human sexuality. John Wiley & Sons, Incorporated. Created from umuc on 2021-11-22 23:15:19.

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system. Contrary to popular belief, there is virtually no risk of HIV infection from exposure to sweat, tears, or saliva, even though this has been taught in some sex education courses (see chapter 11). These bodily fluids contain only trace amounts of the virus, making transmission near impossible. For more common myths and misconceptions about HIV and other STIs, see the Digging Deeper 12.2 box.

Individuals infected with HIV may not realize it for months or potentially even years because there are few symptoms associated with the initial infection. In fact, it is estimated that as many as 12.8% of infected individuals do not yet know they have it (CDC, 2015c), which is one impor- tant reason HIV continues to spread. Unfortunately, there remains no cure for HIV/AIDS; however, treatments have improved dramatically over the past two decades and people are able to live with the infection longer than ever before. Specifically, by taking daily anti-retroviral drugs, the progression of the disease slows considerably and the risk of passing the infection along to sexual partners decreases dramatically because the amount of the virus “free-floating” in bodily fluids drops to almost undetectable levels. In fact, in heterosexual relationships, the rate of HIV transmission in couples with discordant HIV status (i.e., cases where one partner has it and the other does not) is near zero when the HIV-positive partner’s viral load is sup- pressed through drug therapy (Attia, Egger, Müller, Zwahlen, & Low, 2009). These drugs have also made it much less likely that pregnant women with HIV will pass the virus along to their children during birth (European Collaborative Study, 2005).

Although a cure for HIV is still a long way off, researchers have made progress in develop- ing methods that can reduce one’s risk of contracting the virus. One of the most promising preventive measures at this point involves administering anti-retroviral drugs to persons at high risk of contracting the virus, a treatment known as pre-exposure prophylaxis (or PrEP for short). This involves taking one pill per day that consists of a similar, but not identical, version of the medications an HIV-positive person would take to reduce their viral load. Studies have found that, with consistent use, PrEP dramatically reduces the risk of contracting HIV among

Figure 12.3 Out of all world regions, Africa is disproportionately affected by the HIV/AIDS epidemic. ©Joseph Sohm. Used under license from Shutterstock.com.

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Digging Deeper 12.2 Six Myths About Sexually Transmitted Infections Debunked.

Although most people are sexually active, it is surprising how little some people know about sex. In particular, there are a multitude of myths and misconceptions about STIs. Below, we will review six of the most persistent false beliefs about sexual infections.

Mlyih #1: Yix eua uvimed n bly huvmag iTua nSe maniSued in vugmaua iT uaua maiSTeixTnS. Do not believe this one for a second! Almost all STIs have the potential to be transmitted and contracted through oral sex. For instance, many people fail to realize that they can get chlamydia and gon- orrhea infections of the throat. Likewise, a large number of people seemingly have no idea that “cold sores” are caused by the herpes virus, which means that if someone with this infection per- forms oral sex on you (particularly when they are experiencing on outbreak), they can potentially give you genital herpes. Also, keep in mind that “pubic lice” are not just for the pubic area. In fact, they can and will seize the opportunity to live in a moustache or beard if given the chance.

Mlyih #2: Yix eua medSaimnly pSipaS wmih n bly aiikmag ui ihSs uaed/iT manpSeimag ihSmT gSamiuan. Nope. Someone with an STI can look perfectly healthy and there may be nothing out of the ordi- nary with that person’s genitals. The harsh reality of some STIs (such as HPV, HIV, and chlamydia) is that they often cause few to no symptoms initially, yet are still highly contagious.

Mlyih #3: Yix euaaii gSi ihS nusS iwmeS. Just because you had gonorrhea once does not mean you will be inoculated against it or any other STIs in the future. In fact, you can get the same STI from the same partner over and over unless biih in lyix get tested and treated.

Mlyih #4: PSipaS whi xnS eiaedisn euaaii gSi n. Although condoms provide nisS protection against STIs, they do not guarantee complete safety. Unless you are wearing a full-body con- dom, there is still the potential to transmit and contract herpes and HPV through skin contact.

Figure 12.4 One of the most persistent myths about STIs is that condoms provide an absolute safety guarantee. ©Wavebreak Media Ltd/123RF.COM.

(CiaimaxSed)

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MSM, heterosexual couples, as well as injection drug users. However, the “with consistent use” caveat is very important. As some evidence of this, one study of MSM found that PrEP reduced the risk of HIV infection by 44% overall, but among those who took the drug consistently and had detectable levels of it in their blood, their risk was reduced by as much as 92% (Grant et al., 2010)! In addition to being highly effective at preventing HIV, side effects appear to be relatively minor. While all of this certainly sounds great, it is important to note that PrEP does not protect against STIs other than HIV. As a result, condoms are still essential for people who are on it. In other words, PrEP should not be thought of as a replacement for condoms, but rather as an additional layer of protection. It is also important to keep in mind that, while PrEP is covered by many insurance plans, it is a very expensive drug, currently running into the tens of thousands of dollars per person per year to administer. With limited healthcare resources available, it is therefore only cost effective to administer this drug to those who have the highest risk of contracting HIV, such as MSM who have anal sex and who are inconsistent condom users, HIV-negative persons who are in relationships with HIV-positive partners, and injection drug users. If you want to learn more about PrEP and whether it is right for you, consult with your doctor.

Other Infections

The above discussion should not be taken to mean that there are only six possible STIs. The fact of the matter is that there are many other infections that can be spread through sexual contact. One of the more notable ones is trichomoniasis (or “trich” for short), which is actually the most common of the curable STIs, with an estimated 3.7 million persons in the United States currently infected (CDC, 2015d). Trichomoniasis is a parasitic infection that is most likely to be transmit- ted during vaginal intercourse. Most who have it do not show symptoms, but if left untreated, it is linked to several health issues, including elevated risk of preterm birth in pregnant women (CDC, 2015d), as well as increased risk of prostate cancer in men (Stark et al., 2009).

Other infections that can be transmitted via sexual activity include pubic lice and scabies (both of which, like trichomoniasis, are also parasitic infections), as well as hepatitis (a virus

Digging Deeper 12.2 (Continued)

In addition, people make lots of mistakes using condoms, such as putting them on after sex has started or taking them off before sex is over, which undermines the protective benefits.

Mlyih #5: n eua bS iTuansmiiSed ihTixgh pxbame iimaSi nSuin. If you are having sex on top of a toilet, sure! Otherwise, it is pretty unlikely. In reality, many viruses and bacteria cannot live long outside of the human body, and even if you happened to sit in someone else’s bodily fluids, infection can only occur if those fluids get inside your bloodstream or genital tract. So, unless you have a lot of open cuts on your buttocks or enjoy dry humping toilet seats, the risk is pretty minimal.

Mlyih #6: Oaaly naxin gSi n. Many people think they are not at risk for contracting STIs because they do not have “that many” sexual partners. However, you only need to have one partner to potentially get an STI, and it can happen the very first time you have sex.

STIs are a risk that anyone who is sexually active must recognize. However, you can minimize your chances of contracting an infection and experiencing long-term negative effects by under- standing the nature of STIs, taking the appropriate precautions, and getting into the habit of regular screenings.

Note: Reprinted with permission from Se uaed Pnlyehiaigly (www.lehmiller.com).

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Figure 12.5 Anti-retroviral drug therapy significantly reduces the risk of HIV transmission during sexual activity and childbirth, and may potentially serve as a preventive agent for HIV-negative individuals who are at high risk of contracting the virus. ©Nomadsoul1/123RF.COM.

that attacks the liver). It is worth noting that all three types of hepatitis (A, B, and C) can potentially be spread through sexual activity, although there are some differences in the specific activities linked to each variant of this virus.

Consideration of the nature and causes of every possible STI is beyond the scope of this chapter; however, please be aware that the CDC website (cdc.gov) contains a wealth of infor- mation on all possible infections, including common signs, symptoms, and treatment courses.

Factors That Increase the Spread of STIs

Now that you know something about the most common sexual infections and how they are spread, let us look at some of the factors that contribute to the high prevalence of STIs. As you will see below, these factors are biopsychosocial in nature.

Biological

The biological nature of certain STIs makes them very easy to spread. For instance, as pre- viously mentioned, many STIs exhibit few or no initial symptoms, including chlamydia, gonorrhea, HPV, and HIV. Consequently, many infected individuals are unaware of their status and may unknowingly and unintentionally pass along their infection to other sexual partners. Thus, even if you and your partner(s) feel completely normal, it is important to take appropriate precautions and get regular STI screenings because people can still be highly contagious even if they are not actively exhibiting any disease symptoms.

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In addition, the nature of certain STIs not only makes them very easy to transmit, but they can increase your susceptibility to contracting other infections. For instance, both herpes and syphilis are known to create open sores on or around the genitals. Those sores make it very easy for infectious agents to readily enter and exit the body. Thus, someone with herpes or a syphilis chancre would be especially prone to contracting other STIs and spreading their infec- tions to other partners.

Psychological

There are a multitude of psychological factors that promote the spread of sexual infections. First, among different-sex couples, the use of hormonal contraceptives can lull the partners into a false sense of security. By removing fear of unwanted pregnancy from the equation, many couples feel “protected” and therefore stop using condoms (Williams, Kimble, Covell, & Weiss, 1992). However, as discussed in chapter 11, hormonal contraceptives provide no protection against STIs whatsoever. Also, as discussed in chapter 8, sexual infidelity is surprisingly common. Thus, stopping condom use because pregnancy risk has been averted leaves the door open to infection unless both partners have been tested and maintain monogamy.

Second, emotions such as fear and embarrassment often prevent people from getting tested for infections. There is a lot of social stigma and shame associated with STI testing, because getting screened for infections may imply that you have done something wrong. In addition, getting tested can potentially create an awkward scenario in which your current and/or former partners need to be contacted and informed of your results. Consequently, many individuals do not get tested out of fear that they will be judged by others or because they want to avoid embarrassment. Just consider that among men who have never received an HIV test, 59% of them reported that they did not get screened because they feared the potential social conse- quences (Stall et al., 1996). Obviously, this failure to get tested can lead to infections going undiagnosed and allow them to spread further; however, now that in-home HIV testing (e.g., OraQuick) is a reality, testing stigma may become less of a barrier.

Third, if you have ever taken a health psychology course, you have probably learned that people express unrealistic optimism about their own health (Weinstein, 1987). In other words, people think that they are unlikely to encounter health problems (such as STIs) in the future. This may lead some people to forego protection or to use protection inconsistently because they think “it won’t happen to me” or “only sluts get sexually transmitted diseases.” However, as discussed in the Digging Deeper 12.2 box, STIs are an issue that every sexually active person must be cognizant of.

Fourth, being committed to a sexual partner can lead you to view that partner as “safe” or as not representing a risk to your health (Gerrard, Gibbons, & Bushman, 1996). In some ways, this makes sense. As commitment to a relationship grows, we come to trust our partners more and become less concerned that they will lie to us or cheat, which may reduce the feeling that condoms or other forms of protection are needed. However, we know that people in monoga- mous relationships often cheat and, when they do, they frequently fail to use protection with those partners and typically do not disclose such encounters to their primary partner (Conley, Moors, Ziegler, & Karathanasis, 2012; Lehmiller, 2015). Thus, while being committed is almost universally thought of as a good thing, commitment does carry some potential STI risks.

Fifth, the stereotypes we hold about certain people can increase our STI risk. In particular, the widespread stereotype that attractive people are healthier can potentially undermine safer-sex behaviors with some partners. For instance, research has found that participants rate attrac- tive individuals as posing less STI risk (Agocha & Cooper, 1999) and report that they would be less likely to use a condom with an attractive partner (Kelaher, Ross, Drury, & Clarkson, 1994).

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In reality, however, if attractive people are more highly desired, then they probably have more opportunities for sex. To the extent that this translates to a higher number of sexual partners, there could be an increased STI risk associated with highly attractive individuals.

Sixth, repeatedly being infected with the same STI can reduce the amount of concern one has about that particular infection (Plant et al., 2015). For example, to the extent that someone con- tracts syphilis several times, but gets treated for it and recovers each time, that individual might eventually become less worried about contracting another syphilitic infection in the future. Recognizing that one can be cured without experiencing long-term complications may lead some to perceive that the risk is an acceptable one. Alternatively, repeat infections can reduce fear by leading to a sense of inevitability (e.g., “I’m going to get the infection no matter what I do”). Either way, the danger here is that, when people become less concerned about STIs, they are less likely to take the measures necessary to protect themselves.

Finally, attachment styles, personality characteristics, and attitudes toward condoms may predispose individuals to engage in behaviors that increase STI risk. For instance, persons with insecure attachment styles are less likely to practice safe sex (Feeney, Peterson, Gallois, & Terry, 2000), perhaps because highly anxious persons are more inclined to use drugs before sex in order to relieve anxiety, or because they leave safe-sex decisions to their partners (i.e., they may simply agree to whatever a partner wants so as to reduce the risk of the relationship ending). In addition, persons with more erotophilic personalities and those who perceive con- doms as a barrier to sexual pleasure are more likely to report having unprotected sex (Crosby, Salazar, DiClemente, & Yarber, 2004). Likewise, having a sensation-seeking personality is linked to reporting sex without condoms in risky situations, cheating on one’s partner, and contracting more STIs (Ripa, Hansen, Mortensen, Sanders, & Reinisch, 2001). In addition, hav- ing an unrestricted sociosexual orientation is associated with risky sexual behaviors, such as unprotected sex (Seal & Agostinelli, 1994).

Figure 12.6 As people become more committed to one another, safe-sex practices tend to drop off; however, that can create risk if one of the partners ends up cheating. ©ProStockStudio/Shutterstock.

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Social and Environmental

There are also some social factors implicated in the spread of STIs, such as alcohol use in social settings. Research has found that there is indeed a link between alcohol consumption and risky sexual behaviors (e.g., failure to use condoms or to discuss STI history with a new partner); however, the nature of this relationship is complicated (Cooper, 2006). In certain situations, alcohol may increase risky behavior, but in other cases, it can inhibit such behavior. This vari- ability occurs because the nature of the situation interacts with the individual’s beliefs about the effects of alcohol (known in psychological terms as expectancy effects. For instance, indi- viduals who believe that consuming alcohol will disinhibit them tend to show greater levels of social disinhibition when drinking alcohol than people with other expectancies. Thus, there is not a simple and straightforward link between alcohol and risky sex because alcohol affects people in different ways; suffice it to say that, at least in some cases, alcohol increases STI risk.

Social norms also play a role in the spread of STIs because sex remains a taboo topic of discus- sion in many cultures (Baxter & Wilmot, 1985). For instance, imagine you are out on a first date and you are asked the following questions: “How many people have you slept with? Have you ever had an STI? Do you practice safe-sex?” Some people would be offended or embarrassed by these questions and would not know how to react. As a result, these questions are not asked as often as they should be, and many people go on to have sex with partners with whom they have not exchanged meaningful sexual histories. It is ironic that modern society has somehow deemed talking about sex “more personal” than actually having sex. Related to this, research on MSM has found that disclosure of HIV status is less likely to occur when meeting partners in person compared to meeting partners online (Grov, Hirshfield, Remien, Humberstone, & Chiasson, 2013). This may be because the anonymity provided by Internet communications allows people to talk about issues that might be too uncomfortable to discuss in person.

Despite the fact that hookup websites and smartphone apps appear to enhance sexual commu- nication, many scientists have expressed concern that use of such technology is a risk factor for STIs because they facilitate the obtainment of multiple partners very quickly. Indeed, there is some research indicating that MSM who meet their partners through popular smartphone apps such as Grindr tend to report more STIs than those who meet partners offline (Lehmiller & Ioerger, 2014). However, is this because the technology promotes greater sexual activity, or because those who are more sexually active are just more likely to use the technology? Research supports the latter expla- nation, and indicates that MSM who use the Internet and smartphones for casual sex have greater numbers of partners to begin with (Lehmiller & Ioerger, 2014) and are often pursuing partners online and offline simultaneously (Jenness et al., 2010). Thus, the link between the Internet and STI risk is not quite as simple and straightforward as some have suggested.

Lack of health insurance and access to healthcare can also play a role in the spread of STIs by impeding testing and treatment. As previously mentioned, this contributes to the racial and ethnic disparity in STIs we see in the United States. However, while access to care is important, poor communication between doctors and patients about sexual health issues poses another potential problem. For example, does your doctor feel comfortable asking you about your sex life? Research has found that only about one in four doctors ask patients about STIs during rou- tine checkups (Tao, Irwin, & Kassler, 2000)! By the same token, do you feel comfortable talking to your physician about your sex life? Many of us do not, which means there is a reluctance to dis- cuss sex on both sides of the table. As a result, STIs often go undiagnosed and untreated even in the doctor’s office. Further contributing to this problem is the fact that doctors frequently stereotype their patients based upon marital status, assuming that married folks are monoga- mous and therefore do not have the same sexual health concerns as their single counterparts. However, as discussed in chapter 8, this is a bad assumption. Some people are consensually non-monogamous, and many people who make monogamy agreements break them.

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Finally, it is also important to note that the majority of condoms manufactured today come in a “standard” length and width, with the assumption being that condoms are “one size fits all.” However, research finds that men with larger penises report that the average condom is too tight and, more importantly, these well-endowed men are more likely to have engaged in unprotected sex recently (Grov, Well, & Parsons, 2013). Thus, it appears that men who are unable to find condoms that fit well are less likely to take sexual precautions.

The Psychological Impact of STIs

Some STIs are curable and, once the infection has passed, there are no lingering aftereffects. However, other STIs (e.g., herpes, HPV, and HIV) are for life. Once you have it, there is no getting rid of it. As a result, chronic STIs can have a potentially devastating psychological effect. Regular flare-ups of symptoms and/or the act of taking a daily medication may serve as constant remind- ers of one’s disease status, possibly evoking feelings of guilt, shame, embarrassment, or anxiety. The psychological effects are even more severe for persons with HIV, who frequently report feelings of victimization, constant mortality salience, and a fear of becoming dependent upon other people as the disease progresses (Watstein & Chandler, 1998). These psychological effects are compounded by the persistent social stigma surrounding STIs. For instance, there are a lot of myths about STIs that stoke unnecessary fear (e.g., in some US states, it is considered an act of “bioterrorism” for an HIV-positive individual to spit on someone else, even though it is virtually impossible for the infection to be transmitted in this way), and people who have STIs are often blamed for having contracted them because they are thought to have used poor judgment and/ or to have engaged in immoral behavior (Sayles, Ryan, Silver, Sarkisian, & Cunningham, 2007).

Figure 12.7 Both doctors and patients express some reluctance to talking about sex during medical visits, which creates many missed opportunities for STI detection and diagnosis. ©Andres Rodriguez/123RF.COM.

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Persons with STIs may respond to their diagnosis and cope with the resulting stress and stigma in a number of ways. For instance, among persons with HIV, anger and denial are com- mon reactions to the initial diagnosis (Watstein & Chandler, 1998). In rare cases, such reac- tions may lead individuals to lash out by intentionally trying to infect others. At least in the case of HIV, intentional or reckless infection of another person is considered a criminal act in many parts of the world, and some individuals have been prosecuted for this. Fortunately, however, such behavior is uncommon. Other coping mechanisms include turning to alcohol and other substances as a means of psychological “escape” (McKirnan, Ostrow, & Hope, 1996). However, substance abuse can make mental health issues worse and potentially speed up the rate at which HIV infection progresses into AIDS (i.e., the rate at which one’s T4 cell count drops).

Other individuals find more positive ways of coping. For instance, some people immerse themselves in supportive online communities (Reeves, 2000), while others engage in spiritual methods of coping or seek social support from family and friends (Vyavaharkar et al., 2007). Perhaps not surprisingly, people who adopt such approaches tend to experience better psycho- logical adjustment and ultimately experience more positive outcomes.

Implications for Romantic and Sexual Relationships

In addition to feelings of stress and anxiety, persons with chronic STIs often feel as though they have reached the end of their sex and dating lives because they fear that others will not want to put themselves at risk by becoming intimate with someone who has an incurable infection. However, having a chronic STI does not necessarily mean that you must live a single and celi- bate life.

One option is to pursue a partner who has the same infection status as you (although this can be trickier than it sounds because there are multiple strains of some STIs. Thus, for example, having one strain of HPV does not make you immune from catching other strains of that virus, which may be linked to different symptoms and risks). The benefit of having the same infec- tion as your partner is that neither of you will have to worry about passing anything on to the other person, which can increase sexual intimacy (Frost, Stirratt, & Ouellette, 2008). There are a growing number of websites and dating services such as PositiveSingles.com that seek to match partners with the same infection status. Such services have become increasingly popular owing to the fact that so many millions of people have chronic STIs and want to find partners who will not judge them based on their status and history and who will not be as concerned about potential infection risk.

However, you do not have to limit your dating pool in this way, and if you have already met someone you really like who does not share the same infection, things can still work out. In the modern world, it is increasingly possible for couples where the partners have discordant infection status to have happy and healthy sexual and romantic relationships. Of course, such relationships face a few important challenges. For one thing, there is likely to be some social stigma faced by infection-discordant couples. Just think about it—if you are HIV-negative but started dating someone who is HIV-positive, how would your parents or friends react? Many of them would probably not approve of the relationship out of concern for your health.

In addition to dealing with some potentially tricky social issues, such couples also need to figure out how to manage risk to the uninfected partner. In order to do so, couples must be willing to do a few things. First, the infected partner must be good about taking medications to manage symptoms. This would include daily anti-virals for persons with herpes and daily anti-retrovirals for persons with HIV. If the infected partner has HPV, it may be wise for the uninfected partner to get the HPV vaccine if they have not done so already. Second, condoms or other barriers should always be used during sexual activity to minimize risk of transmitting

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the infection. Finally, the couple members must have excellent communication. This includes disclosing infection status at the outset of the relationship, acknowledging and discussing anxi- eties about the potential risks, being cognizant about limiting sexual activity when infection risk is highest (e.g., during herpes outbreaks), and setting and respecting sexual limits and boundaries.

Preventing Infection

To close out this chapter, we will discuss steps you can take to reduce the likelihood of contract- ing STIs in your own sex life. This means practicing safer sex. Keep in mind that there really is no such thing as completely “safe” sex, meaning that there is always some risk associated with any sexual activity. Thus, there is only safer sex. Although risk can never be fully eliminated unless you practice strict abstinence or only engage in solitary activities, there are multiple things you can do to limit your chances of contracting and spreading STIs.

First and foremost, communicate with your partner about your sexual histories. Ask your partner about STIs and recent test results. At the same time, be prepared to answer those ques- tions about yourself. This means that if you have an STI, be honest and upfront about it. Think about it this way—is this the kind of thing you would want someone to lie to you about? And would you really be OK with intentionally passing along an infection to an unsuspecting per- son, especially with your knowledge of the potential physical and psychological consequences of STIs? Discussing your status with a new partner can be tough, and one of the biggest inhibi- tors when it comes to disclosing STI status is fear of rejection. In fact, this is probably why up to a third of persons with HIV (Sullivan, 2005) and herpes (Green et al., 2003) report failure

Figure 12.8 Several websites now offer persons with a positive infection status the chance to meet other partners of the same status. ©PositiveSingles.com.

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to disclose their status to their regular sex partners! However, keep in mind that honesty and mutual respect are vital to having a satisfying sexual relationship, and if you ever hope for a romance to develop with someone, lying is unlikely to lay the foundation for a successful long- term relationship.

Second, get regular STI tests so that you can know your own status and provide your partner(s) with reliable information. Also, if you start a monogamous relationship with some- one, it is advisable for each partner to get an STI test early in the relationship to reduce the risk that one of you will spread an infection to the other, especially if you and your partner are at a point where you are considering stopping condom use. If financial costs are a concern, be advised that if you are a university student, you can usually get STI tests free of charge through your school’s health center and, no, your parents will not find out that you were tested or be sent a copy of the results. If you are not affiliated with a university, many communities have free STI clinics that you can find with a quick online search.

Third, use of barriers during oral, anal, and vaginal sex is advisable because they will limit the possibility of another person’s bodily fluids entering your bloodstream or genital tract. This means using male or female condoms for intercourse. However, be sure to brush up on proper condom use before your next sexual encounter because, as mentioned in chapter 11, condom use errors are incredibly common (Sanders et al., 2012). See Table 12.3 for a list of suggestions that will help ensure consistent condom effectiveness. Also, if you are worried that using con- doms will reduce genital sensitivity or impair your ability to reach orgasm, keep in mind that there are many different condoms on the market that vary in size, thickness, and material. As a result, you may need to do some experimenting to find the right one for you.

During intercourse, the use of artificial lubricants can help reduce the risk of internal tears to the vagina or rectum. A drop or two of lubricant on the inside of the condom may also help to enhance pleasure for the wearer—just do not put too much on the inside or the condom may slip off. Lubricants can be purchased at most drug stores, pharmacies, and sex shops, but be careful when selecting a lubricant to ensure that it is compatible with the type of condom

Table 12.3 Guidelines for proper condom use.

Check packaging for expiration dates, holes, and tears. Throw away expired condoms and punctured packages. Store your condoms somewhere cool and dry. Ideally, this would be your nightstand. Wallets and glove compartments are not good places to store condoms for prolonged periods of time. Put condoms on before beginning sexual activity, and keep them on until it is over. Engaging in “dipping” (i.e., inserting a bare penis into the vagina or anus before putting the condom on) or removing the condom prior to ejaculation still permits an exchange of infectious organisms. Use lubrication with condoms, but select a lubricant that explicitly notes on the bottle that it is compatible with latex condoms. If you put on the condom inside out, throw it away and put on a different one. If you reuse the same condom, you can still expose your partner to infections. Do not unroll the condom or blow it up like a balloon before using it. It may sound like fun, but you will weaken the condom by doing so. Squeeze the tip of the condom when unrolling it down the shaft of the penis to leave a space at the end for catching ejaculate. Remove the penis promptly after ejaculation. If the penis remains inside the other person while the erection subsides, ejaculate can leak out of the condom. Remember that condoms are made for one-time only use!

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you are using. In particular, avoid using oil-based lubricants with latex condoms because the oil can reduce condom efficacy. Thus, if you are in the habit of using items around the house as makeshift lubricants, it would be wise to avoid baby oil, vegetable oil, massage oil and other such products and instead get yourself a bottle of water-based or silicone-based lubricant from the store.

For oral sex, dental dams are worth considering. Dental dams are latex barriers that look kind of like a fruit roll-up (and, in fact, you can buy flavored ones that actually taste fruity). These barriers can be placed over the vulva for cunnilingus or over the anus for anilingus. Dental dams may be hard to find at your local drugstore, but they are readily available over the Internet and are often carried by Planned Parenthood and other STI clinics. If you can- not get your hands on a dental dam, you can make one very easily from an ordinary latex condom. All you need to do is cut off the tip of the condom, and then slit it down the side with a pair of scissors. Unroll and behold your homemade dental dam! Related to this sug- gestion, latex gloves can be used to prevent infection when the fingers are used to stimulate the vagina or anus.

If you share vibrators or other sex toys during partnered sexual activity, it is important to be aware of a study finding that HPV can linger on some vibrators up to 24 hours after use, even after they have been cleaned (Anderson, Schick, Herbenick, Dodge, & Fortenberry, 2014). This suggests that shared sex toys have the potential to transmit STIs and that cleaning does not necessarily eliminate that risk. Thoroughly cleaning sex toys before and after is certainly still an advisable practice; however, beyond cleaning, using condoms or other barriers with shared sex toys might help to provide an additional level of protection.

It may also help to maintain a high level of personal cleanliness and hygiene. This means many things, including keeping fingernails short if fingers will be inserted inside the vagina or

Figure 12.9 If you do not have access to a dental dam, remember that you can create one from an everyday latex condom. ©lim_atos/123RF.

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rectum so as to limit the possibility of creating internal tears. In addition, regularly flossing and brushing your teeth to prevent gum and oral diseases can reduce the odds of spreading and contracting infections during oral sex. That said, flossing should not occur just before or after sex, especially among persons who do not already have healthy gums because of the potential for bleeding to occur. Washing your own and your partner’s hands and genitals before and after sex may offer a limited protective benefit as well, but cleanliness is not a substitute for condoms and barriers. If you do wash after sex, it is best to avoid vaginal or rectal douching (i.e., flushing with water) because that can increase infection risk by irritating internal membranes and push- ing infectious organisms further inside the body.

Finally, use common sense and exercise good judgment. For instance, if you are having a symptom outbreak of an STI (e.g., herpes), avoid partnered sexual activity because those symp- toms can increase risk for both you and your partner(s). Also, avoid sex with at-risk persons (e.g., someone you know or suspect to be an injection drug user or someone you know does not reliably use protection with other partners). And keep in mind that the more sexual partners you have, the more indirect partners you accumulate. This means that when you have sex with someone, you are indirectly being exposed to every other sex partner that person has had. Obviously, the more direct and indirect partners you have, the greater the likelihood that you will be exposed to an STI. It is important to think about these things if you want to make your infection risk as low as possible.

Key Terms

Discussion Questions: What is Your Perspective on Sex?

● Have you ever been tested for an STI? What prompted you to do so? If you have never been tested, why?

● When is the “right” time in a relationship for partners to share their sexual histories and STI status?

● What biopsychosocial factors can you think of that promote the spread of STIs other than those already discussed in this chapter?

References

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